Professional Documents
Culture Documents
Maternal-Child Nursing Care - Optimizing Outcomes For Mothers, Children, & Families (PDFDrive)
Maternal-Child Nursing Care - Optimizing Outcomes For Mothers, Children, & Families (PDFDrive)
Copyright © 2009 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No
part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise, without written permission from the
publisher.
As new scientific information becomes available through basic and clinical research, recommended
treatments and drug therapies undergo changes. The author(s) and publisher have done everything
possible to make this book accurate, up to date, and in accord with accepted standards at the time of
publication. The author(s), editors, and publisher are not responsible for errors or omissions or for
consequences from application of the book, and make no warranty, expressed or implied, in regard to
the contents of the book. Any practice described in this book should be applied by the reader in
accordance with professional standards of care used in regard to the unique circumstances that may
apply in each situation. The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering any drug.
Caution is especially urged when using new or infrequently ordered drugs.
Ward, Susan L.
Maternal-child nursing care: optimizing outcomes for mothers, children, and
families / Susan L. Ward, Shelton M. Hisley.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1486-4 (alk. paper)
ISBN-10: 0-8036-1486-1 (alk. paper)
1. Maternity nursing--Textbooks. I. Hisley, Shelton M. II. Title.
[DNLM: 1. Maternal-Child Nursing--methods. 2. Cultural Diversity. 3.
Evidence-Based Nursing--methods. 4. Holistic Nursing--methods. WY 157.3
W263m 2009]
RG951.W37 2009
618.2’0231--dc22 2008051815
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific
clients, is granted by F.A. Davis Company for users registered with the Copyright Clearance Center
(CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC,
222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy
license by CCC, a separate system of payment has been arranged. The fee code for users of the
Transactional Reporting Service is: 8036-1486-4/09 0 ⫹ $.25.
In loving memory of my mother, Betty A. Tighe, who always said “it’s possible”.
With great love and appreciation to my family, particularly to my intelligent
children Kathleen, Frank, and William.
To my co-author, Shelton Hisley, who has amazing fortitude. To faculty,
administration, and staff at Nebraska Methodist College.
To the skilled and caring nurses at Children’s Memorial and Methodist Hospitals.
To my dear friend, Jeanne Snowden.
Susan Ward
To my husband, Jack, whose love and encouragement, especially during the dark
days of my cancer diagnosis and treatment, kept me aloft and convinced that I could
achieve this goal.
To my parents, Barbara and Hubert McLendon, for a lifetime of love and support.
Also to Susan, my co-author and friend, for whom I hold the greatest admiration
and respect.
Shelton Hisley
Preface
Maternal–Child Nursing Care: Optimizing Outcomes for different outpatient settings. With this text, students learn
Mothers, Children, and Families springs from our passion- that community-based care can take place in a variety of
ate commitment to providing the best nursing care possi- ways at any time and in any place. It is our hope that the
ble to mothers and children and our desire to inspire oth- users of this textbook will acquire the essential knowledge
ers to make that same commitment. In this all-inclusive for professional nursing practice in the specialties of
source, we provide students with current, comprehensive maternal and child nursing and that they will gain insights
information about maternal–child nursing in creative, about providing nursing care in a myriad of settings and
dynamic ways and in a concise, accessible format. Building with diverse populations.
upon theoretical foundations in basic nursing care, com-
munication skills, and principles of health promotion, the
text challenges students to optimize outcomes for their Organization
maternal and pediatric patients using critical thinking as
they care for them in the hospital and community environ- Each chapter opens with a culturally or spiritually oriented
ments. We focus on aesthetics, cultural sensitivity, and a story, literary piece, caring element, or quotation that cre-
caring approach. The textbook also serves as an excellent atively expresses various dimensions of aesthetics in nurs-
resource for practicing nurses who work with women, ing. Because contemporary nursing is a dynamic profession
children, and families in a variety of settings. We believe with a rich past, present, and future, we emphasize and
that combining essential information about the two spe- promote the importance of innovative, state-of-the art tech-
cialties into a single textbook supports good educational nology balanced with compassionate, humanistic care.
practice while being economically practical. “Learning Targets” offer a guided approach to chapter con-
tent and provide a gauge for assessing outcomes.
Chapter introductions provide a preview of content and
Philosophy assist students in identifying essential information and
major concepts. Key words appear in boldface print accom-
The primary objective of this textbook is to identify the panied by brief definitions in the text and are grouped in
myriad of options for holistic, evidence-based practice in the glossary for easy, quick reference on the Electronic
maternal and child nursing care in this new millennium, Study Guide. Color illustrations and photos provide visual
based on a philosophy of physiological and developmental cues to enhance understanding. These features facilitate
normalcy and stressing safety and optimization of outcomes students’ learning and promote an understanding of the
for mother and child. In addition to comprehensive cover- relationship between classroom or textbook information
age of maternal and child nursing care in traditional set- and the delivery of nursing care in the clinical setting.
tings, essential elements for providing cost-effective, high- A short review of anatomy, physiology, and pathophysi-
quality, innovative nursing care in community settings are ology is provided in applicable chapters to foster under-
presented. Discussion of health care delivery in community standing of new applications of concepts previously
settings is crucial in contemporary nursing education and learned. Eye-catching display boxes draw students’ atten-
reflects the present trend for women, families, and children tion to essential information about medications, critical
to obtain health care in the diverse settings in which they nursing actions, nursing procedures, related research stud-
live, grow, play, work, or go to school. ies, assessment tools, diagnostic modalities, safety issues,
This book is built upon a framework that views the therapeutic communication strategies, and family teaching
delivery of nursing care as a continuum spanning the tra- guidelines.
ditional hospital in-patient environment to the community Each chapter concludes with a concept map that visually
setting. Students are presented with information essential summarizes the relationships among the most important
to providing appropriate, culturally sensitive nursing care concepts presented. The map reinforces students’ learning,
to women, families, and children. A variety of creative promotes mastery of information, and assists students in
learning aids are used to assist students in subject mastery critical analysis. It is a useful tool for confirming that stu-
and prompt the delivery of care that appropriately addresses dents have identified the essential chapter elements and for
contemporary needs while incorporating innovative applying classroom information to the clinical setting.
approaches that integrate provider–patient partnerships A number of strategies designed to prompt and enhance
and alliances with coalitions that serve women, families, critical thinking weave through the text. Case studies, nurs-
and children across the lifespan. Because the traditional ing care plans, NCLEX-style review questions, and exer-
hospital experience constitutes an important component cises in clinical decision-making assist students in master-
of nursing education, content on hospital-based nursing ing content and in integrating new information. These
care for women, families, and children examines acute, creative learning activities help students to assimilate and
traumatic, chronic, and terminal conditions. Likewise, internalize information as they build upon previously
content that addresses community-based nursing care for learned nursing knowledge and prepare to apply newly
women, families, and children explores strategies and introduced concepts in various maternal–child clinical
resources for the provision of appropriate care in many practice areas.
ix
x preface
Themes and Key Features actual patient situations. As students work through the
various case studies, they are challenged to apply criti-
The overarching theme of this comprehensive maternal– cal thinking and practice clinical decision-making.
child resource focuses on how to provide contemporary • Nursing Diagnoses foster the development of new
nursing care to women, families, and children in the com- nursing knowledge where diagnoses are developed
munity as well as in the traditional hospital setting. In based on information obtained during a nursing
service to that goal are the broad themes of holistic care, assessment. A standardized statement about the health
critical thinking, validating practice, and tools for care. of a patient is created for the purpose of providing
We use the following key features throughout the chap- nursing care. The nursing diagnoses portray patients’
ters to creatively illustrate and emphasize information responses to their condition where the nurse can
essential for the delivery of safe, effective nursing care to address the problems independently.
diverse populations across care settings, thus ensuring an • “Clinical Alerts” help students recognize emergent
educational experience rich with critical thinking activi- or critical situations and relate classroom or text-
ties and clinical application opportunities. book information as they deliver safe, effective
nursing care in the hospital and community-based
HOLISTIC CARE environments.
• “Critical Nursing Actions” prompt students to assimi-
• Each chapter begins with a culturally or spiritually ori- late and internalize information as they prepare to
ented story, literary piece, caring element or quotation apply important concepts in the clinical area.
that creatively expresses aesthetics in nursing. • NCLEX-style review questions located at the end of
• “Nursing Insight” boxes show students how experi- each chapter prompt and enhance critical thinking and
enced nurses use their five senses to gain a deeper help to prepare students for licensure examination.
understanding about the clinical situation or the • Concept Maps visually summarize the relationships
patient’s condition. among the most important concepts presented in
• “Collaboration in Caring” provides guidelines for every chapter. The concept map can be used by stu-
working with other health care professionals to care dents to think critically, to review, and to more clearly
for patients and families in in-patient and community- see the application of classroom information to the
based environments. clinical setting.
• “Ethnocultural Considerations” emphasize cultural
humility in both the hospital and community settings. VALIDATING PRACTICE
• “What to Say” helps students develop and enhance
their communication skills by providing verbatim • “Moving Toward Evidence-Based Practice” highlights
examples or helpful hints. current relevant research and encourages students to
• Nursing Care Plans incorporating NANDA, NOC, incorporate evidence-based findings into their every-
and NIC terminology relate classroom and textbook day practice.
knowledge to clinical practice, while evidence-based • “Optimizing Outcomes” enhance critical thinking
rationales for interventions show how research sup- skills for clinical application and help establish the
ports practice. best possible outcomes and how to obtain them.
• “Complementary Care” shows students the wide range • “Where Research and Practice Meet” focus on investi-
of complementary options available for integration gative initiatives that may impact practice in the future,
with conventional approaches to provide safe, timely, underscoring the value of clinical inquiry in ensuring
and compassionate care. positive outcomes for patients and their families.
• “Across Care Settings” foster students’ responsiveness • “Be Sure To…” alert new nurses to important legal
to trends in health care by highlighting holistic health issues that impact the clinical environment and help
care in acute care and community-based settings in them recognize how to critically analyze potentially
which children and families live, grow, play, work, or litigious situations.
go to school. Sensitivity to diverse patient populations • “Now Can You?” prepares students to assimilate and
is also underscored. internalize information presented throughout the
• “Family Teaching Guidelines” help students teach chapter and serve as a mini check to ensure mastery of
families essential components about caring for them- material before proceeding to the next section.
selves and their children and are offered both in • “Summary Points” bring together the information
English (in the text and on the Electronic Study students should be most careful to comprehend from
Guide) and Spanish (on the Electronic Study Guide). the chapter.
• References provide current citations that validate prac-
CRITICAL THINKING tice and support the chapter content.
• “Learning Targets” offer a guided approach to chapter
content and provide a gauge for assessing outcomes. TOOLS FOR CARE
• Key words appear in boldface type accompanied by • “A & P Review” of chapter-specific anatomy, physiol-
brief definitions. Key words are also stored in the glos- ogy, and pathophysiology foster understanding of new
sary for easy, quick reference on the Electronic Study applications of previously learned concepts.
Guide and DavisPlus. • “Labs” boxes present crucial information about labora-
• “Case Studies” facilitate students’ practice in the tory testing and its relationship to the patient’s overall
assimilation of content from various chapters into health status.
preface xi
• Procedures provide step-by-step instructions for per- areas of strength and weakness and prepare for course
forming common procedures in maternal–child tests and the national licensure examination.
nursing and the rationales for why things are done a
particular way. Each procedure includes an example of PowerPoint Presentations
documentation to emphasize the critical nature of A collection of slides is provided that form the basis for a
proper, accurate documentation. lecture for each chapter, which can be modified based on
• “Medication” boxes present crucial information about the instructor’s preferences.
commonly prescribed medications and help students
in their care of mothers, children, and families. Media Ancillary
• “Assessment Tools” facilitate understanding of clinical Electronic files of the images from the text are included
evaluation and help students make the connection for use in the classroom, as are audio selections of heart
between classroom or textbook knowledge and the sounds.
clinical setting.
• “Diagnostic Tools” present crucial information about ELECTRONIC STUDY GUIDE
common diagnostic measures and their relationship to
A complimentary electronic study guide is included with
various disease entities.
the text. This is intended to assist and enhance students’
learning and offers creative ways to supplement and rein-
force the textbook information. It contains the following:
Teaching Ancillaries and Other
Related Products Interactive Exercises
These provide a creative and enjoyable way to enhance
INSTRUCTOR’S RESOURCE DISK students’ learning and include:
The components on the Instructor’s Resource Disk seam- • Hangman
lessly guide faculty through the content and offer innovative • Quiz Show
strategies for creatively supplementing the text. This com- • Critical Thinking
plete and easy-to-use collection of teaching aids for mater- • Drag and Drop Bucket
nal–child content includes the following components. • Fill-in-the-Blank Clue
Instructor’s Guide Case Studies
The course syllabus includes a proposed class schedule for Thirty-one relevant case studies from selected chapters
a traditional 15-week semester and for an accelerated 8- facilitate students’ practice in the assimilation of content
week semester along with reading assignments and testing from various chapters into actual patient situations.
content. The syllabi provide a guide for using the text in
the most efficient way. Nursing Care Plans
“Teaching Plans” provide a user-friendly lesson plan All care plans from the textbook are provided and are
for each chapter whether teaching in separate or com- printable. There are also twelve expanded care plans that
bined courses. The Teaching Plans integrate teaching are not included in the text (six for Obstetrics and six for
tips, PowerPoint presentations, and suggested students Pediatrics) to provide in-depth information and guidance
assignments. for planning and providing care to maternity and pediatric
“Tips for Teaching a Combined Maternal–Child patients with commonly encountered normal and patho-
Course” offer suggestions about how to effectively teach logical conditions.
these two specialties in one course.
Family Teaching Guidelines
Case Studies English and Spanish versions of the Family Teaching
The case studies provided to the instructor are more Guidelines from the text, as well as additional ones unique
extensive and detailed than those provided in the text or to the Electronic Study Guide, can be personalized and
on the Electronic Study Guide so they can be used for test- printed and used in actual patient care situations.
ing as well as post-conference discussions. Answers to the
case studies are provided to promote and enhance critical NCLEX-style Review Questions
thinking skills and facilitate the application of theoretical A collection of NCLEX-style questions and rationales can
concepts into the clinical setting. help students identify areas of strength and weakness,
and prepare for course tests and the national licensure
Concept Maps examination.
Concept maps are constructed to underscore the relation-
ships among the essential concepts in each chapter. They Sound Collection
prompt critical thinking and may be used as a guide for Heart sounds depicting various normal and abnormal heart
students assigned to create additional maps about other sounds are included to help students recognize when there
important theoretical elements. is a problem.
Electronic Test Bank Podcasts
The electronic test bank is a collection of NCLEX-style Podcasts directs students to key chapter concepts and
questions and rationales to enable students to identify reinforces essential information.
xii preface
xiii
Contributors
Sharon Akes-Caves, RN, MS, MSN Livingston, Alabama
Corporate Nursing Education Program and Interim ADN Chapter 29
Program Director
Prima Medical Institute Patricia M. Connors, RNC, MS, WHNP
Mesa, Arizona Perinatal Clinical Nurse Specialist
Chapter 1 Massachusetts General Hospital
Boston, Massachusetts
Jan Andrews, RNC, PhD, WHNP Chapter 11
Professor and Associate Dean of Nursing and Health
Sciences Sherrill Anne Conroy, D Phil, Med, BN, RN
Macon State College Assistant Professor
Macon, Georgia University of Alberta
Chapter 6 Edmonton, Alberta, Canada
Chapter 21
Kimberly Attwood, PhD(c), MSN, CRNP, APRN, BC, NP-C
Assistant Professor of Nursing Janine L. Dailey, RN, MSN
DeSales University Instructor
Center Valley, Pennsylvania Nebraska Methodist College
Chapter 15 Omaha, Nebraska
Clinical Pathways in Ancillaries
Deborah Bambini, PhD, WHNP-BC, CNE
Assistant Professor Wendy A. Darby, PhD, CRNP
Grand Valley State University Associate Professor, Family Nurse Practitioner
Grand Rapids, Michigan University of North Alabama
Clinical Pocket Companion Florence, Alabama
Case Studies for Pediatric Chapters in Ancillaries
Sharon Bator, RN, MSN, PNP, CPE, PhD Student
Assistant Professor of Nursing Michele D’Arcy-Evans, CNM, PhD
Southern University School of Nursing Professor
Baton Rouge, Louisiana Lewis-Clark State College
Chapter 32 Lewiston, Idaho
Chapter 9
Bridget Bailey, RN, MSN
Associate Professor Jacqueline Maria Dias, RN, RM, MEd
Iowa Lakes Community College Assistant Professor
Emmetsburg, Iowa The Aga Khan University School of Nursing
Chapter 22 Karachi, Pakistan
Chapter 24
Diane M. Bligh, MS, RN
Associate Professor, Nursing Elizabeth Fahrenholtz, APRN, MSN
Front Range Community College Assistant Professor
Westminster, Colorado Creighton University
Concept Maps in all Chapters and Ancillaries Hastings, Nebraska
Chapter 5
Michelle Lynn Burke, MSN, ARNP, CPN, CPON
Clinical Specialist Brian G. Fonnesbeck, RN, BSN, MN
Department of Hematology Oncology Associate Professor
Miami Children’s Hospital Lewis-Clark State College
Miami, Florida Lewiston, Idaho
Chapter 33 Chapter 3
Roseann Mary Zahara-Such, APRN, BC, MSN, CCNS Kelly K. Zinn, MSN, RN
Assistant Clinical Professor of Nursing Assistant Professor
Purdue University Nebraska Methodist College
Hammond, Indiana Omaha, Nebraska
Chapter 28 Coordinator for certain Ancillary Components
Reviewers
Marie Adorno, APRNC, MN Jami-Sue Coleman, MS, RN Donna Healy, MS, RN
Assistant Professor of Nursing Nursing Instructor Associate Professor of Nursing
Our Lady of Holy Cross College Western Nevada Community College Adirondack Community College
New Orleans, Louisiana Carson City, Nevada Queensbury, New York
Rebecca L. Alleen, RN, MNA Meghan Connelly, MSN, APRN, Debra L. Hyde, RN, MSN, CNS
Assistant Professor CCRN, CPNP-AC Faculty
Clarkson College CNS/NP Aultman College of Nursing and
Omaha, Nebraska Children’s Hospital Health Sciences
Omaha, Nebraska Canton, Ohio
Anita Dupre Althans, RNC, BSN, MSN
Assistant Professor of Nursing Susan Craig, RN, MSN Paula Karnick, PhD, ANP-C, CPNP
Our Lady of Holy Cross College Faculty Associate Professor
New Orleans, Louisiana Butte Community College North Park University
Oroville, California Chicago, Illinois
Elaine Andolina, BS, MS
Director of Admissions, School of Robin Culbertson, RN, MSN, EdS Mary Beth Kempf, BSN, RNC, MSN, OB
Nursing Nursing Instructor Associate Degree Nursing Instructor
University of Rochester Okaloosa Applied Technology Center Northeast Wisconsin Technical
Rochester, New York Fort Walton Beach, Florida College
Green Bay, Wisconsin
Bridget Bailey, RN, MSN Lori DuCharme, RN, BSN, MS
Nursing Instructor Nursing Faculty Cynthia A. Kildare, RN, MSN,
Iowa Lakes Community College Front Range Community College APRN-BC
Emmetsburg, Iowa Westminster, Colorado Assistant Professor
Bryan LGH College of Health
Margaret Batson, RN, MSN Susan Ellison, MSN, RNC Sciences
Nursing Instructor Senior Instructor Lincoln, Nebraska
San Joaquin Delta College The Charles E. Gregory School of
Stockton, California Nursing Karen M. Knowles, RN, MS
Perth Amboy, New Jersey Faculty/Specialty Chairperson
Samantha H. Bishop, MN, RN, CPNP Crouse Hospital School of Nursing
Assistant Professor of Nursing Marie Esch-Radtke, MN, RN Syracuse, New York
Gordon College Nursing Faculty
Barnesville, Georgia Highline Community College Kathleen Nadler Krov, RN, CNM,
Des Moines, Washington MSN, FACCE
Linda Boostrom, RN, MSN Assistant Professor
Instructor of Nursing Program Polly D. Fehler, RN, BSN, MSN Raritan Valley Community College
Henderson Community College Instructor of Nursing Somerville, New Jersey
Henderson, Kentucky Tri-County Technical College
Pendleton, South Carolina Barbara Leser, PhD, RN, RM
Susan J. Brillhart, MSN, APRN, BC, PNP Doctor
Assistant Professor of Nursing Denise M. Fitzpatrick, RNC, MSN Northwest Nazarene University
Borough of Manhattan Community Instructor/Course Coordinator Nampa, Idaho
College Dixon School of Nursing
New York, New York Willow Grove, Pennsylvania Randee L. Masciola, RN, MS, CNP
Clinical Instructor and Women’s
Linda A. Browne, MSN, RN L. Sue Gabriel, MSN, MFS, RN, SANE Health Nurse Practitioner
Program Director/Instructor Assistant Professor Ohio State University
Southwest Georgia Technical College Bryan LGH College of Health Sciences Columbus, Ohio
Thomasville, Georgia Lincoln, Nebraska
Kathleen Matta, MSN, CNS, IBCLC
Tammy Bryant, RN, BSN Marilyn Johnessee Greer, RN, MS Visiting Faculty
Program Director Associate Professor of Nursing University of New Mexico
Southwest Georgia Technical College Rockford College Albuquerque, New Mexico
Thomasville, Georgia Rockford, Illinois
Sheila Matye, MSN, RNC
Gloria Haile Coats, RN, MSN Kristin J. Hanak, MS, RN, PNP Adjunct Assistant Professor
Professor of Nursing Nursing Faculty Montana State University
Modesto Junior College Front Range Community College Great Falls, Montana
Modesto, California Westminster, Colorado
xix
xx reviewers
Trilla Mays, RN, MSN Melissa A. Popovich, RN, MSN Suzan Stewart, RN, BS
Nursing Instructor Clinical Faculty Lab Coordinator
Midlands Technical College Ohio State College of Nursing Community College of Denver
Columbia, South Carolina Columbus, Ohio Denver, Colorado
Barbara McClaskey, PhD, MN, Karen L. Pulcher, ARNP/CPNP, Deborah Terrell, RN, MSN, APN, DNSc
RNC, ARNP MSN, RN Associate Professor
Professor, Department of Nursing Assistant Professor in Nursing Harry S. Truman College
Pittsburg State University University of Central Missouri Chicago, Illinois
Pittsburg, Kansas Lee’s Summit, Missouri
Barbara Tewell, RNC, BSN
Michelle Michitsch, RN, MS, CPNP-PC Jacquelyn Reid, MSN, EdD, CNM, CNE Perinatal Staff Nurse
Adjunct Nursing Professor Associate Professor Naval Medical Center
Borough of Manhattan Community Indiana University Southeast San Diego, California
College New Albany, Indiana
New York, New York Donna J. Gryctz Thomas, RN,
Jean Rodgers, RN, BSN, MN BSN, MSN
Nancy Miller, MSN, RNC, CCM Nursing Faculty Assistant Professor of Nursing
Nursing Professor Hesston College Kent State University
Keiser University Hesston, Kansas New Philadelphia, Ohio
Fort Lauderdale, Florida
Kathryn Rudd, RNC, MSN Joan Thompson, NNP, MSN, RNC
Georgia Moore, PhD, MSNed, RN-BC Clinical Educator Assistant Professor
Consultant/Online educator MetroHealth Medical Center University of Hawaii at Hilo
Louisville, Kentucky Cleveland, Ohio Hilo, Hawaii
Julie Moore, RNC, MSN, MPH, WHNP Christine L. Sayre, MSN, RN Pat Twedt, RN, MS, Med, MS
Associate Professor of Nursing Auxiliary Faculty Associate Professor of Nursing
Hawaii Community College Ohio State University Dakota Wesleyan University
Hilo, Hawaii Columbus, Ohio Mitchell, South Dakota
Cindy Morgan, CNM Gwenneth C. Simmonds, PhDc, CNM, Becky C. Vicknair, RNBS, APRN,
Instructor MSN, RN MSN, PNP
University of Tennessee at Clinical Instructor Pediatric Instructor
Chattanooga Ohio State University Delgado/Charity School of Nursing
Chattanooga, Tennessee Columbus, Ohio New Orleans, Louisiana
Deborah Naccarini, RN, MSN, FNP Lisa H. Simmons, RN, MSN Sherry Warner, RN
Assistant Professor Instructor and Coordinator Child Nursing Instructor
Carroll Community College Health Nursing Fulton-Montgomery Community
Westminster, Maryland University of South Carolina Aiken College
Aiken, South Carolina Johnstown, New York
Debbie Ocedek, RN, BSN, MSN
Professor of Nursing Cordia A. Starling, BSN, MS, EdD Maribeth Wilson, MSN, MSPH
Mott Community College Division Chair of Nursing Nursing Faculty
Flint, Michigan Dalton State University Keiser University
Dalton, Georgia Tallahassee, Florida
Donna Paulsen, RN, MSN
Nursing Faculty Nora F. Steele, DNS, RNC, PNP Jennifer J. Woods, RN, MSN
North Carolina Agricultural and Professor Instructor
Technical State University Charity/Delgado Community College Delgado/Charity School of Nursing
Greensboro, North Carolina New Orleans, Louisiana New Orleans, Louisiana
Detailed Table of Contents
Personal and Cultural Influences and Trends 37
unit one Health Care for the Nation 38
Foundations in Maternal, Family, Delivery Systems 39
Challenges for Nurses in Contemporary Society 39
and Child Care 1 Contemporary Issues and Nursing Roles 41
chapter 1 chapter 3
Traditional and Community Nursing Care for The Evolving Family 46
Women, Families, and Children 1
The Evolving Family 47
Traditional Nursing Care 4 Viewing the Family in a Nursing Context 47
Historical Perspective 4 The Healthy People 2010 National Initiative 47
Health-Wellness Continuum 5 Families Today 47
Changing Demands and Demographics 7 The Changing Family as Reflected in the Media 48
Professional Nursing Roles 7 Stressors on Families Today 49
Contemporary Nursing Care 8 Family Theories and Models 50
Current Health Care Settings 8 Family Systems Theory 51
Family Centered Care 10 Family Developmental Stages and Theory 52
Combining Modern Technology with the Caring Touch 11 Structural-Functional Theory 53
Professional Nursing Roles 13 Communication Theory 53
The Caring Art and Science of Nursing 13 Group Theory 54
Theories that Frame Caring as the Core of Nursing 14 Bowen’s Family Systems Theory 54
Essential Characteristics of Caring 14 Nursing Theories 54
Professional Nursing Roles 15 Family Assessment 55
Evidence-Based Practice 18 The Nursing Role in Family Assessment 55
The Nursing Process 19 Tools to Facilitate the Family Assessment 56
Components of the Family Assessment 58
Assessment of Roles and Relationships 59
chapter 2 Assessment of the Family Developmental Stage 59
Contemporary Issues in Women’s, Families’, Assessment of Family Rituals 60
and Children’s Health Care 25 Assessment for Triangulation 60
Assessment for the Presence of Dyads and Other Subsystems 60
Framework: The Public Health Intervention Model 26 Family-Centered Care 61
How the Intervention Wheel Works 27 Nursing Diagnosis: Altered Family Processes 61
Healthy People 2010: A Blueprint for Action 28 Families with Special Needs 62
Overview of Selected Societal Trends 29 Hospitalization 62
Aging Population with More Chronic Illnesses 29 Chronic Mental Illness 62
Increased Racial and Ethnic Diversity 29 Substance Abuse 63
Disparities in Health Care 30 Sexual or Physical Abuse 64
Childbirth Trends 30 Posttraumatic Stress Disorder 64
Patterns of Physical Fitness 30 Chronic Physical Illness 65
The Intersection of Race, Class, and Health 31 Death of a Family Member 65
The Current Health Status of the Nation 31 Family Cultural Characteristics 66
Infants and Young Children 31 Acculturation and Assimilation 66
Families 33 Identity 66
Women 33 Connectedness 67
Politics, Socioeconomics, and Culture: Contemporary Influences and Communication Patterns 67
Trends 34 Socioeconomic 67
Political Influences and Trends 34 Holistic Nursing Encompasses a Culturally Sensitive Family
Socioeconomic Influences and Trends 35 Approach 67
xxi
xxii detailed table of contents
Planning and Implementation of Care 140 Factors that May Adversely Affect Embryonic and Fetal
Evaluation 142 Development 178
Toward Achieving the National Goals for Reproductive Life Chromosomes and Teratogens 178
Planning 142 TORCH Infections 181
Providing Contraceptive Care: Methods of Contraception 143 The Nurse’s Role in Prenatal Evaluation 182
Medication-Free Contraception 143 Heredity and Genetics 183
Coitus Interruptus 143 Maternal Age and Chromosomes 184
Lactational Amenorrhea Method (Breastfeeding) 143 Multifetal Pregnancy 185
Abstinence 144
The Nurse’s Role in Minimizing Threats to the Developing Embryo and
Barrier Methods 144
Fetus 186
Hormonal Methods 147
Injectable Hormonal Contraceptive Methods 150
Subdermal Hormonal Implant 151
Intrauterine Devices 151
Sterilization 152 unit three
Clinical Termination of Pregnancy 153 The Prenatal Journey 191
Nursing Care Related to Elective Pregnancy Termination 153
Surgical Termination of Pregnancy 153
Medical Termination of Pregnancy 154 chapter 8
The Nurse’s Role in Infertility Care 154 Physiological and Psychosocial Changes During
The Initial Assessment 154 Pregnancy 193
Later Methods of Assessment 155
Treatment Options for Infertility 156 Physiological Preparation for Pregnancy 194
Medications 156 Hormonal Influences 194
Surgical Options 157 Reproductive System 195
Therapeutic Insemination 157 Integumentary System 197
Advanced Reproductive Technologies 158 Neurological System 197
Infertility, ART, and Potential Effects on the Couple’s Cardiovascular System 198
Relationship 159 Respiratory System 201
Lifestyle Choices and Infertility 159 Gastrointestinal System 202
Additional Options for the Infertile Couple 159 Urinary System 202
Endocrine System 203
Musculoskeletal System 204
Nursing Assessment and Health Education 205
Psychosocial Adaptations During Pregnancy 205
chapter 7 Developmental and Family Changes 205
Conception and Development of the Embryo and Maternal Tasks and Role Transition 207
Fetus 164 Paternal Adaptation to Pregnancy 209
Adaptation of Siblings and Grandparents 210
Basic Concepts of Inheritance 165 Maternal Adaptation During Absence of a Significant
The Human Genome Project 165 Other 210
Chromosomes, DNA, and Genes 165 Cultural Influences and Psychosocial Adaptations 210
Inheritance of Disease 167 Hazards of High-Tech Management on Maternal
Multifactorial Inheritance 167 Adaptation 211
Unifactorial Inheritance 167 Societal and Cultural Influences on Family Adaptation 211
Factors that Interfere with Psychosocial Adaptations During
Cellular Division 169 Pregnancy 211
The Process of Fertilization 170 Nursing Assessment of Psychosocial Changes and Prenatal
The Process of Implantation and Placental Development 171 Health Education 211
Development of the Embryo and Fetus 172
The Yolk Sac 172
chapter 9
Origin and Function of the Umbilical Cord 173
The Fetal Circulatory System 173 The Prenatal Assessment 215
Fetal Membranes and Amniotic Fluid 174
A Time of Wonder and Growth...and Ambivalence 216
Human Growth and Development 175
Pre-Embryonic Period 175 Concerns over Self-Preservation 216
Embryonic Period 175 Navigating the Health Care System 217
The Fetal Period 176 CAREing for the Patient 217
xxiv detailed table of contents
chapter 11
chapter 10
Caring for the Woman Experiencing
Promoting a Healthy Pregnancy 256
Complications During Pregnancy 291
Planning for Pregnancy 258
Preconception Counseling: A Tool to Help Promote a Positive Early Pregnancy Complications 292
Pregnancy Outcome 258 Perinatal Loss 292
The Healthy Body 259 Ectopic Pregnancy 293
The Healthy Mind 263 Gestational Trophoblastic Disease 294
Spontaneous Abortion 295
Nutrition and Weight Gain 264
Incompetent Cervix 296
Important Nutritional Elements 265
Hyperemesis Gravidarum 297
Weight Gain During Pregnancy 267
Planning Daily Food Intake 268 Hemorrhagic Disorders 297
Factors Affecting Nutrition During Pregnancy 270 Obstetric Causes of Vaginal Bleeding 298
Exercise, Work, and Rest During Pregnancy 271 Placenta Previa 298
Exercise and Travel 271 Placental Abruption 299
Work 272 Preterm Labor 300
Rest 273 Incidence 300
Medications 274 Etiology and Risk Factors 300
Safe versus Teratogenic Medications 274 Morbidity and Mortality 301
Diagnosis 301
FDA Classification System for Medications Used During
Pregnancy 275 Biochemical Markers 301
Management 301
Common Discomforts During Pregnancy 276
Nausea 276 Premature Rupture of the Membranes 303
Vomiting 276 Pathophysiology 303
Ptyalism 277 Diagnosis 303
Fatigue 277 Management 303
Nasal Congestion 277 Hypertensive Disorders of Pregnancy 304
Upper and Lower Backache 277 Classifications and Definitions 304
Leukorrhea 277 Preeclampsia 305
Urinary Frequency 277 Pathophysiology 305
Dyspepsia 277 Risk Factors for Preeclampsia/Eclampsia 306
Flatulence 278 Maternal and Fetal Morbidity and Mortality 306
detailed table of contents xxv
Distinguishing True Labor from False Labor 367 Pain Perception and Expression 401
Childbirth Settings and Labor Support 369 Factors that Affect Maternal Pain Response 402
Routine Hospital and Birth Center Admission Procedures 369 The Effects of Prepared Childbirth on Pain Pathways 403
Establishing a Positive Relationship 370 Benefits of Comfort and Support on Pain Perception 404
Collecting Admission Data 370 Providing Comfort and Pain Relief 404
Initial Admission Assessments 370 Nonpharmacological Pain Relief Measures 405
The Focused Assessment 370 Pharmacological Pain Relief Measures 410
The Psychosocial Assessment 371 Sedatives and Antiemetics 411
The Cultural Assessment 371 Differentiating Analgesia from Anesthesia 412
Laboratory Tests 371 Systemic Analgesia 413
Documentation of Admission 371 Nerve Block Analgesia and Anesthesia 415
General Anesthesia 421
First Stage of Labor 372
Latent Phase 372 Nursing Care for the Patient Receiving Interventions to Promote
Comfort During Labor and Birth 422
Active Phase 372
Nursing Assessment and Diagnoses 422
Transition Phase 372
Nursing Care During the First Stage of Labor 372
Labor Support 374
chapter 14
Presence 374
Promotion of Comfort 374 Caring for the Woman Experiencing
Anticipatory Guidance 376 Complications During Labor and Birth 427
Caring for the Birth Partner 376
Ensuring Culture-Centered Care 376 Dystocia 429
Dysfunctional Labor Patterns 429
Assessment of the Fetus During Labor and Birth 377
Hypertonic Labor 429
Fetal Position 377
Hypotonic Labor 430
Assessment of the Fetal Heart Rate 378
Precipitate Labor and Birth 431
Variability 381
Pelvic Structure Alterations 432
Accelerations 382
Trial of Labor 432
Decelerations 382
Interpretation of FHR Tracings 384 Obstetric Interventions 432
Nursing Interventions and Diagnoses 384 Amnioinfusion 432
Amniotomy 432
Second Stage of Labor 385
Promoting Effective Pushing 385 Pharmacological Induction of Labor 433
Achieving a Position of Comfort 386 Indications for Induction 433
Preparation for the Birth 386 Nursing Considerations 436
Episiotomy 386 Instrumentation Assistance of Birth 437
Birth 387 Maternal Conditions that Complicate Childbirth 439
The Cardinal Movements 387 Hypertensive Disorders 439
Clamping the Umbilical Cord 388 Diabetes 440
Preterm Labor and Birth 441
Possible Nursing Diagnoses for the Intrapartal Patient 389
Complications of Labor and Birth Associated with the Fetus 442
Third and Fourth Stages of Labor 389
Fetal Malpresentation 442
Third Stage of Labor 389
Version 443
Nursing Care of the Mother During the Third Stage of Labor 391
Shoulder Dystocia 444
Immediate Nursing Care of the Newborn 392 Cephalopelvic Disproportion 445
The Apgar Scoring System 392 Multiple Gestation 445
Identification of the Newborn 393 Non-reassuring FHR Patterns 446
Fourth Stage of Labor 393 Amniotic Fluid Complications 448
Nursing Care During the Fourth Stage of Labor 393 Oligohydramnios 448
Hydramnios 448
Meconium 448
chapter 13 Nuchal Cord 448
Promoting Patient Comfort During Labor and Complications Associated with the Placenta 448
Birth 399 Placenta Previa 448
Placental Abruption 450
The Physiology of Pain During Labor and Birth 400 Disseminated Intravascular Coagulation 451
Defining Pain 400 Rupture of the Uterus 451
Physical Causes of Pain Related to Labor and Birth 401 Uterine Inversion 453
detailed table of contents xxvii
Umbilical Cord Prolapse 453 Promoting Recovery and Self-care in the Puerperium 486
Variations Related to Umbilical Cord Insertion and the Activity and Rest 486
Placenta 455 Nourishment 486
Amniotic Fluid Embolism 456 Elimination 486
Collaboration in Perinatal Emergencies 456 Perineal Care 487
Perinatal Fetal Loss 457 Discomfort Related to Afterpains 487
Cultural Aspects of Loss 458 Special Considerations for Women with HIV/AIDS 487
Cesarean Birth 458 Care of the Postpartal Surgical Patient 488
Definition and Incidence 458 Permanent Sterilization (Tubal Ligation) 488
Indications 458 Care of the Patient After a Cesarean Birth 488
Ethical Considerations of Elective Cesarean Birth 458 Care of the Incisional Wound 488
Surgical Procedures 459 Recovery from Anesthesia 488
Nursing Care 459 Facilitating Infant Nourishment: Educating Parents to Make Informed
Surgical Care 460 Choices 489
Postoperative Care 460 Enhancing Understanding of the Process of Lactation 490
Vaginal Birth After Cesarean 460 Assisting the Mother who Chooses to Breastfeed: Strategies for
Nursing Implications 460 Breastfeeding Success 491
Research Findings and Implications 461 Evaluation of Nourishment: Infant Weight Gain 494
Positions for Breastfeeding 494
Postterm Pregnancy/Prolonged Pregnancy 461
Problems that Result in Ineffective Breastfeeding 495
Medical Management 462
Collecting and Storing Breast Milk 496
Nursing Implications 462
Infant Weaning 497
Assisting the Mother Who Chooses to Formula-Feed Her
Infant 497
Promoting Family and Infant Bonding 498
Facilitating the Transition to Parenthood 498
unit five Assuming the Mothering Role 498
Care of the New Family 467 Bonding and Attachment 499
Maternal 499
Paternal 500
chapter 15
Factors that May Interrupt the Bonding Process 500
Caring for the Postpartal Woman and Her Adjustment of Siblings to the Newborn 501
Family 469 Adjustment of Grandparents to the Newborn 501
Emotional and Physiological Adjustments During the Puerperium 502
Ensuring Safety for the Mother and Infant 470 Emotional Events 502
Early Maternal Assessment 471 Physiological Responses to Emotional Events 502
Vital Signs 471 Postpartal Discharge Planning and Teaching 503
Fundus, Lochia, Perineum 472 Promoting Maternal Self Care 503
Hemorrhoids 473 Components of Maternal Self-assessment 503
A Concise Postpartum Assessment Guide to Facilitate Nursing Planning for the Follow-up Examination 506
Care 473
Patients with Special Needs During the Puerperium 506
The BUBBLE-HE Mnemonic 473
Care of the Adolescent 506
Maternal Physiological Adaptations and Continued Assessment of The Woman Who is Placing Her Infant for Adoption 507
the Patient 481 The Older Woman 507
Hematological and Metabolic Systems 481
Community Resources for the New Family 507
Neurological System 483
Support Groups 507
Renal System, Fluid, and Electrolytes 483
Home Visits 507
Respiratory System 483
Telephone Follow-up 507
Integumentary System 483
Outpatient Clinics 507
Cardiovascular System 483
Immune System 484
Reproductive System 484 chapter 16
Gastrointestinal System 484 Caring for the Woman Experiencing
Musculoskeletal System 485
Complications During the Postpartal Period 511
Care for the Multicultural Family 485
Enhancing Cultural Sensitivity 485 Postpartum Hemorrhage 512
Cultural Influences on the Puerperium 485 Incidence and Definition 512
Clinical Implications of Culturally Appropriate Care 486 Early versus Late Hemorrhage 513
xxviii detailed table of contents
Nursing Care for the Child with a Cardiac Condition 879 chapter 30
Caring for the Child in the Pediatric Intensive Care
Unit 879 Caring for the Child with a Musculoskeletal
Transferring the Stable Child to a Surgical or Medical Condition 962
Unit 880
Caring for Children with Cardiac Conditions Across Care Immobilizing Devices 965
Settings 881 Casts 965
Principles of Traction 968
Skin Traction 968
Skeletal Traction 969
chapter 28
Common Musculoskeletal Conditions found in Children 972
Caring for the Child with an Endocrinological Clubfoot 972
or Metabolic Condition 885 Legg-Calve-Perthes Disease 973
Slipped Femoral Capital Epiphysis 974
Pathophysiological Conditions of the Endocrine System 887 Fractures 975
Conditions of the Anterior Pituitary 887 Soft Tissue Injuries 977
Conditions of the Posterior Pituitary 892
Sports Injuries 978
Conditions of the Thyroid 895
Osgood-Schlatter Disease 979
Conditions of the Parathyroid 897
Conditions of the Adrenals 899 Osteomyelitis 979
Juvenile Arthritis 980
Metabolic Conditions 906
Muscular Dystrophies 982
Diabetes Mellitus Type I 906
Scoliosis 983
Diabetes Mellitus Type 2 912
Kyphosis 986
Diabetic Ketoacidosis 914
Lordosis 986
Spinal Fusion 987
Tetanus 987
chapter 29 Osteogenesis Imperfecta 989
Caring for the Child with a Neurological Osteoporosis 991
or Sensory Condition 921
Altered States of Consciousness 922
The Unconscious Child 923 chapter 31
Persistent Vegetative State 925 Caring for the Child with an Integumentary
Increased Intracranial Pressure 926 Condition 995
Seizure Disorders 929
Inflammatory Neurological Conditions 933 Skin Lesions 997
Meningitis 933 Wounds and Wound Healing 998
Encephalitis 934 Skin Infections 998
Brain Abscess 936 Bacterial Infections 1002
Reye Syndrome 936 Viral Infections 1007
Guillain-Barré Syndrome 938 Fungal Infections 1009
Developmental Neurological Conditions 939 Dermatitis 1011
Spina Bifida 939 Contact Dermatitis 1011
Hydrocephalus 941 Atopic Dermatitis 1011
Cerebral Palsy 944 Seborrheic Dermatitis 1012
Neurological Injuries 945 Cutaneous Skin Reactions 1012
Near Drowning 945 Infestations 1013
Head Injury 946 Lice 1013
Shaken Baby Syndrome 947 Mite Infestation 1013
Spinal Cord Injury 947 Bites and Stings 1014
Nontraumatic Neurological Conditions 949 Insects 1014
Headaches 949 Animal Bites 1015
Sensory Conditions 950 Human Bites 1017
Eye Disorders 950 Diseases from Bites 1017
Eye Injuries 954 Lyme Disease 1017
Hearing Loss 955 Rocky Mountain Spotted Fever 1018
Language Disorders 957 Cat Scratch Disease 1018
detailed table of contents xxxiii
Collaboration in Caring
Complementary Care
A Child with Muscular Dystrophy 983
Anxiety and Depression 93
A Father’s Story 1146
Ayurveda to Enhance the Preconception Period 259
A Severe Allergic Reaction 1011
Behavioral Management and Biofeedback 1059
A Team Approach 889, 1025
Blogging as Therapy 38
Acupressure and Acupuncture as Modalities for Labor Pain
Relief 410 Cabbage Leaves to Diminish Breast Swelling 495
Caring for a Child with a Fracture 977 Chiropractic Care and Chronic Sinusitis 762
Caring for Children in the Community: Where They Live, Commonly Used Herbal Preparations 667
Play, and Go to School 710 Complementary and Alternative Medicine 1144
Child Care for New Families 599 Diarrhea 799
Child Life Specialist 1138 Distraction 1023
Clubfoot 973 Enuresis 1060
Collaboration between the Family and Others 826 Exercise and Bracing 985
Collaboration with Parents 894 Guided Imagery 707
Culturally Sensitive Community Approaches to Herbal Supplements and Infertility 159
Enhanced Health Care for Older Citizens 106 Managing the Symptoms of Menopause 100
Dealing with a Molar Pregnancy 295 Measures for Induction of Labor 436
Education about Food-Drug Interactions 529 Methods to Decrease Perineal Trauma 387
Encopresis 805 Mindful Breathing 721
Enhancing Family and Patient Coping 15 Muscular Dystrophy 983
Five Functions of the Family 49 Nausea and Vomiting of Pregnancy 297
Helping Impoverished Families 18 Nonpharmacological Adjuncts to Pain Management 826
Impaired Fecundity 171 Nonpharmacological Pain Interventions 1079
Increasing Public Awareness of the Problems of Preemie Massage 632
Prematurity 300
Promoting Stress Management during Pregnancy 264
Nurses Caring for Children with Heart Arrhythmias
Red Raspberry and Blue Cohosh 222
871
Tea Tree Oil to Facilitate Episiotomy Healing 479
Partnering with an IBCLC and Other Community
Resources 491 The Benefits of Massage 925
Peanut Allergies in School 830 Therapeutic Touch 889
Preparing the Family for Community-Based Care 9 Therapeutic Touch Enhances Comfort 597
Promoting Optimal Care for the Family 21 Therapies for Postpartum Depression 532
special features xxxix
Define the essential characteristics of caring? 15 Discuss aspects of the genitourinary and immunological
Describe changes in the eyes, nose, and throat and respi- systems? 557
ratory, gastrointestinal, and urinary systems? 203 Discuss aspects of the initial prenatal health assessment?
Describe conditions of the anterior and posterior pituitary? 236
895 Discuss aspects of the male reproductive system? 134
Describe congenital respiratory conditions and structural Discuss aspects of various maternal conditions that
anomalies? 761 complicate childbirth? 442
Describe early postpartal physiological adaptations in the Discuss bacterial, viral, fungal skin infections? 1008
metabolic, neurologic and renal systems? 483 Discuss birth options for a woman with a multiple
Describe major changes that occur in the reproductive gestation? 446
system during pregnancy? 196 Discuss breast milk storage and assist the mother who is
Describe nursing actions that can serve to improve the bottle feeding her infant? 498
current status of children’s health in the Discuss cancer in children? 1106
United States? 32
Discuss cardiac complications during pregnancy? 333
Describe postpartal physiological adaptations in the
Discuss cardinal movements and umbilical cord
respiratory, cardiovascular, and reproductive systems?
clamping? 389
485
Discuss cardiopulmonary transitions in the neonate? 547
Describe structural defects of the urinary system? 1058
Discuss care for the patient on antenatal bed rest? 344
Describe the assessment related to the infant’s head? 581
Discuss care of the pregnant patient with a multiple
Describe the effects of hospitalization on a child? 705
gestation? 315
Describe the role of the nurse as a teacher, collaborator,
Discuss changes in the breasts and uterus during the
and provider? 13
postpartum period? 476
Describe the role of the nurse in antibiotic-resistant
Discuss changes in the cardiovascular system? 201
organisms? 849
Discuss changes in the integumentary and neurological
Describe why critical thinking is key to the successful
systems? 198
clinical practice of nursing? 16
Discuss characteristics of growth in the embryo/fetus?
Differentiate between depression and bipolar disorder?
173
725
Discuss characteristics of pain during labor and birth? 403
Discharge the new family? 600
Discuss characteristics of systemic analgesia used during
Discuss a pain control theory, pain perception, and
labor? 415
considerations for the childbirth setting? 405
Discuss characteristics of the uterine cycle? 131
Discuss abuse during pregnancy? 347
Discuss childbirth preparation, birth plans, and doulas?
Discuss anatomy of the female breast? 124
287
Discuss aspects of an ethical framework for nursing
Discuss childbirth settings and support persons? 369
practice? 41
Discuss comfort measures and pushing techniques for
Discuss aspects of care for the pregnant woman older
the second stage of labor? 386
than age 35? 251
Discuss common discomforts of pregnancy? 279
Discuss aspects of circumcision? 597
Discuss common disorders of the urinary system? 1048
Discuss aspects of cultural practices for healing and
comfort, transpersonal care, and components of the Discuss common paternal reactions and educational
family unit? 7 needs during pregnancy? 264
Discuss aspects of development of the reproductive Discuss complications related to alcohol consumption
system and identify components of the female during pregnancy? 261
reproductive tract? 116 Discuss components of the neonatal respiratory system
Discuss aspects of good nutrition during pregnancy? 267 assessment? 582
Discuss aspects of health promotion and nursing Discuss components of the neonate’s initial adaptation?
aesthetics? 6 569
Discuss aspects of patterns of inheritance? 169 Discuss concepts related to puberty? 128
Discuss aspects of political and socioeconomic influences Discuss contemporary family changes and stressors? 50
that impact the nation’s health? 35 Discuss current trends in clinical nursing practice? 41
Discuss aspects of prenatal care? 217 Discuss deep vein thrombosis? 530
Discuss aspects of the amniotic sac and amniotic fluid? Discuss determination of fetal position during labor? 378
175 Discuss diabetes management during pregnancy? 335
Discuss aspects of the female bony pelvis? 123 Discuss diabetes mellitus? 917
xliv special features
Discuss elements of contemporary nursing and health Discuss major events of the fetal period? 178
care for families and children? 5 Discuss maternal age-related chromosomal problems and
Discuss elements of pulmonary function in the neonate? the origins of twinning? 186
544 Discuss methods of antepartum fetal surveillance? 343
Discuss elements of the current health status of American Discuss neonatal jaundice? 555
families and women? 34
Discuss neonatal skin conditions? 577
Discuss epidural and intrathecal anesthesia? 421
Discuss nonpharmacological methods of pain relief
Discuss essential aspects of the current pregnancy? 228 during labor? 410
Discuss essential components of postpartum nursing Discuss nursing care for musculoskeletal conditions? 971
care? 481
Discuss osteomyelitis? 980
Discuss essential nursing actions associated with
Discuss passenger characteristics important during
newborn safety and skin color assessment? 571
labor? 363
Discuss essential nursing actions during the third stage
Discuss personal and cultural trends that may impact an
of labor? 393
individual’s health status? 38
Discuss evidence-based practice and contrast the focus of
Discuss postpartum blues, depression and psychosis? 534
the advanced practice nurse with that of the profes-
sional registered nurse? 19 Discuss postpartum hemorrhage? 518
Discuss factors associated with impending childbirth? Discuss postpartum vital signs and perineal assessment?
387 473
Discuss factors that impede the progress of labor? 432 Discuss preconception care? 259
Discuss family theory for nursing practice? 55 Discuss pregnancy-related role transitions for the
adolescent, father, siblings and grandparents? 210
Discuss functional disorders of the urinary tract? 1061
Discuss psychosocial adaptation in the newborn? 560
Discuss functional gastrointestinal conditions? 805
Discuss reproductive disorders in girls and boys? 1066
Discuss gastrointestinal functioning in the newborn? 555
Discuss respiratory complications during pregnancy? 330
Discuss health inequities and limited access to health
care? 30 Discuss RhD and ABO isoimmunization? 328
Discuss health promotion strategies for pregnancy? 220 Discuss seizures and related nursing care? 933
Discuss HELLP syndrome? 313 Discuss SGA and LGA? 614
Discuss how the prenatal patient’s medical history guides Discuss sleep disorders? 740
care? 231 Discuss strategies in caring for vulnerable populations?
Discuss human immunodeficiency virus (HIV)? 827 537
Discuss hypertensive complications of pregnancy? 313 Discuss strategies to ensure infant and toddler safety? 79
Discuss implications of a postpartum hematoma? 519 Discuss strategies to ensure maternal-infant safety? 471
Discuss implications of general anesthesia used during Discuss substances that may adversely affect embryo/fetal
childbirth? 422 growth and development? 181
Discuss important aspects for the care of the child in the Discuss substances to be avoided during pregnancy? 263
hospital or clinic setting? 694 Discuss tetanus? 989
Discuss infant and child nutrition? 76 Discuss the breech and shoulder presentations? 364
Discuss infections that occur during the puerperium? 527 Discuss the care of the patient experiencing an early
Discuss informed consent and the use of sedatives and pregnancy loss? 297
antiemetics during labor? 412 Discuss the care of the patient with premature rupture
Discuss issues associated with substance abuse during of the membranes? 303
pregnancy? 340 Discuss the community health map, aspects of
Discuss issues concerning perinatal death? 458 complementary and alternative health healing,
and evidence-based practice? 13
Discuss issues related to the care of minority and
undocumented immigrant women? 537 Discuss the dying child? 1151
Discuss issues surrounding the use of forceps? 438 Discuss the effects of high technology and other influences
on psychosocial adaptation during pregnancy? 212
Discuss key hormones involved in reproduction? 126
Discuss the fourth stage of labor? 394
Discuss labor induction? 437
Discuss the health history for the child? 672
Discuss leukemia? 1109
Discuss the importance of a health assessment for a
Discuss local infiltration, pudendal nerve block, and spinal
child? 681
block anesthesia? 419
Discuss the management of bleeding during pregnancy?
Discuss major changes in the endocrine and musculo-
300
skeletal systems during pregnancy? 205
special features xlv
Discuss the nurse’s role in reproductive health care? 140 Identify gastrointestinal problems in the neonate? 584
Discuss the passageway and passenger? 366 Identify genitourinary conditions in the neonate? 586
Discuss the pelvic examination process? 91 Identify obstructive gastrointestinal disorders? 792
Discuss the physiology of lactation and assist the Identify the types of insect bites? 1015
breastfeeding mother? 495 Identify true labor? 368
Discuss the pre-embryonic and embryonic periods of Identify vulnerable populations of women, children, and
development? 176 families that exist in the United States today? 37
Discuss the psychosocial influences of labor? 366 Obtain neonatal measurements and determine gestational
Discuss the public health intervention model? 28 age? 574
Discuss the significance of a UTI in the pregnant patient? Plan a daily menu for a woman who is pregnant? 269
316 Promote recovery and self-care in the puerperium? 488
Discuss the “tasks of pregnancy”? 209 Promote self-care for the puerperium? 506
Discuss the use of herbal preparations and prescription Provide comforting nursing care during labor? 376
medications in pregnancy? 276
Provide culturally sensitive postpartal care? 486
Discuss the vaginal examination, clinical pelvimetry, and
Provide developmentally appropriate play activities for
assessments routinely made during each prenatal visit?
school-age children? 80
243
Provide nursing care for the surgical postpartal patient?
Discuss thermoregulation in the newborn? 550
489
Discuss three professional nursing roles that rely heavily
Provide nursing care to children with iron-deficiency
on therapeutic communication? 17
anemia and epistaxis (nosebleeds)? 1077
Discuss thromboembolism during pregnancy? 338
Provide safety education to adolescents? 86
Discuss TORCH infections? 182
Provide sensitive, appropriate care for the infertile
Discuss unique aspects of the fetal circulatory system? couple? 160
174
Recognize and intervene in anaphylaxis? 831
Discuss various aspects of adolescent pregnancy? 249
Recognize cultural differences that may impact the nursing
Discuss various aspects of the female reproductive assessment and interventions with the family? 67
system? 121
Recognize the changes created by family-centered care
Discuss various components of the prenatal assessment? for professional nursing in acute care settings? 10
225
Relate the value of having national Healthy People 2010
Discuss various factors associated with the process of goals to align health care improvement efforts? 29
labor? 361
Safely give immunizations? 846
Discuss various methods of clinical fetal assessment? 240
Teach about contraception? 153
Discuss VBAC? 461
Understand the heart? 857
Discuss ways to enhance breast health? 98
Discuss why analysis of statistical health data in the
United States is useful? 29 Nursing Care Plans
Discuss work and fatigue during pregnancy? 274
A Child Who has Undergone Abdominal Surgery 792
Distinguish between Crohn’s disease and ulcerative
colitis? 795 Acute Pain/Discomfort in the Postpartal Patient 482
Enhance communication? 765 Child with Acute Lymphocytic Leukemia 1109
Evaluate uterine contractions? 358 Depressed Child 724
Facilitate family bonding with the newborn? 501 Gestational Diabetes Mellitus 336
Follow the evolution of today’s nursing professional Imbalanced Nutrition 671
roles? 8 Maintaining Newborn Thermoregulation 567
Identify and plan care for special problems and issues Normal Newborn Transition 559
faced by the American family? 66 Patient Who Plans to Use Nonpharmacological Methods
Identify cardiac problems in the neonate? 583 of Pain Relief During Labor 411
Identify certain population trends that relate to health? Persistent Pulmonary Hypertension of the High-risk
31 Newborn 623
Identify characteristics of the first and second stages of The Child with a Cardiac Condition 880
labor? 372 The Child with a Musculoskeletal Disorder 984
Identify danger signs during pregnancy? 281 The Child with a Urinary Tract Infection 1041
Identify essential laboratory tests during preconception The Child with Aplastic Anemia 1090
planning? 260
xlvi special features
The Child with Cystic Fibrosis 760 The Unconscious Child 926
The Child with Eczema 998 Upper Respiratory Disorders 766
The Child with Immunosuppression 823
The Child with Meningitis 935
Nursing Insights
The Child with Type 1 Diabetes 912
The Grieving Family 1148 A Holistic Approach to Care 41
The Hospitalized Child 708 A Language Quick Reference Tool 957
The Patient with Abruptio Placentae 452 A Way to Remember Cyanotic Defects 865
The Woman Experiencing Postpartum Depression 533 Absolute Neutrophil Count (ANC) 1090
Young Primigravida in Labor 377 Acceptance 1149
Accurately Diagnosing Idiopathic (Immune)
Thrombocytopenia Purpura 1085
Nursing Diagnoses Action of Diuretics on the Kidney 893
A Child with Clubfoot 973 Acute Epiglottitis or Supraglottitis; A Medical Emergency
765
A Child with Juvenile Arthritis 981
Additional Treatment Modalities 1114
A Child with Legg-Calve-Perthes Disease 974
Adolescents and Pregnancy Outcomes with Multiple
A Child with Muscular Dystrophy 983 Gestations 249
Acute Renal Failure 1051 Age-Related Differences in Primary Location of the
Bleeding Disorders 1083 Tumor 1110
Bronchopulmonary Dysplasia 758 Alpha-fetoprotein (AFP) 1117
Cellulitis 1007 Alternating Current 1020
Children with Cancer 1123 Amputation 1115
Congenital Adrenal Hyperplasia 904 An Adrenal Crisis is a Life-threatening Condition 899
Congenital Heart Defects 865 An Insufficient Valve 861
Contact Dermatitis 1011 Anger 1148, 1149
Cystic Fibrosis 760 Anticipating Changes in Insulin Needs During Pregnancy
Esophageal Atresia with or without Tracheoesophageal 334
Fistula 753 Anti-infective Medications Contraindicated During
Failure to Thrive 731 Pregnancy 315
Frostbite 1027 Apnea verses Periodic Breathing 616
Guillian-Barré Syndrome 939 Appendicitis Physical Examination 796
Hemodialysis 1057 Applying Duvall’s Theory 651
Hypertrophic Pyloric Stenosis 790 Assessing Cultural Influences of the Laboring Patient 366
Language Disorders 957 Assessing for Hyperreflexia of Muscles 898
Lice and Mite Infestation 1014 Assessing the Child for Suicide Risk 726
Lower Respiratory Disorders 771 Assigning a Numeric Value for Level of Response 923
Oppositional Defiant Disorder and Conduct Disorder 734 Autism Spectrum Disorders 729
Peritoneal Dialysis 1057 Bargaining 1149
Sickle Cell Disease 1080 Benefits of a Medical Home 703
Spinal Cord Injury 949 Bipolar Disorder 724
The Child Undergoing Procedures or Surgery 687 Bone Marrow Transplant 1108
The Child with an Infectious Disease 844 Breech Presentation and Meconium in the Amniotic
The Child with Crohn’s Disease 795 Fluid 442
The Child with Gastroesophageal Reflux GER and GERD Broad-Spectrum Antibiotics 1039
807 Bronchopulmonary Dysplasia 618
The Child with Type 1 Diabetes 911 Burnout, Compassion Fatigue Syndrome, and Moral
The Developing Child 696 Distress 1153
The Dying Child 1147 Candidal Organisms in the Diaper Area 843
The Infant with a Diabetic Mother 611 Cardiac Tumors 868
The SGA Newborn 610 Care of the Child with Congenital Heart Defects 860
special features xlvii
Recognizing Medical Indications for Elective Preterm SPASMS: A Memory Enhancer When Caring for a Patient
Birth in Women with Diabetes 440 with Preeclampsia 306
Recognizing Negative Maternal Effects of Hypotonic Specific Methods for Gene Identification and Testing 183
Labor 431 Splenectomy 1086
Recognizing Normal Neonatal Lung Sounds During Early Staging 1107
Auscultation 544
Subacute Bacterial Endocarditis Prophylaxis (SBE) 861
Recognizing Potential Problems Associated with Mature
Substance Use and Abuse 737
Mothers 344
Subtle Indicators of Grief 1150
Recognizing Signs and Symptoms Indicative of DVT 528
Superficial Wound Management 998
Recognizing Sleep States in the Neonate 558
Systemic Fungal Infection 844
Recognizing the Anxiety–Tissue Anoxia–Pain Connection
412 Taking Care of Children with Cancer 1123
Recognizing the Childbearing Family’s Boundary Teaching about Vitamin B12 Deficiency 271
Permeability 51 Teaching Childbearing Aged Women about Accutane
Recognizing the Relationship between Family Stressors 275
and Poor Health Outcomes 50 Teaching Parents 1097
Recognizing the Unique Characteristics of Childbirth Temperature 607
Pain 401 Tetracycline (Sumycin) 1003
Recognizing the Value of Natural Pressure Anesthesia The Brown Recluse and Black Widow Spiders’ Bite 1015
416
The Definition of Pain 692
Recognizing Variations in the Onset of Eclampsia 304
The Role of the Nurse with Immunizations 845
Recommendation from the National Kidney Foundation
1053 The Stages of Reye Syndrome 937
Reconciliation 1150 Therapeutic Play 705
Regression 1137 Three Classes of Cardiomyopathy 867
Relief Measures for Dyspepsia 277 Three Classic Syndromes 1045
Remorse 1150 Topical Anesthetics 1123
Renal Failure 1050 Toward Meeting the Healthy People 2010 National
Goals 155
Renal Scarring 1038
Uncircumcised Males 680
Renal Tubular Function 1051
Understanding Abnormalities in Sex Chromosomes 167
Respiratory Distress Syndrome 615
Understanding Acromegaly/Gigantism 891
Retractions 677
Understanding Amnioinfusion as an Intervention for
Rhabdomyosarcoma Subtypes 1113 Meconium-Stained Amniotic Fluid 432
Rheumatic Fever 868 Understanding Blood Type 1092
Rhythm Disturbances and the Effect on Cardiac Understanding Classifications for Newborn Weight 573
Output 871
Understanding Hemodynamic Changes in Pregnancy 332
Risk Factors 955
Understanding Mental Health Disparities in Children 719
School Nurses are the Link between Health and
Education 712 Understanding Newborn Classification 605
Screening for Intimate Partner Violence 223 Understanding Reactive Attachment Disorder 730
Screening Techniques for Children 676 Understanding the Origin of Embryonic Stem Cells 171
Shaken Baby Syndrome 947 Understanding Types of Uterine Rupture 451
Shiver Response After Epidural Block Administration Urinary Tract Infections 1038, 1039
420 Use of a Visual Analog Scale for the Assessment of
Short Bowel Syndrome 811 Pain 407
Signs and Symptoms of Anaphylaxis 830 Using a Standardized Assessment for Blood Loss After
Childbirth 513
Signs and Symptoms of Aplastic Anemia 1088
Using Naloxone (Narcan) in a Newborn with Neonatal
Signs and Symptoms of Cushing’s Syndrome 902 Abstinence Syndrome 629
Sinus Arrhythmias 871 Vaccine 844
SLE Resources 829 Vaginal Candidiasis and Diabetes Mellitus 1061
Somatic Grief Response 1147 Vaginal Foreign Bodies 1062
Spacers 781
l special features
Variations of Esophageal Atresia with or without Early Prenatal Care Facilitates Prenatal Diagnosis for the
Tracheoesophageal Fistula 753 Expectant Couple Older than Age 35 250
Ventricular Shunts 941 Early Vision Screening 952
Viral or Aseptic Meningitis 933 Educating Patients about Risk Factors for Puerperal
Vision 950 Infection 520
Voiding Disorders 1058 Endorsing Preconception Care 258
When Counseling Patients about the Cervical Cap 145 Enhancing Comfort and Healing with a Sitz Bath 479
When Teaching about Iron Supplements 266 Enhancing Maternal Anesthesia Knowledge and
Choice 459
Wiskott-Aldrich Syndrome 822
Ensuring Safety for the Newborn 593
Youth Violence: Fact Sheet 733
Expanding Nursing Roles in Genetics Health Care 182
Exploring Concerns of the Woman Experiencing
Optimizing Outcomes Preterm Labor 442
Eye Prophylaxis to Prevent Ophthalmia Neonatorum 567
Abnormal Findings in a Postpartal Patient 477
Family Compliance 1007
Accurately Determining Fetal Age with
Fetal Activity and Well-Being 281
Ultrasonography 341
Financial Resources 890
Actions to Reduce the Risk of Umbilical Cord
Prolapse 453 Follow-up for Women Who Experience Habitual
Abortions 296
Amnioinfusion to Relieve Cord Compression 383
Formulating a Nursing Diagnosis for the Pregnant
Applying Developmental Theory when Caring for the
Adolescent Patient 248
Childbearing Family 52
Formulating Nursing Diagnoses for Women and Couples
Applying the Structural Functional Theory 53
Seeking Genetic Screening and Assessment 186
Assessing for Milk Let-down 493
Grading Reflexes and Checking for Clonus 311
Assessment of Pain During Labor 404
Hearing Screening 676
Assisting with ECV 443
Helping to Achieve Healthy People 2010 National
Being an Advocate for the Patient 218 Goals 400
Breast Shells for Flat, Inverted, or Sore Nipples 495 Helping to Meet Healthy People 2010 National Goals 428
Breastfeeding and Afterpains 476 Holistic Care during Management of a PPH 517
Care of the Breasts during Lactation 492 Hormone Treatment 902
Caring for the Pregnant Woman with Cardiac Disease 331 Identifying Patient Expected Learning Outcomes 17
Celiac Disease 810 Immunizations during Pregnancy 323
Children with Infectious Diseases 841 Including the Father of the Baby 184
Children with VUR and UTI 1042 Intracranial Pressure Monitoring 929
Communicating about FHR Patterns 384 Intrapartal Neonatal Suctioning and Meconium-Stained
Considerations When Caring for the Obstetric Trauma Amniotic Fluid 448
Patient 345 Neutropenic Patient Admitted to a Pediatric Unit 1126
Constipation 804 Newborn Immunization to Prevent Hepatitis B 568
Counseling about Medications that Decrease the Newborn Metabolic Screening 599
Effectiveness of Oral Contraceptives 147
Nutrition 759
Counseling Women with Cystic Fibrosis 330
Obtaining an Accurate Assessment of the Infant’s True
Decreasing the Incidence of STIs in Women and Skin Color 571
Children 322
Overall Goals of Burn Treatment 1022
Demonstrating Professionalism During the Physical
Oximeter 615
Examination 233
Placing the Infant Under the Radiant Heater 566
Diet and Exercise for the Patient with GDM 335
Postnatal Exercises to Promote Physical Fitness 504
Discharge Instructions After Autologous Epidural Blood
Patch 419 Prenatal Genetic Testing 261
During Assessment of Family Communication Patterns 59 Prenatal Screening and Questions Regarding Drug Use 180
During the Second Stage of Labor After Administration Preparing the Patient for an Amniotomy 433
of an Epidural Block 420 Preventing Cold Stress in the Newborn 548
Early Episiotomy Care 479 Preventing Hemolysis 610
special features li
Preventing Neural Tube Defects 176 With Nursing Interventions for Families 60
Promoting a Healthy Beginning for the Fetus 228 When Administering Intravenous Medications During
Promoting Breast Comfort during Pregnancy 236 Labor 413
Promoting Dental Health during Pregnancy 229 When Birth is Complicated By Shoulder Dystocia 444
Promoting Initial Bonding in the Breastfeeding Mother When Caring for the Patient with a UTI 315
558 When Early Postpartum Discharge is Planned 503
Promoting Prenatal Paternal Attachment 209 When Epidural and Intrathecal Opioids are Administered
Prompt Identification of Clinical Signs that may Indicate 421
DIC 451 When Teaching about NFP and FAMs of Contraception
Providing Couplet Care as an Alternative to Rooming-In 143
500 When Teaching Patients about Injectable Hormonal
Providing Pain Relief during Preterm Labor and Contraception 150
Birth 442 When Teaching Patients about Permanent Sterilization 153
Providing Support During a Trial of Labor 432 When Teaching Patients about Postcoital Emergency
Recognizing Cultural Influences on the Experience of Contraception 150
Pain 401 When Teaching Patients about the Contraceptive
Recognizing Hyperventilation 407 Implant 151
Recognizing Reassuring and Non-Reassuring FHR When Teaching Patients about the IUD 152
Patterns 379 When Teaching Patients about the Use of Spermicides 146
Relief of Backache during Pregnancy 277 When Teaching Patients about Use of Oral Contraceptive
Religious Beliefs and Blood Transfusions 300 Pills 148
Resources for Optimal Nutritional Counseling 264 When Teaching Patients about Use of the Cervical Cap
145
Responding to a Non-reassuring FHR Pattern 446
When Teaching Patients about Use of the Contraceptive
Rhythm Disturbances 871
Sponge 147
Safe Administration of Rho(D) Immune Globulin
When Teaching Patients about Use of the Diaphragm 144
(RhoGAM) 328
When Teaching Patients about Use of the Female
Safely Preparing Infant Formula 498
Condom 146
Safety Measures for Women Who Receive Opioid When Teaching Patients about Use of the Male
Analgesics 414
Condom 146
Screening for Breast Cancer 98 When Teaching Patients about Use of the Transdermal
Standards for the Interpretation of FHR Patterns 380 Contraceptive Patch 149
Supporting Women in Their Infant Feeding Choice 490 When Teaching Patients about Use of the Vaginal
Teaching about Fibrocystic Breast Changes 96 Contraceptive Ring 149
Teaching about Perineal Care 487 When Using Heat and Cold for Pain Relief during
Teaching Parents about Umbilical Cord Care 594 Labor 409
Teaching Patients about Aspirin and Anticoagulants 529 With a CenteringPregnancy Program 248
Teaching Patients to Avoid Bone Meal Supplements 266 With Manual (Hand) and Electric Expression of Breast
Milk 496
Tests to Help Identify a Postpartum Infection 520
With Nursing Interventions for Families 60
The Sibling 1138
With the IUD as a Contraceptive Choice 152
Through the Safe Administration of Oxytocin 435
Type and Screen and Type and Crossmatch 1092
Understanding Growth and Development 643 Procedures
Understanding Resilience in the Face of Vulnerability
Assessing for Amniotic Fluid 368
719
Assisting with the Administration of Spinal Anesthesia
Use of the Ballard Gestational Age by Maturity Rating
418
Tool 573
Auscultating the Fetal Heart Tones during Labor 380
Using Time Intervals and Weight to Improve Accuracy of
the Estimate of Perineal Pad Saturation 515 Checking Urine Specific Gravity 1127
Uterine Assessment Crucial during the First Hour Collecting a Urine Specimen 1044
Postpartum 472 Collecting Stool for Culture and Sensitivity and Ova and
Vitamin C and Premature Rupture of the Membranes 234 Parasites 801
Waking the Child during the Night for Vital Signs 881 Inserting an Oro- or Nasogastric Tube 690
lii special features
Foundations in
Maternal, Family,
and Child Care
chapter
Traditional and Community
Nursing Care for Women, 1
Families, and Children
As a Family-Centered Nurse
Learn of the essence of family-centered nursing,
while you walk with a worried family
until you wear side-by-side paths in the carpet;
Suffer the emotions of a troubled family
When they soar in their hope for healing and recovery;
Stay through the darkest hour of a mother, father, sister or brother,
as they silently cry for a member’s pain;
Experience the failure, disappointment and challenges
presented with each health care encounter;
Never cease to be amazed at the resilience
of a family’s strength, spirit and protective value.
—S. Caves
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Explore the impacts of ethnocentrism, ethnopluralism, paternalism, the medical model, and
consumerism on nursing.
◆ Compare the roles of nurses, families, and patients in various health care settings.
◆ Discuss theories of caring and holism as they apply to the nursing care of women, families,
and children.
◆ Clarify nursing responsibilities using NANDA, NIC, and NOC taxonomy related to diagnosis,
management, and outcome evaluation of family-centered medical and nursing problems.
◆ Summarize the importance of cultural competency in fulfilling the role of nurse teacher.
◆ Evaluate the nurse’s role in promoting self-healing.
◆ Discuss how responsibility and professional accountability are enhanced by evidence-based knowledge.
◆ Contrast the focus of the advanced practice nurse with that of the professional registered nurse.
moving toward evidence-based practice Concept Maps and Learning Style Preference
Kostovich, C.T., Poradzisz, M., Wood, K., & O’Brien, K.L. (2007). Learning style preference and student aptitude for concept maps.
Journal of Nursing Education, 46(5), 225–231.
The purpose of this study was to describe the relationship junior year. The students completed the Kolb’s Learning Style
between nursing students’ learning style preference and apti- Survey (LSS) and a Concept May Survey, instruments developed
tude for concept mapping. A correlational, descriptive study by the researchers. The LSS consists of several phases and is
conducted at a private Midwestern university included 120 stu- designed to determine preference for learning experiences, i.e.,
dents enrolled in an adult medical–nursing course taken in the concrete, active experimentation, abstract conceptualization,
continued
3
4 unit one Foundations in Maternal, Family, and Child Care
Introduction may offer one of the most fulfilling roles for the nurse, and
one of the first experiences of empowered caring for the
Most nurses and students have personal understandings of patient. This return to the development of a therapeutic
what it means to be a nurse caring for women, families, nurse–patient relationship through communication and
and children—the field of family and child nursing. They the artistry of nursing provides the nurse the opportunity
may have even developed a broad range of strategies, to experience the ultimate caring component of nursing
knowledge, values, and competencies to use when caring for which the profession is known.
for women, families, and children. Nurses conversely may This chapter begins with an historical overview of nurs-
approach family and child nursing no differently than they ing, family and child health care, and the influences that
would if providing care for any other patient. Realizing have shaped and driven some of the changes toward a
how the nurse, the patient, other health care providers, more contemporary approach to family and child nursing.
and outside forces of influence have framed family and It discusses the many professional roles of the family and
child nursing through the last century provides the nurse child nurse, how they have changed over time, and where
with insights into the level and outcome of care historically the future will take them, irrespective of the type of care
and currently received and given to families and children. setting. The focus of the chapter is on the art of caring and
There is a fairly consistent view of how family and its centrality to the family and child nurse experience.
child patients are defined, from one of three family and
children perspectives: as an individual affected by some
health event; the family unit involved in that event; and Traditional Nursing Care
the whole of supporting mind-body-spirit, culture, and
community affected by the experience (Harmon Hanson, Taking a look at the traditional role of nursing in the care
Gedaly-Duff, & Kaakinen, 2005). Nurses as well as fami- of families and children helps identify the significance of
lies are being challenged by ever-increasing numbers of both positive and unfavorable changes that have occurred
health care and societal changes to adapt and expand during the past century and framed current standards
these perspectives on family and child health. of care.
The traditional hospital that served as the center of care
for families and children has been replaced by a myriad of HISTORICAL PERSPECTIVE
community-based settings. With this change in setting, Physicians, the general public, and the nursing profession
often the thrust of power has shifted from the traditional historically viewed health as the absence of disease and the
nursing and medical models to one of family-centered presence of optimal functioning. Illness was seen as patho-
decision making. logical and something of which the health care provider
Becoming a part of this care experience, engaging in worked to rid, heal, or cure the patient. This curative
the patient’s lived experience throughout its entirety approach commonly was referred to as the medical model.
instead of functioning as a part of the process by doing It often entailed a paternalistic, one-way channel of com-
“for” the patient, is one of the emerging roles for the munication between the powerfully dominant and more
family and child nurse. Using this engaging transpersonal knowledgeable health care provider and the submissive
approach to understanding the experience of the patient’s and uneducated patient or family. The power base for all
entire mind-body-and-soul during times of health threats decisions rested with the medical or, infrequently, the
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 5
nurse provider who together often took an objective, In a culture changing as rapidly as is that of the United
detached biomedical approach (Gordon & Nelson, 2005). States today, ethnocentrism can critically compromise
Over the previous quarter century, a number of influ- effective health care. One of the predominant problems
ences have affected how family and child health and nurs- with a health care system founded on ethnocentrism,
ing care are now defined in the 21st century (Fig. 1-1). The paternalism, and the medical model is the system’s closed-
infusion of multiple cultures and beliefs about health care mindedness and prejudice toward other solutions and
systems, along with exponential growth in scientific and viewpoints of health. It is this viewpoint that often alien-
technological capabilities, have been major forces in shap- ates people in need of health care and deters them from
ing the structure and delivery of nursing care. In addition, seeking or accepting help.
increased consumer access to health-related information
via the Internet, mass media, and other sources that may HEALTH–WELLNESS CONTINUUM
or may not be accurate, the unprecedented rise in health For decades, the goal of nursing has been to move the
care costs, and increasing imposition of cumbersome regu- patient toward well-being and away from disease and
lations have also contributed to change. pathology. The aim of the nurse–patient relationship was
to facilitate the attainment of that goal. The relationship
Now Can You— Discuss elements of contemporary nursing process had a beginning (illness), middle (treatment), and
and health care for families and children? end (wellness). This prominent emphasis on treating
1. Identify a major force that accounts for the present-day shift illness defined the scope of the nurse’s practice, or the
toward family-centered decision making in health matters? nursing process: assess for signs of illness, diagnose
2. Describe a nursing approach that fosters empowered caring alterations in health, determine interventions to restore
for the patient? health, conceptualize a targeted health outcome moving
3. Name four factors that have shaped contemporary family away from illness, and evaluate the treatment plan for
and child health and nursing care? nurse-determined modifications (Fig. 1-2).
In nursing there has recently been a shift in this health–
wellness continuum and process. The emphasis is chang-
The growth of ethnopluralism (diverse cultures) daily ing from a linear beginning-to-end, illness-to-wellness
impacts health care systems and providers. Often each cul- process. No longer is the predominant nursing perspective
ture comes with its own beliefs, values, and practices about to return the patient from illness (beginning) to a prior
health and illness. The United States Department of Com- disease-free state (end) but toward a shared experience of
merce, Bureau of the Census, projects that within the next transcending or controlling the health threat and changing
10 to 12 years, only one-half of the U.S. population will be of it into one of purposeful meaning (LeVasseur, 2002). The
Euro-Caucasian descent, although the medical model formed nurse–patient relationship now is a circular or spiral pro-
and that continues to be supported is based on this group cess formed to motivate the patient or family toward pro-
(U.S. Census Bureau, 2008). The population of other ethnici- motion, maintenance, and restoration of health; health
ties and cultures will double and triple in that time, rapidly potential; prevention of illness; and self-care (Fig. 1-3).
making up the other half of the U.S. population and bringing
to the forefront their beliefs, values, and health practices.
During the past century the values, beliefs, and prac- Ethnocultural Considerations— Perceptions
tices of the predominantly Euro-Caucasian male health of desired health and health outcomes
care provider system drove health care decisions, interac- Based on personal beliefs, values, and practices, an ever-
tions, and treatments based on the belief that these were increasing culturally diverse population has many differing
unquestioningly in everyone’s best interest and by far definitions of health and the outcomes desired during health-
superior to all others: a belief referred to as ethnocentrism seeking encounters.
(Leininger & McFarland, 2002).
Figure 1-1 Evolution of family and child health Figure 1-2 Traditional nursing process.
nursing model.
6 unit one Foundations in Maternal, Family, and Child Care
Nurse Patient Now Can You— Discuss aspects of health promotion and
nursing aesthetics?
Self-care
1. Describe present-day trends in nursing focus related to the
health–wellness continuum?
Promotion Prevention
2. Identify the elements of a health promotion nursing
process?
Health
3. Define “nursing aesthetics” and the role it plays in realizing
health potential?
Threat
Restoration Maintenance Some nursing interventions that fall under this art of
aesthetics include imagery, music therapy, and touch
Potential (Ward, 2002). Guiding the family or child’s imagination
(guided imagery) to visualize repeatedly a positive out-
Meaningfulness come has been demonstrated to enhance healthy outcomes.
Music therapy helps bond the mind–body–spirit compo-
Relationship nents of health and is especially successful with children.
Touch and speech patterns of the nurse have descriptively
Figure 1-3 Health promotion nursing process. been shown to soothe, calm, and encourage patients toward
the health outcome of their choosing. One only needs to
watch a caregiver stroke, rock, and sing to a sick child to
Through health promotion, the nurse helps the woman, know that this form of the nursing art works.
child, or family understand health risk factors and adopt
lifestyle changes that foster health maintenance, prevent Across Care Settings: Teaching simple
health threats through early detection and recognition, strategies for stress relief
and explore options for health restoration.
Most have heard of the beneficial effects of slow, deep,
Across Care Settings: Health protection deliberate abdominal breathing patterns on the stress,
anxiety, and pain associated with labor and birth. Nurses can
for families
teach these simple techniques to patients who anticipate
With increasing international travel comes also the transport stress, anxiety, or pain in any care setting.
of illness vectors previously unknown in certain locales.
Providing information about ways to protect children and Ethnocultural Considerations— Use of
families from these new sources of illness and injury through imagery, chanting, and after-life encounters
the use of individual instruction, educational videos, and use
of the mass media can help the family maintain confidence One often thinks of imagery as a collection of nurse-initiated
in their ability to protect themselves from new threats. instructions given to the patient. To the woman undergoing
treatment for cancer, the nurse may suggest: “Imagine all of
the cancer cells flowing up through your body, gathering all
This form of nursing entails a shared connectedness
of the bad cells with them, and finally bursting into an explo-
between patient and nurse. The goal is to experience the
sion of color and sparkles like an explosion of fireworks from
illness or health threat in the same way the patient per-
your body. Out into the atmosphere they go, floating higher
ceives it. The nurse moves with the patient beyond the ill-
and higher as they disintegrate into outer space.” But, have
ness through the patient’s own inner healing process to a
nurses considered the healing power connected with objects
patient-defined state of coping, harmony, wholeness
used by some non-European Caucasian cultures? For exam-
(holism), and unity with the illness and healing outcome;
ple, the healing feather used by Native Americans, or the “see-
and hope, purpose, meaning (spirituality), and health
ing” of spirits practiced in Asian cultures, the casting of spells
potential beyond the illness toward healing. The power
performed in the Caribbean Island culture, and the prayer
base for this healing and future health decisions rests
beads used in Middle Eastern cultures. The healing effects of
within the patient and his belief in his health potential.
music and speech patterns have been well documented. But
The approach of the nurse provider is to form a caring
do health professionals consider of equal value the healing
relationship through listening, understanding, experienc-
value of chanting by the Native American, or the wails of sor-
ing, presencing, facilitating, valuing, and using nursing
row of the Central and Eastern European culture? One’s
aesthetics. Nursing aesthetics, or the art of nursing, is the
awareness of various cultural practices is important. Even
low-tech, high-touch artistry of caring that strengthens
more important to their healing powers is the nurse’s sensitiv-
the patient’s confidence in her or his ability to manage the
ity and incorporation of them into a shared perspective of
healing process, make change, or master the threatening
healing with the patient and family.
health event (Stichler & Weiss, 2001). It is the way the
nurse and patient help each other find meaning in the expe-
rience. It is a transformative, spiral process with a begin- While the family or child relates stories of a lived expe-
ning (a threat), middle (relational building of trust and rience, maintaining en-face eye contact, symbolically
connection), and future (experiencing new possibilities for enfolding them through proximity, and staying focused
health change and outcomes) (Rhea, 2000). solely on them acknowledges their worthiness. Imagina-
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 7
Nursing’s domain in the earlier times consisted of being a Hospitals and third-party payers responded to increas-
provider of care and a teacher. As a provider of care, the ing costs in a number of ways that included managed care
nurse would change elements of the patient’s environ- systems and the development of alternative settings for
ment through hygienic measures, nourishment, and com- health care delivery. In addition, greater emphasis was
fort to enable the best opportunity for recovery. As a placed on patient and family accountability and responsi-
teacher, the nurse would prepare the patient for proce- bility for their own health promotion and disease preven-
dures, surgery, and the uncertainties of hospitalization. tion. This approach shifted the thrust of decision making
Even in the 1860s, nurses saw their patient responsi- power to the consumer. Other measures included a rede-
bilities not only for the individual for whom they minis- fining of nursing functions, work loads, and methods for
tered but also for the living conditions of the individual’s care delivery.
family. The most frequent cause of illness and death dur-
ing these years was infectious diseases. The nursing CURRENT HEALTH CARE SETTINGS
emphasis on sanitation, nutrition, and family education
played a key role in the decline in deaths well into the Cost containment, tightened reimbursement for services,
1950s when antibiotic drugs and scientific treatments and advanced technology have become important determi-
became widely available. nants of the current settings in which health care is received.
Until the late 20th century, nurses continued to be seen Patients are being discharged earlier from acute care hospi-
as passive, deferential, and compliant advocates to pater- tals. Care is being provided in the home by family members
nalistic physicians. Nurses still practiced from the male using highly technical equipment. Many conditions that
dominated, ethnocentric, patriarchal medical model of the previously required acute care hospital stays are now being
professional nurse. In 1963, the nursing process began to treated in ambulatory settings and the community-based
change that. health care service sector is almost limitless. Hospitals,
The nursing process was developed as a framework of homes, and community service centers have become
systematic problem solving and actions to be used by interdependent providers in the ever-expanding health care
nurses in identifying, preventing, or treating the individ- arena.
ual health needs of patients. The nursing process was Regional and specialized acute care hospitals for
problem oriented, goal directed, and involved critical women, families, and children have undergone a multi-
thinking and decision making. Clear differentiations were tude of changes since their inception in the late 1950s.
made between nursing and medical diagnoses, interven- Liberalized family, sibling, and children visiting; 24-hour
tions, and outcomes. Ten years later, the North American family partnering with caregivers; policies, and proce-
Nursing Diagnosis Association (NANDA) developed a list dures based on theories of child and family growth and
of standardized nursing diagnoses used by the nurse development; and a heightened level of acuity in these
through individualized patient care plans to express to acute care settings have had both beneficial and challeng-
other caregivers the findings of the nurse’s assessment, ing effects on nurses, families, and children. A strong
diagnosis, and plans of action (Johnson et al., 2006). An knowledge base in the care of families and children,
example of the use of the NANDA-I Diagnosis to formu- highly developed critical thinking skills, expertise with
late a nursing care plan for a child with culturally different advanced technology, and dedication to evidence-based
verbal communication is presented in Box 1-1. practice are stringent requirements for nurses caring for
families and children in all settings.
Now Can You— Follow the evolution of today’s nursing When referred to these modern, highly technologically
professional roles? advanced facilities, family members are often separated by
great distances from children and other support persons.
1. Explain the central focus of the nurse as a provider of care
Emotions of separation, anxiety, abandonment, fear, and
and teacher before the 1950s?
guilt compound already tenuous physical conditions. The
2. Describe how the introduction of the nursing process as a
accessibility to follow-up care in these comprehensive set-
systematic framework changed the nurse’s professional role?
tings is frequently made difficult by time, distance, and
coordination of return visits to multiple providers of seg-
mented and specialized care.
Contemporary Nursing Care Even with the heightened acuity of patients in acute
and tertiary care hospitals, the length of stay in the set-
As families became more prosperous in the late 20th cen- tings continues to decrease. With these decreasing hospi-
tury, they also became more conscious of health promo- tal stays, alternative settings were created for what once
tion and advanced health technology. They demanded was considered “inpatient care.”
more knowledge about how to stay healthy, prevent com- At the other end of the health provider environment,
mon illnesses, and use technology to detect and treat early from the specialized tertiary and acute care hospitals, are
signs of health alterations. With this increased demand on the acute care 24-hour observation unit, freestanding
the health care system came increasing costs. In response short stay, and urgent care centers. The facilities are less
to increased health care costs, health care systems and costly than acute care settings, in part because they mini-
third-party payers focused on monitoring, controlling, mize the high cost of advanced technology in specialized
and curtailing expenditures. As the costs for health care hospitals. These settings present their own challenges for
rose, the resultant changes impacted family and child the nurse, family, and patient. Assessment, risk identifica-
health, and nursing’s professional role. tion, counseling, and teaching must all be accomplished
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 9
Patient and Family Data: Extended three-generational family comes to the health care provider with a complaint
of weakness and loss of appetite in a 3-year-old family member. The family has arrived from a Middle Eastern
country within the previous 2 weeks; they do not speak English and converse among themselves loudly and with
much gesturing.
NANDA Nursing Diagnosis: Impaired Verbal Communication related to patient-care provider cultural and language
difference
Measurable Short-term Goal: The family will have an opportunity through appropriate interpretation resources to
share and interpret information regarding the well-being of the child.
Measurable Long-term Goal: The family will express concerns, needs, wants, ideas, questions and understanding
about immediate and long-term home care of the child.
NOC Outcome: NIC Interventions:
Communication (0902): Reception, interpretation, Active Listening (4920)
and expression of spoken, written, and nonverbal Culture Brokerage (7330)
messages
Nursing Interventions:
1. Assess contributing cultural and language factors that may impede simple communication.
RATIONALE: A shared understanding of culture and language is necessary for communication to take place.
2. Evaluate extent and level of impairment.
RATIONALE: Misunderstandings of intent and content are heightened with increased levels of communication
disparity.
3. Establish a therapeutic relationship by listening carefully.
RATIONALE: Communication is enhanced when intent of trust and understanding is established.
4. Assist the family and patient to establish means of communication via an interpreter.
RATIONALE: Law mandates that interpretation services be made available for accurate and precise basic
understanding of medical terminology and care provided.
5. Validate the meaning of nonverbal and verbal communication.
RATIONALE: Words and gestures can easily be misinterpreted, and affect the delivery and reception of important
concepts.
Documentation Focus:
1. Assessment of pertinent patient physical, psychological, and cultural concerns
2. Description and meaning of nonverbal cues as related by interpreter
3. Type of interpreter services utilized
4. Teaching and explanations communicated
5. Level of outcome (NOC) completion/accomplishment
6. Discharge needs, referrals and stated family/patient understanding
in a crucially compressed time. The nurse in these Collaboration in Caring— Preparing the
settings may be responsible for direction of unlicensed family for community-based care
assistive personnel who may not have the highly devel-
oped expertise needed to recognize subtle physiological The nurse can prepare the patient and family for care
changes in a patient’s condition before discharge. Follow- outside of the acute setting by:
up procedures that once were performed and monitored • Discussing the feasibility of using specialized equipment
by nurses in the acute care setting now must be taught to in the home
the patient and family as they prepare for a rapid return • Encouraging the patient and family to investigate health
to their home. insurance coverage for home care
10 unit one Foundations in Maternal, Family, and Child Care
• Suggesting the parents of a young patient contact school priorities, and perceptions at the center of a patient’s health
officials before a child returns after an illness care needs is the essence of family-centered care (FCC).
• Evaluating the family’s transportation needs for follow- Family-centered care requires sensitivity to the beliefs,
up care values, and customs of each family member and those of
• Discerning when an interaction in the acute care setting their supporting culture or community. The role of the
is conducive to teaching and learning family-centered nurse is to facilitate and assist the family
in making informed choices toward the outcome the
Since the early 1990s, there has been a dramatic patient and family desire. Family-centered care necessi-
increase in home- and community-based nursing care. tates that the nurse relinquish an authoritarian role that
Home- and community-based nursing care is provided in tells the family what is best for them while the nurse does
settings such as adult and child day care centers; public things to and for them. The nurse becomes a human just
and private schools; churches and religious body parishes; like all other members of the family, each with their spe-
penal systems; health and disease related camps; foster cial abilities to support the patient. The center of power
homes and homeless shelters; physicians’ offices, public shifts from the one with the most clinical knowledge to
health clinics, and nurse managed care centers (Fig. 1-5). the whole of the group’s knowledge.
Nurses in these settings often experience different degrees This is a large shift for the nurse educated under tradi-
of professional independence and accountability, yet still tional Euro-Caucasian theories of nursing care. The global
need to possess expert skills as providers of clinical inter- nature of health care as a multiethnic (ethnopluralitic),
ventions, health history interviewers, culturally compe- multicultural composite of health-seeking people requires
tent teachers, coordinators of extended care services, an ever-growing sensitivity on the part of the nurse. Conside-
managers of allied health colleagues, supporters of family ration of the family’s cultural influences allows the nurse to
functionality, and advocates for family-centered care. take a more in-depth approach to health assessment and
outcome-directed interventions. For example, the proximity
Now Can You— Recognize the changes created by family- and quality of the family’s support systems; religious and
centered care for professional nursing in spiritual beliefs; customs and traditions, especially as they
acute care settings? relate to health, illness, and healing; micro-living environ-
ment of the home; and macro-living environment of the
1. List at least four characteristics of acute care hospitalization neighborhood all must be incorporated into the plan of care.
that have changed since the introduction of family- Other elements to be considered include financial resources,
centered care? including willingness to ask for and accept additional
2. Identify at least five community-based care settings in which resources; significant historical events, especially crises,
the nurse may practice family-centered care? losses, and new beginnings; and the members’ communica-
3. Compare and contrast the role of the professional nurse in tion patterns and verbal abilities, coping strategies, and
acute and specialized care hospitals and alternative care problem-solving techniques.
settings? One format used for assessing the health of a family is
the community health map (Falk-Rafael, 2004). With this
tool, the nurse assesses the family structure, function, and
FAMILY-CENTERED CARE support networks. The map provides a diagram of signifi-
Acute care providers have made strides toward keeping cant data and helps the nurse focus on the family as it
family members informed of hospital procedures and pro- interacts with the social systems within and around them
cesses affecting their loved ones, and the patient outcomes (Fig. 1-6). Actively including the family members in the
expected. Acute care settings still, however, are major sources development of the community health map provides the
of family disruption during times of stress and illness. Plac- nurse insights into the family’s health experience and fos-
ing family relationships, their coping mechanisms, values, ters the nurse–family alliance. The nurse should remem-
ber that the focus is on family health, past successes, and
current strengths, not on family problems.
Learning, recognizing, and comprehending that these
cultural factors are what shape a family’s perception of
their health and health-related events is known in nursing
as cultural sensitivity. The nurse does not need to seek
congruency between these factors, values, traditions, and
beliefs and his or her own. The nurse does, however, need
to recognize that how the patient and family comprehend
and respond to a particular health event is shaped by these
factors, values, and beliefs.
In order to use cultural competence as a nursing
assessment tool, the nurse must be open and receptive to
gaining awareness and respect of these cultural influences.
Nursing interventions that are based on a solid knowledge
of these values and practices have been demonstrated
to achieve much higher levels of successful outcomes
Figure 1-5 The nurse is instrumental in providing for families and patients (Locsin, 2002). Listening to the
family-centered care in the community setting. cultural voices and experiences of family and patients
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 11
affirms their value and is critically important to unifying helpful to consider elements such as clothing, exercise, sexual
the nurse–patient relationship as it motivates the patient participation, disciplinary efforts, dietary habits, family roles
toward positive health-promoting activities. and relationships, verbal and nonverbal communication,
cleanliness, illness remedies, and displays of emotion.
Across Care Settings: Ensuring cultural
sensitivity and reliable information In some cultures, women and children do not have the
permission, the decision-making power, or the means to
In all care settings, nurses should use the services of access the American health care system. Legal barriers,
professionals who can interpret word meanings correctly. language differences that restrict access to medical care
Relying on family members often results in literal translation and lack of diversity in the health care workforce are some
of words and omission of information—problems that create of the obstacles that may prevent immigrant minorities
confusion and misunderstanding. In settings where from accessing care. In addition to the barrier(s) that cul-
professional interpreters are not available, the use of services ture may place on accessibility of modern health care for
like AT&T, Roget’s International Thesaurus, or handheld women and children, in many situations, health care pro-
personal information devices can be useful alternatives. viders are not available in the areas where culturally
bound groups reside. The real or perceived lack of acces-
Delivering nursing care that is sensitive to and under- sibility, affordability, and availability of health care ser-
stands cultural differences, whether in knowledge, values, vices to growing numbers of individuals leaves the provi-
beliefs, or role expectations, should help the nurse evolve sion of health care delivery to the family, especially in
into a culturally competent professional who makes assess- multicultural societies. In these situations, nurses must
ments and plans interventions from a holistic framework. help family members identify needs, strengths, resources,
Framing one’s nursing assessment, intervention, outcome coping mechanisms, and desired outcomes. The functions
expectation, and evaluation with a holistic perspective of the nurse and family are intertwined and require col-
gives the nurse a better assurance that no significant physi- laborative planning, delegation, coordination, and provi-
ological, psychological, cultural, spiritual, or social com- sion of care (Goldberg, Hayes, & Huntley, 2004).
ponent is excluded.
COMBINING MODERN TECHNOLOGY
WITH THE CARING TOUCH
Ethnocultural Considerations— Cultural
prescriptions and proscriptions for women In settings where modern health care may not be accessible,
and children affordable, and available or is culturally restricted, comple-
mentary and alternative health care/medicine (CAM)
Cultural prescriptions are folk beliefs, practices, and values methods often are used. The focus of these low tech-
of a group that tell women and children what they should high-touch noninvasive, nonintrusive, nontraditional inter-
do—what their respective roles should be. ventions is the support of the family and child’s whole mind,
Cultural proscriptions are folk beliefs, practices, and val- body, energy, environment, and spiritual healing. The nurse
ues of a group that tell women and children what they should approaches this healing methodology from a holistic philos-
not do—what is “not” incorporated in their respective roles. ophy of caring, aimed toward a goal of patient-centered
When assessing cultural prescriptions and proscriptions, it is autonomy and a patient-defined sense of well-being.
12 unit one Foundations in Maternal, Family, and Child Care
In 1998 an Advanced Practice Nurse (APN) established a The family-centered nurse has a responsibility to
“Nurses’ Tool Box” of CAM nursing interventions found to advocate for the patient and family who choose to use
be effective in establishing patient and family autonomy; CAM; to assess for and educate about the implications,
relieving various illness symptoms, controlling pain, improv- contraindications, and benefits of CAM to the family and
ing immune function, decreasing anxiety and depression, patient; and to promote health practices that have been
improving circulation, excreting toxins, and enhancing proven safe and effective in restoring well-being, whether
healing (Ward, 2002). CAM interventions range from guided via conventional treatments or CAM. The nurse must
imagery, aromatherapy, imagining, creating art and writing; recognize that health can be achieved through various
prayer, chanting, meditation, and channeling; therapeutic means, both high-tech and high-touch, and that individ-
touch, stroking, and cuddling; acupressure, tai chi, mag- ual well-being is most optimally accomplished when care
netic forces and massage; music, singing, tonal vibrations, is directed by concerns expressed, interventions chosen,
and various water therapies; to storytelling, joking and and outcomes defined by the patient. It is easy to under-
humor (Helms, 2006) (Fig. 1-7). stand why the nurse–patient relationship and a focus on
It is estimated that Americans spent more than 27 billion the patient as a whole being (mind, body, energy, envi-
dollars on CAM in 2005. This statistic reflects the level of ronment, and spirit) are key to the success of CAM
consumer interest and demand for low-tech medical and healing.
nursing interventions, and self-directed healing (Lucey, Also key to a healthy outcome when using CAM ther-
2006). The nurse must be aware that not all CAM interven- apy, as with all nursing interventions, is the responsibility
tions are noninvasive, nonintrusive, or free from side effects to encourage evidence-based decision making. This
and negative consequences. CAM also involves the use of method of evidence-based practice is built on the prem-
nutritional and herbal supplements, diet adjustments and ise that interventions need to be questioned, examined,
fasting, chiropractic and body manipulation, and the use of and confirmed or refuted in their ability to support
drugs that have not been fully tested for safety and efficacy. healthy outcomes. The nurse using evidence-based prac-
Today, much confusion about CAM remains in both the tice searches computer databases and current literature
consumer and health provider sectors (Box 1-2). for reports that evaluate the safety, quality, and credibility
of particular interventions. These searches produce reports
from rigorous research studies, textbook and journal
Collaboration in Caring— Supporting the readings, stated expert opinions, and best practices result-
family that uses CAM ing from quality improvement activities. It is the nurse’s
responsibility to use the best evidence available and make
The nurse can provide support to the patient or family that decisions accordingly, especially when working with prac-
uses CAM by: tices such as CAM that are viewed by many as mythical,
• Investigating what they think caused a health event and magical, and nontraditional.
how they have been able to avoid it in the past Another source of evidence-based guidelines available to
• Encouraging them to seek all approaches of healing that the nurse is the standards of care/practice developed by
are evidence-based, including both traditional and nursing professional organizations such as the American
alternative medicine Nurses Association (ANA); Society of Pediatric Nurses
• Respecting the participation of a family-chosen folk healer (SPN); National Association of Neonatal Nurses (NANN);
• Acknowledging the patient’s/family’s religious and National Association of Pediatric Nurse Associates and Prac-
spiritual beliefs titioners (NAPNAP) and Association of Women’s Health,
• Reflecting on and understanding personal beliefs and Obstetric, and Neonatal Nurses (AWHONN) (ANA, 2008;
recognizing when they may be in conflict with those of AWHONN, 2008). These published guidelines promote
the patient consistency and quality in nursing care and outcomes.
• Avoiding judgment Because of the time it takes to search and retrieve evidence-
based knowledge, these guidelines provide the nurse a reli-
able source of high-quality interventions on which to base
practice.
A HISTORY OF MEDICINE
(Author unknown)
2000 B.C. “Here, eat this root.”
1000 A.D. “That root is heathen. Say this prayer.”
1850 A.D. “That prayer is superstitious. Drink this potion.”
1940 A.D. “That potion is snake oil. Swallow this pill.”
1985 A.D. “That pill is ineffective. Take this antibiotic.”
2000 A.D. “That antibiotic doesn’t work anymore. Here, eat this root.”
Figure 1-7 Storytelling, joking, and humor are Source: Helms, J.E. (2006). Complementary and alternative therapies: A new
therapeutic complementary and alternative medicine frontier for nursing education? Journal of Nursing Education, 45(3), 117.
interventions.
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 13
Now Can You— Discuss the community health map, Now Can You— Describe the role of the nurse as a
aspects of complementary and alternative teacher, collaborator, and provider?
health healing, and evidence-based 1. Explain how the nurse functions in the role of patient/family
practice? teacher?
1. Discuss the value of a community health map as a nursing 2. Discuss aspects of therapeutic nurse–patient collaboration?
assessment tool? 3. Describe the need for accountability on the part of the nurse
2. Identify at least five ways that nurses can offer support for as a provider of care?
the patient/family who uses CAM?
3. Explain what is meant by evidence-based practice? The nursing process is the foundation for the profes-
sional role as collaborator and provider of care and
guides the nurse in helping the patient and family choose
PROFESSIONAL NURSING ROLES appropriate interventions, and in quantifying and evalu-
Ever since Florence Nightingale’s time, helping patients ating the chosen outcome goal. By using the NANDA
and families gain understanding into their health practices International Nursing Outcomes Classification (NOC)
has been integral to the profession of nursing (Nightingale, and Nursing Interventions Classification (NIC), the
1859). The role of the nurse as patient and family teacher nurse is able to evaluate more clearly associations
has been sustained over the years as a foundation of the between interventions and outcomes (Johnson et al.,
profession and continues to be reinforced through profes- 2006). Using these standards also helps nursing students
sional standards of care/practice. The professional nurse and novice professionals develop the intellectually and
teaches the patient and family by helping them gain technically complex competencies required to link
knowledge and skills about the health risk affecting them, assessment cues accurately with outcomes and interven-
and of behaviors that can assist in accomplishing the tions (Lunney, 2006).
health outcome they desire. There is a sharing of knowl- Nursing interventions are more than the actions nurses
edge, and through that knowledge a gathering of strength take to help patients and families toward their desired
that can be directed toward the health condition. outcome. One NIC may entail up to 30 actions or activi-
The nurse, patient, and family combine their strengths, ties the nurse and family selectively choose from in order
through collaboration, to describe what the health issue is to individualize the intervention to the specific health
and means in their lives, and what interventions and deci- condition as it is perceived at that moment (Johnson et al.,
sions are possible and preferable. This collaboration 2006). The NIC also involves the evidence-based practices
results from, and becomes an act of, mutual respect for and critical thinking processes the nurse undertakes when
each other’s values, abilities, expectations, and experi- judging for appropriateness and feasibility of activities
ences with the health event and life (Rhea, 2000). Collab- chosen to reach resolution of the health problem and
oration with the patient and family about health educa- achieve desired outcomes.
tion needs pulls the nurse away from the traditional Nursing interventions must be appropriate for both the
“banking” concept of patient teaching and learning in selected nursing outcomes and diagnoses. They require
which facts, skills, and knowledge are offered by the nurse comprehensive, preliminary assessment of patient and
and deposited for storage in the patient’s vault (Freire as family strengths and health concerns; acceptability to the
cited in Sanford, 2000, p. 6). patient and family of the chosen interventions; and the
Collaboration requires two-way dialogue and sharing nurse’s and family’s capabilities to fulfill or coordinate
between the patient and nurse of both personal and with other health care providers, both professional and
health-related problems and solutions. Each participant is familial, the chosen health outcomes.
an equal possessor of knowledge and shares the power of Before nursing interventions are selected, appropriate,
determining what is to be learned. Each has a desire to feasible, and family-agreed-upon outcomes must be clearly
learn more from and about the other. Participants become identified. The chosen NOCs help the nurse identify, pri-
personally engaged and share a deeper level of under- oritize, and differentiate the critical from the sometimes
standing of each other, the health risk as each perceives it, exhaustive list of other relevant interventions and actions.
and the available and chosen interventions to explore in Just as nursing interventions are more than the sum of
collaboration. outcome-directed actions, outcomes are more than the
The nurse still holds responsibility as the provider of ultimate, end goal of the health state. Outcomes are
care to implement the chosen interventions, or to accept dynamic and demand frequent measurement of the
accountability for their delivery. Even though family- responsiveness of the chosen interventions. Outcomes
centered care encourages patient and family involvement should be evaluated for continuing meaningfulness, both
in therapy delivery, it is still expected that the nurse will physiologically and personally; for direction and purpose,
be actively involved and skilled in the provision of whether health restoration, maintenance, promotion or
health assessment, treatment, care, and follow-up evalu- threat prevention; and for consistency with the culturally
ation. The nurse plays a vital role in collaborative care lived experience of the patient and family.
across a range of settings, especially in the follow-up
evaluation and ongoing treatment. It is the nurse’s task
to collaborate with the discharge planner, child’s teacher, The Caring Art and Science of Nursing
physician, physical or speech therapist, dietitian, and
community services worker to develop with the family Just as a family’s culture is their centering foundation in
the best plan of care for the desired long-range health times of health and illness, caring is the centering founda-
outcome. tion of nursing. “Caring transcends language, customs,
14 unit one Foundations in Maternal, Family, and Child Care
and cultural differences… it is universal” (Watson as cited encouraging the patient to also release feelings and
in Rexroth & Davidhizar, 2003, p. 298). It “defines the thoughts about the condition and self (Watson, 2005).
characteristics and parameters of practice” (Falk-Rafael, The focus of the encounters, referred to by Watson as car-
2005, p. 38). The National League for Nursing Accredit- ing occasions, is on “caring, healing and wholeness, rather
ing Commission (NLNAC) supports caring as a vital core than on disease, illness and pathology” (Watson, 2005).
value of nursing (NLNAC, 2005). Caring often leads to The goals of the nurse–patient transpersonal therapeu-
new outcomes, ways of being, and experiencing life for a tic relational communication are to find meaning and
patient and family (Watson, 2002). develop a wholeness in the body–mind–spirit; assist the
“Many circumstances in contemporary society have patient in transcending beyond the current health state
made caring more difficult now than in the past” (Rosalynn toward his or her ideal; give meaning to the patient’s
Carter as cited in Cluff & Binstock, 2001, p. 15). Advanced being; and “release some of the disharmony, the blocked
technology, the rapid pace of health care, and a focus on energy that interferes with the natural healing processes;
the legal ramifications of one’s professional actions have thus the nurse helps another through this process to
placed great demands on the time and support a nurse can access the healer within, in the fullest sense Nightingale’s
offer a patient and family. Understanding the many dimen- view of nursing” (Watson, 2005, p. 89).
sions of caring one brings to, and gets from, the patient Madeleine Leininger also believes that caring is the
encounter is essential to the nurse’s ability to recognize the core value of nursing. “Caring is essential for curing, but
pain, suffering, and vulnerability that patients experience. curing is not essential for caring” (Leininger as cited in
Jeffreys, 2006, p. 37). Her Theory of Transcultural Care
Diversity and Universality sees caring and culture as
THEORIES THAT FRAME CARING AS THE CORE embedded with each other. You cannot have one without
OF NURSING the other.
Florence Nightingale’s model of nursing encouraged a Caring necessitates understanding of the patient’s cul-
focus on the spiritual, physical/environmental, emotional, tural beliefs, values, methods of providing or showing
mental, and social needs of the patient and is known as a caring, causes of illness and how it is viewed, and how
holistic view of the patient (Nightingale, 1859). She wellness is achieved. This level of understanding only
described the base of nursing activities as observation, comes through a trusting relationship. Developing that
experience, knowledge of sanitation, nutrition, caring, and trusting relationship is an ongoing process. When the
compassion; and the focus of nursing as the patient rather nurse takes the time to clarify the patient’s health beliefs
than the illness (Nightingale, 1859). Nightingale viewed all and practices, reflect on one’s own health values and
people as equal in their abilities to attain health. In addition actions, and validate through an unprejudiced and unbi-
to her emphasis on improving the patient’s environment, ased eye (avoiding judgment of what seems logical, sensi-
she encouraged the use of imagination and retelling of ble, or reasonable), the strengths and weaknesses of each,
pleasant life events as appropriate healing interventions to a caring relationship is established.
help restore the patient to the best possible condition so
that natural healing could occur (Nightingale, 1859). Now Can You— Compare and contrast the caring base
Watson and Leininger are two modern-day theorists of nursing as described by Nightingale,
known for their inclusion of caring as a core of nursing. Watson, and Leininger?
The commonalities between these two theorists are espe-
1. Describe Nightingale’s focus of nursing?
cially important in understanding how to incorporate 2. List three of Watson’s goals for a caring, therapeutic
caring as a recognized nursing intervention with a mea- nurse–patient relational communication?
surable outcome. 3. Discuss Leininger’s advice for a nurse who wishes to develop
In her Theory of Human Caring, Jean Watson con- a caring nurse–patient relationship?
tends that caring as a nurse demands that attention be
given not only to the body but also to the soul and spiri-
tual dimension of the patient and family (Watson, 2005).
She defines the soul as the ideal self of an individual, and ESSENTIAL CHARACTERISTICS OF CARING
notes that the individual is constantly striving to achieve Trust, built through an interactional relationship in
that ideal self by creating harmony among the body, mind, which the nurse is cognizant of both personal and the
and spirit; between the ideal self (referred to as ‘I’) and the patient’s feelings and meaning of the health experience, is
current self as living the experience (referred to as “me”) an essential characteristic of caring. It can involve such
(Watson, 2005). The state of health is related to the con- concrete actions as listening and observing for cues as to
gruence between I and me, and the effect that the differ- what the health event means to the patient, and what the
ences in I and me is having on the body, mind, and spirit patient views as her needs, how they should be met, and
(Watson, 2005). what the desired outcome should be. It is the aesthetic
By participating in transpersonal therapeutic relational engagement, or art of nursing, that is defined as caring
nurse–patient communication in which each participant (see Fig. 1-4).
gives and gains equally and learns to identify with the Caring provides a sense of empowerment (some believe
other, the nurse and patient demonstrate mutual caring, caring is the opposite of power), capability, inner peace,
recognize the other as more than an object, and move the and self-determination. It requires an understanding of
patient toward a desired state (Watson, 2005). This caring one’s own beliefs, prejudices, and values so that those of
by the nurse begins with the feelings elicited and responses the patient can be addressed with respect and dignity
demonstrated toward the patient’s condition, allowing or (Davis, 2005).
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 15
A study of patients in an intensive care unit (Rosenthal In addition to instrumental and expressive characteris-
as cited in Rexroth & Davidhizar, 2003, p. 301) helped tics of caring, a spiritual component was reported by
divide caring characteristics into instrumental behaviors patients. Spiritual caring, however, did not necessarily
of caring and expressive behaviors of caring, or technical equate with attention to one’s religion, rituals, or beliefs.
and non-technical components. It is important to know Rather, spirituality addressed the meaning of life, includ-
that nursing behavior that is considered caring first ing the present as being experienced, the past, and the
depends on clinical competence and technical expertise. future. It entailed learning about a patient’s and one’s own
“Without knowledge, caring is just a matter of good inten- perceived weaknesses, vulnerabilities, and mortality, and
tions” (Mayeroff as cited in Falk-Rafael, 1998, p. 41). It where the power lies to transcend or accept them (Kelly,
was found that where the patient perceived himself to be 2004). Again, many of the same expressive characteristics
on the health-wellness continuum, or how critically ill, were found when describing nurses who addressed spiri-
played a big role in the value he placed on the instrumen- tual caring (touching, listening, respecting, trusting, and
tal versus expressive caring behavior of the nurse (Meyer- humor). It is important to note that more than 80% of the
off as cited in Falk-Rafael, 1998, p. 41) (Fig. 1-8). patients questioned about caring stated they did not
expect the nurse to address their spiritual needs, although
they would have liked it (Davis, 2005).
Collaboration in Caring— Enhancing family Tolstoy said that “the essence of caring is the need to
and patient coping have one’s position grasped.” (Cluff & Binstock, 2001,
The nurse caring for a patient in an intensive care unit can p. 47) Caring’s “unifying essence, however, is concern for
facilitate coping by: and responsiveness to the needs and worth of the person
• Encouraging family presence, interaction, and touching receiving it….How often do I turn my focus from my per-
• Encouraging the family to adhere to home/daily routines formance to the needs of the patient?” (Cluff & Binstock,
as much as possible 2001, p. 1).
• Including the family in the plan of care; offering choices
when possible Now Can You— Define the essential characteristics
• Encouraging discussion of family fears and anxieties of caring?
• Offering to contact a spiritual leader or healer 1. List three nursing actions designed to build trust?
• Encouraging the family to place familiar and comforting 2. Discuss the importance of instrumental, expressive, and
articles nearby spiritual behaviors of caring?
3. Identify three ways that communication is translated into
caring behavior?
In a 2005 study on the components of caring as
described by patients, expressive behaviors such as smil-
ing, gentleness in touch, praising the patient for her PROFESSIONAL NURSING ROLES
efforts, and making the patient feel important were consis-
tently classified as elements of caring (Davis, 2005). Com- Provider of Care
munication was identified as another essential element. As a provider of care, the nurse expertly includes caring
Communication with the patient and family that they behaviors that address all the physical, psychosocial, and
mattered to the nurse personally; about the patient’s hope- spiritual needs of the patient and family. Through careful
fulness for the future and awareness of a higher source of assessment of all three categories of needs, diagnosis of
healing; and with the physician that things were going the patient’s response to the health event, planning of
well or not going well as defined mutually by the patient interventions that promote the patient’s strengths and
and caregiver were all recognized as supportive, caring follow-up, and evaluation of the patient’s transition and
ways of conveying concern, interest and compassion potential for a new health state, the nurse can accomplish
(Cluff & Binstock, 2001). the most effective, efficient, and desirable outcome.
Mind-Body- Mind-Body-
High-Level Chronic Deteriorating Imminent
Spirit Self-Care Disability Spirit
Wellness Illness Health Death
Harmony Harmony
One of the major responsibilities of the nurse as a pro- health event encounter. Listening to the family commu-
vider of care is to stay current and competent in the opera- nicate can provide insight into the most favorable
tion of technical procedures and monitoring equipment. method of interacting.
This professional responsibility requires knowledge of not The nurse often has the potential to role model for
only how to perform the procedures and operate the the child, and even the parent, effective ways of verbally
equipment, but also an understanding of why the proce- expressing ideas, thoughts, and feelings. One way of
dure and equipment are necessary. role modeling appropriate expressive language is by the
It means the nurse is not only responsible for safely use of reflective listening and rephrasing. A parent who
executing the procedure, but also accountable for recog- tells a 3-year-old, “Now be a good boy and stop crying.
nizing and interpreting the data gathered during the pro- Big boys don’t cry,” might benefit from the nurse
cedure and from the equipment read-outs. This level of rephrasing the statement for her by saying, “Mommy
responsibility and accountability evolves from an ongoing knows your head hurts, and it’s all right to cry. You did
development of critical, analytical thinking on the part of such a good job helping the nurse see how warm your
the nurse. body was.”
Tone and quality of voice sometimes communicate
Critical Thinker more than the actual words themselves. This is especially
Critical thinking is the “precise, disciplined thinking true with infants and toddlers. All audible sounds convey
that promotes accuracy and depth of data collection and meaning, even when the tone is incongruent with the
seeks to clearly identify the problems, issues, and risks word. Caution should be taken when using a stern tone to
at hand” (Alfaro-LeFevre, 2004, p. 61). Much of what it express endearments like, “Get over here so I can put
entails comes from experience, knowledge seeking, some love on you.” The young child is more likely to hear
practiced hands-on work, and contextual discernment. the stern tone of the voice than he or she is to hear the
Much of critical thinking is also built on inner personal loving words. Touch, eye contact, and body language are
skills, including: ability and willingness to self-reflect also key components of communication the nurse must
on values and beliefs, open-mindedness to diverse and recognize as having the potential for enhancing or imped-
unique perspectives, persistence in seeking the most ing a healthy outcome.
reasonable answer, comfort and confidence with calcu-
lated risk-taking, and devotion to listening with a
passion for true comprehension and understanding Ethnocultural Considerations— Patterning
(Alfaro-LaFevre, 2004). The overriding purpose of criti- effective communication styles
cal thinking always is to make the best clinical judgment Most of us have seen the way an infant responds to the pace
possible. of our speech. Talk slowly, and the infant’s body move-
ments become slower to match the pace of the spoken
Now Can You— Describe why critical thinking is key to words. Talk very quickly, and the infant becomes very
the successful clinical practice of nursing? active with her movements. To communicate effectively
1. Define critical thinking? with various cultures, nurses need to become aware of the
2. Name four avenues for developing successful analytical pacing of their speech. The pacing of the spoken word for
critical thinking? people from the southern United States is often slow and
3. Discuss the personal skills that help build critical thinking drawn out, commonly called a “Southern drawl,” while the
analysis? spoken word of the person from New York City is often
rapid and clipped, commonly called “rapid-fire chatter.”
Responding to a Southerner with rapid-fire answers, or to a
Effective Communicator New Yorker with slow, drawn out responses, may be per-
Good listening and communication skills are essential ceived as rude. Listening to the speech pattern of the patient
to the nurse, especially when providing care for chil- can allow the nurse to match that pattern when communi-
dren and families. Often the nurse receives key infor- cating with her.
mation through subtle tones of voice and snippets of
dialogue with a child or parent. Listening carefully
allows the nurse to evaluate the level of language devel- Listening, touching, establishing eye contact, pattern-
opment of a child and to effectively use words that can ing, and paying attention to body language are all essen-
be understood. It also offers the nurse an opportunity to tial components of effective communication. The vital
view how the family communicates with each member, distinguishing factors of therapeutic communication,
often delineating the family roles and structure. Listen- however, are that it is purposeful, goal driven, and
ing to communication patterns can clue the nurse to focused on the outcome. Therapeutic communication
components of the patient’s value system and cultural should most often start with an introduction of the
approaches. For example, some cultures consider it nurse, by name and role. This helps differentiate the
rude to offer an immediate response when asked a ques- purpose of therapeutic communication from that of
tion. Silence signifies that the receiver values the ques- social interaction. Maintaining focus of the communica-
tion and the person, and is giving it serious consider- tion on the outcome desired (i.e., meeting the patient’s
ation. Some cultures communicate through storytelling; needs) helps not only in the nurse’s time management
“Remember when Aunt Margie was in the hospital but also in identifying data that is important from that
and…” The nurse can use this insight to help tailor which may be interesting but not necessary for a healthy
much of the interactions that will take place during the outcome.
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 17
Imbalanced Extreme Stress Increased signifies improvement or deterioration in the health status
Fluid R/T Metabolic of the primary medical diagnosis (Fig. 1-11). Step 3 of the
Volume Hospitalization Demands map involves analyzing the relationships among, and
prioritizing the patient responses that led to the nursing
diagnoses. The problem or diagnosis with the most sup-
Dehydration Decreased Ability
Limited
R/T Acute to Tolerate Fluid porting data is usually the most important (Fig. 1-12).
Mobility R/T
IV Restraining Gastroenteritis Fluctuations Step 4 of the concept map requires the nurse, along
R/T Age with the patient and family, to develop the beneficial goals
Device Medical Diagnosis
and Size
and outcomes they hope to attain. This step corresponds to
the planning phase of the nursing process. The outcomes
Narrow Therapeutic
are what drive the selection of interventions to be initiated
Increased Rapid by the nurse, patient, and family and other caregivers.
Margin of Safety
Fluid Fluid
Needs R/T Loss R/T
for Pharmaceutical They should describe the assessment data that determines
Agents R/T Age if there has been successful progress toward achieving
Fever diarrhea
and Size
them. The outcomes should address clinical health (the
medical diagnosis, signs and symptoms), functional health
Figure 1-9 Concept map construction begins with (mind–spirit–emotions), quality of life (as defined by the
gathering and analyzing assessment data. patient), health risk reduction, health protection, health
promotion, therapeutic relationships and personal satisfac-
tion (Alfaro-LeFevre, 2004). “Simply put, determining
After the initial diagram is constructed, depicting what expected outcomes requires you to reverse the problem
is believed to be the key problems, it is then time to inves- (state what happens when the person doesn’t have the
tigate the medical diagnosis and gain knowledge of the problem)” (Alfaro-LeFevre, 2004, p. 173).
treatment options. A review of assessment and evidence- Whether the nurse uses Maslow’s hierarchy of needs or
based information on the following patient areas guide the a professional theorist to determine the priority status of
nurse in the next step of the map: outcomes and interventions, it is important to recognize
that the context or circumstances in which the health
• Growth and development tasks
problem is occurring plays a key role in the prioritization
• Past medical history
and implementation. When the above mentioned steps are
• Current laboratory values
completed, it becomes much easier to choose interven-
• Medication taken and likely to be ordered
tions that are achievable within the time and environmen-
• Allergies
tal constraints of the health event; build upon the strengths
• Pain rating
of the patient and family; and increase the likelihood that
• Diet and fluid intake, needs, and preferences
they will be carried out by all those providing care.
• Recent elimination patterns
Step 5 of the map is the evaluation of the patient’s
• Usual activity rituals and current limitations
response to the health event, interventions, and progress
Step 2 in developing the concept map is to categorize toward the outcome goals. Evaluation is not a one-time
the assessment data gathered under one or more of the nursing responsibility, but an ongoing process. The nurse
identified patient problem areas (Fig. 1-10). Then the is looking for a pattern of patient responses to the health
nurse describes the essential ongoing assessment data that event that should guide ongoing reassessment, planning,
Imbalanced Fluid Volume Extreme Stress R/T Hospitalization Decreased Ability to Tolerate Fluid Increased Metabolic Demands
• 6 watery stools/2 hours • 3 years old Fluctuations R/T Size and Age • Fever 102.6°F (39.2°C)
• Refuses to take • Starting to develop social skills • 3 years old • Crying
bottle/cup for fluids • Likes to play alongside other children • HR 182, bounding
• No tears when crying • Crying, kicking, temper tantrums common • RR 58
• Diaphoretic • No previous hospitalizations • SAO2 90%
• Dry mucous membranes • Hyperactive bowels
• Urine concentrated, dark
Dehydration
R/T Acute
Gastroenteritis
Medical Diagnosis
Imbalanced Fluid Volume Extreme Stress R/T Hospitalization Decreased Ability to Tolerate Fluid Increased Metabolic Demands
• 6 watery stools/2 hours • 3 years old Fluctuations R/T Size and Age • Fever 102.6°F (39.2°C)
• Refuses to take • Starting to develop social skills • 3 years old • Crying
bottle/cup for fluids • Likes to play alongside other children • HR 182, bounding
• No tears when crying • Crying, kicking, temper tantrums common • RR 58
• Diaphoretic • No previous hospitalizations • SAO2 90%
• Dry mucous membranes • Hyperactive bowels
• Urine concentrated, dark
• Serum sodium 132
Dehydration
• BUN 30
R/T Acute
Gastroenteritis
Observe for weight gain, v.s. stabilization,
return of tears with crying, ability to
tolerate at least 100 mL oral fluids
Medical Diagnosis
Figure 1-11 Identifying essential assessment data to evaluate the health status.
1. Imbalanced Fluid Volume 3.Extreme Stress R/T Hospitalization 6.Decreased Ability to Tolerate Fluid 2.Increased Metabolic Demands
• 6 watery stools/2 hours • 3 years old Fluctuations R/T Size and Age • Fever 102.6°F (39.2°C)
• Refuses to take • Starting to develop social skills • 3 years old • Crying
bottle/cup for fluids • Likes to play alongside other children • HR 182, bounding
• No tears when crying • Crying, kicking, temper tantrums common • RR 58
• Diaphoretic • No previous hospitalizations • SAO2 90%
• Dry mucous membranes • Hyperactive bowels
• Urine concentrated, dark
• Serum sodium 132
Dehydration
• BUN 30
R/T Acute
Gastroenteritis
Observe for weight gain, v.s. stabilization,
return of tears with crying, ability to
tolerate at least 100 mL oral fluids
Medical Diagnosis
and provision of safe and effective care. Concept mapping • Consulting with the case manager when evaluating the
helps the nurse develop disciplined, critical thinking concept map outcomes
that promotes accuracy, depth of data collection, early • Investigating evidence-based practice from all health care
identification of risks, realistic goals, and a broader disciplines (i.e., medicine, nursing, pharmacology,
understanding of patient health problems (Alfaro- respiratory therapy, primary school education, criminal
LeFevre, 2004). justice, and social sciences)
◆ Nursing aesthetics is the low-tech, high-touch compo- 5. The clinic nurse demonstrates for the new nurse
nent of providing health care, and the centering, caring strategies that are helpful to children in a crisis. The
foundation of nursing. nurse maintains ___________ eye contact, stays
◆ The use of a community health map can help the nurse _________ on the children and ________ shares
assess the family’s support systems, strengths, and cop- their experiences.
ing mechanisms. 6. The clinic nurse understands that increased ________
◆ Today, health care may be provided in the acute care has led to many patients and families having an
hospital, tertiary research center, free standing short increased focus on health ________ and _________.
stay unit, community health center, school, nurse- 7. The clinic nurse demonstrates elements of spiritual
managed center, and private home. Different settings caring by learning about a patient’s _________ or
require increased independence, accountability, and __________.
expertise from the nurse.
True or False
◆ The essence of family-centered care is the placement of
8. The nurse who is able to share the patient’s perception
family relationships, coping mechanisms, values, priori-
of a health threat, and support the patient’s changes
ties, and perceptions at the center of the health event.
in order to cope and understand their outcomes is
◆ A holistic view of the patient and family includes the part of a process of engaging transpersonal care.
spiritual, physical, emotional, mental, social, and cul-
9. The nurse collaborates with a family on outcomes
tural indicators of patient health.
that are realistic and culturally appropriate prior to
◆ Concept mapping helps the nurse develop critical the development of any interventions.
thinking that promotes accuracy, depth of data collec-
10. The clinic nurse defines critical thinking as promotion
tion, early identification of risks, realistic patient cen-
of an accurate and strong data collection that clearly
tered goals, and a broader understanding of patient
identifies problems, issues and risks for a patient.
health problems.
◆ When coordinating care for the patient and family who See Answers to End of Chapter Review Questions on the
are receiving services from multiple providers, the Electronic Study Guide or DavisPlus.
nurse must advocate for the patient’s wishes, needs,
plans, decisions, resources and expected outcomes, REFERENCES
and ensure that they are recognized and are the guiding Alfaro-LeFevre, R. (2004). Critical thinking and clinical judgment: a prac-
force in the provision of care. tical approach (3rd ed.). St. Louis, MO: Saunders Elsevier.
American Nurses Association (ANA). (2008). Retrieved from http://
www.nursingworld.org/MainMenuCategories/HealthcareandPolicy-
Issues/ANAPositionStatements.htm (Accessed February 27, 2008).
r e v i e w q u est io n s Association of Women’s Health, Obstetric, and Neonatal Nurses
(AWHONN). (2008). Retrieved from http://awhonn.org/awhonn/
Multiple Choice content.do?name⫽05_HealthPolicyLegislation/5H_PositionState-
ments.htm (Accessed February 27, 2008).
1. The new nurse explains to the clinic nurse that the Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
nursing process currently being taught has an tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
emphasis on: Catalano, J.T. (2006). Nursing now! Today’s issues, tomorrow’s trends
A. Health promotion (4th ed.). Philadelphia: F.A. Davis.
Cluff, L.E., & Binstock, R.H. (2001). The lost art of caring: a challenge to
B. Disease and illness health professionals, families, communities, and society. Baltimore: The
C. Linear progression of the illness Johns Hopkins University Press.
D. Assessment for signs and symptoms of disease Davis, L.A. (2005). A phenomenological study of patient expectations
concerning nursing care. Holistic Nursing Practice, 19(3), 126–133.
2. As a vital part of family-centered care, the clinic Department of Health & Human Services (DHHS). (2000). Healthy people
nurse works with the patient and family to discover 2010. Washington, DC: Author.
what the health issue is and what interventions are Doenges, M.E., Moorhouse, M.F., Murr, A.C., & Murr, A.G. (2006).
preferable in a process of: Nursing care plans: Guidelines for individualizing client care across the
life span. Philadelphia: F.A. Davis.
A. Collaboration Falk-Rafael, A. (2005). Advancing nursing theory through theory-guided
B. Assessment practice: the emergence of a critical caring perspective. Advances in
C. Development Nursing Science, 28(1), 38–49.
D. Knowledge Ford, R.C., & Fottler, M.D. (2000). Creating customer-focused health
care organizations. Health Care Management Review, 25(4), 18–33.
Fill-in-the-Blank Forum on Child and Family Statistics (FCFS). (2005). America’s chil-
dren: key national indicators of well-being. Retrieved from http://
3. The clinic nurse collaborates with other multi- www.childstats.gov (Accessed February 26, 2008).
disciplinary members to provide care to a 60-year-old Freire, P. (1997). Pedagogy of the oppressed. Cited in Sanford, R.C. Caring
woman with uterine cancer who is anticipating a through relation and dialogue: A nursing perspective for patient edu-
cation (healing and caring). Advances in Nursing Science, 22(3), 1–15.
hysterectomy. The patient’s care includes ______ and Goldberg, J., Hayes, W., & Huntley, J. (2004, November). Understand-
_______ needs as well as ______ needs. ing Health Disparities. Health Policy Institute of Ohio, 13.
4. The clinic nurse knows that the patient’s _____ and Gordon, S., & Nelson, S. (2005). An end to angels. American Journal of
Nursing, 105(5), 62–69.
preferences as well as the nurse’s clinical expertise Harmon Hanson, S.M., Gedaly-Duff, V., & Kaakinen, J.R. (2005). Family
combined with the use of national guidelines is health care nursing: theory, practice, and research (3rd ed.). Philadelphia:
described as _____ practice. F.A. Davis.
chapter 1 Traditional and Community Nursing Care for Women, Families, and Children 23
Health Resources & Services Administration (HRSA). (2004). The regis- Watson, J. (2002). Nursing: Human science and human care, a theory of
tered nurse population: National sample survey of registered nurses. nursing. New York: National League for Nursing.
Retrieved from http://www.bhpr.hrsa.gov/healthworkforce/reports/ Watson, J. (2005). Theory of human caring. Retrieved from http://hschealth.
rnsurvey (Accessed February 24, 2008). uchsc.edu/son/faculty/caring.htm (Accessed February 27, 2008).
Helms, J.E. (2006). Complementary and alternative therapies: A new
frontier for nursing education? Journal of Nursing Education, 45(3),
117–123. SUGGESTED RESOURCES
Jeffreys, M. (2006). Cultural competence in clinical practice. NSNA Agency for Health Care Policy and Research: Evidence-based Practice:
Imprint, 53(2), 36–41. http://www.ahrq.gov/clinic/epcix.htm
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Maas, American Academy of Pediatrics: http://www.aap.org
M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and NIC American Association of Birth Centers: http://www.birthcenters.org
Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.). American College of Nurse Midwives: http://www.acnm.org
St. Louis, MO: Mosby Elsevier. American College of Obstetricians and Gynecologists: http://www.
Kelly, J. (2004). Spirituality as a coping mechanism. Dimensions in Critical acog.org
Care Nursing, 23(4), 162–168. American Holistic Nurses’ Association: http://www.ahna.org
Kennedy, M. (2004). APN’s: improved outcomes at lower costs. American American Medical Association Compendium of Cultural Competence
Journal of Nursing, 104(9), 19. Initiatives in Health care: http://www.kff.org/uninsured/loader.
Leininger, M., & McFarland, M.R. (2002). Transcultural nursing: Concepts, cfm?url⫽/commonspot/security/getfile.cfm
theories, research & practice (3rd ed.). New York: McGraw-Hill. American Nurses Association: http://www.nursingworld.org
LeVasseur, J.P. (2002). A phenomenological study of the art of nursing: Assessing Cultural Competence in Health Care: Recommendations for
experiencing the turn. Advances in Nursing Science, 24(4), 14–26. National Association of Maternal and Child Health Programs: http://
Locsin, R.C. (2002). Culture perspectives. Holistic Nursing Practice, amchp.org
17(1), ix–xii. Center for Cross-Cultural Health: http://www.crosshealth.com
Lucey, J.F. (2006). When trust in doctors erode, other treatments fill the Childbirth Connection: http://www.childbirthconnection.org/
void. Pediatrics, 117(4), 1242. Diversity Rx: http://www.diversityrx.org
Lunney, M. (2006). Helping nurses use NANDA, NOC, and NIC: Novice Federal Interagency Forum on Child and Family Statistics: http://www.
to expert. Journal of Nursing Administration, 36(3), 118–125. childstats.gov
Mayeroff, M. (1971). On caring. New York: Harper Perennial. Cited in Georgetown University: National Center for Cultural Competence:
Falk-Rafael, A.R. (1998). Nurses who run with the wolves: The http://www11.georgetown.edu/research/gucchd/foundations/frame-
power and caring dialectic revisited. Advances in Nursing Science, works.html
21(1), 29–42. Healthy Mothers, Healthy Babies Coalition: http://www.hmhb.org
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing Institute for Women’s Policy Research: http://www.iwpr.org
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. International Confederation of Midwives: http://www.internationalmid-
National Coalition on Health Care (2006). The impact of rising eco- wives.org/
nomic costs on the economy. Retrieved from http://www.nchc.gov International Council of Nurses: http://www.icn.ch
(Accessed April 20, 2006). NANDA International: http://www.nanda.org
National Guideline Clearinghouse (2008). http://www.guideline.gov National Association of Pediatric Nurse Practitioners: http://www.
(Accessed February 24, 2008). napnap.org
National League for Nursing Accrediting Commission (2005). Accredita- National Center for Cultural Competence: http://www.11.georgetown.
tion manual with interpretive guidelines by program type for post edu/research/gucchd/nccc/
secondary and higher degree programs in nursing. New York: Author. National Guideline Clearinghouse: http://www.guideline.gov
Nightingale, F. (1859). Notes on nursing. Philadelphia: Lippincott Williams National Institute of Nursing Research: http://www.nih.gov/ninr
& Wilkins. National League for Nursing: http://www.nln.org
Rexroth, R., & Davidhizar, R. (2003). Caring: Utilizing the Watson the- National Library of Medicine – National Institutes of Health: http://www.
ory to transcend culture. The Health Care Manager, 22(4), 295–304. nlm.nih.gov/
Rhea, S.C. (2000). Caring through relation and dialogue: A nursing perspec- National Perinatal Association: http://www.nationalperinatal.org
tive for patient education. Advances in Nursing Science, 22(3), 1–15. National Resource Center for Family Centered Practice: http://www.
Schultz, A. (2005). Clinical scholar mentorship model. Excellence in uiowa.edu/⬃nrcfcp/
Nursing Knowledge, Feb. http://www.nursingknowledge.org (Accessed Survey on Women’s Health in the United States: http://www.kff.
February 24, 2008). org/womenshealth/
Stichler, J.F., & Weiss, M.E. (2001). Through the eye of the beholder: The Association of Women’s Health, Obstetric, and Neonatal Nurses:
Multiple perspectives on quality in women’s health care. Journal of http://awhonn.org
Nursing Care Quality, 15(3), 59–74. The Cochrane Database of Systematic Reviews Library: http://www.
U.S. Census Bureau (2008). The 2008 statistical abstract: The national cochrane.org
data book. Retrieved from http://www.census.gov/compendia/statab The National Institute of Medicine: http://www.ncbi.nlm.nih.gov
(Accessed February 27, 2008). The National Multicultural Institute: http://www.nmci.org
Velsor-Friedrich, B. (2000). Healthy People 2000/2010: Healthy appraisal Urban Institute: National Survey of America’s Families: http://www.
of the nation and future objectives. Journal of Pediatric Nursing, urban.org/center/
15(1), 54–59. U.S. Department of Health and Human Services, Health Resources and
Ward, S.L. (2002). Ask the expert: Balancing high-tech nursing with holis- Services Administration (HRSA), Maternal and Child Health Bureau:
tic healing. Journal for Specialists in Pediatric Nursing, 7(2), 81–84. http://www.mchb.hrsa.gov/
CONCEPT MAP
LEARNING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Describe a multilevel approach for prevention and intervention in addressing contemporary
health care issues.
◆ Discuss the major purpose and goals of Healthy People 2010 and their relevance to nurses.
◆ Explain social, political, economic, and cultural trends that affect the health status of women,
children, and families.
◆ Compare morbidity and mortality statistics between different populations and age groups of
women, children, and families.
◆ Evaluate current gaps in health care delivery systems that impact women’s, children’s, and
families’ health.
◆ Discuss examples of major barriers to accessing health care in the United States.
◆ Apply four bioethics principles to analyze ethical issues in maternal–child and family health.
◆ Describe trends in integrative health care as it is used with women, children, and families.
◆ Identify examples of public policies and programs that have benefited childbearing families.
◆ Describe vulnerable populations in the United States and the nurse’s role in advocating for
neglected and stigmatized persons.
◆ Discuss some potential concerns that a nurse of the future might face and what skills will
be needed.
25
26 unit one Foundations in Maternal, Family, and Child Care
The purpose of this study was to view culturally diverse women’s beliefs. They felt it would be easier to discuss difficult topics
perspectives on health care services as a framework for improv- with such a provider.
ing the quality of health care using Fongwa’s Quality of Care The study participants reported that their providers fre-
Model. The study design was based on an analysis of existing quently appeared rushed and overly busy, which was perceived
data from 15 focus groups that consisted of participants from as a barrier to receiving quality care. They believed that in order
5 different cultural subgroups. Findings from three previous to develop a trusting professional relationship, it was important
studies completed by the researchers were applied to Fongwa’s for the provider to take time and listen, remain nonjudgmental,
Model. The model was selected for its usefulness in identifying and ensure confidentiality. They felt that any care given should
ways to improve the health care system and enhance quality of be modified to fit the specific needs of the individual.
care from the perspective of diverse cultures. The original studies The women preferred that the clinical environment include
were conducted to gain women’s perspectives on alcohol and brochures and flyers written in appropriate languages. In their
drug use, smoking cessation, and domestic violence. Themes that view, these actions would help to create an environment
emerged from these studies were reflective of the women’s responsive to the participants’ needs, and supportive of their
perceptions of the care they received. The findings led the making changes to improve health.
researchers to reframe their focus for the improvement of health The researchers concluded that encouraging women’s input,
care by exploring three common aspects: patient/client/consumer, listening to their needs and modifying the system based on their
provider, and setting. suggestions would encourage the women to recognize their
From the patient/client/consumer perspective, women iden- power in improving their own health and the health care system
tified that they wanted to include their partners in health in general.
promotion activities. They also requested that education on
domestic violence be integrated into a variety of community 1. Based on the study do you believe that sufficient evidence
activities. The participants believed that this approach would exists to generalize these findings to all culturally diverse
allow them to access the information without fear that the populations?
perpetrator of violence would be suspicious of their activities. 2. How is this information useful to clinical nursing practice?
The women further stated that they preferred a female provider See Suggested Responses for Moving Toward Evidence-Based
of their own ethnicity or one who understood their values and Practice on the Electronic Study Guide or DavisPlus.
Di
intervention is to build community sidewalks, establish-
icy Surveillance Heal sease
Pol pment & ing a more inviting environment for children to bicycle or
o t Investh Eve
evel rcemen tiga nt
D nfo
E
tion walk to school. Communities have formed coalitions that
al Population-Based Ou
ci ting
e
tr advocate for neighborhood safety, so that walking, biking,
Ma So
ea
rk
and running can be safe. Some have looked at the strategic
ch
Population-Based geographical proximity of fast food restaurants to schools,
cy
Scr
and have brought those observations to public conscious-
oca
ee n
Case
ness. Fast food restaurants are clustered three to four
Adv
Fin
ing
d i
times more often within walking distances of schools
ng
Population-Based
(Austin et al., 2005). This deliberate geographical place-
Community
Organizing
Referral &
Follow-up
ment exposes America’s children to poor quality food that
is frequently inadequate for health promotion.
Industrial-Focused Other strategies are targeted at schools, such as altering
nt
Coa ing
eme
Ma Case
litio
d
nag
n
Community-Focused
have already done so on their own. Others are advocating
Co
io ed
lla
ns
at
bo
ra
Systems-Focused leg t
ti o
n De unc
F
ing back physical education courses in schools where they
Co
nsu
l t a ti
lth
Hea ing
have been eliminated.
on h
Counselling Teac Currently, only 8% of U.S. public schools require daily
physical education. Some schools collaborate with com-
munity health programs and screen for body mass index
Figure 2-1 The Public Health Intervention Model. (BMI) and refer overweight children for early intervention
and follow-up. Several schools have implemented the
Planet Health program, developed by The Harvard School
macro-level environment. Interventions are targeted of Public Health. The Planet Health curriculum is inter-
toward individuals/families, communities, and larger insti- twined with existing lessons already being taught in mid-
tutional and societal systems. Thus, broad determinants of dle schools, such as science, math, and English. Students
health such as environment, employment, insurance, class, who participated in the pilot Planet Health interdisciplin-
race, social support, access to health services, genetic ary studies increased their fruit and vegetable intake,
endowment, and personal histories can be integrated, decreased their television viewing time, and lowered their
making health care interventions more comprehensive BMI (Gortmaker et al., 1999).
Television presents another avenue for targeting obe-
and effective.
sity in children. Television is used more as an electronic
In short, the public health intervention model is
babysitter than ever before. According to a 2006 Kaiser
population-based, defines levels of practice, and has a com-
Foundation study, children younger than 6 years of age
prehensive prevention focus. There are 17 categories of
intervention tactics outlined in the model: social market- average 2 hours of media viewing per day (Kunkel et al.,
ing, advocacy, policy development, surveillance, disease 2004). It is “used by parents to help manage busy sched-
investigation, outreach, screening, case finding, referral, ules, keep the peace, and facilitate family routines such
case management, delegated functions, health teaching, as eating, relaxing, and falling asleep” (Rideout & Hamel,
counseling, consultation, collaboration, coalition building, 2006). Television viewing contributes to childhood obe-
and community organizing (Keller et al., 2004b). sity because it fosters physical inactivity as well as
exposes children to a bombardment of junk food adver-
tising (Fig. 2-2).
HOW THE INTERVENTION WHEEL WORKS The American Psychological Association has a task
The issue of childhood obesity provides a good example force that researches television advertising that is specifi-
for demonstrating how the Minnesota public health inter- cally aimed at children. The task force has learned that
vention model can be used to confront a contemporary children younger than the age of 8 do not yet have the
health problem. Approaches that are currently being used experience and knowledge to critically evaluate advertis-
to address the problem of childhood obesity range from ing messages, and they tend to accept advertising as fac-
those at the micro-level to the macro-level spheres of tual. American children view an average of 40,000 televi-
practice. sion ads per year (Kunkel, 2001). Many messages are
Childhood obesity has traditionally been framed as an aimed at marketing unhealthy foods to children, and are
issue of personal or parental responsibility. Viewing child- aired strategically at times when children are most likely
hood obesity as merely a personal responsibility excuses to watch. One study demonstrated an average of 11 food
society’s responsibility and limits shared solutions. Nurses commercials per hour during children’s Saturday morning
need to broaden their scope to examine health processes cartoons (Kunkel, 2001). Therefore, an average child is
more globally. For example, nurses need to ensure that exposed to approximately one food commercial every five
social, political, and structural conditions are addressed minutes. Advertising strategies for snacks, sugared cere-
so that it is possible for people to achieve health. als, soft drinks, and fast food contribute to the epidemic
There are many interesting and promising strategies for of childhood obesity, and the task force is urging policy-
addressing childhood obesity. Some urban areas are pro- makers to better protect young children from this expo-
actively collaborating to redesign their communities. One sure (Kunkel et al., 2004).
28 unit one Foundations in Maternal, Family, and Child Care
Despite large health care expenditures, health care and lagging behind countries with half the national income
other resources are unevenly distributed in the United per capita and with a fraction of the expenditure on medi-
States. Persistent health disparities remain disturbing. An cal care. Certain national health problems, including
African American baby, for example, is more than twice as acquired human immunodeficiency virus (AIDS), drug
likely to be low birth weight and two and one-half times abuse, family violence, and homelessness continue to sig-
more likely to die during the first year of life than a Euro- nal special cause for concern. More than 3 million people
pean American baby. Sudden infant death syndrome (SIDS) will experience homelessness in a given year and families
is more than three times higher in American Indian and with children comprise 33% of the homeless population.
Alaska native babies than in European American babies. In addition, more than 38 million individuals living in the
Additional information about health disparities can be United States have experienced what has been termed
accessed at the Centers for Disease Control’s Web site, “food insecurity” (Los Angeles Homeless Services Coali-
http://www.cdc.gov/. tion [LAHSC], 2007).
To understand better the myriad of issues that impact
Now Can You— Relate the value of having national the nation’s health, it is helpful to consider some of the
Healthy People 2010 goals to align major trends that exert an influence on health status.
health care improvement efforts? These include the aging population, ethnic diversity,
health care disparities, childbirth trends, and patterns of
1. Discuss the two overarching goals of Healthy People 2010?
2. Define the three levels of prevention and give an example
physical fitness.
of each?
3. Describe prevention measures that have made a difference Now Can You— Discuss why analysis of statistical health
in reducing heart disease, the leading cause of death in the data in the United States is useful?
United States? 1. Define the term epidemiology and describe how analysis of
epidemiological data may guide public health interventions?
2. Discuss why mortality/morbidity biostatistics about disease
and illness are useful?
Overview of Selected Societal Trends 3. Describe three health problems in the United States today
What is meant by the term “health”? Is health merely the that are of particular concern?
absence of illness? If nurses are to effect improvements in
national health status, a more comprehensive definition of
health is needed. A holistic definition would include more AGING POPULATION WITH MORE CHRONIC
than the physical body and instead extend into the inter- ILLNESSES
connected mental, social, and spiritual realms. Health The population of persons ages 65 and older (one in eight
would encompass energy levels, balance, and resiliency. in the United States) is growing steadily. This trend is
The World Health Organization defines health as a state of attributed to the present increase in life expectancy and is
complete physical, mental, and social well-being and not expected to continue as the baby boom generation ages. It
merely the absence of disease or infirmity. Purnell and is predicted that by 2030, one in five persons will be
Paulanka (2003) expand this definition by describing elderly (U.S. Census Bureau, 2006). With the increased
health as a state of wellness that includes physical, mental, length of life comes more chronic illnesses, such as
and spiritual states and is defined by individuals within strokes, diabetes, arthritis, and Alzheimer’s disease. Man-
their ethnocultural group. agement of chronic illnesses presents a major challenge to
Health as a concept may be self-defined, but to examine health care systems that is expected to continue well into
a population’s health, one is limited to using health status the years ahead.
indicators that can be directly measured. The health of a
nation is measured by collecting statistical data and mak-
ing inferences. Epidemiology is the statistical analysis of INCREASED RACIAL AND ETHNIC DIVERSITY
the distribution and determinants of disease in popula- The composition of the U.S. population is rapidly chang-
tions over time. Mortality (death) and morbidity (ill- ing, and racial and ethnic diversity (difference) is greater
ness) rates are examined for trends. For example, epide- than ever before. The historically designated U.S. minority
miological studies of heart disease reveal how many populations can be classified as Hispanic, Black/African
people develop heart disease, what type of heart disease American, Asian, and Native American. The percentage of
they have, and what factors are associated with heart minority populations increased from 16% in 1970, to 27%
disease, such as smoking, obesity, diet, hyperlipidemia, in 2006, and it is projected to rise to 50% of the popu-
working hazards, family dynamics, and other environ- lation by 2050, if current trends continue. As the popula-
mental factors. Mortality rates provide information about tion becomes more diverse, delivering culturally compe-
where nursing efforts should be focused. Morbidity rates tent care becomes crucial for nurses. The delivery of
identify populations where the illness occurs most health care within a culturally appropriate framework
frequently. will help patients to feel better satisfied with their care
There have been many achievements that translate to and empower nurses to contribute more actively to the
measurable improvements in health status indicators. Yet healing process.
the nation still has a long way to go. According to the Everyone, regardless of his or her professional status, is
United Nations 2006 Human Development Index, the interested in the concept of racial and ethnic diversity.
United States ranks 38th in the world in life expectancy, However, a most important point to remember is that
30 unit one Foundations in Maternal, Family, and Child Care
racial and ethnic categories (Hispanic, Black/African reviewed nursing research from the 1970s to the present.
American, Asian, European American, and Native Ameri- One study examined by these authors was an investiga-
can) are constructed by social systems (i.e., people) and tion by McDonald in 1994, which retrospectively explored
their differences are based on visible physical characteris- pain medication administration after uncomplicated
tics. In scientific terms, these differences are phenotypic appendectomies. Record reviews revealed that “there were
genetic expressions. There is no known biological basis large and unexplainable differences in total doses that
for what society calls “race.” Scientists have noted that were received by Asian, Black and Hispanic Americans
there is more diversity within each of these artificial cate- compared to White patients” (Porter & Barbee, 2004,
gories than there is between them. Migration, intermar- p. 21). These findings provided a clear example of how
riage, and genetic modifications have served to form one nurses’ beliefs and values influenced their clinical
race, the human race. Despite the fact that “race” cannot practice.
be supported by scientists as a biological concept, as a
social concept (i.e., how persons see one other and label Now Can You— Discuss health inequities and limited
one other) it is still very real. access to health care?
1. Identify both the age and racial/ethnic diversity trend of the
DISPARITIES IN HEALTH CARE U.S. population and discuss what that means in terms of
nursing and health care provision?
Health disparities can be viewed as the extra burden car- 2. Describe the greatest factor that limits access to health care?
ried by certain racial, ethnic, gender, and age groups for 3. Explain the roles that discrimination, stereotypes, and racism
different health problems. Statistics indicate that the risk play in perpetuating health inequities?
of death for women of color, for example, is nearly four
times higher than it is for white women. More than half
of 45- to 64-year-old African American women have
hypertension, an incidence that is twice the rate for CHILDBIRTH TRENDS
European Americans. Although Hispanic and African Today, many women are choosing to delay childbirth, and
American women have a lower incidence of breast can- this trend is believed to be due to the desire to complete
cer than European Americans, they experience greater education and to securely establish careers, relationships,
mortality from this disease. For reasons that include and finances. In 1970, the average age for a woman to
gender bias and difficulty establishing a correct diagno- have her first baby was 23.4 years; in 2001, the average
sis, a woman who presents to the hospital with symp- age had risen to 27.6 years. In 1970, 9% of first-time
toms of a heart problem is less likely than a man to mothers were older than age 30; by 2001 that proportion
receive a heart catheterization or to be given certain had risen to 34%. Because fertility decreases with age,
heart medications. The same scenario applies to Hispan- some couples may miss the opportunity to have children
ics and African Americans of both genders. altogether. Other related trends in society include
Access to health care is disproportionate among differ- children leaving home later and forming unions such as
ent population groups. The status of one’s health insurance marriage at an older age.
remains the greatest factor that determines access. Insur- In addition, more women are electing to give birth by
ance status is also the largest predictor of the quality of the Cesarean section even when there is no medical reason for
health care that one receives. Yet insurance status alone doing so. Patient-choice Cesarean births in 2001 accounted
cannot explain racial and ethnic disparities. Disparities for 1.87% of births. However, by 2003, this figure had
exist even when clinical factors, such as comorbidities, risen to 2.55%, representing an increase of 36.6% in only
age, stage of disease presentation, and severity of disease, 2 years (Wax, Cartin, Pinette, & Blacksone, 2004). Much
are taken into account (Issacs & Schroeder, 2004). controversy continues to surround this trend, since a
Many other factors, such as the role of discrimination Cesarean birth is major abdominal surgery with all of the
and stereotyping in health care settings, must also be con- accompanying risks.
sidered when health disparities are analyzed. Nurses have
long considered themselves to be “caring professionals.”
However, nurses are not immune from societal beliefs and PATTERNS OF PHYSICAL FITNESS
values that result in discrimination and stereotyping of Physical inactivity and its consequences are becoming a
different populations. Nurses must continually remain significant health problem for families in the United
vigilant for signs of these attitudes in themselves, and in States. According to the Centers for Disease Control and
turn, develop an awareness of how they influence their Prevention ([CDC], 2005), only 13% of American women
nursing practice. To heighten awareness of these issues, “engage in the recommended physical activity sufficient
the Institute of Medicine published Unequal Treatment: to reduce the risk of cardiovascular disease and other
Confronting Racial and Ethnic Disparities in Health Care in chronic debilitating diseases” (Peterson, Yates, Atwood,
2002. This compilation of studies clearly demonstrated & Hertzog, 2005, p. 94). Research by the American Heart
that racism does indeed exist in medicine—and nursing is Association has shown that physically active women have
no exception. a 60% to 75% lower risk of cardiovascular disease than
Racism can be defined as the assumption that one’s inactive women (Peterson et al., 2005).
“race” is superior to others’, resulting in unfair and harm- Obesity has made a steady climb upward. More than
ful treatment. Racism can include attitudes and behaviors, half of all Americans are overweight or obese (Ogden
it can be overt or covert, and it can exist at the individual et al., 2006). It makes sense that increasing physical activ-
and the institutional levels. Porter and Barbee (2004) ity and reducing obesity are underscored in Healthy People
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 31
2010 as a primary means for reaching the nation’s major children reach school age, interventions are less likely to
health outcome goal: increasing the quality and years of be effective if they have already begun to fail academically
healthy life. or socially. Today, a number of infant and child develop-
ment screening tools have been developed and refined.
THE INTERSECTION OF RACE, CLASS, Unfortunately, however, close to one-third of develop-
AND HEALTH mental or behavioral disorders are not detected until
children begin to attend school (Glascoe, 2000; Tebruegge,
While great strides have been made in family health, the Nandini, & Ritchie, 2004).
progress achieved is not universal. The gap is widening The leading causes of death by age groups are revealing
between persons in lower and upper socioeconomic and offer clues about how to prioritize nursing interven-
classes. “Upper class” in this context refers to those who tions. SIDS is the leading cause of death among infants
live in contented neighborhoods, have a quality educa- between the ages of 1 and 12 months. Accidents, or unin-
tion, and bring home adequate wages. Persons from the tentional injuries, constitute the leading cause of death in
lower classes, many of whom are African American, His- children older than 1 year of age, which suggests that
panic, or Native American, live shorter and less healthy more community education and effort are needed to
lives. Eighteen percent of all children in the United States address child safety hazards. Although the incidence var-
currently live in poverty (U.S. Census Bureau, 2006). ies by age group, congenital malformations and malignant
It is important for nurses to work toward eliminating neoplasms shift between the second and fourth place for
discrimination and racism, but if they are to make a differ- the leading cause of death in children.
ence in rates of illness and premature death, it is also Violence also takes a harsh toll on America’s children.
important to work toward improving socioeconomic Homicidal assaults are the third leading cause of death of
opportunities for all Americans (Isaacs & Schroeder, children in the 1- to 4-year-old age group, and also in the
2004). All too often, life and health choices are limited by 15- to 19-year-old age group. Suicide is the third leading
socioeconomic status. The vision of the “American dream”
cause of death in teenagers and young adults, ages 15 to 24;
and the ideology of “personal choice” obscure the fact that
it is the sixth leading cause of death among children ages
there are enormous constraints and limited choices that
5 to 14. Family violence, child maltreatment, and violence
accompany poverty. A hungry and desperate person loses
in schools such as bullying are also issues of great concern.
the capacity to choose.
Anthropologists such as Sanday (1994) note that in
American culture, “inter-personal violence has become a
Now Can You— Identify certain population trends that national pastime” (p. 2). The most watched television
relate to health? shows of 2005, Law and Order and CSI, were routinely
1. Discuss U.S. fertility trends and trends toward surgical birth based on violent acts. It is estimated that the average child
and what it means for women’s health? will witness 9000 media murders by the time he or she
2. Discuss the trend toward inactivity in the United States and finishes elementary school (Kunkel, 2001).
describe what consequences might be seen in the future Violent video games are a more recent trend and
health care status of Americans as a result? research is still sparse regarding their effects on children.
3. Describe the role poverty plays in increasing health care A study by Anderson and Dill (2000) suggests that they
disparities? may be even more harmful because they are interactive
and the aggressor is the one glorified and with whom the
player identifies.
The Current Health Status of the Nation There are other potentially preventable children’s
health issues. Lead exposure provides another example
INFANTS AND YOUNG CHILDREN where early intervention and teaching can have a posi-
tive impact on children’s health. Exposure to lead can
The plummeting rates of infant mortality in the past cen- occur from contact with lead-based paint in older homes;
tury allowed health care professionals to move forward contaminated soil; a parent’s occupation; certain vinyl
beyond infant survival and focus on prevention and early mini-blinds; various folk remedies; living close to major
intervention with children’s health. Ideally, health pre- highways; and from contact with imported pottery, jew-
vention strategies targeting children’s health would begin elry or cosmetics. The American Academy of Pediatrics
as early as preconception. It has been learned, for exam- (AAP) recommends that all children between the ages of
ple, that folic acid supplementation helps to prevent cer- 1 and 2 years receive testing for lead exposure, since 25%
tain birth defects. A fetus’ exposure to harm could poten- of homes presently occupied by children younger than
tially be prevented if a woman were counseled before the age of 6 have known lead contamination. Lead expo-
pregnancy about the harmful effects of alcohol, tobacco, sure has been linked to a number of medical and devel-
toxoplasma, and other teratogens (substances that opmental problems, including anemia, seizures, and
adversely affect normal cellular development in the mental retardation.
embryo/fetus). The fetal neurological system, especially A trend not well understood is the alarming increase in
the brain, is extremely vulnerable to even small amounts childhood asthma, a condition that constitutes the most
of potentially toxic substances. common cause of time missed from school. Asthma and
Early intervention is especially important when it allergies account for the loss of an estimated 2 million
comes to growth and developmental delays. There is a school days per year. In fact, the number one reason for
well established link between developmental delays and pediatric emergency room visits due to chronic illness is
learning difficulties (Shonkoff & Phillips, 2000). Once for asthma-related problems.
32 unit one Foundations in Maternal, Family, and Child Care
Other trends in children’s health status include a along with demands to meet a cultural ideal, while at the
significant rise in the diagnoses of attention-deficit/ same time deal with pressure to conform to gain peer
hyperactivity disorder (ADHD) and developmental acceptance. The adolescent may have to cope with changes
delays due to autism. Children with ADHD are typically in appearance such as acne and awkwardness. Reproduc-
fidgety, act without thinking, and have difficulty focus- tive issues also arise. Girls must bridge the experience of
ing. ADHD now affects 4% to 8% of all school-age chil- menses, while boys encounter embarrassing erections and
dren (Glascoe, 2000). Autism is the third most common emissions. Issues such as sexuality, teen pregnancy, and
type of developmental delay in the United States. An sexually transmitted infections may pose further stum-
autistic child presents as a solitary child and notably bling blocks. Alcohol, tobacco, and drug use as well as
lacks social responsiveness to others. Autism affects lan- bullies, gangs, and school violence may force more hur-
guage, which is absent, abnormal, or delayed. Autistic dles in the envisioned obstacle course for the child to seek
children may demonstrate a strong resistance to change a full and healthy life.
and show an abnormal attachment to objects. The preva- One way nurses can make a difference is by learning and
lence of this disorder is difficult to gauge, since autism is teaching others how to listen to children respectfully and
not an easily accepted diagnosis, but it is estimated that value their experiences. Nursing can be called a “narrative
it affects approximately 6 out of every 1000 children profession” since patients present first and foremost with
(Charles, 2006). their narratives of symptoms and illness. Children do so as
One way to visualize children’s health is to view it as well but it takes patience to really listen.
an obstacle course. The fortunate child is one who was
desired and planned for before conception and who has
parents with a good genetic profile, adequate resources, Nursing Insight— Listening to our youngest
and who harbor no chronic illnesses. The fortunate patients
child’s mother would have healthy eating habits; main- Children tell us that we do not respect their expertise. The
tain her ideal body weight; access early and regular pre- child who lives with an illness day by day holds the greatest
natal care; and abstain from the use of alcohol, tobacco, insight into what it is to experience that illness. They come to
and other harmful substances. The child who does well know what the illness feels like, what treatments are neces-
through fetal life must then encounter birth and avoid sary, what works, and what doesn’t. They often develop quite
major complications such as prematurity or aspiration sophisticated knowledge about their medications and treat-
pneumonia. ment. The difficulty is that we do not give this knowledge and
Following birth, the child must encounter the hurdles experience the same value as that held by the adults around
of the first year of life to avoid becoming an infant mortal- them. Children also tell us that we do not give them uninter-
ity statistic. She has to dodge SIDS and shaken baby syn- rupted time to tell their story their way. Children, with their
drome, and needs to be taken to health care providers for varying cognitive and communication abilities, need time to
the hectic schedule of immunizations needed to prevent explain their illness experience and time to respond to our
major childhood diseases. She must be fed and stimulated questioning. Sometimes, through adult eyes, their way of tell-
enough to grow physically, psychologically, socially, and ing us seems long and convoluted, and we therefore cannot
emotionally. The child whose mother breastfeeds her resist the temptation of jumping in or interpreting what we
gains an added bonus of immunities. think they are trying to say. Long story-telling does not fit well
As the child matures, there are more obstacles to con- in the busy world of practice (Dickinson, 2006).
front. The child who attends day care faces a significantly
higher risk of infections. The tendency toward obesity and
all the tempting fast food commercials on television offer Two of the priority goals for children in Healthy People
additional stumbling blocks. She has to dodge all kinds of 2010 address childhood vaccinations. One goal is to
accidents that cause unintentional injury, tackle each achieve and maintain effective vaccination coverage levels
developmental milestone, and land solidly in the “nor- for universally recommended vaccines to 90% of children
mal” grid of childhood growth charts. Ideally, she will not from 19 to 35 months of age and increase routine vaccina-
develop asthma, autism, or ADHD. She will hope to avoid tion coverage for adolescents. The second goal is to reduce
the stumbling blocks of sexual abuse, or coping with vaccine preventable diseases as follows: (1) measles,
poverty, and poor housing in unsafe neighborhoods. mumps, and rubella to zero cases and (2) pertussis in
While parents work, the child’s day care environment may children younger than 7 years to no more than 2000 cases
be laden with communicable childhood illnesses to be per year (CDC, 2005).
avoided. School-age children need to dodge being one of
the 16% who are bullied (Volk, Craig, Boyce, & King, Now Can You— Describe nursing actions that can serve to
2006). The obstacle course continues to pose challenges improve the current status of children’s
throughout childhood, and when adolescence arrives, the health in the United States?
child again faces new foothills and crags. 1. Describe two benefits of preconceptual health guidance and
early intervention?
Adolescents
2. Discuss major causes of child mortality and describe nursing
Adolescents represent a population group with a set of interventions that can make a difference?
issues uniquely their own. With regard to health care, 3. Compare and contrast communication strategies for children
adolescents are most often at risk for falling through the with those of adults?
cracks. The adolescent must confront issues of self-esteem
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 33
trends in perinatal health. For example, women are start- Health Care Delivery
ing their prenatal care earlier. In the latest CDC Behav- Changes in health care delivery are omnipresent. The cur-
ioral Risk data (2004), 83.9% of women initiated prenatal rent health care delivery system is less of a system than it
care during the first trimester. Smoking during pregnancy is a collection of entities. Health care today is corporate,
decreased from 20% in 1989 to less than 11% in 2003. and thus is more market driven than based on the com-
Also, today, there is more published information about mon good or the actual needs of populations. Care is
proper nutrition, folic acid, and healthy lifestyles than increasingly centralized into major medical centers. Small
ever before. hospitals are closing due to an inability to remain solvent.
There is evidence that contemporary health care systems Managed care is the rule rather than the exception, and is
are more cognizant of women’s needs. Children maneuver- expanding as more and more health care providers and
ing giant balloons as they eagerly bounce down the post- institutions are pressured into joining networks for health
partum hall en route to visit their mothers and newborn care delivery. Many of the provider networks operate on
siblings is a welcome and familiar sight. There is more capitation, where they negotiate and are paid a set amount
understanding in research circles about the differences in in order to provide complete health care for a certain
the health care needs of women and men. Women are being number of clients.
empowered more in health care settings, enabling them, in Quality of health care and consumer satisfaction are
turn, to make better health care decisions for their families. the drivers of health care, just as in the retail industries.
National databases regarding quality of care and spe-
Now Can You— Discuss elements of the current health cific conditions are only now beginning to be orga-
status of American families and women? nized. Although a dearth of information is available on
the quality of health care in the United States, this is
1. Discuss how recent national trends have affected families’
changing as the focus on accountability in government
access to health insurance?
and institutions moves to the forefront. The trend
2. Identify the three leading causes of death in women in the
toward increased media attention concerning health
United States?
care errors represents a vivid example of a growing
3. Describe a state-wide model developed by nurses to improve
demand for accountability. Workplace satisfaction and
pregnancy outcomes and reduce maternal mortality?
nursing shortages are issues that need to be addressed
as well.
SOCIOECONOMIC INFLUENCES AND TRENDS TANF replaces the former public assistance program that
The most egregious effects of inequality in the United was known as Aid to Families with Dependent Children
States are seen on the streets of the inner cities among (AFDC). There is a maximum period that a person is
persons with little hope for the future. The more subtle allowed to receive public assistance at one time, and
but far-reaching effects are seen in workers with insecure a lifetime limit. The mandates apply to pregnant women
jobs. These are persons who rightly fear that major illness as well as those with infants older than the age of
would result in personal catastrophe. Many single moth- 3 months.
ers report that they are merely one sick child away from The Wage Gap
losing their jobs and entire paychecks (Edin & Lein,
Gender inequity persists and the ratio of full-time work-
1997; Redfern-Vance, 2000).
ing women’s weekly earnings to those of men was 77 cents
In addition, there are the elderly who must expend
to the men’s dollar in 2004. Proportionately, more fami-
nearly all of their resources before they can accept pub-
lies are being supported by women today than ever before.
lic funding for needed long-term care. For the elderly,
Three out of five U.S. families were headed by women and
the cost of medications can add up at the same rapid
22% of all children in the United States lived in mother-
rate as do the chronic health conditions associated with
only families in 1990, an increase of 11% since 1970 (U.S.
the aging process. There are also those who may be clas-
Census Bureau, 2006).
sified in a low- or a high-income group, may be young
or may be elderly, may be living in a busy metropolis, in
Now Can You— Discuss aspects of political and
suburbia, or in a lonesome rural area, and yet maintain-
socioeconomic influences that impact
ing lives that offer little opportunity for control or
the nation’s health?
meaningful social participation. Certainly these inequal-
ities are, in part, inequalities in income. However, more 1. Identify and discuss three socioeconomic trends that have
than an inequality of income is at issue. In a fundamen- a negative impact on the health of persons living in the
tal sense, these inequalities are reflective of a society United States?
that works well for those at the top, and far less well for 2. Describe two public programs intended to improve the
everyone else. health of American women, children, and families?
3. Describe what is meant by the phrase “the feminization
The Increasing Rate of Poverty of poverty”?
Most persons consider items like adequate food, housing,
clothing, heat, electricity, telephone service, and essential Communications and the Digital Divide
health care as necessities rather than luxuries. This is not One of the factors promoting patient empowerment is
true for everyone. Overall, 12.7% of Americans were liv- the ready access to health care information over the
ing in poverty in the United States in 2004. The number Internet. Fox (2006), reporting on the Internet and
has risen each year since 2000 (U.S. Census Bureau, health, found that “looking specifically at online discus-
2006). Economic changes, racial inequality, suburban sion groups devoted to health and well-being, the audi-
movement, manmade and natural disasters, and industri- ence is also stable – about half of internet users helped
alization all contribute to poverty circumstances. someone else through an illness in the past two years;
one in five internet users dealt with their own illness
The Feminization of Poverty during that time” (p. 5).
Women are the most impoverished demographic group in In modern society, however, there exists what has been
American society (Edin & Lean, 1997). In 2005, 56% of termed the “digital divide” (Wagner, Bundorf, Singer,
persons older than age 18 living in poverty were women. & Baker, 2005). Families with discretionary income and
Single mothers with their children constitute 82% of the with some formal education are more likely to access
poverty population. More than 60% of U.S. women with health information and educational resources from the
children younger than the age of 2 now work outside the World Wide Web. Those with less income, in particular
home (U.S. Census Bureau, 2000). those from racial and ethnic minority backgrounds, are
In 2000, one-fifth of all U.S. children were living in less likely to have access to electronic materials. In addi-
poverty. Between 2000 and 2003, the number and per- tion, there is what is called the “gray gap,” referring to
centage of single mothers living in poverty increased seniors who do not use Internet technology. Approxi-
while the percentage of single mothers with jobs fell. At mately 68% of Americans reported ready access to the
the same time, poverty among children rose, and the Internet in 2005. In families with incomes of $75,000,
number of children living below half of the poverty line 95% of children have a computer at home. One out of five
(about $620 a month in 2003 for a single mother with two Americans claims they have never used the Internet or
children) increased by nearly 1 million. These structural e-mail. Again, the “digital divide” separates and discrimi-
features of U.S. society have contributed to what has been nates against the poor or elderly who do not have access
coined as the “feminization of poverty.” to computers or who have not learned computer skills
Single mothers face oppressive barriers to achieve the (U.S. Census Bureau, 2007).
“economic self-sufficiency,” now legislatively prescribed
for them, commonly referred to as “welfare to work.” The Vulnerable Populations
essence of the new legislation, entitled Temporary Assis- Bellah, Madsen, Sullivan, Swiler, and Tipton (1991), who
tance for Needy Families (TANF), is that work now conducted a landmark study of mainstream American
becomes compulsory and lifetime limits are imposed. culture, articulated a problem described as “excessive
36 unit one Foundations in Maternal, Family, and Child Care
individualism.” The cultural norm of individualism focuses UNDOCUMENTED IMMIGRANTS AND REFUGEES. Undocu-
attention away from critical societal issues such as the mented persons who enter the United States illegally in
ever-increasing gap between the “haves” and the “have- order to work constitute another highly vulnerable popu-
nots,” as evidenced by the alarming rise in homelessness, lation. Many persons are from Mexico or Central America
hunger, and violence. The dark side of individualistic and are drawn to the United States for economic reasons
thinking advocates a policy of “choosing and creating your or to escape political conflicts. Undocumented persons
own reality” which then leads to “blaming the victim” and are willing to work in what are considered the lowest
ignoring the social context, where “choices” are not, and paid and least desirable occupations in the United States.
have never, been equal. As a society, it behooves Ameri- They generally have no job security, health care access, or
cans to focus on a shared vision and goals, such as those decent housing. Most face language barriers as well.
afforded to us by the Healthy People 2010 initiative. To do Without financial resources, hospital and health clinic
so, it is important to consider the vulnerable populations doors are generally closed to them. In addition, this pop-
in the United States. As Aday (2001) notes, “as members ulation is experiencing mounting resentment from a
of human families and communities, we are all potentially public that is leaning more and more toward isolationism
vulnerable” (p. 53). Vulnerability encompasses threats to since the World Trade Center attack (Goldman, Smith, &
physical and psychological health, as well as vulnerable Sood, 2006).
social circumstances and stages within the life course.
PERSONS RESIDING IN RURAL AREAS. Persons living in rural
HOMELESSNESS. Homelessness is rising among all popu- neighborhoods are less likely to have access to quality
lations, but most noticeably for families. There is an health care. Primary care providers are increasingly reluc-
increase in families at the extreme poverty level (about tant to locate in rural areas. Many small, rural hospitals
$17,000 for a family of three in 2007). Income levels such have been forced to close because of centralization of
as this are woefully inadequate to maintain a household. intensive care services.
The increase in homelessness has resulted in more and
more entire families who regularly visit homeless shelters ABUSED AND NEGLECTED CHILDREN. The National Child
and soup kitchens across the country. In New York City, Abuse and Neglect Data System (NCANDS) is the federal
73% of the shelter population comprises children and reporting system that analyzes data on child abuse that are
their parents. The random collection of community shel- collected on an annual basis. In 2006, NCANDS reported
ters and free food kitchens that have proliferated through- that the information obtained in the 2004 count included
out the United States during the past several years have 3 million cases of reported child abuse. Child abuse can
had a difficult time keeping up with the needs. It has not take many forms. The most common is child neglect, which
helped that recent policy changes have resulted in the can mean withholding food, clothing, shelter, love, supervi-
elimination of several programs that previously served as sion, or medical attention. Physical and child sexual abuse
safety nets for health care and housing subsidies. Persons are other types and it is not uncommon for all three forms
displaced as a result of wars and disasters have also added of abuse and neglect to overlap. According to the American
to the number of those desperately seeking assistance. Academy of Pediatrics, study estimates predict that one out
For homeless persons and families, health is a momen- of four girls and one out of eight boys will be inappropri-
tous challenge. The poverty, stigma, poor nutrition, and ately touched sexually by the time they turn 18 (Kellogg
increased susceptibility to violence and mental illness all and the Committee on Child Abuse and Neglect, 2005).
take their toll. Access to health care is a problem due to NCANDS reports that three children die of child abuse
lack of transportation and finances, so that hospital emer- in the home each day (U.S. DHHS, 2007). Fewer than 1%
gency rooms are often the only option for medical atten- of children are abused by strangers. Children are most
tion. It is difficult to obtain accurate numbers on the commonly abused by someone they know. In 79% of
homeless population but the Partnership for the Homeless cases, the perpetrator is a parent. Child abuse can set up a
estimates that currently there are about 2 million home- perpetuating cycle of suffering and more violence later in
less persons in the United States, with 8105 homeless life, potentially reaching into future generations.
families in New York City alone. Nurses have a legal obligation to report any observed
known or suspected child abuse to child protective ser-
Nursing Insight— Putting Homelessness into vices. Thus, it is critical for nurses to learn to assess the
Proper Perspective signs and symptoms of child abuse (see Chapter 23).
To enhance understanding of the magnitude of the problem VICTIMS OF SEXUAL VIOLENCE. Historical beliefs and atti-
of homelessness in the United States, it is useful to consider tudes toward women continue to influence women’s lives
the following statistics. These figures relate to families who and health. In the past, women were viewed as physically
were sleeping in Department of Homeless Services (DHS) and psychologically inferior to men. They were denied
city shelters in New York City during 1 month in 2005: rights and privileges routinely granted to men, such as
• 8105 families owning property and voting.
• 13,062 children Sexual violence haunts the lives of all women, both
• 11,854 adults with its frequency and its impact. In a U.S. Department of
• Average family size: 3.18 Justice, Office of Justice Programs, National Violence
• Average length of stay: 361 days Against Women Survey (NVAWS), nearly one out of five
• 32.3% remain in shelters more than 1 year to six women report having been raped (Tjaden &
Source: http://www.partnershipforthehomeless.org/ Thoennes, 2000). Some have called the United States a
“rape-prone” society (Buchwald, Fletcher, & Roth, 1995).
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 37
Sexual violence is linked with deleterious long-term The Girl Scouts of America organization has developed
psychological, social, and physical effects such as sub- a unique program for girls who are separated from their
stance abuse, major depression, gynecological disorders, mothers because of incarceration (Hufft, 2004). Called
and others (Koss & Harvey, 1991; Wolfe, 1996). Unwanted “Girl Scouts Behind Bars,” this program is similar to regu-
sexual attention also devalues women and takes a toll on lar scouting programs and has the same goals of self-
their health. Lewd sexual comments, cat calls, whistling, esteem building and incremental accomplishments. It
and intrusive looks are demeaning actions that negatively includes prison visitation between mothers and daugh-
affect women’s health (Esacove, 1998). ters, and especially targets social risks for which these
young women are more vulnerable. The program also
VICTIMS OF INTIMATE PARTNER VIOLENCE. It is difficult to attempts to help incarcerated women hone their parenting
obtain accurate numbers about intimate partner violence skills. Forensic psychiatric nurses play an important con-
(IPV) because of varying definitions and widespread under- sulting role in this national program, now operational in
reporting. The National Violence Against Women Survey 13 states.
(National Institute of Justice and the Centers for Disease A nurse who is able to deliver culturally competent
Control and Prevention) revealed that nearly 5.3 million care to incarcerated populations quickly becomes cogni-
incidents of IPV occur each year among U.S. women ages zant of the challenges as well as the importance of raising
18 and older, and 3.2 million IPV incidents occur among standards and improving the present system. Work per-
men. The majority of reported assaults did not result in formed with this vulnerable population is significant far
serious injury and consisted of pushing, grabbing, shoving, beyond the prison walls. Nearly 95% of prisoners will
slapping, and hitting (Tjaden & Thoennes, 2000a). eventually be released into communities where they will
Research suggests that nurses in clinical settings are likely face poverty, stigma, unemployment, and deficien-
still reluctant to question patients about intimate partner cies in health care.
violence. Nurses need to routinely ask the violence screen-
ing questions and offer to help abused patients develop a PERSONS WHO ARE SUBSTANCE ABUSERS. Substance abuse
safety plan. It is important for nurses to know that the is a major health issue for families. Unfortunately, chil-
most dangerous times for abused women are during preg- dren are often the ones who suffer the most. Children in
nancy and when a woman tries to leave her partner. families with substance use problems are likely to be
abused and neglected. These same children are also more
GAY/LESBIAN/TRANSGENDERED INDIVIDUALS. Studies repeat- likely to become substance users themselves. See Chapters
edly demonstrate that access to sensitive health care for 11 and 23 for further information.
gay, lesbian, and gender transitioning patients is extremely
limited. Stigma and prejudice continue to prevail in atti- Now Can You— Identify vulnerable populations of women,
tudes toward those living an “other than heterosexual” children, and families that exist in the
lifestyle (see Chapter 6 for further discussion about United States today?
specific health issues among this population).
1. Identify and describe four vulnerable populations in the U.S.?
INCARCERATED WOMEN. An invisible population of mar- 2. Describe the population group at present experiencing the
ginalized women exists within the hidden pockets of the largest rise in homelessness?
richest country in the world. One hears very little about 3. Explain why undocumented immigrants are considered a
incarcerated women, yet they currently inhabit U.S. jails vulnerable population?
and prisons in ever increasing numbers, with a sixfold
increase during the past 20 years (Braithwaite, Arriola,
& Newkirk, 2006). The growth rate of women prisoners PERSONAL AND CULTURAL INFLUENCES
has now bypassed the growth rate of male prisoners, and at AND TRENDS
present, women constitute 10% of the total inmate popu- The world of today has dramatically changed from the
lation (Hufft, 2004). In this country, which has the highest era when telephones, televisions, and airplanes were
incarceration rate in the world, there are approximately giant novelties. Now nursing students “text message”
1 million women behind bars. friends on their cell phones in real time. The popula-
As a population, incarcerated women are not healthy. tion relies on mass media for news and entertainment
They tend to have a myriad of health problems, particularly and the electronic gaming industry is thriving. Even
illnesses that stem from the stresses of poverty, physical dating relationships have changed. According to the
and sexual abuse, addiction, and motherhood. Imprisoned U.S. Census Bureau, of the 44% of American adults
women frequently do not have access to the benefits of who are single, 40% have tried online dating (Madden
health education. Mental health issues abound in this vul- & Lenhart, 2006). The global education businesses
nerable population as well. that use e-learning are estimated to climb to a worth of
More than 70% of incarcerated women are mothers. $212 billion by the year 2010.
This is an issue that greatly impacts the health of families. Other cultural changes include an increase in lan-
Approximately 1.3 million minor children have no mother guage barriers and cultural differences within the U.S.
to care for them on a daily basis. Inevitably, children are population. There is also a cultural component to many
affected by the abrupt changes commonly associated with health issues. For example, the dramatic rise in eating
incarceration of a parent. They may experience a sudden disorders demonstrates how present-day popular culture
change in caretaking arrangements, social stigma, the can strongly influence health. Media images of so-called
potential for abandonment, and the loss of family support “perfection” flood the media, yet these images rarely
and financial resources. represent healthy role models.
38 unit one Foundations in Maternal, Family, and Child Care
delivering health services across care settings. The United means that all patients should be treated equally. Discrimi-
States leads the world in its investment in biomedical nation should not occur based on social or economic status
technology, and owns 85% of the intellectual property or type of illness.
associated with biotechnology. Telemedicine/home tel- The problem is that it is not unusual for those princi-
ecare provides one example of an innovative approach ples to be in conflict. Consider, for example, the Jehovah’s
that has become increasingly available during the past Witness mother who refuses to accept blood, even if it
decade. means the death of herself or her child. Beneficence and
respect for autonomy are clearly in conflict. Jonson,
Siegler, and Winslade (2002) suggest that beyond the four
DELIVERY SYSTEMS
principles, ethics must consider contextual data to be
Telemedicine more useful in the complex medical world that nurses
Telemedicine, whereby specialists can be remotely based work in today. These authors developed a clinical pocket
and still assess and counsel patients, is another growing guide to help clinicians analyze case circumstances in
trend in health care delivery systems. Digital photos can context (Table 2-1).
be sent by the Internet from the patient’s location to the
specialist, at substantial cost savings. For example, in Collaboration in Caring— Providing a nursing
sexual assault crisis centers, a nurse practitioner can perspective for resolving ethical dilemmas
capture a colposcopy image and have ready access to a
consultant through telecommunications technology. Many health care settings have bioethics committees who
Wireless technology has progressed to the point where confront the more difficult ethical problems. Nurses are
remote telemetry is possible. Wireless sensors are capa- often asked to sit on these types of interdisciplinary
ble of detecting changes in blood pressure, or respiratory committees that usually include clergy, attorneys, social
rate and sending alerts. It is possible to monitor medica- workers, physicians, and ethics consultants.
tion adherence, and when a pill is missed an alert can be
sent to the patient’s pharmacist or provider. Webcams
can be used to assess patients who have disabilities or IMPLICATIONS OF THE HEALTH INSURANCE PORTABILITY AND
live in remote areas. As the aging population increas- ACCOUNTABILITY ACT (HIPAA). The Health Insurance Porta-
ingly grows, so do chronic health disabilities. Because bility and Accountability Act (HIPAA) is a law that was
the majority of health care providers remain concen- passed in 1996. It has several components, including pro-
trated in metropolitan areas, this type of technology may cedural mandates designed to protect the privacy of an
help bridge the gap, especially for those in remote or individual’s health information. The portability compo-
rural locations. nent ensures that a person moving from one health plan
Telemedicine technology can be used for access to to another will be able to continue his or her insurance
medical interpreters, desperately needed in many areas coverage. Expanded federal sanctions attached to health
with multiethnic populations. It can also be used for home care fraud are also included in the HIPAA law.
surveillance of elderly persons. Eighty percent of elderly HIPAA resulted in a flurry of health care system-wide
persons who need help with their activities of daily living modifications. Many office settings were required to
are cared for by family members, most of whom work. It is reorganize their sign-in procedures. Others had to
now possible to turn on a webcam at work to “look in” on rebuild patient interviewing spaces, install expensive
a grandparent who is at home alone. In some areas, pedi- computer safeguarding mechanisms, supply units with
atric remote home monitoring services are offered to reach paper shredders, and extend continuous training to
underserved children who have asthma. employees. With this law, patients clearly have the right
to protected health information (PHI). The conse-
CHALLENGES FOR NURSES IN CONTEMPORARY quences for breaking a HIPAA law can be both civil and
SOCIETY criminal charges. Substantial fines and imprisonment
An Ethical Framework for Professional Practice can be imposed if a patient’s health information is
knowingly disclosed.
Nurses are intimately drawn into daily encounters with
Since nurses frequently have ready access to confiden-
other humans, and as a result often face difficult legal and
tial patient data, extreme vigilance is required. Addresses,
ethical concerns. The Patient’s Bill of Rights, informed
telephone numbers, occupations, and e-mail addresses
consent, confidentiality, pain relief, and end of life care
need to be protected, along with the patient’s medical
are examples of ethical concerns.
history, diagnosis, and condition. Nurses must be particu-
There are four basic principles that are commonly used
larly cautious with conversations that take place in public
to help solve ethical dilemmas. Those principles are
places such as elevators and lunchrooms. Communication
beneficence, nonmaleficence, respect for autonomy, and
needs to be limited to only those who need to know the
justice or fairness. Beneficence means acting for the
specific information in order to provide care for the
patient’s benefit. Nonmaleficence is known best by the
patient.
saying that is credited to Hippocrates, “First, do no harm”
or “Primum non nocere” in Latin. Respect for autonomy THE HUMAN GENOME PROJECT. The Human Genome
means that patients have a right to make decisions about Project (HGP) was a 13-year project completed by the
themselves as well as the right to have the information that U.S. Department of Energy and the National Institutes of
is needed to make certain decisions. Justice or fairness Health. In 2003, the project produced the first draft of a
40 unit one Foundations in Maternal, Family, and Child Care
The Principles of Beneficence and Nonmaleficence The Principle of Respect for Autonomy
1. What is the patient’s medical problem? history? diagnosis? 1. Is the patient mentally capable and legally competent? Is there evidence
prognosis? of incapacity?
2. Is the problem acute? chronic? critical? emergent? reversible? 2. If competent, what is the patient stating about preferences for
3. What are the goals of treatment? treatment?
4. What are the probabilities of success? 3. Has the patient been informed of benefits and risks, understood this
information, and given consent?
5. What are the plans in case of therapeutic failure?
4. If incapacitated, who is the appropriate surrogate? Is the surrogate using
6. In sum, how can this patient be benefited by medical and appropriate standards for decision-making?
nursing care, and how can harm be avoided?
5. Has the patient expressed prior preferences, e.g., Advance Directives?
6. Is the patient unwilling or unable to cooperate with medical treatment?
If so, why?
7. In sum, is the patient’s right to choose being respected to the extent
possible in ethics and law?
Quality of Life Contextual Features
The Principles of Beneficence and Nonmaleficence and Respect The Principles of Loyalty and Fairness
for Autonomy
1. What are the prospects, with or without treatment, for a 1. Are there family issues that might influence treatment decisions?
return to normal life? 2. Are there provider (physicians and nurses) issues that might influence
2. What physical, mental, and social deficits is the patient likely treatment decisions?
to experience if treatment succeeds? 3. Are there financial and economic factors?
3. Are there biases that might prejudice the provider’s 4. Are there religious or cultural factors?
evaluation of the patient’s quality of life?
5. Are there limits on confidentiality?
4. Is the patient’s present or future condition such that his or
her continued life might be judged undesirable? 6. Are there problems of allocation of resources?
5. Is there any plan and rationale to forgo treatment? 7. How does the law affect treatment decisions?
6. Are there plans for comfort and palliative care? 8. Is clinical research or teaching involved?
9. Is there any conflict of interest on the part of the providers or the
institution?
Source: Jonson, A.R., Siegler, M., & Winslade, W.J. (2002). Clinical ethics: A practical approach to ethical decisions in clinical medicine (5th ed.).
New York: McGraw-Hill.
map that identified the estimated 20,000 to 25,000 genes it is thought to be predictive of a genetically related illness
in human DNA. More than 3 billion sequences of human or condition? Could the information potentially jeopar-
DNA base pairs were revealed. The base pairs are the dize insurance coverage for an entire family? Technolo-
chemical building blocks (A, T, C, and G) that are con- gies developed for more sophisticated fetal testing will
tained in the long, twisted chains that make up the invariably lead to more controversy regarding reproduc-
DNA of the 24 different human chromosomes. It is the tive rights. The ethical, legal, and social issues associated
DNA that provides the gene with detailed instructions with the Human Genome Project were built in as part of
about how to manage all the processes within the human the scientific study, and many have called the project the
body. In May 2006, Human Genome Project (HGP) “world’s largest bioethics program.”
researchers filled in gaps from the first draft and com- The American Nurses Association (ANA) proactively
pleted the DNA sequence for the last of the 24 human produced a thoughtful position statement on cloning in
chromosomes. preparation for future ethics challenges. In their state-
Knowledge gained from the Human Genome Project ment, the ANA emphasizes that nurses “…must be able
offers great potential in health care. It also brings to the to participate actively in the public debate about the
surface some difficult ethical issues. For example, who possibility of cloning human beings by means of blasto-
will control genetic information? Commercialization has mere splitting or somatic cell nuclear transplantation.
already begun in the areas of genetic testing and explora- It is likely that there will be attempts to clone human
tion of the promise of gene therapy, including more tar- beings in the near future and nurses must be able to
geted medications. Yet social consequences have not been speak to the ethical implications of such developments
fully resolved. If sophisticated genetic testing is available, and point out possible advantages and disadvantages
how will privacy be maintained? What will be the psycho- for the human species” (ANA, June 2000, p. 1, see
logical impact of having genetic information, especially if Chapter 7).
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 41
2. The clinic nurse is aware that a specific health Annie E. Casey Foundation—Kids Count data. Retrieved from http://www.
concern for Black women in the population between aecf.org/cgi-bin/aeccensus.cgi?action⫽profileresults&area⫽00N
(Accessed May 28, 2007).
45 and 64 years of age is: Austin, S.B., Melly, J., Sanchez, B.N., Patel, A., Buka, S., & Gortmaker,
A. Stroke S.L. (2005). Clustering of fast food restaurants around schools: A
B. Breast cancer novel application of spatial statistics to the study of food environ-
C. Hypertension ments. American Journal of Public Health, 95(9), 1575–1581.
Bellah, R., Madsen, R., Sullivan, W., Swidler, A., & Tipton, S. (1991).
D. Motor vehicle collisions The good society. New York: Vintage Books.
3. The clinic nurse understands that nonmaleficence is Braithwaite, R.L., Arriola, K.J., & Newkirk, C. (2006). Health issues
a concept used in ethical decision making. It means: among incarcerated women. Piscataway, NJ: Rutgers University Press
Buchwald, E., Fletcher, P., & Roth, M. (1995). Transforming a rape
A. First do no harm culture. Minneapolis, MN: Milkweed Editions
B. Acting on the patient’s behalf Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
C. Patients have a right to information tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
D. Patients should be treated equally Centers for Disease Control and Prevention (CDC). (2005). Trends in
leisure-time physical inactivity by age, sex, and race/ethnicity—
True or False United States, 1994–2004. MMWR: Morbidity and Mortality Weekly
Recommendations and Reports, 54(39), 991.
4. The perinatal nurse is aware of the Intervention Charles, J.M. (2006). Autism spectrum disorders: An introduction and
Wheel and its potential for nurses working with review of prevalence data. Journal of the South Carolina Medical
community leaders to examine health issues more Association, 102(8), 267–270.
Dickinson, A.R. (2006, May). ‘We are just kids’: Children within healthcare
holistically. relationships. Contemporary Nurse, 21(2), Retrieved from http://www.
5. Nurses who are taking a more proactive approach to contemporarynurse.com/18.1/18-1p3.php (Accessed January 13, 2007).
childhood obesity would support the Food and Drug Edin, K., & Lein, L. (1997). Making ends meet: How single mothers survive
welfare and low-wage work. New York: Russell Sage Foundation.
Administration (FDA) program to increase food Esacove, A.W. (1998). A diminishing of self: Women’s experiences of
labeling and decrease portion sizes in restaurants. unwanted sexual attention. Health Care for Women International, 19,
181-192.
6. The clinic nurse is aware that with telemedicine, Fox, S. (2006). Demographics, degrees of Internet access, and health.
photos may be sent to the clinic doctors from remote Presented June 19–20 at: Identifying and disseminating best practices
sites and diabetics may send their “logs” for review for health eCommunities, Chapel Hill, NC : http://www.pewinternet.
before their appointments. org/ppt/Fox_UNC_June_2006.pdf (Accessed March 19, 2007).
Ginsburg, F.D. (1998). Contested lives: The abortion debate in an American
Fill-in-the-Blank community. Berkeley, CA: University of California Press.
Glascoe, F.P. (2000). Detecting and addressing developmental and behav-
7. The clinic nurse is aware of the Healthy People 2010 ioural problems in primary care. Pediatric Nursing, 26(3), 251–266.
report and its identification of health _______ for Goldman, D.P., Smith, J.P., & Sood, N. (2006, November–December).
the nation. Immigrants and the cost of medical care: Immigrants use dispropor-
tionately less medical care than their representation in the U.S. popu-
8. The public health nurse understands that when lation would indicate. Health Affairs, 25(6), 1700–1711.
studying effects of diseases, it is the _________ rate Gortmaker, S.L., Peterson, K.E., Wiecha, J.L., Sobol, A.M., Dixit S., Fox,
that should be the focus of attention. M.K., & Laird, N. (1999). Reducing obesity via a school-based inter-
disciplinary intervention among youth: Planet Health. Archives of
9. The pediatric nurse is aware that “race” as a concept Pediatric Adolescent Medicine, 153(4), 409–418.
is best defined as how persons _______ one another Hufft, A.G. (2004, March/April). Supporting psychosocial adaptation for
and _______ one another. the pregnant adolescent in corrections. MCN, American Journal of
Maternal Child Nursing, 29(2), 122-127.
10. The clinic nurse is aware of the effects of poverty on Isaacs, S.L., & Schroeder, S.A. (2004, September 9). Class—the ignored
the families seen in the clinic as the poverty rate has determinant of the nation’s health. The New England Journal of
Medicine, 351(11), 1137–1142.
________ yearly since the year 2000. At present, the Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
most impoverished group is _________. Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and
NIC Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.).
See Answers to End of Chapter Review Questions on the St. Louis, MO: Mosby Elsevier.
Electronic Study Guide or DavisPlus. Jonson, A.R., Siegler, M., & Winslade, W.J. (2002). Clinical ethics: A
practical approach to ethical decisions in clinical medicine (5th ed.).
New York: McGraw-Hill.
REFERENCES Kaiser Family Foundation. (2006). New study shows how kids’ media
Aday, L.A. (2001). At risk in America: The health and health care needs of use helps parents cope. Available at http://www.kff.org/entmedia/
vulnerable populations in the United States (2nd ed.). San Francisco: entmedia052406nr.cfm (Accessed March 17, 2007).
John Wiley & Sons, Inc. Keller, L.O., Strohschein, S., Schaffer, M.A., & Lia-Hoagberg, B. (2004a).
American Holistic Nurses’ Association (AHNA). (2005). About AHNA. Population-based public health interventions: Innovations in prac-
Flagstaff, AZ: Author. www.ahna.org/about/about.html (Accessed tice, teaching, and management, part II. Public Health Nursing, 21(5),
March 21, 2007). 469–487.
American Nurses Association (ANA). (2000). http://www.nursingworld. Keller, L.O., Strohschein, S., Schaffer, M.A., & Lia-Hoagberg, B. (2004b).
org/readroom/position/ethics/Etclone.htm (Accessed March 17, 2007). Population-based public health interventions: Practice-based and
American Nurses Association (ANA) Council of Cultural Diversity in evidence supported, part I. Public Health Nursing, 21(5), 453–468.
Nursing Practice. (1991, October). ANA Ethics and Human Rights Kellogg, N., and the Committee on Child Abuse and Neglect (2005).
Position Statement. American Academy of Pediatrics Clinical Report. The evaluation of
American Nurses Association (ANA) Council. (2000, June). Human sexual abuse in children. Pediatrics, 116, 506–512.
cloning by means of blastomere splitting and nuclear transplanta- Koss, M.P., & Harvey, M.R. (1991). The rape victim: Clinical and commu-
tion. ANA Ethics and Human Rights Position Statement. nity interventions. Newbury Park, CA: Sage Publications.
Anderson, C.A., & Dill, K.E. (2000). Video games and aggressive Kunkel, D. (2001). Children and television advertising. In D. Singer,
thoughts, feelings, and behavior in the laboratory and in life. Journal & J. Singer (Eds.), Handbook of children and the media. Thousand
of Personality and Social Psychology, 78(4), 772–790. Oaks, CA: Sage Publications.
44 unit one Foundations in Maternal, Family, and Child Care
Kunkel, D., Wilcox, B., Cantor, J., Palmer, E., Linn, S., & Dowrick, P. http://www.kff.org/entmedia/upload/7500.pdf (Accessed February 2,
(2004). Report of the APA task force on advertising and children, 2007).
Section: Psychological issues in the increasing commercialization of Sanday, P.R. (1994). Trapped in a metaphor. Institute for Criminal Justice
children. Retrieved from http://www.apa.org/releases/childrenads.pdf Ethics, 13(2), 32–39.
(Accessed September 12, 2007). Shonkoff, J.P., & Phillips, D.A. (2000). Executive summary. In
Los Angeles Homeless Services Coalition (LAHSC). (2007). United J.P. Shonkoff & D.A. Phillips (Eds.), From neurons to neighborhoods.
States homeless statistics. Retrieved from http://www.lahsc.org/ The science of early childhood development. Washington, DC: National
wordpress/educate/statistics/united-states-homeless-statistics/ Academy Press.
(Accessed February 29, 2008). Spencer, N. (1999). Health of children—Causal pathways from macro to
Madden, M., & Lenhart, A. (2006). Online Dating. PEW Internet & micro environment, Health Ecology, 175–192.
American Life Project. Washington, DC. Tebruegge, M., Nandini, V., & Ritchie, J. (2004). Does routine child health
Mantle, F. (2005). Complementary medicine and children. Primary surveillance contribute to the early detection of children with pervasive
Health Care, 15(8), 23–25. developmental disorders? An epidemiological study in Kent, U.K. BMC
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing Pediatrics, 3(4), 4.
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. Tjaden, P., & Thoennes, N. (2000). Full Report of the Prevalence, Inci-
NANDA International. http://www.nanda.org dence, and Consequences of Intimate Partner Violence Against Women:
National Center for Health Statistics (NCHS). (2005). Health, United Findings from the National Violence Against Women Survey. Report
States, 2005 with chartbook on trends in the health of Americans. for grant 93-IJ-CX-0012, funded by the National Institute of Justice and
Hyattsville, MD. the Centers for Disease Control and Prevention. Washington, DC: NIJ
National Child Abuse and Neglect Data System (NCANDS). http://www. U.S. Census Bureau. (2007). Internet access and usage and online service
ndacan.cornell.edu/NDACAN/AboutNDACAN.html (Accessed May usage. Retrieved from http:///www.census.gov/compendia/statab/
28, 2007). tables (Accessed August 14, 2007).
National Coalition on Health Care (NCHC). (2007). Health insurance U.S. Department of Health and Human Services (DHHS), Health
cost. Retrieved from http://www.nchc.org/facts/cost.shtml (Accessed Resources and Services Administration (2005a). Women’s health USA
March 21, 2007). 2005. Rockville, MD: Author.
Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., U.S. Department of Health and Human Services (DHHS), Office of the
& Flegal, K.M. (2006). Prevalence of overweight and obesity in the Assistant Secretary for Planning and Evaluation. (2005b). Overview
United States, 1999–2004. JAMA 295, 1549–1555. of the Uninsured in the United States: An analysis of the 2005
The Partnership for the Homeless. (2005). The cycle of homelessness. Current Population Survey. Rockville, MD: Author. Retrieved
Retrieved from http://www.partnershipforthehomeless.org/ (Accessed from http://aspe.hhs.gov/health/reports/05/uninsured-cps/ (Accessed
March 17, 2007). May 17, 2007).
PBS, Frozen Angels. Retrieved from http://www.pbs.org/independentlens/ U.S. Department of Health and Human Services (DHHS), Administration
frozenangels/makingbabies.html (Accessed June 8, 2007). on Children, Youth and Families. (2007). Child Maltreatment 2005.
Peterson, J., Yates, B., Atwood, J., & Hertzog, M. (2005). Effects of a Washington, DC: U.S. Government Printing Office.
physical activity intervention for women. Western Journal of Nursing Volk, A., Craig, W., Boyce, W., & King, M. (2006). Adolescent risk cor-
Research, 27(1), 93–110. relates of bullying and different types of victimization. International
Porter, C.P., & Barbee, E. (2004). Race and racism in nursing research: Journal of Adolescent Medical Health, 18(4), 575–586.
Past, present and future. In J.J. Fitzpatrick, A.M. Villarruel, & C.P. Wagner, T.H., & Bundorf, M.K., Singer, S.J., & Baker, L.C. (2005,
Porter (Eds.), Annual review of nursing research (Vol. 22). New York: April). Free internet access, the digital divide, and health informa-
Springer Publishing. tion. Medical Care, 43(4), 415–420.
Purnell, L.D., & Paulanka, B.J. (2008). Transcultural health care: A cul- Warren, E. (2005, February 9). Sick and broke. Washington Post.com.
turally competent approach (3rd ed). Philadelphia: F.A. Davis. Retrieved from http://www.washingtonpost.com/wp-dyn/articles/
Redfern-Vance, N. (2000). “Can’t win for losin’”: The impact of WAGES A9447-2005Feb8.html (Accessed May 5, 2007).
on single mothers with young children in a North Tampa Commu- Wax, J.R., Cartin, A., Pinette, M.G., & Blacksone, J. (2004). Patient
nity. Practicing Anthropology, 22(1), 12–19. choice cesarean: An evidence–based review. Obstetrics & Gynecologi-
Rideout, V., & Hamel, E. (2006, May). The media family: Electronic media cal Survey, 59(8), 601–616.
in the lives of infants, toddlers, preschoolers, and their parents. Menlo Wolfe, J. (1993). Female military veterans and traumatic stress. PTSD
Park, CA: The Henry K. Kaiser Family Foundation. Retrieved from Research Quarterly, 4(1), 1–7.
CONCEPT MAP
Complementary Care:
• Blogging to facilitate
healing: promote sense
Now Can You: of community
• Discuss the Intervention Wheel and Healthy
People 2010 goals
Collaboration In Caring: • Identify population trends that relate to health,
• Bioethical committees including identifying vulnerable populations
• Describe nursing actions that improve children’s Across Care Settings:
health in the US • Parish nurse serving
• Discuss influences that impact the the church community
nation’s health
chapter
The Evolving Family
3
Question of Family
What is a family but a collection of beings dwelling together?
But it is more than that
One person might see a refuge from the storms of society…
Another, a prison to prevent help from the outside world.
It can be both and more.
We draw our first breath in the presence of our family and hopefully
… we are held in family’s arms when we sigh our last.
We learn all that is good in its caring boundaries or keep secrets of terror locked in its heart.
The difference between knowing love and trust and learning never to love or trust is in what
passes between members of the family and what is passed on through members to their
families.
What have you learned from your family?
What will you pass to your family?
— Brian Fonnesbeck, 2006
L EA R NIN G T AR G E T S At the completion of this chapter, the student will be able to:
◆ Identify different structures of the modern American family.
◆ Describe theoretical concepts that apply to the family.
◆ Assess the family using selected family assessment tools during an interview.
◆ Apply specific family nursing diagnoses and interventions to the family.
◆ Discuss special family problems that often require nursing intervention.
◆ Compare various family cultural characteristics that may impact nursing care.
◆ Expand patient care to include and involve the family in every nursing setting.
moving toward evidence-based practice: Parenting Concepts Among Culturally Diverse Cultures
McEvoy, M., Lee, C., O’Neill, A., Groisman, A., Roberts-Butelman, K., Dinghra, K., & Porder, K. (2005). Are there universal parenting
concepts among culturally diverse families in an inner-city pediatric clinic? Journal of Pediatric Nursing, 19(3), 142–150.
The purpose of this study was to examine universal concepts in long established immigrant neighborhoods, tolerance, and plen-
parenting philosophies and practices, which are in common tiful jobs, factors that have been instrumental in attracting
across multiple cultures. The researchers used a grounded theory diverse cultures during the past century.
approach with ethnographic interviews of 46 English-speaking Interviews were completed using a question guide com-
families representing 27 countries. All participants were from posed of open-ended questions, which were developed by the
families of well children in an inner city hospital clinic in research team. The purpose of the questions was to elicit stories
the Bronx, New York. The children’s ages ranged from 7 days to or examples from parents regarding the everyday care of their
15 years of age. The researchers stated that New York City has children. From transcribed interviews, 22 thematic categories
(continued)
46
chapter 3 The Evolving Family 47
or the family of choice (the family adopted through mar- For example, in the 1950s and 1960s, a nuclear family
riage or cohabitation). A single person belongs to a family was presented with little emphasis on the extended family.
of origin, but may choose not to become a member of a Programs such as Ozzie and Harriet, Leave It to Beaver, The
family of choice. A single individual cannot constitute a Dick Van Dyke Show, and Father Knows Best portrayed the
family. Instead, most definitions of family include a prereq- typical family as one that included the mother and father
uisite of at least one other person who is self-defined as along with one to three children. Family roles typically
being a part of the family (Harmon Hanson et al., 2005; portrayed a father-dominated household and a homemaker
Friedman et al., 2003; Wright & Leahey, 2005). mother who would occasionally flex her decision-making
authority when the father’s advice did not work. Issues
were generally simple and resolvable with an occasional
Nursing Insight— Differentiating among various foray into societal issues such as racism or mental health.
family configurations
When problems such as alcoholism were presented, they
In contemporary society, the traditional nuclear family, which tended to be in the context of an outsider who temporarily
consists of a male partner, female partner and their children, touched the family and then left. Rarely was there depiction
actually represents only a small number of families. Other fam- of a serious internal family mental health problem. Instead,
ily members, termed extended family, may also live in the scenarios involved events such as girlfriend–boyfriend situ-
same household. According to the Urban Institute, there are ational crises or friend-related peer pressure. Occasional
five categories of families (Wherry & Finegold, 2004): variations in family structure were offered in weekly pro-
1. The married-parent family includes biological or grams such as Bonanza, Family Affair, and My Three Sons
adoptive parents. This family structure accounts for that portrayed households run by males who received assis-
approximately 64% of American families. It describes tance from a housekeeper or relative.
69% of Caucasian, 55% of Hispanic, and 26.6% of African Programming during the 1960s and early 1970s
American families (Wherry & Finegold, 2004). reflected a growing trend toward themes that included
2. The single-parent family consists of an unmarried biological blended families with shows such as The Brady Bunch.
or adoptive parent who may or may not be living with other These weekly programs tended to present upper income
adults (Wherry & Finegold, 2004). The homosexual family families with housekeepers and stay-at-home mothers
(lesbian and gay) consists of same-sex partners who live who deferred major decisions to the father. Widowhood,
together with or without children. This family structure as opposed to divorce, usually constituted the reason for
may also consist of single gay or lesbian parents or multiple remarrying, and this situation neatly sidestepped the
parenting figures (Friedman et al., 2003). unpleasantness of a broken home resulting from divorce.
3. The married-blended family, formed as a result of death Family issues continued to relate primarily to difficul-
or divorce, consists of unrelated family members who join ties associated with school and dating. Major breakthroughs
together to form a new household. were achieved with All in the Family, The Jeffersons, What’s
4. The cohabiting-parent family describes one in which Happening, and other sit-coms in the 1970s that dealt with
children live with two unmarried biological parents or two the turbulent issues of civil rights and sex equality and
adoptive parents. changing views on race and gender.
5. The no-parent family is one in which children live During this time, there were also shows that began to
independently in foster or kinship care, such as living present selected variations of family. For example, The
with a grandparent or aunt. Mary Tyler Moore Show centered on a career woman
whose close work relationships served as a central compo-
nent of family. Gilligan’s Island presented family-like asso-
ciations that dealt with work or survival issues as a team
Ethnocultural Considerations— Patterns and shared support and platonic love and loyalty that
of family structure would have normally been received from a family. The
Patterns of family structure tend to be culturally influenced. 1990s to 2000s version of this theme was expanded in
For example, Hispanic children are more than twice as likely Friends and Seinfeld, programs that introduced the idea
as African American children to live in cohabiting-parent that people could remain single longer without the expec-
families and they are approximately four times as likely as tation that a family was defined by marriage and procre-
Caucasian children to live in this type of family configuration ation. This trend is again reflected in more recent pro-
(Wherry & Finegold, 2004). grams such as Grey’s Anatomy, where unrelated individuals
form a family with “ties” that sometimes are actually
stronger than those with their biological relatives who
may not always “be there” for them.
THE CHANGING FAMILY AS REFLECTED Television programs during the 1980s and 1990s also
IN THE MEDIA began to address variations in social class and politics with
Family changes and adaptations from the Cro-Magnon era shows such as Family Ties, which explored social issues
to the present day have been well researched and docu- such as premarital sex, dealing with the death of friends,
mented, but it is useful to examine the more recent and Alzheimer’s disease. Interestingly, the episodes did not
changes that have taken place over the past 20 to 40 years. always present a clean resolution of an issue but instead
During this time, family structure and roles have changed focused on the importance of family closeness and support
rapidly and at present seem to be in a state of flux. As in dealing with the problem within the context of battling
American families transition and evolve, television and political views. The Cosby Show depicted a black upper
theater often provide useful insights into the predominant middle-class family in which both parents were white-
family themes of the time. collar professionals.
chapter 3 The Evolving Family 49
The 1990s brought increased awareness of the chal- such as Medicare and Social Security. In many instances,
lenges facing families dealing with poverty, alcoholism, families have no options for insurance because of part-
and abuse within their own ranks rather than as a problem time work or unemployment.
that occurred only outside of the family. Grace Under Fire At present, more than 45 million families in the United
presented a single head of household who was a recover- States are uninsured (U.S. Department of Health and
ing alcoholic. Roseanne revolved around a matriarchal Human Services [DHHS], 2005b) and as many as 13.5 mil-
family structure in a lower economic setting where both lion individuals have been homeless at some point during
parents had to work to make ends meet. One particular their lifetime (Harmon Hanson et al., 2005). All too fre-
episode in this series dealt with how to write a check in a quently, families are counted among these staggering sta-
way that delayed cashing (and subsequently, “bouncing”) tistics. Health issues among homeless families and individ-
it, to allow extra time for sufficient funds to be deposited uals are numerous and usually result from a lack of
into the account. preventive care and a lack of resources in general. For
Television sitcoms in the new millennium continue to example, in addition to the problems associated with
reflect trends consistent with societal changes. Family extreme poverty, homeless women are at an increased risk
structures such as the binuclear arrangement (two intact for illness and injury and many have been victims of rape,
nuclear families sharing a home), and the divorced family assault, and domestic abuse (American College of Obstetri-
living with a brother and sharing responsibility for rearing cians and Gynecologists [ACOG], 2005).
a son (Two and a Half Men) are examples of alternate fam- The rural homeless are more likely to be families who
ily themes that have emerged in recent times. Programs are living with other families or migrant workers who live
such as these may be preparing the way for shows that in vehicles and follow crop harvesting. Access to health
depict same-sex unions with or without children. care and discrimination in health care practices are major
Also reflective of contemporary society is the trend of problems for this population. At present, there are approx-
sitcoms that feature extended family members such as the imately 3 million migrant and seasonal farm workers in
live-in father in King of Queens and the very intrusive par- the United States, and of these, 21% are women. Although
ents in Everybody Loves Raymond. The success of the the workers represent a number of ethnic and cultural
movie My Big Fat Greek Wedding opened the door for groups, 75% were born in Mexico, 81% speak Spanish,
depicting ethnic families that were keeping their own val- their average age is 33, and the majority have not been
ues and beliefs separate from those of the prevailing cul- educated beyond the seventh grade (U.S. Department of
ture. Hispanic, Jewish, Asian, and other ethnic groups Labor National Agricultural Workers Survey, 2005). As
have revealed their differences in humorous but culturally the nation becomes more culturally diverse, there is a
sensitive ways. The media, however, generally provides growing imperative to eliminate racial and ethnic health
only a superficial representation of the varied and com- care disparities by providing ready access to quality care
plex challenges faced by the modern-day family. for diverse populations (Weissman et al., 2005).
Nursing Insight— Recognizing the relationship • Be proactive: Become an agent of change in the family.
between family stressors and poor health outcomes • Begin with the end in mind: Develop a family mission
statement.
Families may have multiple stressors that increase their vul-
nerability to poor health outcomes. Problems such as sub- • Put first things first: Make the family a priority in a
turbulent world.
stance abuse, mental illness, domestic violence, and limited
access to medical care due to unemployment, loss of medical • Think “win–win”: Move from me to we.
insurance, or inadequate insurance coverage can affect fami- • Seek first to understand then be understood: Solve
lies across all strata of society. family problems through empathetic communication.
• Synergize: Build family unity through celebrating
Societal Pressures differences
The family also faces societal pressures. The incidence of • Sharpen the saw: Renew family spirit through traditions
violent crimes has decreased in major urban areas, but
suicide among children and adolescents continues to rep-
resent an important societal issue. The number of families
currently affected by AIDS is increasing at a startling rate. case study The Family with Same-Sex
Women and children, a vulnerable population due to bar- Partners
riers associated with access to health care, constitute the
fastest growing segment of the population to contract Julia, a 37-year old comatose woman, is dying of ovarian cancer.
HIV. Public education is in a state of crisis as demands She is on life support in the hospital. The family, which includes
increase on teachers who are confronted with diminishing ex-husband, Dan, and two children—John, age 12 and Tami, age
14—has gathered in the visitors’ lounge. Cindy, Julia’s life partner,
resources.
is also present in the lounge. The family is discussing whether to
These and many other issues continue to challenge fami- extend Julia’s present level of care or to begin to wean her from
lies. Meanwhile, family structure and roles are undergoing life support. Although Julia has a living will, there is concern and
changes that frequently increase the potential for further conflict among the family members and Cindy regarding how and
family problems. Present trends show a diminishing num- when the will should be honored. Dan questions the appropriate-
ber of nuclear family households. The traditional family ness of Cindy’s being in attendance for the discussion.
structure is being replaced by one that includes a single head 1. What would the nurse need to know to help the family
of household, most frequently a divorced or abandoned problem-solve in this situation?
mother. The number of unmarried mothers continues to
increase. Statistics reflect the current trend: the percentage 2. What resources are available to the family and the nursing
staff to help clarify these issues?
of children living with two married parents decreased from
85% in 1970 to 68% in 2004. A divorced or single woman is ◆ See Suggested Answers to Case Studies in text on the
usually the head of household in those families, although Electronic Study Guide or DavisPlus.
recently there has been an increase in single male head of
household families from 1% to 5% (Child Trends Data Bank,
2006). In other situations, the head of household is homo- The skip generation, an arrangement in which the
sexual or sharing a home with a same-sex partner. grandparents rear grandchildren with or without the par-
These trends reflect increasing opportunities for alterna- ents’ help, describes another present-day variation in
tive forms of parenthood within contemporary American family structure. In 1994, 16% of preschool children of
society. The nontraditional parenting arrangements result working parents were cared for by a grandparent. Today,
from more liberal social mores as well as the technological 2.4 million grandparents assume primary responsibility
and medical advances that now offer the possibility of for more than 6 million children and many of these house-
parenthood to single men and women (Greenfield, 2005). holds do not have the children’s parents living in the
Homosexuality and same-sex partnerships/marriages and home with them (AARP, 2006).
their effects on the family raise political, social, and reli-
gious issues that have increasingly found their way into Now Can You— Discuss contemporary family changes
present-day discussions. Although the far-reaching impact and stressors?
of same-sex relationships on family structure and function
1. Define family and identify five family categories?
has not been adequately studied, areas that frequently must
2. Identify three changes in family structure that have been
be addressed concern child custody, legal consent, power of
highlighted in the media?
attorney, and confidentiality. The following case study pro-
3. Identify five stressors faced by the American family today?
vides an example of some of the issues and questions that
may need to be addressed by the family and the patient’s
care providers.
Family Theories and Models
— Effective tools for families Development of a specialized body of knowledge provides
the foundation for a profession. While nursing theories
Covey (2006) discusses effective tools that may enhance and models are essential in defining nursing and nursing
family performance. The nurse can communicate these practice, theories from other disciplines are important in
principles to families that may promote healthy family providing insights into other dimensions of health and
functioning. human behavior. For example, family theory, which draws
chapter 3 The Evolving Family 51
from a number of related disciplines (Harmon Hanson Families of alcoholics soon learn not to disclose infor-
et al., 2005), helps to guide assessment and intervention mation about their problems to outsiders. Conversely, a
within a holistic framework that views the entire family as family that is so lacking in structure that it allows an unin-
client. The following discussion presents several theore- terrupted free flow of information/intervention to and
tical models representing a cross section of useful concepts from outsiders can be said to have an open boundary or
to assist in the nursing assessment and to facilitate a cre- no boundary at all. For example, an open boundary exists
ative application to various family interactions. with a family whose children are so neglected that they
rely on friends or neighbors to feed them.
FAMILY SYSTEMS THEORY
A systems approach to understanding the family centers Nursing Insight— Recognizing the childbearing
on the recognition that changes that occur in one member family’s boundary permeability
affect the entire family. The family systems theory, which
views persons as “open systems,” has at its central theme: The extent to which the suprasystem (the broad system that
“The sum of the parts is greater than the whole” (Harmon surrounds the family unit, such as the cultural community)
Hanson et al., 2005). According to this theory, the family influences the childbearing family’s participation in activities
shares a unique identity that is far more complex than that such as childbirth education, prenatal care, and infant care is
of its collective members. The family is dynamic, con- dependent upon the family’s boundary permeability.
stantly adjusting to information that filters in from the
surrounding environment and from within the family.
Subsystems
Nursing Insight— Clinical application of the Family systems are further divided into subsystems. A fam-
family systems theory ily of four may constitute the “main” system. The mother
and father represent a subsystem that has a permanent or
When working with families, the nurse uses the family systems temporary relationship that is a part of, yet separate from,
theory to “view the family as a unit and focus on observing the the main family system. Children often form alliances with
interaction among family members rather than studying family other siblings or with one parent. A subsystem can develop
members individually” (Wright & Leahey, 2005). when a sibling marries or cohabits with another individual
who is temporarily or permanently accepted into the fam-
ily. Subsystems are necessary parts of family functioning,
The following situation helps to illustrate application
especially in health crisis situations when families must
of the family systems theory: An addicted member receives
make decisions for sick or disabled members, or when new
help for the addiction and then returns to the family sys-
dependent members join the family. For example, the
tem. The changes in the recovering family member have a
birth of a baby introduces a new member who becomes
significant impact on how the entire family acts and
part of the family system, but is also a subsystem with the
reacts. A new system of communication is established. In
mother or father or other family caregiver(s).
the new system, the family members communicate assert-
ively and supportively with each other and no longer
adhere to the former framework of denial that a problem Ethnocultural Considerations— Boundaries
exists and secret keeping. The nurse working with the and receptivity to information
family recognizes that teaching and referrals to appropri-
ate community resources are most likely be needed to Families that have recently immigrated to this country may be
facilitate the family’s healthy adjustment to the changes. receptive to health information only from extended family
members or from persons within their cultural community.
Boundaries
Another concept inherent in family systems theory concerns
boundaries. Each system contains a boundary that affects Balance and Homeostasis
how the outside world is allowed to interact with the family The family system continually strives to return to balance
members. Stated another way, boundaries identify the fami- or achieve homeostasis after a crisis. When a family mem-
ly’s control of how the family system interacts with the out- ber is sick or injured, or when an emergency arises that
side world. A family whose children obtain food and shelter requires a reorganization of the family (i.e., an evacuation
by begging from the neighbors demonstrates a problem with during a storm), the family quickly attempts to return to
boundaries that are too permeable. Permeability refers to the former routines and rules as a way of reestablishing
degree that information and interchange are allowed to flow homeostasis. At certain times the family is unable to return
between systems. An ideal system is one that is semiperme- to former normalcy and instead must adjust or form adap-
able. In a semipermeable system, the boundaries are secure tive behaviors. For example, the family may learn to work
enough to keep the family intact, but still allow for free with a wheelchair and other adaptive devices when a mem-
interchange with the outside world. In this situation, the ber suffers a stroke or spinal cord injury. Over time, adap-
family system readily interacts with outside systems. A tations become the norm for the family.
healthy family has a semipermeable boundary that allows Maladaptive behaviors are an alternate adaptation that
and encourages interaction with outside agencies such as involves the use of unhealthy or abnormal behaviors to
work, school, church, and family, and friends. adapt to a family crisis. Enabling and codependency are
A closed boundary serves to keep family secrets inside common maladaptive behaviors that are often adopted by
and therapeutic interventions outside. Closed boundaries an addictive family (Townsend, 2005). Enabling involves
often occur in families with issues of addiction or abuse. making excuses or obtaining substances for the addictive
52 unit one Foundations in Maternal, Family, and Child Care
family member. Codependency is a maladaptive behavior pattern disturbances related to feeding and changing
in which the nonaddicted family member joins the diapers through the night. Along with strategies for suc-
addicted member in the use of alcohol or other substances cessfully coping with these adjustments, the nurse can
as a way of interacting or communicating. offer support and reassurance. The nurse assesses the
family’s readiness and openness to learn and receive help
FAMILY DEVELOPMENTAL STAGES (an open boundary) and, according to specific needs,
AND THEORY may provide additional information concerning nutri-
tion, the importance of well-baby visits, car seats, immu-
Developmental theory (Friedman et al., 2003; Harmon nization schedules and infant crib monitors.
Hanson et al., 2005) has at its core the idea that every life
moves through developmental stages with tasks that need
to be accomplished before moving on to the next stage. Optimizing Outcomes— Applying developmental
Duvall identifies eight family stages: beginning, childbear- theory when caring for the childbearing family
ing, preschool children, school-age, teenagers, launching, An understanding of the normal phases of the life cycle
middle-aged, and retirement (Friedman et al., 2003). Each helps the nurse to provide anticipatory guidance for the
stage is accompanied by specific tasks that are performed childbearing family. Strategies to bolster the young child’s
to assist with the physical and emotional development of sense of security when a newborn is brought home may
the family members in that particular stage. divert a potential family crisis.
When working with families, the nurse should identify
what stage(s) the family is in and assess how well the
needs for that particular stage are being met. Learning, Preschool Stage
attachment, and grieving represent specific tasks that are The preschool developmental stage includes toddlerhood
affected by the developmental stage. Teaching needs and and attending kindergarten. During this stage, the child
nursing interventions are structured and implemented has learned to walk and actively explore her world, which
according to the developmental stages of the family and its encompasses siblings and other family members and
members. Although the stages follow one another in a friends. At this time, families need information about the
linear progression, some families may simultaneously be prevention of injuries and interventions for accidents that
in more than one stage or they may revert to previous usually result from the child’s increased motor abilities
stages (Wilkinson & Van Leuven, 2007). coupled with less-developed judgment and coordination.
The nurse should be alert for signs of abuse or neglect
Beginning Families during this stage. Points of contact that allow the nurse to
Beginning families are those that have just been formed assess developmental progress occur during well-child
through marriage or that self-identify as family, as in the checks, immunization appointments and office or hospital
case of common-law unions. The beginning family identi- visits for the child or other family members.
fies shared goals that may include career paths, home-
building, and planning for children. Creating shared time School-Age and Adolescent/Teenage Stages
together in order to build the relationship constitutes a The school-age and adolescent/teenage developmental
central developmental task for all families and this special stages provide the optimal opportunity for teaching about
together time traditionally is initiated during the honey- drugs, sex, and health promotion. Personal values are
moon period. Combined households and property are shaped and clarified and ethical development occurs dur-
common features of all families. One of the limitations of ing this time. Surveys have shown that nurses are included
Duvall’s theory concerns its application with the childless among the top ten trusted people sought by school-aged
family. If the family has no children, many of the develop- children to discuss issues important to them.
mental stages are not applicable until the couple reaches
middle age and beyond. If the family does have a child, the Launching, Middle Age, and Retirement Stages
family developmental stage parallels the age of the child. The launching, middle-age, and retirement developmental
When more than one child is present, the family is usually stages bring the family full-circle back to the early issues
in more than one developmental stage. of self and couple-building with less emphasis on children
(if successfully launched) and more involvement in com-
Childbearing Stage munity and hobby-related interests. The young adult who
The childbearing developmental stage begins with con- is not successfully launched from the childhood home
ception. Early tasks during this stage include seeking presents a complication of incomplete launching. This
prenatal care and planning for space for the child. If situation may represent a temporary arrangement neces-
there are other children already in the home, the family sary for continuing education or it may provide a conve-
begins to prepare and socialize the other children into a nient and economical “non-action” by the son or daughter
sibling role. Ideally, the family involves the children in until ties with others have been established. The nurse’s
decision making related to preparation for the expected role in this situation is to assess whether the living
baby. For example, siblings can help to choose paint arrangement creates a problem (e.g., anger, frustration,
colors for the baby’s room or offer advice regarding toys and delay in meeting goals) for either the parents or the
or clothes to select for the baby. When the baby is born, child. Interventions may include strategies to improve
the family must adapt its routines to include the various communication between the parents and the child and/or
tasks associated with feeding and caring for the baby. community referrals for assistance with goal setting and
Family teaching needs may include dealing with sleep vocational training.
chapter 3 The Evolving Family 53
relation to the power base, decision making processes, affec- BOWEN’S FAMILY SYSTEMS THEORY
tion, trust, and coalitions. Dysfunctional communication
Family systems theory, based on Bowen’s concepts, is use-
inhibits healthy nurturing and diminishes personal feelings of
ful when identifying family problems or challenges that are
self-esteem and self-worth.
rooted in family processes such as communication, con-
necting between members, and teaching values (Harmon
The nurse or family therapist assesses a repeating nega- Hanson et al., 2005). The nuclear family emotional system
tive pattern such as excessive drinking to determine if it describes the pattern of adaptive/maladaptive emotional
has been replaced instead by an assertive yet supportive expression that exists as a theme in the family. According
and positive communication. For example, a wife com- to this theory, one family could be characterized as stoic or
plains to the nurse that her husband drinks more when- cold in their interactions with others, while another is
ever they have an argument about their children. The described as emotional and highly reactive to situations
husband notes that his wife complains to him about the and circumstances.
children whenever he tries to relax by drinking. The nurse According to family systems theory, differentiation of
educates the family that interventions regarding either the self is demonstrated when a family member breaks away
arguing or the drinking could help to break the pattern of from the learned emotional system and instead expresses
negative communication and refers them to a support emotions that differ from the learned family pattern. For
group or a counselor to learn new patterns. example, a father whose family of origin is nondemonstra-
tive of love and caring may openly hug and kiss his spouse
GROUP THEORY and children and verbally express his love for them. In an
emotional cut-off, a family member has separated from
Group theory can be applied to the family as a group.
the original family pattern in a dramatic and sometimes
Norms (rules of conduct), roles, goals, and power struc-
permanent way. This may occur when a family member
ture are inherent family concepts along with the division
who was reared in a dysfunctional family chooses not to
of household chores, expectations of completed home-
perpetuate the learned pattern of alcoholism or abuse.
work, and curfew enforcement. According to group the-
Family systems theory also views birth order as a predic-
ory, stages of groups (forming, storming, norming, per-
tor of certain patterns of behavior that may be desirable or
forming, and adjourning/terminating) explain expected
conflicting, depending on the birth order of the chosen
behaviors that occur in any given stage (Clark, 2003;
mate. A firstborn child with behaviors related to high
Johnson & Johnson, 2003).
responsibility and control may clash with a spouse who is
Forming describes the beginning phase of the group. In
also a firstborn. The “baby of the family” (youngest sibling)
families, the forming stage usually occurs through mar-
may seek out a spouse who was a firstborn to serve as a
riage or cohabitation. Storming, the next stage, is the dis-
caretaker.
ordered time of confusion or chaos when two or more
With the family systems approach, most interactions
distinct personalities discover their differences. Norming
take place in the form of a duo or dyad. Triangulation
describes how groups (or families) adjust to individual
occurs when the dyad diverts attention away from its own
members by applying rules and procedures that the mem-
conflict by focusing on a third person such as the child,
bers agree to obey. Performing is the ideal stage in which
teacher of the problem child, or police officer who comes
the group (i.e., the family) accomplishes their goals and
into a domestic disturbance. Police, nurses, and counselors
produces results. In the family, desirable results would
have often taken the displaced anger of a couple they are
include good citizenship, education and health of its
trying to help and have instead unwittingly become the
members, and active contribution to society. Adjourning/
third part of a triangle.
terminating represents the final stage in a group when it
The multigenerational transmission process describes
has accomplished its goals and disbands to possibly form
how one learns or transmits family emotional systems
a different group. Families experience this stage when
across generations. Watching grandparents express affec-
members die, divorce, or leave the family to begin their
tion teaches patterns to grandchildren who will model simi-
own families.
lar behaviors to their children (unless self-differentiation
Since families represent long-term relationships
or an emotional cut-off changes the pattern). Family pro-
anchored in the performing stage of meeting goals and tak-
jection process is how and what children are taught. Soci-
ing care of one another, the stages tend to be more stable
etal regression describes patterns of the family projection
than with groups. Forming occurs when a child is brought
process that exist in cultures as part of a dominant theme.
into the family by birth or by adoption. Storming describes
For example, in the United States, independence and indi-
the emotional clashes that occur during times of transition
viduality are recognized as desirable qualities and thus are
(i.e., an adolescent testing the rules) or crisis (i.e., adjust-
replicated throughout family culture. This is in contrast
ing to a move or job change). Norming generally occurs
with some Asian cultures that value interdependence and
when parental rules are imposed. For example, family
the importance of being a part of a group.
norming may involve teaching the children to talk more
softly inside the house than when playing in the yard. Per-
forming occurs as each family member performs specific NURSING THEORIES
duties to accomplish the daily tasks of life. Adjourning or Nursing theories define the family–nurse relationship in
termination may follow a death in the family, or it can also various ways. Nightingale viewed family as a support sys-
follow the launching of a high school graduate into col- tem for the primary patient. King described interactions
lege. The healthy family adjusts for the loss and resets roles that result in a shared or mutual transaction (similar to
and norms to fit the new family structure. the nursing care plan). Roy placed family in the context of
chapter 3 The Evolving Family 55
the adaptive system of the client. Neuman viewed families Family Size and Structure
as systems and subsystems. According to this framework, Family size has generally decreased since the founding of
the family can become the self-care agent of a patient who the country when large families ensured more workers for
is unable to meet her own needs. Rogers described the the family business. As recently as one generation ago, fami-
family as an open system that interacts through the lies consisting of more than six members were more reflec-
exchange of matter and energy (George, 2002). tive of the norm than today’s families that average two and
Many nursing theorists and practitioners blend theo- a half children. Birth rates have declined in Caucasian fami-
ries, which then become “integrated” nursing theories. lies while remaining the same in some ethnic cultures. It has
Friedman et al. (2003) merged concepts from general sys- been predicted that by the year 2020, the “minority” family
tems theory and structural functional theory to form an will represent 51% of the total American population.
assessment model. Harmon Hansen and colleagues (2005) Family structure is becoming increasingly different
used the family assessment intervention model with the from the traditional two-parent, two-child nuclear family
Family Systems Stressor-Strength inventory to apply portrayed during the 1950s. Single-parent (mother or
Neuman’s theory in a quantitative measurement tool for father head of household), binuclear (two families living
assessing families. The Calgary Family Assessment Model together), skip-generation (grandparents rearing grand-
(Wright & Leahey, 2005) draws on postmodernism, sys- children), and extended family (grandparents or other
tems theory, cybernetics, communication theory, change relatives living with the nuclear family) are all represented
theory, and biology of cognition to form a multidimen- in the American family of today.
sional assessment model for family nursing care.
The theories described in this chapter have been Parenting Style
selected for their clarity and applicability to a variety of
Parenting style is the manner in which knowledge and
family structures and situations. Many theories from nurs-
values first observed and ingrained during one’s own
ing and related disciplines have utility in a range of family
upbringing and other observed experiences are then used
settings and can be successfully applied to guide and direct
in rearing one’s own children. Parenting style includes
nursing care. Familiarization with a variety of theories
discipline, communication, and distribution of power.
allows for selection of the theory or theories that best fits
Blue collar or working class families tend to view corporal
the family nursing assessment and interventions. Nursing is
punishment (usually in the form of spanking) as the nor-
both an art and a science. The science component involves
mal approach to discipline. Conversely, white-collar (pro-
the research of concepts and development of theories to
fessional class) families favor disciplinary measures that
describe phenomena. The art of nursing is the application
include times-out, positive reinforcement, and other non-
of theory or theories to a specific family interaction.
physical methods. Three distinct styles of parenting have
been identified:
Now Can You— Discuss family theory for nursing practice?
• Authoritarian or dictatorial: Enforces absolute rule;
1. Identify at least four types of theories used in family nursing?
parents enforce rules and strict expectations of each
2. Name three components of Bowen’s Family Systems Theory?
family member; children have little say in decision-
3. Discuss a theory that describes stages experienced by the
making and punishment follows any deviation from
family during the life span of the children?
the established rules; punishment is not necessarily
corporal but often includes withdrawal of approval;
children from this style of parenting tend to be shy,
FAMILY ASSESSMENT sensitive, conforming, submissive, loyal, and honest.
Theories are useful for helping to explain and categorize • Laissez-faire or permissive: Allows the children
behaviors of individuals and families. The next logical control over their environment and subsequent
step, applying theory to the assessment of families, pro- behavior with less input from the parents; few rules to
vides information from which to base interventions to follow; children are able to make their own decisions;
either improve or correct the family’s health. The nurse is punishment is inconsistent when used; children from
sensitive to family needs and is in a unique position to this family tend to be disrespectful, aggressive, and
interact with the family during the assessment process. disobedient, possibly growing up to be irresponsible
members of the community.
• Authoritative or democratic: Parents have a combi-
THE NURSING ROLE IN FAMILY ASSESSMENT nation of characteristics from both the authoritarian
It is difficult to fit modern American families into any and laissez-faire parenting styles; parents find a
particular mold. Variations in size and structure and par- common ground between enforcing rules and allowing
enting style, along with religious, cultural, and socioeco- some freedom for their children to participate in deci-
nomic orientation all affect how the family deals with sions; parents are firm, set realistic standards and pun-
economic, educational, social, and health care issues. To ishment centers on assisting the child develop an
guide the delivery of appropriate care to the family unit, it inner consciousness about behavior; produces children
is helpful to examine the nurse’s role in assessment and who are assertive, self-reliant, and highly interactive
intervention and explore some of the major factors that with high self-esteem (Wilson, Hockenberry-Eaton,
influence family structure. During the assessment inter- Winkelstein, & Schwartz, 2001). Although each type
view, the nurse addresses important concepts including of parenting style has benefits and drawbacks, authori-
family size and structure; parenting style; and religious, tative parenting tends to meet the child’s needs better
cultural, and socioeconomic orientation. than the other styles.
56 unit one Foundations in Maternal, Family, and Child Care
The nurse recognizes that disciplining children is an considered a part of the primary family. In some Native
important concept for parents to understand. Discipline is American tribes, a sister or aunt or grandparent may be the
training the child to meet a pattern of behavior with the primary caretaker of the family and this individual needs to be
intention of instilling good moral judgment, achieving included in health planning and teaching. Certain cultures
competence and maintaining self-control, promoting self- give preference to the matriarch while others are more male-
direction, and learning to respect others. Consistency with dominated. In some Hispanic cultures, the adult son makes
rule setting is a key concept that parents must understand. health care decisions for the family. Nonverbal forms of com-
A reliable and steady discipline approach by parents rein- munication can vary widely across cultures. There may be
forces to the child that their misbehavior will be corrected. differences in eye contact, the practice of formal and informal
Often, redirecting the child away from the behavior to alter- touch, the level and tone of voice, and how respect is shown.
native activity can be an effective way to discipline. With A nod by individuals in some Pacific Rim countries may be an
older children, reasoning or explaining to the child why the indicator of respect but does not necessarily convey an under-
behavior is unacceptable may also be useful. The nurse can standing of the nursing instructions given. Although a family
help parents understand that positive and effective child- member translator may be comforting to the family, this situ-
rearing practices can be straightforward and firm without ation is not reflective of best practice methods, especially for
being negative or abusive. informed consent purposes. Instead, a non-family professional
During the family parenting style assessment, the nurse translator should be used (Ehrlich, McCloskey, & Daly, 2004;
observes for indicators of neglect or physical abuse, but Wilkinson & Van Leuven, 2007).
otherwise supports consistent and predictable conse-
quences and rewards appropriate to the age of the child. Socioeconomic status impacts the family’s ability to
Parents should be given information about disciplining access and pay for health care and other services. The nurse
consistently and without anger. When indicated, parents assists with referrals to social workers or other community
can be referred to parenting courses or support groups. experts to secure resources appropriate to the family’s
Religious, Cultural, and Socioeconomic Orientation needs. Available resources include state and government
supplemental programs, insurance sources, loans and grants,
Religious orientation has varying effects on families. The
and church or community programs that aid families
majority of Americans claim some affiliation with a church
through catastrophic losses such as fire or health crises.
or spiritual group, but fewer than 30% actually attend a
Historically recognized as important advocates for the
spiritual institution on a regular basis (McIntosh, 2004).
family, nurses lead efforts to change or adjust laws and legis-
Values that tend to be rooted in religious beliefs include
lation to assist and empower families in areas such as child
practices concerning the observation of holidays and
care, elder care, work leave for births or care of sick family
beliefs toward abortion, birth control, marriage, and
members, tax breaks for dependents including elderly mem-
advance directives (legal documentation that directs that
bers, assistance with health care costs, and public service
“no heroic” measures be taken to extend life).
education for health care choices. Legislation concerning
Religion also influences attitudes toward alternate lifestyle
helmets, seat belts, and child safety seats illustrates several
choices such as homosexuality and sexual abstinence and
government interventions designed to foster and enhance the
other moral choices such as euthanasia or suicide. Religious
well-being of families and individuals. Policies concerning
beliefs can provide comfort and a sense of peace to believers
stem-cell research, same-sex marriage, property laws, pro-
in times of sickness or grieving. Religion-based movements
choice rights, and minimum wages are but a few examples of
such as the “Promise-Keepers” and the “Million Man March”
the government’s far-reaching impact on the family.
were created, in part, as a positive force to encourage men to
become more responsible fathers and husbands.
The nurse assesses the family’s religious or spiritual TOOLS TO FACILITATE THE FAMILY
affiliation and, when indicated, assists in contacting the ASSESSMENT
appropriate spiritual advisor or clergy member. Hospitals Qualitative and Quantitative Surveys
provide clergy and chaplain services for a variety of needs For most hospital settings, assessment of the family is lim-
and occasions. The nurse avoids imposing personal beliefs ited to gathering a history, usually during admission,
and values on the family, but instead helps them obtain related to the patient’s illness. However, in a family nursing
the resources necessary to help them to regain balance in approach that encompasses care of the entire family, more
crisis situations. thorough formats for family assessment are used. Friedman
Cultural orientation includes family communication et al. (2003), Harmon Hanson et al. (2005), Wright and
styles, structure of family, health beliefs, and power distri- Leahey (2005), and others have developed family nursing
bution. The nurse assesses family cultural affiliation and assessment forms to provide either a qualitative or a quan-
avoids generalities or stereotypes by validating all cultural titative view of the family. A variety of assessment tools are
information with the family. available and those frequently used include surveys, geno-
grams, ecomaps, and strengths and problems lists.
Ethnocultural Considerations— When Qualitative tools assess the description and depth of
assessing families family experiences. Quantitative tools measure the fre-
quency with which behaviors or situations exist. Most sur-
It is important for the nurse to be aware of ethnocultural vari- vey tools emphasize either the qualitative or quantitative
ations that may exist in family structure and communication dimensions of family, but usually contain elements of both.
styles. Many cultures emphasize the extended family to a Friedman et al. (2003) have developed both a long form and
much greater extent than the American nuclear family. Often, a short form to qualitatively assess the roles and structure
grandparents as well as aunts, uncles, and cousins may be of the family and its members. Harmon Hanson et al. (2005)
chapter 3 The Evolving Family 57
utilize the Family Systems Stressors-Strength Inventory, an provide input based on observations related to the family’s
instrument that elicits a numbered ranking of each family strengths and weaknesses, but should not take over this
member’s perception of the severity of stressors in selected process. In the therapeutic situation, the family must
categories. Wright and Leahey (2000) use the Calgary Fam- assume ownership of all identified strengths and problems
ily Assessment Model (CFAM) and combine this tool with so that they can participate fully during the assessment
the Calgary Family Intervention Model (CFIM) to provide a and treatment phases of the nursing intervention. The
complete assessment and treatment map. nurse helps the family focus on major issues or problems
Before implementation of the selected assessment tool, that will form the starting point of intervention.
agreements and sometimes written consents are obtained Next, the family makes a commitment with the nurse
that relate to the confidentiality of the information sought, and appropriate referral agencies to participate in the
how it will be used, and what treatment options and refer- mutually agreed upon interventions. Depending on
rals may be recommended. Before the assessment, it is the situation, the family may be assisted in completion of
important for the family to understand that the nurse is the assessment tools or the tools may be given to each
legally bound to mandatory reporting obligations in cases member to complete and return at a later date. Usually,
of abuse or violence, and also that member safety remains more tools are completed when the family is assisted with
a priority above all other interventions. Following these this task in the nurse’s presence.
disclosures, or “ground rules,” the family may choose to The nurse compiles and summarizes the information
end the therapeutic relationship with the nurse before any provided and discusses the results with the family. The
information is shared. initial assessment, which utilizes the selected assessment
Jason Jared
b. 1968 b. 1968
Brett
b. 1987
Runs away
Helen’s Background:
Helen’s parents Herman and Joyce were married in 1959 until Herman’s death in 1989.
Herman was an alcoholic.
Helen was closer to her father than to her mother.
Joyce is very active in her local community.
Helen has brothers who are identical twins, Jason and Jared. They are very close.
Chris’ Background:
Chris’ parents Sirus and Mary were married in 1961, but have been separated since 1999.
Sirus has health difficulties due to diabetes and relies often on Chris to help him.
Chris’ sister Anna is in a relationship with Donna, which has distanced her from their mother Mary. Figure 3-1 cont’d Example
Chris is close to Anna. of a genogram template.
Key to Ecomap When working with the childbearing family, nurses need to be
Circles represent systems that aware that social class and cultural norms frequently affect the
interact with Smythe Family roles of various family members. The male’s likelihood to par-
Dotted line indicates strained ticipate in the childbearing experience, for example, is culturally
relationship influenced. Traditional Mexican and Arab families may view
Figure 3-2 Example of an ecomap. pregnancy and birth as events that are strictly “female affairs.”
The nurse looks for themes of emotional connected- The nurse assesses the effectiveness of family roles by
ness or isolation among the family members. There may observing the condition of the house and living conditions
also be clues that indicate the presence of family violence (by conducting a home visit, if possible, or by obtaining
or neglect. In their interactions, the healthy family con- the information during the interview), the clothing and
veys a sense of connection and an appreciation of the fam- personal hygiene of the family members, and gathers
ily unit and of its individual members. The healthy family other information to determine if family members are car-
is open with problem identification and exploring coping rying out individual role assignments. There is much
patterns. There may also be clues that indicate the pres- variation on how different family members meet their role
ence of family violence or neglect. Conversely, the requirements. For example, a single mother may need to
unhealthy family tends to control or hide information or seek public assistance in order to fulfill the provider role
block access (of information) from other family members. and obtain essential resources for her family. This process
The nurse should always conduct follow-up interviews involves contacting various agencies, completing lengthy
with family members who were absent or not accessible forms, waiting in lines, and engaging in other activities
during the initial interview. that can sometimes take as much time as working at a job
to meet the family’s needs. Fulfilling roles also encom-
passes the completion of tasks appropriate to each mem-
Optimizing Outcomes— During assessment of family ber’s and the family’s stage of development.
communication patterns
During the family interview, the nurse should be cautious ASSESSMENT OF THE FAMILY
not to rely solely on information provided by family mem- DEVELOPMENTAL STAGE
bers. Often, dysfunctional communication patterns are The Family Developmental Stage (Friedman et al., 2003;
suppressed as members attempt to present themselves Harmon Hanson et al., 2005; Wright & Leahey, 2005) is
most favorably. It is important to observe verbal and non- the time in the family’s lifespan that is focused on a par-
verbal communication with and among family members. ticular age of a child or a specific family situation. This
stage is assessed by means of the interview, the applica-
tion of tools and surveys, and during observation of the
family. At any given time, most families exist in simul-
ASSESSMENT OF ROLES AND RELATIONSHIPS taneous stages. They may be launching a high school
Roles and relationships are the job descriptions and connec- graduate off to work or college and still have an infant
tions of the individual family members. One or more family (their child or grandchild) in the home. The family must
members assumes the responsibility of earning or obtaining accomplish a specific set of tasks for each stage. An infant
money and resources, paying bills, providing meals, clean- requires feeding and changing and napping and nurturing
ing the living space, transporting family members, choosing throughout the day. The high school graduate most likely
entertainment and recreation activities, and promoting needs assistance and support whether planning for college
health and emotional security. The nurse assesses (through or making career choices. An extended living situation
observation and/or application of assessment tools/surveys) at home may be needed while a family member is in tran-
for the delegation of tasks that meet the family needs on a sition. The nurse assesses (by the observation of the
daily basis. Certain roles clearly fall in the domain of specific presence or absence of resources and material goods such
family members, such as the parent who pays the bills. as clothing, food, and furniture appropriate to the family
60 unit one Foundations in Maternal, Family, and Child Care
stage) that the family is successfully meeting the tasks for triangulation is being negatively used and teach families
each stage or that they are obtaining appropriate assis- other strategies for maintaining stability.
tance from outside resources (e.g., a student loan) to help
meet their needs. ASSESSMENT FOR THE PRESENCE OF DYADS
AND OTHER SUBSYSTEMS
ASSESSMENT OF FAMILY RITUALS
A dyad (Bowen, 1978; Harmon Hanson et al., 2005) is a
Family rituals consist of routines or activities that the fam- structure in which two family members form a bond to
ily performs and teaches its members as a part of continu- become a subsystem of the greater family system. Within
ity and stability. Rituals encompass meal and bedtime rou- a family of four, existing dyads generally include the
tines, greeting and dismissing behaviors (a kiss goodbye or husband–wife dyad, father–son dyad, brother–sister dyad,
goodnight; a hello or a good-morning shout across the or other combinations. The dyad may be a natural alliance
room), and observation of celebrations or terminations for the purposes of intimacy or play or related activities.
(birthdays or funerals). The nurse assesses (through obser- Dyads may form as siblings team up against a perceived
vation and direct inquiry, or as guided by the assessment unfair parental rule. The nurse observes for the presence
survey) for family member agreement on how important of dyads, and notes whether or not they are self-identified,
days are observed or if they are acknowledged at all. For and whether a positive or negative impact on the family is
example, birthday celebrations may be elaborate, informal, known or acknowledged.
or summarily dismissed. Holiday presents may be opened
before or during the holiday or not exchanged at all. Fami-
lies may always or never share meals together. — Specific questions to ask during
the family assessment
Nursing Insight— Family building activities, rules, To elicit family identifying data, the nurse may ask:
mottos, and beliefs “Who in your family lives in your home?”
Family-building activities are an extension of rituals that cen- “What other family members live elsewhere?”
ter on recreation and leisure, such as family trips and vaca- “What are the sources of income or other resources for
tions. Although a best friend may be invited to participate in your family?”
some family events, a healthy family generally designates spe- Questions to determine the family’s developmental stage
cial “together time” that isn’t open to non-family members. can include:
Family rules, mottos, and beliefs are the ways the family views
“What are the ages of the children in family?”
itself and describes itself to others. “We always finish what we
start” or “We stick together through thick and thin” are oft- “What jobs or tasks take up the most time in providing
used sayings that a family may identify with, whether or not care for the children?” Environmental data includes
they are consistent in holding to those beliefs. As a component information about the neighborhood of residence and
of the assessment, the nurse can ask for three or four sayings local resources such as stores, schools, hospitals, and
or beliefs that the family feels are important in maintaining entertainment centers. Other questions are intended
their family system. The nurse then asks for examples of to elicit information concerning family structure
responses to situations that illustrate or confirm this belief. (“Who makes decisions?”), function (“How is
emotion and affection shown?”), and health care
(“What health appointments are made and by whom?”)
ASSESSMENT FOR TRIANGULATION (Friedman et al., 2003).
Triangulation, assessed through family observation,
occurs when two family members focus on or team up Once all pertinent information has been obtained and
against a third family member to compensate for friction documented, the nurse elicits the family’s assistance in
between the two members (Bowen, 1978; Harmon prioritizing the most pressing and problematic issues.
Hanson et al., 2005). Triangulation balances the family in These issues are then addressed in the family treatment
a manner similar to how a furniture builder adds a third plan that forms the basis for all family-centered inter-
leg to balance a two-legged stool. The family reaches out ventions. Depending on the specific situation, nursing
or even attacks a third member or outside person as a way interventions for families most often include referrals,
to decrease tension between two members and to obtain education, and counseling.
balance. For example, rather than blame one another for
the child’s asthma symptoms, the parents instead focus
on seeking outside medical help for the condition. This Optimizing Outcomes— With nursing interventions
scenario illustrates a positive use of triangulation. for families
Conversely, tobacco-using parents who focus on their Referrals may be made to support groups (i.e., Alcoholics
child’s asthma symptoms while ignoring their own Anonymous, Al-Anon, Gamblers Anonymous), physicians,
tobacco addiction (and the unhealthy environment that social services, and mental health agencies. Education may
accompanies it) illustrate a potentially negative triangula- center on the use of prescribed medications and therapies,
tion. Two brothers who team up against the policeman nutrition, and family health promotion. When indicated,
called to break up their drunken dispute is an example of licensed professional counselors, nurse practitioners, psy-
triangulating with an outside source. Family therapists chologists, and family therapists provide in-depth family
are particularly vulnerable to triangulation when working counseling.
with families, and they must learn to recognize when
chapter 3 The Evolving Family 61
Now Can You— Apply tools and concepts to assess new roles brought about by the baby’s arrival. The mother
a family? feels resentful that the father is not helping more; the
father senses the resentment but doesn’t recognize what is
1. Describe two tools used to diagram family structure and wrong. The nurse identifies clues to tension in the rela-
function? tionship during well-baby check-ups or perhaps even prior
2. Discuss at least five concepts that can be assessed in the to discharge from the hospital.
family?
3. Explain the nurse’s role in the assessment of the family? GOAL: RETAIN/MAINTAIN OPEN LINES OF COMMUNICATION. The
family will discuss feelings openly and nonjudgmentally
with each other using “I feel” statements (Clark, 2003)
and avoiding defensive communication techniques (John-
Family-Centered Care son & Johnson, 2003). All members will negotiate what it
is they would want for the other member to understand
After the assessment process has been completed, the nurse
about their feelings and needs.
selects all applicable nursing diagnoses and formulates the
family care plan. The family’s assistance is elicited to ensure GOAL: ADAPT TO CHANGES IN FAMILY PROCESS/SITUATION BY
that they are in agreement with the identified diagnoses. SHARING RESPONSIBILITIES. To meet this goal, various family
The nurse guides the family in writing mutually agreed- roles need to be adjusted. For example, having an older
upon goals that they will work on together. Diagnoses may sister help babysit the infant in order to give the mother
be psychosocial, physiological, or both and they may be more time for rest represents a family adaptation necessi-
focused on the individual or on the family (Box 3-1). tated by a change in the home situation. After the birth of
In the following discussion the nursing diagnosis a baby, the father may need to take family leave so that he
“Altered Family Processes” is presented and described can share in child care. In another family, the mother-
in detail to illustrate the possible goals, interventions, in-law may be asked to assume a more active role in assist-
and evaluation criteria that could be appropriate for ing with newborn or child care.
families experiencing problems in their day to day
functioning. GOAL: RESPECT THE INDIVIDUALITY OF EACH MEMBER’S ACTIONS.
The family may need to allow a member to isolate from an
NURSING DIAGNOSIS: ALTERED FAMILY event until he or she is able to handle the situation with the
PROCESSES rest of the family. For example, it is developmentally appro-
priate for a teenager to want to continue with contact from
This nursing diagnosis describes a family that experiences friends while the family is experiencing a situational crisis.
problems in their everyday functioning. Problems often
center on communication issues or difficulties with mem- GOAL: PARTICIPATE IN THE CARE OF INDIVIDUALS. The family
ber role fulfillment. In these situations, the family is in needs to prioritize care for its sick or disabled members
need of education and/or intervention to help them return over lesser psychosocial needs such as having friends over
to normal daily functioning. As an example, a family with for the school-aged children. All needs should be addressed
an infant may not be communicating about sharing the eventually, but safety and physiological needs should be
addressed first.
GOAL: SEEK/ACCEPT RESOURCES AS NEEDED. As a system,
Box 3-1 Examples of Family Nursing Diagnoses the family opens its boundaries to appropriate outside
sources (i.e., the pediatrician, internist, and social worker
Any NANDA diagnosis may be appropriate for describing an individual
family member’s health status. A family diagnosis is intended to describe
or community health department) as needed to help pro-
the health status of the family as a whole. Examples of family diagnoses vide appropriate health care for its members. Families
include the following: with issues such as domestic violence often have diffi-
Caregiver Role Strain (actual and risk for) culty trusting another system due to the fear of legal
Dysfunctional Family Processes: Alcoholism
intervention. The family may have difficulty accepting
help if they do not perceive or acknowledge the problem.
Family Coping: Compromised
The nurse may use a number of interventions to help the
Family Coping: Disabled
family obtain their goals under this nursing diagnosis.
Impaired Parenting (actual and risk for) The following are examples of applicable nursing
Ineffective Family Therapeutic Regimen Management interventions.
Readiness for Enhanced Family Coping
Readiness for Enhanced Parenting INTERVENTION: IDENTIFY FAMILY DYSFUNCTION AND THE FAMILY’S
AWARENESS OF THE PROBLEM(S). As part of an ongoing col-
Risk for Parent-Infant-Child Attachment
laborative process with the family, the nurse adds
Social Isolation
entries to the problem list as needed to keep the list
Spiritual Distress current and applicable. The problem list is then
NOC outcomes specifically for families as units are included in the NOC domain reviewed during each nursing visit. For example, the
“Family Health.” This category includes the following classes: Family Caregiver Sta- nurse may recognize that the family does not use
tus, Family Member Health Status, Family Well-Being and Parenting. Outcomes from proper car safety seats for the younger children.
other domains may also apply. NIC interventions for families as units are included Throughout the collaborative process, as problems are
in the NIC domain “Family.” This category includes the following classes: Childbear-
ing Care, Childrearing Care and Life-Span Care.
identified by a family member, the nurse assesses other
Sources: Carpenito-Moyet (2006); Wilkinson & Van Leuven (2007). members’ understanding and willingness to participate
in the proposed solutions.
62 unit one Foundations in Maternal, Family, and Child Care
low profile at home and school and does not usually fail but relationship with the abuser and with one other. If the
also does not particularly stand out in anything, either. abused member is removed from the family, there may be a
Along with the family roles are family rules that are transfer of the behavior to another member.
implicitly followed by all members, such as: “Don’t talk In all situations, the nurse is legally obligated to report
and don’t feel.” Family members know not to discuss fam- the abuse to the proper investigating agency. However,
ily problems with outsiders such as teachers, nurses, or the nurse is not responsible for investigating or interven-
even friends. Secrets are the hallmark of addictive families ing with the family once the report has been made. When
both for social and legal reasons. Family members also unsure, the nurse can verify suspicions of abuse with
learn not to feel the disappointment or anger or sadness other treatment team members, but once the suspicions
that the addiction causes them. Parents do not make it to are confirmed, either the nurse, nursing supervisor, or
the children’s games or teacher conferences, or even to treatment team leader is mandated to report the abuse.
major events such as graduation. The children deny that The nurse then makes a therapeutic alliance with the fam-
the parent’s lack of involvement impacts their feelings. If ily unit (probably without the abuser) to help return them
changes do not take place in these types of family systems, to normal roles and relationships. The nurse must remain
there is a great likelihood that the children will be socially vigilant for signs of continued abuse or violence with
and personally impaired and a high percentage turns to the remaining members or with the primary abuser if he
substance abuse themselves (Townsend, 2005). (or she) is returned to the family.
The nurse and the family with substance abuse/alcohol
abuse must assess the amount, type, and length of time the
addiction has been a part of the family. If the main sub- case study Elder Abuse in the Family
stance abuser is actively engaged in treatment, the family
should be referred to therapy or support groups such as Al- The nurse is conducting a home visit with an 85-year-old mother
who is being cared for by her adult daughter. The daughter
Anon that can help them to identify and change their own
exhibits an attitude of detachment toward her mother. A gen-
behaviors, wants, and needs apart from those of the alco- eral assessment of the elderly patient is remarkable for strong
holic. If treatment is not obtained for the affected member, body odor, stained clothes, and an overall disheveled appear-
the nurse should refer family members to organizations ance. The mother is alert but hesitant to talk with the nurse and
such as Alcoholics Anonymous or to legal agencies that can evasive with her answers. The daughter appears to be impatient
identify options for getting the member into treatment or and explains that she needs to go shopping.
strategies for keeping the family safe from the member. 1. What other assessment information would be needed to
verify whether or not the patient was being neglected?
case study The Family Members of an 2. What steps should be taken if abuse or neglect is suspected?
Alcoholic ◆ See Suggested Answers to Case Studies in text on the
Electronic Study Guide or DavisPlus.
A 9-year-old boy has been sent home from school several times
for fighting. The father has a history of scrapes with the law
related to public drunkenness and bar fights. The mother tells
the school nurse that the father has been laid off at work and POSTTRAUMATIC STRESS DISORDER
has a lot of issues on his mind to work through. She further Posttraumatic stress disorder (PTSD) is a condition that
states that the boy has been nothing but trouble and is an
results from experiencing a catastrophic event such as rape,
embarrassment to the family, unlike his sister, who is a junior
high cheerleader and “straight A” student. battering, accident, mugging, or war. The survivor or survi-
vors of the traumatic event may experience nightmares and
1. What roles are being played in this family? flashbacks (vivid re-experiencing of events while awake)
2. What is the purpose of these roles? and frequently develop a detached view of life. Involved
families “lose” an active participant in their lives while the
3. What interventions would the nurse bring to this family?
family member with PTSD vacillates between apathy and
◆ See Suggested Answers to Case Studies in text on the extreme vigilance and overprotectiveness. The affected
Electronic Study Guide or DavisPlus. family member may also turn to substance abuse in an
attempt to dull the memories associated with the event.
An entire family may experience PTSD after a shared
event such as surviving a flood or tornado that destroyed
SEXUAL OR PHYSICAL ABUSE everything and left them homeless. Often, symptoms do
Sexual or physical abuse in the family is similar to sub- not appear for days or weeks following the event. The
stance abuse in how it affects the family system. In general, delay may result from the initial gestures of support pro-
this problem can exist only in a family system that keeps vided by the family and the community. The nurse
secrets and creates specific roles that allow its continuance. assesses for symptoms of PTSD during the interview, with
When an incestuous father/child sexual relationship occurs, questions focused on sleep disturbances or flashbacks of
the mother or marital partner has taken on the role of either the traumatic event and the individual’s inability to par-
ignoring or covering up the abuse. In some situations, the ticipate fully in the family’s life. When identified, the fam-
mother feels threatened and acts as a sexual competitor ily member(s) is referred for appropriate intervention.
(against the daughter) for the husband’s affection. In many Alternately, the nurse may elicit the assistance of an
cases, one person is singled out for the physical or sexual expert trained in Critical Incident Stress Debriefing or
abuse. Other family members have a relatively normal who has experience with other proven techniques for
chapter 3 The Evolving Family 65
treating survivors. Support groups are usually therapeutic them to get the information necessary to provide con-
in helping both the victim and the family ease the affected tinued support and treatment of their family member.
member back into their world. To learn more about caring for the family with chronic
physical illness, see Chapter 35.
CHRONIC PHYSICAL ILLNESS
Asthma, diabetes, and Crohn’s disease are often viewed case study The Family of a Diabetic Teen
as medical conditions that are affected by psychological
factors (Kneisl, Wilson, & Trigoboff, 2004) because of Shelley is a 15-year-old with type 1 diabetes mellitus who pres-
the strong emotionality involved. Although emotions do ents periodically to the emergency department with a blood
not cause these illnesses, they may exacerbate the symp- sugar level of greater than 300 mg/dL. The family states she has
toms by decreasing the family member’s compliance been snacking on foods not on her diet, is sporadic with her
with the treatment or by increasing the anxiety related blood sugar testing, and inconsistent in the management of
to the symptoms. Families need to be educated about her sliding scale method of insulin administration. The nurse’s
various aspects of daily care for members who experi- conversation with Shelley reveals that Shelley is resentful of her
ence chronic illness. For example, the nurse may teach illness and angry that she has to do things that “the other girls
do not have to do.”
about monitoring the diabetic family member’s blood
glucose analysis or self-administration of insulin or how 1. In view of Shelley’s developmental stage, what information
to assist the asthmatic with inhalation therapy. should the nurse give to Shelley and her family regarding
In some situations, a teenager may not fully accept diabetes?
his illness and choose not to take prescribed medica- 2. How would the information be presented differently if
tions. This behavior often stems from a need to prove to Shelley were 6 years old?
self or others that he does not truly need the medica-
tions or treatment. An older adult living in the home ◆ See Suggested Answers to Case Studies in text on the
may not fully understand the temporal demands associ- Electronic Study Guide or DavisPlus.
ated with a medication schedule and may require addi-
tional teaching and close monitoring, especially if the
medications have recently been changed. The nurse
DEATH OF A FAMILY MEMBER
helps the family transition from dependence on the The nurse is often the first point-of-contact when a family
health care worker to family member independence, member has died in the hospital or at home if home nursing
although, depending on the circumstances, some super- was involved in the member’s care. The particular develop-
vision by the family may always be necessary. The fam- mental stage affects the way in which each family member
ily benefits through an ongoing partnership with a pro- grieves. While the length of time that elapses between the
vider or clinic that enables them to receive progress stages of grief and the manifestations of grief vary, all family
reports, treatment updates, and needed medications. members grieve in some manner. Stages of grieving have been
The nurse facilitates family empowerment by helping described by a number of theorists; several are presented in
Denial (shock Reeling (stunned Shock, Outcry, and Denial High Anxiety (physical Avoidance (confusion and
and disbelief) disbelief) (external response to loss) response to emotional dazed state, avoidance of
upheaval) reality of loss)
Anger (toward God, Feelings (emotionally Intrusion of thoughts, Denial (protective Confrontation (intense
relatives, the health care experiencing the loss) distractions, and obsessive psychological reaction) emotions, anger, sadness,
system) reviewing of the loss feeling the loss)
(internal response, isolation)
Bargaining (trying to Dealing (taking care Confiding in others to Anger (directed inwardly, Reestablishment
attain more time, of details, taking care emote and cognitively toward another family (intensity declines,
delaying acceptance of of others) restructure (integration of member, or toward others) and the parents resume
the loss) internal thoughts and their lives)
external actions to move on)
Acceptance (readiness to Healing (recovering Remorse (feelings
move forward with and reentering life) of guilt and sorrow)
newfound meaning or
purpose in one’s own life)
Grief (overwhelming sadness)
Reconciliation (adaptation to
existing circumstances)
66 unit one Foundations in Maternal, Family, and Child Care
Table 3-1. The nurse provides time and space (family visiting Now Can You— Identify and plan care for special problems
room, chapel, or the patient’s room) for the family to gather. and issues faced by the American family?
The nurse also inquires about the family’s preferences con-
cerning participation in preparation activities before the 1. List eight special problems that may be experienced by
arrival of the mortuary representatives. Some cultures and families?
religions wish to ritually bathe and dress the body. 2. Identify various nursing roles and interventions appropriate
The family must also decide which members should be for these families?
involved in the various tasks and this decision is affected 3. Describe the nurse’s role when abuse is suspected?
by the age or developmental level of the child or adult. For
example, a developmentally challenged adult may need
the same approach as a younger child. In most situations, Family Cultural Characteristics
viewing the deceased (after equipment such as tubes and
drainage bags have been removed) helps family members An understanding of the prevailing concepts of accultura-
of all ages accept that death has occurred. They can then tion, assimilation identity, time, connectedness, commu-
begin the grieving process. nication, and social class facilitates the nursing assessment
The nurse participates in the accepting/searching for and guides the application of interventions within differ-
answers stage that often occurs early during grieving by ent cultural frameworks. To enhance understanding of the
providing answers regarding the illness or procedures or concepts, it is helpful to examine characteristics of the
treatments that were involved. As appropriate, the nurse “typical” American family. General comparisons with
may seek assistance from the physician, other members of selected cultural groups provide the nurse with a staring
the health care team, or from other resources. The family’s point for understanding and interacting with families in a
minister or hospital chaplain may be asked to offer spiri- culturally appropriate way.
tual support, provide counseling, and address concerns.
The nurse may wish to participate in prayer led by the ACCULTURATION AND ASSIMILATION
family’s clergy or hospital chaplaincy. Providing a presence
and remaining with the family as long as possible are often The American family exhibits many variations owing to its
the best nursing approaches for the family that has experi- unique blending with other cultures. The rich cultural
enced a loss. The nurse may also have an opportunity to heritage that has evolved from the mixing of various ethnic
advise family friends that a critical time for them to be groups that comprise the American family constitutes the
available to the family is around the third or fourth week hallmark of this relatively new culture. Acculturation
after the funeral, when the family is left to deal with the describes the changes in one’s cultural pattern to match
full impact of the loss (Wilkinson & Van Leuven, 2007). those of the host society (Spector, 2004). The changes
occur within one group or among several groups when
individuals from different cultures come into contact with
Across Care Settings: Family care in inpatient, one another. Certain characteristics of the primary culture
outpatient, and hospice settings may be retained while other practices of the dominant cul-
tural society are adopted. For example, culturally influ-
In hospital inpatient units, families should be oriented enced customs and traditions such as food choice and
to visiting hours, waiting rooms, meals, and overnight preparation, language patterns, and health practices are
accommodations. Nurses reinforce patient admission data usually retained for long periods of time. Assimilation is
such as advance directives and organ donation policies the process in which the family loses its unique cultural
and encourage an open discussion between the patient and identity and identifies instead with the prevailing or domi-
family to prevent confusion regarding who would act as the nant culture (Spector, 2004).
patient’s agent to make decisions in the event of incapacity
or death. Families often need assistance with medical IDENTITY
information, billing information, and admission and
discharge information. In pediatrics units, families should The identity (how the family views itself) of the American
be alerted to policies concerning staying with their sick family is related to whether or not the family aligns itself
child and assistance should be offered in making with a particular ethnic group (e.g., Italian American, Irish
arrangements for the care of other children. In long-term American) or instead only sees itself as “American.” Identi-
inpatient settings, families rely on visits, telephone calls, mail, fying with a particular ethnic group usually involves ado-
and e-mail to stay in touch with members. In outpatient pting that group’s world view or approach to life. Anglo-
units, nurses can educate the family about strategies to Americans, for example, view themselves as independent
enhance patient recovery, reinforce discharge instructions, individuals often separate from families (Friedman, 2003).
and provide written information about follow-up visits. Other cultures (i.e., Hispanic, Asian, and Pacific Islander)
In home health and hospice settings, the nurse assists consider individuals in the context of family members and
the family in reaching a comfortable balance between direct place less of an emphasis on who they are as individuals
involvement in the family member’s care and respite time (Wilkinson & Van Leuven, 2007).
for family building activities with other members. The American family may influence a member’s choice
Demystifying medical procedures such as medication of occupation, but usually to a lesser degree than that
administration, catheterization, and tube feeding empowers found in some cultures. For example, in earlier times,
the family to decide what they can do and how and when the English names of “Butcher” and “Baker” reflected a
to seek assistance from the nurse and other care staff. family occupation and set of expectations. In general,
an American child is free to choose a career based on
chapter 3 The Evolving Family 67
personal preferences and talents that have been devel- The American family member is more likely to speak
oped in outside systems such as school, church, or extra- on her own behalf in public situations such as in schools
curricular activities rather than one exclusively imposed and health care settings and is encouraged (within legal
by the family. limits) to do so. Language other than American English
Time orientation is a concept that refers to whether or often contains built-in formal and informal variations of
not the family views itself to be strongly connected to words intended to convey respect to parents and elders,
previous generations. The American family tends to be who frequently serve as spokespersons in settings such as
focused on the present and future much more so than hospitals and physicians’ offices.
many cultures. This current-future time orientation may
be related to the relative newness of America as a country, SOCIOECONOMIC CLASS
as compared to an ancient civilization such as China. In Social class refers to occupation and economic status. In
the American family, the individual is expected to be America, status is related to social and economic variables,
punctual and conform to deadlines at school and work. and mobility between the different classes is more fluid
Making future plans by saving money or pursuing higher than in some countries. Religious and political influences
education is also valued. Many industrialized countries significantly influence how the family interacts and responds
share a present and future time orientation, while other to outside systems such as schools and community health
countries value a slower pace with greater emphasis on programs. For example, some religious groups advocate
the connection to the past in terms of ancestors and tradi- home, rather than public schooling; political and religious
tional beliefs (Friedman et al., 2003; Townsend, 2005). orientation often shapes family beliefs about abortion or
birth control. Other values are influenced by the prevailing
CONNECTEDNESS societal view. For example, the contemporary American
Connectedness is a concept that emphasizes who the family tends to value its members according to the individ-
family identifies with and relates to as family members. ual’s line of work and educational achievements rather than
The generality that American families are often orga- the family’s identity (Harmon Hanson et al., 2005).
nized into smaller nuclear families that consist of one or
two parents and children is being replaced by the fact HOLISTIC NURSING ENCOMPASSES A
that only 52% of American families presently fit that pat- CULTURALLY SENSITIVE FAMILY APPROACH
tern (Friedman et al., 2003). Some American families Family assessment is integral to the delivery of competent,
and many other cultures highly value and place great appropriate, holistic care. For most nurses, developing a
importance on the inclusion of grandparents, aunts, knowledge base that is sensitive to the cultural variations of
uncles, and cousins in their family circle. That level of structure and function in the American family presents a per-
extended connectedness may also include the commu- sonal challenge. Awareness of personal perceptions and val-
nity, especially if other members of the same ethnic ues that may negatively impact therapeutic interactions with
group live in the neighborhood. In some American fami- families is a professional responsibility. Nurses at every level
lies, members spend more time commuting to outside of preparation and throughout their professional careers must
interests than engaging in neighborhood and home- engage in an ongoing process of developing and refining atti-
based family activities. tudes and behaviors that will promote culturally competent
care (Taylor, 2005). The professional nurse grows in cultural
COMMUNICATION PATTERNS competence by seeking more knowledge through review of
literature and evidence-based practice, attendance at cultural
Patterns of communication vary according to ethnic group. seminars, and exposure to other cultures in a variety of set-
Cultural customs often guide selection of the family mem- tings. The more we learn about other cultures, the more we
ber who will be designated as the primary historian in a learn about ourselves as nurses and as human beings.
health care interview. American families tend to be more
fluid and open in designating which member speaks to out-
Now Can You— Recognize cultural differences that may
siders, although legal contracts most often favor the parents.
impact the nursing assessment and
Other cultures (i.e., Hispanic families from Mexico) may be
interventions with the family?
more patriarchal (male dominant) or matriarchal (female
dominant) and the caregiver role may rely heavily on a 1. Identify “typical” characteristics of the American family
grandparent or aunt rather than the parents. The designated related to time and goal orientation?
caregiver is usually the communicator in the health care 2. Explain how culture influences the family’s degree of
setting. When planning interventions, it is important to connectedness and patterns of communication in the health
consider the cultural role of the family member who makes care setting?
the primary decisions (Wilkinson & Van Leuven, 2007). 3. Describe adjustments the nurse may make to heighten
cultural awareness and enhance a culturally appropriate
Nursing Insight— Culture, communication and family assessment and intervention?
emotional expression
Culture is the essence of what defines us as people. Gaining summar y poi nt s
an understanding of culture gives insights into family patterns
of human interaction as well as expressions of emotion ◆ The competent nurse views the family as a focus of
(Munoz & Luckmann, 2005). care, not as an inconvenient intrusion into the nursing
routine.
68 unit one Foundations in Maternal, Family, and Child Care
Hitchcock, J., Schubert, P., & Thomas, S. (2003). Community health (NC-EST 2004-02). Source: Population Division, U.S. Census Bureau
nursing: Caring in action. Clifton Park, NY: Thomson–Delmar Release Date: June 9, 2005. http:/www.census.gov/popest/national/
Learning. asrh/ (Accessed September 14, 2008).
Johnson, D., & Johnson, F. (2003). Joining together: Group theory and U.S. Department of Health and Human Services (USDHHS). (2000).
group skills. Boston: Allyn and Bacon. Healthy people 2010: Understanding and improving health. Washington,
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, DC: Author, Government Printing Office.
J., Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, U.S. Department of Health and Human Services (USDHHS). (2005a).
and NIC Linkages: nursing diagnoses, outcomes, & interventions Health Resources and Services Administration. Women’s Health USA
(2nd ed.). St. Louis, MO: Mosby Elsevier. 2005. Retrieved from www.hrsa.gov/womenshealth (Accessed May
Kaiser Commission on Medicaid and the Uninsured. (2003a). The unin- 15, 2007).
sured in rural America. Retrieved from www.kff.org/uninsured/ U.S. Department of Health and Human Services (DHHS), Office of the
upload/The-Uninsured—in-Rural-America-Update-PDF.pdf Assistant Secretary for Planning and Evaluation. (2005b). Overview of
(Accessed February 27, 2008). the uninsured in the United States: An analysis of the 2005 Current
Kneisl, C., Wilson, H., & Trigoboff, E. (2004). Contemporary psychiatric- Population Survey. Rockville, MD: Author. Retrieved from http://aspe.
mental health nursing. Upper Saddle River, NJ: Pearson-Prentice–Hall. hhs.gov/health/reports/05/uninsured-cps/ (Accessed May 17, 2007).
McIntosh, G. (2004). One church four generations. Grand Rapids, MI: U.S. Department of Labor, Office of the Assistant Secretary for Policy,
Baker Books Office of Programmatic Policy. (2005). Findings from the National
Mohanty, S., Woolhandler, S.L., Himmelstein, D., Pati, S., Carrasquillo, Agricultural Workers Survey (NAWS) 2001-2002. A demographic and
O., & Bor, D. (2005). Health care expenditures of immigrants in the employment profile of United States farm workers. Washington, DC:
United States: A nationally representative analysis. American Journal Author, Office of the Assistant Secretary for Policy, Office of Program-
of Public Health, 95(8), 1431–1438. matic Policy, Research Report No. 9. March 2005. Retrieved from
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing www.doleta.gov/agworker/naws.cfm (Accessed February 27, 2008).
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. Weissman, J., Betaqncourt, J., Campbell, E., Park, E., Kim, M., Clarridge,
Munoz, C., & Luckmann, J. (2005). Transcultural communication in B., et al. (2005). Resident physician’s preparedness to provide crosscul-
nursing (2nd ed.). Clinton Park, NY: Thompson Delmar Learning. tural care. JAMA, 294(9), 1058–1067.
NANDA International. http://www.nanda.org Wherry, L., & Finegold, K. (2004). Marriage promotion and the living
Spector, R. (2004). Cultural diversity in health and illness (6th ed.). Upper arrangements of black, Hispanic and white children. The Urban
Saddle River, NJ: Prentice-Hall. Institute. Retrieved from www.urban.org/url.cfm?ID311064
Taylor, R. (2005). Addressing barriers to cultural competence. Journal (Accessed May 15, 2007).
for Nurses in Staff Development, 21(4), 135–142. Wilkinson, J.M., & Van Leuven, K. (2007). Fundamentals of nursing:
Townsend, M. (2005). Essentials of psychiatric mental health nursing Theory, concepts & applications. Philadelphia: F.A. Davis.
(5th ed.). Philadelphia: F.A. Davis. Wilson, D., Hockenberry-Eaton, M., Winkelstein, M.L., & Schwartz, M.
U.S. Census Bureau Population Estimates by Demographic Characteris- (2001). Wong’s Essentials of Pediatric Nursing. St. Louis: C.V. Mosby.
tics. Table 2: Annual Estimates of the Population by Selected Age Wright, L., & Leahey, M. (2005). Nurse and families. (4th ed). Philadelphia:
Groups and Sex for the United States: April 1, 2000 to July 1, 2004 F.A. Davis.
CONCEPT MAP
Family Theories/Models:
guide holistic nursing care
• Family systems theory Family stressors: Family with special needs:
• Family developmental stages and theory • Health care access • In situational crises
• Structural-functional theory • Insurance/lack of - Disasters, losses
• Communication theory • Homelessness • Developmental crises
• Group theory • Catastrophic events - e.g., adolescence
• Bowen’s Family Systems theory • Societal pressures: • Hospitalization
• Nursing theories: Florence Nightingale; - Crime, suicide, AIDS • Chronic mental illness
King, Roy; Neuman; Friedman; Hansen: • Changing family • Substance abuse
Calgary Family model structure • Physical/sexual abuse
• ”Skip” generation • PTSD
responsibilities • Chronic physical illness
Family cultural characteristics: • Death of a member
• Acculturation and assimilation
• Identity
• Time orientation Contemporary Family
• Connectedness Categories
• Communication No-parent
• Social class Family of origin
Cohabiting-parent
• Two or more members
F a m i l y
• Self identify as family Married blended
Patient • Interact/depend on
each other: socially,
emotionally, financially Single parent
Married parent
Family of choice
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Determine appropriate timing for health screening examinations based on national
recommendations.
◆ Discuss health promotion and disease prevention strategies related to infants and children,
including nutrition, dental care, safety, activity, immunizations, and sexuality.
◆ Discuss health promotion and disease prevention strategies related to adolescents, including
nutrition, dental care, safety, health promotion screening, sexual behavior, and menstrual disorders.
◆ Discuss health promotion and disease prevention strategies related to young adults, including
safety, health promotion screening, and gynecological disorders.
◆ Discuss health promotion and disease prevention strategies related to middle-aged adults, including
health promotion screening, perimenopause, menopause, and gynecological disorders.
◆ Discuss health promotion and disease prevention strategies related to older adults, including health
promotion screening, gynecological disorders, prostate cancer, and mental and emotional health.
The purpose of this study was to analyze the body mass index For study purposes, a 24-hour recall form was developed to
(BMI) percentile and eating and physical activity habits of ado- obtain information related to eating and physical activity habits.
lescents in relation to gender, ethnicity, country of birth, and Questions focused on the number of hours of sleep and awake
household type. An additional purpose was to evaluate diet and time, participation in sports or exercise, time spent doing home-
activity analysis software for use by practitioners and clients. work and engaged in other school-related activities, and time
A convenience sample of 74 participants included 9th-grade spent watching TV and engaging in tobacco use (smoking). Pri-
students enrolled in physical education classes, Jr. ROTC, and vate interviews were conducted to ensure accuracy of the infor-
cooking classes. The age range of the participants was from 14 to mation provided, and each participant’s height and weight were
18 years and 53% were females. Sixty percent were Hispanic; recorded at this time.
22% were Asian, Pacific Islanders or Philippino; 16% were Participants were assisted in developing a personal profile
African American or African; and 3% were Caucasian. Sixty per- on the MyPyramidTracker program available online through the
cent of the participants were U.S. born and 65% were from two- U.S. Department of Agriculture (2005). Each participant’s age,
parent households. Twenty percent lived with a single mother, gender, height and weight, and 24-hour recall data were
11% lived with a single father, and 4% lived with other relatives. entered into the program. Exercise and eating habits in relation
(continued)
71
72 unit one Foundations in Maternal, Family, and Child Care
sociology, and psychology, along with knowledge of cur- HEALTH SCREENING SCHEDULE
rent health promotion research, enables nurses to provide The health maintenance examination (HME) (Michigan
accurate patient information in the areas of nutrition, Quality Improvement Consortium, 2005a, 2005b) is one
physical activity, stress management, and safer sexual of the primary components of health promotion screen-
practices. ing. Screening should begin in adolescence and should
Nurses assume many roles when caring for families. cover a diversity of health promotion topics (Box 4-1).
Theory-driven knowledge, experiential understanding, According to these guidelines, adolescents and young
and evidence-based clinical practice are essential tools adults 18 to 49 years of age should have one HME every
that enable nurses to teach patients at a variety of age and 1 to 5 years according to their risk status. Adults 50 to
developmental levels. In the areas of infant and child 64 years of age should have one HME every 1 to 3 years
health, major health promotion concerns include nutri- based on their risk status, and older adults 65 years of age
tion, safety, activity and play, and immunizations. and older should have one HME at least every 2 years
Adolescents can be considered to be relatively healthy regardless of risk status.
individuals. As such, health promotion for this age group
is often ignored. Because peer relationships constitute an
important component of adolescent development, peer Infant and Child Health
pressure can precipitate high-risk behaviors that may lead
to health complications and the early initiation of chronic Health promotion and anticipatory guidance are particu-
illnesses. Nurses play a vital role in the education of ado- larly important in infant and child health. Parents need to
lescents in health care settings and in the community. A have an understanding of nutritional needs, including
holistic approach is tremendously beneficial with this selection of healthy snacks. Proper dental care is also
patient population. Teaching healthy practices regarding important in maintaining a child’s health. Since infants
nutrition, safety, health screening, and safe sexual prac- and children are developing cognitively and physically
tices and sexual health can provide avenues for improve- during this time, there are specific considerations that
ment in health practices that can last a lifetime. must be given to safety needs. Immunizations provide
During young adulthood, there continue to be health protection from and prevention of disease and selection of
concerns related to nutrition and safety. However, the appropriate toys encourages developmental play that
primary focus of health promotion for this population meets safety requirements and facilitates development of
shifts to reproductive concerns, as this is the time when social roles. Sexual development and sexual education
many patients are engaging in more mature relationships, promote healthy sexual behavior in later years.
marriage, and childbearing. For women, gynecological
disorders, including infertility, may be diagnosed, requir- NUTRITIONAL GUIDANCE
ing additional education for maintaining health and pre-
venting complications. Infant Feeding
Health screening is essential for patients in middle The first decision that parents make regarding infant
adulthood. For this age group, health promotion screen- nutrition is the decision to breast feed or bottle feed their
ing includes mammography, colonoscopy, cholesterol newborn. Although the composition of infant formula is
and lipid screening, and osteoporosis screening. While similar to that of breast milk, and many babies thrive on
gynecological disorders are still a major health concern proprietary formula, breast milk is still considered to be
for women, reproductive health begins to concentrate on the best option for optimal health promotion and disease
the period preceding menopause, known as perimeno- prevention in the newborn. One of the primary benefits of
pause, with interest targeted on the physiological and breastfeeding is the decreased incidence of bacterial and
psychological changes that occur, the hormone replace- viral infections as a result of passive immunity, acquired
ment debate, and the use of alternative therapies for via the transfer of maternal antibodies. According to the
symptom relief. U.S. Department of Health and Human Services’ Office on
Older adults experience physical and psychological Women’s Health (2005), breastfed infants are less likely to
changes due to the aging process. These changes shift develop allergies, gastrointestinal tract diseases, respira-
health promotion concerns for older adults, including tory tract diseases, ear infections, and childhood obesity.
concerns related to sexual functioning, exercise and activ- They also have fewer systemic bacterial infections, urinary
ity, and cognitive functioning. Gynecological topics that tract infections, and bacterial and viral infections of the
nurses should address for women include menopause, respiratory tract.
osteoporosis, cancer, and pelvic floor dysfunction. Since an infant’s immune system does not become
fully mature until 2 years of age, the maternal transfer of
antibodies and immune factors enhances development of
Health Promotion Screening the immune system and facilitates the neonate’s immune
system response. The longer the time that an infant is
Health screening is essential for all family members. Rec- breastfed, the stronger the protection against infection
ommendations for examinations, laboratory, and diag- and the earlier the maturation of the infant’s immune
nostic tests have been developed by diverse professional system. In addition, some studies have indicated that
and community agencies. Guidelines for addressing high- breastfed infants experience lower rates of diabetes, lym-
priority services through preventive screening delivery phoma, leukemia, Hodgkin’s disease, and sudden infant
(Institute for Clinical Systems Improvement, 2005) have death syndrome (SIDS) (American Academy of Pediatrics
been developed and are presented in Table 4-1. [AAP], 2005).
74 unit one Foundations in Maternal, Family, and Child Care
Aspirin Prophylaxis Discuss with women post-menopause, men over age 40, and younger individuals at increased risk for coronary
heart disease
Breast Cancer Screening Annual mammogram for women Annual mammogram for women
with risk factors; every 1–2 years with risk factors; every 1–2 years
for women 50 to 64 years of for women 65 and older with no
age with no risk factors risk factors
Cervical Cancer Screening First Pap smear at age 21 or 3 years Every 3 years after 3 Pap smear with new sexual partner
after first sexual intercourse, whichever is consecutive normal results
earlier; every 3 years after 3 consecutive
normal results
Chlamydia and Gonorrhea All sexually active females, including asymptomatic women aged 25 years and younger
Screening
Sources: American College of Obstetricians and Gynecologists (2007); U.S. Preventive Services Task Force (2007); Institute for Clinical Systems Improvement (ICSI, 2005).
Childhood Nutrition
Family Teaching Guidelines... Once the child reaches 3 years of age, parents should be
Introducing Solid Foods to Infants introduced to the Food Pyramid for Kids (U.S. Department
of Agriculture, 2005). As with the Food Pyramid devel-
The baby is ready for the introduction of solid foods at oped for adults, the servings per day are calculated based
approximately 6 months of age. To help determine if the on weight and activity. Specific suggestions are included,
baby is ready for solid foods, look for developmental cues such as limiting the intake of juice, ensuring that all juices
such as the ability to sit well with support and the decrease are 100% natural, and incorporating whole grains to com-
or disappearance of the extrusion reflex. The baby may prise half of the daily grain intake (Fig. 4-1).
watch very intently as you eat, and may seem hungry Snacks for children are often the most difficult aspect of
between bottles or breastfeeding. planning meals. Parents need to be taught that snacks
◆ Iron-fortified rice cereal is recommended as baby’s first should be nutritious, and that any food item that is appro-
solid food for a couple of reasons. Rice is the least priate for a meal is appropriate for a snack. Children typi-
allergenic of the grains and the iron helps the baby cally need to eat every 3 to 4 hours to maintain energy
replenish the iron needed for growth and develop- needs. Thus, parents must consider portion sizes when pro-
ment. When introducing the rice cereal to the baby, viding snacks for their children. Nutritious snacks include
you can mix it with formula, breast milk, or boiled grain products, fruit and vegetable juices, fresh fruits and
and cooled water until it is very soupy. As the baby vegetables, dried fruit, nuts, and seeds (Box 4-2).
becomes accustomed to solid foods, the consistency
of the cereal can be gradually adjusted to create a less DENTAL CARE
soupy texture. Teething typically begins between 4 and 7 months of age.
◆ When the baby is eating about 4 tablespoons of cereal The first teeth to erupt are usually the bottom central inci-
twice a day, introduce vegetables and fruits. It is rec- sors followed by the upper central and lateral incisors. The
ommended to start with vegetables and then expose next to erupt are the bottom lateral incisors followed by the
the baby to the sweet taste of fruits, as babies are typi- first molars. An infant may have any range from no teeth to
cally more accepting of the sweet tastes. eight or more teeth by her first birthday. Most children will
◆ Introduce one food at a time, waiting 3–5 days have all 20 of their primary teeth by their third birthday.
between new foods so you will be able to identify any Signs of teething include increased drooling, irritability,
reactions to particular foods. desire to chew on objects, crying episodes, disrupted sleep-
ing, and eating patterns. Caregivers can be encouraged to
◆ Introduce food before formula or breastfeeding when give teething infants a cool wet washcloth, teething rings
the infant is hungry, and follow each solid food meal that have been cooled in the refrigerator, or a clean finger
with breast milk or formula. rubbed on the gums to help ease the discomfort.
Seeking Additional Help: The American Dental Association (ADA) recommends
◆ If the infant is not growing or gaining weight, if he is that a dentist examine a child within 6 months of the
unable to suck or swallow or shows any signs of an eruption of the first tooth and no later than the first birth-
allergic reaction, it is important to promptly seek help day. Daily dental care can begin even before the first tooth
from the primary health care provider, nearby clinic, emerges. Gums can be gently wiped with a damp wash-
or emergency room. cloth or gauze, and when the first tooth emerges, a soft
toothbrush and water can be used. Toothpaste cannot be
Essential Information: used until age two.
◆ Keep salt, sugar, and additives to a minimum or avoid
them altogether. If you make your baby’s food, do not SLEEP AND REST
add salt or sugar. Newborns sleep approximately 15 to 20 hours per day in
◆ Never put food in bottles or mix food with formula 2- to 3-hour increments. By 3 months of age, infants sleep
because it can cause choking. approximately 15 hours in a 24-hour period. At 6 months,
◆ Offer only small bites of food to prevent choking and the infant may have two naps of 2 hours each during the
pay close attention to your baby when feeding. day and sleep 9 to 14 hours per night. From 9 months to
1 year, the length of naps may decrease slightly, with
nighttime sleep remaining in the 9- to 14-hour range.
Data from American Academy of Pediatrics. (2005). Policy
statement: Breastfeeding and the use of human milk. Pediatrics,
Infants are not born knowing how to put themselves to
115(2), 496–506. sleep. To help the infant learn to fall asleep on his own,
caregivers can put the infant to bed drowsy but awake,
rather than breastfeeding or rocking the infant to sleep. By
Now Can You— Discuss infant and child nutrition? training the infant to fall asleep independently, if he wakens
1. Discuss the benefits of breastfeeding when compared to in the night, he is more likely to self-soothe back to sleep.
bottle feeding? Dr. T. Berry Brazelton describes six states of behavior in
2. Describe the recommended process for introducing solid the newborn: quiet sleep, active sleep, drowsiness, quite
foods into an infant’s diet? alert, active awake, and crying. These states include body
3. Identify at least four safe, nutritious finger foods for infants activity, eye movements, facial movements, breathing pat-
and toddlers? terns, and response to external and internal stimuli. The
nurse can provide anticipatory guidance by educating
chapter 4 Caring for Women, Families, and Children in Contemporary Society 77
Injury Prevention
Family Teaching Guidelines... One of the best methods for prevention of injury to infants
Preventing Plagiocephaly and children is for parents to prepare and keep their
homes safe. This process, ideally begun before the infant
◆ Infant skulls are soft and flexible during the first year is brought home from the hospital, should be re-evaluated
of life as the skull enlarges to accommodate the and modified as the child moves through each develop-
growing brain. During this time, the infant skull can mental stage. Smoke and carbon monoxide detectors
become misshapen or deformed by external pressure. should be installed throughout the home. Medications
This condition is rarely life threatening, but can cause and chemicals should be moved to a high shelf, placed in
permanent facial and skull deformities, or in severe a sealed area, or stored in a cupboard equipped with child
cases, the child’s vision can be affected. safety locks. A fire extinguisher should be readily available
◆ Constant pressure on one area of the infant’s head can on every floor in the home and an additional unit placed
flatten or reshape it. The Back to Sleep campaign initi- in the kitchen. A fire escape route should be planned.
ated by the American Academy of Pediatrics has had An appropriate car seat should be obtained in anticipa-
the unintended effect of increasing the incidence of tion of bringing the new infant home from the hospital.
plagiocephaly. Proper positioning during sleep and Proper use of a car seat, which has been shown to reduce
waking periods spent in car seats and baby chairs the chance of injury by 70% and the chance of death by
often require the infant to spend considerable time on 90%, includes placing the unit in a backward-facing direc-
his or her back. tion in the back seat.
◆ Place the baby on the stomach to play for several times When the infant is brought home from the hospital,
each day. When the baby is very young, placing a new areas of concern must be considered. Crib safety is
rolled towel or blanket under his arms for support one of these. Parents should be cautioned about buying
helps the infant to be more comfortable. This interven- older (made prior to 1989) models of cribs, as they do not
tion removes pressure from the skull and facilitates the meet current safety standards. The distance between the
development of strong neck and arm muscles needed slats of the crib railings should be less than 2 3/8 inches to
for sitting and crawling. prevent head entrapment and potential strangulation.
There should be no sharp edges, and the crib mattress
◆ Alternating the direction the baby faces in the bassinet should fit snugly with the end panels extending below the
or crib during sleep times is also helpful. If the baby’s mattress to prevent suffocation. Bumper pads should be
crib is positioned against a wall, alternating the end of used to pad the crib; these should be removed once the
the bed where the baby’s head is placed allows her to infant is able to stand. The furniture paint should be non-
look out toward the room rather than at the less stim- toxic and all furniture in the infant’s nursery should be
ulating wall. positioned to avoid windows, curtains, blinds, lamps,
SEEKING ADDITIONAL HELP electrical cords, outlets, and appliances.
With regard to infant feeding and safety, teach parents
◆ If you notice a flattened area on the baby’s skull that to warm bottles slowly, never to use a microwave oven to
does not seem to be improving with positioning heat breast milk or formula, and never prop a bottle in the
changes, you should talk with the physician. The baby infant’s mouth, as this practice creates a choking hazard.
may need to be fitted with a customized helmet that is Remind parents to keep all hot liquids and foods away
worn for 23 hours a day. This helmet is designed to from the baby and to place them well away from the edges
prevent the baby’s head from assuming one position, of tables and counter tops. If a pacifier is used, one with
and allows the skull to expand into the flattened area. shields large enough to prevent placement of the entire
pacifier in the mouth should be selected, and the pacifier
ESSENTIAL INFORMATION
should be frequently inspected for breakage or cracks.
◆ The baby may also be placed on his side while he is Never place the pacifier on a cord around the infants’ neck
awake. The mother can lie on her side, face the baby, or attached to the infant’s clothes with a clip or cord.
and both parties can entertain each other with toys and At 3 months of age, infants begin to roll over from stom-
facial expressions. It is a wonderful way to bond with ach to back and to turn toward loud sounds. These activi-
the baby. Newborn babies love to look at their parents’ ties can pose a safety hazard related to the changing tables
faces, so this is a very enjoyable activity for them. used for changing diapers. Teach parents to keep one hand
on the infant at all times and never to leave the infant alone
Data from American Academy of Pediatrics (1992). on the table. Powders, oils, and lotions should be used cau-
tiously to prevent poisoning or illness if swallowed. To
prevent aspiration, powders should never be shaken close
to the infant’s face. Current recommendations for powder
SAFETY use include having the parents first place the powder in
Infants and children are at particular risk for accidents their hands and then rub it onto the infant.
and injuries as a result of their cognitive and physical Since serious falls and injuries can occur with the use of
development during these years. Parents need to be taught high chairs, playpens, strollers, and swings, these items
how to prevent injuries and accidents, as well as how to should be used only under supervision of an adult. Play-
prepare for risk-taking behaviors that may arise in late pens should not be used in place of cribs in order to pre-
childhood. These risk-taking behaviors may include vent injury from suffocation that can occur while the
experimenting with substance use and sexual activity. infant is asleep. The use of walkers is not recommended, as
chapter 4 Caring for Women, Families, and Children in Contemporary Society 79
serious brain injury, fractures, and concussions have fenced-in yard with a locked gate and ensuring that all
resulted from accidents that involve the walker tipping playground equipment is installed securely. A soft surface
over or falling down a staircase. Also, the development of should be placed under playground areas to provide cush-
gross motor skills may be hindered with walker use, as ioning for falls. All yard equipment should be safely stored
babies who use them learn to walk on the tips of the toes. away from children.
Play time and bath time are associated with potential Water safety is also important. Swimming in pools,
hazards as well. Risks of accidental choking and suffoca- lakes, and rivers should take place only under adult super-
tion are significant for children younger than the age of vision, and children should not be allowed to dive or jump
6 months who tend to place small objects in their mouths into water less than 12 feet in depth. Chemicals used in
as their cognitive and fine motor skills are developing. pools and hot tubs are poisonous and should be kept out
Parents must ensure that crib gyms and mobiles are of the reach of children. If possible, a separate fence should
placed at an appropriate height, toys and stuffed animals be placed around the pool, equipped with a safety alarm
have no removable parts or sharp edges, and pull toys do system to alert parents when children are near the water.
not have long cords. Bath safety includes ensuring that the
water temperature is below 120°F. Teach parents to test Risk-taking Behaviors
the water temperature before placing the child in the bath Children engage in risk-taking behaviors as a normal pro-
and to use bath mats or towels to prevent slipping. During gression through cognitive development. Risk-taking
the bath, the parent should keep both hands positioned enables children to develop skills and self-confidence as
securely on the infant, while using one hand to constantly well as to understand their strengths and limitations.
hold the infant and the other hand to wash the infant. Through risk-taking behavior, children learn boundaries
By 14 months of age, the child has developed the skills and develop an awareness of the outside world.
necessary for walking; the majority of children walk well
TESTING LIMITS. Risk-taking actually begins in infancy,
by this time. Once the child begins to crawl, creep, and
as infants explore their worlds, place objects in their
walk, additional environmental safety hazards are present.
mouths, and learn to identify parental facial expressions
Kitchen and bathroom cabinets should be equipped with
and gestures. Once the child begins to walk, limit-testing
firm latches or locks to prevent injury from medications,
heightens through activities such as climbing, reaching,
poisonous chemicals, and sharp implements. Stove guards
and balancing. Parents who allow the child’s exploration
should be placed over knobs and burners to prevent acci-
send a message that when performed in appropriate situa-
dental injury from burns. Remind parents to turn all pot
tions, a certain degree of risk-taking is necessary for devel-
handles away from the front of the stove and to install
opment. Conversely, parents who do not allow explora-
locks or latches on appliance doors to prevent entrapment
tion convey the message that experimentation is
and suffocation.
undesirable and should not be done. Close to age 2, when
Stairs and windows present safety hazards related to
the child enters the developmental stage of autonomy ver-
falls. Safety gates at the tops and bottoms of staircases
sus shame and doubt, risk-taking may present itself in the
should be used at all times; accordion gates are not recom-
form of saying “no” to parents.
mended. Railings on steps, decks, and balconies should be
Preschoolers may engage in risk-taking behaviors as a
covered with netting to prevent children from getting
result of their physical development. As gross motor skills
trapped between the posts or falling. Safety guards can be
develop, their physical abilities exceed their ability to logi-
placed on windows to prevent them from opening more
cally reason the danger associated with their activities.
than 4 inches; however, these should not be used on win-
Parents need to monitor their children’s activities, while
dows designated for fire escape. Furniture should not be
allowing them to maintain a sense of control. In so doing,
placed near windows as children can climb on the furni-
the parent helps the child to develop the confidence
ture and fall through the windows. Poisoning accidents
needed to try something new or difficult in the future and
can occur through the ingestion of harmful plants or peel-
facilitates the child’s successful mastery of the develop-
ing paint chips, particularly in homes built before 1978
mental task associated with initiative versus guilt.
that contain lead-based paint.
School-age children’s risk-taking behavior, as opposed
to the preschoolers’ behavior, is more closely related to
Now Can You— Discuss strategies to ensure infant and cognitive rather than physical development. At this time,
toddler safety? the child has moved into the stage of industry versus infe-
1. Describe methods for ensuring crib safety? riority and is developing a sense of self-esteem. Risk-
2. Identify ways to promote bath safety? taking allows the school-age child to experience height-
3. Discuss strategies for making stairways and window ened feelings of self-worth following success and to learn
areas safe? to evaluate mistakes and develop alternative strategies
for the future when they meet with failure. See Chapter 20
for more information on developmental stages.
By 24 months of age, cognitive skills have developed
that allow the toddler to begin logical reasoning. During
this time, play activities pose the greatest risk of injury. PLAY
While playing indoors, children should not be allowed Play enables children to explore their world, express their
to run or jump, and the kitchen and bathroom should thoughts and feelings, and meet and solve problems. The
be off limits. Refrigerators and freezers should be locked, foundation for play begins immediately after birth. The
and closets, attics, and basements should be sealed to pre- infant reflexively grasps objects or moves extremities and
vent accidental injuries. Outside safety includes having a through this, discovers enjoyment of the sounds, tastes,
80 unit one Foundations in Maternal, Family, and Child Care
characteristics, body-related experiences, social response hyperinsulinemia, result in insulin resistance syndrome.
to appearance, and social value placed on body character- Insulin resistance is highly associated with the develop-
istics. Each of these factors has an effect on personality ment of type 2 diabetes mellitus, long thought to be an
development, and is influenced by individual responses. adult disease. Over the past 10 years, however, there has
Many times, these factors combine to create a focus on been an increased incidence of type 2 diabetes mellitus
excessive dieting and scale-weighing behaviors. In addi- developing in childhood and adolescence (Menon, Burgis,
tion, there is a relationship between impaired body image & Bacon, 2007).
in adolescents and depression. For the adolescent female, insulin resistance and obe-
sity may affect reproductive and gynecological health.
SOCIAL FACTORS. Social factors such as the influence of
Insulin resistance causes an increase in circulating insu-
family and peers interact with the psychological factors
lin, and stimulates an increase in the production of andro-
that impact adolescent obesity. In many families, eating
gens. Increased androgens, combined with the increased
and mealtime behaviors are instituted at an early age. Lit-
levels of circulating insulin, have been reported to trigger
tle time may be spent on meal preparation, and time spent
polycystic ovarian syndrome (PCOS) (Dunaif, 2006).
with family members while eating may be nonexistent. As
PCOS is associated with anovulation, and is manifested by
the dual-income family has become the norm in modern
dysmenorrhea, hirsutism, and acne. Insufficient proges-
society, fast food and eating “on the go” has also become
terone production results in infertility and an increased
the norm. Eating patterns that lead to adolescent obesity
risk of endometrial cancer.
may include the regular consumption of high-calorie,
low-nutrient-dense foods, a lack of understanding about
nutrition, a lack of structure and sociability in eating pat- — When talking with an adolescent
terns, a tendency to eat late in the evening, binge eating about losing weight
when hungry or bored, and the habit of eating rapidly.
Adolescence is also a time when peer relationships Discussions about weight loss can be a sensitive issue for
become extremely important in the development of a many overweight patients. During adolescence, body
personal identity. Adolescents frequently congregate and weight has a dramatic effect on the development of self-
socialize in areas where food is consumed, such as fast image and self-esteem and can be an even more sensitive
food restaurants, pizza parlors, and at parties. For many, issue for discussion. An important strategy in discussions
eating becomes a social event in and of itself. In these about weight and weight loss with adolescents is to
settings, peer pressure may influence the healthy eaters to begin the conversation with expressions of respect that
consume high-fat, high-caloric food in order to fit in with are sensitive to cultural differences related to food
the majority. Over time, many adolescents become condi- choices and eating patterns. Regardless of whether or
tioned to eat poorly and to elude structure in their eating not the patient is ready to begin a weight control
behaviors. program, she may still benefit from talking openly about
One’s level of physical activity is associated with weight, healthy eating and exercise. To open the conversation,
and a sedentary lifestyle constitutes a significant factor in the nurse can begin with a simple question to determine
obesity. When adolescents are not with their peers, they if the patient is willing to talk about the issue:
are often engaging in sedentary activities, such as watch- “Cindy, can we talk about your weight? What are your
ing television, using the computer, talking on the tele- thoughts about your weight right now?”
phone, and text messaging. Without energy expenditure, To determine the degree of readiness to engage in
the excess in calorie consumption increases the number of weight control, additional questions can be asked:
adipose cells and leads to further weight gain. “What are your goals concerning your weight?”
“What kind of help would you like from me regarding
MEDICAL FACTORS. The psychological and social factors your weight?”
may predispose to an increased risk for disease related to Nurses should avoid the use of words that may make
overeating and obesity. Depression is one of the most patients feel uncomfortable, such as “obese,” “obesity,”
common disorders associated with adolescent obesity. “fat,” and “excess fat.”
While attempting to fit into the peer group by engaging in
unhealthy eating behaviors, adolescents are meanwhile
being bombarded with media images of thin, attractive
individuals overeating and societal messages that obesity Eating Disorders
is unattractive and shameful. There is an unspoken view- In addition to overweight and obesity associated with
point that obese individuals are overindulgent and lack overeating, other eating disorders such as anorexia ner-
self-control. These influences negatively impact the ado- vosa and bulimia nervosa may develop during adoles-
lescent’s body image and self-esteem, and create a risk for cence. These two eating disorders adversely affect nutri-
depression, feelings of social isolation, rejection, failure, tion and the overall health status and impact growth and
and thoughts of suicide. development. The underlying issue associated with eating
Obesity in adolescence leads to medical problems, disorders concerns the improper use of food: eating too
including cardiovascular disease, type 2 diabetes mellitus, little, eating too much, or eating too much and purging in
kidney disease, gallbladder disease, liver disease, and an attempt to rid the body of excessive calories.
orthopedic problems. Hypercholesterolemia and hyperlip- Eating disorders are rooted in issues related to body
idemia increase the workload on the heart, resulting in image development. The core of the problem involves a
hypertension. These disorders, when combined with distortion in body image and a delay in achieving progress
84 unit one Foundations in Maternal, Family, and Child Care
toward a healthy, adult body image. In essence, adoles- throat irritation, esophageal inflammation, and parotitis
cents with severe eating disorders are struggling with from vomiting, as well as rectal bleeding from overuse of
another developmental task, that of autonomy. They tend laxatives. While life-threatening conditions are less com-
to have an unrealistic view of themselves, and depend on mon in adolescents with bulimia than in adolescents with
social opinions and judgments, as evidenced by their pre- anorexia, they may still be at risk for dehydration, electro-
occupation with food, dieting, and exercise patterns. lyte imbalances, ruptures in the gastrointestinal tract, kid-
ney disease, and cardiac arrhythmias.
ANOREXIA NERVOSA. Anorexia nervosa is a chronic eat-
ing disorder that stems from a distorted body image. This DENTAL CARE. For adolescents, twice yearly dental visits
condition develops as a result of obesity or a perception of for check-ups and cleaning are required. It is common for
obesity that creates an obsession with weight loss and a adolescents to have dental work performed to correct
denial of hunger. The fear of gaining weight, combined tooth malformations. Obvious dental correction can cre-
with a low self-esteem, creates a life-threatening disorder ate body image problems, particularly if wearing braces or
that can, if not properly treated, lead to serious medical a headgear is required. Education regarding the proper
complications and death. Individuals with anorexia ner- care of teeth with dental appliances must be received at
vosa undertake strict and severe diets and engage in rigor- the dentist’s office and reinforced by caregivers at home.
ous excessive exercise in order to maintain an unrealistic
body weight. Psychological traits associated with anorexia
SLEEP AND REST
nervosa include perfectionism, obsessive–compulsive
behavior, social isolation, a focus on high achievement Adolescents are commonly chronically sleep deprived as
without satisfaction, and depression (Menon et al., 2007). activities, schoolwork, and after-school jobs keep them up
Due to a pervasive malnutrition that affects all organ later at night. Often the adolescent sleeps extensively on
systems, symptoms include weakness, dizziness, excessive weekends to make up for the deficiency during the week,
weight loss, intolerance to cold, bradycardia, hypotension, but this is generally more detrimental as the body has dif-
bone loss with consequent fractures, constipation from ficulty adapting to irregular sleeping patterns. Sleep depri-
dehydration, and the development of lanugo. The contin- vation can impair memory and inhibit creativity, making
ued restriction of calories suppresses the hypothalamic– it difficult for sleep-deprived adolescents to learn.
pituitary–adrenal axis, and results in decreased production The nurse can encourage caregivers and adolescents to
of cortisol and growth hormone. In females, luteinizing keep evening activities to a manageable level that allows
hormone and follicle-stimulating hormone are suppressed, for some quiet time before bed and an appropriate bed-
resulting in a decreased production of estrogen. Decreased time. Involving the adolescent in the decision-making
estrogen levels are associated with anovulation, amenor- process regarding which activities to reduce or eliminate
rhea, loss of secondary sex characteristics, and infertility. will help the teen comply with the limits set. In addition,
Over time, inadequate nutrition results in blood and elec- if the adolescent adheres to a similar bedtime and wake
trolyte abnormalities, which may lead to death. time on the weekends as during the week, excessive
fatigue can be controlled.
BULIMIA NERVOSA. Bulimia nervosa is a syndrome that
consists of a cycle of binge eating and purging. Binge eat-
ing entails eating large amounts of food at least 2 days per SAFETY
week for at least 3 months. When this behavior is com- Since adolescents are still developing formal thought
bined with extreme measures to rid the body of the excess operations, they may not have the cognitive abilities to
food, a cycle ensues. Adolescents with bulimia may use make appropriate decisions regarding safety. Their deci-
laxatives, diuretics, or emetics to rid the body of excess sions are likely to result in accidents and injuries and risk-
calories (purging behavior), or they may engage in exces- taking behaviors for which adults may not be at risk.
sive exercise or fasting (nonpurging behavior). These However, the accidents and injuries most common in
behaviors are performed in an effort to alleviate the guilt adolescents differ from those in infancy and childhood. In
associated with overeating; as the guilt feelings pass, the addition, adolescents must be taught information related
tension returns, and the binging behavior begins once to safe sexual practices, substance use and abuse, vio-
again. lence, and suicide prevention.
Adolescents with bulimia nervosa typically maintain a
normal weight, although psychological factors associated Accidents and Injuries
with bulimia include poor impulse control, low self- The three leading causes of death in adolescents are
esteem, depression, and anxiety disorder. In addition, motor vehicle accidents, homicide, and suicide, respec-
comorbid behaviors such as alcohol and substance abuse, tively. The risk for motor vehicle accidents is greater
unprotected sexual activity, self-mutilation, and suicide among adolescents than for any other age group, with
attempts may be present. Similar to anorexia, bulimia is more than 5000 adolescents between the ages of 16 and
an eating disorder that is usually associated with some 19 dying from injuries related to crashes (Insurance Insti-
degree of depression. tute for Highway Safety, 2005). For male adolescents, the
Physically, the adolescent with bulimia nervosa may risk is two times higher than that of female adolescents.
present with symptoms related to forced excessive vomit- Risk factors for these statistics include the inability to
ing: cracked and damaged lips, tooth damage, callused assess hazardous situations while driving, speeding, driv-
fingers and hands, and broken blood vessels in the face. ing under the influence of drugs or alcohol, and a low
Symptoms that may not be physically noticeable include compliance with seat belt use.
chapter 4 Caring for Women, Families, and Children in Contemporary Society 85
In relation to homicides, approximately one-third of Health care providers and parents can assist adoles-
all homicides in the United States occur among adoles- cents in finding alternative behaviors to provide outlets
cents. Individual factors related to this level of violence for identity development through providing them with
in adolescence include a history of abuse and the obser- challenges that create risk while promoting healthy deci-
vation of violent acts at home. Certain familial character- sion making (Box 4-4).
istics have also been linked to adolescent homicide:
distant, passive, or absent fathers; dominant, overprotec- Injury Prevention
tive, and sexually inappropriate mothers; violence Unhealthy risk-taking often leads to injuries for adoles-
between family members; turmoil in the home setting; cents, and the most common injuries are related to motor
and feelings of distrust among the children in the home. vehicles, bicycles, firearms, and water. Nurses and parents
Health care providers need to be aware of protective can provide valuable teaching to adolescents and empower
factors that have been identified in order to provide them to take necessary precautions to avoid injury. One of
health care teaching to adolescents and empower them the most important ways in which parents can affect ado-
with strategies to reduce their risk. Education, spiritual lescent safety is to set a good example and be a positive
support, improved economic conditions, conflict resolu- role model.
tion skills, and reduced use of drugs and alcohol are
DRIVING SAFELY. Since motor vehicle accidents occur so
areas of education focus and patient advocacy that can be
commonly and cause such significant injury, there needs
addressed by health care providers. Finally, since access
to be a strong focus on injury prevention for this activity.
to guns impacts the adolescent homicide rate, imple-
Recommendations for parents to ensure safe driving
mentation of gun safety classes is another appropriate
include establishing limits, such as the number of passen-
area for intervention.
gers and restriction to daytime driving, enforcing penal-
Suicide is the third leading cause of death in adoles-
ties for unsafe driving practices, adult supervision of ado-
cents, and, as such, needs to be understood and addressed
lescents while driving, ensuring mechanical safety, and
by health care providers. As a result of their developing
mandating the use of seat belts.
personality and peer and family pressures, adolescents
may become easily overwhelmed and anxious and look to BICYCLE SAFETY. Another common area of injury in ado-
suicide as an answer to their distress. Although female lescence, and one that is not often discussed includes
adolescents are more likely to engage in suicide attempts, activities that involve bicycles, in-line skating, and skate-
males are more likely to complete them, and account boarding. Head injuries related to these activities are quite
for approximately 85% of all suicides, while females common in this age group. Approximately 50% of young
account for 15%. Adolescent Native Americans and Alas- adolescents hospitalized for a bicycle-related injury have
kan Natives have the highest rates of suicide; African some degree of brain injury. Behaviors that cause the
Americans, Hispanics, and Asians have the lowest rates of majority of the injuries include riding into a street with-
suicide (Menon et al., 2007). out yielding or stopping, swerving into traffic, and riding
Common symptoms of suicidal ideation that can be against the flow of traffic.
addressed by health care providers include the following:
reports of crying frequently, fatigue and insomnia; feel-
ings of isolation; and changes in body weight. Adoles-
cents may exhibit additional symptoms, such as behavior
problems, violence, sexual promiscuity, a drop in aca- Box 4-4 Healthy Risk Alternatives for Adolescents
demic performance, and school absence. Nurses who are
• Physical activities
aware of any of these symptoms should ask if the adoles-
• Team sports
cent has plans to commit suicide, the means to commit
suicide, and if there have been any previous attempts at • Horseback riding
suicide. Adolescents who are determined to be at low risk • Camping
for suicide should be referred to a mental health profes- • Rock climbing (with supervision)
sional; those determined to be at high risk for suicide • White water rafting (with supervision)
should be immediately evaluated by a mental health • Creative activities
professional. • Joining a band
• Acting in a play
Risk-taking Behaviors
• Photography
As in childhood, it is normal for adolescents to engage in • Dance
risk-taking behavior. Taking healthy risks provides an
• Producing a video
avenue for discovering and developing one’s own identity.
• Developing relationships
Parents need to be taught that they can facilitate healthy
risk-taking through talking with their adolescent openly • Talking openly about sex and relationships
and honestly and helping their child to understand the • Volunteering in the community
consequences of healthy versus non-healthy risk-taking • Participating in a student exchange program
behaviors. Ongoing dialogue provides an opportunity to • Learning responsibility
explore alternative actions and sharing a personal history • Getting a part-time job
of past risk-taking behaviors conveys the message that • Tutoring
making mistakes is not a fatal act.
86 unit one Foundations in Maternal, Family, and Child Care
Consistent use of a helmet is one of the best preventive include human development, reproductive anatomy and
strategies. It is essential that the helmet fit properly—it physiology, relationships, personal coping skills and
should not move around when the straps are fastened— decision-making, sexual behavior, contraceptive use, con-
and the straps should remain fastened when in use. When dom use, sexual health, and gender role development.
worn and used correctly, helmets can reduce the risk of a It is also important that the information provided is
head injury by 85% and the risk of brain damage by 88%. appropriate to the age and sexual experience of the ado-
All helmets should meet the standards established by the lescent. For those who have not engaged in sexual inter-
American National Standards Institute, the American course, an approach that focuses on abstinence as the only
Society for Testing and Materials, and the United States absolute way to avoid pregnancy and sexually transmitted
Consumer Product Safety Commission. infections may be appropriate. Education that focuses on
the avoidance of unprotected sex by the use of a condom
FIREARM SAFETY. Curiosity and impulse control remain with every sexual encounter may be an appropriate
important factors in firearm-related injuries and deaths approach for adolescents who have begun to have sexual
among adolescents. Parents should consider the risks intercourse. Life-building skills that are necessary for ado-
associated with storing a firearm in the home. In this age lescents, and which may facilitate appropriate decision-
group, ready access to a firearm is the most frequent cause making, include negotiation skills, values clarification,
of the experimentation. If parents choose to keep a firearm goal setting, and interpersonal communication.
in the home for protection or for hunting, it should be
safely stored in a locked cabinet and all ammunition SUBSTANCE ABUSE. Experimentation and risk-taking behav-
placed in a separate, locked location. A firearm safety class ior as a means of self-discovery and identity development are
should be mandatory for adolescents who engage in the common during adolescence. Often this experimentation
sport of hunting with parents or peers. involves the use of drugs and alcohol. The reasons that ado-
lescents give for trying drugs and alcohol include: to satisfy
WATER SAFETY. Adolescents, who are in the process of curiosity, to achieve a feeling of well-being while under the
developing formal operational thought, have an increased influence, to reduce stress, and to fit in with peers. Adoles-
risk of drowning when swimming due to an overestima- cents who are at an increased risk for developing dependency
tion of ability and skill, a lack of awareness of water depth are those with low self-esteem, a family history of substance
and currents, and the use of alcohol and drugs. Safety abuse, depression, and those who do not feel accepted by
measures include insisting that adolescents do not swim their peers.
alone and teaching them never to dive into shallow water, Alcohol and marijuana are the most common drugs
above-ground pools, or the shallow end of an in-ground used by adolescents. On average, alcohol use begins at
pool. In addition, adolescents riding in a boat should be age 12 and marijuana use at age 14. Adolescent substance
required to wear personal flotation devices that are use is associated with school failure, an increased risk for
securely fastened. Parents and health care providers accidents, violence, suicide, and unplanned and unsafe
should routinely incorporate safety education into discus- sexual activity.
sions with adolescents. There are many warning signs to alert parents to ado-
lescent substance abuse. Physical signs include fatigue,
Now Can You— Provide safety education to adolescents? red and glazed eyes, chronic cough, and health com-
1. Identify the three leading causes of death in adolescents? plaints. Emotional signs include personality changes, sud-
2. Discuss methods for improving driving safety? den mood swings, irritability, poor judgment and decision
3. Identify the best method of preventing injury related to making, depression, and lack of interest in things that
bicycle riding? were of previous interest. As the substance abuse contin-
4. Describe methods to facilitate firearm safety? ues, adolescents may demonstrate a negative attitude,
withdraw from the family or from previous friends, and
become increasingly argumentative and secretive. Aca-
demic performance often drops and school officials report
REPRODUCTIVE HEALTH SAFETY Safety with regard to repro-
problems with truancy and discipline.
ductive health can be positively impacted through proper,
Parents need to be informed about the types of drugs
sensitive, and honest education on topics related to sexual
that adolescents may use as well as the possible adverse
activity. While the majority of parents indicate that they
consequences associated with each. Early and ongoing
believe education on issues of sexual health should be
parent-adolescent education, open communication, appro-
taught in the family, most also agree that they do not feel
priate role modeling and the early recognition of develop-
prepared to do so alone. Many schools have subsequently
ing problems are the best strategies for prompt identifica-
incorporated education on sexuality into curricula in an
tion and interventions for substance use.
effort to facilitate transfer of factual information.
Developmentally, adolescence is characterized by VIOLENCE AND ABUSE. Negative consequences are also
attempts to develop a personal identity, which includes seen in the rising degree of violence and abuse in the
sexual and gender identity. Young people are bombarded adolescent population. In a nationwide survey of high
with sexual images from music, television, advertisements, school students, 33% reported being involved in a
and movies on a daily basis. Providing adolescents with physical fight one or more times in the preceding year,
correct information on issues of sexuality helps to empower while 17% reported carrying a weapon one or more
them to make healthy decisions regarding their own sexual days in the preceding month (Centers for Disease
behavior. Whether taught by parents, health care provid- Control and Prevention, 2004). It is estimated that 30%
ers, or classroom educators, educational content should of all middle school students encounter some type of
chapter 4 Caring for Women, Families, and Children in Contemporary Society 87
bullying, either as the bully, as a victim of the bully, • Destroying the partner’s personal property
or both. • Threatening to hurt oneself if the partner breaks up
Violence is a learned behavior. Adolescents learn to with him
solve problems through violence by watching parents, • Repeatedly contacting the partner after a break-up
teachers, and others in the community and in the media
Indications of abuse, which may be directed toward the
and by role modeling their behavior. In order to engage in
male or female partner, can include rude and swearing
problem-solving behavior without violence, adolescents
talk, forcing sexual activity against the partner’s will,
need to be taught how to assess the conflict, see the other
humiliating one’s partner in front of other people, and hit-
person’s point of view, and then redefine the conflict so
ting or hurting one’s partner in any way. If any of these
that they and the others involved can negotiate to a deci-
behaviors are known by parents, it is the parents’ respon-
sion without violence.
sibility to intervene, even to the point of legal action.
Parents need to allow the adolescent to develop social
Through interaction and communication, parents can
relationships outside of the family in order to mature and
have a lasting effect on helping their adolescent to develop
define their identity. At the same time, they need to con-
future healthy relationships with others.
tinue to set limits to adolescent behavior, maintain open
and honest communication on problem-solving, and allow TATTOOING AND BODY PIERCING. Tattooing and body
the adolescent to evaluate options to conflict resolution in piercing are examples of adolescent risk-taking behavior
passive, yet assertive ways. (Roberts & Ryan, 2002; Stephens, 2003), and are associ-
Successful conflict resolution strategies enable the ado- ated with other high-risk activities, including smoking,
lescent to remain calm in a potentially violent situation alcohol use, use of smokeless tobacco, and riding in a
and to understand that the aggressor is attempting to vehicle driven by another individual who has been drink-
resolve the conflict in ways that are understood by him. If ing. Health risks associated with tattooing and body pierc-
communication and respect are not facilitating conflict ing may be infectious or noninfectious.
resolution, the adolescent should be taught to remove Infectious health risks include viral, bacterial, and fun-
himself from the potentially dangerous situation. gal diseases, most commonly infections caused by viruses
and bacteria. The most common infections associated
with tattooing and body piercing include hepatitis, human
Ethnocultural Considerations— Exploring immunodeficiency virus (HIV), and human papilloma
differences in ethnicity and race in adolescent virus (HPV). Bacterial infections may be caused by Staph-
violence ylococcus, Streptococcus, Pseudomonas, Clostridium, and
• African Americans, Native Americans, and Hispanics are Mycobacterium (Drifmeyer & Batis, 2007). These organ-
more likely to be victims or the persons responsible for isms have the potential to cause lifelong infection with
fatal violence than Asians or Caucasians. adverse effects on various body systems or the progression
• These differences are more pronounced in adolescent to other diseases, such as cancer and tuberculosis. Allergic
aggression resulting in homicide than adolescent or hypersensitivity reactions are the most common nonin-
aggression not resulting in homicide. fectious responses to tattooing and body piercing.
• African Americans, Native Americans, and Hispanics are Although these reactions may be transient, they can lead
arrested more often for acts of interpersonal violence than to the development of more serious lesions that require
Asians or Caucasians. surgical intervention.
• Hispanic adolescent males are more likely to be victims
of homicide than African Americans or Caucasians. HEALTH PROMOTION
• African Americans account for the majority of all Although the majority of adolescents have not yet become
adolescents known to have committed murder. sexually active, it is important that health care providers
Source: Center for the Study and Prevention of Violence (2004). CSPV fact promote activities to prevent health problems from
sheet: Ethnicity, race, class and adolescent violence. Boulder, CO: Author. developing as they mature. Adolescents can be taught to
perform breast self-examination (BSE) early in their
development and to engage in activities to promote opti-
Adolescents are particularly vulnerable to violence and mal bone health. Once adolescents become sexually
abuse in dating relationships as well. Parents should be active, they should be encouraged to have regular gyne-
encouraged to discuss these issues openly before dating cological examinations.
begins in order to prevent this type of abuse from occur-
ring. Dating provides an opportunity to develop healthy Prevention of Osteoporosis
love relationships that are built on mutual respect and
While adolescents are not at high risk for the development
trust. Similar to abusive situations, relationships can
of osteoporosis (a condition characterized by loss of bone
become coercive and escalate to physical abuse at a later
mass throughout the skeleton), it is essential that steps be
time. Indicators of a coercive relationship include:
taken at this early age to decrease the risk later in life.
• Telling a partner what to wear Strategies that are appropriate for adolescents include
• Telling a partner where she is allowed to go maintaining an adequate intake of calcium and vitamin D
• Telling a partner who she can be friends with or and engaging in regular exercise. Adolescents are at an
talk to increased risk for unhealthy eating behaviors that result in
• Making a partner do something she does not want a calcium intake that falls far short of the amount needed
to do for bone strengthening. Thus, nutritional intake during
88 unit one Foundations in Maternal, Family, and Child Care
Gynecological Examinations
Another aspect of developing health practices that contin-
ues into later years is the initiation of gynecological Figure 4-4 Using the thumb and index finger to
examinations during adolescence. It is important for par- separate the labia to assess the external genital
ents and adolescents to understand that the first visit may structures.
not necessarily include an internal pelvic examination and
collection of specimens.
mal spotting or bleeding. After the age of 40, pelvic exami-
The first visit, which should occur between the ages of
nations should be performed every 1 to 3 years, based on
13 and 15, should be used as an introduction to reproduc-
personal risk factors and history (Institute for Clinical
tive health care. The health care provider should discuss
Systems Improvement, 2005).
issues of sexuality with the adolescent to help prepare her
The nurse assists the patient with relaxation techniques
for making appropriate decisions. Information and reas-
before the pelvic examination, performed in a lithotomy
surance can be provided regarding normal development
position, is initiated. Anxiety is common, especially in
and education on sexually transmitted infections and sex-
women with a history of sexual abuse or assault. Deep
ual behavior can empower the adolescent for informed
breathing, a helpful relaxation strategy, is easy to perform.
sexual decision-making.
The patient is encouraged to take slow, deep breaths, in
The first pelvic examination should be performed at
through the nose and out through the mouth. She should
age 21 or 3 years after the initiation of sexual activity,
be observed for signs of hyperventilation and instructed to
whichever comes first. Other reasons for pelvic examina-
slow down her breathing if necessary. Visual imagery is
tion include unexplained pain in the lower abdomen or
another useful relaxation technique. Many health care
pelvic region; vaginal discharge that causes itching, burn-
providers place engaging pictures on the ceiling for the
ing, or has an odor; delayed menstruation; prolonged
recumbent patient to view. Some women relax with con-
menstruation lasting more than 10 days; dysmenorrhea;
versation. Others prefer to quietly concentrate on deep
and missed periods.
breathing and visualization. It is important to ask the
PELVIC EXAMINATION. The frequency of pelvic examina- patient whether or not she prefers to talk during the
tions varies based on age. Females should have pelvic examination.
examinations once they become sexually active. Women
EXTERNAL INSPECTION. The skin, including the labia
ages 20 to 40 should undergo a pelvic examination at least
majora, is inspected for color, bruising, erythema, lesions,
every 3 years or annually if high risk. “High risk” includes
and hair distribution (Fig. 4-3). Using a gloved hand, the
those with abnormal findings on previous examinations,
examiner gently spreads the labia to assess the external
the presence of sexually transmitted infection, sexual
genital structures (Fig. 4-4). The clitoris, labia minora,
activity before age 18, multiple sexual partners, or abnor-
urethral opening, and vaginal opening are inspected for
inflammation, lesions, and lumps. Bartholin’s glands,
which secrete fluid for lubrication, are palpated using the
index finger and thumb, and are assessed for edema, pain,
Prepuce of and discharge. The vaginal orifice is opened slightly, and
clitoris
the patient is asked to squeeze the vaginal muscles. This
Clitoris technique allows the examiner to inspect for cystocele,
rectocele, uterine prolapse, and incontinence.
Labia Urethral
majora orifice VULVAR SELF-EXAMINATION. Nurses can play a vital role in
Labia
the early detection and treatment of vulvar and vaginal can-
minora Skene's cer by teaching patients about monthly self-examination.
ducts Routine self-examination frequently allows for the early
Bartholin's Vaginal identification and evaluation of abnormalities.
glands orifice
INTERNAL INSPECTION. The examiner uses a speculum for
the internal inspection (Fig. 4-5). The speculum should be
Perineum Hymen warmed or maintained at room temperature and moistened
with water to avoid damage to cells that are collected for
Anus cytological analysis. Depending on the situation, specimens
may be collected for cervical cancer screening (Papanico-
laou test), gonorrhea, chlamydia, trichomoniasis, bacterial
Figure 4-3 Female external genitalia. vaginosis, candidiasis, group B Streptococcus, and herpes
chapter 4 Caring for Women, Families, and Children in Contemporary Society 89
Source: Holloway, B.W., Moredich, C., & Aduddell, K. (2006). OB peds women’s health notes: Nurse’s clinical pocket guide. Philadelphia: F.A. Davis.
RECTOVAGINAL PALPATION. The examiner changes gloves pation are repeated, allowing the examiner to palpate the
before this component of the examination. Following rectovaginal wall, the posterior side of the uterus, and the
application of a water-based lubricant, the examiner area behind the adnexa. Palpation should reveal no ten-
inserts the index finger into the vagina and the middle derness or the presence of fissures or masses along the
finger into the rectum. To facilitate insertion and assess- rectovaginal wall. The uterus and adnexa should be non
ment of muscle strength, the patient is asked to bear down tender, soft, movable and absent of masses (Figs. 4-10,
during the insertion. The procedures of the bimanual pal- 4-11, and 4-12).
chapter 4 Caring for Women, Families, and Children in Contemporary Society 91
Figure 4-6 Opening the speculum. Figure 4-10 Inserting fingers for rectovaginal exam.
Figure 4-7 The vaginal canal is palpated for the Figure 4-11 Performing rectovaginal exam.
presence of tenderness, lesions and nodules.
Figure 4-8 Palpating the uterus. Figure 4-12 Proper position of hands.
MENSTRUAL DISORDERS
Figure 4-9 Palpating the ovaries. Various menstrual disorders may occur during adoles-
cence. The most common conditions are menstrual cramps,
dysmenorrhea (painful menstruation that interferes with
daily activities), and premenstrual syndrome (PMS). Pain-
ful cramping in the uterus during menstruation occurs
92 unit one Foundations in Maternal, Family, and Child Care
from myometrial contractions induced by prostaglandins another individual as a partner or spouse. With the
during the second phase of the menstrual cycle. Prosta- increased independence associated with young adulthood
glandins are chemical mediators that cause pain as part of and the concomitant increase in age, new challenges to
the inflammatory response; during menstruation, the health promotion and disease prevention arise. During
cramps are frequently accompanied by back pain and young adulthood there is a focus on safety, sexual health,
headache. Peaking levels of prostaglandins cause the symp- reproductive health promotion that includes monthly
toms to begin a day or two before the beginning of men- breast self-examination and yearly clinical breast exami-
strual flow and continue until about the second or third nations, and awareness of potential gynecological disor-
day of menstrual flow. ders common to this age group.
Dysmenorrhea is painful menstruation that affects a
woman’s ability to perform daily activities for 2 or more SAFETY
days each month. Health care teaching for females experi-
As young adults attempt to engage in dating relationships,
encing dysmenorrhea should be holistic in nature and
the safety risks associated with substance use, sexual prac-
include relaxation and breathing techniques, the use of
tices, and domestic violence become more evident. It is
heat to reduce uterine contractions and increase blood
during this time, when young adults are developing rela-
flow to the uterine tissues, exercise or rest, and the use of
tionships with members of the opposite or same sex in
nonsteroidal anti-inflammatory drugs to inhibit the syn-
intimate ways, that nurses can provide education and
thesis of prostaglandin. For some women, dysmenorrhea
counseling and empower women to care for themselves in
is symptomatic of other conditions, including pelvic
healthy ways.
inflammatory disease and endometriosis. Severe pain and
dysmenorrhea that disrupts a women’s life should be Substance Use
evaluated by a health care provider.
Once young adults reach the age of 21, they can legally
Premenstrual syndrome (PMS) is another commonly
purchase and consume alcoholic beverages. This “rite of
occurring disorder associated with menstruation that
passage” places them at an increased risk for problems
affects adolescents. Approximately 85% of all females
associated with alcohol use. The newly gained indepen-
experience some degree of symptoms related to PMS.
dence that comes as the young adult moves out of the
Symptoms range from irritability and mood changes to
parent’s home, combined with the social acceptance of
fluid retention, heart palpitations, and visual disturbances.
drinking during this time, may coincide to place the
While the most common cause of PMS is the normal fluc-
young adult in situations where excessive and binge
tuation of estrogen and progesterone during the menstrual
drinking can be common and frequent. Although formal
cycle, other factors may be associated with PMS symp-
operational thought has been developed by this age, the
toms as well. For example, some PMS symptoms may
brain continues to mature during young adulthood. Heavy
result from the following: an imbalance in the levels of
or binge drinking during this time of brain development
estrogen and progesterone; hyperprolactinemia (an
and independent decision-making may cause serious
excessive secretion of prolactin, the hormone responsible
health risks as well as risks to social growth.
for stimulation of breast development); alterations in car-
In addition to alcohol consumption, young adults con-
bohydrate metabolism and hypoglycemia; and an exces-
tinue to be at risk for the use of illicit drugs. Peak use,
sive production of aldosterone resulting in sodium and
similar to that of alcohol, occurs during the early 20s,
water retention.
declines in the late 20s, and tends to come to an end
Recommendations for reducing the severity of the
around age 30. The most reliable theory related to illicit
symptoms associated with PMS include the incorporation
substance use focuses on role development during young
of simple lifestyle changes. Adolescents should be encour-
adulthood, specifically with regard to role normalization
aged to exercise three to five times a week, eat a well-
and role compatibility. As young adults take on more
balanced diet, and get adequate sleep and rest. Dietary
adult roles associated with employment, marriage, and
changes include increasing the daily intake of whole
parenting, the use of illicit drugs may decrease as perfor-
grains, vegetables, and fruits, while decreasing the intake
mance is altered or the person is unable to meet role
of salt, sugar, and caffeine.
expectations. Similarly, when the adult roles are seen
For more problematic symptoms, treatment may
as being incompatible with illicit drug use and non-
include the use of diuretics to reduce fluid retention, the
normative behavior, substance use declines.
administration of nonsteroidal anti-inflammatory drugs to
inhibit synthesis of prostaglandins and provide pain relief, SEXUAL HEALTH. While increased alcohol consumption
oral contraceptives to inhibit ovulation, central nervous and illicit drug use are associated with greater degrees
depressants to promote relaxation, antidepressants, and of sexual freedom and loss of sexual inhibition, young
vitamin supplements. adults are faced with sexual decision making regardless
of substance use. Both males and females tend to have
their sexual peak, with regard to interest, desire, ability,
YOUNG ADULTHOOD HEALTH and performance in the mid- to late-20s, with sexual
Formal operational thought is completed as individuals interest and ability beginning to decrease during the
move from adolescence into young adulthood (ages 19 30s. This is particularly true of males, as testosterone
to 34). The developmental stage during this time period is production and ejaculation decline later during young
intimacy versus isolation. The individual no longer views adulthood.
the family as the primary source of identity and develop- With regard to safe sex practices during young adult-
mental tasks center on making a personal commitment to hood, it is essential for nurses to educate women regarding
chapter 4 Caring for Women, Families, and Children in Contemporary Society 93
the anatomy and physiology of their bodies in an effort common cancer in men 35 to 39 years of age, and the
to facilitate an understanding of the heightened risk of third most common cancer in men between the ages
susceptibility to sexually transmitted infections. Physio- of 15 and 19. Risk factors for testicular cancer include
logical factors that predispose women to increased sus- a positive family history and a personal history of
ceptibility include an increased genital mucosal surface undescended testes; congenital gonadal dysgenesis; and
area, retention of semen in the vagina for several hours Klinefelter’s syndrome, a sex-linked genetic disorder.
following intercourse, and the pH of the vagina. During Interestingly, the majority of testicular tumors are discov-
menstruation, women are more vulnerable to infection as ered during self-examination. The National Cancer Insti-
the pH of the vagina becomes more alkaline, thereby tute (2006) does not recommend routine screening, other
becoming more hospitable to viral and bacterial transmis- than clinical palpation, for testicular cancer since treat-
sion and growth. ment is effective at each state of diagnosis. However, all
During young adulthood, abstinence remains the only males should be taught to palpate the testes for abnormal
safe method for protection against sexually transmitted lumps and masses on a regular basis.
infections. However, as young adults begin to experiment
with sexual activity, nurses must continue to educate
them on the proper use of condoms, including the use of
Family Teaching Guidelines…
a water-based lubricant to prevent tears in the mucosa,
use of a barrier during oral sex, and protection and clean- Testicular Self-examination
ing of sexual toys that may be used. While some nurses The best time to perform a testicular self-examination is
may find these topics difficult to approach and discuss during or immediately following a hot shower or bath since
openly, it is only through open communication that the scrotum is more relaxed at this time. The following steps
young adults are likely to incorporate safe practices into should be performed, examining one testicle at a time:
their development and experimentation. 1. Examine the testicles. One should be slightly larger
than the other, usually the right testicle.
HEALTH PROMOTION 2. Feel for lumps and bumps along the front and sides.
Health practices, both positive and negative, that were 3. Using both hands, place your thumbs over the top of
initiated during adolescence will likely continue into the testicle and your index fingers and middle fingers
young adulthood. During this time, dietary and exercise underneath the testicle. Gently roll the testicle, using
behaviors are more likely to either protect from or slight pressure, between your fingers (Fig. 4-13).
increase the risk of developing obesity, hypertension, 4. The epididymis, which carries the sperm, can be felt at
type 2 diabetes mellitus, and cardiovascular disease. Spe- the top of the back part of each testicle. It should feel
cifically, the chronic illnesses that are more likely to soft and rope-like and be slightly tender to pressure.
emerge during young adulthood include cancer, cardio- This is a normal finding.
vascular disease, type 2 diabetes mellitus, and autoim- 5. Notify your doctor if you notice any swelling, lumps,
mune diseases such as lupus erythematosus and multiple pain, or changes in color or size of either testicle.
sclerosis.
For women, stress-related disorders become more Source: The Nemours Foundation (2007). How to perform
apparent during this time. Stress can trigger behaviors a testicular self-examination. Retrieved from http://www.
such as overindulgence in comfort foods, alcohol abuse, kidshealth.org/teen/sexual_health/guys/tse.html
and the use of marijuana and other drugs to reduce ten-
sion. It is encouraging that women in young adulthood
are more likely to experiment with alternative therapies
to relieve stress. Herbal methods, homeopathic reme-
dies, spiritual approaches, music and dance, and art
therapy may be used. Nurses need to understand and
support these positive, alternative methods for stress
reduction to promote a holistic approach to health and
wellness.
GYNECOLOGICAL DISORDERS. Along with specific medical the goal of stabilizing the release of estrogen and proges-
problems, certain gynecological disorders are more com- terone to decrease tissue swelling and bleeding.
mon during young adulthood as well. Endometriosis, cer- When pregnancy is not an immediate goal, oral contra-
vical cancer, breast cancer, and urinary tract infections are ceptives with a low estrogen to progestin ratio may be used
more likely to occur during this time. Also, since young to inhibit the production of hormones and suppress ovula-
adulthood marks the time when most women try to begin tion. Gonadotropin-releasing hormone (Gn-RH) agonists
a family, problems associated with infertility may be dis- and antagonists, such as leuprolide (Lupron) or nafarelin
covered at this time as well. (Synarel), suppress the secretion of pituitary gonadotro-
pins, decrease the release of follicle-stimulating hormone
ENDOMETRIOSIS. Endometriosis, a benign disorder of
(FSH) and luteinizing hormone (LH), and diminish ovar-
the reproductive tract, is characterized by the presence and
ian function. Danazol (Danocrine), another medication
growth of endometrial tissue outside of the uterus. Women
that suppresses the release of FSH and LH, may be used.
ages 30 to 40 are most likely to develop endometriosis.
However, the side effects of acne and facial hair growth
Endometrial tissue may implant on the fallopian tubes,
make danazol a less commonly prescribed medication.
ovaries, and the tissues surrounding and lining the pelvis.
Medroxyprogesterone (Depo-Provera) is an injectable
The endometrial tissue responds to hormonal influences
medication used to reduce the growth of the endometrial
during the secretory and proliferative stages of the men-
tissue, but its undesired side effects include weight gain
strual cycle, where it grows and thickens, in a similar fash-
and depression. Newer pharmacological modalities utilize
ion to the endometrial tissue lining the uterus. However,
aromatase inhibitors, including anastrozole (Arimidex),
during the ischemic and menstrual phases of the cycle, the
exemestane (Aromasin), and letrozole (Femara), chemi-
misplaced endometrial tissue breaks down and bleeds into
cals that block the conversion of androgens to estrogen
the surrounding tissue, causing inflammation. The blood
and suppress the production of estrogen from the abnor-
becomes trapped in the surrounding tissues causing the
mal endometrial tissue, thereby decreasing tissue growth.
development of blood-containing cysts. Recurring inflam-
When pharmacological approaches are not successful,
mation in the areas outside of the uterus eventually result
or when pregnancy is desired, the endometrial tissue
in scarring, fibrosis, and the development of adhesions,
growths, scar tissue, and adhesions can be removed surgi-
scar tissue that binds the organs together causing increased
cally through laparoscopy. When endometriosis is severe,
abdominal pain and a risk of infertility.
however, radical surgery that includes removal of the
Abdominal pain of varying intensity is the most com-
uterus, fallopian tubes, and ovaries (bilateral salpingo-
mon symptom associated with endometriosis. However,
ööphorectomy) may be indicated.
the degree of pain associated with endometriosis is not a
reliable indicator of the extent of the disorder. Other CERVICAL CANCER. Cervical cancer develops gradually as
symptoms may include pain during ovulation (mitt- cells change their growth pattern. Pre-cancerous cellular
elschmerz), heavy bleeding during menstruation, and changes, called dysplasia, eventually become cancerous.
episodes of diarrhea and constipation, which may be mis- There are two types of cervical cancer: squamous cell car-
taken for irritable bowel syndrome. Women may also cinoma and adenocarcinoma. Approximately 80% to 90%
experience dyspareunia or pain during defecation. of all cervical cancers are squamous cell carcinomas that
Although the etiology of endometriosis is unknown, cover the surface of the cervix.
the most commonly held theory is “retrograde menstrua- While not all cervical dysplasia develops into carci-
tion.” During menstruation, endometrial tissue is refluxed noma, screening and treatment of cervical dysplasia sig-
through the fallopian tubes and out into the peritoneal nificantly reduces the chances that carcinoma will develop.
cavity where it implants on the ovaries and surrounding This fact lends credence to the recommendation that
organs. While 90% of all women experience retrograde screening through Papanicolaou testing be performed on
menstruation, only about 5% to 10% develop endometrio- all young adults. Furthermore, 50% of all women diag-
sis, indicating a possible difference in immune function, nosed with cervical cancer are diagnosed during the ages
genetic predisposition, or environmental influence. of young adulthood.
The diagnosis of endometriosis may be made by pelvic The primary risk factor for cervical cancer is human pap-
examination although it is often impossible to palpate small illoma virus (HPV) infection. There is a strong correlation
areas of localized endometrial tissue. A vaginal ultrasound between infection with the high-risk types of HPV and the
may be performed to provide imaging of the displaced development of cervical cancer. Seventy percent of cervical
endometrial tissue or cyst. The physician may also perform cancers are caused by HPV-16 or HPV-18. Other types of
a laparoscopy to visualize the abdominal organs and locate HPV are associated with the development of papillomas,
signs of abnormally located endometrial tissue. Laparos- which are benign growths found primarily in the genital and
copy provides information concerning the location, size, anal regions. While there is no treatment for HPV, a new
extent of disease, and the presence of scars and adhesions. vaccine, Quadrivalent Human Papillomavirus (Types 6, 11,
Medical management includes pain control, the use of 16, 18) Recombinant Vaccine (Gardasil), has recently been
hormonal therapy to shrink the abnormal tissue, and, at marketed and is targeted for adolescent and young adult
times, surgery to remove the abnormal tissue. The pain women. This vaccine is recommended for girls and women
associated with tissue inflammation may be managed with ages 9 through 26 years to protect against the development
nonsteroidal anti-inflammatory drugs, such as ibuprofen, of cervical cancer; abnormal lesions of the cervix, vulva, and
to inhibit the synthesis of prostaglandin and reduce the vagina; and genital papillomas (Merck & Co., Inc., 2006). It
inflammation. If conservative treatment is not helpful, is important for nurses to remind patients receiving the vac-
supplemental hormonal therapy may be introduced, with cine to continue to have routine cervical cancer screenings.
chapter 4 Caring for Women, Families, and Children in Contemporary Society 95
The vaccine is given in three doses: the second dose is URINARY TRACT INFECTIONS. Urinary tract infections
administered 2 months after the first dose, and the third (UTIs) can be very serious in young adults and may lead
dose is administered 6 months after the first dose. to major problems if not diagnosed or treated. Infections
Medical management is determined by biopsy and stag- of the urinary tract are the second most common type of
ing of the cancer. Following identification of an abnormal infection in adults, and young adults are more susceptible
Pap smear, colposcopy (use of a stereoscopic binocular due, in most instances, to increased sexual activity during
microscope to examine the cervix under magnification) is this time. Women tend to be more vulnerable than men
usually performed. An acetic acid solution applied to the because the short urethral length and the proximity of the
cervix enhances visualization of the epithelium and helps urethral meatus to the anus allow for the easy ascension
to identify areas for biopsy. Cervical biopsies are then of bacteria. However, urinary tract infections in men can
obtained and pathologically examined for the presence and be more serious than in women. The majority of UTIs are
extent of cancer. Several outpatient biopsy methods are caused by the microorganism Escherichia coli (E. coli),
available. The endocervical curettage (ECC) is an effective which is normally found in the colon. Once introduced
diagnostic method in about 90% of cases. The cone biopsy into the urethra, the bacteria colonizes, causing urethritis.
involves removal of a cone- or cylinder-shaped sample of As the bacteria multiply and migrate into the bladder,
tissue. Loop electrosurgical excision procedure (LEEP) cystitis develops. Left untreated, the infection can
is a newer method for cervical biopsy and the removal of spread up the ureters and into the kidneys, causing
abnormal cells. With this procedure, an electrically charged pyelonephritis.
wire loop is inserted through a speculum and a thin layer Symptoms of urinary tract infections include burning,
of cells is removed from the cervix. The LEEP technique urinary frequency, and urgency during urination, and a
provides excision and cautery with minimal tissue damage. strong sensation of the need to void followed by passage
Patients should be instructed that vaginal drainage is of only a small amount of urine. Women often report a
normal and expected following the procedure and may last sensation of fullness noted above the symphysis pubis; in
up to 3 weeks. The patient should refrain from using men, infection triggers a sensation of rectal fullness. Other
tampons or having sexual intercourse for the following clinical manifestations of infection include fever, general
4 weeks to minimize the risk of infection. Nonsteroidal malaise and fatigue, elevated white blood cell count, and
anti-inflammatory medications may be taken to reduce the chills. The urine may appear cloudy due to the presence
mild cramping that may occur following the procedure. of white blood cells.
Following the biopsy, further and more extensive treat- Medical management centers on the use of antibiotics.
ment may be required if the cancer has spread to other Trimethoprim/sulfamethoxazole (Bactrim, Septra) are the
areas of the cervix or beyond the cervix. The three pri- medications most commonly prescribed. Depending on
mary methods of cervical cancer treatment include sur- the strain of bacteria and results from culture and sensi-
gery, radiation, and chemotherapy. It is not uncommon tivity testing, other agents such as amoxicillin (Amoxil,
for a combination of two treatment methods to be used. Trimox) and ampicillin (Omnipen) may be used. Nitro-
furantoin (Macrodantin) or ciproflaxin (Cipro) may be
prescribed for more complicated infections.
case study Young Adult with Cervical Patient education should focus on the prevention of
Dysplasia urinary tract infections. Everyone should drink adequate
water each day and urinate when the urge is felt. Following
Vanessa, a 32-year-old woman, visits the women’s health clinic urination and defecation, women should wipe from front
in a small, rural community. She requests a gynecological exami- to back to prevent bacteria from entering the urethra from
nation, and states this is her first exam in 3 years. Vanessa has the colon, and encouraged to take showers instead of tub
recently married and engages in normal sexual activity with her
baths. Bath oils, perfume, and bubble baths should be
husband. Her medical history is positive for asthma, and she
takes one Singular 10 mg tablet at bedtime and Flovent two
avoided if tub baths are taken. Feminine hygiene sprays
puffs twice daily. Her Pap test reveals cervical dysplasia, and the and scented douches should be avoided to prevent irrita-
physician recommends a LEEP procedure, with follow-up Pap tion, and cotton underwear should be worn to decrease
tests every 3 months for 1 year. perineal moistness and warmth that can enhance the
1. Review the preceding information. List as many potential growth of bacteria.
patient problems or risks as you can identify; prioritize
your list. MIDDLE ADULTHOOD HEALTH
2. Write a nursing diagnosis for each problem. As the young adult matures into middle age, which
3. Develop a care plan for the top three nursing diagnoses. includes ages 40 to 64, there is a decrease in the risk for
Include: (a) goals for the patient, (b) nursing interventions, some health problems and an increased risk for others. It
(c) rationale(s) for each nursing intervention, and (d) how you is during this age group that mammography screenings
would evaluate whether or not each goal was met. should begin, along with colonoscopies, cholesterol and
Did you include Deficient knowledge or patient teaching in lipid screening, and osteoporosis screening. Most women
your care plan? Be sure to include the overall goal of your teach- begin to experience symptoms of perimenopause during
ing, teaching strategies, content to be taught, and how you will middle age and need to make decisions on managing
evaluate patient learning. these symptoms. Certain gynecological disorders become
◆ See Suggested Answers to Case Studies in the text on the more common during middle age, including fibroid
Electronic Study Guide or DavisPlus. tumors, ovarian cysts, ovarian cancer, and endometrial
cancer.
96 unit one Foundations in Maternal, Family, and Child Care
Breast Self-examination
Familiarization with one’s breasts facilitates the early 4. Palpate the breast and axillae. Recline on the bed and
detection of problems and allows for prompt evaluation. place a pillow under each shoulder during palpation.
Breast self-examination (BSE) is a way for women to learn Use the left hand to palpate the right breast, and the
how their breasts normally feel. Routinely performing BSE right hand to palpate the left breast. Using the finger
is an approach that focuses on the importance of self- pads of the three middle fingers, palpate the entire
awareness and helps women to notice changes in breast surface of the breast. Use overlapping dime-sized
tissue (ACS, 2003). circular motions and apply three different levels of
pressure: light pressure is best to feel the tissue closest
to the skin; medium pressure is best to feel a little
deeper; and firm pressure is used to feel the tissue
Family Teaching Guidelines… closest to the chest and ribs.
Breast Self-Examination
1. Visually inspect the breasts in front of a mirror. Assess
for color, contour, shape, and size. Assess for dimpling
or puckering of the skin; change in nipple direction;
and redness, rash, or swelling.
Mammography
A mammography examination is used to aid in the early
diagnosis of breast cancer. The examination, which requires
exposure to small doses of ionizing radiation, allows for
identification of small breast tissue abnormalities that may
require further investigation. Two enhancements have
been made to traditional mammography: digital mammog-
raphy and computer-aided detection (CAD). Digital mam-
mography, also called full-field digital mammography
(FFDM), converts the x-rays to electrical signals, similar to
those found in digital cameras. These signals produce
images that can be viewed on a computer screen or printed
98 unit one Foundations in Maternal, Family, and Child Care
on special film. The images are stored for future compari- Now Can You— Discuss ways to enhance breast health?
son. Preliminary results from a clinical study sponsored
by the National Cancer Institute indicate that digital 1. Identify the steps for performing breast self-examination?
mammography provides improved screening for women 2. Discuss recommendations regarding clinical breast
determined to be at high risk for developing breast cancer examination and mammography?
(Pisano et al., 2005). This latest technology is enhanced 3. Discuss risk factors associated with breast cancer?
with the use of computer software that highlights areas of 4. Identify lifestyle choices that decrease the risk of developing
increased density, masses, and calcifications. breast cancer?
plastic surgeon, is a personal decision that requires con- • Lower colon double-contrast barium enema
siderable individualized counseling and education. Since (x-ray films are taken of the colon and rectum)
the reconstruction can be performed at the same time as • Digital rectal exam (usually included as part of a
the mastectomy, it is important to consider the options routine physical exam)
early. Breast reconstruction methods include use of a syn-
A colonoscopy is an examination that involves inser-
thetic breast implant or reconstruction using one’s own
tion of a colonoscope (a thin catheter with a light and
tissue. Synthetic implants typically are composed of a sili-
lens) into the rectum to allow the physician to visualize
cone shell filled with a saline solution. A tissue expander
and photograph the tissues and, when indicated, remove
may be needed to cover the implant. To accomplish tissue
specimens for pathological examination. Preparation for
expansion, an empty implant shell is placed under the
the procedure usually includes a clear liquid diet for 1 to
skin and muscles and gradually filled with the saline solu-
3 days before the examination and administration of a
tion over several months. Once the skin is stretched suffi-
laxative or enema on the evening prior to the procedure.
ciently, the expander is removed and replaced with a per-
Patients who take anticoagulants, nonsteroidal anti-
manent implant. Recovery usually takes several weeks.
inflammatory drugs, or oral antidiabetic agents are
Women who choose to undergo breast reconstruction
instructed when to withhold their medications in prepara-
using their own tissue may have a transverse rectus
tion for the procedure.
abdominis myocutaneous (TRAM) flap procedure. The
Colonoscopy is performed under conscious sedation.
breast is reconstructed using fat and muscle tissue taken
The patient is placed on the left side and given an analge-
from the abdomen, back, and buttocks. Recovery follow-
sic and a sedative. Once the patient is relaxed and the
ing the procedure usually takes 6 to 8 weeks, and there is
colonoscope is inserted into the rectum, the patient is
an increased risk of infection and tissue necrosis. Deep
asked to change positions several times to enhance visual-
inferior epigastric perforator (DIEP) reconstruction is a
ization of the colon. Abnormal growths or tissue are
slightly less complicated surgical procedure. This method
removed for laboratory analysis. The procedure usually
is similar to the TRAM flap procedure, but the abdominal
takes about 30 to 60 minutes and the patient may experi-
muscles are left intact. The DIEP procedure is associated
ence mild cramping and slight bleeding afterwards.
with fewer complications and less postoperative pain. Fol-
lowing reconstruction of the breast tissue, the surgeon can Cholesterol and Lipid Screening
reconstruct the nipple and areola using tissue from other
Cholesterol is essential for cell membranes, synthesis of bile
areas of the body. A small mound is constructed to resem-
acids, and synthesis of steroid hormones. Included in the
ble a nipple, and tattooing may be used to create an areola;
cholesterol are chylomicrons, very low density lipids
the areola may also be created by using a skin graft and
(VLDLs), low-density lipids (LDLs), and high-density lip-
slightly raising the skin, then tattooing the skin graft.
ids (HDLs). Chylomicrons are lipoproteins that are present
Adjuvant therapies may include radiation therapy, che-
shortly after eating, then disappear within a couple of hours
motherapy, or hormone therapy. Radiation is usually
following a meal. HDLs are considered to exert a positive
begun 3 to 4 weeks after surgery, and treatments are given
influence on prevention of heart disease: they carry choles-
5 days per week for 5 to 6 weeks. Chemotherapy that
terol to the liver for excretion in the bile. Conversely, LDLs
includes a combination of two or more drugs may also be
carry cholesterol into the bloodstream. Comparison of
prescribed. Chemotherapeutics may be administered
results with normal values provides the nurse with infor-
orally or intravenously, and usually require four to eight
mation to evaluate cardiac disease risk and provide patient
treatments over 3 to 6 months. Hormone therapy is most
education on healthy eating behaviors (Box 4-7).
commonly used to treat advanced metastatic cancer or as
an adjuvant treatment to prevent recurrence of cancer.
Normally, estrogen and progesterone bind to receptor THE CLIMACTERIC, MENOPAUSE,
sites in the breast tissue and encourage growth of cancer- PERIMENOPAUSE, AND POSTMENOPAUSE
ous cells. Prescribed hormone medications bind to the The climacteric is a transitional time in a woman’s life
sites instead, and prevent estrogen from reaching them. marked by declining ovarian function and decreased hor-
Medications used in hormone treatment include tamoxi- mone production. The climacteric begins at the onset of
fen (Nolvadex), a selective estrogen receptor modulator ovarian decline and ends with the cessation of postmeno-
(SERM), and aromatase inhibitors, which block the con- pausal symptoms. Menopause, a term derived from Latin
version of androgens into estrogen. mensis for month and Greek pausis, meaning to cease,
refers to the last menstrual period and can be dated with
Colon Cancer Screening certainty only 1 year after menstruation ceases. The aver-
A colonoscopy is the best method for identifying possible age age at menopause in the United States is 51.4 years; the
colon and rectal cancer. Since more than 90% of colon and normal age at menopause ranges from 35 to 60 years.
rectal cancers are diagnosed after the age of 50, recom- Perimenopause is the period of time preceding meno-
mendations suggest having a colonoscopy at this age. pause, usually between 2 and 8 years before menopause.
Other tests that can be helpful in screening for colon can- The age at onset of perimenopause ranges from 39 to
cer include: 51 years (Speroff & Fritz, 2005). Although perimenopause
may last as few as 2 or as many as 10 years, on average, it
• Fecal occult blood test (small amounts of blood can be lasts 4 years. During this time of transition, levels of estro-
detected in the stool) gen and progesterone increase and decrease at uneven
• Sigmoidoscopy (detects polyps and cancer inside the intervals, causing the menstrual cycle to become longer,
rectum) shorter, and eventually absent. Ovulation is sporadic.
100 unit one Foundations in Maternal, Family, and Child Care
a liberating time that brings freedom from the worry of an Ovarian Cysts
unplanned pregnancy; an end to childrearing responsibilities; Ovarian cysts are benign fluid-filled sacs that develop on
and an opportunity to focus on hobbies, career, interpersonal the ovaries and cause pain and, at times, bleeding. The
relationships, and self-discovery. most common type of ovarian cyst is a functional, or
“simple” cyst in which fluid is contained within a thin
wall inside the ovary. Functional ovarian cysts result
when the ovarian follicle fails to rupture and release an
GYNECOLOGICAL DISORDERS oocyte. Instead, the fluid remains in the follicle and devel-
During middle age, there is an increased incidence of cer- ops into a cyst. This type of cyst occurs most often during
tain gynecological disorders due to hormonal and envi- a woman’s childbearing years and disappears without
ronmental influences. Leiomyomas are present in about treatment.
20% of women during this age period. Ovarian cysts, There are, however, other types of ovarian cysts. A fol-
which may occur at any age, are most common during the licular cyst develops when ovulation does not occur or
childbearing years up to the time of menopause. Endome- when an immature follicle does not reabsorb fluid follow-
trial cancer is the most common malignancy of the repro- ing ovulation. Follicular cysts are usually asymptomatic
ductive system. Ovarian cancer, the second most fre- and shrink after two or three menstrual cycles. However,
quently occurring reproductive cancer in females, is the rupture of the cyst causes severe pelvic pain.
most common cause of death of all of the reproductive A corpus luteum cyst occurs after ovulation. Under
cancers due to its rapid growth and nonspecific symptom- normal circumstances, if fertilization does not occur, the
atology. Endometrial cancer is slow-growing and when corpus luteum shrinks and disappears. When the corpus
detected at a localized stage, the survival rate is much luteum persists, it can become filled with fluid or blood
greater than with ovarian cancer (ACS, 2006a). and remain on the ovary. Symptoms associated with a
corpus luteum cyst include abdominal pain, ovarian ten-
Leiomyomas derness, and delayed or irregular menses. If bleeding
Leiomyomas, or uterine fibroid tumors, are benign growths occurs within the cyst, it is known as a hemorrhagic cyst.
that arise from the smooth muscle in the uterus. They occur Rupture can cause an intraperitoneal hemorrhage. Corpus
most often after age 50 and are more common in African luteum cysts typically resolve spontaneously within one
American women and in women who have never been preg- or two menstrual cycles.
nant. While the exact cause is unknown, their growth is A dermoid cyst is a germ cell tumor that usually affects
dependent on estrogen. Leiomyomas begin as small masses women at an earlier age. This type of ovarian cyst may
of tissue that spread into and throughout the myometrium. grow to 6 inches in diameter, and can contain fat, teeth,
They rarely become malignant and shrink after menopause bone, hair, and cartilage. Dermoid cysts can develop bilat-
when levels of the ovarian hormones have declined. erally and may cause lower abdominal pain or complica-
Leiomyomas are often asymptomatic and may not be tions related to torsion. Surgical removal is the usual
detected until there is evidence of infertility. Symptoms, if treatment.
present, may include a sensation of fullness or pressure in Endometrioid cysts result from the growth of endome-
the lower abdomen, increased pain and cramping with trial tissue in the ovaries. They are often filled with dark
menstrual periods, abdominal distention, urinary fre- blood and may cause chronic pelvic pain. Treatment
quency, or heavy menses. Uterine tumors may be identi- involves removal to prevent rupture and the development
fied during a pelvic examination through palpation of the of a hemoperitoneum.
uterus. A transvaginal ultrasound may be performed to
confirm the diagnosis. If cancer is suspected, a laparos- Ovarian Cancer
copy may be indicated. Cancer of the ovary is the second most frequently occur-
Medical management may include the use of nonsteroi- ring reproductive cancer and causes more deaths than any
dal anti-inflammatory drugs for dysmenorrhea. Oral con- other genital tract cancer (ACS, 2006a). While the cause
traceptives may be prescribed to control heavy periods is unknown, there are identified risk factors, including
and decrease tumor growth. Leuprolide (Lupron), a medi- nulliparity, pregnancy later in life, presence of BRCA1 and
cation that suppresses the production of estrogen and BRCA2 genes, a personal history of breast cancer, and a
progesterone, may be used to shrink leiomyomas although family history of breast or ovarian cancer. Associative
patients may complain of menopausal symptoms such as causes include the use of fertility medications, exposure to
vaginal dryness, hot flashes, and mood changes. asbestos, genital exposure to talc, a high-fat diet, and
If the fibroid tumors are growing inside the uterus, a childhood mumps infection. Older women are at increased
hysteroscopic uterine ablation (vaporization of tissue) risk as compared to younger women. Approximately two-
may be performed under local or general anesthesia. In thirds of the deaths associated with ovarian cancer occur
this procedure, a hysteroscope, a small camera, and surgi- in women who are age 55 and older, while approximately
cal instruments are inserted through the vagina and into 25% occur in women between the ages of 35 and 54. Preg-
the uterus. After the procedure, scarring and adhesions nancy and oral contraceptive use provide some protection
that interfere with fertility may form in the uterine cavity. against ovarian cancer, and the use of postmenopausal
Myomectomy (removal of the fibroid tumor) is an alter- estrogen may increase the risk (ACS, 2006a).
native surgical treatment that may be performed for Symptoms are usually vague and nonspecific, and
women who wish to preserve their fertility. Myomectomy include pelvic fullness, lower abdominal pain, weight
can be done through an abdominal incision, or through a gain, irregular menstrual cycles, back pain, abdominal
laparoscopic or vaginal (hysteroscopic) approach. distention and increased abdominal girth (related to
102 unit one Foundations in Maternal, Family, and Child Care
ovarian enlargement or ascites), urinary urgency, urinary wrinkles, and increased body fat may cause the older adult
frequency, indigestion, lack of appetite, feeling full after to feel less attractive and experience a reduced libido.
eating only a little bit and bloating (Goff et al., 2007). Talking to one’s partner about these feelings and emotions
Since ovarian cancer is a rapidly growing neoplasm, the can stimulate intimacy and help the couple connect on a
diagnosis is usually not made until the cancer has metas- more comfortable level with one other.
tasized, giving rise to the nickname for ovarian cancer as For those who are single, it is imperative that health
“the silent killer.” providers address sexually transmitted infections and safe
The diagnosis is made via transvaginal ultrasonogra- sex practices. About 20% of all adults with HIV infection
phy, CA-125 antigen (a tumor-associated antigen) test- are older adults, and the risk increases for women due to
ing, or laparotomy. The preferred treatment for ovarian the increased dryness and loss of elasticity of the vaginal
cancer is surgical removal, and usually requires a hyster- mucosa. Barriers should be used for sexual intercourse as
ectomy with bilateral salpingo-ööphorectomy. After sur- well as for oral sex for all sexually active adults.
gery, chemotherapy is used to treat any remaining cancer.
Radiation therapy may be used as a palliative measure Exercise and Activity
although it is not typically used as a treatment option for Maintaining exercise and activity during the later years
ovarian cancer. can improve an adult’s strength, balance, flexibility, and
endurance, which can combine for healthier living and
increased independence. Strength exercises build mus-
Older Adulthood Health cles, increase metabolism, and help with maintaining
healthy body weight and blood sugar levels. Exercises
As individuals move into the later stages of life, physiolog- that can be performed safely by older adults to help in
ical changes as well as psychological changes alter their strength building include arm raises, bicep curls, triceps
health and increase their risk of disease. During these extensions, and knee flexion. Balance exercises help
years, health promotion and disease prevention is impera- adults to build leg muscles, which can help to prevent
tive in order to maintain quality of life and encourage falls. Included in the balance exercises are side leg raises,
empowerment in managing health and daily activities. hip flexion, and hip extension. Stretching exercises
Health care management focuses on gynecological health improve movement and allow one to be more physically
and mental and emotional health. active during the later years. Included in the stretching
exercises are triceps stretches and double hip rotations.
HEALTH PROMOTION Endurance exercises include cardiovascular exercises that
increase the heart rate and respiratory rate and help to
Health promotion is complex and challenging in older build up endurance gradually. The activities can include
adults as they are experiencing changes in sexual func- any activity that builds cardiovascular health in this way,
tioning, exercise and activity, cognition, and function. from walking to jogging to swimming and biking. Older
Many considerations must be incorporated into patient adults who have not engaged in endurance exercises
education during older age. should begin slowly, with only about 5 minutes of activ-
ity per day.
Sexual Functioning
Intimacy and sexual activity during the later years remain Cognitive Functioning
important in fulfilling relationships that can positively While cognition includes memory and knowledge, there
affect one’s physical and emotional health. However, are other factors incorporated into cognitive ability. Cog-
physical and psychological changes that occur in the body nition is a combination of acquiring knowledge, perceiv-
can affect intimacy as one ages. Testosterone, the hor- ing events that surround us, using language, making deci-
mone that regulates the sex drive, does not decrease sig- sions, using judgment, and executing motor skills. As
nificantly as one ages. Instead, other changes exert a more cognitive changes occur due to the aging process, older
immediate impact on intimacy and sexual functioning. adults begin to notice changes in memory and the ability
For women, the most significant change is the decrease to execute normal daily functions.
in estrogen that accompanies menopause. Low levels of Most of the decline seen in cognitive functioning due
estrogen are associated with decreased vaginal lubrication to the aging process is irreversible. However, there
and a slowed response to sexual stimulation. In addition, are some factors that can slow the decline. Stress man-
the vaginal tissue loses elasticity, resulting in increased agement and coping strategies can lessen depression and
dryness and dyspareunia. Prolonged foreplay and use of a increase concentration and memory. Medical manage-
water-soluble lubricant or an estrogen cream that can be ment of physical illnesses can control renal disease, liver
applied directly to the vagina can facilitate lubrication and disease, endocrine disorders, and electrolyte imbalances
help in maintaining elasticity. that can contribute to diminishing cognitive functioning.
For men, it may take longer to achieve an erection. Good nutritional intake, including folate, riboflavin, and
Once achieved, the erection may not be as firm or last as thiamine can improve cognition. Finally, moderation
long as in previous years. To help with this problem, the or elimination of alcohol use can reduce cognitive
health care provider can make recommendations including impairment.
medications, a penile vacuum pump, or vascular surgery. A simple cognitive assessment that can be performed
For both genders, changes in physical appearance can on all adults includes the use of clock drawing, box copy-
adversely affect one’s emotional ability to develop an inti- ing, and narrative writing to describe a pictured scene.
mate relationship with another. The presence of gray hair, These activities allow the health care provider to gather
chapter 4 Caring for Women, Families, and Children in Contemporary Society 103
preserve bone mass, and increase bone density. The most transitions, one at a time, to the next heaviest cone. It is
common bisphosphonates are alendronate (Fosamax), helpful to use the cone while doing Kegel exercises as
ibandronate (Boniva), and risedronate (Actonel), which well. As the pelvic muscles strengthen, patients can use
can be taken on a weekly or monthly basis. Raloxifene, a the cones while engaging in exercise.
selective estrogen receptor modulator, can also be used for Electrical stimulation during Kegel exercises stimulates
women with osteoporosis since this medication reduces and contracts the pelvic muscles in a manner similar to
loss of bone density without increasing the risk of breast or the Kegels. This approach, conducted in the health care
endometrial cancer. practitioner’s office, may be helpful for women who have
Prevention is the best strategy for reducing the risk of difficulty contracting the pelvic muscles voluntarily. With
fractures associated with osteoporosis. Health-promoting biofeedback, the patient is taught to voluntarily control
activities that facilitate prevention include adequate the pelvic muscles and bladder. With an electrode attached
amounts of calcium and vitamin D, moderate exposure to to the skin, biofeedback machines measure the electrical
sunlight, strength training exercises, endurance exercises, signals elicited when the pelvic muscles and urinary
adding soy, which contains plant estrogens, to the diet, sphincter are contracted. Through the visual cues from
cessation of smoking and the avoidance of excess caffeine the graph shown on the monitor, patients can learn to
and alcohol. control these muscles voluntarily.
Some women choose to use a pessary, which is a
Pelvic Floor Dysfunction device inserted into the vagina to support the prolapsed
The pelvic muscles atrophy after menopause, becoming bladder or uterus. This device must be fitted by a health
weak and unable to adequately support the pelvic struc- care practitioner, and needs to be removed and cleaned
tures and organs. As the pelvic organs shift position, they regularly with soap and water to reduce the risk of
begin to press against the vagina, resulting in prolapse, infection.
usually of the vagina or bladder. The most common cause Pharmacological management of incontinence is aimed
of pelvic muscle weakness results from damage to the at relaxing the involuntary contractions that occur in the
muscles during vaginal birth, particularly if the baby was bladder. For overactive bladder, common medications
large or if the labor was difficult. Other factors related to include tolterodine (Detrol), oxybutynin (Ditropan), and
weakening of the pelvic floor include obesity, chronic imipramine (Tofranil). Common side effects associated
cough, chronic constipation, and strenuous exercise. A with these medications include dry mouth, nausea, dizzi-
prolapse can result in pain during intercourse and urinary ness, drowsiness, and constipation. For urinary stress
incontinence. In severe cases, the vagina may prolapse incontinence (USI), in which there is an involuntary loss
and protrude through the vaginal orifice. of urine during sneezing, coughing, or laughing, the goal
Different types of prolapse can occur, depending upon of treatment is to increase muscle tone in the urinary
the muscles and organs that are affected. A cystocele sphincter. Postmenopausal women may choose to use
results when the bladder herniates into the vagina. Symp- estrogen replacement therapy following careful consider-
toms include difficulty in voiding, incontinence, and dys- ation of the risks and benefits. For weak or underactive
pareunia. A rectocele occurs when the muscles behind bladder problems, bethanechol (Urecholine) is the usual
the vagina are damaged, allowing the rectum to press into medication of choice.
the vagina. When the muscle damage occurs in a higher Surgical interventions include laparoscopic or abdom-
location in the colon, it is referred to as an enterocele. inal procedures to support the bladder and urethra in
Symptoms associated with both of these types of prolapse the correct anatomical position or methods to tighten
include constipation, difficulty in completing a bowel the sphincter muscles. In one type of procedure, the
movement, and dyspareunia. Uterine and vaginal vault surgeon sutures the vaginal wall to the tissue near the
prolapses occur when the uterus and cervix press down- pubic bone. Another involves the creation of a sling
ward, resulting in a sensation of pressure in the abdomen using synthetic material or tissue taken from the abdo-
and vagina, dyspareunia, and back pain. men or from beneath the thigh. The sling is then posi-
Exercise can strengthen the muscles; however, muscle tioned beneath the urethra to provide support and pre-
damage cannot be reversed. Surgery is the primary treat- vent urine leakage. A newer procedure uses a mesh-like
ment for pelvic prolapse; the timing of the surgery depends tape, called tension free transvaginal tape (TVT), which
upon the woman’s symptoms and their effect on her daily is surgically inserted through the vagina and positioned
activities. to support the neck of the urethra and the bladder. This
Some symptoms can be medically managed until sur- procedure is performed under local anesthesia and
gery is appropriate. Many treatment options are available intravenous sedation. A final procedure involves injec-
for urinary incontinence, especially if it is not accompa- tions of collagen or silicone into the lining of the ure-
nied by a cystocele. Exercises to strengthen the pelvic thra. The injected substance increases the bulk of the
muscles, including Kegel exercises, can be beneficial in surrounding tissues, allowing the urethra to close tightly
decreasing the incidence of urinary incontinence (see and prevent leakage of urine. This technique usually
Chapter 10 for more information). Vaginal cones, which requires two to three injections before symptom
may also be vaginal weights, can be used to strengthen the improvement is noticed.
vaginal muscles as well. These tampon-shaped cones are Following either type of surgical repair, the patient
inserted into the vagina, beginning with the lightest should not engage in exercise for 2 weeks and avoid lifting
weight. Once inserted, the patient should contract the objects weighing more than 10 pounds for 3 months after
pelvic muscles in an effort to keep the cone in place the surgery. At that time, exercises to protect and
for minutes. As the muscles strengthen, the patient then strengthen the pelvic muscles are initiated.
chapter 4 Caring for Women, Families, and Children in Contemporary Society 105
Endometrial Cancer before the age of 40, more than 50% of men in their 60s
Endometrial cancer occurs most often in women between and 90% of men in their 70s and 80s have some symptoms
the ages of 60 and 70, and is the most common malignancy of BPH, including difficulty voiding, dribbling, and uri-
of the reproductive system. Endometrial cancer is slow nary retention.
growing and most women are symptomatic in the early Prostate screening should be initiated at age 50. Two
stages, factors that lead to early diagnosis and, frequently, screening tests are used to determine the need for prostate
successful treatment. For postmenopausal women, the biopsy: the digital rectal examination (DRE) and the
cardinal symptom is vaginal bleeding; perimenopausal serum prostate specific antigen (PSA). To perform a DRE,
women may have heavy or prolonged menstruation or the examiner inserts a gloved and lubricated finger into
spotting or bleeding between menses. Other symptoms for the rectum and carefully palpates the prostate gland. The
all women with endometrial cancer include pelvic pain, examination is considered normal when palpation reveals
dyspareunia, and/or weight loss. a prostate that is smooth, absent of nodules, and of nor-
An increased estrogen level, which stimulates growth mal size and shape.
of the endometrium during the menstrual cycle, is the When the DRE is determined to be normal, there may
most common cause of endometrial cancer. However, be other findings (i.e., changes in the texture of the pros-
several additional risk factors have been identified: early tate over time or the presence of cysts that cannot be dif-
age of menarche (before the age of 12), combined with ferentiated from a tumor) that signal a need for further
late menopause; nulliparity; irregular ovulation, which screening. If the DRE reveals the presence of enlargement,
may result from obesity or polycystic ovarian syndrome; a nodules or an abnormal glandular shape, a blood test mea-
high-fat diet, which increases the levels of circulating suring the serum tumor marker prostate-specific antigen
estrogen; diabetes (a condition closely related to obesity (PSA) is obtained. The total PSA and free PSA ratio are
and a high-fat dietary intake); estrogen-only replacement used to determine the risk of prostate cancer in men whose
therapy; ovarian tumors that produce estrogen; age greater total PSA is greater than 4 ng/mL. A total PSA between
than 40 years; a personal history of breast cancer or ovar- 4 and 10 ng/mL indicates a 25% risk of prostate cancer; a
ian cancer; breast cancer treatment with tamoxifen; Cau- total PSA greater than 10 ng/mL indicates a 67% risk of
casian race; and hereditary nonpolyposis colorectal cancer prostate cancer. Men whose total PSA is greater than 4 ng/
(HNPCC), a specific type caused by a gene that inhibits mL benefit from the inclusion of a free PSA test, which is
DNA repair. the ratio of free-circulating PSA and total PSA. Men who
The diagnosis is made by histologic examination. Most have a free PSA of 20% or less should have a prostate
often, tissue is obtained by endometrial biopsy, an out- biopsy performed to determine if cancer is present.
patient procedure performed using local anesthesia. A A prostate biopsy is typically performed with the assis-
suction-type curette is used to remove the tissue for labo- tance of transrectal ultrasonography. During the proce-
ratory analysis. Dilatation and curettage (D and C), a sur- dure, an ultrasound probe is inserted into the rectum and
gical procedure performed under general anesthesia, may ultrasonographic pictures are transmitted for viewing.
also be used to obtain endometrial tissue for sampling. If This procedure allows the physician to determine the size
endometrial cancer is present, staging, which may include and shape of the prostate and location of abnormal
chest radiography, abdominal CT scan, and serum testing growths. A fine needle is then inserted into the gland and
for the presence of cancer antigen 125 (CA 125, released several samples of prostate tissue are removed for patho-
by some endometrial and ovarian cancers), is done to logical examination.
determine the degree of metastasis.
Hysterectomy (surgical removal of the uterus) is the Preparation for Prostate Biopsy
most common treatment for endometrial cancer. In most Patients are provided with the necessary information for
cases, a bilateral salpingo-ööphorectomy is also performed, biopsy preparation at least 2 weeks before the procedure.
along with removal of local lymph nodes. If metastasis has Although men who have a history of cardiac valvular
occurred, adjunctive treatment may be needed. Radiation disease must receive antibiotic prophylaxis before the pro-
therapy may be recommended if the cancer has metasta- cedure, many physicians prescribe prophylactic antibiotic
sized or if there is a high risk for recurrence. Hormone therapy for all patients prior to the procedure to decrease
therapy involving synthetic progestin may be used for the incidence of postprocedure infection. Patients who are
those premenopausal patients or for those who wish to taking coagulation-modifier agents or anti-inflammatory
preserve fertility. Chemotherapy may also be used to agents are instructed to discontinue the use of these medi-
reduce the tumor size or prevent recurrence. cations 7 to 10 days before the procedure, and blood tests,
including prothrombin time (PT) and international nor-
malized ratio (INR), are performed before the procedure
PROSTATE CANCER SCREENING on the day of the biopsy to determine if bleeding times
Prostate cancer is the most common cancer diagnosed in are normal. The patient is also instructed to administer an
men. Risk factors include a positive family history, envi- enema for bowel cleansing the day before the scheduled
ronmental exposure to carcinogens, hormonal influences, procedure.
especially elevated levels of androgens, and advancing After the procedure, the patient is instructed to refrain
age. Currently, prostate cancer in the leading cause of from taking coagulation-modifier agents and anti-inflam-
cancer in men, regardless of race. Benign hypertrophy of matory agents for 3 days, and to drink plenty of water. A
the prostate (BPH) is associated with prostate cancer. sitz bath or warm soak is recommended for rectal tender-
However, there is no evidence that a causative link exists. ness. Antibiotics are prescribed for all postprocedure
While BPH does not usually cause symptoms in men patients to prevent infection.
106 unit one Foundations in Maternal, Family, and Child Care
MENTAL AND EMOTIONAL HEALTH Advancing age raises issues related to death and dying
Some older adults may experience declines in health and for most individuals. As they age, individuals may lose a
cognitive ability, which can lead to behavioral and emo- spouse, family member, or close friend, which can signifi-
tional problems and physical complaints. Signs of altered cantly alter their living situation and their emotional health.
mental and emotional health may begin with subtle As with persons of any age, the patient needs to be encour-
changes in personality or with dramatic alterations that aged to grieve. However, it is essential for the nurse to be
require immediate intervention from a health care profes- sensitive to the specific issues that frequently arise follow-
sional. Symptoms that require immediate intervention ing the loss of the loved one: fear about living arrange-
include hallucinations, paranoia, incoherent thinking or ments; preoccupation with one’s own death; agitation and
language, extreme lack of motivation or flat affect, and an inability to perform daily activities; and an overwhelm-
expression of suicidal thoughts or actions. Less serious ing sadness or withdrawal. Counseling, support groups,
symptoms that also require intervention include changes and antidepressant medications are often beneficial for
in sleeping or eating patterns, loss of interest in activities, individuals who are experiencing difficulty with coping.
neglect of grooming and personal hygiene, changes in Another issue related to emotional and mental health
sexual habits, and refusal to take prescribed medications. concerns the older person’s ability to remain connected to
Treatment for alterations in mental and emotional health other people. Declines in health, physical mobility, and
requires a collaborative approach. Psychologists and neu- cognitive function may contribute to problems of isola-
rologists may be involved in initial testing and diagnosis, tion for the older adult. Family members should be
while psychiatrists and nurses become an integral part of encouraged to maintain frequent contact and engage the
the treatment and management team. Pharmacists are an elderly in a variety of social activities to keep their loved
important part of the team as they have specialized knowl- ones involved in life and socially connected. Many com-
edge in drugs and drug interactions. Psychologists provide munity health agencies or elder day care facilities offer
psychotherapy treatment and counseling for the patient programs with supervised stimulation for adults experi-
and the family. Social workers are essential in coordinating encing difficulty in these areas. Respite care, which allows
care with regard to medical care, benefits, and housing. family members an opportunity for time away from the
Occupational therapists are experts that evaluate and care-giving situation, may also be beneficial.
restructure a person’s physical environment as well as pro-
vide mental activities to enhance independent functioning.
Community health nurses visit the home to assess the summar y poi nt s
patient and family and to gauge understanding and accep-
tance of the treatment plan. ◆ Health promotion screening can provide early detec-
tion and treatment of health disorders, including rep-
roductive cancers, hyperlipidemia, osteoporosis, and
Collaboration in Caring— Culturally sensitive gynecological disorders
community approaches to enhanced health care for ◆ Nurses play a key role in collaborative care for all patients,
older citizens at each stage of the lifespan, from infancy to older age
Organizations, groups, and health care facilities recognize ◆ A holistic approach to health promotion includes focus-
the importance of culturally sensitive approaches to meet ing on nutrition, dental care, safety, injury prevention,
the health needs of older citizens. Information gained from screening for early diagnosis and treatment, and other
these collaborative endeavors benefits diverse communities strategies to facilitate healthy development
by generating new knowledge and understanding and by ◆ Cultural and ethnic differences must be taken into con-
providing insights for further investigation. Examples of sideration when providing anticipatory guidance and
successful projects include the following: health promotion education to patients
• The National Asian Pacific Center on Aging (NAPCA)
organized community forums to share assessment results
with participants. Three translators were available through-
r evi ew quest i ons
out the forums. Working groups were then developed to Multiple Choice
implement interventions to meet the identified needs. 1. The outpatient clinic nurse correctly makes a
• An advisory committee was used to evaluate the recommendation that Henry, a 65-year-old patient,
methodology and language used for a breast cancer study schedule a health maintenance examination every:
in Vietnamese women conducted by the University of A. Year
California at San Francisco. Vietnamese women were B. 2 years
hired to conduct the interventions in the study to C. 3 years
improve accuracy of the results. D. 5 years
• The American Society on Aging conducted a study to
determine the drinking habits of elders in the Chinese 2. The pediatric clinic nurse correctly identifies the
community. The written survey was translated into most appropriate milk to introduce to the child at
Chinese, and included alcoholic beverages specific to that 1 year of age as:
culture, including plum wine. The researchers were able A. Whole milk
to acquire more accurate results by using culturally B. 1% milk
appropriate content (American Society on Aging, 2006). C. 2% milk
D. Skim milk
chapter 4 Caring for Women, Families, and Children in Contemporary Society 107
3. The clinic nurse teaches new parents that the most American Cancer Society (ACS). (2003). Role of breast self-examination
normal time for children to ask about “where babies changes in guidelines: Focus on awareness rather than detection.
Retrieved from http://www.cancer.org/docroot/NWS/content/NWS_
come from” is approximately: 1_1x_Role_Of_Breast_Self-Examination_Changes_In_Guidelines.
A. 2 to 3 years of age asp (Accessed March 4, 2008).
B. 3 to 5 years of age American Cancer Society (ACS). (2006a). Cancer facts and figures 2006.
C. 5 to 7 years of age New York: Author.
American Cancer Society (ACS). (2006b). What are the risk factors for
D. 7 to 9 years of age breast cancer? Retrieved from http://www.cancer.org/docroot/CRI/
4. The clinic nurse assesses Tom’s risk for obesity by content/CRI_2_4_2X_What_are_the_risk_factors_for_breast_cancer_
reviewing his parent’s health records. Both of his 5.asp?sitearea⫽ (Accessed October 29, 2006).
American Cancer Society (ACS). (2007). How to perform a breast self-
parents have a BMI (body mass index) of 32. This exam. Retrieved from http://www.cancer.org/docroot/CRI/content/
finding gives Tom a risk of obesity of: CRI-2-6x-How-to-perform-a-breast-self-exam-5.asp (Accessed March
A. 25% 4, 2008).
B. 50% American College of Obstetricians and Gynecologists. (2007). Women’s
health care: a resource manual. (3rd ed.). Washington, DC: Author.
C. 75% American Society on Aging. (2006). Conducting culturally appropriate
D. 90% needs assessments. In Blueprint for health promotion: Foundation
module. Retrieved from http://www.asaging.org/cdc/module1/
Select All that Apply phase1/phase1_3cbis2.cfm (Accessed March 14, 2007).
5. The clinic nurse teaches the new mother about Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
feeding readiness that she may see in her infant: Center for the Study and Prevention of Violence (2004). CSPV fact sheet:
A. Reaching 4 to 6 months of age Ethnicity, race, class and adolescent violence. Boulder, CO: Author.
B. A doubling of the infant’s birth weight Centers for Disease Control and Prevention. (CDC). (2004). Youth risk
C. An ability to hold up the head behavior surveillance—United States, 2003. Morbidity and Mortality
Review 53(SS02), 1–96.
D. Hunger after five or six breast feeds per day or Centers for Disease Control and Prevention. (CDC). (2006a). Recom-
30 ounces of formula mended adult immunization schedule, United States, October 2006–
6. Julie, a mother of a 9-month old infant, asks about September 2007. Morbidity and Mortality Weekly Report, 55(40),
Q1–Q4.
appropriate finger foods for her baby. The clinic Centers for Disease Control and Prevention (CDC). (2006b). Recom-
nurse could suggest: mended immunization schedules for persons aged 0–18 years—
A. Small pieces of ripe banana United States, 2007. Morbidity and Mortality Weekly Report, 55(51 &
B. Teething crackers 52), Q1–Q4.
Centers for Disease Control and Prevention (CDC). (2006c). Sexually
C. Cooked spiral pasta transmitted diseases treatment guidelines. Retrieved from www.cdc.
D. Bite-size orange sections gov/std (Accessed June 5, 2007).
7. The clinic nurse recognizes that adolescents have an Drifmeyer, E., & Batis, K. (2007). Breast abscess after nipple piercing.
Consultant (April), 481–482.
increased risk of injury and disease due to: Dunaif, A. (2006). Insulin resistance in women with polycystic ovarian
A. The importance placed on peer relationships syndrome. Fertility and Sterility, 86(Suppl. 1), S13–S14.
B. An increased level of sex hormones Goff, B.A., Matthews, B.J., Larson, E.H., Andrilla, C.H., Wynn, M.W.,
C. A developmental need to learn to trust Lishner, D.M., & Baldwin, L.M. (2007). Predictors of comprehensive
surgical treatment in patients with ovarian cancer. Cancer, 109(10),
D. The natural development of primary sexual 221–227.
characteristics Husaini, B.A., Sherkat, D.E., Bragg, R., Levine R., Emerson, J.S., Mentes,
C.M., et al. (2001). Predictors of breast cancer screening in a panel
Fill-in-the-Blank study of African American women. Women and Health, 34(3), 35–51.
8. The clinic nurse is aware that water safety is an Institute for Clinical Systems Improvement (ICSI). (2005, October).
Preventive services in adults. Bloomington, MN: Author.
important health promotion topic to discuss with Insurance Institute for Highway Safety (IIHS). (2005). Fatality facts:
adolescents and their parents. Teens have an increased Teenagers 2003. Arlington, VA: Author.
risk of drowning due to an overestimation of their Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
________ and ________ in the water. Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and
NIC Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.).
9. The clinic nurse is aware that the greatest effect on St. Louis, MO: Mosby Elsevier.
________ ________ is the media. Teens watch Kagawa-Singer, M., & Pourat, N. (2000). Asian American and Pacific
approximately 3 to 4 hours of television a day which Islander breast and cervical carcinoma screening rates and healthy
people 2000 objectives. Cancer, 89(3), 696–705.
increases the likelihood for decreased exercise and Lehman, C.D., Gastonis, C., Kuhl, C., Hendrick, R.E., Pisano, E.D.,
adds to their risk for ________ . Hanna, L., Peacock, S., et al., (2007). MRI evaluation of the contra-
lateral breast in women with recently diagnosed breast cancer. The
10. As a component of health promotion, the clinic New England Journal of Medicine, 356(13), 1295–1303.
nurse screens all overweight teens in the clinic for Menon, S., Burgis, J., & Bacon, J. (2007). The college-aged examination:
________ because of their increased risk for this A comprehensive approach to preventive medicine. The Female
condition. Patient, 32(7), 32–36.
Merck & Co., Inc. (2006). USPPI Patient Information about Gardasil®.
See Answers to End of Chapter Review Questions on the Whitehouse Station, NJ : Author.
Electronic Study Guide or DavisPlus. Michigan Quality Improvement Consortium. (2005, July). Adult preven-
tive services (ages 18–49). Southfield, MI: Author.
Michigan Quality Improvement Consortium. (2005, July). Adult preven-
REFERENCES tive services (ages 50–65⫹). Southfield, MI: Author.
American Academy of Pediatrics (AAP). (2005). Policy statement: Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing
Breastfeeding and the use of human milk. Pediatrics, 115(2), outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V.
496–506. Mosby.
108 unit one Foundations in Maternal, Family, and Child Care
National Cancer Institute (2006, July 21). Testicular Cancer (PDQ®): The Women’s Health Initiative Steering Committee (2004). Effects of con-
Screening. Retrieved from http://www.cancer.gov/cancertopics/ pdq/ jugated equine estrogen in postmenopausal women with hysterectomy.
screening/testicular/HealthProfessional (Accessed October 30, 2006). Journal of the American Medical Association, 291(14), 1701–1712.
National Comprehensive Cancer Network. (2006, October 1). Your breast Tufts New England Medical Center (2007). The Mini Mental State Exami-
cancer survival guide. Retrieved from http://www.nccn.org/about/ nation. Retrieved from http://www.nemc.org/psych/mmse.asp
publications/pdf/Your_Breast_Cancer_SURVIVAL_Guide.pdf (Accessed May 27, 2007).
(Accessed March 14, 2007). U.S. Department of Agriculture (USDA), Food and Nutrition Service
National Women’s Health Resource Centers, Inc. (2006, September 20). (2005). MyPyramid for kids. Washington, DC: U.S. Government
Take 10 for breast cancer awareness. Retrieved from http://www. Printing Office.
healthywomen.org/breastcancer2006/pg1.html (Accessed October 29, U.S. Department of Agriculture (USDA). (2005). MyPyramid-
2006). Tracker. [Computer software]. Retrieved from http: www.
Nedrow, A., Miller, J., Walker, M., Nygren, P., Huffman, L.H., & Nelson, mypyramidtrackergov (Accessed May 5, 2007).
H.D. (2006). Complementary and alternative therapies for the man- U.S. Department of Health and Human Services (USDHHS). (2000).
agement of menopause-related symptoms: A systematic evidence Healthy People 2010: Understanding and Improving Health. Washington,
review. Archives of Internal Medicine, 166(14), 1453–1465. DC: U.S. Government Printing Office.
Nelson, H.D., Helfand, M., Woolf, S.H., & Allan, J.D. (2002). Screening U.S. Department of Health and Human Services (USDHHS), Office on
for postmenopausal osteoporosis: A review of the evidence for the US Women’s Health. (2005, October). Benefits of breastfeeding. Retrieved
Preventive Services Task Force. Annals of Internal Medicine, 137, from http://www.4woman.gove/Breastfeeding/index.cfm?page⫽227
529–541. (Accessed February 11, 2007).
Pisano, E., Gatsonis, C., Hendrick, E., Yaffe, M., Baum, J., Acharyya, S., U.S. Preventive Services Task Force (USPTF). (2005). The guide to clini-
et al. (2005). Diagnostic performance of digital versus film mammog- cal preventive services 2005. Screening for cervical cancer. AHRQ Pub-
raphy for breast cancer screening: The results of the American Col- lication No. 05-0570, June 2005. Rockville, MD: Agency for Health-
lege of Radiology Imaging Network (ACRIN) digital mammographic care Research and Quality.
imaging screening trial (DMIST). The New England Journal of Medi- U.S. Preventive Services Task Force (USPSTF). (2007). The guide to clini-
cine, 353(17), 1773–1783. cal preventive services 2007: Recommendations of the U.S. Preventive
Roberts, T.A., & Ryan, S.A. (2002). Tattooing and high-risk behavior in Services Task Force. AHRQ Publication No. 07-05100, September
adolescents. Pediatrics, 110(6), 1058–1063. 2007, Rockville MD. Available at http://www.ahrq.gov/
Speroff, L., & Ritz, M. (2005). Clinical gynecologic endocrinology and Veterans Health Administration, Department of Defense. (2006). VHA/
infertility (7th ed.). Philadelphia: Lippincott Williams & Wilkins. DoD clinical practice guideline for the management of dyslipidemia in
Stephen, M.B. (2003). Behavioral risks associated with tattooing. Family primary care. Washington, DC: Author.
Medicine, 35(1), 52–54. Vulval Pain Society. (2005). How to perform a vulval self-exam. Retrieved
The Nemours Foundation. (2007). How to perform a testicular self- from http://www.vulvalpainsociety.org/html/selfexam.htm (Accessed
examination. Retrieved from http://www.kidshealth.org/teen/sexual_ March 15, 2007).
health/guys/tse.html (Accessed March 14, 2007). Writing Group for the Women’s Health Initiative Investigators (2002).
The North American Menopause Society (NAMS). (2007). Position State- Risks and benefits of estrogen plus progestin in health postmeno-
ment: Estrogen and Progestogen use in peri and post menopausal pausal women: Principal results from the Women’s Health Initiative
women: March 2007 position statement of the North American randomized controlled trial. JAMA, 288(3), 321–333.
Menopause Society. Menopause: The Journal of the North American Wu, T.Y., & Bancroft, J. (2006). Filipino American women’s perceptions
Menopause Society, 14(2), 168–182. and experiences with breast cancer screening. Oncology Nursing
Forum, 33(4), E71–E78.
CONCEPT MAP
Infant/Child Health Caring for Women, Families, and Adolescent Health
Nutrition: Children in Contemporary Society Nutrition:
• Feeding: bottle vs. breast • To facilitate optimal growth/development
• Solid food introduction based on • Risk factors for obesity: psychological/societal/medical
developmental stage • Risk for eating disorders: anorexia/bulimia
• For >3 yrs: use food pyramid guide
Dental:
Dental: • Check-up and cleaning twice yearly
• Daily dental care
Sleep/Rest:
Sleep/Rest: • May need to decrease extracurricular activities
• Nighttime rest and naps based on
developmental level Safety:
Health Disease • Accidents/injuries; MVA, homicides, suicides
Safety: Promotion Prevention • Risk-taking behaviors; developing own identity
• Home safety for injury prevention
• Injuries: MV, bikes, firearms, water
• Control environment: crib, car, toys
• Substance abuse: ETOH, drugs
• Risk-taking behavior: testing limits;
• Violence/abuse
sexual exploration
• Tattooing and piercing
Activity:
• Reproductive health
• 5 types of developmental play with
specific toys/games Health Promotion:
• Begin osteoporosis prevention
Immunizations:
• Gynecological exams: introduction to reproductive
• CDC recommendations
health care
Sexuality: • Pap tests; pelvic exams; BSE; TSE
• Child perception based on • Manage menstrual disorders: dysmenorrhea; PMS
developmental level
Collaboration In Caring:
Be Sure To: Optimizing Outcomes:
• Approach to senior
• Provide accurate info on • Monthly BSE: clinical breast exam; care in community should
menopausal therapies mammograms all help to detect be culturally sensitive
cancer early
The Process of
Human Reproduction
chapter
Reproductive Anatomy
and Physiology 5
Since you are like no other being ever created since the beginning of time, you are
incomparable.
— Brenda Ueland
LEA R NING T AR G ET S At the completion of this chapter the student will be able to:
◆ Describe gender differentiation and differences in male and female embryos including timing
of anatomical sexual differences.
◆ Identify anatomy of the female and male reproductive systems.
◆ Explain physiological functions of the reproductive organs.
◆ Analyze the actions and interactions of hormones from the hypothalamus, pituitary, gonads,
and other hormones that affect the reproductive system.
◆ Describe the process of sexual maturation.
◆ Discuss various physiological events that accompany the menstrual cycle.
◆ Develop an understanding of physiological changes that occur during the menopause years.
◆ Identify several age-related issues for men.
The purpose of this study was to determine the variability in the 98.8% of the time. The participants were also taught how to
phases of the menstrual cycle among 165 healthy, regularly record monitor readings and the days of menstruation on a fertil-
menstruating women. The sample consisted of 21- to 44-year- ity chart. The fertility charts were reviewed with each participant
old women from four major U.S. cities. All participants reported at 1, 2, 6, and 12 months.
having regular menstrual cycles that occurred every 21–42 days. This prospective descriptive study utilized a data set with
None of the women had used depot medroxyprogesterone ace- biological markers to estimate menstrual cycle parameters:
tate (Depo-Provera) for the previous 12 months or oral or sub- • Length of the follicular, fertile, luteal, and menstrual phases
dermal contraceptives for 3 months before the study. None of • The estimated day of ovulation based on the “peak fertil-
the women had known fertility problems. To be included in the ity” monitor reading (determined by the urinary luteiniz-
study, breastfeeding mothers must have experienced at least ing hormone surge)
three menstrual cycles after infant weaning. • The cycle length, determined by counting the number of
The participants were taught how to monitor fertility by the days beginning with the 1st day of menses to the begin-
use of the Clearblue Easy Fertility Monitor, a handheld electronic ning of the next menses
device designed to read wick-type urine test strips. The monitor • The fertile phase, defined as a 6-day interval beginning
notes “low,” “high,” or “peak” fertility status based on urine with the 5 days preceding and including the second “peak
hormone levels. According to the manufacturer, the Clearblue fertility” day (the estimated day of ovulation)
Easy Fertility Monitor is accurate in detecting a hormone surge (continued)
113
114 unit two The Process of Human Reproduction
Female Reproductive System terior opening of the vagina). Similar to but smaller than
the labia majora, these structures are moist and absent of
EXTERNAL STRUCTURES (PUDENDUM hair follicles and resemble mucous membrane. The labia
MULIEBRE) minora contain a number of sebaceous glands that pro-
vide lubrication and protective bacteriocidal secretions.
The external genital structures include the mons pubis, labia During puberty the labia minora enlarge. After meno-
majora, labia minora, clitoris, vestibule of the vagina, ure- pause they become smaller due to declining hormonal
thral (urinary) meatus, Skene’s glands, Bartholin’s glands, levels. The mons, labia majora, and labia minora all func-
vaginal introitus (opening), hymen, and the perineum tion to protect the clitoris and vestibule.
(Fig. 5-1).
The vulva (pudendum femininum) is the portion of Clitoris
the female external genitalia that lies posterior to the The clitoris is located at the upper junction of the labia
mons pubis. It consists of the labia majora, labia minora, minora. The prepuce, or clitoral hood, is a small fold of
clitoris, vestibule of the vagina, vaginal opening, and Bar- skin that partially covers the glans (head) of the clitoris.
tholin’s glands (Venes, 2009). Composed of erectile tissue, the clitoris is primarily the
Mons Pubis organ of sexual pleasure and orgasm in women. The clito-
ris contains a rich blood and nerve supply, and is extremely
The mons pubis, or mons veneris, is a layer of subcutane- sensitive. Sensory receptors located in the clitoris send
ous tissue anterior to the genitalia in front of the symphy- information to the sexual response area in the brain. This
sis pubis. It is located in the lowest portion of the abdo- message prompts the clitoris to secrete a cheese-like fatty
men and typically is covered with pubic hair that grows in substance with a distinctive odor called smegma. It is
a transverse pattern. The texture and amount of pubic hair believed that smegma is a pheromone (chemical signal
vary ethnically. In Asian women, the hair is fine and sent between individuals). Anatomically, the clitoral shape
sparse. In women of African descent, the hair is thick and is similar to that of the urinary meatus, and the structural
curly. The mons pubis is essentially a fatty pad that cush- similarity of the two organs sometimes results in mis-
ions and protects the pelvic bones, especially during guided and painful catheterization attempts. Some cul-
intercourse. tures remove the clitoris and other external genitalia in a
Labia ritualistic process called female circumcision.
The labia majora are the two folds of tissue that lie lateral Vestibule
to the genitalia and serve to protect the delicate tissues The vestibule is essentially an oval-shaped space enclosed
between them. The external labia are covered with pubic by the labia minora. It contains openings to the urethra
hair while the medial surfaces, which are moist and pink, and vagina, the Skene’s glands, and the Bartholin’s glands.
are without pubic hair. During pregnancy, the labia This area of a woman’s anatomy is extremely sensitive to
majora are highly vascular due to hormonal influences. chemical irritants. Nurses should be prepared to educate
The labia majora share an extensive lymphatic network women about the potential discomforts associated with
with other vulvar structures, leading to an enhanced the use of dyes and perfumes found in soaps, detergents,
capacity to spread diseases such as malignant carcinomas. and feminine hygiene products, and encourage their dis-
The labia majora become less prominent after each continuation if symptoms develop.
pregnancy.
The labia minora are two folds of tissue that lie within Urethral (Urinary) Meatus
the labia majora and converge near the anus to form the The urethral or urinary meatus (opening) is located in the
fourchette (a tense fold of mucous membrane at the pos- midline of the vestibule, approximately 0.4 to 1 inch (1 to
2.5 cm) below the clitoris. The small opening is often
shaped like an inverted “V.” The vaginal orifice or introitus
Prepuce of lies in the lower portion of the vestibule posterior to the
clitoris
urethral meatus. It is essentially a boundary between
Clitoris the internal and external genitals. The hymen, a connec-
tive tissue membrane, encircles the vaginal introitus.
Labia Urethral
majora orifice Skene’s Glands and Bartholin’s Glands
Labia The Skene’s glands (paraurethral glands), located on each
minora Skene's
ducts
side of the urethra, produce mucus that helps to lubricate
the vagina. The Skene’s glands are not readily visible. To
Bartholin's Vaginal
orifice
facilitate examination, the margins of the urethra are
glands
drawn apart and the mucous membrane gently everted to
reveal the small glandular opening on each side of the
Perineum Hymen floor of the urethra (Venes, 2009).
The Bartholin’s glands, also known as the greater ves-
Anus tibular or vulvovaginal glands, are located deep within the
posterior portion of the vestibule near the posterior vagi-
nal introitus. These glands secrete a clear mucus that
Figure 5-1 Female external genitalia. moistens and lubricates the vagina during sexual arousal.
116 unit two The Process of Human Reproduction
Urinary meatus
Ischiocavernosus
muscle
Vaginal introitus
Pubococcygeal
(pubovaginal)
Pelvic fascia muscle
Transverse perineal Puborectal Levator
muscle muscle ani
Gluteus maximus muscle Iliococcygeal
Anus
muscle
Rectum
Uterus
Bladder
Symphysis
pubis
Posterior
Urethra fornix of
vagina
Cervix
Clitoris Anterior
fornix of
vagina
Labia Labia
majora minora Vagina Anus
Figure 5-3 Internal female genitalia and cross section of the rectum.
and progesterone. This important endocrine function helps produced. The remaining three cells, termed polar bodies,
to regulate the menstrual cycle. have no function and deteriorate. A mature ovarian folli-
cle, also called a graafian follicle, contains the secondary
A & P review Oogenesis oocyte and if the egg is fertilized, the second meiotic divi-
sion occurs and the ovum nucleus becomes the female
Oogenesis begins in the ovaries and is regulated by follicle pronucleus. ◆
stimulating hormone (FSH), which initiates the growth of
ovarian follicles. Each follicle contains an oogonium, or Microscopically, the ovarian surface is termed the ger-
egg-generating cell (Fig. 5-5). FSH also stimulates the fol- minal epithelium. Each ovary has hundreds of thousands
licle cells to secrete estrogen, which promotes maturation of follicles that contain immature female sex cells. All of
of the ovum. For each primary oocyte that undergoes the follicles in a woman’s ovaries develop in utero and are
the process of meiosis, only one functional egg cell is present at birth. During a postpubertal woman’s monthly
Ovary
Broad ligament
Body of uterus
Cervical canal
Cervix
Vagina
Figure 5-5 Oogenesis is the processes of mitosis and
meiosis. For each primary oocyte that undergoes
Figure 5-4 Internal structures of the adnexa. meiosis, only one functional ovum is formed.
118 unit two The Process of Human Reproduction
menstrual cycle, one follicle develops and releases a the site of ovum fertilization. The third division of the fal-
mature ovum. (Please refer to the menstrual cycle discus- lopian tube, the isthmus, is nearest the uterus and is typi-
sion later in this chapter for additional information.) cally the site for tubal ligation (permanent sterilization).
Throughout a woman’s reproductive years, only 300 to A patent fallopian tube is able to convey the ovum from
400 follicles develop into mature ova and are released for the ovary to the uterus and the spermatozoa from the
potential fertilization by a sperm. uterus toward the ovary. Fertilization usually occurs in
The ovaries are supported in their position in the pelvis the outer one third of the fallopian tube, which provides a
by three important ligaments: the mesovarium, the ovar- safe, nourishing environment for the ovum and sperm. If
ian ligament, and the infundibular pelvic ligament or sus- fertilization occurs, the fertilized ovum (termed a zygote
pensory ligament. The ovarian ligament positions the until the first cell division) is slowly and gently swept into
fimbriae (finger-like projections) of the fallopian tube in the uterus by fallopian peristalsis and cilia movement,
contact with the lower pole of the ovary to enhance “pick- where implantation takes place. If fertilization does not
up” of the ovum following ovulation. occur, the ovum dies within 24 to 48 hours and disinte-
grates, either in the tube or in the uterus.
ACCESSORY ORGANS Internally, each tube connects laterally with its corre-
sponding ovary and medially with the uterus. Thus, there
Fallopian Tubes is a continuous route that passes from the vagina into the
The (two) fallopian tubes are also called the uterine tubes uterus and then on out to the tubes and ovaries. If the
or oviducts. Measuring approximately 4 inches (10 cm) vagina is infected by a pathogen, the potential exists for
in length, the lateral end of each fallopian tube encloses an retrograde transmission to the ovaries. Although most
ovary; the medial end opens into the uterus. Anatomi- vaginal infections can be readily treated and cured, resid-
cally, the fallopian tubes are composed of four layers. ual scarring from the inflammatory process can cause
Beginning with the external layer and progressing inward tubal narrowing leading to an increased risk for tubal
to the internal layer, these include the peritoneal (serous), pregnancies or infertility resulting from blockage.
which is covered by the peritoneum, the subserous (adven-
titial), the muscular, and the mucous layers. The blood Uterus
and nerve supplies are housed in the subserous layer. The The uterus, centrally located in the pelvic cavity between
muscular layer has an inner circular and an outer longitu- the bladder (anteriorly) and rectum (posteriorly), is
dinal layer of smooth muscle. It provides peristalsis that approximately 3 inches long by 2 inches wide (7.5 cm
assists in transporting the ovum toward the uterus for 5 cm). It is a pear-shaped organ with the narrower end
potential implantation. The mucosal layer contains cilia positioned closest to the vagina (Fig. 5-7). The uterine
(hairlike projections) that also assist in directing the interior is hollow and forms a path from the vagina to the
ovum toward the uterus (Venes, 2009). fallopian tubes. Because the uterine walls are very thick
The fallopian tubes are attached at the upper outer and collapsed upon each other, the interior cavity is, in
angles of the uterus, and then extend upward and outward actuality, a “potential space.”
(Fig. 5-6). The diameter of each tube is approximately Two major functions of the uterus are to permit sperm to
6 mm. Anatomically, the tubes consist of three divisions: ascend toward the fallopian tubes and to provide a nourish-
infundibulum, ampulla, and isthmus. The infundibulum is ing environment for the zygote until placental function
the funnel-shaped portion located at the distal end of the begins. In addition, it provides a safe environment that pro-
fallopian tube. The ovum enters the fallopian tube through tects and nurtures the growing embryo/fetus until the preg-
a small opening (ostium) located at the bottom of the nancy has been completed. In the absence of conception, the
infundibulum. Several finger-like processes (fimbriae) sur- uterus sheds the outermost layers of the inside of the endo-
round each ostium and extend toward the ovary. The lon- metrium (menstruation) in order to prepare for another
gest fimbria, the fimbria ovarica, is attached to the ovary. menstrual cycle by regeneration of the endometrium.
The ampulla, which is the second division of the fallopian The arteries of the uterus are the uterine, from the
tube, is two-thirds the length of the tube and is most often hypogastric arteries, and the ovarian, from the abdominal
Intrauterine part
of fallopian tube Ovarian Ovarian
Fallopian tube Fundus
of uterus ligament vessels
Ampulla
Isthmus
Infundibulum
Fimbriae
Germinal
epithelium Ovary
Tunica Round
albuginea Cortex ligament
of ovary of uterus
Fimbriae
Fallopian tube
Ovary
Uterus
Sacrum
Cervix
Symphysis pubis
Rectum
Urinary bladder
Opening of ureter
Clitoris
Urethra
Figure 5-7 Uterus and
surrounding structures of Anus
the female genitourinary
system shown in a
midsagittal section through Labium minor Vagina
the pelvic cavity. Labium major Bartholin's gland
aorta. This rich blood supply helps to ensure ample oxy- CORPUS
genation and nutrition to facilitate the growing uterus and
The layers of the corpus of the uterus include the perime-
fetus during pregnancy. The uterine veins drain into the
trium, the myometrium, and the endometrium. The peri-
internal iliac veins. The vasculature of the uterus is
metrium is the outer, incomplete layer of the parietal
twisted and tortuous and as the gravid (pregnant) uterus
peritoneum (the serous membrane that lines the abdomi-
expands, these vessels straighten out, allowing a contin-
nal wall). The myometrium, or middle layer, is com-
ued rich blood supply throughout pregnancy.
posed of layers of smooth muscle that extend in three
The uterus receives its nerve supply via the afferent (sen-
directions—longitudinal, transverse, and oblique—and
sory) and efferent (motor) autonomic nervous systems.
are continuous with the supportive ligaments of the
These two systems are important in regulating both vaso-
uterus (Fig. 5-9). The tridirectional formation of the
constriction and muscle contractions. The uterus also has
muscular layers is important in facilitating effective uter-
an innate intrinsic motility as well. Thus, a patient with a
ine contractions during labor and birth. The endome-
spinal cord injury above level T6 may still have adequate
trium is the third and innermost uterine layer. It is
enough uterine contractions to deliver a fetus vaginally.
composed of three layers, and of these, two are shed with
Uterine pain nerve fibers reach the spinal cord at levels
each menses.
T11 and T12. Because of this location and the presence of
other pain receptors there, pain from the ovaries, ureters,
and uterus may all be similar and may be reported by a ISTHMUS
woman who identifies pain in the flank, inguinal, or vulvar The isthmus is a slight constriction on the surface of the
areas. Several sensory nerve fibers that contribute to dys- uterus midway between the uterine body (the corpus, or
menorrhea (painful menstruation) are housed in the upper two-thirds), and the cervix, or “neck.” During
uterosacral ligaments. pregnancy, the isthmus becomes incorporated into the
lower uterine segment and acts as a passive or noncon-
tractile part of the uterus during the labor process. The
Uterine Anatomy isthmus is the site for the uterine incision when a low-
transverse cesarean section is performed.
The uterus is divided into three sections: the corpus, the
isthmus, and the cervix.
The corpus of the uterus is the upper two-thirds of the CERVIX
uterine body and contains the cornua portion, where the The cervix is the lower, narrow end of the uterus. It is
fallopian tubes enter, and the fundus or uppermost sec- similar to a neck or tube and extends from the inside of
tion superior to the cornua (Fig. 5-8). the uterus, opening into the vagina. The cervix secretes
120 unit two The Process of Human Reproduction
Fimbriae
Ovary
Fundus
Corpus Fertilization Fallopian of uterus Ovarian
luteum of ovum tube ligament
Body of uterus
Endometrium
Myometrium
Mature
follicle Sperm
Broad
ligament
Cervix of uterus
Round
ligament Vagina Figure 5-8 Female reproductive system
Artery shown in anterior view. The left ovary has
and vein been sectioned to show the developing
Rugae
follicles. The left fallopian tube has been
sectioned to show fertilization. The uterus
and vagina have been sectioned to show
internal structures. Arrows indicate the
Bartholin's gland movement of the ovum toward the uterus
and the movement of sperm from the
vagina toward the fallopian tube.
Infundibulopelvic
ligament Fallopian tube
Ovarian
Uterus ligament
Round
ligament
Cardinal ligament
Ureter
Uterosacral ligament Cervix
Vagina External cervical os
Figure 5-10 Uterine ligaments.
The round ligaments expand both in diameter and in tube that passes from the bladder to outside of the body to
length during pregnancy and this normal physiological allow micturition. Its position is posterior to the symphy-
change may be associated with maternal discomfort sis pubis and anterior to the vagina. The urethra is
termed “round ligament pain.” As the uterus expands, the approximately 1.2 inches (3 cm) in length.
round ligaments become stretched tight and sudden move-
ments such as position changes, coughing or stretching Now Can You— Discuss various aspects of the female
may result in sharp pains that can be quite concerning reproductive system?
until the woman understands the physiology for the dis- 1. Identify the location of the perineum and describe its
comfort. The round ligaments also play an important role importance during childbirth?
during labor by pulling the uterus forward and down- 2. Describe three functions of the uterus?
ward, thereby holding it steady to facilitate the movement 3. Name the five functions of the cervix?
of the fetal presenting part toward the cervix. The cardinal
ligaments prevent uterine prolapse and are the major sup-
port structures for the uterus and cervix.
Bony Pelvis
Vagina The pelvis forms a bony ring that transmits body weight
to the lower extremities. In women, the bony pelvis is
The vagina is a tubular organ approximately 4 inches structured to adapt to the demands of childbearing. The
(10 cm) in length that internally extends between the pelvis functions to support and protect the pelvic contents
uterus and perineal opening. It is located between the and to form a relatively fixed axis for the birth passage
rectum, urethra, and bladder. The collapsible vagina is (Cunningham et al., 2005).
composed of smooth muscle lined with mucous mem- The pelvis is composed of four bones: the sacrum, the
brane arranged in rugae (small ridges), which allow dis- coccyx, and two innominate (hip) bones. The bilateral
tention during childbirth. The vagina has five functions: innominate bones are formed by the fusion of the ilium,
(1) to provide lubrication to facilitate intercourse, (2) to ischium, and pubis bones (Fig. 5-11).
stimulate the penis during intercourse, (3) to act as a
receptacle for semen, (4) to transport tissue and blood
during menses to the outside, and (5) to function as the True/False Pelves
lower portion of the birth canal during childbirth.
The apex of the vagina, also termed the vaginal vault or The pelvis consists of two sections known as the “false
fornix, is the upper, recessed area around the cervix. Fol- pelvis” and the “true pelvis.” These sections are divided by
lowing intercourse, sperm pool in the fornix, where they the linea terminalis, or pelvic brim. The false pelvis is
have close contact with the cervix and its alkaline pH. The superior to the linea terminalis. Its anterior boundary is
vaginal pH is typically acidic (4.5 to 5.5) during the repro- the abdominal wall, its posterior boundary is the lumbar
ductive years. The acid environment, though harmful to vertebra, and the lateral boundary is the iliac fossa. The
sperm, helps to protect the genital tract from pathogens. false pelvis helps to support the gravid uterus and direct
the fetal presenting part down toward the true pelvis.
The true pelvis, located below the linea terminalis, is
Ureters, Bladder, and Urethra important for childbearing. Its size and structure direct
the fetus downward for delivery and its dimensions must
The ureters, bladder, and urethra and its external opening be large enough to deliver the fetus for a vaginal birth. Its
or meatus are part of the urinary system and are not repro- boundaries are partly bony and partly ligamentous. Supe-
ductive organs. The urethra is a mucous membrane–lined riorly, the true pelvis is bounded by the sacral promontory
122 unit two The Process of Human Reproduction
False Inlet
pelvis
Linea
terminalis
True Midpelvis
Ilium
pelvis
Sacrum
Ischial Inlet Outlet
spine
Coccyx Pubis
Outlet Ischium
Sacroiliac Sacral
joint promontory
Sacrospinous Iliac crest
Innominate bone ligament
Ilium
Ilium
Sacrum
Sacrococcygeal
joint Ischial spine
Coccyx Pubis
Pubis Ischium Symphysis
Ischium Pubic arch pubis Figure 5-11 Female bony pelvis.
(anterior projecting portion of the base of the sacrum) ence a trial of labor (allowing uterine contractions in
and the sacral alae (broad bilateral projections from the order to evaluate labor progress, e.g., cervical dilation and
base of the sacrum), the linea terminalis, and the upper fetal descent) to assess the feasibility of vaginal birth.
margins of the pubic bones. Inferiorly, the lowest por- Three portions of the true pelvis are measured during
tion of the true pelvis is termed the pelvic outlet. The pelvimetry: the pelvic inlet, the midpelvis, and the pelvic
anterior landmarks of the true pelvis consist of the pubic outlet. The narrowest portion of the pelvic inlet is the
bones, the ascending superior rami of the ischial bones, line between the sacral promontory and the inner pelvic
and the obturator foramen. The sacrum serves as the arch including the symphysis pubis. It is termed the obstet-
posterior landmark. Bilaterally, the true pelvis is bor- rical conjugate and should measure at least 4.5 inches
dered by the ischial bones and the sacrosciatic notches (11.5 cm). Once the fetus passes this landmark, the pre-
and ligaments. The true pelvis is divided into three sec- senting part is “engaged” in the pelvis. The midpelvis,
tions: the inlet, the midpelvis, and the outlet, and each which constitutes the area between the ischial spines, is the
of these three components are important during the narrowest lateral portion of the female pelvis. This mea-
labor process. surement needs to be at least 4.7 inches (12 cm) to allow
for a vaginal birth. During labor, the ischial spines serve as
a landmark for assessing the level of the fetal presenting
Pelvic Diameters and Planes part into the pelvis. At the pelvic outlet, two measurements
are assessed: the angle of the ascending rami (pubic arch),
In order to assess the adequacy of a woman’s pelvis for which should be at least 90 to 100 degrees and the distance
delivery of a fetus of average size, health care providers between the ischial tuberosities, which should be at least
may use pelvimetry (measurement of the pelvis to predict 3.9 inches (10 cm). These are the minimal measurements
the feasibility of a vaginal birth). (See Chapter 9 for further deemed necessary to allow the fetus to descend through the
discussion.) Measurements of the pelvis are approximate pelvis for birth. During pregnancy the joints of the pelvis
for two reasons: an inability to measure it directly and the soften and become more mobile due to effects of the hor-
presence of soft tissue covering the pelvis that can distort mone relaxin. This important physiological change creates
the actual size. Despite findings from clinical pelvimetry, additional space to accommodate childbirth (see Chapter
in most situations, women in labor are allowed to experi- 12 for further discussion).
chapter 5 Reproductive Anatomy and Physiology 123
Blood levels:
Pituitary Gonadotropins
Follicle-stimulating
hormone (FSH)
Menstrual
Follicular phase Luteal phase
phase
2 4 6 8 12 14 16 20 24 28
Ovarian cycle
Uterus
Estrogen
Ovulation
Ovary Progesterone
Endometrial cycle
Growth spurt Adolescent growth spurt Height increase 2.4–4.3 inches 10 11.8
(6–11 cm) in 1 year
Secondary Thelarche Breast budding 9.8 14.6
Adrenarche ↑ Adrenal androgen secretion 10.5
→ axillary and pubic hair
Primary Menarche First menstrual period 12.8
128 unit two The Process of Human Reproduction
MENSTRUAL PHASE
A B C The menstrual phase is time of vaginal bleeding (approxi-
mately days 1 to 6). The onset of menses signals the begin-
ning of the follicular phase of the ovarian cycle. Menstrua-
tion is triggered by declining levels of estrogen and
progesterone produced by the corpus luteum. The decrease
in hormones results in poor endometrial support and con-
striction of the endometrial blood vessels. These changes
lead to a decreased supply of oxygen and nutrients to the
D E
endometrium. Disintegration and sloughing of the endo-
Figure 5-16 Maturation states in females. metrial tissue occurs. During menstruation, constriction
A, Preadolescent. No pubic hair, just fine body hair of the endometrial blood vessels limits the likelihood of
similar to hair on abdomen. B, Sparse growth of long, hemorrhage.
downy hair, straight or slightly curled mainly along Prostaglandins also play a role in menstruation. The
labia. C, Darker, courser, curlier hair that spreads over uterus releases prostaglandins that cause contractions of
pubic symphysis. D, Hair is course and curly and covers the smooth muscle and decrease the risk of hemorrhage.
more area. E, Adult. Hair may spread over medial Prostaglandin-induced uterine contractions often produce
surfaces of thighs, but not over abdomen. dysmenorrhea (painful menstruation) in the days sur-
rounding the onset of menstrual flow. Other systemic
effects of prostaglandins include headache and nausea.
development, termed “Tanner stages” measure the pre-
Over-the-counter medications that inhibit prostaglandin
dictable stages of pubertal body changes in both genders
synthesis such as nonsteroidal anti-inflammatory agents
(Tanner, 1962). A sexual maturity rating concerning
can be used to control the discomfort associated with dys-
development of pubic hair in the female is presented in
menorrhea and premenstrual syndrome.
Figure 5-16.
Menstrual fluid is composed of endometrial tissue, blood,
cervical and vaginal secretions, bacteria, mucus, leukocytes,
Now Can You— Discuss concepts related to puberty?
prostaglandins, and other debris. The color of menstrual
1. Trace the hormonal events associated with the onset of fluid is dark red, but variable throughout the days of men-
puberty in females? ses. The amount of discharge is typically 30 to 40 mL and
2. Explain why the first few menstrual periods are often the duration of bleeding is 4 to 6 days 2 days.
irregular?
3. Identify six female secondary sex characteristics that precede
PROLIFERATIVE PHASE
menarche?
The proliferative phase is the end of menses through ovu-
lation (approximately days 7 to 14). At the beginning
of the proliferative phase, the endometrial lining is 1 to
The Menstrual Cycle and Reproduction 2 mm thick. Circulating estrogen levels are low. Gradually
increasing levels of estrogen, enlarging endometrial glands,
Menstruation is the periodic discharge of bloody fluid and the growth of uterine smooth muscle characterize the
from the vagina that women experience during reproduc- proliferative phase. Endometrial receptor sites for proges-
tive years. Menstrual flow begins at puberty and continues terone are developed during this time. Systemic effects of
for approximately three to four decades. The menstrual the increasing amounts of estrogen include an increased
cycle refers to the changes that occur in the uterus, cervix, secretion of thyroxine-binding globulin (TBG) by the
and vagina associated with menstruation and during the liver, an increase in the breast mammary duct cells, thick-
interval between each menstruation, termed the “inter- ening of the vaginal mucosa, and changes in cervical
menstrual period.” The average time for a menstrual cycle mucus (i.e., increased amount and elasticity) to facilitate
is 28 to 32 days, although there is considerable variation sperm penetration at midcycle.
among women and monthly cycles. Factors such as stress,
nutritional status, excessive exercise, fatigue, and illness
can alter an individual’s cycle intervals and length. SECRETORY PHASE
Menstruation and ovulation, key elements in the repro- The secretory phase is the time of ovulation to the period
ductive cycle, are controlled by positive and negative feed- just prior to menses (approximately days 15 to 26). This
back systems associated with hormones released by the phase of the endometrial cycle is characterized by changes
hypothalamus, pituitary, and ovaries. In synchrony, the induced by increasing amounts of progesterone. Progester-
hormones coordinate the complex biochemical events one functions to create a highly vascular secretory endome-
that result in the monthly menstrual cycle. Regulation of trium that is suitable for implantation of a fertilized ovum.
the menstrual cycle involves an overlapping of the uterine Glycogen-producing glands secrete endometrial fluid in
(endometrial), hypothalamic-pituitary and ovarian cycles preparation for a fertilized ovum. At this time, endometrial
(see Figs. 5-14 and 5-15). growth ceases and the number of estrogen and progester-
chapter 5 Reproductive Anatomy and Physiology 129
one receptors decrease. Other progesterone effects during ovary to produce androgens which convert to estrogen in
the secretory phase include increased glandular growth of the granulosa cells of the ovary. Immediately before ovu-
the breasts, thinning of the vaginal mucosa, and increased lation, the hypothalamus secretes gonadotropin-releasing
thickness and stickiness of the cervical mucus. hormone (GnRH). This action prompts the anterior
pituitary to release LH and FSH. The surge of LH stimu-
ISCHEMIC PHASE lates the release of the ovum and ovulation generally
occurs within 10 to 16 hours after the LH surge.
The ischemic phase is from the end of the secretory phase Ovulation signifies the end of the follicular phase of the
to the onset of menstruation (approximately days 27 to ovarian follicular cycle. The ovum is capable of fertiliza-
28). During the ischemic phase, estrogen and progester- tion by a sperm cell for approximately 12 to 24 hours after
one levels are low and the uterine spiral arteries constrict. ovulation. The follicle that contained the mature ovum
The endometrium becomes pale in color due to a limited remains in the ovary and becomes the corpus luteum, a
blood supply and the blood vessels ultimately rupture. structure that plays a major role during the second half, or
Rupture of the endometrial blood vessels leads to the luteal phase, of the ovarian cycle.
onset of menses (this event marks day 1 of the next cycle)
and initiation of the menstrual phase of the cycle.
LUTEAL PHASE
HYPOTHALAMIC–PITUITARY–OVARIAN CYCLE The luteal phase of the ovarian cycle begins at ovulation
and ends with the onset of menses. When pregnancy is not
The menstrual cycle is controlled by complex interactions achieved following ovulation, the corpus luteum domi-
between hormones secreted by the hypothalamus, ante- nates over the second half of the menstrual cycle. In the
rior pituitary, and ovaries (see Fig. 5-14). Hormones from absence of fertilization, the life span of the corpus luteum
the hypothalamic–pituitary–gonadal (ovarian) axis inter- is 14 days. Thus, the luteal phase of the uterine cycle is
act with one another and influence the secretion of hor- predictable in length and lasts for 14 days. The corpus
mones from other sites. The hypothalamus and anterior luteum secretes estrogen and progesterone, producing a
pituitary communicate through the hypophyseal portal negative feedback that signals the anterior pituitary gland
system (a system of venous capillary blood vessels that to decrease production of FSH and LH. As the end of the
supplies blood and endocrine communication between luteal phase nears (approximately 8 to 10 days), low levels
the hypothalamus and pituitary). The major interacting of FSH and LH cause regression of the corpus luteum.
hormones include GnRH (hypothalamus), LH, and FSH Degeneration of the corpus luteum is associated with
(pituitary), and estrogen and progesterone (ovaries). declining levels of estrogen and progesterone. The resul-
tant low progesterone levels stimulate the hypothalamus to
HYPOTHALAMIC–PITUITARY COMPONENT secrete GnRH, while the decreased levels of estrogen and
The pituitary receives GnRH input from the hypothala- progesterone trigger endometrial sloughing. The corpus
mus. GnRH stimulates the secretion of FSH and LH. FSH albicans (“white body”) forms from the remnants of the
prompts the ovaries to secrete estrogen and progesterone corpus luteum and eventually disappears.
and these hormones inhibit the continued secretion of
hypothalamic GnRH. FSH also induces the proliferation
of ovarian granulosa cells. LH stimulates the growth of the Body Changes Related to the Menstrual
ovarian follicles and prompts ovulation and luteinization Cycle and Ovulation
(formation of the corpus luteum) of the dominant follicle.
The corpus luteum produces high levels of progesterone Before ovulation, several events occur to indicate that the
along with small amounts of estrogen. woman’s body is preparing for fertilization of the released
ovum. Increased estrogen secretion by the ovaries produces
OVARIAN COMPONENT changes in the cervical mucus that assist the sperm in suc-
The ovarian portion of the hypothalamic–pituitary–ovarian cessfully locating the ovum. There is a dramatic increase in
axis occurs in two phases: the follicular phase and the luteal the amount and quality of the cervical mucus. It becomes
phase. The phases are distinguished by events in the ovar- watery and clear, creating a pathway for sperm to readily
ian cycle, especially those related to ovulation. swim through the cervix. The elasticity (spinnbarkheit) of
the cervical mucus increases and the woman can assess
this change by stretching the mucus between her fingers
FOLLICULAR PHASE (Fig. 5-17). Another method of assessment involves stretch-
Day 1 of the menstrual cycle begins with the onset of ing the cervical mucus between two glass slides. At the time
bleeding (menstruation). This event marks the beginning of ovulation, the cervical mucus can be stretched to
of the follicular phase, which lasts about 14 days, but can 8 to 10 cm or longer. If the mucus is thin, watery, and
vary from 7 to 22 days. This variance often accounts stretchable the woman is ready to conceive.
for the irregularity in menstrual cycles in some women There is also an increase in the ferning capacity (crys-
(Fehring, Schneider, & Raviele, 2006). The follicular tallization) of the cervical mucus (Fig. 5-18). Ferning, an
phase is characterized by dominance in estrogen, follicle- indirect indicator of estrogen production, results from a
stimulating hormone (FSH), and leutinizing hormone decrease in the levels of salt and water that interact with
(LH). (Please refer to the earlier discussion concerning glycoproteins in the mucus during midcycle. The clinician
the role of estrogen and the endometrial cycle.) assesses for the presence of ferning by placing a sample of
FSH stimulates the ovary to prepare a mature ovum for cervical mucus on a glass slide, allowing it to air dry and
release at ovulation. LH stimulates the theca cells of the examining it under a microscope for a fernlike pattern.
130 unit two The Process of Human Reproduction
Physiological changes also accompany ovulation. The with lower estradiol (estrogen, E2) levels. Decreased cir-
basal body temperature (BBT) increases 0.3 to 0.6°C culating estrogen levels prompt the anterior pituitary to
approximately 24 to 48 hours after ovulation and some secrete follicle-stimulating hormone (FSH). Elevated
women experience mittelschmerz (abdominal pain that serum FSH levels combined with low estradiol levels are
occurs at the time of ovulation, typically described as a usually indicative of perimenopause/menopause.
cramping sensation) and midcycle spotting. It is still pos- The peri-/postmenopausal period is characterized by
sible to become pregnant at this point in the menstrual greatly decreased amounts of endogenous estrogen. During
cycle, even when spotting is present. this time, estrone (E1), created from the peripheral conver-
sion of androstenedione, becomes the predominant form of
estrogen. A number of physical changes may accompany
Natural Cessation of Menses the estrogen depletion. These include vasomotor instability
(hot flashes/flushes/night sweats), atrophy of the urogenital
CLIMACTERIC PHASE sites (vaginal dryness, urinary disturbances), amenorrhea
The climacteric is a phase characterized by the decline in (cessation of menses), skin changes (hyper/hypopigmenta-
ovarian function and the associated loss of estrogen and tion, decreased sweat and sebaceous gland activity, thin-
progesterone production. ning of the epidermal and dermal skin layers, decrease in
hair distribution), musculoskeletal changes (bone thinning
and osteoporosis), and psychological changes (anxiety,
PERIMENOPAUSAL PHASE depression, irritability, libido changes, insomnia).
Perimenopause, the time preceding menopause, is the The hot flashes associated with perimenopause usually
period associated with declining fertility for two reasons: occur at night and result from vasodilation associated
the number of ovarian follicles responsive to gonadotro- with decreased estrogen levels. Vaginal atrophy, also
pins is decreased; and the responsive follicles do not related to estrogen deficiency, results in vaginal dryness
develop as quickly as before. Because of these normal and increased sensitivity and pain, particularly during
changes, many cycles during perimenopause are anovula- sexual intercourse. Atrophy of the urinary tissues may
tory (no ova are released from ovary). Anovulatory men- cause urinary incontinence. Alterations in mood, such as
strual cycles are irregular and often variable in the amount depression, mood swings, and tiredness also result from
of blood flow. Fewer functioning follicles are associated decreased estrogen levels.
A number of long-term effects occur with the diminish-
ing hormone levels during menopause. Decreased estro-
gen, associated with lower levels of high-density lipids
and elevated levels of low-density lipids, increases the risk
for cardiovascular disease. As estrogen diminishes, there
is a loss in skeletal bone mass, which results in more brit-
tle bones, and leads to the development of osteoporosis
and a loss of spinal flexibility.
MENOPAUSE
Menopause simply refers to the last menstrual period.
POSTMENOPAUSAL PHASE
Postmenopause, the time after menopause, is character-
ized by estrogen production solely by the adrenal glands.
Although controversial, hormone replacement therapy,
Figure 5-18 A fern-like pattern of cervical mucus prescribed on a highly individual basis, may be used to
occurs with high estrogen levels. minimize the symptoms and improve quality of life. HRT
chapter 5 Reproductive Anatomy and Physiology 131
can be provided as estrogen only or estrogen and progestin. Male Reproductive System
Estrogen-only HRT reduces the symptoms of menopause.
However, the continuous administration of estrogen with EXTERNAL STRUCTURES
no progesterone to facilitate shedding of the endometrial
lining should be used only after hysterectomy or after The external structures consist of the perineum, penis,
menopause is complete to reduce the risk of endometrial and scrotum (Fig. 5-19).
cancer. Estrogen-only HRT also increases the risk of breast
Perineum
cancer. Estrogen-progestin therapy increases the risk of
cardiovascular disease, stroke and deep vein thrombosis by The male perineum is a roughly diamond-shaped area that
decreasing protective factors. extends from the symphysis pubis anteriorly to the coccyx
Selective serotonin reuptake inhibitors may be pre- posteriorly and laterally to the ischial tuberosity.
scribed for alleviation of symptoms. These medications
decrease hot flashes in approximately half of the women Penis
who take them, and are also useful in managing the mood The penis is composed of three cylindrical masses of erec-
changes that occur during perimenopause. Gabapentin tile tissue that surround the urethra. The function of the
(Neurontin) and clonidine (Catapres) reportedly reduce penis is to contain the urethra and serve as the terminal
hot flashes, but are associated with side effects including duct for the urinary and reproductive tracts by excreting
drowsiness, dizziness, and sexual dysfunction. Selective urine and semen. During sexual arousal, the penis becomes
estrogen receptor modulators (SERMs) such as raloxifene erect to allow penetration for sexual intercourse.
(Evista) mimic the effects of estrogen without increasing The glans penis is the tip of the penis. It contains many
the risk of breast cancer and endometrial cancer; how- nerve endings, is very sensitive and important in sexual
ever, hot flashes are a common side effect of SERMs. arousal. The urethra is approximately 8 inches (20 cm) long
and serves as a passageway for both urine and ejaculated
Now Can You— Discuss characteristics of the uterine cycle? semen. It extends from the urinary bladder to the urethral
1. Outline the four phases of the uterine cycle and describe
meatus at the tip of the penis. Circumcision is a surgical
the major physiological events that occur during each
procedure in which the prepuce (epithelial layer covering
phase?
the penis; foreskin) is separated from the glans penis and
2. Trace the hormonal interplays that characterize the
excised. (See Chapter 18 for further discussion.)
hypothalamic–pituitary–ovarian cycle?
Scrotum
3. Describe four physiological changes that occur in the female
body around the time of ovulation? The scrotum is a two-compartment pouch covered by skin.
4. Discuss the hormonal events that accompany perimenopause? It is suspended from the perineum and contains two testes,
the epididymis, and the lower portion of the spermatic
Sacrum
Symphysis pubis
Opening of ureter
Ductus deferens
Rectum
Urinary bladder
Seminal vesicle
Ejaculatory duct
Corpus cavernosum
Prostate gland
Cavernous urethra
Anus
Glans penis
Epididymis
Prepuce
Membranous urethra
Scrotum
Testis
Figure 5-19 The male reproductive system shown in a midsagittal section through the
pelvic cavity.
132 unit two The Process of Human Reproduction
Spermatic cord
Testicular artery
and veins
Ductus deferens
Nerve
Rete testis
Interstitial cells
Epididymis
Capillaries Sustentacular cell
Lumen
Seminiferous
tubules
Figure 5-20 A, Midsagittal section of portion of a testis; the epididymis is on the posterior
side of the testis. B, Cross section through a seminiferous tubule showing development
of sperm.
Stem cell
Mitosis
Primary
spermatocytes
First
meiotic division
Secondary
Meiosis spermatocytes
Second
meiotic division
Spermatids
Spermatozoa
(mature sperm)
secreted during ejaculation and is slightly alkaline with a descend into the scrotum through the inguinal canal after
pH of about 7.5. The typical amount present in one ejacu- 35 weeks’ gestation. Scrotal examination is an important
late is 2 to 5 mL. There are approximately 120 million component of the male neonate’s physical assessment to
sperm cells in each milliliter of ejaculate and, typically, ensure that the testes have descended and do not remain
around 40% of the sperm are motile. There are also about in the inguinal canal. Cryptorchidism is the condition in
5 million white blood cells in each milliliter of semen which the testes fail to descend; sterility results unless the
along with secretions from the testes, epididymi, seminal testes are surgically placed in the scrotum (Scanlon &
vesicles, prostate and bulbourethral glands. The following Sanders, 2003) (See Chapter 18 for further discussion). It
pathway traces the events from the formation of sperm to is important to locate both testes in a newborn as testicu-
the ejaculation of semen: lar failure to descend may indicate gonadal malgenesis,
which can lead to testicular cancer and fertility issues in
1. The testes produce sperm that are transported to
young adulthood.
the epididymis.
The reproductive functions of the testes begin at the
2. Move to the vas deferens
time of puberty. Once critical hormone levels have been
3. From there the seminal fluid moves to the ejacu-
reached, the final stages of reproductive system develop-
latory duct before exiting the body through the
ment take place. A gradual decline in hormone produc-
urethra.
tion normally occurs during late adulthood. Although the
Sperm are capable of surviving in optimal favorable hormonal decline may be associated with a decrease in
alkaline conditions for up to 72 hours postejaculation in a sexual desire and fertility, most men maintain the ability
woman’s body. The average length of time for sperm to to reproduce into old age.
locate from the cervix to the fallopian tubes is approxi-
mately 5 minutes under favorable conditions. Now Can You— Discuss aspects of the male reproductive
system?
1. Identify the three external structures of the male reproductive
Male Hormonal Influences system and describe one function for two of them?
2. Discuss the functions of the testicles, epididymis, vas
TESTOSTERONE deferens and prostate gland?
The testes produce androgens, the male sex hormones. 3. Trace the pathway from sperm production to semen
Testosterone is the dominant male hormone. At the time of ejaculation?
puberty, testosterone stimulates enlargement of the testes 4. Name five male secondary sex characteristics that result
and accessory organs and prompts development of the sec- from the influence of testosterone?
ondary sex characteristics. The male secondary sex charac-
teristics include changes in body hair (coarse hair on face,
chest, and pubic area and sometimes decreased hair on the summar y poi nt s
head), a deepening of the voice, thickened skin, increased
upper body musculature and narrow waist, and a thicken- ◆ Gender is determined at the moment of conception.
ing and straightening of bone (Shier, Butler, & Lewis, Identifiable sexual characteristics are apparent in the
2003). Testosterone also prompts a linear growth spurt. embryo at 8 weeks of gestation.
◆ Gender maturation is a lengthy process that begins
during embryonic development and reaches full matu-
Fertility rity during late adolescence.
◆ External structures of the female reproductive system
Male fertility is related to overall sperm number, size,
shape, and motility. Decreased fertility is associated with include the mons pubis, labia, clitoris, vestibule, ure-
insufficient sperm counts affected by active contact sports; thral meatus, Skene’s and Bartholin’s glands, vaginal
smoking; and tight, constrictive clothing. Decreased fertil- introitus, hymen and perineum.
ity is also associated with an autoimmune disorder that ◆ Internal structures of the female reproductive system
results in the manufacture of antibodies to one’s own include the ovaries, fallopian tubes, uterus, and vagina.
sperm. The presence of varicose veins on the scrotum ◆ The female bony pelvis supports and protects the con-
(varicocele) can cause testicular warming and adversely tents of the pelvis and provides a fixed axis for the pro-
affect the life span of the sperm. Decreased sperm motility cess of childbirth.
or “slow swimming” caused by an ineffective flagella also
affects male fertility. ◆ The breasts or mammary glands are considered to be
accessory organs of the female reproductive system.
◆ Hormones secreted by the pituitary gland are essential in
Age-related Development of the Male the regulation of gonadal, thyroid and adrenal function,
Reproductive System lactation, body growth, and somatic development.
◆ Menstruation and ovulation are controlled by a com-
Similar to embryological development in the female, the plex interplay of positive and negative feedback systems
male genital organs develop in the abdomen of the fetus, associated with hormones released by the hypothala-
but are immature. The testes develop near the kidneys and mus, pituitary, and ovaries.
chapter 5 Reproductive Anatomy and Physiology 135
CONCEPT MAP
Other Reproductive
Anatomy & Physiology
Puberty
Female Male
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Discuss the nurse’s role in providing sexual and reproductive health care.
◆ Identify advantages and disadvantages of barrier and hormonal contraceptive methods, intrauterine
devices and permanent sterilization.
◆ Teach patients how to use various methods of contraception.
◆ Assess a patient for short-term complications after an induced abortion.
◆ Analyze the nurse’s role in infertility care.
◆ Differentiate among the various advanced reproductive technologies.
◆ Identify potential alternatives to childbearing for the infertile couple.
The purpose of this review was to determine whether in vitro Data analysis revealed the following: (1) IVF was found to be
fertilization (IVF) improves the probability of live births in the significantly better than expectant management in two studies;
context of unexplained infertility, compared to alternative man- (2) there were no significant differences in live birth rates
agement approaches. Unexplained infertility was defined as among patients who received IVF and those who received intra-
failure to conceive after 1 year in couples in whom no abnor- uterine insemination; and (3) one study reported a greater live
malities were found during an infertility work-up. IVF is a pro- birth rate associated with IVF as compared with GIFT. The use
cess that involves stimulation of the ovaries with gonadotropins, of clomiphene citrate (Clomid) was not compared with other
egg retrieval, and fertilization in the laboratory. Pregnancy rates infertility therapies in any of the studies.
achieved with IVF therapy have been reported to reach 30%. The researchers concluded that there were insufficient data
Alternative management approaches to achieve live births to allow for the comparison of IVF with other methods of infer-
included: (1) expectant management, (2) the administration of tility treatment and recommended larger randomized trials.
clomiphene citrate (Clomid), (3) intrauterine insemination (IUI) It was noted that the cost of a single cycle of IVF reportedly
with or without controlled ovarian stimulation, and (4) gamete exceeds $10,000.00. Insurance coverage for IVF varies from
intrafallopian transfer (GIFT). zero to 100% reimbursement.
Of the ten randomized controlled trials (RCT) reviewed, six Risks associated with infertility therapies include psychological
met the study criteria and were included in the meta-analysis. stress (e.g., anxiety and depression), multiple gestations, opera-
Significant variations among study outcomes and therapies tive risks, and ovarian hyperstimulation syndrome. Approximately
were found; the live-birth rate per patient was considered to be 25% of IVF pregnancies involve multiple gestations, which
the outcome of interest. are frequently associated with maternal–fetal complications.
(continued)
137
138 unit two The Process of Human Reproduction
Muscular contractions occur in the man’s accessory repro- harder at achieving conception than other women. Signifi-
ductive organs (vas deferens, seminal vesicles, and ejacula- cant health issues also exist for this population. Women
tory duct). There is a relaxation of the bladder sphincter who are lesbians are more at risk for breast cancer due to
muscles along with contractions of the urethra and peri- their lower rates of breastfeeding. They are also at risk for
rectal muscles followed by ejaculation as orgasm occurs. sexually transmitted infections (including HIV) and cervi-
An overall release of muscular tension takes place dur- cal cancer. However, woman-to-woman transmission of
ing the resolution phase. Both genders experience a feeling sexually transmitted infections is much lower than in
of warmth and relaxation and women may experience a heterosexual relationships. Since not all gynecological
brief refractory period or “rest time” before they are inter- cancers are related to sexual activity, lesbian women who
ested in sexual intercourse again. Women are capable of have never had children may be at an increased risk for
experiencing multiple orgasms. endometrial and ovarian cancer. Further, their risk for
Masters and Johnson were instrumental in opening the other cancers (e.g., lung and colon) and heart disease is
topic of human sexual response for discussion and study not different from that of heterosexual women. It is essen-
in the United States. The media often send the message tial that health care providers give correct advice and
that sexuality involves only a physical expression such as conduct appropriate cancer and other disease screening
the act of sexual intercourse. In actuality, human sexual- for these women. The nurse should develop an approach
ity is a multidimensional phenomenon that touches and that does not assume that all patients are heterosexual
permeates many aspects of human behavior. (Martinez, 2007; Stevens & Hall, 2001). As is true with
any group, homosexual women deserve to have their
healthcare concerns addressed by compassionate, non-
EXPLORING DIMENSIONS OF SEXUALITY
judgmental healthcare providers who are knowledgeable
Sexual Orientations about the healthcare needs of women with alternative
Even though it constitutes an integral and normal dimen- sexual preferences.
sion of every human being, sexuality evokes controversy
when it involves alternative sexual orientation or sexual
expression at either end of the age spectrum. Heterosexual A Nursing Framework for Promoting
sexual orientation is the sexual attraction to or sexual
activity with a person of the opposite sex or gender. Het- Women’s Sexual and Reproductive
erosexuality is often considered the norm in America, and Health
any other form of sexual expression is viewed as being
outside the realm of “normal.” Nurses who work with women in reproductive care set-
Homosexuality is the sexual attraction to or sexual tings must understand what is meant by healthy sexual
activity of a person with another individual belonging to function before they can begin to recognize and under-
the same sex or gender. The term “gay” is often used for stand how a behavior becomes dysfunctional. A newer
homosexual males; “lesbian” is used for females. An esti- vision of sexuality in women (Basson, 2002; Katz, 2007)
mated 2.3 million women in the United States presently takes into account relationships for women by including
identify themselves as lesbians (Marrazzo, 2004). Although emotional intimacy, sexual stimuli, and relationship satis-
a genetic factor has been linked with male homosexuality, faction as a model of sexual response. Thus, women’s sex-
no such etiology has been identified for lesbians (Ridley, ual response is far more complex and complicated than
2000). Thus, the origin of this sexual orientation in women the achievement of an orgasm with intercourse. Sexuality
remains basically unknown. for women encompasses much more than the physical
Masters and Johnson (1966) refuted the idea that dimension of the sex act.
homosexuality is a mental health disorder. Yet lesbians Sexual dysfunction for women is defined as any sexual
and bisexuals (individuals who are sexually active with situation that causes distress for the woman herself. If the
others of both sexes) are more likely to report that they woman is comfortable with a situation, there is no dys-
experience poor physical and mental health (Mays, Yancey, function. If she is distressed by any physical, emotional, or
Cochran, Weber, & Fielding, 2002). Although the exact relationship aspect of her sexuality, she may be experienc-
etiology of diminished health status among this population ing a dysfunction (Hicks, 2004). Dysfunction can be
is not clear, one factor may relate to homosexual/bisexual manifested in the form of pain, arousal disorder, orgasmic
women’s hesitancy in seeking health care. The mental and disorder, or desire disorder (American Psychiatric Associ-
physical discomforts associated with seeking medical ation [APA], 2000).
attention may translate into a failure to obtain timely pro-
fessional help for health concerns or illnesses. Some lesbi-
ans may be reluctant to disclose their sexual orientation to ASSESSMENT
their health care provider owing to fears related to hostil- A first step in the sexual and reproductive health assess-
ity, inadequate health care, or breach of confidentiality. ment involves the establishment of a trusting relation-
Also, in many health care settings, patient heterosexuality ship where the patient feels safe asking questions and
is assumed and interview questions are structured toward sharing concerns. Discussion of sexual issues can be
a heterosexual orientation. embarrassing for women. Nurses need to be aware of
Lesbians who decide to bear a child often must undergo their own sexual biases and beliefs and educate them-
a number of medical procedures in order to conceive. In selves about the many aspects of sexuality. When assess-
general, lesbian women who choose to have children are ing women for sexual concerns, it is important not to
firmly committed to their decision, for they must work make assumptions about partner preferences or sexual
140 unit two The Process of Human Reproduction
activity. Misguided assumptions can bring an abrupt each sexual partner, this information is very important
ending to any therapeutic communications. For exam- for women whose reproductive life plan includes future
ple, speaking with a woman about contraceptive choices pregnancy. Sexual health promotion includes providing
may halt further dialogue with the patient who is lesbian correct information about the implications of multiple
and has sexual concerns unrelated to a heterosexual rela- sexual partners; this information empowers women to
tionship (Martinez, 2007). make knowledgeable, informed choices. Depending on
When working with very young patients, the nurse the situation and purpose of the visit, other appropriate
must avoid communicating personal views that adoles- components of the patient assessment may include a
cent sexual behavior is wrong or shameful. Regardless of physical examination and diagnostic testing.
involvement in sexual activity, teenagers need a reliable
source of education and information. They must first feel Now Can You— Discuss the nurse’s role in reproductive
accepted before they can ask questions and share concerns health care?
about sexuality and sexual behavior. 1. Explain why nurses who work in a reproductive health care
Assessing women for current or past problems that may setting must be comfortable with their own sexuality?
interfere with or contraindicate pregnancy or the use of cer- 2. Develop six questions that will assist with taking a patient’s
tain types of contraception (products that prevent preg- sexual history?
nancy) is an important nursing role in reproductive health 3. Analyze the nurse’s role in the reproductive health
care. For example, women with chronic health problems assessment?
such as diabetes, stroke, multiple sclerosis, cancer, or pain
may be taking medications that are contraindicated with
certain contraceptives or are associated with fetal anomalies
(Table 6-1). Individualized counseling, guidance, and reli- NURSING DIAGNOSES FOR PATIENTS SEEKING
able information helps empower them to make informed, CONTRACEPTIVE CARE
realistic choices about reproductive planning. Other chronic Depending on the purpose of the visit and analysis of the
conditions, including endometriosis and polycystic ovarian assessment findings, a number of nursing diagnoses may
disease, may interfere with fertility and create a sense of be appropriate. For women seeking contraception, diag-
powerlessness in those who desire pregnancy. Nurses are in noses may include decisional conflict regarding choice of
a unique position to listen generously to these women, make birth control because of a health concern, contraceptive
appropriate referrals, and assist them in resolving their grief alternatives, or the partner’s willingness to agree on the
and feelings of loss (Katz, 2007; Martinez, 2007). contraceptive method. Other possible nursing diagnoses
Women also need to be counseled about the ideal age are listed in Box 6-1.
for childbearing and the implications of delaying preg-
nancy too long. Those who have not conceived by the
mid- to late 30s may remain childless and burdened with
PLANNING AND IMPLEMENTATION OF CARE
guilt. Outside pressures exerted by cultural influences and Regardless of the patient’s age and contraceptive method
family expectations often compound the feelings of selected, the nurse must first seek the woman’s confirma-
remorse. Providing all women with current, factual infor- tion that she truly wants contraception. Birth control is
mation about the natural aging process and its influence always an individual choice. Feelings of helplessness and
on fertility empowers women of all ages to make informed manipulation may result when the woman believes that
decisions that best suit their needs. someone else has decided what is “best” for her or coerces
her into contraceptive use.
Obtaining the Sexual History One of the primary goals during the contraceptive care
The sexual history elicits information concerning prior visit is to determine and provide the contraceptive method
treatment for sexually transmitted infections (STIs), pain of “best fit” for the woman or couple. Obtaining the medi-
with intercourse (dyspareunia), postcoital spotting or cal, social, and cultural history helps to safeguard the
bleeding, and frequency of intercourse. Women who
have intercourse more frequently and on a regular basis
are more likely to become pregnant. The probability for
pregnancy with each unprotected intercourse is about Box 6-1 Possible Nursing Diagnoses for Reproductive Care
20% (Nelson & Marshall, 2004). An important compo-
nent of holistic reproductive care centers on helping Ineffective Sexuality patterns related to fear of pregnancy
women to understand their body’s natural functioning in Knowledge Deficit related to new use of the contraceptive method
relation to the menstrual cycle, so that they can problem- of choice
solve about the timing of intercourse to achieve preg- Effective Therapeutic Management related to birth control method
nancy, if desired. of choice
The nurse also inquires about the number of past sex- Risk for Spiritual Distress related to discrepancy between religious or
ual partners. This information is useful in developing an cultural beliefs and choice of contraception
estimate of the patient’s risk for STIs and guides the Risk for Infection related to use of contraceptive method or unprotected
nurse in providing appropriate education about safe sex sexual intercourse
practices. It is estimated that 4 out of 10 Americans Broken skin or mucous membrane after surgery or intrauterine device
between 18 and 59 years of age have had five or more (IUD) insertion
partners (Haffner & Stayton, 2004). Since the risk of Fear related to contraceptive method side effects
contracting a sexually transmitted infection increases with
chapter 6 Human Sexuality and Fertility 141
Table 6-1 Drugs that Adversely Affect the Female Reproductive System
Drug Class Drug Possible Adverse Reactions
Source: Dillon, P.M. (2007). Nursing health assessment. Clinical pocket guide (pp. 234–235). Philadelphia: F.A. Davis.
Reprinted with permission.
patient’s health and guide discussion of the contraceptive tions for using a method, and her level of commitment to
choices available to her. Patients often come for care with use the method consistently. On occasion, the desired
a specific birth control method in mind. However, it is contraceptive method is contraindicated or associated
essential that the nurse explore the woman’s knowledge with side effects that outweigh the personal benefits.
and understanding of contraceptive choices, her motiva- Open, honest discussion where appropriate information
142 unit two The Process of Human Reproduction
can be provided in a nonthreatening environment empow- method are at risk for pregnancy. Ideally, patients should
ers the patient to make an informed choice of a birth con- be reassessed within a few weeks after initiating a new
trol method that is best suited to her lifestyle (Fig. 6-1). method. At this time, appropriate outcomes may include
the following.
The patient:
Across Care Settings: Enhancing contraceptive
decision making • Has used the contraceptive method correctly and
consistently.
The choice of a contraceptive method usually rests with the • Has experienced no adverse side effects from use of
individual, although certain types of birth control may not the contraceptive method.
be the best fit for special populations. Methods that require • Voices continued satisfaction with the selected contra-
planning ahead, visiting a restroom for insertion, or are ceptive method.
considered “messy” may not be the best choice for • Consistently uses the contraceptive method without
adolescents. Combination hormonal methods may be pregnancy for the following year.
contraindicated in women with a history of breast cancer or
diabetes, and these patients need assistance in finding
another method that safely suits their lifestyle and health Toward Achieving the National Goals
needs. An essential nursing role centers on obtaining a
comprehensive history and educating patients about options, for Reproductive Life Planning
special considerations, and side effects. Often the nurse
enlists the assistance of other health professionals such as The Healthy People 2010 national initiative includes a
health educators, social workers, translators, and home number of goals that directly address reproductive health
health workers in teaching about contraception and in (Box 6-2). Individuals and couples who seek assistance
managing appropriate follow-up care. with this aspect of their lives may need counseling about
fertility and methods of contraception. Seeking guidance
and making decisions about contraception are prompted
by a number of influences but generally center on a desire
EVALUATION to take control over one’s reproductive life.
When obtaining contraception is the purpose of the Nurses can be instrumental in helping the nation to
reproductive health visit, an immediate evaluation may achieve the objectives by assisting women who want to
take place at the conclusion of the patient encounter. This practice safe sex and providing effective contraception
evaluation centers on mutually agreed upon outcomes when they do not desire to be pregnant. Women of all
that reflect the patient’s understanding of, and comfort ages are capable of responsible sexual behavior when
level with, the chosen method. Examples of possible out- given enough education, motivation, and opportunity.
comes are listed below. One of the challenges for nurses in the community con-
The patient: cerns poor women who are unable to afford contraception
as well as those with fertility problems who cannot afford
• Voices understanding about the selected contraceptive
special treatments to achieve pregnancy. Nurses must
method.
advocate for all women to ensure that reproductive care is
• Voices an understanding of all information necessary
available to all persons, regardless of socioeconomic
to provide informed consent.
status.
• Voices a comfort level with use of the contraceptive
method selected.
Intermediate and long-term evaluation of outcomes is Box 6-2 Healthy People 2010 National Goals Related
especially important in the area of contraceptive care to Reproductive Life Planning
because patients who discontinue use of a birth control
Several of the National Health Goals are related to reproductive life
planning. These include the following:
• Reduce the proportion of women experiencing pregnancy despite use
of a reversible contraceptive method from a baseline of 13% to a
target of 7%.
• Increase the proportion of pregnancies that are intended from a baseline
of 51% to a target of 70%.
• Decrease the proportion of births occurring within 24 months of a
previous birth from a baseline of 11% to a target of 6%.
• Increase the proportion of females at risk for unintended pregnancy
(and their partners) who use contraception from a baseline of 93% to
a target of 100%.
• Increase the number of health care providers who provide emergency
contraception.
• Increase male involvement in pregnancy prevention and family planning
efforts (new goal; baseline to be determined).
Source: Department of Health and Human Services (DHHS). (2000). Healthy People
Figure 6-1 Teaching about contraception is an essential 2010. Washington, DC: DHHS.
component of reproductive health care.
chapter 6 Human Sexuality and Fertility 143
Although the rate of unintended pregnancies in the The kits vary in price and procedure but most are similar
United States has declined, the rate of unintentional preg- to home pregnancy tests and are performed on the wom-
nancy remains highest among young, less educated women an’s urine. Intercourse can then be timed to avoid or
with low income (American Medical Women’s Associa- achieve pregnancy.
tion, 2005). These individuals, who may be less likely to
afford birth control or reach a health care clinic, must be
a major focus for education and support from nurses in COITUS INTERRUPTUS
the community. All women deserve holistic health care
along with culturally, educationally, and developmentally Coitus interruptus or the “withdrawal method” involves
appropriate information to empower them to make realis- the man withdrawing his penis from the vagina before ejac-
tic decisions about reproductive life planning. ulation. However, ejaculation may occur before withdrawal
is complete and spermatozoa may be present in the pre-
ejaculation fluid. Men with unpredictable or premature
ejaculation have difficulty using this method successfully.
Providing Contraceptive Care: Methods
of Contraception Effectiveness
The typical effectiveness rate for this method is about 71%.
MEDICATION-FREE CONTRACEPTION
• Natural Family Planning (NFP) is a contraceptive LACTATIONAL AMENORRHEA METHOD
method that involves identifying the fertile time period (BREASTFEEDING)
and avoiding intercourse during that time every cycle. Breastfeeding can be a form of contraception, although it
It is the only method of contraception acceptable to is used more effectively in underdeveloped countries
the Roman Catholic Church. where mothers breastfeed their infants exclusively. Some
• Fertility Awareness Methods (FAMs) identify the fertile lactating mothers may ovulate but not menstruate. It is
time during the cycle and use abstinence or other con- difficult to determine when fertility is restored. This
traceptive methods during the fertile periods. These
methods require motivation and considerable counseling
to be used effectively. They may interfere with sexual Days of Menstrual Cycle
spontaneity and require several months of symptom/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7
cycle charting before they may be used effectively. 6
4 SAFE SAFE DAYS
Effectiveness 2 Ovulation
The effectiveness in preventing pregnancy depends on the 99.0
exact method used, but it is generally around 75% 8
Temperature
effective. 6
4
2 Menstruation
Optimizing Outcomes— When teaching about NFP 98.0 Menstruation
and FAMs of contraception 8
6
The patient and her partner need to be fully committed to 4
use these methods successfully. There are several varia- 2
tions: (1) the calendar, or rhythm method in which the 97.0
fertile days are calculated; (2) the standard days method
Example line only 1234
in which color-coded strung beads are used to track infer- (Not safe)
tile days; (3) the cervical mucus method (also called the
Figure 6-2 A basal body temperature chart.
“ovulation detection method” or the “Billings method”)
where the changes in cervical mucus are used to track
fertile periods; (4) the basal body temperature (BBT)
method in which body temperature changes are used to
Box 6-3 Basal Body Temperature as an Indicator
detect the fertile period (Fig. 6-2; Box 6-3); and the
of Ovulation
symptothermal method that combines the BBT and cervi-
cal mucus methods and involves recording various symp- During the preovulatory phase, the basal temperature is usually below
toms such as changes in cervical mucus, mittelschmerz 98°F (36.7°C). As ovulation approaches, estrogen production increases.
(abdominal pain at midcycle), abdominal bloating, and At its peak, estrogen may cause a slight drop, then a rise, in the basal
the BBT to recognize signs of ovulation (Hatcher et al., temperature. Before ovulation, a surge in luteinizing hormone (LH) stimu-
2005). The woman needs to realize that stress or illness lates the production of progesterone. The LH surge causes a 0.5°F–1°F
can affect her cycle and cause a variation in the fertile (0.3°C–0.6°C) rise in the basal temperature. These changes in the basal
days. These methods are not best suited for adolescents temperature create the biphasic pattern consistent with ovulation. Pro-
gesterone, a thermogenic, or heat-producing hormone, maintains the
or couples who would be devastated by an unplanned
temperature increase during the second half of the menstrual cycle.
pregnancy. Since the “natural” methods identify fertile Although the temperature elevation does not predict the exact day of
periods, couples who are attempting to conceive may also ovulation, it does provide evidence of ovulation about one day after it has
wish to use them. occurred. Release of the ovum probably occurs 24–36 hours before the
Ovulation predictor kits detect the surge in luteinizing first temperature elevation.
hormone (LH) that occurs 24–36 hours before ovulation.
144 unit two The Process of Human Reproduction
Effectiveness
When the above conditions are met, the effectiveness rate
for this method is about 98% (Hatcher et al., 2005).
ABSTINENCE
Abstinence is the only contraceptive method with a 100%
effectiveness rate. If a couple chooses to be abstinent
(refrain from vaginal intercourse), intimacy and sexuality
may be expressed in many other ways. Abstinence requires
commitment and self-control, but success with this method
can lead to increased self-esteem and enhanced communi- Figure 6-3 Diaphragm insertion.
cation about emotions and feelings. Abstinence can help
adolescents learn negotiation skills (Hatcher et al., 2005). diaphragm should be replaced every 2 years, and it may
need to be refitted after weight loss or weight gain, term
BARRIER METHODS birth or second trimester abortion (Hatcher et al., 2005).
Barrier methods are relatively inexpensive and some types SIDE EFFECTS. Other than occasional allergic reactions to
can be used more than once. Although less effective than the diaphragm or spermicide, there are no side effects
certain other forms of contraception, barrier methods from a well-fitted device. There is an increased risk of uri-
have gained in popularity as a protective measure against nary tract infections due to pressure of the diaphragm
the spread of STIs. If the woman is under 30 years of age, against the urethra, which may interfere with complete
uses alcohol or recreational drugs, or has intercourse emptying of the bladder. Thus, women with a history of
three or more times weekly, barrier methods are usually frequent urinary tract infections (UTIs) should avoid this
not as effective because of a decreased likelihood to use method. The diaphragm should not be used during men-
them consistently (Cates & Stewart, 2004). ses due to the risk of toxic shock syndrome (TSS), a rare,
Many women dislike barrier methods because they must sometimes fatal disease caused by toxins produced by
be inserted or applied before intercourse. Most require a certain strains of the bacterium Staphylococcus aureus.
water-based lubricant and these should never be used with Women with pelvic relaxation syndrome or a large cysto-
an oil-based lubricant (i.e., baby oil, petroleum jelly, vegeta- cele are not suitable candidates for the diaphragm.
ble oil) or vaginal yeast cream as these products cause latex
EFFECTIVENESS. The effectiveness in preventing preg-
deterioration. Barrier methods have few side effects, although
nancy for typical use is 84% (Bachmann, 2007). For this
latex allergy may lead to life-threatening anaphylaxis. There
reason, the diaphragm may not be the best choice for a
is evidence that consistent use of latex condoms reduces the
woman who would consider pregnancy a disaster in her
rate of HIV transmission, and both condoms and diaphragms
life or for a woman who feels uncomfortable touching her
can reduce the risk of cervical STIs (Hatcher et al., 2005).
genital area. Since it is made of latex, the diaphragm is
Each of the barrier methods must be applied or inserted with
contraindicated in women with latex allergies.
clean hands. The key to success with these contraceptives is
consistent and correct use, and the nurse must ensure that
women know how to use their barrier method correctly and Optimizing Outcomes— When teaching patients about
that they are satisfied with their choice. use of the diaphragm
Spermicides
Optimizing Outcomes— When teaching patients Spermicides are available in the form of gels, creams, films,
about use of the male condom
and suppositories. All are inserted into the vagina or used
It is important to choose and use the correct size of condom. with diaphragms or cervical caps. Spermicidal condoms are
The condom is rolled onto the erect penis and should fit no longer recommended for use. Spermicides act as chemi-
snugly. The reservoir tip should be left unobstructed or cal barriers that cause death of the spermatozoa before they
extra space at the end (of a condom with no reservoir tip) can enter the cervix. Although spermicides can be messy,
should be provided for collection of the semen. Care must the lubrication afforded by the spermicide-based methods
be taken not to tear the condom or spill its contents during may improve sexual satisfaction for both partners.
removal. When possible, patients should practice placing a Women who are at risk for HIV should not use spermi-
condom on a penile model to enhance understanding of the cides as their only method of birth control (Hatcher et al.,
proper technique. Immediately after intercourse, the man 2005). Since spermicidal suppositories and films require
should hold the condom at the base of the penis and with- 15 minutes to become effective, women who feel they can-
draw the penis while still erect, then check the condom for not comply with this time constraint may wish to use a
the presence of tears after removal. Expiration dates should spermicidal foam, cream, or gel instead. Because of the low
be checked often and out-of-date condoms discarded. Con- effectiveness rates associated with spermicides, the woman
doms should always be stored in a cool, dry place and latex who believes that pregnancy would be personally disas-
condoms only used with water-based lubricants (Nelson & trous may wish to choose another contraceptive method.
Le, 2007).
SIDE EFFECTS. Spermicides should not be used in women
with acute cervicitis because of the potential for further
cervical irritation. Rarely, topical irritation may develop
FEMALE CONDOMS. Made of polyurethane in a “one size
from contact with spermicides. When this occurs, the
fits all,” the female condom or vaginal sheath (Fig. 6-5)
product should be discontinued and another contracep-
is less widely used than the male condom. The female
tive method selected.
condom resembles a sheath with a ring on each end: the
closed end is inserted into the vagina and anchored EFFECTIVENESS. The typical use effectiveness of spermi-
around the cervix; the open end is placed at the vaginal cides in preventing pregnancy is 71%.
introitus. Although no prescription is needed, female
condoms are often difficult to find, and they are more
expensive than male condoms. Because they contain no Optimizing Outcomes— When teaching patients
about the use of spermicides
latex, female condoms are safe for use in individuals
with latex allergies. The woman should wash her hands before inserting any
spermicide. Spermicides are most effective when used with
Optimizing Outcomes— When teaching patients a diaphragm or cervical cap. Most contraceptive films and
about use of the female condom suppositories require a period of 15 minutes to elapse after
insertion to become effective and they should be inserted
Female condoms cannot be used at the same time as male no longer than one hour before intercourse. The spermi-
condoms. The man must carefully direct his penis into the cide should be inserted deep into the vagina so that it
condom to keep from inserting it between the condom and makes contact with the cervix. Although douching is never
the vaginal wall. The female condom can be used during recommended, it should be avoided for 6 hours after inter-
oral sex. Some individuals complain that female condoms course to avoid washing the spermicide away (Hatcher
generate “noise” during intercourse, but lubricant seems to et al., 2004). Douching in and of itself is not a reliable form
help alleviate this problem. of birth control.
Contraceptive Sponge
The contraceptive sponge was recently returned to the
U.S. market. It is a soft, round disposable polyurethane
device that fits over the cervix (one size fits all). The
sponge is permeated with the spermicide nonoxynol-9.
One side is concave to enhance fit over the cervix; the
other side contains a woven polyester loop to facilitate
removal.
SIDE EFFECTS. The contraceptive sponge is contrain-
dicated in women who are allergic to the spermicide
nonoxynol-9. The sponge should not be left in place for
more than 30 hours (which includes the 6-hour waiting
period after the last act of intercourse) due to the risk of
toxic shock syndrome. It should not be used during men-
struation or immediately after abortion or childbirth or if
Figure 6-5 Insertion of a female condom. a woman has a history of toxic shock syndrome.
chapter 6 Human Sexuality and Fertility 147
EFFECTIVENESS. The typical use effectiveness of the con- tion primarily by creating a thickened cervical mucus
traceptive sponge in preventing pregnancy is 84% to 87%. (which produces a hostile environment for sperm penetra-
tion) and by causing endometrial atrophy. These alterations
inhibit egg implantation and decrease the penetration of
Optimizing Outcomes— When teaching patients about
use of the contraceptive sponge
sperm and ovum transport (Rice & Thompson, 2006).
In the United States, oral contraceptives are available in
The patient should wash her hands before inserting the monophasic, biphasic, and triphasic preparations. Mono-
sponge. The sponge is moistened thoroughly with tap phasic formulas provide fixed doses of estrogen and pro-
water and inserted into the vagina prior to intercourse. It gestin throughout a 21-day cycle. Biphasic preparations
provides up to 24 hours of protection for repeated sexual provide a constant amount of estrogen throughout the
intercourse. The sponge must remain in the vagina for at cycle but there is an increased amount of progestin during
least 6 hours after the last act of intercourse. The contra- the last 11 days. Triphasic formulas, designed to more
ceptive sponge offers no protection against STIs or HIV. closely mimic a natural cycle, provide varied levels of
estrogen and progestin throughout the cycle. Triphasic
preparations reduce the incidence of breakthrough bleed-
ing (bleeding that occurs outside of menstruation) in
Be sure to— Teach about toxic shock syndrome many women.
Women who wish to use oral contraceptives are exam-
Women who use the diaphragm, cervical cap, or contra-
ined before the medication is prescribed and then yearly
ceptive sponge should be aware of the possible association
thereafter. The mandatory examination includes a his-
between these devices and toxic shock syndrome (TSS).
tory, weight, blood pressure, general physical and pelvic
Common signs of TSS include fever of sudden onset
examination, and Pap smear. Most providers schedule
greater than 101.1ºF (38.4ºC), rash, and hypotension with
women for a return visit approximately 3 months after
a systolic blood pressure less than 90 mm Hg.
initiating the medication to confirm patient acceptance
and correct use of the method and to detect any
complications.
HORMONAL METHODS
Hormonal contraceptive methods include oral medica- Optimizing Outcomes— Counseling about
tions, the transdermal patch, the vaginal ring, long-acting medications that decrease the effectiveness of oral
injectables, the subdermal implant, and the progestin- contraceptives
releasing intrauterine device. Estrogen and progestins It is essential for the nurse to take a thorough history on
decrease the pituitary’s release of follicle-stimulating hor- any patient who wishes to use oral contraceptives for
mone and luteinizing hormone to prevent ovulation. Pro- birth control. Certain medications such as rifampin
gestins also thicken cervical mucus to prevent sperm (Rifadin, Rimactane), isoniazid, barbiturates, and griseo-
penetration. fulvin (Fulvicin-U/F, Gris-PEG, Grifulvin V) can decrease
the effectiveness of oral contraceptives, and higher doses
Oral Contraceptives of estrogen must be used. Vomiting and diarrhea affect
This method, known as “the pill,” or oral contraceptive the absorption of oral contraceptives, thus patients who
pill (OCP), has been available for more than 40 years. experience these symptoms should use a back-up method
Throughout that time, the dose of estrogen has signifi- such as condoms. Recent research indicates that antibiot-
cantly decreased and newer generation progestins have ics do not affect the effectiveness of oral contraceptives
become safer with fewer side effects. It was once recom- (Hatcher et al., 2005). Interactions with certain drugs
mended that patients occasionally “take a break” from the such as acetaminophen, anticoagulants, and some anti-
pill because of the high hormonal dosages they contained. convulsants (e.g., phenytoin sodium, carbamazepine,
With today’s formulations however, patients can continue primidone, topiramate), may reduce efficacy of the OCP.
to take oral contraceptives into the perimenopausal years.
Oral contraceptives are the most extensively studied med-
Many noncontraceptive benefits are associated with
ications in history (Hatcher, 2004).
OCPs (Box 6-4). Perimenopausal women who do not
Hormonal contraceptives contain estrogen in the form
smoke, who maintain a normal blood pressure and who
of ethinyl estradiol or mestranol; ethinyl estradiol is the
have a normal well-woman annual exam can safely use
most common estrogen used. Estrogens work by prevent-
oral contraceptives. Oral contraceptives can moderate the
ing the release of follicle-stimulating hormone (FSH) from
irregular bleeding that often occurs during the perimeno-
the anterior pituitary. When FSH levels are kept low, the
pausal period and provide contraception as well. When
ovarian follicle is unable to form and ovulation is pre-
used on an extended cycle basis, hot flashes and vaginal
vented (Rice & Thompson, 2006).
dryness may also be alleviated (Clark & Burkman, 2006).
Progestins provide effective contraception when used
The onset of menopause in women who use hormonal
alone or in combination with estrogen. When combined
contraception may be difficult to detect.
with an estrogen, progestins inhibit the luteinizing hormone
(LH) surge, which is required for ovulation. When used CONTRAINDICATIONS. There are several absolute and rel-
alone, progestins are believed to inhibit ovulation inconsis- ative contraindications to the use of combined oral con-
tently. Progestin-only contraceptives are thought to func- traceptive pills and the nurse must be fully aware of
148 unit two The Process of Human Reproduction
Low-Dose Progestin-Only Contraceptive Pills trations of ethinyl estradiol (the estrogen component).
Low-dose progestin-only contraceptive pills are often referred There is a potential for increased adverse events in women
to as the “mini pill” because they contain no estrogen. using the patch (Rice & Thompson, 2006).
Although ovulation may occur, the progestins cause thicken- EFFECTIVENESS. The patch is about 99% effective in pre-
ing of the cervical mucus and endometrial atrophy. These venting pregnancy. Due to concerns that excessive adi-
changes inhibit implantation and decrease the penetration of pose tissue may be associated with inconsistent levels of
sperm and ovum transport (Rice & Thompson, 2006). The hormonal absorption, it is not recommended for women
minipill is used primarily by women who have a contraindi- who weigh more than 198 pounds. In general, patient
cation to the estrogen component of the combination OCP. compliance is enhanced because of the once-weekly
It must be taken at the same time every day. The minipill administration (Potts & Lobo, 2005).
may be used during breastfeeding because it does not inter-
fere with milk production.
SIDE EFFECTS. Irregular menses frequently occur with the Optimizing Outcomes— When teaching patients
progestin-only pills. Also, this type of oral contraceptive about use of the transdermal contraceptive patch
may be associated with an increased number of persistent The patch can cause skin irritation, particularly if it is
ovarian follicles (Hatcher et al., 2005). Women with a his- placed on damp skin or in the same location every time.
tory of functional ovarian cysts, a history of ectopic preg- Thus, rotating the application site is recommended.
nancy or those with unexplained vaginal bleeding should Hypopigmentation at the site of the patch placement has
not take the progestin-only oral contraceptive pills. been reported (Hatcher et al., 2005). Some women have
complained that the patch adhesive catches fibers from
EFFECTIVENESS. The progestin-only contraceptive pills their clothing; placing the patch on the buttock under the
are 92% effective in preventing pregnancy (Hatcher underpants may be desirable. Bathing and swimming
et al., 2005). should not interfere with the patch. If the patch becomes
detached for more than 24 hours, a new one should be
applied and another form of contraception used for the
case study Young Woman Who Believes following 7 days (Burki, 2005). The transdermal contra-
She Is Infertile ceptive patch offers no protection against STIs or HIV.
another method of contraception should be used for the thicken cervical mucus, alter sperm transport to prevent
following 7 days (Burki, 2005). Unopened vaginal rings fertilization, and interfere with normal endometrial devel-
must be protected from sunlight and high temperatures. opment. Emergency contraception is ineffective if implan-
The vaginal contraceptive ring offers no protection against tation has already occurred and it does not harm a develop-
STIs or HIV. ing embryo (Smith, 2007).
The IUD is suitable for women who wish to have the
benefit of long-term contraception. Insertion of the IUD
within 5 days after intercourse causes an alteration in the
Emergency Postcoital Contraception endometrium to prevent implantation. Patients should
Emergency contraception (EC) is available to women contact their health care providers if no period occurs
whose birth control methods fail or who have been the within 3 weeks after insertion (Lever, 2005). Emergency
victims of sexual assault. Two forms of emergency post contraception offers no protection against STIs or HIV.
coital contraception are available: hormonal methods,
which include estrogen and progestin or progestin-only
oral contraceptive pills; and the insertion of a copper
releasing intrauterine device (IUD). Emergency contra- INJECTABLE HORMONAL CONTRACEPTIVE
ception is available by prescription, office visit or, in some METHODS
states, over the counter.
Depo-Provera (DMPA), Depo-SubQ Provera 104
HORMONAL METHOD. Often referred-to as “the morning (Depot Medroxyprogesterone)
after pill,” or the “emergency contraceptive pill” (ECP), Depo-Provera (medroxyprogesterone acetate) is a progestin-
there are two FDA-approved OC products specifically only long-term contraceptive. Its effects last about 3 months,
packaged for emergency contraception. Preven is a kit and it is injected either intramuscularly (150 mg) or subcu-
that contains four combination estrogen/progestin tablets taneously (104 mg). The first injection should be given
and a pregnancy test. Plan B contains two progestin-only within the first 5 days of menstruation to ensure the
tablets. The hormonal preparations are most effective patient is not pregnant. Medroxyprogesterone 150 mg is
when taken as soon as possible after unprotected inter- injected into the deltoid or gluteal muscle and functions by
course. The first dose should be taken within 72 hours suppressing ovulation and altering the cervical environ-
(after intercourse); the second dose 12 hours later. Nau- ment (Rice & Thompson, 2006). The administration site
sea and vomiting is a common side effect with both prod- should not be massaged after injection, as it may reduce
ucts and may be minimized by taking an antiemetic the effectiveness of DMPA.
1 hour before the first EC dose (Burki, 2005; Lever, 2005). Depo-SubQProvera 104 was the first subcutaneous
Although regular OCPs can be taken for emergency con- hormonal contraceptive product available. It is adminis-
traception, the dose varies with the brand and may require tered into the anterior thigh or the abdomen and func-
taking a large number of tablets. The risk of pregnancy is tions by preventing ovulation and producing thinning of
reduced by 75% after completion of the EC dose. the endometrium. On average, ovulation is restored within
IUD METHOD. The copper IUD can be inserted within 10 months after discontinuation of the medication (both
5 days of unprotected intercourse. Because of the product’s dosages).
cost and the need for insertion by a trained professional, SIDE EFFECTS. Irregular bleeding is the most common
the IUD is used less frequently than the ECPs. The IUD is side effect of Depo-Provera. Most women who use this
not recommended for women who have been raped or are method experience spotting during the first few months,
at risk for STIs and pelvic infections (Burki, 2005). usually until the second injection. Amenorrhea often
SIDE EFFECTS. Fewer side effects are associated with occurs after about 6 months of use. Other side effects
oral emergency contraceptive pills than with continuous include weight gain, depression, headache, and breast ten-
oral contraceptives. Side effects include nausea and vom- derness. Although Depo-Provera may reduce bone mineral
iting and bleeding within a few days after administration. density, the subcutaneous injectable form may not be asso-
The side effects for the IUD are the same whether it is ciated with a loss in bone density (Hatcher et al., 2005).
being used as an emergency contraception method or as
EFFECTIVENESS. The typical effectiveness for the 150-mg
a long-term contraceptive. (See later discussion in this
intramuscular dose of Depo-Provera is 98% to 99%. The
chapter.)
typical effectiveness rate of the subcutaneous 104-mg
EFFECTIVENESS. Emergency contraceptive pills are 98.9% Depo-Provera injection appears to be greater than 99%
effective in preventing pregnancy if used correctly and the (Hatcher et al., 2005).
IUD is 99% to 100% effective (Hatcher et al., 2005).
Optimizing Outcomes— When teaching patients
Optimizing Outcomes— When teaching patients about injectable hormonal contraception
about postcoital emergency contraception
Women who desire pregnancy within the next year may
Emergency contraception in either form (pills or IUD) wish to choose another contraceptive method that is more
does not cause abortion although it is often confused with easily reversible. Depo-Provera is associated with weight
the medical abortion procedure. The high hormone levels gain and a reduction in bone mineral density. Patients who
in the oral contraceptive pills prevent or delay ovulation, use DMPA should include adequate calcium in their diet
chapter 6 Human Sexuality and Fertility 151
(1200 mg/day) and perform daily weight-bearing exercise weight increase, headache, depression, dysmenorrhea,
to enhance bone density maintenance and to offset weight and acne.
gain. Clinic visits must be scheduled every 3 months for
EFFECTIVENESS. Effectiveness rates approach 100%.
the contraceptive injection. Providing a reminder card that
includes the date of the next injection is helpful, and some
women set their PDA calendars or cell phones to alarm Optimizing Outcomes— When teaching patients
on the date. Since DMPA is injected, it cannot be reversed about the contraceptive implant
or stopped abruptly. Women who wish to hide their use of
The Implanon contraceptive is appropriate for women who
contraception from a partner or others may find this
desire long-term reversible contraception and who have no
method to be particularly appealing. Because it contains no
objections to the insertion/removal procedures or to pal-
estrogen, DMPA can be safely given to breastfeeding moth-
pating the implant when it is in place. It must be removed
ers. Injectable hormonal contraception offers no protec-
and replaced every 3 years if continued contraception is
tion against STIs or HIV.
desired. After removal, ovulation occurs within 3 to
6 weeks. Contraceptive efficacy in obese women (⬎130%
of ideal body weight) has not been studied (Darney &
Mishell, 2006). The contraceptive implant offers no pro-
where research and practice meet: tection against STIs or HIV.
Detrimental Effects of Depo-Provera on Bone
Mineral Density in Adolescents
Findings from a 2005 prospective cohort trial established that ado- INTRAUTERINE DEVICES
lescents are at increased risk for detrimental effects of Depo-Provera
on bone mineral density (BMD). Study participants included 14- to The intrauterine device (IUD) is a small plastic device that
18-year-old women, in whom bone density is expected to increase is inserted into the uterus and left in place for an extended
due to continued bone growth and development. Those who used period of time, providing continuous contraception. The
Depo-Provera experienced significant losses in bone mineral density exact mechanism of action is not fully understood although
at both the hip and spine in comparison to participants not using it is believed that the IUD causes a sterile inflammatory
Depo-Provera, whose bone mineral density increased. After discon- response that results in a spermicidal intrauterine envi-
tinuation of Depo-Provera, BMD significantly improved (Scholes ronment. Few sperm are able to reach the fallopian tubes
et al., 2005). These findings suggest that the adverse effect is and if fertilization does occur, the intrauterine environ-
reversible in adolescents if therapy is withdrawn. Recommendations
ment is unfavorable for implantation (Epsey, 2005).
from professional organizations including the American College of
Obstetricians and Gynecologists (ACOG), the Society for Adolescent Two types of intrauterine devices (IUDs) are currently
Medicine (SAM), and the World Health Organization (WHO) state available in the United States: the levonorgestrel-releasing
that for the majority of adolescents, the benefits of DMPA use out- intrauterine system (LNG-IUS) (Mirena), which releases a
weigh the potential risks (Arias, Kaunitz, & McClung, 2007). During progestin, and the copper T380A (ParaGard) (Fig. 6-6).
contraceptive counseling, nurses must empower young patients with The Dalkon Shield IUD was removed from the market in
information about decreased bone mineral density and Depo- the 1970s due to pelvic infections associated with it.
Provera and assist them in making appropriate contraceptive choices Today’s IUD manufacturers have corrected the design
(Rice & Thompson, 2006). problem that accompanied the Dalkon Shield, and IUDs
are once again safe to use.
LNG-IUS (Mirena) slowly releases a small amount of
levonorgestrel, a progestin, on a constant basis. It must be
SUBDERMAL HORMONAL IMPLANT replaced every 5 years. The ParaGard IUD has copper wire
Implanon
Implanon is a subdermal contraceptive that is effective for
3 years. The single-rod implant, which is inserted on the
inner side of the woman’s upper arm, contains etonoges-
trel (ENG), a progestin. It is simpler to insert and remove
than the previously available six-capsule levonorgestrel Drug reservoir
implant (Norplant) (Schulman, 2007). Implanon func- (progesterone)
tions to prevent pregnancy by suppressing ovulation and Rate controlling
by creating a thickened cervical mucus that hinders sperm membrane
penetration. Etonogestrel is metabolized by the liver.
Hepatic-enzyme inducers, including certain antiepileptic Monofilament
agents, may interfere with absorption and contraceptive thread (string)
effectiveness (Clinician Reviews, 2006; Darney & Mishell,
2006).
SIDE EFFECTS. Bleeding irregularities frequently occur
during the first several months after insertion; amenor-
rhea becomes more common with increasing duration Figure 6-6 Intrauterine device (IUD) properly
of use. Other symptoms include emotional lability, positioned in the uterus.
152 unit two The Process of Human Reproduction
blockage. A hysterosalpingogram (dye test to evaluate viability (usually 20 to 24 weeks) varies from state to
tubal patency) is performed at 3 months to ensure that state. Abortion has been legal in the United States since
both tubes have been blocked. Patients are instructed to the 1973 Supreme Court decision in Roe v. Wade.
use an alternate form of contraception until bilateral tubal An abortion performed at the patient’s request is
blockage has been confirmed (Holloway, Moredich, & termed an elective abortion; when performed for rea-
Aduddell, 2006). sons of maternal or fetal health or disease, the term
therapeutic abortion applies. Abortions performed dur-
SIDE EFFECTS. As with any surgery, complications
ing the first trimester are technically easier and safer
include infection, hemorrhage and blood vessel injury, than abortions performed during the second trimester.
damage to adjacent organs, and complications from anes- Methods for performing early elective abortion include
thesia (Hatcher et al., 2005; Holloway et al., 2006). vacuum aspiration and medical methods. Second-trimes-
EFFECTIVENESS. The effectiveness depends on the type of ter abortion is associated with increased complications
procedure used and ranges from 96.3% with the clip pro- and costs and involves cervical dilation and removal of
cedure to better than 99% with the postpartum procedure the fetus and placenta.
(Hatcher et al., 2005).
a curet to ensure that the uterus is empty. Patients may analogue that promotes expulsion of the pregnancy.
experience cramping for 20 to 30 minutes following the Misoprostol is commonly associated with nausea, vomit-
procedure. Complications include uterine perforation, ing, and cramping.
cervical lacerations, hemorrhage, infection, and adverse Uterine bleeding begins several days after medication
reactions to the anesthetic agent. administration, and most patients experience a period of
Abortion during the second trimester involves cervical painless heavy bleeding along with the expulsion of tis-
dilation with removal of the fetus and placenta. This pro- sue (the products of conception). This experience may
cedure is termed “dilation and evacuation” (D & E). Simi- trigger strong emotions. The nurse should advise the
lar to vacuum curettage, greater cervical dilation and use patient that she would most likely benefit from the pres-
of a larger cannula are required because of the increased ence of a caring, trusted close friend, or relative who can
volume in the products of conception. Laminaria are help her through the experience and lend emotional and
inserted 24 hours before the procedure to dilate the cer- physical support (Stewart et al., 2004). Follow-up visits
vix. D & E may be associated with long-term adverse include ultrasonography (to confirm that the uterus is
effects from cervical trauma. empty) and assessment of hCG levels. A surgical abortion
Nursing care during surgical abortion includes contin- procedure may be necessary if medical attempts are
ued patient assessment and emotional support. The unsuccessful.
woman should be informed about what to expect: abdom- Medical termination of pregnancy is probably not the
inal cramping and sounds emitted by the suction machine. ideal choice for adolescents, and for this reason, some clin-
After the procedure, the patient rests in a recovery area for ics offer this method of abortion only to women 18 years
1 to 3 hours to ensure that no excessive cramping or of age or older. Interestingly, this method has been proven
bleeding occurs. The aspirated uterine contents are useful in evacuating pregnancies that occur in the fallopian
inspected to ascertain that all fetal parts and adequate pla- tubes. Medical termination of a tubal pregnancy has
cental tissue have been aspirated. enabled many women to avoid surgery and preserve the
Although check-up visits are usually scheduled between fallopian tubes for future pregnancy conceptions.
2 weeks and 6 weeks postabortion, serum levels of human Medical termination during the second trimester most
chorionic gonadotrophin (hCG) may remain elevated often includes an administration of prostaglandins via
even if the abortion successfully ended the pregnancy. vaginal suppository, gel, or by intrauterine injection.
Women whose hCG levels are still present in the urine Repeated doses are often needed and side effects including
(at the follow-up appointment) should be encouraged to nausea, vomiting, diarrhea, and cramping usually occur.
return for urine hCG levels every 2 weeks until the test is Rarely used methods include the intrauterine instillation
negative. Persistently elevated hCG levels are associated of hypertonic solutions such as saline or urea and utero-
with a delay in the return of menses. tonic agents (e.g., misoprostol and dinoprostone).
Complications
clinical alert Legal abortion is actually safer than pregnancy, especially
Signs of short-term complications after clinical when performed early in pregnancy. All patients should
termination of pregnancy be told to expect cramping and some bleeding after an
• Fever of 40°C (104ºF) abortion. Some of the rare complications associated with
abortion include infection, incomplete abortion, hemor-
• Abdominal pain or tenderness in the abdomen
rhage, Asherman syndrome (condition characterized by
• Prolonged or heavy bleeding or passing large clots the presence of endometrial adhesions or scar tissue), and
• Foul vaginal discharge postabortal syndrome (severe abdominal cramping and
• No menstrual period within 6 weeks pain from intrauterine blood clots) (Hatcher et al., 2005).
Patients should be cautioned to call the office should any
Source: Hatcher et al. (2004).
signs of short-term complications (i.e., excessive bleeding,
pain, fever) occur. Most complications develop within the
first few days after the abortion. All patients should return
in 2 weeks for a follow-up examination.
MEDICAL TERMINATION OF PREGNANCY
“Medical abortion” is an alternative for the surgical form of
abortion, and for some women this method is more “natu-
ral” and more closely resembles a miscarriage (Stewart The Nurse’s Role in Infertility Care
et al., 2004). A medical abortion can be performed for up
to 63 days of gestation. The woman who considers medical THE INITIAL ASSESSMENT
abortion should be carefully educated about what to Fertility requires that the sperm and the ovum can meet,
expect. Specific medications are used to induce uterine that the sperm is viable, normal, and able to penetrate a
contractions to end the pregnancy. These include mifepris- viable, normal egg, and that the lining of the uterus can
tone (Mifeprex, originally called RU-486), an abortifacient, support the implanted embryo. Sterility is the term
and methotrexate (amethopterin, Folex, Rheumatrex, applied when there is an absolute factor that prevents
Trexall), an antimetabolite used to treat certain types of reproduction. Infertility is diagnosed if a woman has not
cancer. Both medications may be followed by a vaginal conceived within 12 months of actively attempting preg-
administration of misoprostol (Cytotec), a prostaglandin nancy. At present, 10% to 15% of heterosexual couples in
chapter 6 Human Sexuality and Fertility 155
the United States are infertile (Nelson & Marshall, 2004). ovarian function, cervical mucus (amount and receptivity
Approximately 40% of cases of infertility can be attrib- to sperm), sperm adequacy, tubal patency, and the general
uted to female problems, 40% can be attributed to male condition of the pelvic organs.
causes, and the remaining cases of infertility are attribut- Instructions about recording the basal body tempera-
able to a combination of male and female factors, or ture are usually provided at the initial visit. An in-depth
are undeterminable (Mooney, 2005). Delays in childbear- interview, preferably with both partners, may reveal
ing and increased consumer awareness of reproductive medical problems (i.e., chronic illness), lifestyle patterns
technology have prompted more heterosexual couples, (i.e., substance abuse, sexual orientation) or other factors
single women, and same-sex couples to seek fertility such as advanced age that can adversely affect fertility.
assistance than ever before. The nurse’s role in infertility The physical examination includes evaluation of the pel-
care begins with education and counseling during the vis (bimanual and rectovaginal assessment) and labora-
initial assessment. tory testing.
Table 6-2 Common Diagnostic Methods Used in the Evaluation of Female Infertility
Type/Name of Test Role of the Nurse
Prediction of Ovulation
To identify the LH surge – precedes ovulation by 24–36 Teach the couple how the information helps to determine timing of intercourse
hours. Also identifies the absence of ovulation. Tests include to coincide with ovulation. Instruct the woman about recording the BBT and
basal body temperature, commercial ovulation predictor kits, assessing cervical mucus; reinforce directions for using commercial ovulation
and assessment of cervical mucus. predictor kits.
Ultrasound Examination
To evaluate structure of the pelvic organs; identify maturing Reassure the patient that sonography uses sound waves, not radiation, to evaluate
ovarian follicles and the timing of ovulation. the pelvic structures. The examination may be conducted transabdominally or
transvaginally and specific instructions are given, depending on method.
Hysterosalpingogram
(see Diagnostic Tools)
Endometrial Biopsy
Involves the removal of a sample of the endometrium with a Teach the patient about the purpose and appropriate timing of the test: it should
small pipette attached to suction. Provides information about be performed not earlier than 10–12 days after ovulation (2–3 days before
the effects of progesterone (produced by the corpus luteum menstruation is expected). Cramping, pelvic discomfort, and vaginal spotting may
after ovulation) on the endometrium. occur; a mild analgesic (i.e., ibuprofen) may be used to alleviate the discomfort.
Clomiphene citrate (Clomid) Antiestrogen that binds with estrogen receptors to Contraindicated with hepatic impairment. Patients
trigger FSH and LH release. may experience ovarian enlargement, vasomotor
flushes, abdominal distention, nausea and vomiting,
breast tenderness, blurred vision, headache, pelvic
pain, abnormal uterine bleeding. May cause multiple
ovulation.
Bromocriptine mesylate (Parlodel) Reduces elevated prolactin secretion by the anterior Patients may experience nausea and vomiting,
pituitary, which improves gonadotropin-releasing headache, dizziness, orthostatic hypotension,
hormone secretion and normalizes follicle-stimulating blurred vision, diarrhea, metallic taste, dry mouth,
hormone and luteinizing hormone release. Ovulation urticaria, rash.
is restored and increased progesterone by the corpus
luteum supports early pregnancy.
GnRH agonists (gonadorelin); Stimulates release of pituitary FSH and LH in patients Advise patients of potential side effects: headache,
goserelin [Zoladex], leuprolide with deficient hypothalamic GnRH secretion. FSH depression, nasal irritation (Synarel), vaginal
[Lupron], nafarelin [Synarel] and LH stimulate ovulation (female) and testosterone dryness, breast swelling and tenderness, hot flashes,
and spermatogenesis (male). vaginal spotting, decreased libido, and impotence.
GnRH antagonists; cetrorelix Reduces extent of endometriosis; used with Patients are closely monitored for ovarian
[Cetrotide], ganirelix [Antagon], medications that stimulate ovulation by suppressing hyperstimulation (ascites with or without pain,
abarelix [Plenaxis], histrelin LH and FSH. pleural effusion, ruptured ovarian cysts, multiple
[Supprelin] births), headache, nausea.
Human chorionic gonadotropin Used after failure to respond to therapy with When used with menotropins, risk for ovarian
(hCG) (Profasi HP, Pregnyl, clomiphene citrate, induces ovulation; used in hyperstimulation, and arterial thromboembolism;
Chorex) conjunction with gonadotropins (FSH and LH other side effects include headache, irritability,
[Pergonal], [Repronex], [Humegon]); ovulation restlessness, and depression.
usually occurs within 18 hours. Also stimulates
production of progesterone by the corpus luteum.
Progesterone (IM, intravaginal) Provides luteal phase support—prepares the Common side effects include nausea, weight gain,
endometrial lining to promote implantation of the and fluid retention.
embryo.
is used. Clomiphene citrate and ultrasound monitoring the normally developing embryos are placed in the
for follicle development are frequently used to ensure tim- uterus (Fig. 6-7). Success with IVF is dependent upon
ing of the insemination with ovulation. Fertilization most many factors, such as the woman’s age and the indica-
often occurs in the fallopian tube. The technique involves tion for the procedure. On average, women who undergo
the insertion of a small catheter into the vagina and three IVF cycles have a good chance of achieving
through the cervix to facilitate the deposition of sperm pregnancy.
directly into the uterus. Since seminal fluid is rich in pros-
taglandins, IUI prevents the nausea, cramping, abdominal Embryo Cryopreservation
pain, and diarrhea that can result from the absorption of Cryopreservation, or freezing, is used in some instances to
prostaglandins by the cervical lining. store sperm or ovarian tissue for future use or to freeze
Before the IUI, the sperm are “washed”: they are excess embryos that have resulted from an in vitro fertiliza-
removed from the seminal fluid and placed in a special tion procedure. If no pregnancy results, the frozen embryos
solution that enhances motility and improves the chances can be processed and replaced in the uterus. This option
for fertilization. An added advantage of washing sperm allows the couple to attempt another pregnancy without
concerns sperm antibodies. After infection or surgery, a the need for ovarian stimulation and egg retrieval.
woman’s immune system may produce antibodies that An initial fee is charged for the freezing process; addi-
cause sperm clumping and adversely affect motility and tional fees are incurred for the continued preservation of
ovum penetration. Sperm washing may correct the clump- the frozen reproductive tissues. One of the ethical and
ing, increase sperm motility and improve the likelihood of sociocultural issues involved with cryopreservation arises
fertilization (Mooney, 2005). when excess embryos are no longer needed or desired by
the woman or couple. In most situations, the embryos are
ADVANCED REPRODUCTIVE TECHNOLOGIES destroyed although a social debate presently concerns an
alternate use of the embryos for research.
Gamete Intrafallopian Transfer
Advanced reproductive technologies (ARTs) are proce- Micromanipulation
dures intended to achieve pregnancy by placing gametes Micromanipulation is a process that involves the use of
together to promote fertilization. Although assisted repro- micromanipulators—fine, specialized instruments—to
ductive methods are more common today than in the handle individual sperm and ova. Intracytoplasmic sperm
past, they are very expensive, and are often unavailable to injection (ICSI) allows a sperm cell to be directly injected
women of lower socioeconomic status. Gamete intrafal- into an ovum. Assisted embryo hatching is used as an IVF
lopian transfer (GIFT) is a technique that involves lapa- adjunct for women in whom the normal “hatching pro-
roscopy and ovulation induction. The patient must have cess” is impeded because of a thickening of the zona pel-
at least one patent fallopian tube. Three to five oocytes lucida. A small opening created in the zona pellucida
are harvested from the ovary and immediately placed into facilitates the hatching process by allowing the embryo to
a catheter along with washed, motile donor or partner escape from the zona pellucida to interact with the endo-
sperm. The sperm and oocytes are injected into the fim- metrium for implantation. Blastomere analysis allows for
briated ends of the fallopian tube(s) through a laparo- chromosomal analysis using a single cell from the six-to
scope. Since fertilization normally takes place in the fal- eight-cell embryo before implantation.
lopian tube, this technique increases the likelihood of
conception in situations where the sperm and ovum may
be prevented from uniting. Supplemental progesterone is
given to promote implantation and provide support for
the early pregnancy.
Zygote Intrafallopian Transfer
Zygote intrafallopian transfer (ZIFT) is a procedure that
evolved from the GIFT procedure. Following ovulation
induction, retrieved oocytes are fertilized outside the
woman’s body and the subsequent zygotes are placed in
the distal fallopian tube(s).
A B
Tubal Embryo Transfer
Tubal embryo transfer (TET) involves placement at the
embryo stage. The patient must have at least one patent
fallopian tube. Exogenous progesterone is used to enhance
endometrial preparation.
In Vitro Fertilization
C D
In vitro fertilization (IVF) involves retrieval of the
oocytes from the ovaries, usually via an intra-abdominal Figure 6-7 The process of in vitro fertilization.
approach or a transvaginal approach under ultrasound A, Ovulation. B, Intra-abdominal retrieval of the ova.
guidance. The oocytes are then combined with partner C, Ova fertilization and growth in culture medium.
or donor sperm in the laboratory. After fertilization, D, Fertilized ova is placed in the uterus.
chapter 6 Human Sexuality and Fertility 159
Table 6-4 Herbs to Avoid When Attempting to Achieve absent or anomalous uterus or medical condition that
Pregnancy would be life threatening during pregnancy. A gestational
carrier contracts to carry a pregnancy that is not geneti-
Category Herb cally her own offspring. Adoption may be considered after
repeated attempts for pregnancy. Today, there are fewer
Anthraquinone Laxatives Aloe infants and children available for adoption. Consequently,
Buckthorn the adoptive process is often prolonged and difficult
unless the couple considers a foreign-born or physically
Cascara sagrada or cognitively challenged child.
Docks Surrogacy and the use of gestational carriers involve
legal as well as ethical considerations. Financial resources,
Meadow saffron
personal values, and religious beliefs are all factors that
Senna may prohibit these options from being viable alternatives
Uterine Stimulants American mandrake
to a traditional pregnancy. Individuals and couples who
consider these options should be advised to see an attor-
Black cohosh ney to ensure that their rights, the surrogate’s/carrier’s
Blue cohosh rights, and the rights of the child are protected. This very
important visit for legal counsel may avoid later heart-
Bloodroot break and legal entanglements for the patient and her
Calamus family. If the surrogate/carrier changes her mind or the
parents change their minds, safeguards must be in place
Cayenne for all parties, including the child.
Fennel Remaining childless is another option for fertile and
infertile couples. Many advantages, such as opportunity
Feverfew
for career fulfillment, travel, and continued education
Flax seed make a child-free lifestyle the right choice for many cou-
Goldenseal
ples. When working with couples who are exploring these
alternative options, the nurse’s role centers on education,
Lady’s mantle advocacy, and empowerment. Using a framework that
Licorice encompasses the cultural, spiritual, and environmental
domains, the nurse provides information and guidance to
Make fern community and national resources to assist the couple in
Sage dealing with these important issues.
Tansy
Thuja Now Can You— Provide sensitive, appropriate care for the
infertile couple?
Thyme
1. Discuss emotions and stressors frequently experienced
Wild cherry
during infertility treatment?
Wormwood 2. Analyze the nurse’s role in infertility care?
Mayapple 3. Create a teaching plan that describes the various
reproductive technologies available?
Mistletoe
Passion flower
Pennyroyal summar y poi nt s
Periwinkle
◆ Sexuality is a multidimensional concept that is influ-
Poke root enced by ethical, spiritual, cultural, and moral factors.
Rhubarb ◆ A variety of contraceptives are available; contraceptive
care should empower the patient to choose the method
Alkaloids/Bitter Principles Barberry
best suited for her.
Bloodroot
◆ Tubal ligation and vasectomy are permanent steriliza-
Celandine tion procedures that have become increasingly popular.
Cinchona ◆ Infertility is the inability to conceive and carry a child
when the couple wishes to do so.
Ephedra
◆ Abortion performed during the first trimester is safer
Goldenseal than abortion performed during the second trimester.
Adapted from Herbs to avoid during pregnancy. Pregnancy Today. Retrieved ◆ Reproductive alternatives include IVF, GIFT, ZIFT,
from http://pregnancytoday.com/articles/medications-and-herbs-to-avoid-during- oocyte/embryo donation, TDI, surrogate motherhood,
pregnancy-2293/ and adoption.
chapter 6 Human Sexuality and Fertility 161
Holloway, B., Moredich, C., & Aduddell, K. (2006). OB peds women’s Potts, R.O., & Lobo, R.A. (2005). Transdermal drug delivery: clinical
health notes. Philadelphia: F.A. Davis. considerations for the obstetrician-gynecologist. Obstetrics and Gyne-
Interventions labels and definitions. Nursing Interventions Classification cology, 105(5 pt 1), pp. 953–961.
(NIC). (4th ed.). Retrieved from http://www.nursing.uiowa.edu/ Rice, C., & Thompson, J. (2006). Selecting a hormonal contraceptive
centers/cncce/nic/labeldefinitions.pdf (Accessed March 2, 2006). that suits your patient’s needs. Women’s Health Ob-GYN Edition.
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, (November–December), 26–34.
J., Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and Ridley, M. (2000). Genome. New York: Harper Collins.
NIC Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.). Scholes, D., LaCroix, A.Z., Ichikawa, L.E., et al. (2005). Change in bone
St. Louis, MO: Mosby Elsevier. mineral density among adolescent women using and discontinuing
Katz, A. (2007). Sexuality and women: The experts speak. Nursing for depot medroxyprogesterone acetate contraception. Archives of Pedi-
Women’s Health, 11(1), 38–42. atric Adolescent Medicine, 159(2), 139–144.
Lever, K.A. (2005). Emergency contraception. Lifelines, 9(3), 218–227. Schulman, L.P. (2007). New paradigms in hormonal contraception. The
Marrazzo, J.M. (2004). Barriers to infectious disease care among Forum, 5(1), 19–22.
lesbians. Emerging Infectious Disease [serial on the Internet]. Schulman, L.P., & Westhoff, C.L. (2006). Contraception and cancer.
Retrieved from http://www.cdc.gov/ncidod/EID/vol10no11/04-0467. Dialogues in Contraception, 10(3), 5–8.
htm (Accessed May 1, 2007). Smith, D.M. (2007). Emergency contraception: An update. Dialogues in
Martinez, L. (2007). Effective communication: Overcoming the embar- Contraception, 11(1), 8–9.
rassment. The Female Patient, 32, 33–35. St.Hill, P.F., Lipson, J.G., & Meleis, A.I. (2003). Caring for women cross-
Masters, W., & Johnson, V.E. (1966). Human sexual response. Boston: culturally. Philadelphia: F.A. Davis.
Little Brown. Stevens, P., & Hall, J. (2001). Sexuality and safer sex: The issue of lesbi-
Mays, V.M., Yancey, A.K., Cochran, S.D., Weber, M., & Fielding, J.E. ans and bisexual women. Journal of Obstetric, Gynecologic and Neona-
(2002). Heterogeneity of health disparities among African American, tal Nursing, 30(4), 439–447.
Hispanic, and Asian American women: Unrecognized influences of Stewart, F. H., Elbertson, C., & Cates, W. Abortion. In Hatcher, R.A.,
sexual orientation. American Journal of Public Health, 92, 632–639. Trussell, J., Stewart, F., Nelson, A., Cates, W., Guest, F., & Kowal,
Mooney, B. (2005). Catalyzing conception. Advance for Nurses, South- D. Contraceptive Technology (18th ed.). New York: Ardent Media.
eastern States, August, 25–27. Trussell, J. (2004). Contraceptive efficacy. In Hatcher, R.A., Trussell, J.,
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing Stewart, F., Nelson, A., Cates, W., Guest, F., & Kowal, D. Contraceptive
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. technology (18th ed.). New York: Ardent Media.
NANDA International (2007). NANDA-I Nursing Diagnoses: Definitions Warner, L., Hatcher, R.A., & Steiner, M.J. (2004). In Hatcher, R.A., Trus-
and Classifications 2007-2008. Philadelphia: NANDA-I. sell, J., Stewart, F., Nelson, A., Cates, W., Guest, F., & Kowal, D.
Nelson, A.L., & Le, M.H.H. (2007). Modern male condoms: not your Contraceptive technology (18th ed.). New York: Ardent Media.
father’s ‘rubbers’. The Female Patient 32, 59–66. World Health Organization. (2004). Medical eligibility criteria for contra-
Nelson, A.L., & Marshall, J.R. (2004). Impaired fertility. In Hatcher, ceptive use (3rd ed.). Geneva, Switzerland: World Health Organiza-
R.A., Trussell, J., Stewart, F., Nelson, A., Cates, W., Guest, F., & tion; 2004. Retrieved from http://www.who.int/reproductive-health/
Kowal, D. Contraceptive technology (18th ed.). New York: Ardent publications/mec/index.htm (Accessed June 4, 2007).
Media.
CONCEPT MAP
You are a child of the universe no less than the trees and the stars; you have a right
to be here.
And whether or not it is clear to you, no doubt the universe is unfolding as it should.
—From the poem “Desiderata”
L EA R NIN G T AR G E T S At the completion of this chapter, the student will be able to:
◆ Explain the basic concepts of inheritance.
◆ Outline the process of germ cell formation.
◆ Outline the process of fertilization, implantation, and placental development.
◆ Discuss the structure and function of the placenta and umbilical cord.
◆ Trace a drop of blood through the fetal circulatory system.
◆ Explain the origin and purpose of the fetal membranes and amniotic fluid.
◆ Identify the time intervals and major events of the pre-embryonic, embryonic, and fetal stages
of development.
◆ Discuss threats to embryo/fetal well-being and development.
◆ Explain the nurse’s role in minimizing threats to the developing fetus.
The purpose of this study was to examine the relationship through local area clinics. Forty-nine percent of the participants
between vitamin E and fetal growth. The researchers theorized were Hispanic and 39.7% were African American. Women with
that antioxidants such as vitamin E may decrease adverse serious nonobstetric problems were excluded from the study.
maternal–fetal outcomes, such as preeclampsia, preterm birth, Data collection methods included interviews and 24-hour
and low birth weight (LBW) by reducing oxidative damage to dietary recalls along with serum concentration levels of vitamin E.
the mother and the fetus. Antioxidants are naturally produced Multiple linear regression was used to examine the relation-
by the body or are consumed in the diet. Naturally occurring ships among the plasma concentrations of vitamin E, the mater-
vitamin E (-tocopherol) and dietary-consumed vitamin E nal diet, and the use of prenatal multivitamins.
(-tocopherol) levels were examined. Findings:
The sample consisted of 1231 pregnant women from Cam-
den, NJ who entered the study at approximately 16 weeks of 1. Women with the highest concentrations of naturally occur-
gestation. Vitamin E plasma concentrations were measured at ring and dietary vitamin E were generally older, multiparous,
the time of entry into the study, at 20 weeks’ gestation, and and tended to have a higher body mass index (BMI).
again at 28 weeks’ gestation. The participants included women 2. Obese women had lower concentrations of -tocopherol
18 years to 45 years of age who received prenatal care and higher concentrations of -tocopherol.
(continued)
164
chapter 7 Conception and Development of the Embryo and Fetus 165
Ova
4 5
1 2 3
6 7 8 9 10 11 12 Sperm
16 17 18
13 14 15
Key
BB Genotype: homozygous brown (2 dominant genes)
Phenotype: brown
Figure 7-1 The sex chromosomes. (Courtesy of National Figure 7-2 Use of a Punnett square to demonstrate
Human Genome Research Institute.) inheritance of eye color.
chapter 7 Conception and Development of the Embryo and Fetus 167
the beginning of the woman’s LNMP. Gestation is defined and congenital heart disease that may range from mild to
as the length of time from conception to birth. The gesta- severe, depending on the number of genes for the particular
tional period in humans ranges from 259 to 287 days. In defect and the amount of the environmental influence.
this chapter, the weeks of gestation are calculated from
the time of fertilization. UNIFACTORIAL INHERITANCE
Unifactorial mendelian or single-gene inheritance describes
Nursing Insight— Understanding abnormalities a pattern of inheritance that results when a specific trait or
in sex chromosomes disorder is controlled by a single gene. There are many
more single-gene disorders than chromosomal abnormali-
Turner syndrome, the most common sex chromosome deviation ties. Patterns of inheritance for single-gene disorders
in females, is characterized by a chromosomal constitution of include autosomal dominant, autosomal recessive, and
45X: one X chromosome is missing (monosomy X). Affected X-linked dominant and recessive modes of inheritance.
females usually exhibit juvenile external genitalia, undeveloped
Autosomal Dominant Inheritance
ovaries, short stature, and webbing of the neck. Intelligence
may be impaired. In males, Klinefelter syndrome, or trisomy Autosomal dominant inheritance disorders are caused by a
XXY, is the most common sex chromosome deviation. The single altered gene along one of the autosomes. In most sit-
presence of the extra X chromosome results in poorly devel- uations, the affected individual comes from a family of
oped male secondary sexual characteristics, small testes, and multiple generations that have the disorder. The variant
infertility. Intelligence may be impaired as well. allele may also arise from a mutation (a spontaneous, per-
manent change in the normal gene structure). In this situa-
tion, the disorder occurs for the first time in the family. An
affected parent who is heterozygous for the trait (e.g., has a
Inheritance of Disease corresponding healthy recessive gene for the trait) has a
50% chance of passing the variant allele to each offspring.
Heritable characteristics describe those that can be passed Examples of autosomal dominant disorders include neuro-
on to offspring. The manner in which genetic material is fibromatosis (a progressive disorder of the nervous system
transmitted to the next generation is dependent on the that causes the formation of nerve tumors throughout the
number of genes involved in the expression of the trait. A body), Marfan syndrome (a connective tissue disorder in
number of phenotypic characteristics can result when two which the child is taller and thinner than normal and has
or more genes on different chromosomes act together associated heart defects), Factor V Leiden mutation (a disor-
(known as multifactorial inheritance). A trait or disorder der that significantly increases the individual’s risk for deep
may also be controlled by a single gene (referred to as venous thrombosis and pulmonary emboli) (Foster, 2007;
unifactorial inheritance). A family pedigree, or map of Moll, 2006), achondroplasia (dwarfism), Huntington’s dis-
family relationships, is useful for assessing the incidence ease (a progressive disease of the central nervous system
of inherited disorders. characterized by involuntary writhing, ballistic or dance-like
movements), and facioscapulohumeral muscular dystrophy
(a form of osteogenesis imperfecta, a disorder in which the
MULTIFACTORIAL INHERITANCE bones are extremely brittle). A typical pedigree of a family
The majority of congenital malformations result from mul- with neurofibromatosis, a dominantly inherited autosomal
tifactorial inheritance, a combination of genetic and envi- disorder, is shown in Figure 7-4. Several human genetic
ronmental factors. Examples include malformations such diseases, with their patterns of inheritance, are described
as cleft lip, cleft palate, neural tube defects, pyloric stenosis, in Table 7-1.
22Y 22X
Sperm Sperm
22X 22X
Egg
(ovum)
Fertilized
44XY egg 44XX Well female Well male
Sickle-cell anemia (R) The most common genetic disease among people of African ancestry. Sickle cell hemoglobin forms rigid
crystals that distort and disrupt red blood cells; oxygen-carrying capacity of the blood is diminished.
Cystic fibrosis (R) The most common genetic disease among people of European ancestry. Production of thick mucus clogs
the bronchial tree and pancreatic ducts. Most severe effects are chronic respiratory infections and
pulmonary failure.
Tay–Sachs disease (R) The most common genetic disease among people of Jewish ancestry. Degeneration of neurons and the
nervous system results in death by the age of 2 years.
Phenylketonuria of PKU (R) Lack of an enzyme to metabolize the amino acid phenylalanine leads to severe mental and physical
retardation. These effects may be prevented by the use of a diet (beginning at birth) that limits phenylalanine.
Huntington’s disease (D) Uncontrollable muscle contractions begin between the ages of 30 and 50 years, followed by loss of
memory and personality. There is no treatment that can delay mental deterioration.
Hemophilia (X-linked) Lack of Factor 8 impairs chemical clotting; may be controlled with Factor 8 from donated blood.
Duchenne’s muscular dystrophy Replacement of muscle by adipose or scar tissue, with progressive loss of muscle function; often fatal
(X-linked) before age 20 years due to involvement of cardiac muscle.
R recessive; D dominant.
Source: Scanlon, V.C. and Sanders, T. (2007). Essentials of anatomy and physiology (5th ed., p. 490). Philadelphia: F.A. Davis.
Mom
Carrier of color blindness
Xc X
Xc X
Well
male
Male with
disease
Female with
disease
X X XcX XX
Dad
Normal color vision
Figure 7-6 Family pedigree for X-linked dominant
inheritance. Y Y XcY XY
Key: XX X chromosome with gene for normal color vision
gene. Thus, when the male receives a “single dose” of the Y Y chromosome (has no gene for color vision)
altered gene, the disorder is expressed. For the disorder to Xc X chromosome with gene for red-green color blindness
be expressed in the female, the altered gene must be pres- Figure 7-7 Inheritance of red-green color blindness.
ent on both X chromosomes.
A female who is a carrier of a gene that causes an
X-linked recessive disorder has a 50% risk of passing the
abnormal gene to her male offspring. Each son has a 1 in
2 chance of expressing the disorder. The female carrier comes from the father. Cells reproduce through either
also has a 50% chance of passing the altered gene to her meiosis or mitosis. Meiosis is a process of cell division
female offspring, who will have a 1 in 2 chance of becom- that leads to the development of sperm and ova, each
ing carriers of the altered gene. A son who is affected by containing half the number (haploid) of chromosomes as
an X-linked disorder has a 100% chance of passing the normal cells. Mitosis is the process of the formation of
variant X to his daughters since the affected father has two identical cells that are exactly the same as the origi-
only one X to pass on. Fathers cannot transmit the altered nal cell and have the normal (diploid) amount of
gene to their male offspring because they transmit the Y chromosomes.
instead of the X chromosome to their sons. The Punnet Meiosis occurs during gametogenesis, the process in
square in Figure 7-7 illustrates the inheritance pattern for which germ cells, or gametes, are produced. During cell
red-green color blindness, an X-linked recessive inheri- division, the genetic complement of the cells is reduced
tance disorder. Other X-linked recessive inheritance dis- by one half. During meiosis, a sex cell containing
orders include hemophilia A, Duchenne (pseudohyper- 46 chromosomes (the diploid number of chromosomes)
trophic) muscular dystrophy and Christmas disease, a divides into two, and then four cells, each containing
blood-factor deficiency (Lashley, 2005). 23 chromosomes (a haploid number of chromosomes).
The resulting “daughter cells” are exactly alike, but they
Now Can You— Discuss aspects of patterns of inheritance? are all different from the original cell. The process of
meiosis includes two completely different cell divisions.
1. Differentiate between unifactorial and multifactorial patterns
During the first cell division, the chromosomes replicate
of inheritance?
each of the 46 chromosomes (diploid number of chro-
2. Compare and contrast autosomal dominant, autosomal
mosomes). The chromosomes then become closely inter-
recessive, and X-linked inheritance disorders?
twined and the sharing of genetic material occurs. New
3. Construct a Punnett square to illustrate inheritance patterns
combinations are produced, and this process accounts
for a dominant trait?
for the variations of traits in individuals. Next, the chro-
mosomes separate and the cell divides and forms two
daughter cells, each containing 23 double structured
chromosomes (the same amount of DNA as a normal
Cellular Division somatic cell).
In the second division, each chromosome divides and
Human cells can be categorized into either gametes each half (or chromatid) moves to opposite sides of the cell.
(sperm and egg cells) or somatic cells (any body cell that The cells divide and form four cells containing 23 single
contains 46 chromosomes in its nucleus). Gametes are chromosomes each, a haploid number of chromosomes, or
haploid cells. They have only one member of each chro- half the number of chromosomes present in the somatic
mosome pair and contain 23 chromosomes. Somatic cell. Gametes must contain the haploid number of chromo-
cells are diploid, which means that they contain chromo- somes. When the female and male gametes unite to form a
some pairs (a total of 46 chromosomes). One member of fertilized ovum (zygote), the normal (diploid) number of
each pair comes from the mother, and one member 46 chromosomes is reestablished. The entire process results
170 unit two The Process of Human Reproduction
in the creation of four haploid gamete cells from one serve a dual action: movement of the ovum toward the
diploid sex cell. uterus and movement of the sperm from the uterus
Mitosis is the phase in the cell cycle that permits dupli- toward the ovary. Of the 200 to 600 million sperm
cation of two genetically identical daughter cells each deposited, approximately 200 actually reach the fertil-
containing the diploid number of chromosomes. The pro- ization site.
cess of mitosis allows each daughter cell to inherit the Sperm must undergo a process called capacitation,
exact human genome. whereby a glycoprotein coat and seminal proteins are
removed from the surface of the sperm’s acrosome (the
caplike structure surrounding the head of the sperm).
The Process of Fertilization The sperm become more active during this process of
capacitation, which takes about 7 hours and usually
Fertilization is a complex series of events. Transportation occurs in the fallopian tube but may begin in the uterus.
of gametes must occur to allow the oocyte and the sperm An acrosome reaction occurs when the capacitated
to meet. Most often, this meeting takes place in the sperm comes into contact with the zona pellucida sur-
ampulla of the uterine (fallopian) tube (Fig. 7-8). rounding the secondary oocyte. During the acrosome
After completion of the first meiotic division, the reaction, enzymes from the sperm’s head are released.
secondary oocyte is expelled from the ovary during ovu- This helps to create a pathway through the zona pellu-
lation. The oocyte then makes its way to the infundibu- cida, allowing the sperm to reach the egg and fertiliza-
lum (funnel-shaped passage) at the end of the fallopian tion to occur.
tube and passes into the ampulla of the tube. At the time Once a sperm penetrates through the zona pellucida, a
of ejaculation, about 200 to 600 million sperm are reaction takes place to prevent fertilization by other
deposited around the external cervical os and in the sperm. The oocyte then undergoes its second meiotic divi-
fornix of the vagina. During ovulation, the amount of sion and forms a mature oocyte and secondary polar body.
cervical mucus increases and it becomes less viscous The nucleus of the mature oocyte becomes the female
and more favorable for sperm penetration. Propelled by pronucleus. The sperm loses its tail within the cytoplasm
the flagellar movement of their tails, sperm travel into of the oocyte, and then enlarges to become the male pro-
the uterus and upward through the fallopian tubes. nucleus. Fusion of pronuclei of both the oocyte and sperm
Muscular contractions of the tubal walls, believed to be create a single zygote containing the diploid number of
enhanced by prostaglandins in the semen, facilitate the chromosomes. The zygote is genetically unique in that it
sperm movement. The fallopian tubes are lined with contains half of its chromosomes from the mother and
cilia, hairlike projections from the epithelial cells that half from the father.
2 cell stage
(36 hours)
4 cell stage
(48 hours)
Fertilization
Morula
Primary follicles
Ovulation
Maturing follicles
Ovary
Maternal blood
sinus
Chorionic
villus
Maternal Maternal
arteriole venule
Fetal arteriole
and venule
Umbilical cord
Umbilical vein
Umbilical
Myometrium arteries
Endometrium
(maternal
part of
placenta)
Chorion
(fetal part of
placenta) Figure 7-9 Placenta and umbilical cord.
• Active transport: Substances transported via this fibers in the cervical collagen tissue, increases the pituitary
mechanism include amino acids, water-soluble secretion of prolactin, increases serum binding proteins
vitamins, calcium, iron, and iodine. and fibrinogen, decreases plasma proteins, and increases
• Pinocytosis and endocytosis: Globulins, phospholip- sensitivity of the uterus to progesterone in late pregnancy.
ids, lipoproteins, antibodies, and viruses use these The placenta also plays an important role in protecting
mechanisms of transport. the fetus from pathogens and in preventing maternal
• Bulk flow and solvent drag: Water and electrolytes use rejection of the pregnancy. Although many bacteria are
these mechanisms of transport. too large to pass through the placenta, most viruses and
• Accidental capillary breaks: Facilitate the transport of some bacteria are able to cross the placenta. Maternal
intact blood cells. antibodies (i.e., all subclasses of IgG) transit the placenta
• Independent movement: Maternal leukocytes and primarily by pinocytosis; others cross by the process of
microorganisms such as Treponema pallidum use this diffusion. Although the fetus has a unique genetic makeup
mechanism of transport. that is different from the mother’s, maternal rejection of
the fetus usually does not occur. The exact reason for this
Placental endocrine activity plays a crucial role in
phenomenon is not known.
maintaining the pregnancy. The four main hormones
produced by the placenta are human chorionic gonado-
trophin (hCG), human placental lactogen (hPL), proges-
terone, and estrogens. Human chorionic gonadotropin Development of the Embryo and Fetus
maintains the corpus luteum (a structure that secretes
progesterone) during early pregnancy until the placenta THE YOLK SAC
has sufficiently developed to produce adequate amounts Early in the pregnancy, the embryo is a flattened disc
of progesterone. Human placental lactogen regulates glu- that is situated between the amnion (thick membrane
cose availability for the fetus and promotes fetal growth that forms the amniotic sac that surrounds the embryo
by altering maternal protein, carbohydrate, and fat metab- and fetus) and the yolk sac. The yolk sac is a structure
olism. Progesterone helps to suppress maternal immuno- that develops in the embryo’s inner cell mass around day
logical responses to fetal antigens, thereby preventing 8 or 9 after conception. It is essential for the transfer of
maternal rejection of the fetus. Progesterone has a num- nutrients to the embryo during the second and third
ber of additional functions: decreases myometrial activity weeks of gestation when development of the uteropla-
and irritability, constricts myometrial vessels, decreases cental circulation is underway. Hematopoiesis (forma-
maternal sensitivity to carbon dioxide, inhibits prolactin tion and development of red blood cells) occurs in the
secretion, relaxes smooth muscle in the gastrointestinal wall of the yolk sac beginning in the third week. This
and urinary systems, increases basal body temperature, function gradually declines after the eighth gestational
and increases maternal sodium and chloride secretion. week when the fetal liver begins to take over this pro-
Estrogen production increases significantly during preg- cess. As the pregnancy progresses, the yolk sac atrophies
nancy. This essential hormone enhances myometrial activ- and is incorporated into the umbilical cord. Key events
ity, promotes myometrial vasodilation, increases maternal that take place during early development of the embryo
respiratory center sensitivity to carbon dioxide, softens are shown in Figure 7-10.
chapter 7 Conception and Development of the Embryo and Fetus 173
Approximately 12 days
Embryonic
disc
Approximately 14 days
Embryonic
disc
Approximately 20 days
Head of
embryo
Chorionic
villi
Head of embryo
Endometrium Umbilical
Tr ophoblast cord
Amnion
Yo lk sac Limb buds
Embryo
Placenta Figure 7-10 Key events during early
Chorion
development of the embryo.
ORIGIN AND FUNCTION OF THE UMBILICAL 2. Describe seven mechanisms used for the transport of
CORD nutrients across the placenta?
3. Discuss how human placental lactogen (hPL) promotes fetal
During the time of placental development, the umbilical
growth?
cord is also being formed. The body stalk connects the
embryo to the yolk sac that contains blood vessels connect-
ing to the chorionic villi. The vessels contract to form two THE FETAL CIRCULATORY SYSTEM
arteries and one vein as the body stalk elongates and devel-
ops into the umbilical cord. Maternal blood flows through The embryo receives nutrition from maternal blood by
the uterine arteries and into the intervillous spaces of the diffusion through the extraembryonic coelom (fluid-filled
placenta. The blood returns through the uterine veins and cavity surrounding the amnion and yolk sac) and the yolk
into the maternal circulation. Fetal blood flows through the sac by the end of the second week. Blood vessels begin to
umbilical arteries and into the villous capillaries of the pla- develop in the yolk sac during the beginning of the third
centa. The blood returns through the umbilical vein and week and embryonic blood vessels begin to develop about
into the fetal circulation. Wharton’s jelly is a specialized two days later. A primordial heart tube joins with blood
connective tissue that surrounds the two arteries and one vessels in the embryo, connecting the body stalk, chorion,
vein in the umbilical cord. This tissue, in addition to the and yolk sac to form a primitive cardiovascular system.
high volume and pressure in the blood vessels, is important The heart begins to beat and blood begins to circulate by
because it helps to protect the umbilical cord from com- the end of the third week.
pression. Most umbilical cords have a central insertion site During the third week, capillaries develop in the chori-
into the placenta and at term are approximately 21 inches onic villi and become connected to the embryonic heart
(55 cm) long with a diameter that ranges from 0.38 to through vessels in the chorion and the connecting stalk.
0.77 inch (1 to 2 cm). By the end of the third week, embryonic blood begins to
flow through capillaries in the chorionic villi. Oxygen and
nutrients from maternal blood diffuse through the walls in
Now Can You— Discuss characteristics of growth in the the villi and enter the embryo’s blood. Carbon dioxide and
embryo/fetus? waste products diffuse from blood in the embryo’s capil-
1. Identify where the developing embryo obtains nutrients laries through the wall of the chorionic villi and into the
prior to development of the feto–maternal circulatory maternal blood. The umbilical cord is formed from the
placental unit? connecting stalk during the fourth week.
174 unit two The Process of Human Reproduction
Blood travels through the fetus in a unique way. The Superior Aortic arch Ductus
umbilical cord contains three vessels: two arteries and one vena cava arteriosus
vein. Blood flows through the vein from the placenta to Non-inflated Left
atrium
the fetus. A small amount of blood flows through the liver lung
and then empties into the inferior vena cava. Most of the
blood bypasses the liver and then enters the inferior vena
Pulmonary
cava by way of the ductus venosus, a vascular channel veins
that connects the umbilical vein to the inferior vena cava.
The blood then empties into the right atrium, passes Right
through the foramen ovale (an opening in the septum atrium
between the right and left atrium) into the left atrium, Foramen
ovale
then moves into the right ventricle and on into the aorta. (open) Inferior
From the aorta, blood travels to the head, upper extremi- vena cava
ties, and lower extremities. Blood returning from the head Ductus
venosus Aorta
enters the superior vena cava, then the right atrium and
the right ventricle before entering the pulmonary artery. Liver
Oxygen saturation
Most of the blood that enters the pulmonary artery Portal of blood
bypasses the lungs and enters the aorta through the ductus vein High
arteriosus, a vascular channel between the pulmonary Medium
Umbilical
artery and descending aorta. The remaining blood flows to vein Low
the pulmonary circulation to support lung development.
The blood then returns through the pulmonary vein to the To legs
left atrium, the left ventricle, to the aorta, and returns to
the placenta through the two arteries. Most of the blood Umbilical
in the lower extremities enters the internal iliac artery and cord
the umbilical arteries to the placenta to be re-oxygenated Placenta Internal iliac
and re-circulated. Some of the blood in the lower extremi- artery
ties passes back to the ascending vena cava and is mixed Umbilical arteries
with oxygenated blood from the placenta without being
oxygenated. Urinary bladder
The placenta is the site of oxygenation and waste elimi-
nation. Blood travels through the umbilical vein from the
placenta to the fetus (Fig. 7-11). There are three shunts Figure 7-11 Fetal circulation.
unique to fetal circulation:
1. Some blood circulates through the liver, but most
bypasses the liver through the ductus venosus and toward the placenta. The low PO2 level is important in
enters the inferior vena cava. maintaining fetal circulation, as it keeps the ductus arteri-
2. Blood from the superior vena cava enters the right osus open and the pulmonary vascular bed constricted.
atrium, passes through the foramen ovale, through Fetal hemoglobin enables the fetus to adapt to the lowered
the right ventricle and into the aorta, supplying PO2. This unique type of hemoglobin has a high affinity
blood to the head and upper and lower extremities. for oxygen at low tensions, which improves saturation
3. Blood returning from the head enters the right and facilitates oxygen transport to the fetal tissues. The
atrium, and then flows through the right ventricle increased perfusion rate (as compared to the adult) also
and into the pulmonary artery. Most of this blood helps to compensate for the lower oxygen saturations and
bypasses the lungs through the ductus arteriosus. A increased oxygen–hemoglobin affinity.
small amount of blood flows through the pulmo-
nary circulation, back into the right atrium, right Now Can You— Discuss unique aspects of the fetal
ventricle, and then into the aorta. circulatory system?
1. Name the three shunts found in the fetal circulatory system?
The arterial PO2 of the fetus is about one-fourth of the
2. Identify where the highest and lowest fetal oxygen
maternal PO2 because of the structure and function of the
concentrations are found?
placenta (i.e., oxygenation of fetal blood takes place at a
3. Explain how fetal hemoglobin is unique?
low PO2), and because arterial blood in the fetal circula-
tion is formed by the mixing of maternal oxygenated
blood with fetal deoxygenated blood. Fetal hemoglobin
has a lower oxygen content than that of the adult. The FETAL MEMBRANES AND AMNIOTIC FLUID
highest oxygen concentration (PO2 30 to 35 mm Hg) is The embryonic membranes (chorion and amnion) are
found in the blood returning from the placenta via the early protective structures that begin to form at the time of
umbilical vein; the lowest oxygen concentration occurs in implantation. The thick chorion, or outer membrane,
blood shunted to the placenta where re-oxygenation takes forms first. It develops from the trophoblast and encloses
place. The blood with the highest oxygen content is deliv- the amnion, embryo, and yolk sac. The chorion contains
ered to the fetal heart, head, neck, and upper limbs, while fingerlike projections (chorionic villi) that may be used for
the blood with the lowest oxygen content is shunted genetic testing (chorionic villus sampling) during the first
chapter 7 Conception and Development of the Embryo and Fetus 175
trimester. The villi beneath the embryo grow and branch The loss of a fetus before 20 to 22 weeks’ gestation (less
out into depressions in the wall of the uterus, and from this than 500 grams) is referred to as an abortion because the
structure, the fetal portion of the placenta is formed. fetus is considered too immature to survive the extrauterine
The amnion arises from the ectoderm during early (outside of the uterus) environment. A fetus born before the
embryonic development. This membrane is a thin, protec- completion of 37 weeks is considered to be preterm or
tive structure that contains the amniotic fluid. The amni- premature.
otic cavity, or space between the amnion and the embryo,
houses the embryo and yolk sac, except in the area where PRE-EMBRYONIC PERIOD
the developing embryo attaches to the trophoblast via the
The pre-embryonic period refers to the first 2 weeks of
umbilical cord. With embryonic growth, the amnion
human development after conception. Rapid cellular mul-
expands and comes into contact with the chorion. The
tiplication, cell differentiation, and establishment of the
two fetal membranes are slightly adherent and form the
embryonic membranes and primary germ layers occur dur-
amniotic fluid-filled sac (the amniotic sac), also called
ing this time. Development takes place in a pattern that is
the bag of waters. The fetal membranes provide a barrier
cephalocaudal, proximal to distal and general to specific.
of protection from ascending infection.
Amniotic fluid is vital for fetal growth and development.
It cushions the fetus and protects against mechanical injury, EMBRYONIC PERIOD
helps the fetus to maintain a normal body temperature, Critical development that occurs during the embryonic
allows for symmetrical fetal growth, prevents adherence of period involves cleavage of the zygote, blastogenesis (early
the amnion to the fetus, and aids in fetal musculoskeletal development characterized by cleavage and formation of
development by providing freedom of movement. It is three germ layers that later develop into tissues and
essential for normal fetal lung development. Amniotic fluid organs), and the early development of the nervous system,
volume is dynamic, constantly changing as the fluid moves cardiovascular system, and all major internal and external
back and forth across the placental membrane. structures. The pre-embryonic period refers to the first
Amniotic fluid first appears at about 3 weeks. Approxi- 2 weeks beginning at fertilization, which for most is
mately 30 mL of amniotic fluid are present at 10 weeks’ approximately 2 weeks after the last normal menstrual
gestation, and this amount increases to approximately period. The embryonic period is the time period begin-
800 mL at 24 weeks’ gestation. After that time, the total ning with the third week after fertilization and continuing
fluid volume remains fairly stable until it begins to until the end of the eighth week. This period is known as
decrease slightly as the pregnancy reaches term. the organogenetic period that denotes the formation and
During late gestation, fetal urine and fetal lung secre- differentiation of organs and organ systems.
tions are the primary contributors to the total amniotic
fluid volume. Fetal swallowing and absorption through Week 1
the placenta are the primary pathways for amniotic fluid Fertilization usually occurs in the outer third portion of the
clearance. The fetus swallows approximately 600 mL uterine tube. The zygote then travels toward the uterus,
every 4 hours and up to 400 mL of amniotic fluid flows while undergoing cleavage (series of mitotic cell division)
from the fetal lungs every 24 hours. Amniotic fluid is and forming blastomeres (cells formed from the first mitotic
slightly alkaline and contains antibacterial and other pro- division). Approximately 3 days after fertilization, a morula
tective substances similar to those found in maternal (a ball of 12 or more blastomeres) enters the uterus. A cav-
breast milk (e.g., transferrin, beta-lysin, peroxidase, fatty ity forms within the morula, creating a blastocyst that con-
acids, immunoglobulins [IgG and IgA], and lysozyme). It sists of a trophoblast that encloses both the embryoblast
also contains albumin, uric acid, creatinine, lecithin, (gives rise to the embryo and some extraembryonic tissues)
sphingomyelin, bilirubin, vernix, leukocytes, epithelial and the blastocystic cavity (fluid-filled space). The tropho-
cells, and lanugo (fine, downy hair). blast begins to invade the uterus and the blastocyst is super-
ficially implanted by the end of the first week.
Now Can You— Discuss aspects of the amniotic sac and
amniotic fluid? Week 2
1. Identify the origins of the embryonic membranes? The trophoblast undergoes rapid proliferation and differ-
2. Name five functions of the amniotic fluid? entiation as the blastocyst continues the process of uterine
3. Discuss where amniotic fluid originates? implantation. The yolk sac develops, the amniotic cavity
appears, and the embryoblast differentiates into the bilam-
inar embryonic disc. Implantation of the blastocyst is
completed by the end of the second week.
Weeks 21 to 25
The fetus gains much weight during this time. The skin
appears pink or red as blood is now visible in the capil-
laries. Rapid eye movements begin at 21 weeks. By
Figure 7-13 The embryo at 8 weeks (56 to 24 weeks, the fetus has fingernails and the lungs have
57 postovulatory days) has a human appearance. begun to secrete surfactant, a substance that decreases
(Smith, B.R. (2008). The multidimensional human surface tension in the alveoli and is necessary for survival
embryo, Carnegie Stages. Retrieved from http:// following birth.
embryo.soad.umich.edu/carnstages/)
Weeks 26 to 29
ized by rapid body growth and differentiation of tissues, A fetus may survive if born during this time because the
organs, and systems. The rate of head growth during this lungs can breathe air, and the central nervous system can
period of time slows down as compared to the rate of body regulate body temperature and direct rhythmic breathing.
growth. During the last 12 weeks of pregnancy there is a The eyelids are open, the toenails are evident, and subcuta-
substantial increase in fetal size: the weight triples and the neous fat is present under the skin. Erythropoiesis occurs
body length doubles. in the spleen but ends at 28 weeks when the bone marrow
takes over that function.
Weeks 9 to 12
The fetal head is half the length of the crown–rump Weeks 30 to 34
length at the beginning of the ninth week. The face is At 30 weeks, the pupillary light reflex is present.
recognizably human at 10 weeks. Body growth increases,
and as a result, the crown–rump length more than dou- Weeks 35 to 40
bles by the twelfth week. Head growth does not keep pace At 35 weeks, the fetus has a strong hand grasp reflex and
with body growth and slows considerably by the twelfth orientation to light. At 38 to 40 weeks, the average fetus
week but remains proportionately large as compared to weighs 3000 to 3800 grams, and is 17.3 to 19.2 inches
the rest of the body. Ossification centers appear in the (45 to 50 cm) long (Table 7-3).
skeleton. The intestines leave the umbilical cord and
enter the abdomen. The external genitalia differentiate
and are distinguishable by week 12. At 9 weeks, the liver Across Care Settings: Empowering through
serves as the major site for red blood cell production education
(erythropoiesis). However, by 12 weeks, the spleen begins
The nurse who works in any perinatal setting can help
to take over this process. Urine production commences
to promote self-care and empowerment by increasing
between 9 and 12 weeks.
the pregnant woman’s understanding of the prenatal
Weeks 13 to 16 journey and by encouraging her active involvement in
safeguarding her pregnancy. Providing information
There is very rapid growth during this period. Although
regarding normal fetal growth and development
coordinated movements of the limbs occur by the four-
constitutes an important component of the early and
teenth week, they are too small to be felt by the mother.
ongoing bonding process for many women. Displaying
Ossification of the skeleton takes place and the bones
fetal growth charts in visible areas and discussing
become clearly visible on ultrasound examination. The
developmental landmarks throughout gestation facilitate
external genitalia are recognizable by 12 to 14 weeks, the
discussion and enhance understanding for the patient
ovaries are differentiated, and the primordial (primitive)
and her family. Other professional resources including
ovarian follicles are present by 16 weeks.
the nutritionist, social worker, and home health worker
Weeks 17 to 20 can be instrumental in helping to ensure healthy fetal
Growth continues but slows during this period. Mater- growth and development.
nal awareness of fetal movements (quickening) is fre-
quently reported during this time. The skin is now cov-
ered with a thick, cheese-like material called vernix
caseosa that protects the fetal skin from exposure to the Nursing Insight— Preterm birth at less than
amniotic fluid. By 20 weeks, hair appears on the eye- 38 weeks’ gestation
brows and head. Fine downy hair (lanugo) is usually It is important to understand fetal growth and development so
present by 20 weeks and covers all parts of the body that the nurse can anticipate specific types of problems that
except the palms, soles, or areas where other types of may occur when infants are born prematurely. An infant born
hair are usually found. Subcutaneous deposits of brown at 28 weeks will have significantly different needs from an
fat, used by the newborn for heat production, help to infant born at 38 weeks’ gestation.
make the skin less transparent in appearance. The fetal
178 unit two The Process of Human Reproduction
Now Can You— Discuss major events of the fetal period? is unknown in approximately 50% to 60% of cases. Con-
1. Identify the developmental week when the fetal face genital anomalies may occur singularly or in combination
becomes human in appearance? with other defects (multiple anomalies) and they may be
2. Name the cheese-like substance that covers and protects of little or of great clinical significance. Single, minor
the skin? anomalies occur in approximately 14% of newborns. The
3. List three developmental events that occur from 26 to greater the number of anomalies present, the greater
29 weeks? the risk of a major anomaly. Statistically, 90% of infants
with three or more minor anomalies will also have one
or more major anomaly. Major developmental defects are
more common in early embryos that are usually sponta-
Factors that May Adversely Affect neously aborted. It has been estimated that approximately
one-third of all birth defects are caused by genetic
Embryonic and Fetal Development factors.
Before fertilization, damage may have already occurred
Damage to the developing embryo/fetus may result from
to the chromosomes of one or both parents, or they may
genetic factors or from maternal exposure to various envi-
carry defective genes inherited from their own parents.
ronmental hazards. In most circumstances, the uterus
Alterations in the development of sperm or an ovum may
provides a safe and peaceful environment for the develop-
also cause alterations in the development of the embryo.
ing embryo and fetus. However, teratogens (drugs, radia-
Teratogens or environmental factors may adversely affect
tion, and infectious agents that can cause developmental
the process of implantation and result in loss of the
or structural abnormalities in an embryo) and a variety of
zygote. Teratogens may have specific effects associated
internal and external developmental events may cause
with congenital anomalies (e.g., alcohol: fetal alcohol syn-
structural and functional defects.
drome; rubella: cataracts; tetracycline: stained teeth) or
they may produce dysmorphic (damage to the structure
CHROMOSOMES AND TERATOGENS and form) features. The extent of the teratogenic effect
Genetic defects and congenital anomalies usually result depends on the developmental timing, duration, and dos-
from genetic factors, environmental hazards (e.g., drugs age of exposure as well as the maternal genetic suscepti-
and viruses), or a combination of both (multifactorial bility. Greater exposure during early gestation is associ-
inheritance). However, the exact cause of anomalies ated with more severe effects.
chapter 7 Conception and Development of the Embryo and Fetus 179
vasoconstriction of the uterine blood vessels, resulting in depression. The fetus is at an increased risk for intrauterine
a decreased blood flow and supply of nutrients and oxy- growth restriction, prematurity, cardiac anomalies, cleft
gen to the fetus. Cigarette smoking doubles the risk of low palate, and placental abruption. Following birth, affected
birth weight and increases the likelihood of giving birth neonates may exhibit hypoglycemia, sweating, poor visual
to a small for gestational age (SGA) infant (Reed, Aranda, tracking, lethargy, and difficulty feeding. (See Chapter 9 for
& Hales, 2006). Cessation of smoking during pregnancy further discussion.)
is beneficial to the developing fetus, and infants born to
MARIJUANA. -9-Tetrahydrocannabinol (THC), the active
women who stop smoking during the first trimester have
component in marijuana, passes through the placenta and
birth weights similar to those of infants born to nonsmok-
may remain in the fetus for up to 30 days. The carbon mon-
ing women. (See Chapter 10 for further discussion.)
oxide levels produced with marijuana smoking are five
CAFFEINE. Caffeine, present in many beverages (sodas, times higher than amounts produced with cigarette smok-
coffee, tea, hot cocoa) and other substances including choc- ing. Marijuana may cause intrauterine growth restriction,
olate, cold remedies, and analgesics, is the most popular and research has indicated that maternal use of marijuana
drug in the United States. Caffeine stimulates central ner- during pregnancy has adverse effects on neonatal neurobe-
vous system and cardiac function and produces vasocon- havior (e.g., hyperirritability, tremors, photosensitivity) and
striction and mild diuresis. The half-life of caffeine is tripled can affect cognitive and language development in infants up
during pregnancy. Although caffeine readily crosses the pla- to 48 months of age (Chiriboga, 2003). In addition, mater-
centa and stimulates the fetus, it is not known to be a terato- nal marijuana use is often combined with other drugs such
gen. However, there is no assurance that maternal consump- as cocaine and alcohol. Repeated marijuana use during preg-
tion of large quantities of caffeine is safe for the developing nancy may increase the incidence of maternal anemia and
fetus. (See Chapter 10 for further discussion.) low weight gain. (See Chapters 9 and 10 for further
discussion.)
COCAINE AND CRACK. Cocaine and crack (a form of free-
base cocaine that can be smoked) use during pregnancy RADIATION. High levels of radiation during pregnancy
causes vasoconstriction of the uterine vessels and adversely may cause damage to chromosomes and embryonic cells.
affects blood flow to the fetus. Cocaine use in pregnancy is Radiation can adversely affect fetal physical growth and
associated with spontaneous abortion, abruptio placentae, cause mental retardation. Unborn babies are particularly
stillbirth, intrauterine growth restriction (IUGR), fetal dis- at risk to damage from radiation exposure during the first
tress, meconium staining, and preterm birth. Problems trimester. Consequences of radiation exposure during this
manifested in children born to women who use cocaine dur- time include stunted growth, deformities, abnormal brain
ing pregnancy include altered neurological and behavior function, or cancer that may develop sometime later in life
patterns, neonatal strokes and seizures, and congenital mal- (Centers for Disease Control and Prevention [CDC],
formations (genitourinary anomalies, limb reduction defor- 2005).
mities, intestinal atresia, and heart defects) (Chiriboga,
2003). (See Chapters 9 and 10 for further discussion.) LEAD. Lead passes through the placenta and has been
found to be associated with spontaneous abortion, fetal
OPIATES. Morphine, heroin, and methadone are opiates anomalies, and preterm birth. The nervous system is the
sometimes used by pregnant women. Maternal effects from most sensitive target of lead exposure. Fetuses and young
these substances include spontaneous abortion, premature children are especially vulnerable to the neurological
rupture of the membranes, preterm labor, an increased inci- effects of lead because their brains and nervous systems
dence of sexually transmitted infections, hepatitis, an are still developing and the blood–brain barrier is incom-
increased potential for HIV exposure, and malnutrition. plete (USDHHS, 1999). Fetal anomalies associated with
Methadone is a habit-forming synthetic analgesic drug with lead exposure include hemangiomas, lymphangiomas,
a potency equal to that of morphine but with a weaker nar- hydrocele, minor skin abnormalities (e.g., skin tags and
cotic action. It is frequently given to pregnant women who papillae), and undescended testes (Gardella, 2001).
enter drug addiction programs. Fetal death, intrauterine
growth restriction, perinatal asphyxia, prematurity, intellec-
tual impairment, and neonatal infection are associated with Optimizing Outcomes— Prenatal screening and
maternal opiate use. Neonatal withdrawal syndrome, char- questions regarding drug use
acterized by hyperirritability, gastrointestinal dysfunction, Due to the teratogenic effects of drugs and other sub-
respiratory distress, and autonomic disturbances, has been stances on the developing embryo/fetus, prenatal screening
reported in 50 to 80% of infants born to opiate-dependent for maternal drug use is an important component of the
mothers (Chiriboga, 2003). (See Chapters 9 and 19 for fur- prenatal interview. The nurse should ask questions regard-
ther discussion.) ing maternal drug use in a nonjudgmental manner that
SEDATIVES. Barbiturates and tranquilizers produce conveys caring and concern. Questions should be specific,
maternal lethargy, drowsiness, and CNS depression. In and begin with inquiries that concern innocuous drug use
the neonate, these substances are associated with with- and then progress to the most harmful substances. Exam-
drawal syndrome, seizures and delayed lung maturity. ples of questions to ask include the following:
Do you drink any caffeinated beverages? How many
AMPHETAMINES. Amphetamines are also known as in a day?
“speed,” “crystal,” and “ice”; use of these substances during Do you smoke cigarettes? How many in a day?
pregnancy is associated with maternal malnutrition, tachy- Do you drink alcohol? What kind, and how much
cardia, and withdrawal symptoms that include lethargy and in a day?
chapter 7 Conception and Development of the Embryo and Fetus 181
been associated with varicella infection that occurs after that occurs later in the pregnancy may result in fetal intra-
20 weeks’ gestation (Moore & Persaud, 2003) although uterine growth restriction, microphthalmia, chorioretinitis,
approximately 25% of infants born to mothers who become blindness, microcephaly, cerebral calcification, mental
infected with varicella in the last 3 weeks of pregnancy will retardation, deafness, cerebral palsy, and hepatospleno-
develop clinical varicella (Gershon, 2006). megaly. In the neonate, asymptomatic CMV infections are
The human immunodeficiency virus may be transpla- often associated with audiological, neurological, and neu-
centally transmitted to the fetus in utero. Infection may robehavioral disturbances.
also occur intrapartally (during labor and birth) from
exposure to maternal blood and body fluids, and post- Herpes Simplex Virus (HSV)
partally (after birth), through breast milk. Without Spontaneous abortion is increased threefold if maternal
medical intervention, the risk of perinatal transmission infection from herpes simplex virus occurs in early preg-
of HIV is approximately 25%; with appropriate treat- nancy. Infection after the twentieth gestational week is
ment, the rate of perinatal transmission can be reduced associated with an increased rate of prematurity. The
to 2% (Havens & Walters, 2004). (See Chapter 11 for transmission of the herpes virus occurs at the time of deliv-
further discussion.) ery during passage through the birth canal, but may also
Treponema pallidum, the microorganism that causes occur transplacentally via ascending infection before labor
syphilis, readily crosses the placenta. The fetus may become or rupture of the membranes. Congenital anomalies asso-
infected during any time of gestation. Serious fetal infection ciated with the herpes simplex virus include extensive
and congenital anomalies are almost always associated with dermatological scarring or bullae, microencephaly, hydren-
primary maternal infections that occur during pregnancy. cephaly, encephalitis, microphthalmia, chorioretinitis, and
However, Treponema pallidum can be destroyed with ade- hepatosplenomegaly (Pan, Cole, & Weintrub, 2005). (See
quate treatment that will prevent placental transmission Chapter 19 for further discussion.)
and fetal infection. Secondary infections acquired before
pregnancy rarely result in fetal disease and anomalies. Left
Now Can You— Discuss TORCH infections?
untreated, only 20% of pregnant women with primary
syphilis infections will give birth to a normal term infant. 1. Identify the components of the acronym “TORCH”?
Neonatal manifestations of congenital syphilis infection 2. Describe a teaching need for pregnant women who have
include prematurity, skin rash, hydrops fetalis, failure to indoor cats?
thrive, hepatosplenomegaly, lymphadenopathy, and bone 3. Explain why pregnant women should avoid individuals
lesions (osteochondritis, osteomyelitis, and periostitis). infected with chickenpox and rubella?
Late-onset manifestations of congenital syphilis infection
include keratitis (inflammation of the cornea), deafness,
and bowing of the shins (Woods, 2005).
The Nurse’s Role in Prenatal
Rubella
The virus that causes rubella (also known as German
Evaluation
measles) can cause damage to the developing embryo/ The clinical gestational period is divided into three trimes-
fetus. The earlier in the pregnancy that the disease is con- ters that each last for 3 months. By the end of the first tri-
tracted, the greater the risk to the developing embryo. If mester, all major organs are developed. During the second
the pregnant woman experiences a primary rubella infec- trimester, the fetus continues to grow in size and most fetal
tion during the first trimester, there is a 20% risk that the anomalies can be detected using high-resolution real-time
fetus will also become infected. When maternal rubella ultrasound. By the beginning of the third trimester the
infection occurs during the first 4 to 5 weeks after fertil- fetus has a chance for survival and most survive if born at
ization, the majority of infants will demonstrate congeni- or after 35 weeks’ gestation.
tal anomalies. If rubella is contracted during the second At the initial prenatal visit, the nurse performs an
and third trimesters, the risk of congenital anomalies is assessment that includes careful consideration of cultural,
decreased to 10%, but mental retardation and hearing loss emotional, physical, and physiological factors that may
may result from infection that occurs late in the gestation. signal a need for genetics counseling and comprehensive
Birth defects associated with congenital rubella syndrome fetal evaluation.
include hearing loss, eye defects causing vision loss or
blindness, heart defects, and mental retardation.
by extrinsic mechanical factors (e.g., clubfoot that results with Down syndrome may be born to mothers of any age:
from intrauterine fetal restraint or fetal compression defects approximately 80% of children with Down syndrome are
that result from decreased amniotic fluid [oligohydram- born to mothers younger than 35 years (National Down
nios]). Dysplasia (an abnormal development of tissue) is Syndrome Society, 2006).
caused by an abnormal organization of cells that results in A trisomy occurs when there are three particular
abnormal tissue formation. (See Chapter 11 for further chromosomes instead of the normal number of two.
discussion.) Figure 7-14 illustrates the extra chromosome that occurs
Damage that may alter embryological development can with Down syndrome. The three most common triso-
occur to the chromosomes of one or both parents prior mies found in live newborns are trisomy 18 (Edward
to conception. During the pre-embryonic period (up to syndrome), trisomy 21 (Down syndrome), and trisomy
14 days after conception), while the zygote is protected by 13 (Patau syndrome).
the zona pellucida, exposure to teratogens most likely Trisomy 13 and trisomy 18 are rare; each occurs only
causes either no harmful effects or produces severe dam- about once in every 5000 live births. Trisomy 21 is the
age that results in loss of the pregnancy. most common trisomy and occurs in approximately
every 650 live births (Scanlon & Sanders, 2007). The
prognosis for both trisomy 13 and 18 is very poor;
— Prenatal identification of a fetal
approximately 70% of infants with these chromosomal
anomaly
disorders die within the first 3 months of life from
Prenatal testing may identify a fetus with a congenital complications associated with respiratory and cardiac
anomaly. When this occurs, families are generally faced abnormalities. Neonatal effects from these three most
with a flood of emotions and difficult decisions. The common trisomies include central nervous system
nurse plays an important role in providing support and abnormalities, mental retardation, and hypotonia at
education regarding options available to these couples. A birth. Although children with Down syndrome are men-
nonjudgmental and caring attitude is vital at this difficult tally retarded, there is a wide range of mental ability
and vulnerable time. among this group.
Therapeutic communication is enhanced when the Deletion and translocation describe other chromo-
nurse uses statements such as: somal abnormalities. Women younger than 35 years of
“It’s normal to have fear, grief, or even be angry.” age who have previously given birth to a child with a
“It’s normal to have concerns about your ability to chromosomal abnormality have a 1% increased risk of
have a normal baby.” having another affected child. A deletion is a loss of a por-
“I am here to answer your questions and listen to tion of DNA from a chromosome (Fig. 7-15). This altera-
your concerns. If I don’t know the answers I will either tion can be caused by an unknown event, mutation, or
find and share them or arrange for a colleague to meet exposure to irradiation, or it may occur during cell divi-
with you. sion. When a gene necessary for cell function is absent,
The nurse should avoid using statements such as: disease may result. A translocation occurs when all or a
“You can always have other children.” segment of one chromosome breaks off and attaches to the
“I know how you feel.” same or to a different chromosome (Fig. 7-16). Parents
“At least you don’t know the baby yet.” who have a chromosomal translocation or who have had
a child with structural malformations are at increased risk
for having another affected child.
1 2 3 4 5 6 7 8 9
Deleted
area
Derivative
Chromosome 4
Before After
deletion deletion Chromosome 4
Figure 7-16 Translocation. (Courtesy of National Human
Figure 7-15 Deletion. (Courtesy of National Human
Genome Research Institute.)
Genome Research Institute.)
Multifetal Pregnancy
Monozygotic (identical) twins develop from one fertilized
oocyte (zygote) that divides into equal halves during an
early cleavage phase (series of mitotic cell divisions) of
development (Fig. 7-17). This type of twinning occurs in
approximately 1 of 250 live births (Benirschke, 2004).
Monozygotic twins are genetically identical, always the
same gender, and very similar in physical appearance. The
number of amnions and chorions depends on the timing of
division (cleavage) of the zygote. If the division occurs dur-
ing the two to eight cell stages, there will be two amnions,
two chorions, and two placentas. For most monozygotic
twins, the division occurs at the end of the first week after A B
fertilization and results from the division of the singular
embryoblast into two embryoblasts. When the division Uterine wall Amnion
occurs during this time, each fetus has its own amnion, but Placenta Umbilical cord
resides within a single chorion and receives oxygen and Chorion Amniotic fluid
nutrients from the same placenta. Depending on the timing
of cleavage, the following multifetal combinations occur:
Figure 7-17 Multiple gestations. A, Monozygotic twins
• Division that occurs during the first 72 hours after with one placenta, one chorion and two amnions.
fertilization: two embryos, two amnions, and two B, Dizygotic twins with two placentas, two chorions
chorions develop with two distinct placentas, or a and two amnions
single fused placenta.
• Division that occurs between the fourth and eight day:
two embryos, each in a separate amnion sac covered
by a single chorion.
• Division that occurs approximately 8 days after fertil- Dizygotic (fraternal) twins develop from two zygotes
ization after the chorion and amnion have differenti- and may be the same or different genders. Dizygotic
ated: two embryos in a common amniotic sac. twins are no more genetically similar than other siblings
• Division that occurs after the embryonic disk has formed: born to the same parents. There are separate amnions
cleavage is incomplete and conjoined twins result. and chorions although the chorions and placentas may
be fused. The incidence of dizygotic twinning is approx-
Conjoined twins occur when the embryonic disc does imately 1 in 500 Asians, 1 in 125 Caucasians, and as
not divide completely, or when adjacent embryonic discs high as 1 in 20 in some African populations. Triplets
fuse. Conjoined twinning occurs in approximately 1 in may result from the division of a single zygote into three
50,000 to 100,000 births. Twins may be connected to one zygotes (one original fertilized egg), or from the divi-
another by the skin only or by cutaneous and other tis- sion of one zygote (identical twins are formed) plus
sues. In many cases, surgical separation is possible but, another zygote (a total of two original fertilized eggs),
depending on the anatomical region of attachment and or from three different zygotes (a total of three original
the sharing of vital organs, may not be feasible. fertilized eggs).
186 unit two The Process of Human Reproduction
disorders are enrolled in appropriate service interven- 3. When describing fetal growth and development, the
tions in a timely manner. Additional information about perinatal nurse correctly identifies the gestational
the Healthy People 2010 national initiative is available at week that the heart begins to beat as the:
http://www.healthypeople.gov/Publications. A. Second
B. Third
C. Fourth
s umma ry p o in t s D. Sixth
◆ The Human Genome Project that ended in 2003 pro- 4. The perinatal nurse provides information about fetal
vided important insights into our understanding of the growth and development to parents in a prenatal
genetic complexity of humans. class. The nurse explains that fetal urine production
begins at:
◆ A genotype is an individual’s gene composition; a phe- A. 6 to 8 weeks
notype refers to the observable expression of a person’s B. 9 to 12 weeks
genotype; a genome is a complete copy of the genes C. 12 to 16 weeks
present. D. 15 to 18 weeks
◆ The developing embryo/fetus lives in a unique environ- 5. During preconception counseling, the clinic nurse
ment where all essential elements needed for normal explains that the time period when the fetus is most
growth and development is provided. vulnerable to the effects of teratogens is from:
◆ The gestational period, which lasts an average of A. 5 to 10 weeks
40 weeks from the time of fertilization, occurs in three B. 2 to 8 weeks
stages: the pre-embryonic stage; the embryonic stage; C. 4 to 12 weeks
and the fetal stage. D. 6 to 15 weeks
◆ During the embryonic stage the heart begins to beat True or False
and the body’s circulation is established.
6. The perinatal nurse describes the process of inception
◆ Structural refinement and perfection of function of all for identical twins as monozygotic or coming from
systems occur during the fetal stage. one fertilized oocyte.
◆ Teratogens, substances that cause harm to the develop- 7. When describing fetal circulation to the student
ing fetus, may be in the form of chemicals, viruses, nurse, the clinic nurse explains that most of the
environmental agents, physical factors, and drugs. fetus’s blood bypasses the lungs by shunting through
◆ By educating pregnant women about fetal developmen- the ductus arteriosus.
tal events and avoidance of potential hazards, nurses
can help to ensure a healthy outcome for the mother Fill-in-the-Blank
and her infant. 8. The clinic nurse is aware that the primary sources
of amniotic fluid in pregnancy are fetal _______ and
_________ secretions.
r e v i e w q u est io n s 9. The perinatal nurse explains to the student nurse
that the growing embryo is called a ________
Multiple Choice beginning at _______ weeks of gestational age.
1. The nurse working in reproductive health is aware 10. The perinatal nurse defines a ________________ as
that the goal of the Human Genome project was to: any substance that adversely affects the growth and
A. Identify exact human DNA sequences and genes. development of the fetus.
B. Identify human DNA and RNA sequences.
C. Measure exact human DNA sequences for See Answers to End of Chapter Review Questions on the
chromosomal diseases. Electronic Study Guide or DavisPlus.
D. Measure exact human DNA sequence maps for
disease prevention. REFERENCES
2. At the obstetrician’s office, a couple receives Benirschke, K. (2004). Multiple gestation. The biology of twinning.
information about assisted reproductive technologies. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine:
Principles and practice (5th ed.). Philadelphia: W.B. Saunders.
The nurse explains that the in vitro fertilization Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
procedure involves the following: tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
A. Approximately 35 to 60 hours after fertilization Centers for Disease Control and Prevention (CDC), Division of Parasitic
in the laboratory, an embryo is injected into the Diseases. (2004a). Parasites and health: Toxoplasmosis. Retrieved
from www.dpd.cdc.gov/DPDx/HTML/Toxoplasmosis.htm (Accessed
woman’s cervix. June 21, 2007).
B. An embryo is injected into the fallopian tubes at Centers for Disease Control and Prevention (CDC). National Vital Statistics
50 hours after fertilization in the laboratory. Reports (2004b), Vol. 53(10). Infant mortality statistics from the 2002
C. Many sperm cells and ova are injected into period linked birth/infant death data set. Retrieved from http://origin.cdc.
the fallopian tubes to achieve fertilization inside gov/nchs/data/nvsr/nvsr53/nvsr53_10.pdf (Accessed June 21, 2007).
Centers for Disease Control and Prevention (CDC), Emergency Pre-
the tubes, where it normally occurs. paredness & Response. (2005). Possible health effects of radiation
D. Many sperm cells and ova are injected into the exposure on unborn babies. Retrieved from www.bt.cdc.gov/radiation/
cervix to achieve fertilization inside the woman. prenatal.asp (Accessed June 21, 2007).
188 unit two The Process of Human Reproduction
Chiriboga, C.A. (2003, November). Fetal alcohol and drug effects. The Lashley, F. (2005). Clinical genetics in nursing practice (3rd ed.). New York:
Neurologist, 9(6), 267–279. Springer.
Cunningham, F.G., Leveno, K.J., Bloom, S.L., Hauth, J.C., Gilstrap III, L.C., Moll, S. (2006). Thrombophilias – practical implications and testing
& Wenstrom, K.D. (2005). Fetal growth and development. caveats. Journal of Thrombosis and Thrombolysis, 21(1), 7–15.
Williams obstetrics (22nd ed., pp. 129-166). New York: McGraw-Hill. Moore, K.L., & Persaud, T.V.N. (2003). The developing human: Clinically
Evans, M.I., Llurba, E., Landsberger, E.J., O’Brien, J.E., & Harrison, H.H. oriented embryology (7th ed.). Philadelphia: Elsevier.
(2004, March). Impact of folic acid fortification in the United States: Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing
Markedly diminished high maternal serum alpha-fetoprotein values. outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
Obstetrics & Gynecology, 103(3), 474–479. National Center for Health Statistics (NCHS). (2006). Health data for
Foster, C. (2007). Factor V Leiden mutation: What is it? What are the allages. Retrieved from www.cdc.gov/nchs/health_data_for_all_ages.
implications for clinical practice? The American Journal for Nurse htm (Accessed June 21, 2007).
Practitioners, 11(6), 35–46. National Down Syndrome Society (2006). NDSS Statement on the CDC’s
Gallo, A., Angst, D., Knafl, K., Hadley, E., & Smith, C. (2005). Parents new study on the prevalence of Down Syndrome. Retrieved from
sharing information with their children about genetic conditions. www.ndss.org/content.cfm?fuseaction_InfoResGeneralArticle&artic
Journal of Pediatric Health Care, 19(5), 267–275. le_29 (Accessed June 13, 2007).
Gardella, C. (2001, April). Lead exposure in pregnancy: A review of the Pan, E.S., Cole, F.S., & Weintrub, P.S. (2005). Viral infections of the
literature and argument for routine prenatal screening. Obstetrical fetus and newborn. In H.W. Taeusch, R.A. Ballard, & C.A. Gleason.
and Gynecologic Survey, 56(4), 231–238. Avery’s diseases of the newborn (8th ed., pp. 495–529). Philadelphia:
Gershon, A. (2006). Chickenpox, measles and mumps. In J. Remington, Elsevier.
J. Klein, C. Baker, & C. Wilson (Eds.), Infectious diseases of the fetus Reed, M., Aranda, J., & Hales, B. (2006). Developmental pharmacology.
and newborn infant (6th ed., pp. 446-459). Philadelphia: W.B. In R. Martin, A. Faranoff, & M. Walsh (Eds.), Fanaroff and Martin’s
Saunders. neonatal-perinatal medicine: Diseases of the fetus and infant (8th ed.,
Guttmacher, A., & Collins, F. (2005). Realizing the promise of genomics pp. 672–681). Philadelphia: C.V. Mosby.
in biomedical research. JAMA, 294(11), 1399–1402. Scanlon, V.C., & Sanders, T. (2007). Essentials of anatomy and physiology
Havens, P.L., & Walters, D. (2004). Management of the infant born to a (5th ed.). Philadelphia: F.A. Davis.
mother with HIV infection. Pediatric Clinics of North America, 51, Smith, B.R. (2008). The multidimensional human embryo, Carnegie
909–937. Stages. Retrieved from http://embryo.soad.umich.edu/carnstages/
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., (Accessed June 8, 2007).
Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and Tillett, J., Kostich, L., & VandeVusse, L. (2003, January/March). Use of
NIC Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.). over-the-counter medications during pregnancy. The Journal of Peri-
St. Louis, MO: Mosby Elsevier. natal & Neonatal Nursing, 17(1), 3–18.
Kenner, C., Gallo, A., & Bryant, K. (2005). Promoting children’s health U.S. Department of Health and Human Services (USDHHS). (1999).
through understanding of genetics and genomics. Journal of Nursing Agency for Toxic Substances and Disease Registry (ATSDR). Case
Scholarship, 37(4), 308–314. studies in environmental medicine (CSEM) lead toxicity physiologic
Kenner, C., & Moran, M. (2005). Newborn screening and genetic test- effects. Retrieved from www.atsdr.cdc.gov/HEC/CSEM/lead/
ing. Journal of Midwifery & Women’s Health, 50(3), 219–226. physiologic_effects.htm (Accessed June 21, 2007).
Khairy, P., Ouyang, D., Fernandes, S., Lee-Parritz, A., Economy, K., & U.S. Department of Health and Human Services (USDHHS). (2005).
Landzberg, M. (2006). Pregnancy outcomes in women with congeni- Office of the Surgeon General, Advisory on Alcohol Use in Preg-
tal heart disease. Circulation, 113(4), 517–524. nancy. Retrieved from www.surgeongeneral.gov/pressreleases/
Khoury, M. (2003). Genetics and genomics in practice: The continuum sg02222005.htm (Accessed June 21, 2007).
from genetic disease to genetic information in health and disease. Venes, D., Ed. (2009). Taber’s cyclopedic medical dictionary (21st ed.).
Genetics in Medicine, 5(4), 261–268. Philadelphia: F.A. Davis.
Klipstein, S. (2005). Preimplantation genetic diagnosis: Technological Woods, C. (2005). Syphilis in children: Congenital and acquired. Seminars
promise and ethical perils. Fertility and Sterility, 83(5), 1347–1353. in Pediatric Infectious Diseases, 16(4), 245–257.
Korenromp, M. (2005). Long-term psychological consequences of preg- Yudkin, M., & Gonik, B. (2006). Perinatal infections. In R. Martin, A.
nancy termination for fetal abnormality: A cross-sectional study. Fanaroff, & M. Walsh (Eds.). Faranoff & Martin’s neonatal-perinatal
Prenatal Diagnosis, 25(3), 253–260. medicine: Diseases of the fetus and infant (8th ed.). Philadelphia: C.V.
Lamberg, L. (2005). Risks and benefits key to psychotropic use during Mosby.
pregnancy and postpartum period. JAMA, 294(13), 1604–1608.
CONCEPT MAP
Conception and Development
of the Embryo/Fetus
Conception
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Describe the physiological changes that occur during pregnancy and their etiologies.
◆ Identify nursing measures to relieve the discomforts caused by the physiological changes.
◆ Describe the psychosocial changes that occur during pregnancy and the factors that influence
these changes.
◆ Identify nursing interventions to help families adapt to the psychosocial changes.
The purpose of this study was to (1) distinguish perceived paren- execute actions that produce results, and situation-specific tasks
tal efficacy from parental confidence and parental competence; related to parenting a child.
(2) clarify perceived parental efficacy by identifying its attributes, Based on interpretation of Bandura’s theory, concept defini-
antecedents, and consequences; (3) explore changes that have tions included:
occurred in the concept over time; and (4) explore areas of
• Parents beliefs/judgment: Refers to judgments held by the
agreement and disagreement across the nursing and psychology
parent and strength of that judgment
disciplines. A concept analysis of literature from psychology and
• Capabilities: Refers to what “one can do under a different
nursing covering a 20-year period from 1980 to 2000 was com-
set of conditions with whatever skills one possesses”
pleted to include the topics of parental self-efficacy, competence,
• Actions that are organized and executed to produce a set
and confidence. One hundred and thirteen articles were obtained.
of tasks: Means “being able to integrate sub skills into
Of these, 30 were selected to represent each discipline based on
appropriate courses of actions and to execute them well
the extent to which the concepts were represented in the discus-
under difficult circumstances”
sion. Data analysis was carried out in a thematic manner similar
• Situation-specific tasks related to parenting a child: Refers to
to the content analysis suggested by Rodgers and Knafl (2000).
situation-specific tasks that are related to parenting, be they
The researchers defined parental efficacy as “beliefs one holds
instrumental tasks such as feeding, or affective tasks, such
in one’s capabilities to organize and execute the courses of
as comforting” (de Montigny & Lacharité, 2005, p. 390).
actions required to produce given attainments” as identified in
Bandura’s Social Cognitive Theory. The following theory concepts The attribute “perceived parental efficacy” included positive
were selected to serve as the framework for the concept analysis: enactive mastery experiences, vicarious experiences, verbal per-
personal beliefs, capabilities and power, ability to organize and suasion, and an appropriate physiological and affective state.
(continued)
193
194 unit three The Prenatal Journey
absorption of essential nutrients for fetal development, as the contractions are irregular in frequency and last for less
and it relaxes the uterine muscle to prevent the onset than 60 seconds, the patient may be reassured of their nor-
of labor until term. Progesterone has been called the malcy. However, if a pattern of contraction regularity is
“pro-pregnancy hormone.” noted or if the contractions are associated with bleeding,
nausea, vomiting, or intense pain, the patient should be
REPRODUCTIVE SYSTEM instructed to promptly report to her health care provider for
evaluation.
The reproductive system undergoes the greatest changes Blood flow is increased from the effects of progesterone
in size and function and every organ within this system is on the smooth muscle of the vasculature to provide ade-
affected by or focused on the needs of the growing fetus. quate circulation for endometrial growth and placental
Uterus function. The enhanced uterine circulation is important
for ensuring adequate fetal nutrition and the removal of
The uterus provides a home for the growing fetus for its
waste products.
10-lunar-month stay in the woman. Its pattern of growth is After implantation, the endometrium lining the uterus is
very predictable for the first 20 weeks of the pregnancy.
termed the decidua. The decidua consists of three layers:
Depending on fetal size, uterine growth over the next
20 weeks varies. The shape of the uterus changes dramati- Decidua vera is the external layer and it has no
cally. Very early in pregnancy the uterus is shaped like a contact with the fetus.
“lightbulb” or inverted pear. By the end of the first trimester Decidua basalis is the uterine lining beneath the site
the uterus has developed into a soft, enlarged globular struc- of implantation.
ture that has risen out of the pelvis and into the abdominal Decidua capsularis is the endometrial tissue that
cavity (Fig. 8-1). Under the influence of estrogen and pro- covers the embryo (Fig. 8-2).
gesterone, the myometrial cells and muscle fibers undergo
hyperplasia and hypertrophy, processes that allow the uterus Cervix
to enlarge and stretch as the fetus grows. By term, the uter- One of the earliest signs of pregnancy is the discoloration,
ine wall thins to 0.6 inch (1.5 cm) or less and its weight will or bluish purple hue, that appears on the cervix, vagina,
have increased from 1.8 oz. to 2.2 lb. (70 g to 1100 g). and vulva. This color change is known as Chadwick’s
Estrogen causes the uterine muscles to contract. Braxton- sign (Fig. 8-3). High levels of circulating estrogen cause
Hicks contractions are irregular and painless and may begin stimulation of the cervical glandular tissue, which increases
as early as the 16th week of gestation. As the pregnancy in cell number and becomes hyperactive. Increased blood
advances and the fetal size increases, the contractions flow and engorgement produces the bluish discoloration.
become increasingly more frequent and intense and are eas- Stimulation from the hormones estrogen and proges-
ily felt by the woman. Until late in the second trimester the terone produces cervical softening (Goodell sign). This
contractions serve to prepare the uterine muscles for the physiological change is related to several events, including
synchronized activity necessary for effective labor. As long a decrease in the collagen fibers of the connective tissue,
increased vascularity and edema, and slight tissue hyper-
trophy and hyperplasia. Before pregnancy, the cervix is
firm and its texture resembles that of the tip of the nose.
After conception, the cervix softens and its texture begins
Xiphoid to resemble that of an ear lobe.
process Estrogen and progesterone cause a proliferation of the
Ribs mucus-producing cervical glands. Early in pregnancy, the
Weeks of endocervical tissue begins to take on a honeycomb appear-
gestation ance. Cervical mucus fills the endocervical canal and forms
36 a mucus plug (operculum), which helps to keep harmful
40
32
Decidua
26 After vera
lightening
20 Umbilicus
16 Oviduct
12 Uterine
8 Decidua wall
basalis
Decidua
capsularis
Symphysis
pubis
Figure 8-1 Pattern of uterine growth during Figure 8-2 The layers of the decidua.
pregnancy.
196 unit three The Prenatal Journey
Ovaries
After ovulation, the pituitary hormone luteinizing hormone
(LH) stimulates the corpus luteum (functional cyst that
remains on the ovary) to produce progesterone for 6 to
7 weeks. Once the placenta is developed and functional, it
begins to take over the task of progesterone production. At
that time, the corpus luteum ceases to function and is gradu-
ally absorbed by the ovary. The corpus luteal cyst enlarges
while functioning and may reach the size of a golf ball before
it begins to recede. In some cases the cyst may rupture, caus-
ing the woman some pelvic discomfort associated with
bleeding into the pelvic cavity. The pain should dissipate as
the cyst and blood are absorbed. If the pain is persistent or
if vaginal bleeding occurs, the nurse should advise the
woman to seek medical care. Ovulation ceases during preg-
Figure 8-3 Chadwick’s sign. nancy due to the high circulating levels of estrogen and pro-
gesterone, which inhibit the pituitary release of follicle-
agents out of the uterus. Leukorrhea, an increased whitish stimulating hormone (FSH) and LH.
vaginal discharge, results from hyperplasia of the vaginal
mucosa and increased mucus production from the endocer- Breasts
vical glands. The discharge is often profuse and may be Estrogen and progesterone produce a number of changes
worrisome. As the due date approaches, cervical effacement in the mammary glands. Breast enlargement, fullness, tin-
and dilation cause a breakdown of the mucus plug, resulting gling, and increased sensitivity occur during the early
in an increased vaginal discharge. The nurse should reassure weeks of gestation. The superficial veins become more
the patient about the normalcy of leukorrhea during preg- prominent from the vascular relaxation effects of proges-
nancy and instruct her to call her health care provider if the terone. Often the venous congestion is more noticeable in
discharge appears thicker; becomes bloody or yellowish/ primigravidas. Melanotropin, a hormone secreted by the
green; is accompanied by a foul odor; or if it causes itching, pituitary gland, causes the nipples to become tender and
irritation, or pain in the vulvar or vaginal area. more pronounced with darkening of the areola. The
Montgomery tubercles (sebaceous glands) on and around
Vagina and Vulva the areola enlarge and provide lubrication for the nipple
Changes that occur in the vagina and vulva are similar to tissue. Striae gravidarum (stretch marks) may develop as
those that take place in the cervix. An increased blood flow the breast tissue stretches (Fig. 8-4).
(hyperemia) produces a bluish-purple hue (Chadwick’s During the second trimester, pre-colostrum, a clear
sign). Thickening of the vaginal mucosa develops and the thin fluid, is found in the acini cells, the smallest parts of
rugae (vaginal folds) become more prominent. The rugae the milk glands. Pre-colostrum becomes colostrum, a
deepen from hyperplasia and hypertrophy of the epithelial creamy whitish-yellow liquid that may leak from the nip-
and elastic tissues and this change allows for adequate ples as early as the 16th week of gestation. This pre-milk
stretching of the vaginal vault during childbirth. As the substance contains antibodies, essential proteins, and fat
pregnancy progresses, the area becomes edematous from to nourish the baby and prepare his intestines for diges-
poor venous return due to the weight of the gravid uterus. tion and elimination. Colostrum is converted to mature
For some women, the increased pelvic congestion can lead milk during the first few days after birth.
to a heightened sexual interest and increased orgasmic During prenatal care, the nurse should discuss the need
experience (McKinney, James, Murray, & Ashwill, 2005). for changes in bra size, options for infant feeding, and, if the
Leukorrhea results from increased cervical mucus along patient wishes to breast feed, strategies to help her prepare
with elevated glycogen levels in the vaginal cells, which for successful breast feeding. The process of lactation should
produces rapid sloughing of tissue. The increased glycogen be reviewed and the woman should be given a list of lacta-
levels also create a vaginal environment more susceptible to tion support resources. Soft cotton liners can be used to pad
the growth of Candida albicans. Thus, during pregnancy the the bra if leaking of the nipples is troublesome.
woman is more susceptible to the development of monilial
vaginitis (yeast infections). The pH of the vaginal fluids Now Can You— Describe major changes that occur in the
becomes more acidic, and decreases from 6.0 to 3.5. This reproductive system during pregnancy?
change results from the action of Lactobacillus acidophilus 1. Identify four physiological changes that occur in the uterus
on the increased glycogen levels in the vaginal epithelium and possible symptoms that may accompany these changes?
(Cunningham et al., 2005). The increased acidity helps to 2. Explain the hormonal basis for changes in the vagina and vulva
control the growth of most pathogens in the vaginal canal. and identify patient teaching needs concerning the changes?
The nurse should discuss the importance of vulvar 3. Describe three breast changes and identify the hormones
hygiene with the patient. Gentle external cleansing with responsible for the changes?
plain soap and water is adequate. Douching, or internal
chapter 8 Physiological and Psychosocial Changes During Pregnancy 197
Striae
gravidarum
Darkened
areola
Prominent
veins
Linea
nigra
Striae
gravidarum
Figure 8-5 Chloasma.
CARDIOVASCULAR SYSTEM
Heart
As growth of the fetus exerts pressure on the diaphragm,
the maternal heart is pushed upward and laterally to the left
(Fig. 8-7). Cardiac hypertrophy results from the increased
blood volume and cardiac output. Exaggerated first and
third heart sounds and systolic murmurs are common find-
ings during pregnancy. The murmurs are usually asymp-
tomatic and require no treatment. If symptomatic, the
Figure 8-6 Palmar erythema. woman may experience palpitations, chest pain, shortness
of breath, or a decreased tolerance to activity. The nurse
should advise the patient that if these symptoms occur, she
should see her health care provider immediately for evalua-
going to sleep. Nurses can advise patients that afternoon tion. Systolic murmurs usually resolve within the first
napping may help alleviate the fatigue associated with the 2 weeks postpartum after the plasma volume levels return
sleep alterations. Providing anticipatory guidance related to to normal. They may recur in subsequent pregnancies.
expected alterations is key in facilitating the woman’s accep-
tance of these changes. Blood Volume
Edema from vascular permeability can lead to a collec- An increase in maternal blood volume begins during the
tion of fluid in the wrist that puts pressure on the median first trimester and peaks at term. The increase approaches
nerve lying beneath the carpal ligament. This alteration 40% to 45% and is due primarily to an increase in plasma
leads to carpal tunnel syndrome, a condition that usually and erythrocyte volume. Additional erythrocytes, needed
develops during the third trimester. It is manifested by because of the extra oxygen requirements of the maternal
pain and paresthesia (a burning, tingling, or numb sensa- and placental tissue, ensure an adequate supply of oxygen
tion) in the hand that radiates to the elbow. The pain to the fetus. The elevation in erythrocyte volume remains
occurs in one (usually the dominant) or both hands and is constant during pregnancy.
intensified with attempts to grasp objects. Elevation of the Most of the increased blood flow is directed to the
hands at night may help to reduce the edema. Occasion- uterus, and of this amount, 80% is channeled to the pla-
ally, a woman may need to wear a “cock splint” to prevent centa. Blood flow to the maternal kidneys is increased by
the wrist from flexing, an action that puts additional pres- 30% to 50%, and this alteration enhances the excretion of
sure on the median nerve. Carpal tunnel syndrome usually maternal and fetal wastes. Dilation of the capillaries and
subsides after the pregnancy (and the accompanying increased blood flow to the skin assist the woman in
edema) has ended although some women may require eliminating the extra heat generated by fetal metabolism.
surgical treatment if symptoms persist. The extra blood volume decreases during the first 2 weeks
Syncope (a transient loss of consciousness and postural postpartum and a substantial amount of fluid loss in the
tone with spontaneous recovery) during pregnancy is first 3 postpartal days occurs through maternal diuresis.
frequently attributed to orthostatic hypotension and/or
inferior vena cava compression by the gravid uterus Iron
(Cunningham et al., 2005). It may also occur as increased Iron is necessary for the formation of hemoglobin, the
intra abdominal pressure from the growing uterus places oxygen-carrying component of the erythrocyte. The
pressure on the vagus nerve. Coughing, straining during increased need for oxygen requires the pregnant woman
bowel movements, and upward pressure from the growing to increase her iron intake. The fetal need for iron is great-
fetus can trigger a vasovagal response that produces faint- est during the last 4 weeks of pregnancy, when the fetal
ness or loss of consciousness. Lightheadedness, sweating, iron stores are amassed.
nausea, yawning, and feelings of warmth are warning During pregnancy, the woman’s hematocrit values may
signs that often precede syncope. Educating the patient appear low due to the increase in total plasma volume
about signs and symptoms often helps to alleviate the
fears that frequently accompany the fainting episodes. If
lightheadedness or other warning signs are experienced,
the woman is instructed to immediately assume a sitting
or lying position. A left side-lying position is preferred to
avoid compression of the vena cava (which can lead to
supine hypotension) from the gravid uterus.
(on average, 50%). Since the plasma volume is greater than women must add supplemental iron to meet the needs of
the increase in erythrocytes (30%), the hematocrit (a mea- the expanded erythrocytes and those of the growing fetus.
surement of the red blood cell concentration in the plasma)
decreases by about 7%. This alteration is termed “physio- Leukocytes, Proteins, Platelets, Immunoglobulins
logical anemia of pregnancy” or “pseudoanemia.” The The number of leukocytes also increases and the average
hemodilution effect is most apparent at 32 to 34 weeks. white blood cell count ranges from 5000 to 15,000 /mm3.
The mean acceptable hemoglobin level in pregnancy is During labor and postpartum these levels may climb as
11 to 12 g/dL of blood. Some women experience symptoms high as 25,000/mm3. Although the exact reason for this
of fatigue related to this phenomenon although altered increase is unclear, it is known that leukocyte counts nor-
sleep patterns may also contribute to the fatigue. The nurse mally increase in response to stress and vigorous exercise
should teach the patient to hydrate adequately by drinking (Cunningham et al., 2005). Normal laboratory values
6 to 8 glasses of water each day, and also to ensure that her during pregnancy are presented in Table 8-1.
diet is high in protein and iron. Although gastrointestinal Plasma proteins also increase, although due to the
absorption of iron is enhanced during pregnancy, most hemodilution effect during pregnancy, there is a decrease
Serum Values
Hemoglobin 11.7–15.5 g/dL Decreased by 1.5–2 g/dL
(mean Hgb is 0.5–1.0 g lower in African Americans, Lowest point occurs at 30–34 weeks
Mexican and Asian Americans have a higher
hemoglobin & hematocrit than Caucasians)
Hematocrit 38–44% Decreased by 4–7%, lowest point at
30–34 weeks
Leukocytes 4.5–11.0 103/mm3 Gradual increase of 3.5 103/mm3
Platelets 150–400 103/mm3 Slight decrease
Amylase 30–110 U/L Increased by 50–100%
Chemistries
Albumin 3.4–4.8 g/dL Early decrease by 1 g/dL
Calcium (total) 8.2–10.2 mg/dL Gradual decrease of 10%
Chloride 97–107 mEq/L No significant change
Creatinine 0.5–1.1 mg/dL Early decrease by 0.3 mg/dL
Fibrinogen 200–400 mg/dL Progressive increase of 1–2 g/L
Glucose (fasting) 65–99 mg/dL Gradual decrease of 10%
Potassium 3.5–5.0 mEq/L Gradual decrease of 0.2–0.3 mEq/L
Protein (total) 6.0–8.0 g/dL Early decrease of 1 g/dL then stable
Sodium 135–145 mEq/L Early decrease of 2–4 mEq/L then stable
Urea nitrogen 8-20 mg/dL Decrease in 1st trimester by 50%
Uric acid 2.3–6.6 mg/dL First trimester decrease of 33%, rise at term
Urine Chemistries
Creatinine 11–20 mg/kg per 24 hr No significant change
Protein 10–140 mg per 24 hr Up by 250–300 mg/day by the 20th week
Creatinine clearance 75–115 mL/min/1.73 m2 Increased by 40–50% by the 16th week
Serum Hormones
Cortisol 8–21 g/dL Increased by 20 g/dL
Prolactin 3.3–26.7 ng/mL Gradual increase, 5.3–215.3 ng/mL, peaks at term
Thyroxine (T4) total 5.5–11.0 mcg/dL 5.5–16.0 mcg/dL
Triiodothyronine (T3) total 70–204 ng/dL Early sustained increase of up to 50%
116–247 ng/dL (last 4 months of gestation)
200 unit three The Prenatal Journey
in protein concentrations, especially in the level of albu- During pregnancy, resistance to infection is decreased
mins. Decreased plasma albumin leads to a drop in as a result of depressed leukocyte function. Due to this
osmotic pressure, which causes body fluids to move into normal physiological alteration, maternal autoimmune
the second space. This change produces edema. diseases such as lupus erythematosus may improve during
Although the platelet cell count does not change sig- pregnancy. (See Chapter 11 for further discussion.) Because
nificantly, fibrinogen volume has been shown to increase of the increased susceptibility to infection, patients should
by as much as 50%. This alteration leads to an increase in be instructed to avoid crowds and individuals with active
the sedimentation rate. Blood factors VII, VIII, IX, and X infections. Frequent, consistent hand washing and good
are also increased, and this change causes hypercoagula- respiratory hygiene should also be stressed.
bility. The hypercoagulable state, coupled with venous
stasis (poor blood return from the lower extremities), Cardiac Output
places the pregnant woman at an increased risk for venous Cardiac output increases, and peaks around the 20th to
thrombosis, embolism, and when complications are pres- 24th week of gestation at about 30% to 50% above pre-
ent, disseminated intravascular coagulation (DIC). (See pregnancy levels. It remains increased for the duration of
Chapter 11 for further discussion.) the pregnancy. With the increased vascular volume and
The production of maternal immunoglobulins (IgA, cardiac output, vasodilation (related to progesterone-
IgG, IgM, IgD, IgD) is unchanged in pregnancy. Immunog- induced relaxation of the vascular smooth muscle) prevents
lobulins protect the body from a variety of bacterial, viral, an elevation in blood pressure. The woman’s pulse rate fre-
and parasitic infections. Three major types of immuno- quently increases up to 10 to 15 beats per minute to facili-
globulins (IgG, IgA, and IgM) are primarily involved in tate effective circulation of the increased blood volume.
immunity. Circulating levels of maternal IgG are decreased During the first trimester, blood pressure normally
during pregnancy because of transfer across the placenta. remains the same as pre-pregnancy levels but then gra-
As the only immunoglobulin transported across the dually decreases up to around 20 weeks of gestation. After
placenta, IgG is active against bacterial toxins (Hacker, 20 weeks, the vascular volume expands and the blood pres-
Moore, & Gambone, 2004). Although transport of IgG sure increases to reach pre-pregnancy levels by term.
begins around the 16th week of gestation, the fetus does not Because of the relaxed vascular resistance and stasis of
acquire a significant amount of IgG until the last 4 weeks blood in the lower extremities, there is an increased risk of
of pregnancy. At birth, the neonate’s primary immunoglo- varicose veins and hemorrhoids. The nurse should instruct
bulins (IgG) have been acquired from the mother via a pro- the woman to elevate her lower extremities by lying on
cess termed “passive acquired immunity” (Cunningham her left side with the feet higher than her heart for 15 to
et al., 2005). Due to its large molecular size, IgM is unable 20 minutes daily to improve venous return from the lower
to cross the placenta. IgA, IgD and IgE also remain in the extremities. Daily walks enhance circulation and also
maternal circulation. IgA, which is believed to provide pro- improve intestinal peristalsis, important in facilitating regu-
tection to various secreting surfaces such as those in the lar bowel function. Patients should be advised to drink
respiratory tract, gastrointestinal tract, and eyes, is passed to at least 8 to 10 glasses of water each day and include ade-
the neonate in breast milk (Smeltzer & Bare, 2004). Immu- quate roughage in their diet. These strategies help prevent
noglobulins and their major actions are summarized in constipation and straining with bowel movements, both of
Table 8-2. which increase the likelihood of hemorrhoids.
Adapted from Smeltzer, S.C., & Bare, B.G. (Eds.). (2004). Textbook of medical-surgical nursing (10th ed.).
Philadelphia: Lippincott Williams & Wilkins.
chapter 8 Physiological and Psychosocial Changes During Pregnancy 201
ENDOCRINE SYSTEM
Thyroid Gland
The thyroid gland changes in size and activity during preg-
nancy. On palpation, the increase in size is appreciated.
Enlargement is caused by increased circulation from the
progesterone-induced effects on the vessel walls, and by
Liver estrogen-induced hyperplasia of the glandular tissue. In
pushed up early pregnancy, elevated levels of thyroxine-binding glob-
Stomach ulins cause an increase in the total thyroxine (T4) and total
compressed 3,5,3-triiodothyronine (T3) (Beckmann et al., 2006). The
active hormones free T4 and free T3 remain unchanged
from normal non-pregnant levels. Levels of total T4 con-
tinue to be elevated until several weeks postpartum.
Increased T4-binding capacity is noted by an increase in the
serum protein-bound iodine (PBI). These changes in thy-
roid regulation cause a progressive increase in the basal
metabolic rate (BMR) of up to 25% by term. The BMR is the
amount of oxygen consumed by the body over a unit of
Bladder largely in time (mL/min). Maternal effects of the increase in BMR
pelvis therefore include heat intolerance and an elevation in pulse rate and
frequent urination cardiac output. Within a few weeks following birth, thyroid
function returns to normal levels (Hacker et al., 2004).
Parathyroid Glands
Figure 8-10 Compression of the bladder results from The parathyroid glands, which regulate calcium and phos-
the growing uterus. phate metabolism, increase in size from estrogen-induced
hyperplasia and hypertrophy. Maternal concentrations of
medium for the growth of microorganisms. Patients should parathyroid hormone increase as the fetus requires more
be encouraged to drink at least 8 to 10 glasses of water each calcium for skeletal growth during the second and third
day and empty their bladders at least every 2 to 3 hours and trimesters. Calcium intake is extremely important for the
immediately after intercourse. These measures help to pre- pregnant woman, whose daily intake should be at least
vent stasis of urine and the bacterial contamination that 1200 to 1500 mg.
leads to infection.
The glomerular filtration rate (GFR) and renal plasma Pituitary Gland and Placenta
flow are increased due to hormonal changes, blood volume The anterior lobe of the pituitary gland, stimulated by the
increases, the woman’s posture, physical activity level, and hypothalamus, increases in size and in weight. Pregnancy
nutritional intake. During the second trimester, the GFR is possible because of the actions of FSH (stimulates
increases up to 50% in most women. This alteration growth of the graafian follicle) and LH, which prompts
prompts an increase in renal tubular reabsorption. During final maturation of the ovarian follicles and release of the
pregnancy, there is a greatly increased load of glucose pre- mature ovum (Varney, 2004). If conception occurs, ele-
sented to the renal tubules. As a result, glucose excretion vated levels of estrogen and progesterone (produced by
increases in virtually all pregnant women (Beckmann the corpus luteum until about 14 weeks of gestation,
et al., 2006). Although it may be a normal finding, glucos- when the placenta takes over this function) suppress pro-
uria should always be investigated to rule out gestational duction of FSH and LH. During pregnancy, ovarian follicle
diabetes, as the quantitative urine glucose does not maturation may continue but ovulation does not occur.
accurately reflect blood glucose levels. (See Chapter 11 for Prolactin, also produced by the anterior pituitary
further discussion.) gland, is responsible for initial lactation. Although this
hormone increases 10-fold during pregnancy, the elevated
Now Can You— Describe changes in the eyes, nose, and levels of estrogen and progesterone inhibit lactation by
throat and respiratory, gastrointestinal, interfering with prolactin-binding to the breast tissue.
and urinary systems? Prolactin may also play a role in fluid and electrolyte shifts
1. Describe one alteration that occurs in each of the following: across the fetal membranes (Hacker et al., 2004).
eyes, nose, throat and suggest interventions for relief from Oxytocin and vasopressin are produced in the poste-
the accompanying symptoms? rior lobe of the pituitary. Oxytocin primarily causes uter-
2. Identify changes during pregnancy that compensate for ine contractions but high levels of progesterone prevent
the reduced diaphragmatic movement that results from contractions until close to term. Oxytocin also stimulates
the enlarging uterus? milk ejection from the breasts, or the “let down” reflex.
3. Differentiate among epulis gravidarum, ptyalism, and pyrosis Vasopressin causes vasoconstriction. Vasoconstriction
and delineate patient teaching needs concerning these leads to an increase in maternal blood pressure and exerts
symptoms? an antidiuretic effect that promotes maternal fluid reten-
4. Explain the physiological basis for glucosuria during pregnancy? tion to maintain circulating blood volume. The increased
blood volume that occurs during pregnancy, along with
204 unit three The Prenatal Journey
Adrenal Glands
The adrenal glands, located above the kidneys, change lit-
tle during pregnancy. The adrenal cortex produces corti-
sol, a hormone that allows the body to respond to stress- Figure 8-11 Lumbar lordosis.
ors. Cortisol is increased during pregnancy due to decreased
renal secretion (an alteration prompted by high estrogen
levels). Cortisol regulates protein and carbohydrate metab- Low back pain usually accompanies this physiological
olism and is believed to promote fetal lung maturation and change. Separation of the rectus abdominis muscles along
stimulate labor at term. Following birth, it may take up to with an increase in intra-abdominal pressure from the grow-
6 weeks for maternal cortisol levels to return to normal. ing uterus may exacerbate an abdominal wall hernia.
By the second trimester, the adrenal cortex secretes Relaxin, a hormone produced by the placenta, along
increased levels of aldosterone, a mineral corticoid that with the action of progesterone, causes a relative laxity of
causes the renal reabsorption of sodium. This physiologi- the ligaments. The pubis symphysis separates at approxi-
cal alteration promotes the reclaiming of water and helps mately 28 to 30 weeks gestation. These changes, coupled
to enhance circulatory volume. The increase in aldoste- with the change in the maternal center of gravity, result in
rone may be a protective response to the increased renal an unsteady gait and a greater tendency toward falls. The
and excretory gland sodium excretion that occurs due to patient’s gait takes on the appearance of a “pregnancy
the effects of progesterone. waddle” as the bones of the pelvis shift and move. The
woman should be encouraged to maintain good posture
Pancreas and keep the abdominal muscles toned through exercise.
The pancreas secretes insulin produced by the beta cells Sitting in a firm chair and the use of a small pillow or
of the islets of Langerhans. Pregnancy prompts an increase blanket rolled and placed in the lumbar region (lumbar
in the number and size of the beta cells. These changes are roll) for support can help decrease lower back pain.
responsible for the alterations that occur in carbohydrate Pregnant women frequently complain of sharp pain in
metabolism during pregnancy. the lower abdominal quadrants or in the groin area. Most
often, the pain is related to stretching and hypertrophy of
Prostaglandins the round ligaments that support the uterus (round liga-
Prostaglandins are lipid substances found in high concentra- ment pain). Because of dextrorotation of the gravid uterus
tions in the female reproductive tract and in the uterine as it rises out of the pelvis, the right maternal side is most
decidua during pregnancy. Their exact function in pregnancy commonly affected. Once a serious medical condition
is unknown although they may maintain a reduced placental (e.g., appendicitis) has been ruled out, the nurse should
vascular resistance. A decrease in prostaglandin levels may offer reassurance and instruct the patient to sit in a chair
contribute to hypertension and preeclampsia. At term, an or rest on her left side. The application of heat may also
increased release of prostaglandins from the cervix as it soft- be helpful. A brief review of the anatomical changes that
ens and dilates may contribute to the onset of labor. occur during pregnancy may alleviate the patient’s fear of
appendicitis. Since the appendix is pushed up and poste-
rior by the gravid uterus, the typical location of pain
MUSCULOSKELETAL SYSTEM (McBurney’s Point) is not a reliable indicator for a rup-
As the pregnancy progresses, the abdominal wall weakens tured appendix during pregnancy. The pain should gradu-
and the rectus abdominis muscles separate (diastasis recti) ally subside but if it persists or is accompanied by fever, a
to accommodate the growing uterus. As the weight of the change in bowel habits, or decreased fetal movement, the
uterus shifts upward and outward, a lumbar lordosis (ante- patient should promptly contact her medical provider.
rior convexity of the lumbar spine) develops (Fig. 8-11). Mobilization of calcium stores occurs to provide for the
This alteration compensates for the changing center of grav- fetal calcium needs necessary for skeletal grown. The total
ity and allows centering to remain over the woman’s legs. maternal serum calcium decreases, but the ionized calcium
chapter 8 Physiological and Psychosocial Changes During Pregnancy 205
Table 8-3 Health Education Topics Related to the Physiological Adaptations of Pregnancy
Topics to Include First Trimester Second Trimester Third Trimester
Physiological Changes Pain and tingling in breasts Enlargement of the abdomen Dyspnea
of Pregnancy and Related
Discomforts
Adapted from Mattson, S., & Smith, J.E. (2004). Core curriculum for maternal-newborn nursing. St. Louis: W.B. Saunders.
chapter 8 Physiological and Psychosocial Changes During Pregnancy 207
Table 8-4 Health Education Topics Related to the Psychosocial Adaptations to Pregnancy
Topics to Include First Trimester Second Trimester Third Trimester
Developmental Tasks Mother: Acceptance of pregnancy Mother: Binding-in to the pregnancy, Mother: Separating herself from
of Pregnancy into her self-system ensuring safe passage, and the pregnancy and the fetus, trying
differentiating the fetus from herself various caregiving strategies
Father: Announcement and Father: Anticipation of adapting to Father: Role adaptation,
realization of the pregnancy the role of fatherhood preparation for labor and birth
Couple: Realignment of Couple: Realignment of roles and Couple: Preparation of the nursery
relationships and roles division of tasks
Psychosocial Changes Ambivalence about pregnancy Active dream and fantasy life Dislikes being pregnant but loves
During Pregnancy the child
Introversion Concerns with body image Anxious about childbirth, but sees
labor and birth as deliverance
Passivity and difficulty with Nesting behaviors The couple experiments with
decision making various mothering or fathering roles
Sexual and emotional changes Sexual behavior adjustment Woman is introspective
Changing self-image Expanding to a variety of methods
of expressing affection and intimacy
Ethical dilemmas of prenatal testing
Adapted from Mattson, S., & Smith, J.E. (2004). Core curriculum for maternal-newborn nursing. St. Louis: W.B. Saunders.
must be introduced and incorporated into the existing considerable amount of emotional and physical support
family structure. Sibling rivalry, or competitiveness among from her family and friends.
the children, is common and can often be diminished by
parental actions that actively involve each child with the Acceptance of the Child
pregnancy and anticipated birth. Acceptance of the child is critical to a successful adjust-
ment to the pregnancy. Acceptance must come from the
MATERNAL TASKS AND ROLE TRANSITION expectant woman as well as from others. During early
Rubin (1975) described specific tasks that a woman must pregnancy, announcements are made to one another and
accomplish to integrate the maternal role into her person- to family and friends. A positive response from those clos-
ality. The “tasks of pregnancy” generally occur concur- est to the pregnant woman helps to foster her acceptance
rently during the pregnancy and help the woman develop of the child. There is a great value attached to this unborn
her self-concept as a mother. To be successful in accom- child and she wants and needs others in the family to
plishing these tasks, the pregnant woman must incorpo- accept the child as well. In the second trimester, the
rate the pregnancy into her total identity. That is, she immediate family needs to exhibit behaviors consistent
must “accept the reality of the pregnancy” and integrate it with relating to the child as a sibling, a son or a daughter.
into her self concept, “accept the child,” “reorder” her In the third trimester, the woman must develop an uncon-
relationships, learn to “give of herself for the child,” and ditional acceptance of the child or she and others may
“seek safe passage through the pregnancy, labor and reject him for not meeting their expectations.
birth” (Mattson & Smith, 2004). A summary of the mater-
nal tasks of pregnancy is presented in Table 8-5. Reordering Relationships
To facilitate the necessary family transition, the pregnant
Acceptance of the Pregnancy woman must reorder her relationships to allow for the
The mother-to-be needs to accept the pregnancy and child to fit into the existing family structure and learn to
incorporate it into her own reality and self-concept. This give of herself to the unknown child. At this time, she
process is known as “binding in.” During the first trimes- becomes reflective and examines what things in her life
ter, the woman’s focus centers on her physical discomforts may need to be given up or changed for the infant. If this
(i.e., fatigue, nausea) and needs rather than on the devel- is her first child, she may grieve the loss of her carefree life.
oping child. By the second trimester, she feels fetal move- As the pregnancy progresses, the woman begins to identify
ment (quickening), has most likely seen the baby on with the child and makes plans for their life together after
ultrasound and heard his heartbeat, and begins to concep- the birth. During the last few weeks of the pregnancy, the
tualize the child as an individual within her. During the woman must work through doubts of her ability to be a
third trimester, as the due date approaches, the mother- good mother. At this time, positive support from family
to-be wants the child and just as strongly wants the preg- and friends is essential in boosting her confidence and in
nancy to be over. At this point, she is tired and needs a assisting her in overcoming these feelings of self-doubt.
208 unit three The Prenatal Journey
Adapted from Mattson, S., & Smith, J.E. (2004). Core curriculum for maternal-newborn nursing. St. Louis: W.B. Saunders.
Seeking Safe Passage Through Pregnancy, Labor, or wanted. Instead, the nurse should facilitate discussion
and Birth of uncertainties or concerns with the patient and her fam-
Seeking safe passage through the pregnancy, labor, and ily to facilitate acceptance of the pregnancy. Many women
birth are maternal tasks that receive the most attention fantasize and dream about their pregnancy and how it will
during the pregnancy. In the first trimester, the woman change their lives. The woman must incorporate the fetus
focuses on her own discomforts and places her needs into her body image, a process termed “fetal embodiment.”
before those of the fetus. Symptoms of fatigue, nausea, Accomplishing this task allows her to accept the changes
and breast tenderness can be overwhelming during this in her body size and shape as the pregnancy progresses.
often difficult time. In the second and third trimesters, the The significant other plays an important role as the woman
woman develops an increasing sense of the value of her becomes increasingly dependent on that individual for
infant. She comes to conceptualize her fetus as a separate helping to meet her daily needs.
being (fetal distinction) and she accepts her changing As the pregnancy advances, the woman begins to concep-
body image. She becomes extremely vulnerable during her tualize the fetus as a separate individual. She comes to view
seventh month and increasingly worried about the her changing body as a “vessel of new life” and often feels
impending labor and birth. As the due date approaches, closer to her own mother at this time. This deeper relation-
the woman’s fears about labor may diminish as she begins ship with her mother begins as one of dependency and pro-
to view childbirth as an “end point.” Participation in gresses to one in which she identifies with her mother as a
childbirth preparation classes can greatly assist the woman peer. If her mother is not available, she may reach out to
and her family in dealing with the anxiety and fears that another valued maternal figure for identification and sup-
often surround labor and birth. port. As she reaches the end of the third trimester, the
Other developmental tasks take place during the pas- woman begins to give up her symbiotic relationship with
sage of pregnancy as well. The woman needs to validate the fetus. She harbors feelings of anxiety about the child-
the pregnancy, and initial feelings of uncertainty or ambiv- birth process and begins to gather supplies and prepare
alence are normal. When caring for expectant women, the for the baby’s entry into the home. This process is termed
nurse should never assume that the pregnancy was planned “nesting.” At this point in pregnancy, the woman is often
chapter 8 Physiological and Psychosocial Changes During Pregnancy 209
impatient with the awkwardness related to her increasing and depression by the pregnant woman’s partner. Men who
size and has a strong desire to see the pregnancy end so that experience the couvade syndrome often assume a more
she can begin her next phase as a mother. involved paternal role during the childbearing year.
The father of the baby also experiences specific tasks
Now Can You— Discuss the “tasks of pregnancy”? of pregnancy that correspond with the trimesters. During
1. Describe why it is important for the pregnant woman to the first trimester, the father is in an “announcement
successfully accomplish the tasks of pregnancy? phase.” Similar to the woman’s experience, the father
2. Discuss the value of ongoing family support throughout may be ambivalent at this time. He must first accept the
pregnancy in fostering acceptance of the child? pregnancy as “real” in order to begin to incorporate the
3. Identify what is meant by “seeking safe passage”? future child into his life and assume the expectant father
4. Explain why pregnant women often feel closer to their own role. In the second trimester, or “moratorium phase”, the
mothers as the pregnancy progresses? man’s “binding in” usually takes longer to achieve than
the woman’s, and this is related to his “remoteness” to
the fetus. At this time, involvement in prenatal visits, lis-
Developmental Tasks and the Pregnant Adolescent tening to the baby’s heartbeat, and visualization of the
For the pregnant adolescent, ongoing age-related develop- fetus during ultrasound can make the fetus seem more
mental tasks can create conflict when coupled with the real to the father. He begins to accept the woman’s chang-
developmental tasks of pregnancy. Tasks associated with ing body and the reality of the fetus as a child when he
adolescence focus on growth and maturity. They include can feel fetal movement.
developing a personal value system, choosing a vocation
or career, developing personal body image and sexuality, Optimizing Outcomes— Promoting prenatal paternal
achieving a stable identity, and attaining independence attachment
from parents. Conflicts may arise when these tasks are
overshadowed by the developmental tasks of pregnancy. The nurse can be instrumental in promoting early paternal
While seeking safe passage, the adolescent may not seek attachment. Encouraging the father to actively “engage”
prenatal care unless pressured by authority figures or with the fetus through reflective journaling is one way to
peers to do so. By nature, adolescents are not future ori- enhance prenatal bonding. One father later shared his
ented. Hence, the pregnant adolescent may not be able to recorded insights:
readily accept the reality of the unborn child. Because the My earliest memories with Trina started the day she was
adolescent’s sense of identity is still incomplete, bodily born. No, they started before that. They started in the
changes often feel awkward. Because the family may not womb. I would come home and I would say, “Hello,” and
react positively to the pregnancy, acceptance of the preg- she would flick and flitter in the womb. She would start
nancy by self and others may be hindered. Many times, kicking. If I put my hand on my wife’s tummy when she
the adolescent’s parents come to assume the role of par- was carrying Trina, she would move over to where my hand
ent. Although this may be helpful at times, this situation was. If I put it on the other side, she would move to that
limits the young mother’s involvement with the newborn side. I used to sing to her. It’s always been that way and has
and her ability to fully give of herself. just continued pretty much that way. I remember one night
laying with my head on my wife’s stomach and singing a
lullaby or something, I can’t remember exactly which song.
PATERNAL ADAPTATION TO PREGNANCY
She was very active but she settled down, and then I put my
Pregnancy is psychologically stressful for men. Expectant hand on her stomach and she moved my hand.
fathers often experience a variety of reactions to the preg- Excerpt from Callister, L.C., Matsumura, G., &
nancy. Some enjoy the role of nurturer and marvel in the Vehvilainnen-Julkunen, K. (2003). He’s having a baby.
changes that occur in the woman. Others feel alienated and The paternal childbirth experience. Marriage & Families.
begin to stray from the relationship. Many men view preg- Retrieved from http://marriageandfamilies.byu.edu/issues/
nancy as positive proof of their masculinity and take steps 2003/January/baby.aspx
to assume a dominant or more supportive role in the rela-
tionship. Others find no meaning or personal value in the
pregnancy and consequently fail to develop any sense of The couple’s sexual relationship often changes as
responsibility toward the mother or the child. There are some men deal with fears of harming the fetus. The
several styles of paternal involvement during pregnancy, expectant father may also feel a rivalry with a male health
including “observer,” where the father is passive and care provider. Involvement of the father during examina-
detached; “expressive,” where the expectant father attempts tions and tests with thorough explanations of the need
to experience the pregnancy as much as possible, and for them can minimize the father’s feelings of being left
“instrumental,” where the father is the caretaker (Callister, out. His partner’s intense introspective nature may be
Matsumura, & Vehvilainnen-Julkunen, 2003). confusing at times and he may feel pushed away. The
Couvade, in the traditional sense, is the observance of man also fantasizes about being a father, although his
certain rituals and taboos by the male to signify his transi- fantasies are often centered on an older child rather than
tion to fatherhood. This action affirms the man’s psychoso- on an infant.
cial and biophysical relationship to his partner and the In the third trimester, the expectant father enters a
child. In recent times, couvade has come to describe the “focusing phase.” During this time he negotiates what his
unintentional development of pregnancy-related symptoms role in labor and birth will be; prepares for the reality
such as weight gain, nausea, back pain, difficulty sleeping, of parenthood; alters his self-concept to reflect that of a
210 unit three The Prenatal Journey
more mature, or fatherly figure; becomes involved in set- Grandparents are very often excited and eagerly await
ting up the nursery; and copes with his fears of the mutila- the birth of a grandchild, although this is not always the
tion or death of his partner or child during birth. Fears case. The grandparents’ age at the time of the birth can
and concerns are often lessened somewhat by participa- exert a positive or a negative effect on their reactions. For
tion in prenatal and parenting classes. The nurse should example, if they will become first-time grandparents dur-
be aware of cues (i.e., lack of participation in prenatal ing their 30s or 40s, they may be ambivalent or feel they
care, behaviors that signal lack of interest in the woman, are not yet ready to assume the grandparent role. Con-
the fetus, or the pregnancy) that may indicate paternal versely, those who are already grandparents may be
detachment from the mother and the pregnancy. Referral excited with the prospect of another grandchild. Other
for counseling, childbirth preparation classes, or other factors (e.g., if the pregnancy was unplanned, if the
community resources may be appropriate. Pastoral care or mother is very young or unwed) may prompt feelings of
local fathering support groups, if available, may also assist anger and disappointment. Along with the woman’s part-
the father with his need for involvement. Problems such ner, the grandparents usually harbor concerns about the
as a troubled relationship with his own father, a dysfunc- health and well-being of the expectant woman and her
tional couple relationship, and sociocultural factors may fetus. They also may be unsure about extent to which they
be barriers that prevent the man from assuming a paternal should become involved in the childrearing process.
role (Callister et al., 2003). Not uncommonly, the behav-
ior associated with a “dead beat dad” stems from feelings MATERNAL ADAPTATION DURING ABSENCE
of being pushed away or left out by the expectant woman OF A SIGNIFICANT OTHER
and her other support systems.
If the woman has no involved significant other, she will
need the presence of a strong support person to help her
ADAPTATION OF SIBLINGS adapt to the pregnancy and the demands of parenting.
AND GRANDPARENTS The future she has planned for the child, such as the
The psychosocial reactions of other family members to the decision to place the child for adoption, can heavily
pregnancy and childbirth must also be explored, as these influence her psychological needs. During prenatal vis-
individuals often have a significant influence on the wom- its, the nurse should ensure that the woman is given the
an’s passage through the developmental tasks of pregnancy. opportunity to discuss her future plans for the child.
The reactions of siblings correlate closely to their age and After assessing the woman’s needs, the nurse can make
level of involvement with the pregnancy. Children may referrals to appropriate community resources that may
express excitement, anticipation, anger, or despair. The include prenatal classes, psychological counseling, pas-
toddler, characteristically involved in his own little world, toral care or social services.
may initially exhibit a reaction of indifference. However,
the parents must be advised about the strong likelihood of Now Can You— Discuss pregnancy-related role transitions
a regression in age-appropriate behavior. For example, the for the adolescent, father, siblings and
child may want to nurse, drink from a bottle, or wear a dia- grandparents?
per like the baby. The school-age child usually appears 1. Describe why the adolescent may have difficulty achieving
more interested but grasping the full reality of a baby in the the developmental tasks of pregnancy?
family may not be realistic, since the process of concrete 2. Explain what is meant by the couvade syndrome?
thinking is not fully developed until around age 10. Engag- 3. Discuss the “focusing phase” that occurs during the third
ing the child in family discussions about the anticipated trimester and identify two behaviors that may indicate a lack
birth, encouraging the child to feel fetal movements, and of paternal attachment?
listening to the fetal heart beat, sharing age-appropriate 4. Contrast behaviors of toddlers, school-age, and adolescent
educational materials, and allowing him to attend sibling children in response to the pregnancy?
preparation classes are strategies that may help the child to 5. Identify two factors that may influence the grandparents’
feel that he is sharing in the pregnancy experience. ability to make role transitions in response to the pregnancy?
When a child reaches early adolescence, changing sexu-
ality associated with this developmental phase may create
a barrier between him and his mother. This sort of barrier
makes it difficult for the adolescent to view his parent as a CULTURAL INFLUENCES AND PSYCHOSOCIAL
pregnant woman and may give rise to feelings of resent- ADAPTATIONS
ment toward the new child about to join the family. Par- Universally, some type of ritual or ceremony is attached
ents need to be aware of ways to cope with potential nega- to important life events. In pregnancy and childbirth, this
tive behaviors and recognize that adolescents often appear ritual may involve special care of the mother and baby,
to have knowledge and understanding about pregnancy events planned to welcome the new member of the family,
and birth but their information may be incorrect and or rigid requirements that must be met by the family and
incomplete. The nurse can suggest that the child attend health care providers. There are a multitude of cultural mes-
prenatal visits to listen to the baby’s heartbeat and, if pos- sages that may influence the woman’s adaptation to preg-
sible, view the fetus during ultrasound examinations. Par- nancy, birth, and the newborn. The nurse should explore
ents should be assisted in developing other strategies to these cultural influences with the patient and her family. By
include the adolescent in the changes that are taking place acknowledging and documenting specific beliefs and needs,
during pregnancy and that will occur following the birth. the nurse can help guide the woman and her family through
Older children may benefit from attending prenatal classes the prenatal and intrapartal care system more effectively.
or touring the birthing facility. Through open discussion, erroneous or conflicting beliefs
chapter 8 Physiological and Psychosocial Changes During Pregnancy 211
can be addressed and a plan can be developed to ensure a drinks—coconut water and tea—are taboo during pregnancy
satisfactory, positive experience for the childbearing year. because they contribute to poor blood circulation. For the
Chinese, other taboo foods are those considered to be “acidic,”
HAZARDS OF HIGH-TECH MANAGEMENT such as pineapple, mango, lime, sour orange, tapai (fermented
ON MATERNAL ADAPTATION tapioca rice), and concentrated coconut milk. These foods are
believed to possibly induce bleeding or miscarriage.
The technology-focused society of today can lead to an
Many “Old Wives’ Tales” surround pregnancy. One suggests
increase in the level of anxiety and number of stressors
that raising the hands up over the head can cause the baby to
experienced by the pregnant woman and her family.
become entangled in its cord. Another warns the pregnant
Moral and ethical dilemmas may arise from positive diag-
woman not to take baths because germs may enter the vagina
nostic tests. The pregnant woman’s emotional and inter-
and pass to the baby. Another encourages abundant water intake
personal needs may be overlooked by those caring for her
so that the baby won’t get dirty.
as added importance is placed on the technology that sur-
Adapted from Weiss, R.E. (2007). Old Wives’ Tales. Retrieved
rounds the care. Full enjoyment of the pregnancy may
from http://pregnancy.about.com/cs/myths/a/aa042299.htm
not be possible, as the woman instead comes to focus on
each test and its results. In this situation, the pregnancy
becomes a “tentative pregnancy.” A conflict of interest
develops between the technology and the woman’s trust
FACTORS THAT INTERFERE WITH
of her own instincts and inner feelings. These conflicts
PSYCHOSOCIAL ADAPTATIONS
can further undermine the woman’s self-confidence. Col-
DURING PREGNANCY
lectively, these stressors interfere with the woman’s abil-
ity to move through the tasks of maternal role develop- Grief and loss during the perinatal period can be triggered
ment and delay her preparation for parenting. by spontaneous abortion; elective termination; plans to
relinquish the child for adoption or surrogacy; and loss of
SOCIETAL AND CULTURAL INFLUENCES the perfect child through prematurity, illness, deformity,
ON FAMILY ADAPTATION or less preferred gender. Parental reactions can produce a
separation from the infant and delay attachment, prompt
Cultural influences often affect how pregnancy is viewed feelings of personal inadequacy concerning the inability to
and accepted by the woman and her family. Many cultures, produce a healthy infant, and alter healthy methods of
such as the tribal Native Americans and most Latinos, con- relating to the infant.
sider pregnancy to be a normal and expected life event, not The importance of prenatal education, labor and birth
a state of illness. Some African nations impose rigid taboos preparation, and parenting classes cannot be stressed
concerning what a woman can eat, drink, wear, and do enough by the nurse. Many women bypass the courses
during her pregnancy. In some Middle Eastern cultures, offered by their health care providers or hospitals in lieu
pregnancy is viewed as “woman’s work” and the father’s of watching birth stories on television. These programs
involvement is minimal. In Korean and other southeastern are a good adjunct but must be placed into context by
Asian cultures, a harmonious balance such as yin/yang information obtained at the prenatal visits and during
(masculine/feminine) or hot/cold must be closely observed. attendance at prenatal and childbirth education classes
In the equilibrium model of health, achievement of balance taught by nurses and certified personnel.
allows for the normal growth of the baby and ensures the
mother’s recovery from the pregnancy. Some cultures
place emphasis on certain behaviors designed to protect NURSING ASSESSMENT OF PSYCHOSOCIAL
the pregnancy, such as avoidance of particular foods and CHANGES AND PRENATAL HEALTH EDUCATION
harmful substances. Immigrants to America become accul- Nursing assessment of the psychosocial changes that occur
turated to Western society. In so doing, they may give up during pregnancy must include a thorough history includ-
their own health protective beliefs and behaviors and ing the family background, past obstetrical events, and the
instead turn to the use of alcohol, drugs, and tobacco, or status of the current pregnancy. Each prenatal visit provides
consume fast foods rather than a balanced diet. The nurse’s an opportunity to ask the patient about her pregnancy expe-
role is to assess each patient’s beliefs and develop a plan of rience since the last visit, address current concerns, and
care that is individualized and incorporates the woman’s offer anticipatory guidance of what to expect from the pres-
customs while providing comprehensive and safe care. ent visit to the next appointment. Based on this information,
the nurse formulates appropriate nursing diagnoses related
Ethnocultural Considerations— Myths, to the maternal psychosocial adaptation to pregnancy
taboos, and “Old Wives’ Tales” (Box 8-2). Health education should be focused according to
the current trimester and evaluated by the patient’s or cou-
In all cultures and subcultures there are myths, tales, and ple’s ability to verbalize the content presented, their efforts
taboos associated with pregnancy. These have developed to to seek assistance and support with psychological concerns,
explain the changes that occur during pregnancy or to link a and indicators of satisfactory coping with the psychological
cause to negative pregnancy outcomes. One myth concerns transitions that are occurring. Suggested topics for health
heartburn: if heartburn is experienced during pregnancy, the teaching during each trimester are presented in Table 8-5.
baby will be born with lots of hair. Another involves using the Pregnancy represents a time of great physical and emotional
shape and height of the woman’s belly or shape and fullness change. The woman and her family require ongoing support
of her face as indicators to determine the baby’s sex. and education to ensure that they safely and successfully
The Chinese and Malays believe that certain “cooling” move through the stages of pregnancy and, in the end, are
foods—cucumber, cabbage, bananas, pineapples—and iced prepared to welcome the new baby into their lives.
212 unit three The Prenatal Journey
CONCEPT MAP
Physiological Changes
Psychosocial Changes
Factors Affecting Family Adaptations: Maternal Adaptations: Paternal Adaptations Factors that Interfere
Adaptation: • Reorganization of the • Incorporation of • Varying degrees of with Adaptation
• Absence of home; realignment of pregnancy into involvement • Termination of
significant others duties self-concept: fetal – Observer; expressive; pregnancy
• Pregnancy in • Change in money embodiment instrumental – Spontaneous
adolescence management • Unconditional • Corresponding tasks: by abortion/elective
• Cultural and • Interfamily role change: acceptance of child trimesters termination
societal influences child to parent • Reorder relationships – Announcement phase: • Plan to relinquish child
• High-tech • Incorporation of each accommodate child into acceptance • Loss of the “perfect”
management new child into existing family structure – Moratorium phase: child
family structure • Nesting “binding in”
• Participation in labor – Focusing phase:
and birth increased involvement;
• Work through post-birth role clarification
doubts • Couvade syndrome
Ethnocultural Considerations:
Optimizing Outcomes:
• Many cultural myths/tales exist
• Promote early paternal Now Can You: that explain changes and
attachment through • Identify the major physiological and psychosocial negative outcomes that occur
reflective journaling changes that occur during pregnancy during pregnancy
chapter
The Prenatal Assessment
9
We are weaving the future on the loom of today.
—Grace Dawson
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Outline a schedule for and describe the benefits of prenatal care.
◆ Summarize the components of the first prenatal visit in relation to history taking, physical
assessment, and risk assessment.
◆ Discuss factors that influence participation in prenatal care.
◆ Discuss how nurses can empower women to become shared decision makers and active participants
in planning their prenatal care.
◆ Recognize lifestyle choices that may be detrimental to maternal and fetal well-being.
◆ Differentiate presumptive, probable, and positive signs of pregnancy.
◆ Determine the estimated date of delivery together with the woman’s gravidity and parity.
◆ Describe components of the focused obstetric examination.
◆ Discuss aspects of prenatal care for the adolescent and for women over age 35.
The purpose of this study was to explore the relationship among a calculation that included the contraceptive risk index and the
decreasing adolescent pregnancy rates, improved contraceptive percentage of those who reported sexual activity.
use, and declining sexual activity. Data were analyzed from a Declines in sexual activity among the 18–19 years-of-age
national probability survey. The national survey is conducted every group were considered to be nonsignificant. The contraceptive
7 years. For the purpose of this research, data from female respon- risk index declined 46% among teens 15–17 years of age. The
dents who were 15–19 years of age during the previous two sur- pregnancy risk index among the same group also declined by
vey years were used. Data were limited to include noninstitutionali- 38% overall. Seventy-seven percent of the decline in pregnancy
zed U.S. citizens 15–19 years of age, which included 1396 for the risk was attributed to improved contraceptive use and 23% (of
year of 1995 and 1150 for 2002. The analysis was based on two the decline) to a decrease in sexual activity. The researchers con-
central measures: sexual activity and contraceptive use at the time cluded that the decline in pregnancy rates was related to an
of the most recent intercourse (within 3 months of the interview). improved use of contraceptives.
The researchers developed two indices: contraceptive risk index
and overall pregnancy index. The “contraceptive risk index” was a 1. What may be considered as limitations to this study?
summary of the overall effectiveness of contraceptive use among 2. How is this information useful to clinical nursing practice?
sexually active adolescents and included information concerning See Suggested Responses for Moving Toward Evidence-Based
the nonuse of contraceptives. The “overall pregnancy index” was Practice on the Electronic Study Guide or DavisPlus.
215
216 unit three The Prenatal Journey
Prenatal care usually begins in the first trimester of insurance or Medicaid coverage can result in an over-
pregnancy, when the patient is seen every 4 weeks until whelming, frightening experience. Many women have no
she reaches 28 to 32 weeks’ gestation. At that time, the financial resources for maternity care or for health care of
appointments are changed to visits every 2 weeks and any kind. Despite recent changes in legislation, approxi-
then occur weekly from 36 weeks of gestation until birth. mately 45 million Americans remain without any source
Although this schedule has to some extent become the of health care insurance (Centers for Disease Control and
“standard of care,” it has not been possible to substantiate Prevention [CDC], 2007). For uninsured women, preg-
the necessity for such frequent visits. Interestingly, the nancy can create a major financial stress since health care
number of total prenatal visits varies tremendously from for a single pregnancy may well exceed $20,000.00,
as few as 3 to 4 visits for low-risk women in some Euro- depending on the type of birth and the development of
pean countries to 14 or more visits for women with complications.
uncomplicated pregnancies in the United States (Partridge
& Holman, 2005).
A recent meta-analysis revealed that a reduction in the CAREing for the Patient
total number of prenatal visits did not negatively affect
maternal or infant outcomes, but did negatively affect the Throughout the childbearing experience, the nurse’s pri-
women’s level of satisfaction with the care received (Vil- mary role is to “CARE” for the patient. The “CARE” prin-
lar, Carroli, Khan-Neelofur, Piaggio, & Gulmezoglu, ciple centers on communicating, advocating, respecting
2004). Based on these findings, a more patient-centered and enabling/empowering the individual (Box 9-2). Some
approach to care for low-risk women may entail fewer patients find both the health care system and the health
visits with a medical provider and more frequent visits care staff to be intimidating and nonreceptive when they
with a nursing team who can provide continuity of care, attempt to voice concerns, doubts, or desires. There is a
psychological support, and individualized strategies to lack of effective communication between the patient and
meet the patient’s educational needs. the nurse. When this occurs, many women adopt what is
perceived as the “typical patient role”—one where the
Now Can You— Discuss aspects of prenatal care? patient simply does as requested without question. Unfor-
1. Discuss why ambivalence is frequently experienced during tunately, nurses sometimes have a tendency to facilitate
the first trimester? and reinforce this behavior.
2. Name three goals of prenatal care? The nurse’s role encompasses that of being an advocate
3. Describe the common prenatal visit schedule for a low-risk for the patient. An advocate verbalizes the patient’s wishes
pregnancy? if the patient is unable to do so herself and ensures that
the patient’s questions are answered in an understandable
and comprehensive way. It is also the advocate’s responsi-
bility to help the patient to become an informed recipient
Navigating the Health Care System
A woman’s initial contact with the health care system may
occur when she first seeks prenatal care. Attempts to navi- Box 9-2 CARE Principles
gate the system while becoming familiar with health
Communication
The exchange of information between individuals, for example, by means
of speaking, writing, or using a common system of signs or behavior
Box 9-1 Possible Nursing Diagnoses for the Prenatal A spoken or written message
Patient The communicating of information
• Knowledge Deficit related to normal physiological changes of A sense of mutual understanding and sympathy
pregnancy Advocate
• Altered Nutrition Risk: less than body requirement One who argues for a cause; a supporter or defender
• Risk for Fatigue One who pleads in another’s behalf; an intercessor: Advocates for abused
• Risk for Disturbance in Body Image children and spouses
• Risk for Altered Role Performance Respect
• Altered sexual patterns To feel or show admiration and deference toward somebody or
something
• Family coping
To pay due attention to and refrain from violating something
• Change in comfort level related to advancing pregnancy
To show consideration or thoughtfulness in relation to somebody or
• Change in sleep pattern disturbance
something
• Altered urinary elimination due to enlarging uterus or engagement of
Enable
fetal part
To provide somebody with the resources, authority, or opportunity to do
• Anxiety
something
• Family coping
To make something possible or feasible
• Adolescent
• Family processes, altered Source: Encarta® World English Dictionary © 1999 Microsoft Corporation. All
rights reserved. Developed for Microsoft by Bloomsbury Publishing Plc. (review
Adapted from Doenges (2005). http://www.npaf.org/ - National Patient Advocate Foundation).
218 unit three The Prenatal Journey
of care. Respecting the patient involves valuing her as an effect. This physiological response to engagement in friendship
individual, listening attentively, and addressing all of her behaviors helps women to dissipate stress (Taylor et al., 2002).
concerns. From a nursing perspective, there are a number of ways in
which this information can be used. One strategy is to incor-
porate continuity of care, so that as the patient sees the same
Optimizing Outcomes— Being an advocate for the
nursing staff throughout pregnancy, a professional relation-
patient
ship develops. This bond helps the patient to develop a sense
The nurse is the ideal person to be an advocate for the of being cared for, appreciated and known as an individual by
pregnant patient. An advocate is a person who supports her care providers. Ultimately, this simple action can help to
and represents the rights and interests of another individ- reduce maternal stress.
ual in order to ensure the individual’s full legal rights and
access to services.
Maternal stress during pregnancy can be associated
with difficulty accessing care. Transportation problems,
The nurse has the knowledge base to educate the appointment schedules that conflict with work commit-
patient and inform her of safe options or alternatives to ments, and personal or family member illness may prevent
meet her particular needs. The nurse also has the skills to the woman from keeping her prenatal appointments.
communicate effectively with the patient, her family Communication difficulties, perceptions of staff disinter-
members, and her care provider. Thus, the nurse facili- est, and a lack of understanding about the importance of
tates shared decision making and helps to promote patient frequent prenatal visits are all potential sources of stress
satisfaction with the health care services received. that may diminish the patient’s ability to comply with the
An informed recipient of care is an individual who has plan of care. By using an individualized approach with a
been made aware of available health care options and the focus on communication, personalized care, and educa-
possible consequences or outcomes of the choices made. tion, nurses may help to reduce the patient’s stress and
Thus, the informed pregnant woman is able to discuss the increase her adherence to the care plan.
advantages and disadvantages of various screening tools, Pregnancy is a time of entering the unknown. The
diagnostic tests, and treatment options and she is empow- pregnant woman faces unpredictability and quite possi-
ered to make an informed choice that is right for her and bly the loss of control. Since the course of the pregnancy
her family. For the nurse, an important aspect of the advo- may differ from the anticipated experience, women need
cate role involves remaining nonjudgmental and able to to be able to adapt to unexpected situations and meet
listen and respond accurately and objectively. unforeseen challenges as the pregnancy advances. The
As health care professionals, nurses need to empower new stressors associated with pregnancy can become a
women by caring, actively listening, and recognizing their deterrent to seeking or continuing prenatal care. There-
inner wisdom, strength, and abilities. In so doing, nurses fore, nurses must be cognizant of the fact that women,
gain insights to help them meet their patient’s needs in irrespective of culture, may face different stressors and
relation to education; health promotion; and physical, often require a variety of resources and interventions to
psychological, emotional, and spiritual support. The preg- help them deal effectively with stress and improve their
nant woman has a journey ahead of her that should lead utilization of prenatal care.
to greater self-understanding, enhanced feelings of self- Racial disparities exist in the provision and utilization
worth, and the knowledge that she has the internal power of prenatal care. The effects of these discrepancies on
to succeed. pregnancy outcomes have been recognized for more than
90 years. One of the goals of the Healthy People 2010
national initiative is to address these racial disparities
Diminishing Stress and Improving and to increase the uptake of prenatal care in the first
Pregnancy Outcomes trimester of pregnancy for all women to 90% (Healy
et al., 2006). By using the “CARE” principles, the nurse
Pregnancy is a developmental crisis that necessitates role can provide individualized support to all patients irre-
adaptation and a restructuring of the tasks involved in spective of race or culture.
daily living. It is a life-changing event that requires adjust- As an advocate, nurses can provide information about
ments to the many physical and emotional changes that stress management for their patients. Social support is
will take place. By nature, change is associated with stress. an important and positive factor in the reduction of
Eustress is defined as a normal, healthy level of stress. stress (Fig. 9-2). If the pregnant woman has a good
Most individuals are equipped with the resources needed social support system, she is much more likely to have
to readily deal with eustress. However, when perceived a venue to discuss issues of concern and gain morale
stress exceeds the individual’s resources, strategies, and support. It is important to note that a support system
abilities to effectively deal with it, the person moves into may be lacking for women who are trying to conceal a
a state of distress. pregnancy or for women who are trying to keep the
news of their pregnancy from relatives or friends until
Nursing Insight— Diminishing maternal stress results from genetic tests are known. These individuals
may need additional support from their nurses and
Women release oxytocin as a response to stress and when they other health care providers as they are placed in a pow-
engage in “tend and befriend” activities with friends. Oxytocin erless situation while awaiting results and face a preg-
appears to buffer the stress response and produces a calming nancy that may be in jeopardy.
chapter 9 The Prenatal Assessment 219
Box 9-4 Informed Consent and Communication Across Care Settings: The health care
safety net
Informed consent is the willing and uncoerced acceptance of a medical
intervention by a patient following the clinician’s full disclosure of informa- The health care safety net consists of a wide variety of
tion that includes the nature of the intervention, the risks and benefits of providers who deliver care to low-income and other
the intervention, and the risks and benefits of any alternatives. The patient vulnerable populations, including the uninsured and those
also has the right to informed refusal, that is, the right to refuse recom- covered by Medicaid. Many of these providers have either a
mended medical treatment. Open, on-going communication about rele- legal mandate or an explicit policy to provide services
vant information empowers the patient to exercise personal choice, and is regardless of a patient’s ability to pay.
central to the patient-clinician relationship. Major safety net providers include public hospitals and
Source: Amercian College of Obstetricians and Gynecologists (ACOG). (2007). Guide- community health centers as well as teaching and community
lines for Women’s Health Care. A resource manual. (3rd ed.). Washington, DC, ACOG. hospitals, private physicians, and others who deliver a
substantial amount of care to the targeted populations.
The health care safety net—the Nation’s system of
providing health care to low-income and other vulnerable
procedures performed only when the advantage to the populations—was recently described as “intact but endangered”
patient outweighs any possible disadvantage. (Agency for Healthcare Research and Quality 2003). Safety net
The provision of prenatal care offers the nurse a unique monitoring initiative. Retrieved from http://www.ahrq.gov/data/
opportunity to make a difference not only in the patient’s safetynet/netfact.htm
life but also in the lives of her family. To truly take advan-
tage of this opportunity, the nurse needs an expansive
array of tools including the ability to communicate effec-
tively with patients irrespective of cultural background, Now Can You— Discuss health promotion strategies for
educational level, health care beliefs, or age, to under- pregnancy?
stand family and group dynamics; and to accept diversity 1. Identify and describe each component of the “CARE”
without prejudice or bias. Family care during the prenatal principle?
period centers on education and health promotion. 2. Discuss how stress adversely affects pregnancy and identify
A number of issues affect a woman’s willingness to use nursing interventions to help decrease patient stress?
health care services. These include personal beliefs about 3. Describe four important elements of a teaching plan for
pregnancy, cultural expectations, previous relationships family health promotion during pregnancy?
with health care providers and perceived benefits of prenatal
care, together with the more practical issues of access to
care, medical insurance and/or financial support. By using
therapeutic communication, the nurse can gain insights into
the patient’s belief system and manage care appropriately. The First Prenatal Visit
Maintaining a nonjudgmental attitude is essential, for exam-
ple, if the woman is a late recipient of prenatal care. Creating THE COMPREHENSIVE HEALTH HISTORY
an atmosphere where the patient feels accepted and valued Before initiating the interview, it is helpful for the nurse to
for seeking care is a therapeutic, positive approach and one review the paperwork to become familiar with the infor-
that will hopefully foster patient adherence. mation to be gathered and to ensure an understanding of
Through discussion, the nurse can gain an understand- the relevance and appropriateness of the questions to be
ing of the availability and acceptability of traditional asked. The initial interview time with the patient should be
health care services and whether they meet the patient’s used to build a positive, nonthreatening relationship and
individual health care needs. Each culture embraces dif- to gain her confidence. Strategies that are useful include
ferent customs and health practices that need to be active listening, validating responses when needed, main-
respected, and wherever possible, accommodated. These taining eye-to-eye contact, and the use of humor as appro-
requirements may relate to the gender of the health care priate to relax the patient. Honesty is essential for effective
provider, the patient’s clothing requirements, diet, and/or communication. When uncertain of the answer to a ques-
food preparation. The prenatal interview provides an tion, the nurse should make a note to find the answer and
opportunity to develop a positive relationship with the report back to the patient at the end of the interview.
patient and emphasize the benefits of prenatal care for her The first prenatal visit is an extremely important one
and her unborn child. that should take place as early in pregnancy as possible.
In both the local and national arenas, nurses can empower Therapeutic communication skills are of paramount impor-
women and their families by advocating for prenatal care tance when obtaining the prenatal history. The informa-
that is readily available and affordable for all, especially for tion requested can often be of a very personal nature and
low-income and vulnerable populations. The “Health Care it may be difficult for patients to disclose certain aspects of
Safety Net” is one mechanism for providing health services their past histories. Therefore, care must be taken to man-
for the needy. Despite the availability of these types of pro- age the environment to promote privacy and provide the
grams, there are still women who receive inadequate or no patient with psychological and physical comfort.
prenatal care. In 2005, close to four percent of women in the It is important to avoid medical or technical jargon that
United States received inadequate prenatal care (National may interfere with the patient’s understanding, may intim-
Center for Health Statistics [NCHS], 2007). idate her, or cause her to feel embarrassed due to a lack of
chapter 9 The Prenatal Assessment 221
D DIET This is an ideal time to review the family diet and the way that foods are prepared.
Encourage consumption of whole grains, dark green, yellow and orange vegetables,
dry beans and peas; a variety of fresh or dried/canned fruit; increased low-fat and fat-
free foods, milk and calcium-rich foods; poultry, low-fat meats, fish that are lowest in
mercury (whitefish, haddock, pollock, sole, trout), nuts, and seeds.
E EXERCISE Aerobic exercise maintains physical fitness and promotes self-esteem and body
image. It is a family activity that benefits all family members.
E EDUCATION Many childbirth education options are available to meet the needs of women and
their families.
P PLAY Play is essential to health, happiness, and creativity. Fun family (couple) activities
refresh, promote optimism, and provide an opportunity to “recharge and
reconnect.”
E EXPECTATIONS Pregnancy is a time of great expectations. Families need to know what changes are
likely to occur and to be able to recognize normal from abnormal so they can recog-
nize when to seek medical assistance.
R RELAXATION Relaxation benefits all family members by boosting immunity, lowering blood pres-
sure, reducing stress, and increasing energy levels. Activities may include medita-
tion, yoga, and visualization/positive thinking.
C COMMUNICATION Effective communication is essential to promote family cohesiveness. Communica-
tion includes both verbal and nonverbal language such as body posture, gestures,
facial expressions, and tone of voice. Within the family, communication needs to be
open and truthful and received in a nonjudgmental and accepting manner, ultimately
affirming and supporting one other.
A ATTITUDE Positive thinking is under each individual’s control but can be modeled. A positive
attitude to life is associated with released stress, improved coping abilities, improved
immunity, and a greater sense of well-being.
R RESPECT Healthy relationships require mutual respect, honesty, and trust. Compromise,
negotiation, and shared responsibility are intrinsic to a positive relationship, as is
equal distribution of power and control.
E EMERGENCIES Family members need to know the following danger signs of pregnancy and how to
seek medical help:
◆ Reduction in fetal movements
◆ Signs of preterm labor such as low, dull backache, pelvic pressure feelings,
uterine contractions, or menstrual cramps
◆ Vaginal fluid loss or vaginal bleeding
◆ Maternal fever over 100.5ºF (38.1ºC)
◆ Persistent headache associated with blurred vision or flashing lights in front of
the eyes
◆ Continuous vomiting with weight loss, dehydration, weakness, dizziness, or
fainting
◆ Couple has an “inner feeling that something is just not right.” It is always better
to confirm normality rather than deal with an avoidable emergency.
comprehension. Questions should be phrased in a way to provide a user-friendly service that is efficient, effective,
encourage the patient to discuss and share information caring, and patient centered. One major goal for this first
rather than asking closed-ended questions that require visit is to explain the purpose of prenatal care and to
only a “yes” or “no” response. The value the patient places establish specific goals. Care goals are determined through
on the care she receives and her interactions with person- shared decision making with the patient and focus on
nel will determine whether she returns for subsequent promoting maternal and fetal health through assessment,
prenatal care. Therefore, the prenatal team’s objective is to education, screening, diagnosis, and treatment.
222 unit three The Prenatal Journey
physical examination that is suspicious of ongoing physi- drugs and their effects on the pregnancy and the infant are
cal abuse. It is estimated that every day at least three presented in Table 9-1.
women in the United States die as a result of intimate part- The nurse’s role is to promote a healthy life style for both
ner violence (Bureau of Justice Statistics, 2003). Femicide the woman and her developing fetus. Recreational drug use
is presently the leading cause of pregnancy-associated puts both patients at increased risk, not only from the
death in the United States (Stevens, 2005). Femicide refers direct effects of the drugs but also from the behaviors
to the death of a woman resulting from an act of violence needed to procure and maintain the supply of drugs.
against that woman (Bull, 2003). Women using drugs are more likely to have poor nutri-
IPV is a difficult subject to discuss and the nurse may tional status and they are more prone to infection due to a
fear insulting or psychologically hurting the patient lack of skin integrity and increased exposure to infective
more. A nonthreatening approach is to ask patients agents such as those responsible for sexually transmitted
directly whether they feel safe going home and whether infections. Sex may be used as a bargaining tool or as a
they have been hurt physically, emotionally, or sexually means of income to support a drug habit.
by a past or present partner. If the partner has accompa- Developing a therapeutic nonjudgmental relationship
nied the woman to the prenatal visit, these questions are with a drug-addicted woman is essential in order to pro-
postponed until the nurse is alone with the patient, for vide education, support, and guidance. The majority of
obvious reasons. expectant women wish to do the best they can for their
An alternative method is to use a standardized form that babies, so pregnancy is an ideal time to direct the woman
has valid and reliable questions concerning IPV. The form to drug counseling, support groups, and medical care with
could be incorporated into the intake assessment data the goal of reducing and eventually stopping the habit. For
obtained from all patients. Women who have been sexually a woman to be successful in overcoming drug addiction,
abused as children are at greater risk of IPV in adult rela- she must be internally motivated. The course to success
tionships. Sequelae of abuse include depression, anxiety, with this problem is not an easy one and the nurse can be
substance abuse and post-traumatic stress disorder (Coid instrumental in helping her to achieve this goal.
et al., 2001). As a women’s advocate, nurses have a duty to
be observant, to actively listen and to use communication Psychological Assessment
skills to gain clarification and understanding. The Centers Pregnancy is a time of change, and usually change of any
for Disease Control and Prevention (CDC) have adopted nature is linked with additional stress. How an individual
the acronym “RADAR,” a term originally developed by the deals with stress depends on learned behaviors, coping
Massachusetts Medical Society (Alpert, Freud, Park, Patel, mechanisms, and support systems. Pregnancy is a major life
& Sovak, 1992) to guide nurses as they interview patients change or developmental phase for all women. Each
about relationship violence: woman’s approach to her pregnancy encompasses cultural
values and family traditions and beliefs. One’s status in rela-
• Routinely screen every patient
tion to marriage or partnership, financial security, career,
• Ask directly, kindly, and in a nonjudgmental manner
or educational achievements are influential factors that
• Document your findings
shape the overall childbearing experience. Past obstetric
• Assess the patient’s safety
experiences including pregnancy outcomes, interactions
• Review options and provide referrals
with care providers, and level of physical health during and
after pregnancy are instrumental in forming the woman’s
Nursing Insight— Screening for intimate partner attitude toward this pregnancy. The loss of a previous preg-
violence nancy may adversely affect a woman’s ability to bond with
her present pregnancy. Understandably, she may be reluc-
Domestic violence during pregnancy is more common than tant to invest in a pregnancy that she fears may not come to
preeclampsia or gestational diabetes (Parson, 2000). Each year,
fruition. In other situations, acceptance of pregnancy may
approximately 324,000 pregnant women are abused by their
be delayed if it was unplanned or unwanted. Ambivalence
intimate partner and that number increases by a factor of 2 to 4
is a normal initial reaction to pregnancy that usually dimin-
if the pregnancy was unplanned (Gazmarian et al., 2000). Inti-
ishes as the woman accomplishes the developmental tasks
mate partner violence can occur for a first time during preg-
of pregnancy.
nancy. Screening should be available to all pregnant women
Although the developmental tasks of pregnancy may be
irrespective of social class or educational background.
reviewed in a systematic way, it is important to remember
Nurses need to promote screening for intimate partner
that each woman is an individual who harbors a host of
violence so that it becomes a routine part of prenatal care.
unique medical and psychological factors. For example, a
woman with a history of a previous eating disorder may
Women may use a number of defenses to emotionally experience difficulty maintaining a healthy diet and
deal with abuse. One method may involve the use of recre- achieving appropriate weight gain during pregnancy.
ational drugs. Irrespective of a history of intimate partner Another woman may have struggled with anxiety and
abuse, it is estimated that approximately 3% of pregnant depression or alcohol or drug use or issues related to
women use nonprescription drugs such as cocaine, amphet- domestic violence prior to pregnancy. These are all factors
amines, heroin, marijuana, or ecstasy (March of Dimes, that can have a significant impact on the prenatal course.
2006). Illegal or recreational drug use can have a number of Many tools such as “The Edinburgh Postnatal Depression
detrimental effects (e.g., spontaneous abortion, low birth Scale” are available to guide the nurse in conducting the
weight, placental abruption, and preterm labor) on maternal prenatal and postpartal psychological assessment. (See
and fetal health during pregnancy. Selected recreational Chapter 16 for further discussion.)
224 unit three The Prenatal Journey
THE OBSTETRIC HISTORY genetic test for the early diagnosis of the syndrome (National
Previous Pregnancies
Human Genome Research Institute, 2003). Because of the
rapid advances in the field of genetics, nurses must have a
One of the first steps in the prenatal interview process is to working knowledge of genetics terminology and recent find-
obtain an accurate and detailed obstetric history that pro- ings so that they can initiate referrals when appropriate. The
vides the interviewer with essential information so that “Core Competencies in Genetics Essential for All Health
questions can be formulated and asked in a manner that Care Professionals” is a useful document with which all
respects and acknowledges the patient’s past experiences perinatal nurses should be familiar (Appendix 9-2).
with pregnancy. The history should cover the current
pregnancy as well as all previous pregnancies and their
outcomes, since complications experienced in a prior preg- Nursing Insight— Preconception genetics
nancy often reoccur in subsequent pregnancies. counseling
A history of preterm labor and delivery, defined as a
Birth defects affect about one in every 33 babies born in the
birth that occurs before the 37th completed week of preg-
United States each year. They are the leading cause of infant
nancy, provides one example of the importance of the
deaths and account for more than 20% of all infant deaths.
obstetric history in identifying potential problems during
the current pregnancy. Preterm labor is the leading cause
of perinatal mortality and morbidity in the United States, Although it is never possible to guarantee a family a
where the incidence is 11%, although this figure is much “perfect” baby, nurses can help recognize patients who may
lower (5%) in some European countries including France benefit from preconception or prenatal counseling and
and Finland. Once a woman has experienced a preterm genetic testing. Keeping abreast of advances in prenatal
birth, her risk of preterm labor in subsequent pregnancies genetic diagnosis or knowing where to seek pertinent infor-
is increased by 20% to 40%. Although the etiology for this mation is a valuable asset in providing patient centered-care
condition remains largely unknown, there are a number (CDC, 2007).
of predisposing factors. Education, resources, and early The loss of a previous pregnancy or the death of an
interventions are important strategies since earlier diagno- infant brings a staggering cascade of emotions to a subse-
sis means earlier treatment and better outcomes. (See quent pregnancy. Fear of another fetal loss or infant death
Chapter 11 for further discussion.) undoubtedly increases the couple’s anxiety and stress.
A previous history of preeclampsia increases the woman’s Although no couple is ever guaranteed a baby that is 100%
likelihood of a recurrence during subsequent pregnancies. perfect, the couple who has dealt with the death of a child
(See Chapter 11 for further discussion.) Interestingly, if a or loss of a pregnancy faces the prospect of awaiting prena-
woman did not experience preeclampsia with previous preg- tal diagnostic test results with increased trepidation. Sup-
nancies but has a new partner for her current pregnancy, her port and continuity of care are essential along with provid-
risk of developing preeclampsia is similar to that of a woman ing advice and listening to the woman’s (couple’s) concerns.
who is pregnant for a first time. Although preeclampsia is a As is true with any pregnant patient, emphasis on healthy
systemic disorder that occurs only during pregnancy, it is lifestyles is of paramount importance. If the previous loss
generally recognized via two classic symptoms: elevated was a result of sudden infant death syndrome (SIDS), the
blood pressure and proteinuria. The complication of pre- nurse should provide the patient with information about
eclampsia places both the patient and her fetus at additional strategies to reduce the incidence of SIDS, such as breast
risk both during pregnancy and in the postpartum period. feeding if at all possible, avoiding cigarette smoke and posi-
A history of pregnancy-related diabetes or gestational tioning the baby on the back to sleep. Support groups may
diabetes (GDM) (carbohydrate intolerance that occurs also help couples facing a new pregnancy after the loss of a
during pregnancy) is also significant. GDM is estimated to previous one. (See Chapter 14 for further discussion.)
affect up to 7% of pregnancies, and approximately one During the initial prenatal visit it is especially important
half of women who have had a previous pregnancy to educate the woman about the developing embryo/fetus
affected by GDM will develop this condition again in a during the first few weeks of pregnancy. This is a time when
subsequent pregnancy (American Diabetes Association, the woman needs to be particularly conscious of potential
2003). Since GDM is associated with a number of fetal and teratogens. A teratogen is a substance that adversely affects
maternal complications, early screening is essential. (See fetal development. The vulnerability of the developing
Chapter 11 for further discussion.) embryo/fetus during the early weeks of gestation underscores
Patients who indicate a pattern of repeated spontaneous the importance of a healthy body and a healthy lifestyle.
miscarriages most likely would benefit from genetic coun-
seling, preferably during the preconception period. A family Now Can You— Discuss various components of the
pedigree is often useful in determining the need for further prenatal assessment?
screening and specific testing. Prenatal genetic screening 1. Describe biographical information to be elicited from the
questionnaires have been developed to guide counseling prenatal patient?
and intervention approaches. The Human Genome Project, 2. Explain how to ask the patient about intimate partner violence?
completed in April 2003, provided information useful in 3. Discuss why the psychological assessment is an important
facilitating the early diagnosis of genetic disorders and the component of the prenatal assessment?
timely initiation of medical care. For example, in April 2003, 4. Explain the importance of past pregnancies in the obstetric
the gene for Hutchinson-Gilford Progeria Syndrome (HGPS) history?
was identified. This finding prompted the development of a
226 unit three The Prenatal Journey
THE MEDICAL HISTORY labor (López, Da Silva, Ipinza, & Gutiérrez, 2005). Oral
To provide the patient with appropriate care to meet caries may also pose a greater threat during pregnancy.
medical needs during pregnancy, it is essential that a This is especially true during early pregnancy, when vom-
detailed medical history be obtained. This information iting from “morning sickness” causes the mouth to harbor
gives insights into the patient’s past and present health an acid environment that favors cariogenic activity. Other
status and use of preventative services. The nurse should investigators suggest that women’s dental health practices
obtain contact information for the primary care provider suffer after pregnancy due to a lack of time and result in an
in order to facilitate continuity of care. Lack of a family increase in dental caries (Hey-Hadavi, 2002). To promote
physician may be related to financial difficulties, lack of dental health among pregnant women, some European
medical insurance, or cultural/value differences. The nurse countries such as England offer free dental care during
can explore these issues through sensitive and respectful pregnancy and for the first year following childbirth. Part
questioning and when appropriate, refer the patient and of the nurse’s role during the prenatal period is to promote
her family to local agencies that provide services such as dental hygiene to reduce the incidence of periodontal dis-
the WIC (Women, Infants, and Children) program for ease such as gingivitis (which is reversible). Pregnant
nutritional support (Box 9-6). women need to receive regular dental examinations and
Some European countries offer “shared” care for low- appropriate treatment as determined by their dental
risk patients to serve as a link between the patient’s pri- practitioner.
mary care provider and her obstetrician. The pregnant
woman visits her family physician for the majority of her Optimizing Outcomes— Promoting dental health
prenatal care but also sees an obstetrician for two to three during pregnancy
visits. If any complications arise, the patient is transferred
for the remainder of the pregnancy to the care of the • Encourage regular dental examinations.
obstetrician. Since any complications that occur during • Promote twice daily brushing and flossing.
pregnancy are associated with maternal and family stress, • Recommend the use of a fluoride toothpaste.
referral to a “known” obstetrician hopefully helps to • Encourage a healthy diet.
diminish some of the anxiety. • Encourage chewing gum containing Xylitol after meals.
Dental Health
Together with the overall evaluation of medical well-being, Eye Health
it is essential to explore dental health. The initial interview An ophthalmic evaluation is also recommended early in
is an ideal time to provide education about the benefits of pregnancy, most often during the first trimester or at any
preventative dental care and to dispel common myths such time visual changes occur. This is especially important for
as “for every pregnancy, a tooth is lost.” It has been well women with medical conditions such as essential hyper-
established that the hormones of pregnancy predispose tension, Graves’ disease, or diabetes mellitus, and for
women to increased plaque and the development of gingi- women who wear contact lenses. During pregnancy, a
vitis, or gum inflammation (Hey-Hadavi, 2002). number of normal physiological ophthalmic changes
There is a link between periodontal disease in preg- occur, including corneal thickening, increased curvature
nancy, gingivitis, and preterm labor. It is believed that oral of the cornea, and a decrease in corneal sensitivity and
bacteria and their products travel via the bloodstream to intraocular pressure. These changes usually resolve spon-
the placental membranes, where an inflammatory response taneously during the postpartum period. Medical condi-
occurs. The inflammation may trigger the onset of preterm tions peculiar to pregnancy such as pregnancy-induced
hypertension, eclampsia, and gestational diabetes can also
have detrimental effects on eye health and vision (Somani
& Ahmed, 2004).
Box 9-6 WIC at a Glance
The WIC target population includes those who are low-income and
nutritionally at risk: where research and practice meet:
• Pregnant women, and up to 6 weeks postpartum or after pregnancy
Eye Examinations During Pregnancy
ends During an eye examination, it is a relatively common practice to dilate
• Breastfeeding women (up to infant’s first birthday) the pupils to facilitate ocular assessment. Although occasional use of
• Non-breastfeeding postpartum women (up to 6 months after the birth parasympatholytics (i.e., atropine) and sympathomimetics (i.e., epi-
of an infant or after pregnancy ends) nephrine) is thought to be safe, repeated use is contraindicated
• Infants (up to first birthday). WIC serves 45% of all infants born in the
because of possible teratogenic effects. Mydriatics (medications that
United States
dilate the pupils) are also contraindicated for breastfeeding mothers
because they have a hypertensive and anticholinergic effect on the
• Children up to their fifth birthday infant (Somani & Ahmed, 2005). This information is important to
BENEFITS nurses who counsel prenatal and postpartal patients. All prenatal and
• Supplemental nutritious foods breastfeeding patients should be advised that certain components of
the eye examination may carry risks during pregnancy and they should
• Nutrition education and counseling at WIC clinics
make certain their eye care professional is aware that they are preg-
• Screening and referrals to other health, welfare, and social services nant (or breastfeeding).
230 unit three The Prenatal Journey
Immunizations
Another essential component of the medical history con- Box 9-7 Educational Strategies for Patients Who Are
cerns patient immunizations. Nurses and their patients need Hepatitis Carriers
to be aware that some infections contracted during preg-
The nurse teaches prenatal patients who are hepatitis carriers to:
nancy can be detrimental to the developing fetus. Rubella
• Avoid drugs that are hepatotoxic such as acetaminophen (Tylenol).
(German measles) is one of the most commonly recognized
viral infections known to cause congenital problems. If a • Avoid alcohol.
woman contracts rubella during the first 12 weeks of preg- • Choose noninvasive prenatal diagnosis techniques, such as ultrasound
nancy, the fetus has a 90% chance of being adversely and AFP screening rather than invasive procedures such as chorionic
villus sampling (CVS) and amniocentesis (Boxall et al., 2004).
affected. Maternal exposure to rubella later in pregnancy is
associated with a decreased fetal risk. If the pregnancy is • Make certain that the pediatrician is aware of the maternal hepatitis B
status.
between 12 and 16 weeks when rubella infection occurs,
the fetal risk decreases to 20%. Typical symptoms of con- • Practice “daily living” precautions to prevent transmission to household
members. Strategies include covering cuts or skin lesions and not shar-
genital rubella syndrome include intrauterine growth restric-
ing toothbrushes or razors.
tion, cardiac detects, sensorineural defects, cataracts, and Patients are also advised that:
microcephaly (Laartz, Gompf, Allaboun, Marinez, & Logan,
• The neonate will need to receive hepatitis B immune globulin (HBIG)
2006). According to the National Coalition for Adult Immu- at birth. This action will provide antibodies to the hepatitis B virus
nization, approximately 7 million childbearing-aged women and afford some initial protection to the newborn. The intramuscular
in the United States are currently susceptible to the rubella injection must be administered within 12 hours of birth. The hepatitis
virus (National Foundation for Infectious Diseases, 2007). A B vaccine (Recombivax HB, Engerix-B), which induces protective anti-
maternity patient who is not immune to rubella should be hepatitis B antibodies, may be administered at the same time as HBIG
offered the rubella immunization after childbirth, ideally but at a different site. The hepatitis B vaccine is given again at 1, 2,
before hospital discharge. After the immunization, she and 12 months of age.
needs to be advised against becoming pregnant for at least • There is at present no correlation between breastfeeding and the inci-
4 weeks (Vaccine Information, 2005). dence of mother-to-infant transmission of hepatitis B (Reuters, 2005).
Other viruses known to cause complications during • The method of birth does not appear to influence the incidence of
pregnancy include varicella (chickenpox) and rubeola (red mother-to-child transmission (Reuters, 2005).
measles). Information regarding the latest recommenda-
tions for immunizations can be found by visiting the Web
site for the American Academy of Pediatrics: http://www.
aap.org/family/parents/immunize.htm. (See Chapter 11 for tests positive when screened, due to the presence of the
further discussion.) antibodies.
Women who are considered to be at risk for hepatitis B
HEPATITIS B INFECTION. Although a vaccination is avail- also need to be screened for hepatitis C (HCV). The main
able to prevent hepatitis B, the rate of new cases of hepati- route of transmission for this infection (previously known
tis B in the United States continues to rise and today as “non-A, non-B hepatitis”) is through intravenous drug
approximately 1.25 million Americans are infected (Braun, use. Approximately 4 million Americans have HCV, which
Sanne, & Bartlett, 2006). During the prenatal period, it is is now listed by the Institute of Medicine as an emerging
important to screen for hepatitis B since a positive diagno- infectious disease (Holloway & D’Acunto, 2006). Up to
sis will influence both the maternal and newborn medical 80% of patients with acute HCV are asymptomatic, with
management. When an acute infection occurs during seroconversion occurring in approximately 8 to 9 weeks.
pregnancy, the rate of vertical transmission from mother Preterm labor is the main pregnancy risk associated with
to fetus ranges from approximately 10% in the first trimes- HCV. However, there is a low (4% to 8%) risk of transmis-
ter to 80% to 90% in the third trimester (ACOG, 1998). sion to the neonate. If the mother is coinfected with HIV,
From a nursing perspective, the patient will need sup- the transmission rate to the newborn increases to around
port and education relating to both the present and long- 13%. It is recommended that all infants born to mothers
term implications (Box 9-7). Clinical management focuses with HCV undergo testing at 12 to 18 months of age
on the potential effects of hepatitis B on the pregnancy as (CDC, 2006b).
well as the long-term maternal risks, including chronic
liver disease. It is strongly recommended that household
members and intimate partners of a positive hepatitis B
where research and practice meet:
carrier undergo screening, and, depending on the results,
Gender and Neonatal Hepatitis C
receive the vaccination.
Other populations at risk for hepatitis B infection include There is no known method to prevent the vertical transmission of
individuals from countries such as India, Africa, Asia, and hepatitis C virus (HCV) from the mother to her infant. Presently, the
the Pacific Isles. Due to needle sharing and a potentially transmission rate is approximately 4% to 8% and it is dependent on
high number of sexual partners (as payment for drugs), factors such as maternal viral load (Tajiri et al., 2001). A study con-
ducted in 2005 with a population of 1787 HCV-infected pregnant
intravenous drug users are also at an increased risk for
women from 33 centers found that female infants were twice as
hepatitis B. Most adults in the United States contract hepa- likely as males to be infected with HCV. Variables such as mode of
titis B through sexual contact, and it is estimated that about delivery, gestation, and infant feeding practices were examined. The
25% of individuals who are sexually active with a hepatitis Italian investigators speculated that the gender differences in the
B infected individual will seroconvert (CDC, 2002). Sero- infection rate may be due to either genetic or hormonal factors
conversion is the process whereby an individual develops (Reuters Health Information, 2005).
antibodies in response to an infection and subsequently
chapter 9 The Prenatal Assessment 231
count is obtained and assessed using laboratory values of perinatal transmission (HIV-positive mother to her
established for pregnancy. Testing for antibody to the fetus) ranges from 25% to 35%. Maternal treatment with
human immunodeficiency virus (HIV) is recommended zidovudine (AZT, Retrovir) reduces the risk of perinatal
for all pregnant women (ACOG, 2004) and a sickle cell transmission and the risk of infant death. Elective cesar-
screen is recommended for women of African, Asian, or ean birth has been shown to significantly reduce the risk
Middle Eastern descent. In the United States, sickle cell of transmission from the mother to the infant (Brocklehu-
anemia is one of the most common genetic blood disorders rst & Volmink, 2002).
and occurs most often in African American populations In 2004, the American College of Obstetricians and
(NIH, 2006). (See Chapter 11 for further discussion.) Dur- Gynecologists (ACOG) published a recommendation that
ing this visit, a Tine or purified protein derivative (PPD) all pregnant women be tested for HIV as part of the rou-
tuberculin test may also be administered to assess for tine battery of prenatal tests, although patients may
exposure to tuberculosis. choose to opt out of this testing. Screening for HIV is done
via an enzyme-linked immunosorbent assay (ELISA) on a
SEXUALLY TRANSMITTED INFECTIONS blood sample. If the result from this test is positive, the
Based on the patient’s risk factors, screening for sexually finding is confirmed via a Western blot test.
transmitted diseases/infections (STDs/STIs) may need to Nurses need to be patient advocates and ensure that
be repeated during the pregnancy. The presence of an patients receive individualized and informed care. One
STI can predispose to a number of adverse pregnancy aspect of the nurse’s role in this situation is to make cer-
outcomes including ectopic pregnancy, spontaneous tain that each patient receives comprehensive pre- and
abortion, preterm labor, and increased neonatal morbid- post-counseling in relation to HIV testing. Clearly, it is
ity. Taking a sexual history is an important component medically advantageous for the pregnant patient to be
of the prenatal nursing assessment. Self-awareness and diagnosed and treated (for HIV) during pregnancy to pro-
the use of effective communication techniques foster mote maternal well-being and to reduce the incidence of
open, honest discussion of sensitive issues in a non- perinatal HIV transmission (Nielsen, 2006).
threatening environment (Box 9-8). Syphilis
The sexual history should include signs or symptoms
(i.e., vaginal/rectal discharge, dyspareunia, ulcers, rashes, A syphilis infection during pregnancy can cause signifi-
or anogenital itching) that may be indicative of infection. cant damage to the fetus after the 16th to 18th week of
Information concerning recent sexual partners is also intrauterine life, when the cytotrophoblastic layer of the
important so that when indicated, prior contacts can be placental villi has atrophied and is no longer protective.
notified and offered treatment. High-risk behaviors such as Caused by the spirochete Treponema pallidum, syphilis is
intravenous drug use, acquisition of tattoos, exposure to readily treated with penicillin or erythromycin. If the con-
blood or blood products or sex with an individual from a dition is treated before the 18th week, the fetus is rarely
high-risk category (e.g., a sex industry worker) should also affected. Left untreated, transplacental transmission to the
be noted (SexuallyTransmitted Diseases Services, 2005). fetus is likely to occur (congenital syphilis) and may
result in deafness, cognitive difficulties, osteochondritis,
Human Immunodeficiency Virus or fetal death.
Infection with human immunodeficiency virus (HIV) Chlamydia trachomatis, Neisseria gonorrhoeae
leads to a progressive disease that results in acquired
immunodeficiency syndrome (AIDS). (See Chapter 11 for Other routine screening tests including chlamydia and gon-
further discussion.) Perinatal transmission may occur orrhea are obtained during the pelvic examination. Secre-
transplacentally, at birth from exposure to maternal blood tions from the cervix, vagina, and anus may be used to
and vaginal secretions and via breast milk. The incidence obtain samples for culture media. Chlamydia trachomatis is
a bacterial infection that is prevalent in sexually active pop-
ulations, especially those in the under 25-age group. Most
patients with this infection are asymptomatic and conse-
Box 9-8 Tips for Taking A Sexual History quently do not seek treatment. Complications of chlamyd-
ial infections include salpingitis, pelvic inflammatory dis-
SELF-AWARENESS ease, infertility, ectopic pregnancy, premature rupture of
Know your own comfort level and your ease at discussing sexual issues
the membranes, and preterm birth. Transmission to the
with patients.
neonate may occur during birth and results in ophthalmia
Acknowledge areas of discomfort.
neonatorum and chlamydial neonatal pneumonia. During
EFFECTIVE COMMUNICATION pregnancy, chlamydia is treated with oral anti-infectives or
If you are embarrassed, this will be apparent though body language, penicillin-based agents. (See Chapter 11 for further discus-
eye-to-eye contact, tone of voice, type of questioning chosen, for example, sion). It is recommended that pregnant women be retested
closed-ended questions as opposed to exploratory questions. 3 weeks after treatment, although the validity of this prac-
Use terminology: words/terms that the patient understands. tice has not yet been established (CDC et al., 2006a).
Environment: ensure privacy and confidentiality. Gonorrhea is caused by the gram-negative intracellu-
Never make assumptions or be judgmental in your response or attitude lar diplococcal bacteria Neisseria gonorrhoeae. It is read-
ily treated with antibiotics. When left untreated, ascend-
Source: Royal Adelaide Hospital Clinic, Sexually Transmitted Diseases Services. STD
interview checklist (2005). Retrieved from http://www.stdservices.on.net/management/
ing maternal infection may occur after rupture of the
checklists/cl_interview.htm. membranes. Transmission to the fetus can occur during
vaginal delivery and may result in disseminated infection
chapter 9 The Prenatal Assessment 233
and ophthalmia neonatorum. (See Chapter 11 for further Before the examination begins, the patient should receive
discussion.) Concomitant treatment for gonorrhea and an explanation of what the examination will involve and
Chlamydia is recommended because coinfection is com- what she is expected to do. Obtain her consent to be exam-
mon (CDC et al., 2006a). ined. During a physical examination, the patient is usually
scantily clothed and must remain on her back in a vulnera-
Herpes Simplex Virus ble position for the majority of the time. Gaining permission
Herpes simplex virus type 1 (HSV-1), transmitted non- from the patient before proceeding gives her control, as she
sexually, is most commonly associated with fever blisters. “allows” the examiner to continue. This action is especially
Herpes simplex virus II (HSV-2) is usually transmitted important for women with a history of abuse, particularly,
sexually and is associated with genital lesions, although sexual abuse. Actively engaging the patient through dia-
depending on sexual practices, both types are not exclu- logue during the examination process provides an excellent
sively associated with the respective sites. HSV-2 occurs opportunity for teaching. Also, ongoing interaction while
more frequently in women (23%) than in men (11%), describing the findings and their relevance empowers the
which most likely results from the greater likelihood of patient and dispels the oft-experienced feeling that some-
male-to-female transmission. Although HSV infection is thing is being “done” to her. Before beginning the physical
not a reportable disease, it is estimated that 50 million examination, the nurse should have collected all of the
Americans are infected with genital herpes (CDC, 2006a; equipment that may be needed, along with any teaching lit-
Winer & Richwald, 2007). erature that the patient should receive. It does not inspire
The initial HSV genital infection generally produces flu- confidence or relieve the patient’s anxiety if the nurse is
like symptoms including malaise, muscle aches, and head- constantly leaving the room to retrieve forgotten items.
ache accompanied by dysuria and the appearance of multi-
ple painful blister-like lesions. The symptoms may persist Optimizing Outcomes— Demonstrating
for several weeks. A prodromal period characterized by professionalism during the physical examination
marked skin sensitivity and nerve pain in the affected area
may precede the outbreak of lesions (Gardner, 2006). To convey respect and minimize the transmission of infec-
HSV-2 infection during pregnancy can have adverse tion, the nurse should:
effects on both the mother and her fetus. Primary infec- • Ensure that the fingernails are short and all jewelry
tion during the first trimester is associated with congeni- items that may cause skin trauma have been removed.
tal infection and an increased risk of pregnancy loss. In • Wash hands thoroughly in the patient’s presence. This
the neonate, herpes simplex virus infection is associated simple act demonstrates respect and an understanding of
with a 60% mortality rate, and of those who survive, and appreciation for the risk of cross-infection.
approximately 50% suffer serious neurological damage • Develop the habit of always washing the hands when
(Gardner, 2006). There is no cure for genital herpes. Care entering and leaving a patient’s room.
management centers on providing symptomatic relief.
Although several antiviral agents are available, the safety
The physical examination should proceed in the same
of these medications during pregnancy and lactation has
order each time (preferably head to toe) to reduce the
not been established (CDC, 2006a). (See Chapters 4, 11,
likelihood of unintentionally omitting any component.
and 19 for further discussion.)
The examination should be organized in a manner that
reduces the movements the patient must make. Also, it is
CERVICAL CANCER less threatening to the patient when less invasive proce-
Cervical screening is usually a component of the first pre- dures are performed first. Throughout the examination, it
natal examination. Screening and treatment of cervical is essential for the nurse to use good communication skills
dysplasia (cancerous cellular changes) significantly and to advocate for and treat the patient with respect.
reduces the chances that carcinoma will develop. This fact These actions empower patients to participate actively in
lends credence to the recommendation that screening via all health care decisions. The time before, during, and
Papanicolaou testing be performed on all young adults. after the examination provides the nurse with an excellent
Furthermore, 50% of all women diagnosed with cervical opportunity to develop a good rapport while enhancing
cancer are diagnosed during the ages of young adulthood. the patient’s comfort level. Proper management of the
(See Chapter 4 for further discussion.) clinical environment plays an important role in facilitat-
ing the patient’s feelings of safety, privacy, and security.
The nurse then obtains anthropometric measurements. weight, activity level, pregnancy weight gain, and risk fac-
When obtaining the weight it is valuable to ask the patient tors. The Higgins Method, still relevant today, is grounded
what her normal prepregnant weight was and to document in the philosophy that each woman has specific dietary
this information (Fig. 9-4). The prepregnant weight gives an needs, and by meeting those needs, one can promote opti-
indication of how the patient is adapting to pregnancy. A mal growth and development of the fetus (Higgins, 1976).
dramatic, unintended weight loss can be indicative of severe (See Chapter 10 for further information about dietary
nausea and vomiting (hyperemesis gravidarum). The height needs in pregnancy.)
and weight are also recorded and used to calculate the
patient’s body mass index (BMI) and to determine nutri- Optimizing Outcomes— Vitamin C and premature
tional needs. The BMI can be used to calculate whether the rupture of the membranes
maternal weight is appropriate for height. (See BMI discus-
sion in Chapter 10.) Woman who are underweight before Low levels of vitamin C may predispose women to prema-
pregnancy and have a low weight gain during the pregnancy ture rupture of membranes. As the cellular availability of
are at a greater risk for preterm labor. vitamin C decreases, the rate of degradation of cervical col-
lagen increases (Vadillo et al., 1995; Woods et al., 2001,
Obtaining Information and Promoting Good Nutrition cited in Modena, Kaihura, & Fieni, 2004). With decreased
An important nursing goal is to promote appropriate weight collagen, the cervix ripens more easily, prompting efface-
gain during pregnancy through healthy nutrition. It may be ment and dilatation.
helpful to use a 24-hour diet recall form to help provide
pertinent information about the patient’s nutritional intake
and food preparation/cooking preferences. On average, dur-
Recording Vital Signs
ing the second and third trimesters a woman’s caloric need
increases by 300 per day. A well-balanced diet that contains The vital signs are taken and documented. Blood pressure
the necessary vitamins and nutrients is essential. It is impor- is a particularly important measurement and should be
tant to educate women that prenatal vitamins are an option recorded under standardized conditions (making note of
to ensure that their daily needs are being met, but mega- the arm used and the patient’s position) and with the
doses of vitamins can be harmful. A woman’s need for folic appropriate size blood pressure cuff. Since the initial pre-
acid doubles during pregnancy and ideally supplementation natal visit may be the patient’s first adult interaction with
with 400 mcg/day should be initiated prior to conception a health care professional, physiological indicators of
and continued at least through the first 3 months of preg- anxiety (e.g., tachycardia, elevated blood pressure) may
nancy, to help reduce the incidence of open neural tube be present. In these situations, the nurse should record
defects (NTDs) (CDC, 2005). (See Chapters 7 and 10 for the first set of vital signs and then repeat the recordings
further discussion.) later when the patient has had time to become familiar
In the mid-1970s, nutritionist Agnes Higgins devel- with her surroundings and is more relaxed.
oped “The Higgins Method of Nutritional Rehabilitation
During Pregnancy.” This program focused on the individ- Ethnocultural Considerations—
ual woman’s nutritional needs based on age, prepregnant Hypertension and pregnancy
Nurses should be aware that hypertension is more prevalent
in African American and Mexican American cultures, proba-
bly due to hereditary factors (Nabel, 2003). It is the most
common medical condition affecting pregnancy and may
worsen as the pregnancy progresses.
Documentation
1/10/10 1100 Patient educated re midstream urine
collection. Patient verbalized understanding. Sample
obtained, labeled with name, date, time and type of
specimen. Sent to lab at 1120 per Dr. Garner’s order.
—M. D’Arcy-Evans, RN, CNM
Patient cleansing labia.
236 unit three The Prenatal Journey
information relating to the patient’s usual state of health, her The Breasts
use of health promotion and maintenance strategies, and The patient is assisted to a recumbent position for the
details of any present concerns or symptoms. The physical breast examination. Depending on the gestational age, it
examination is a basic review of systems that includes ears, may be advisable to place a wedge under one of her hips
nose, mouth, and throat; cardio-respiratory; musculoskele- to prevent compression of the vena cava from the gravid
tal; and neurological function with an in-depth evaluation of uterus (supine hypotension syndrome). Inspection of the
the maternal physical adaptation to the pregnancy. breasts usually reveals pregnancy-related changes including
nodularity, striae, and enlargement and hyperpigmentation
Now Can You— Discuss aspects of the initial prenatal of the nipples and Montgomery tubercles. Areas of indenta-
health assessment? tion or skin puckering are not normal findings. Colostrum,
1. Identify five screening tests routinely performed on the a precursor to breast milk, may be expressed from the nip-
patient’s serum during the initial prenatal examination? ples as early as the first trimester of pregnancy. The lymph
2. Briefly discuss why screening for human immunodeficiency nodes should not be palpable.
virus and Chlamydia trachomatis is recommended during
pregnancy? Optimizing Outcomes— Promoting breast comfort
3. Identify four major components of the prenatal physical during pregnancy
assessment?
As a component of health teaching during pregnancy, the
nurse should encourage patients to wear a firm, supporting
bra. For some, professional fitting/measuring may be ben-
THE FOCUSED OBSTETRIC EXAMINATION eficial to promote both support and comfort. As the breasts
increase in weight, bras with wider straps may be more
Head, Neck, and Lungs
comfortable. Some women choose to wear a “sleeping” bra
With the patient in a sitting position, the physical exami- during the night for added comfort.
nation proceeds in a head to toe fashion beginning with a
general evaluation of the skin and hair. Many women
notice that their hair is healthier and more luxurious dur-
ing pregnancy. Hair loss, common during the postpartum The Abdomen
period, can be indicative of a vitamin or mineral defi- The obstetric abdominal examination focuses on recog-
ciency. Increased levels of estrogen are responsible for a nizing signs and changes associated with pregnancy. It is
number of objective and subjective changes such as not intended to replace a comprehensive abdominal
hypertrophy of the gingival tissue, nasal stuffiness, and an examination. The patient should be appropriately draped
increased tendency for nosebleeds. to maintain her privacy, comfort, and body temperature.
The thyroid gland is palpated while the patient The abdominal shape is assessed and inspected for the
remains in a sitting position. Enlargement is common presence of scars (previous surgery should be docu-
during pregnancy due to increased vascularity and mented), linea nigra, striae gravidum, or signs of injury
hyperplasia of the glandular tissue. The size and posi- (i.e., bruising). As the pregnancy advances, visual inspec-
tion of the thyroid are documented along with the pres- tion of the abdominal shape may reveal the fetal position,
ence of nodules or swelling (Koscica & Berstein, 2003). especially if transverse. Also, it may be possible to observe
Anterior and posterior lung sounds are auscultated and and palpate fetal movements. Patients generally become
the cardiac rhythm and rate are evaluated for adventi- aware of fetal movements around the 16th to 20th week
tious sounds. During pregnancy, approximately 90% of of pregnancy. A primigravida is usually able to identify
women exhibit systolic heart murmurs due to an increase fetal movements around 18 to 20 weeks; a multigravida
in blood volume. The systolic murmur may be clearer may notice fetal movements as early as 16 weeks. This
when the woman holds her breath. Heart sounds should difference in awareness of fetal activity is most likely due
be evaluated with the woman in both a sitting and lying to past experience in recognizing the movements along
position. Beginning late in the second trimester, the with a decrease in maternal abdominal muscle tone.
gravid uterus causes an upward and lateral displacement
of the heart and the point of maximal impulse. Also, as Uterine Size and Fetal Position
pregnancy advances, the patient’s breathing becomes Abdominal palpation is used to evaluate the uterine size, to
thoracic in nature (rather than abdominal) due to the determine fetal position, and later in pregnancy, to deter-
enlarged uterus. mine whether the presenting part has engaged in the
maternal pelvis. (See Chapter 12 for further discussion.)
The Skin Fundal height is an indication of uterine size; periodic
Assessment the skin may reveal pregnancy-associated measurements of the fundal height should correlate
changes such as chloasma (the mask of pregnancy) and strongly with fetal growth (Fig. 9-5). The relationship of
hyperpigmentation of the areolae, vulva, abdomen, and the fundus (top part) of the uterus to specific maternal
linea (linea nigra). The skin is evaluated for color consis- abdominal landmarks is used throughout pregnancy as a
tent with the woman’s ethnic background, and for the pres- gauge to assess fetal growth. The fundal height measure-
ence of lesions or indicators of drug abuse (i.e., skin ment correlates to the weeks of gestation from approxi-
scratches, bruising or track marks, nasal discharge or irri- mately 22 to 34 weeks of gestation (Table 9-2). At 12 weeks
tated mucosa, constricted or dilated pupils). of gestation, the fundus should be at the level of the
chapter 9 The Prenatal Assessment 237
Figure 9-7 First Leopold maneuver. Figure 9-10 Fourth Leopold maneuver.
Figure 9-9 Third Leopold maneuver. Figure 9-11 Assessing fetal presentation/position.
Fetal Heart Auscultation determine if the two heart rates are synchronous. If they
The information obtained during fetal palpation includes are synchronous, the maternal pulse has inadvertently
fetal presentation, lie, position, and engagement status been auscultated through the abdomen and an attempt
(Table 9-3). (See Chapter 12 for further discussion.) Deter- should be made to locate the fetal pulse. If the two pulses
mining the fetal presentation facilitates fetal heart auscul- differ, the nurse should position the patient on her left
tation. The fetal heart rate (FHR) is heard most clearly side and seek assistance. Oxygen may be administered by
directly over the fetal upper back (the maternal right or left mask and the patient should be instructed to take slow
lower abdominal quadrants) in a vertex presentation. The deep breaths. The nurse should continue to monitor the
intensity of the fetal heart tones (FHT) varies according to fetal heart rate and provide explanations and reassurance
the fetal position (Fig. 9-12). With a breech presentation, to the patient.
the fetal heart tones may be best heard in the patient’s right The fetal heart can be auscultated using a number of dif-
or left upper abdominal quadrants. If fetal heart tones are ferent devices. The least intrusive method involves the use
auscultated most clearly in that location, the patient’s care of a Pinard stethoscope or a fetoscope (Fig. 9-13). Both of
provider should be advised, as further assessment may be these devices are used without any additional equipment.
indicated to confirm the fetal presentation. This is espe- However, they do require the examiner’s ability to be able
cially important when the patient is in labor. However, to palpate the woman’s abdomen accurately to determine
before approximately 32 weeks of pregnancy, it is not the fetal position and locate the fetal shoulder to ascertain
uncommon for the fetus to be in a breech presentation. In the correct location for placement of the stethoscope. This
most instances, by 36 to 37 weeks of gestation, the major- method of fetal heart auscultation is ideal if the patient has
ity of fetuses will have spontaneously converted to a vertex expressed a desire to avoid an ultrasound (Doppler) stetho-
(head down) presentation. scope. Following the invention of the Doppler ultrasound
The normal heart rate for a fetus is approximately stethoscope, use of the fetoscope and Pinard stethoscopes
120 to 160 beats per minute (bpm). If a slower heart rate in clinical practice has decreased. The Doppler ultrasound
is detected, the maternal pulse should first be evaluated to stethoscope is a hand-held device that uses ultrasound to
chapter 9 The Prenatal Assessment 239
LSA LOP
Table 9-3 Defining Terms in Relation to Maternal
Abdominal Palpations
Lie of the Where is the fetal spine in relation to the maternal
Fetus spine? The maternal spine is always longitudinal.
If the fetal spine is parallel to the maternal spine,
the fetus is in a “longitudinal lie.”
RSA
If the fetal spine lies horizontally across the maternal
spine, the fetus is in a “transverse lie.”
ROP
If the fetal spine lies obliquely across the maternal
spine, the fetus is in an “oblique lie.”
“Lie” describes the relationship of the fetus to the
long axis of the mother. Normal lie is longitudinal
(the fetal long axis, or spine, is in line with the
maternal long axis). RMA LMA
ROA LOA
Presentation Refers to the fetal part that would be delivered first
in a vaginal birth. Figure 9-12 Fetal heart tone intensity varies according
to the fetal position. RSA = right sacrum anterior;
Normally, the fetal head is the part of the fetus that LSA = left sacrum anterior; ROP = right occipito-
is presenting.
posterior; LOP = left occipito-posterior; RMA = right
Position The head is the most common presentation. mentum anterior; LMA = left mentum anterior; ROA =
right occipito-anterior; LOA = left occipito-anterior.
When the fetus is in a well-flexed position (the fetal
knees and chin against its body), the occiput area is
determined to be the presenting part since this is the
lowest part of the fetal head.
To determine position, it is necessary to assess where
the fetal occiput is, in relation to the maternal pelvis.
If the fetal occiput faces toward the front near the
symphysis pubis, the fetus is in an anterior position.
If the occiput is on the maternal right side, the fetus
is in a right occipito-anterior position (ROA). If on
the maternal left side, the fetus is in a left occipito-
anterior position (LOA).
If the fetal occiput is toward the side of the maternal Figure 9-13 Auscultating the fetal heart tones with a
pelvis, the fetus is in a lateral (or transverse) position. fetoscope.
If the occiput is on the maternal right, the fetus is in a
right occipito-lateral position (ROL). If on the maternal
left, it is a left occipito-lateral (LOL) position.
If the fetal occiput is toward the maternal spine, the
fetus is in a posterior position. If the occiput is on
the maternal right, the fetus is in a right occipito-
posterior position (ROP). If on the maternal left,
it is a left occipito-posteror (LOP) position.
Engagement When palpating the presenting part, is it moveable?
If the presenting part is fixed (i.e., you are unable to
move it) when palpating the maternal abdomen, the
presenting part is said to be engaged.
Some sophisticated Doppler models provide a print- the patient can view her cervix or be shown changes
out similar to those of the more conventional fetal heart such as Chadwick’s sign.
rate monitors. Beginning in the later weeks of the second There are essentially four components to the examina-
trimester, standard electronic fetal monitors may be used tion, which begins with an assessment of the external
to record the fetal heart rate in conjunction with uterine genitalia (Fig. 9-15). Information can be obtained regard-
activity. Electronic fetal monitoring during the prenatal ing secondary sexual characteristics by observing the
period is generally limited to pregnancies designated as pattern of hair growth. This is also an ideal time to check
being high risk due to maternal or fetal factors. In these for the presence of pediculosis, or pubic lice. Signs of
situations, a non-stress test (NST) may be ordered to vaginal infection may be indicated by redness, edema, or
provide an evaluation of the fetal heart rate in response an offensive vaginal discharge. The presence of lesions,
to fetal movement and/or uterine activity. A reactive test condylomata (human papillomavirus), vesicles (herpes),
(the desirable result), is one in which the heart rate ulceration (syphilitic chancre), or inflammation need to
accelerates by at least 15 beats per minute for at least recognized and investigated. Bruising or tenderness may
15 seconds, with at least three “acceleration episodes” in be present as a result of trauma or abuse. Observation of
a 20-minute period of monitoring. It is important to the perineal body may show evidence of a previous episi-
remember that a reactive non-stress test is only an indi- otomy or perineal tear. Women who have been subjected
cator of the fetus’s present condition rather than a test to female circumcision show varying degrees of genital
that can be used to predict future fetal well-being. (See mutilation. Women from cultures that support this prac-
Chapter 11 for further discussion.) tice may prefer to have a female care provider.
Nurses must be cautious not to place too much reliance The second part of the examination includes visual
on technology. Instead, nurses should use clinical skills inspection of the vaginal mucosa and cervix along with the
coupled with evidence-based theory to transition from collection of specimens such as the Papanicolaou test (Pap
novice to expert practitioner. To attain this level of exper- smear), cultures for gonorrhea or Chlamydia and, if indi-
tise, it is essential to maintain hands-on patient care. cated, wet smear slides to determine the cause of vaginal
Experienced clinical nurses attain a sixth sense, or “spe- discharge. The examiner selects an appropriate size specu-
cialty intuition,” that enables them to quickly recognize lum. Specula may be constructed of metal or plastic and
deviations from normal and provide expert care in a are generally available in two types: the Graves’ speculum,
timely manner. With regard to electronic fetal monitoring useful for examining multiparous women, and the more
and other high-tech modalities, the nurse must be careful narrow, flat Pedersen speculum, commonly used for chil-
not to rely on imperfect tools and instead use sound clini- dren, women who have never been sexually active, nullipa-
cal judgment and decision-making. rous women and some postmenopausal women. The spec-
ulum is inserted into the vagina at an oblique angle, then
Now Can You— Discuss various methods of clinical fetal rotated to a horizontal angle and gently advanced down-
assessment? ward against the posterior vaginal wall. Once in position,
1. Describe how to perform a fundal height measurement? the speculum blades are opened to allow visualization of
2. Identify how to perform each component of Leopold the cervix (Fig. 9-16).
maneuvers and explain what the findings indicate?
3. Compare and contrast the technique of fetal heart
auscultation using a fetoscope and a Doppler ultrasound
stethoscope?
The cervix and vaginal mucosa are inspected for color reinserted into the vagina; the middle finger is inserted
and for the presence of inflammation, lesions, ulcerations, into the rectum. The rectal finger is advanced forward as
or erosion. The cervix is usually about 1 inch (2.5 cm) in the abdomen is depressed with the nondominant hand.
length and the external cervical os is round in women Palpation of the tissue between the examining fingers
who have never given birth (nulliparous) and appears allows for assessment of the strength and irregularity of
“slit” shaped in the multigravida (Fig. 9-17). the posterior vaginal wall. The fingers are withdrawn
The remaining part of the assessment includes clinical and any stool present on the glove may be tested for
pelvimetry and the bimanual examination. Bimanual occult blood.
examination is an evaluation of uterine shape, position, The final component of the physical examination
and size (Fig. 9-18). The uterus is normally anteverted involves the clinical evaluation of the pelvis, also known
(tipped forward). As it enlarges during pregnancy, the as clinical pelvimetry. The goal of this assessment is to
uterus becomes more midline and globular in shape. The recognize any abnormality in shape or size that may be
size of the pregnant uterus should be equal to the esti- associated with a difficult or traumatic vaginal birth. The
mated weeks of gestation. If the uterus is larger than four basic pelvic types include the gynecoid, found in
anticipated, this finding may be associated with a number more than 40% of women, the android (male), the
of factors including miscalculation of the date of concep- anthropoid (most common in nonwhite races), and the
tion, multiple pregnancy, hydatidiform mole, uterine platypelloid, which is the most rare type and is found in
fibroid tumors or, later in pregnancy, a condition known fewer than 3% of women. The internal pelvic measure-
as hydramnios (an increase in the volume of amniotic ments provide the diameters of the inlet and outlet
fluid). A uterus smaller than expected may indicate mis- through which the fetus must pass during birth. The
calculation of dates or a missed abortion. (See Chapter 11 measurements most commonly made include the diago-
for further discussion.) The manual examination pro- nal conjugate, the true conjugate (conjugate vera), and
vides an ideal time to evaluate vaginal and perineal mus- the ischial tuberosity diameter. Clinical pelvimetry is
cle tone and to determine the presence of a cystocele performed by the physician, nurse midwife, or advanced
(bladder prolapse), urethrocele (urethral prolapse), or practice nurse; it is generally not repeated in women
rectocele (rectal prolapse). Women should be reminded who have previously given birth to an infant weighing
to practice Kegel exercises to help maintain perineal 7 pounds or more (3.18 kg) unless there is a history of
muscle tone. pelvic trauma in the intervening period between
The rectovaginal examination is performed after com- pregnancies.
pletion of the bimanual examination. The examiner The diagonal conjugate is the distance between the
removes his or her hand from the vagina and dons a anterior surface of the sacral prominence and the anterior
clean pair of gloves. A water-based lubricant is applied to surface of the inferior margin of the symphysis pubis.
the fingertips of the dominant hand. The index finger is This measurement, performed with the patient in a
A
B
D
Figure 9-16 A, Inserting the speculum. B, Proper position of speculum in the vagina.
C, Opening the speculum. D, View through the speculum.
242 unit three The Prenatal Journey
Ultrasound Some health care providers offer routine ultrasound examinations in the first trimester of pregnancy to confirm dates
and ensure single pregnancy; may be repeated later in pregnancy
Prenatal screening MSAFP – screening for open neural tube defects and Down syndrome is done around 16 weeks – if indicated,
follow-up may include amniocentesis
Screening for gestational diabetes Offered around 24-28 weeks gestation
Patient drinks solution containing 50 g of glucose and then has blood drawn 1 hour later – results should be below
140 mg/dL.
Rh screening Rh negative woman: Check for Rh antibodies and if negative, 300 mcg of Rh0 immune globulin (RhoGAM) is
prescribed at 28 to 32 weeks of gestation.
Hemoglobin/hematocrit Usually repeated mid–pregnancy and then as indicated.
Group B Streptococcus Normally offered at 37 weeks of gestation to determine whether antibiotic coverage is needed during labor.
screening
Confirm the patient’s contact information (address/telephone numbers) and ensure she has a scheduled return appointment. Always provide time for the patient to ask questions,
confirm her understanding and that she has no other concerns that need to be addressed.
chapter 9 The Prenatal Assessment 245
Strategies that use a holistic family approach such as Some groups advocate mandatory sex education for all
promoting open communication between parents/guardians adolescents; others support programs that only teach sexual
and teenagers, together with teaching self-respect, setting abstinence. There is little scientific evidence to determine
boundaries, and providing appropriate supervision are which approach is most effective. Because individuals’
essential components of any successful approach to reduce responses and actions are shaped by personality, cultural
teenage pregnancy (Table 9-4). norms, and observed social patterns and behaviors, any one
doctrine is rarely applicable to every group.
Impact on Society
— Dialoging with teens about sex APPROACHES TO ADDRESSING THE PROBLEM OF ADOLESCENT
When talking with teens about sex, it is important to use PREGNANCY. Over the years, a variety of local and national
language with which they can relate. For example, the efforts have attempted to dissuade adolescents from engag-
nurse may say: ing in early sexual activity. Strategies have ranged from
“You would not give your $100 mobile phone to just public awareness campaigns to public chastisement, con-
anyone, so do not give your body to just anyone” viction as a sex offender, and institutionalization for unac-
(Harris, 2005, p. 15). ceptable moral behavior. The various approaches have met
with some success, but usually on a short-term basis.
Source: The National Campaign to Prevent Teen and Unplanned Pregnancy (2004). Parent power: What parents need to know and
do to help prevent teen pregnancy.
246 unit three The Prenatal Journey
Identifying Adolescents at Greatest Risk • Grow up: Being a competent mother demands maturity
for Unwanted Pregnancy with the ability to place someone else’s needs before
Adolescents who lack the support, security, and love of a one’s own. Developmentally, teenagers are typically at
family home are more likely to engage in high-risk behav- an egocentric stage of development. Being a mother is
iors including sex at an early age, multiple sexual partners, demanding and requires the sacrifice of being a care-
failure to use contraception, and unplanned pregnancy. free teenager (Kaiser, 2002).
Incarcerated juveniles constitute the most vulnerable
group, especially when placed in an environment away Delayed Entry into Care
from family support. These teenagers often have histories Denial, a common reaction to an unplanned and unwanted
of physical neglect as well as severe physical, emotional, pregnancy, is often the reason why adolescents do not seek
and sexual abuse. This group is more likely to experiment early prenatal care. In some situations, even close family
with high-risk behaviors, such as substance abuse, gang members do not suspect or recognize the signs of advancing
involvement, and violence. They may be more susceptible pregnancy. Unfortunately, denial and postponement of care
to peer pressure and are more likely to succumb to nega- may place the teenager and her fetus at a greater risk for
tive behaviors in an attempt to gain acceptance or peer sta- medical problems. Complications such as iron-deficiency
tus. Consequently, many begin sexual experimentation at anemia, preterm labor, and preeclampsia may progress
a very early age and predictably experience unwanted teen- without detection and treatment. Without ongoing emo-
age pregnancy (Carbone, 2001). tional support and education throughout pregnancy, the
teenager enters labor psychologically unprepared and lack-
The Impact of Pregnancy on Meeting the ing a knowledge base to understand the natural events that
Developmental Tasks of Adolescence surround birth. (See Chapter 11 for further discussion.)
A pregnant teenager is required to be able to make Dulit (2000) describes three clinical types of adolescent
informed decisions regarding continuing the pregnancy pregnancy denial. During the first of these clinical types, the
and, if the pregnancy comes to fruition, future plans for teenager realizes that pregnancy is a possibility but contin-
the child. This action hinges upon the premise that the ues to hope that it will not come to fruition, and if it does,
adolescent has the necessary skills to appreciate the impli- that it will disappear on its own accord. As the pregnancy
cations of these decisions as well as the potential life-long advances, the adolescent recognizes the need to acknowl-
consequences associated with these decisions. Kaiser and edge the pregnancy and will usually seek assistance.
Hays (2004) assert that pregnant adolescents face a dual The second type of denial is a continuation of the first
task: meeting the developmental tasks of being a teenager, except that the teenager actively conceals the pregnancy
coupled with the developmental tasks associated with and deliberately uses whatever skills necessary to inten-
adapting to become a mother. tionally deceive and hide the changes taking place in her
body. The third type is considered true denial. In this situ-
Nursing Insight— Pregnancy and the ation, the teenager is absolutely unaware of any of the
developmental tasks of adolescence physical or psychological signs or symptoms of pregnancy
and experiences an unconscious denial of impeding moth-
According to Erikson (1963), there are four developmental erhood. In this situation, the onset of labor is truly an
tasks of adolescence: unexpected event. A teenager who experiences this type of
• To establish a sense of self-worth and a value system clinical denial is displaying psychopathology coupled
• To establish lasting relationships with a significant ego pathology. The trauma of the birth
• To emancipate from parents may be sufficient to trigger a psychotic episode.
• To choose a vocation Infants born to this group of teenagers are at highest
Pregnancy during adolescence creates an especially vulner- risk for being victims of neonaticide, as the mother fails to
able situation because the developmental tasks of pregnancy develop any form of attachment. Neonaticide is defined as
are superimposed on those of adolescence. the killing of a baby within the first 24 hours of birth.
Active neonaticide is a deliberate action that occurs when
the infant’s death is the intended outcome of an act of vio-
For a teenager to successfully adapt and fulfill the role lence. Passive (negligent) neonaticide results from an
of being a mother, she must achieve four major develop- inability to provide the means for infant survival, for
mental tasks: example, by maintaining an open airway, keeping the baby
• Gain acceptance of pregnancy: This involves disclos- warm, or providing nutrition. Unfortunately, the victims
ing the presence of the pregnancy to her family, the are often the infants found abandoned in dumpsters or in
father of the child, and her friends; facing family public restrooms.
reactions; and hopefully gaining support.
• Set goals: Make realistic and attainable plans for the
future. These goals will be different from her original Be sure to— Advocate for newborns at risk
ones and will focus on her role as a mother of a Nurses must actively advocate for newborns at risk. One way
dependent child. is by becoming knowledgeable about their practice state’s
• View self as mother: This task addresses self-image and Safe Haven laws and programs. This information may be
redefining self as a woman with a child rather than as a accessed at: http://www.adopting.org/adoptions/legalized-
teenager with the freedom to explore being an adoles- abandonment-state-safe-haven-laws-and-programs.html
cent and the opportunity to mature gradually.
248 unit three The Prenatal Journey
Nursing Care of the Pregnant Adolescent visit. Use of the Doppler stethoscope allows the patient to
For a teenager, pregnancy presents a number of issues: hear the fetal heart tones. This action reinforces the pres-
deciding whether to continue with the pregnancy; secur- ence of the fetus and helps the teenager to acknowledge
ing a means for gaining access to prenatal care; planning the reality of her pregnancy. Emphasizing the progression
for infant/child care in a secure home environment; and in the fundal height measurement at each visit confirms
arranging for economic resources to meet the needs of a that her fetus is growing and reinforces that she is success-
dependent new family member. Social isolation may fully nourishing her developing child.
leave the expectant teen without peer support. When DIAGNOSIS AND PLANNING. Because of unawareness or
this occurs, the physical, emotional, and psychological denial of the pregnancy, adolescents often do not enter the
transitions associated with pregnancy are more difficult prenatal care system until the second or third trimester.
for the teenager to accomplish successfully. Since the They may be frightened, confused, and unsure where to
risk of pregnancy complications (e.g., iron-deficiency go for care. They are usually unaware of maternal needs,
anemia, preeclampsia, intrauterine growth restriction, such as nutritional requirements, during pregnancy. Pre-
and cephalopelvic disproportion) are increased among natal care is often received sporadically in the adolescent
this group, early and ongoing prenatal care is essential. population.
A nursing approach that is designed to meet the special
needs of the adolescent patient promotes adherence and
an optimal pregnancy outcome. Optimizing Outcomes— Formulating a nursing
diagnosis for the pregnant adolescent patient
ASSESSMENT. Assessment of the pregnant adolescent is
similar to that of older women. The initial visit includes a Due to a lack of information about pregnancy, “Risk for
personal health history and family history to determine Ineffective Health Maintenance related to lack of knowl-
whether medical problems such as diabetes or infectious edge of measures to promote health during pregnancy and
diseases may threaten maternal or fetal health. Through- family stress” is an appropriate nursing diagnosis for most
out the course of pregnancy, the young patient needs to pregnant adolescent patients.
be closely monitored for iron-deficiency anemia, STIs, and Expected outcomes are based on the situation. For
preeclampsia. She should also be assessed for high-risk example, the patient will: keep scheduled prenatal appoint-
behaviors such as tobacco, alcohol, and drug use and ments; follow recommended strategies for health promo-
screened for sexual abuse. Therapeutic communication tion; attend childbirth and child care classes; and the fam-
with the adolescent is enhanced when the interview is ily will: voice emotions and concerns and provide consistent
conducted in a warm, conversational style that conveys support throughout the childbearing experience.
caring and acceptance.
It is important to assess the young patient’s knowledge
INTERVENTIONS: STRATEGIES TO PROMOTE A HEALTHY
and level of understanding concerning personal care dur-
PREGNANCY. Nursing interventions are structured to
ing pregnancy and care of the infant following birth. An
address the patient’s identified needs. For example, the
educational plan individualized to meet the adolescent’s
young patient may have difficulty accessing care due to
specific needs can be developed during the initial visit and
her school schedule or transportation difficulties. The
refined and altered as needed throughout the pregnancy.
nurse helps to locate a prenatal clinic that schedules
An approach that values the patient’s support persons
appointments in the late afternoon or evening and when
while recognizing the need to foster her personal sense of
needed, works with community resources to arrange for
independence is essential. A plan of care that combines
transportation to the clinic. Many facilities offer “teen
the collaborative efforts of various professionals including
clinics” that are geared to meet the special needs of young
the physician, nurse, health educator, nutritionist, school
pregnant women. Some of these provide after-school
counselor, and social worker is important in optimizing
transportation to the clinic, serve nutritious snacks,
the outcomes for the young patient and her fetus. Rein-
encourage patient participation in certain aspects of care
forcing information, allowing ample time to discuss con-
(i.e., checking the urine with a dipstick; recording the
cerns, emphasizing the need to keep return appointments,
weight), and provide education in small peer-oriented
and confirming that the patient can verbalize when and
group settings that use repetition and reinforcement of
how to seek help are essential components of each visit.
information.
Be sure to— Allow the pregnant adolescent to Optimizing Outcomes— with a CenteringPregnancy
make health care decisions program
Sometimes it is difficult for parents to allow an adolescent CenteringPregnancy is a group prenatal care program devel-
daughter to make health care decisions concerning her oped to improve pregnancy outcomes in the adolescent popu-
pregnancy. By law, a pregnant adolescent is an emanci- lation. The CenteringPregnancy model incorporates a holistic
pated minor (a person capable of making health care deci- approach that recognizes the adolescent’s developmental
sions), so she may sign for her own care. need for socializing and peer support. Comprehensive prena-
tal care that includes risk assessment, education, and support
is provided in a group-focused environment (Moeller, Vezeau,
Framing the physical examination in a friendly, learn- & Carr, 2007; Reid, 2007). Additional information may be
ing context helps to diminish the young patient’s anxiety found at: http://www.centeringpregnancy.com/
and fear and reinforces the information provided at each
chapter 9 The Prenatal Assessment 249
◆ Early and ongoing prenatal care is key to an optimal 6. The clinic nurse routinely includes information on
maternal–fetal outcome. Families should be involved genetic testing and diseases as a component of
in activities for health promotion and educated about prenatal care to ensure informed choice for women
strategies for self-care during the childbearing year. and their families.
◆ The diagnosis of pregnancy is based on three types of Fill-in-the-Blank
signs: presumptive, probable, and positive. Presump-
tive and probable signs may be caused by conditions 7. The clinic nurse encourages and schedules prenatal
other than pregnancy; positive signs can have no other visits with patients because health care provided
cause. during pregnancy __________ mortality and _______
morbidity.
◆ The teenage pregnant patient is at risk for a number of
obstetric complications including anemia, preeclamp- 8. The clinic nurse uses the RADAR acronym as a tool
sia, and preterm birth. for abuse screening. The “D” refers to _____ your
___________.
◆ Factors including education, culture, spiritual beliefs,
and family support and income impact the occurrence 9. The clinic nurse is aware that obtaining a woman’s
of adolescent pregnancy. obstetric history is important to her care. A history of
a ________ birth increases the woman’s chances by
◆ Preconception and prenatal care for the woman over 35 20% to 40% of a reoccurrence in a subsequent
focuses on the recognition and management of chronic pregnancy.
medical problems and strategies to promote a healthy
lifestyle. 10. The clinic nurse teaches pregnant women in
their first trimester that frequency of urination is
due to ________ on the bladder exerted by the
________.
r e v i e w q u est io n s See Answers to End of Chapter Review Questions on the
Electronic Study Guide or DavisPlus.
Multiple Choice
1. The clinic nurse informs the low-risk pregnant REFERENCES
woman at 20 weeks’ gestation that she should Agency for Healthcare Research and Quality (2003). Safety net monitor-
schedule her next routine prenatal appointment for: ing initiative. Retrieved from http://www.ahrq.gov/data/safetynet/
A. 1 week netfact.htm (Accessed April 1, 2008).
Alan Guttmacher Institute (2004). Facts on American Teens’ sexual and
B. 2 weeks reproductive health. Retrieved from http://www.guttmacher.org/
C. 3 weeks sections/pregnancy.php (Accessed April 2, 2008).
D. 4 weeks Alliance for the Improvement of Maternity Services (AIMS). The Preg-
nant Patient’s Bill of Rights. Retrieved from http://www.aimsusa.org/
2. Laura, a 38-year-old woman, calls the clinic to ask ppbr.htm (Accessed April 2, 2008).
about a pregnancy test as she has missed her last Alpert, E.J., Freud, K.M., Park, C.C., Patel, J.C., & Sovak, M.A.
period by 2 weeks. The clinic nurse recommends (1992). Partner violence: how to recognize and treat victims of
that Laura use a home pregnancy test: abuse. Massachusetts Medical Society, Waltham, MA.
American College of Nurse-Midwives (ACNM). (2005). Nurse-Midwifery
A. That is specific to the beta subunit of hCG in 2005: Evidence Based Practice. A Summary of Research on Nurse-
B. That is specific to the alpha subunit of hCG Midwifery Practice in the United States. Author: Silver Spring, MD.
C. In 1 week American College of Obstetricians and Gynecologists (ACOG). (1998).
D. At the end of 2 weeks Viral hepatitis in pregnancy. Educational Bulletin No. 248. International
Journal of Gynaecology and Obstetetrics, 63, 195–202.
3. The clinic nurse knows that a probable sign of American College of Obstetricians and Gynecologists (ACOG). (2004).
pregnancy is: Prenatal and perinatal human immunodeficiency virus testing:
A. Piskacek sign Expanded recommendations. Committee Opinion No. 304. Obstetrics
and Gynecology, 104(6), 1119–1124.
B. Nausea and vomiting American College of Obstetricians and Gynecologists (ACOG). (2005).
C. Fetal heartbeat Smoking cessation during pregnancy. Committee Opinion No. 316.
D. Frequency of urination Obstetrics and Gynecology 106(2), 883–888.
American College of Obstetricians and Gynecologists (ACOG). (2007,
4. The clinic nurse obtains information from Emma, a January). Screening for fetal chromosomal abnormalities. ACOG
22-year-old primigravida. Her last menstrual period Practice Bulletin, no. 77, 920–929.
was December 25th and it lasted 3 days (normal Amercian College of Obstetricians and Gynecologists (ACOG). (2007).
duration for Emma). The calculated Expected Date Guidelines for Women’s Health Care. A resource manual. (3rd ed.).
Washington, DC, ACOG.
of Birth (EDB) would be: American Diabetes Association (2003). Gestational diabetes mellitus.
A. October 1 Retrieved from http://care.diabetesjournals.org/cgi/content/full/26/
B. September 1 suppl_1/s103 (Accessed April 2, 2008).
C. October 2 Banks, E., Berrington, A., & Casabonne, D. (2001). Overview of the
relationship between use of progestogen-only contraceptives and
D. September 30 bone mineral density. BJOG: An International Journal of Obstetrics &
Gynaecology, 108(12), 1214–1221.
True or False Barts and The London Queen Mary’s School of Medicine and Dentistry
(2006). Antenatal screening services. Retrieved from http://www.
5. The perinatal nurse recognizes that the diagnosis of wolfson.qmul.ac.uk/epm/screening/ (Accessed April 1, 2008).
pregnancy may cause a woman to be afraid for her Bloom, K.C., Bednarzyk, M.S., Devitt, D.L., Renaulty, R.A., Teaman, V.,
own safety. & Van Loock, D.M. (2004). Barriers to prenatal care for homeless
chapter 9 The Prenatal Assessment 253
pregnant women. Journal of Obstetric, Gynecologic, and Neonatal Gilliland, F.D., Li, Y.F., & Peters, J.M. (2001). Effects of maternal smok-
Nursing, 33(4), 428–435. ing during pregnancy and environmental tobacco smoke on asthma
Bobak, M. (2000). Outdoor air pollution, low birth weight, and prema- and wheezing in children. American Journal of Respiratory and Criti-
turity. Environmental Health Perspectives 108, 173–176. cal Care Medicine, 163(2), 429–436.
Boxall, E.H., Sira, J., Standish, R.A., Davies, P., Sleight, E., Dhillon, A.P., Haire, D. (2000). Prepared for: American Foundation for Maternal and
Scheuer, P.J., & Kelly, D.A. (2004). Natural history of hepatitis B in Child Health by Doris Haire. Alliance for the Improvement of Mater-
perinatally infected carriers. Archives of disease in Childhood (Fetal nity Services (AIMS) The Pregnant Patient’s Bill of Rights. Retrieved
and Neonatal edition), 89(5), F456–F460. from http://www.aimsusa.org/ppbr.htm (Accessed May 25, 2006).
Braun, J.E.D., Sanne, I.M., & Bartlett, J. G., (2006). Treatment of chronic Harper, M.A., Byington, R.P., & Espeland, M.A. (2003). Pregnancy- related
hepatitis B (HBV) and HIV-HBV coinfection. Medscape. Retrieved from death and health care services. Obstetetrics and Gynecology, 102, 273.
http://www.medscape.com/viewprogram/5241 (Accessed January 12, Harris, S. (2005). Under-12s have sex one night and play with Barbie
2007). dolls the next. Nursing Standard, 19(39), 14–16.
Brocklehurst, P., & Volmink, J. (2002). Antiretrovirals for reducing the Healy, A.J., Malone, F.D., Sullivan, L.M., Porter, T.F., Luthy, D.A.,
risk of mother-to-child transmission of HIV infection (Cochrane Cornstock, C.H., Saade, G., Berkowitz, R., Klagman, S., Dugoff, L.,
Review). The Cochrane Library, Issue 3. Oxford: Update Software. Craigo, S.D., Timor-Tritsch, I., Carr, S.R., Wolfe, H.M., Bianchi,
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing inter- D.W., & D’Alton, M.E. (2006). Early access to prenatal care –
ventions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. Implications for racial disparity in perinatal mortailty. Obstetetrics
Bull, S.D. (2003, June).Violence against women: Media (mis)representation and Gynecology, 107 (3), 625–631.
of femicide. Paper presented at the “Women Working to Make a Dif- Heaney, R.P. (2006). Role and importance of calcium in preventing and
ference,” IWPR’s Seventh International Women’s Policy Research managing osteoporosis. Medscape. Retrieved from http://www.med-
Conference. Washington, DC. scape.com/viewprogram/5237?sssdmh⫽dm1.187248&src⫽nlcmealert
Bunting, L., & McAuley, C. (2004). Research Review: Teenage pregnancy (Accessed April 2, 2008).
and parenthood: The role of fathers. Child and Family Social Work, Hernandez-Diaz, S., Werler, M.N., Walker, A.M., & Mitchell, A.A.
9, 295–303. (2000). Folic acid antagonists during pregnancy and the risk of birth
Bureau of Justice Statistics. (2003, February). Crime data brief. Intimate defects. New England Journal of Medicine, 343(22), 1608–1614.
Partner Violence, 1993–2001. Hey-Hadavi. J.H. (2002). Women’s oral health issues sex differences and
Carbone, D.J. (2001). Under lock and key: Youth under the influence of clinical implications. WOMEN’S HEALTH in Primary Care, 5(3), 44–52.
HIV. Body Positive Magazine. Retrieved from http://www.thebody. Higgins, A.C. (1976). Nutritional status and the outcome of pregnancy.
com/bp/may01/feature_02.html (Accessed January 12, 2007). Journal of the Canadian Diet Association, 37, 17.
Caughey, A.B., Hopkins, L.M., & Norton, M.E. (2006). Chorionic villus Hodnett, E.D. (2004). Continuity of caregivers for care during preg-
sampling compared with amniocentesis and the difference in the rate nancy and childbirth. Cochrane Database System Review (Issue 2),
of pregnancy loss. Obstetrics & Gynecology, 108, 612–616. CD000062.
Centers for Disease Control and Prevention (CDC). (2002). Sexually Holloway, M., & D’Acunto, K. (2006, June). An update on the ABCs of
transmitted diseases treatment guidelines. MMWR May 10, viral hepatitis. The Clinical Advisor, 29–39.
2002/51(RR06); 1–80. Retrieved from http://www.cdc.gov/STD/ Jaakkola, J.J.K., & Gissler, M. (2004). Maternal smoking in pregnancy,
treatment/4-2002TG.htm (Accessed May 21, 2006). fetal development, and childhood asthma. American Journal of Public
Centers for Disease Control and Prevention (CDC). (2005). Folic acid: PHS Health, 94(1), 136–140.
recommendations. Updated July 26, 2005. Retrieved from http:// Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
www.cdc.gov/ncbddd/folicacid/health_recomm.htm (Accessed April 2, Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and
2008). NIC Linkages: nursing diagnoses, outcomes, & interventions (2nd ed.).
Centers for Disease Control and Prevention (CDC). (2006a). Sexually St. Louis, MO: Mosby Elsevier.
transmitted diseases treatment guidelines, 2006. Morbidity and Mor- Kaiser, M.M. (2002). Transition to motherhood in adolescence: The devel-
tality weekly Report, 55(RR-11), 1–94. opment of the Adolescent Prenatal Questionnaire. Unpublished doctoral
Centers for Disease Control and Prevention (CDC). (2006b). Viral hepati- dissertation, University of Nebraska Medical Center.
tis C – Fact sheet. Retrieved from http://www.cdc.gov/ncidod/diseases/ Kaiser, M.M., & Hays, B.J. (2004). The adolescent prenatal question-
hepatitis/c/fact.htm (Accessed April 1, 2008). naire: Assessing psychosocial factors that influence transition to
Centers for Disease Control and Prevention (CDC). (2007). Birth motherhood. Health Care for Women International, 25, 5–19.
defects. Retrieved from http://www.cdc.gov/ncbddd/bd/default.htm Kandinov, L.D. (2005). Periconceptual exposure to oral contraceptives
(Accessed April 1, 2008). and risk for Down syndrome. Ask the experts about obstetrics and
Coid, J., Petruckevitch, A., Feder, G., Chung, W.S., Richardson, J., & maternal-fetal medicine. Medscape Ob/Gyn & Women’s Health, 10(1).
Moorey, S. (2001). Relation between child sexual and physical abuse Retrieved from http://www.medscape.com/viewarticle/498685
and risk of re-victimisation in women: a cross-sectional study. Lancet, (Accessed April 2, 2008).
358, 450–454. Kirkham, C., Harris, S., & Grzybowski, S. (2005). Evidence-based prena-
Cole, L.A., Khanlian, S.A., Sutton, J.M., Davies, S., & Rayburn, W.F. tal care: Part I. General prenatal care and counseling issues. Amerian
(2004). Accuracy of home pregnancy tests at the time of missed men- Family Physician, 71(7), 32–41.
ses. American Journal of Obstetrics and Gynecology, 190, 100–105. Koscica, K.L., & Berstein, P. (2003). Thyrotoxicosis in pregnancy: Ask the
Dugoua, J.J., Perri, D., Seely, D., Mills, E., & Koren, G. (2008). Safety experts about obstetrics and maternal-fetal medicine. Retrieved from
and efficacy of blue cohosh (Caulophyllum thalictroides) during preg- http://www.medscape.com/viewarticle/451718 (Accessed July 3,
nancy and lactation. The Canadian Journal of Clinical Pharmacology, 2007).
15(1), e66–73. Laartz, B., Gompf, S.G., Allaboum, K., Marinez, J., & Logan, J.L. (2006).
Dulit, E. (2000). Girls who deny a pregnancy girls who kill the neonate. Viral infections and pregnancy. Retrieved from http://www.emedicine.
In: A.H. Esman, L.T. Flaherty, & H.A. Horowitz (Eds.), Adolescent com/med/topic3270.htm (Accessed April 1, 2008).
psychiatry: Developmental and clinical studies, (vol. 25, p. 304). Hills- Liu, S., Krewski, D., Shi, Y., Chen, Y., & Burnett, R.T. (2003). Associa-
dale, NJ: The Analytical Press. tion between gaseous ambient air pollutants and adverse pregnancy
Dyjack, D., Soret, S., Chen, L., Hwaqng, R., Nazari, N., & Gaede, D. Resi- outcomes in Vancouver, Canada. Environmental Health Perspectives,
dential environmental risks for reproductive age women in developing 111, 1773–1778.
countries. Journal of Midwifery & Women’s Health, 50, 309–314. Lopez, N.J., DaSilva, I., Ipinza, J., & Gutierrez, J. (2005). Periodontal
El Kady, D., Gilbert, W., Xing, G., & Smith, L. (2005). Maternal and therapy reduces the rate of preterm low birth weight in women with
neonatal outcomes of assaults during pregnancy. Obstetrics and pregnancy-associated gingivitis. Journal of Periodontology, 76(7 Suppl.),
Gynecology, 105(2), 356–363. 2144–2153.
Erikson, E.H. (1963). Childhood and society. New York: W.W. Norton. Luo, Z.C., Wilkins, R., & Kramer, M.S. (2004). Disparities in pregnancy
Gardner, J. (2006). What you need to know about genital herpes. Nursing outcomes according to marital and cohabitation status. Obstetetrics
2006, 36(10), 26–29. and Gynecology, 103(6), 1300–1307.
Gazmarrian, J.A., Lazorick, S., Spitz, A., Ballard, T.J., Saltzman, L.E., & Maisonet, M., Bush, T.J., Correa, A., & Jaakkola, J.J. (2001). Relation
Marks, J.S. (2000). Violence and reproductive health: Current knowl- between ambient air pollution and low birth weight in the northeast-
edge and future research directives. Maternal and Child Health Journal, ern United States. Environmental Health Perspectives 109(Suppl 3),
4(2), 79-84. 351–358.
254 unit three The Prenatal Journey
March of Dimes. (2006). Illicit drug use during pregnancy. Quick refer- Rosengard, C., Phipps, M.G., Adler, N.E., & Ellen, J.M. (2005). Psycho-
ence: Fact sheet. Retrieved from http://www.marchofdimes.com/ social correlates of adolescent males’ pregnancy intention. Pediatrics,
professionals/14332_1169.asp (Accessed April 1, 2008). 116(3), e114–e119.
Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Menacker, F., Royal Adelaide Hospital Clinic, Sexually Transmitted Diseases Services. STD
& Munson, M.L., (2003). Late or no prenatal care. Child Trends interview checklist (2005). Retrieved from http://www.stdservices.on.
DataBank. Retrieved from http://www.childtrendsdatabank.org/ net/management/checklists/cl_interview.htm (Accessed April 2, 2008).
indicators/25PrenatalCare.cfm (Accessed April 2, 2008). Rubin, R. (1984). Maternal Identity and maternal experience. New York:
McFarlane, J., Campbell, J., Sharps, P., & Watson, K. (2002). Abuse dur- Springer.
ing pregnancy and femicide: Urgent implications for women’s health. Safety net monitoring initiative. Fact sheet. AHRQ Publication No. 03-P011,
Obstetrics and Gynecology, 100(1), 27–36. August 2003. Agency for Healthcare Research and Quality, Rockville,
Modena, A.B., Kaihura, C., & Fieni, S. (2004). Prelabor rupture of the MD. http://www.ahrq.gov/data/safetynet/netfact.htm
membranes: Recent evidence. Acta Biologia Medica Ateneo Parmense, Sexually Transmitted Diseases Services (Royal Adelaide Hospital). (2005).
75(Suppl. 1), 5–10. Retrieved from http://www.actabiomedica.it/ STD interview checklist. Retrieved from http://www.stdservices.on.
data/2004/supp_1_2004/bacchi.pdf (Accessed April 2, 2008). net/links/default.htm (Accessed May 20, 2006).
Moeller, A.H., Vezeau, T.M., & Carr, K.C. (2007). CenteringPregnancy: Shumpert, M.N., Salihu, H.M., & Kirby, R.S. (2004). Impact of maternal
A new program for adolescent prenatal care. The American Journal for anemia on birth outcomes of teen twin pregnancies: A comparative
Nurse Practitioners, 11(6), 48–58. analysis with mature young mothers. Journal of Obstetrics and Gyne-
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing cology, 24, 16–21.
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. Silbergeld, E., & Patrick, T. (2005). Environmental exposures, toxicologic
Nabel, E.G. (2003). Cardiovascular disease. New England Journal of mechanisms, and adverse pregnancy outcomes. American Journal of
Medicine, 349(1), 60–72. Obstetrics and Gynecology, 192(5), S11–121.
NANDA International. (2007). NANDA-I Nursing Diagnoses: Definitions Silverman, J.G., Raj, A., & Clements, K. (2004). Dating violence and
and Classifications 2007-2008. Philadelphia: NANDA-I. associated sexual risk and pregnancy among adolescent girls in the
The National Campaign to Prevent Teen Pregnancy. (2003). National United States. Pediatrics, 114, 220–225.
campaign to prevent teen pregnancy 14 and younger. (2003). The Smith, O.W. (1948). Diethylstilbestrol in the prevention and treatment
sexual behavior of young adolescents. Author: Washington, DC. of complications of pregnancy. American Journal of Obstetrics and
Retrieved from http://www.teenpregnancy.org/resources/reading/ Gynecology, 56, 821–834.
youngteens/default.asp (Accessed May 4, 2006). Somani, S., & Ahmed, I.K. (2005). Pregnancy: Special considerations.
The National Campaign to Prevent Teen Pregnancy. (2004, May). Fact Retrieved from http://www.emedicine.com/oph/topic747.htm
Sheet: Teen sexual activity, pregnancy and childbearing among black (Accessed April 1, 2008).
teens in the US. Retrieved from http://www.teenpregnancy.org/ Stevens, L. (2005). Improving screening of women for violence – basic
resources/reading/fact_sheets/default.asp (Accessed May 4, 2006). guidelines for healthcare providers. Retrieved from http://www.
National Cancer Institute, National Institute of Environmental Health medscape.com (Accessed April 2, 2008).
Sciences, Office of Research on Women’s Health, US Public Health Tajiri, H., Miyoshi, Y., Funada, S., Etani, Y., Abe, J., Onodera, T., Goto, M.,
Service’s Office on Women’s Health, Centers for Disease Control and Funato, M., Ida, S., Noda, C., Nakayama, M., & Okada, S. (2001). Pro-
Prevention. (1999). DES research update: Current knowledge, future spective study of mother-to-infant transmission of hepatitis C virus.
directions. Proceedings. Bethesda, MD: NIH. Pediatric Infectious Disease Journal, 20(1), 10–14. Retrieved from http://
National Center for Health Statistics. (2007). Prenatal care. Retrieved www.pidj.com/pt/re/pidj/abstract.00006454 (Accessed April 16, 2006).
from http://www.cdc.gov/nchs/fastats/prenatal.htm (Accessed April 1, Taylor, S.E., Klein, L.C., Lewis, B.P., Gruenewald, T.L., Gurung, R.A., &
2008). Updegraff, J.A. (2002). Biobehavioral responses to stress in females:
National Human Genome Research Institute (2003). Researchers iden- Tend-and-befriend, not fight-or-flight. Psychology Review, 107(5),
tify gene for premature aging disorder. Retrieved from http://www. 411–429.
genome.gov/11006962 (Accessed April 1, 2008). U.S. Department of Health and Human Services (DHHS). National Cen-
National Foundation for Infectious Diseases. (2007). Facts about rubella ter for Health Statistics (NCHS). (2007). Early release of selected
for adults. Retrieved from http://www.nfid.org/pdf/factsheets/ estimates based on data from the 2006 National Health Interview
rubellaadult.pdf (Accessed April 1, 2008). Survey. Retrieved from http://www.cdc.gov/nchs/about/major/nhis/
National Institutes of Health (NIH). (2006a). Genetics home reference. released200706.htm. (Accessed July 7, 2007).
Bethesda, MD: Author. Vaccine Information (2005). Rubella vaccine. Retrieved from http://
National Institutes of Health. (2006b). NHLBL Scientists find blood test www.vaccineinformation.org/rubella/qandavax.asp (Accessed August
predicts common and severe complication of sickle cell disease, and 25, 2006).
identifies patients at highest risk of death. Retrieved from http://www. Vadillo, O.F., Pfeffer, B.F., Bermejo, M.M.L., Hernandez, M.M.A., Beltran,
nih.gov/news/pr/jul2006/nhlbi-18.htm (Accessed August 25, 2006). M.J., Tejero, B.E., Casanueva y Lopez, E. (1995). Dietetic factors and
National Patient Advocate Foundation. (2006). CARE Principles. Retrieved premature rupture of fetal membranes. Effects of vitamin C on collagen
from http://www.npaf.org (Accessed July 6, 2007). degradation in the chorioamnion. Ginecologia Obstetrica Mexico, 63, 15.
Natural Standard (2008). Red raspberry. Retrieved from http://www. Villar, J., Carroli, G., Khan-Neelofur, D., Piaggio, G., & Gulmezoglu,
naturalstandard.com/ (Accessed April 1, 2008). M. (2004). Patterns of routine antenatal care for low-risk pregnancy.
Nielsen, K.A. (2006). Prevention of mother-to-child HIV transmission: Cochrane Database System Review Issue 4, CD000934.
after 25 years, what have we learned? Retrieved from http://www. Wald, N., & Rudnicka, A. (2004). Antenatal screening for Downs syn-
medscape.com/viewarticle/525167 (Accessed May 21, 2006). drome. Retrieved from http://www.wolfson.qmul.ac.uk/epm/research/
Parson, L. (2000). Violence against women and reproductive health: (Accessed May 5, 2006).
Towards defining a role for reproductive health care services. Mater- Winer, S., & Richwald, G.A. (2007). Genital HSV update. The Forum,
nal and Child Health Journal, 4(2), 135. 5(2), 18-22.
Partridge, C. A., & Holman, J.R. (2005). Effects of a reduced-visit prena- Woodrow, N., Permezel, M., Butterfield, L., Rome, R., Tan, J., & Quinn, M.
tal care clinical practice guideline. The Journal of the American Board (1998). Cervical carcinoma associated with pregnancy. Australia and
of Family Practice, 18, 555–560. New Zealand Journal of Obstetrics and Gynaecology, 38, 161–165. Cited in
Reddy, U.M., & Mennuti, M.T. (2006). Incorporating first-trimester Colposcopy and Programme Management – Guidelines for the NHS Cer-
Down syndrome studies into prenatal screening. Obstetrics and Gyne- vical Screening Programme. NHSCSP Publication No. 20, April 2004.
cology, 107(1), 167–173. World Health Organization (WHO). (2005a). WHO multicountry study
Reid, J. (2007). CenteringPregnancy: A model for group prenatal care. on women’s health and domestic violence against women. Summary
Nursing for Women’s Health, 11(4), 383–388. report of initial results on prevalence, health outcomes, and women’s
Reuters Health Information. (2005) Vertical HCV transmission may responses. Geneva: Author.
occur more often among female infants. Journal of Infectious Disease World Health Organization (WHO). (2005b). Report: Make every woman
192, 1865–1866, 1872–1879. Retrieved from http://www.medscape. and every child count. Retrieved from http://www.who.int/whr/2005/
com/viewarticle/519850 (Accessed April 16, 2006). en/index.html (Accessed March 22, 2006).
CONCEPT MAP
Our love combined as one You are our miracle soon to behold
Creating a miracle of joy For life is a beauty sometimes unseen
Filling our hearts completely Ten tiny fingers, ten tiny toes
Producing a baby boy. Perfection only to be seen.
Even though we have never seen your face You are so tiny, so small
Or even heard your first cry So fragile, so sweet
A special bond has been formed A life not yet known
Well deep from inside. And yet loved so complete.
L EA R NIN G T AR G E T S At the completion of this chapter, the student will be able to:
◆ Discuss holistic approaches for empowering women in planning for a healthy pregnancy.
◆ Describe factors that must be integrated to achieve optimal nutrition and weight gain during
pregnancy.
◆ Assist a pregnant patient in formulating a daily food intake plan.
◆ Develop an exercise plan for women in the first, second, and third trimesters of pregnancy.
◆ Identify the signs of pregnancy and methods to manage the common associated discomforts.
◆ Recognize signs of impending complications of pregnancy and discuss interventions to decrease
morbidity and mortality.
◆ Discuss the various methods of childbirth education.
◆ Assist a pregnant patient in developing a birth plan.
256
chapter 10 Promoting a Healthy Pregnancy 257
The purpose of this longitudinal study was to investigate the • Vitamin D levels during late pregnancy were insufficient in
effect of maternal vitamin D levels during pregnancy on childhood 31% and deficient in 18%.
skeletal growth. The sample was composed of 198 Caucasian • All shared the same social class and general body build.
women who had participated in a previous study related to Of the offspring:
maternal nutrition and fetal growth. Other criteria for inclusion in
• Birth size and gestational length were similar.
the study were:
• Birth weight, length, and abdominal and head circumfer-
• Age greater than 16 years ence were unrelated to the maternal vitamin D level
• Initiated prenatal care before 17 weeks of gestation measured late in the pregnancy.
• Delivered a singleton fetus at term • Anthropometric characteristics at age 9 years were simi-
During the first and third trimesters the women completed a lar; the boys were slightly taller, heavier, and had a lower
lifestyle questionnaire that included information concerning pre- fat mass than the girls did.
pregnancy weight, smoking habits, and the use of dietary supple- • Those whose mothers had lower serum concentrations of
ments during pregnancy. Assessments of maternal body build, vitamin D during late pregnancy had a reduced whole body
nutritional status, and serum vitamin D levels were conducted. bone mineral content and bone area at age 9 years.
Beginning in the 7th month of gestation, personal exposure to • Neither height nor lean body mass were associated with
ultraviolet B radiation was estimated from the number of hours of the mother’s vitamin D status during pregnancy.
sunshine recorded by a local meteorological station. Based on the findings, the researchers reached the following
After birth, each neonate’s weight, crown–heel length, conclusions:
crown–rump length, and mid-upper-arm circumference were
• Reduced maternal serum concentrations of vitamin D dur-
measured. Serum calcium levels were obtained from cord blood
ing late pregnancy were associated with decreased whole
to provide a baseline indicator for vitamin D status, since vita-
body and lumbar spine bone mineral content in the chil-
min D is essential for the metabolism of calcium.
dren at age 9 years.
Approximately 9 years later, the study participants and their
• Bone mass in children and maternal vitamin D concentra-
children who continued to reside in the community were inter-
tion were related to maternal use of vitamin D supple-
viewed. At that time, nutritional status, physical activity pat-
ments and ultraviolet B radiation during late pregnancy.
terns, and socioeconomic status were assessed for each mother
• Insufficient vitamin D during pregnancy is associated with
and child. Each child’s height, weight, whole body and lumbar-
reduced bone-mineral accumulation during childhood.
spine bone mineral content, bone area, and bone density were
• Vitamin D supplements taken during pregnancy may
also obtained.
reduce the risk for osteoporosis-related fractures in the
Findings from the study included the following:
offspring.
Of the women participants:
• Average age was 27 years. 1. What might be considered as limitations to this study?
• 53% were primiparous. 2. How is this information useful to clinical nursing practice?
• 31% smoked at the time of the last menstrual period; See Suggested Responses for Moving Toward Evidence-Based
20% continued to smoke during pregnancy. Practice on the Electronic Study Guide or DavisPlus.
Introduction
exercise, work, and rest must be balanced in order to
This chapter focuses on health promotion of childbearing achieve an optimal pregnancy outcome. Health care provid-
women during preconception and throughout pregnancy. ers must provide guidelines for safe and beneficial exercise,
Counseling is an essential component of preconception which include teaching pregnant women about the effects
care and provides information and education to women of exercise and work.
and families, which enables them to plan for their preg- This chapter also discusses the effects of medications
nancy and to develop a healthy body and a healthy mind during pregnancy and provides information concerning
surrounding the pregnancy. safe versus unsafe medications. Included in this section is
Another important facet of health promotion during information about over the counter medications, herbal
pregnancy is adequate nutrition and weight gain. Women therapies, and prescription medications. Certain medica-
need to have an understanding of essential elements tions are considered to be safe for use during pregnancy
required for a healthy pregnancy and of how to incorporate and these are incorporated into the discussion about the
them into their daily diets. Along with diet and nutrition, common discomforts of pregnancy.
258 unit three The Prenatal Journey
Nurses and other health care providers can teach through preconception counseling, individualized prenatal
patients about common pregnancy discomforts to help care, and identification and treatment of medical concerns
alleviate anxiety and fear. Prenatal education also pro- and problems throughout the pregnancy.
motes empowerment that encourages women to manage Pregnancy care is a continuum that begins in adoles-
pregnancy in a healthy manner. Pregnant women must cence. Once a female reaches menarche and is capable of
also be knowledgeable about signs and symptoms of dan- reproduction, she should be cognizant of the fact that she
ger, including interventions that can be incorporated at could become pregnant and strive to achieve the best
home along with an understanding of when to seek pro- level of health that is possible. This timeframe, which
fessional care. represents the earliest stage of the pregnancy continuum,
The course of a normal pregnancy, along with informa- is called preconception. The pregnancy continuum spans
tion concerning prenatal visits, is discussed in this chap- across the childbearing years and encompasses the prena-
ter. Included in this section is a schedule for prenatal tal period, birth, postpartum, and parenthood. Pericon-
visits, information to be covered by the nurse at each visit, ception is a term that generally refers to the time imme-
and laboratory tests that are completed with each visit. diately before conception through the period of
The nursing diagnosis: “health seeking behaviors related to organogenesis, while interconception is the time period
interest in maintaining optimal health during pregnancy” is between the end of one pregnancy and the beginning of
usually appropriate for women who regularly engage in the next pregnancy. It is considered to be an optimal time
prenatal care. Examples of other nursing diagnoses that to address problems that occurred with the previous
address health promotion of the pregnant woman and her pregnancy to minimize the likelihood of a repeated poor
fetus are presented in Box 10-1. pregnancy outcome (Moos, 2006).
Lastly, this chapter presents information about child-
birth education, including a comparison of methods and
strategies for finding information about various prenatal PRECONCEPTION COUNSELING: A TOOL TO
and childbirth education classes. As an integral part of HELP PROMOTE A POSITIVE PREGNANCY
promoting a healthy pregnancy and incorporating a holis- OUTCOME
tic approach to care, women should be encouraged to It is during preconception that a woman builds the foun-
develop a birth plan, which includes their preferences for dation for a healthy pregnancy long before she may ever
care during the labor and birth of their child. even think of becoming pregnant. When a woman
accesses her care provider during this time, it is known
as preconception care. Ideally, health promotion for the
Planning for Pregnancy pregnant woman should begin during the preconception
period. Working with her health care provider during
Healthy People 2010 targets women of childbearing age with this time provides opportunities for empowering the
the goal of improving “the health and well-being of women, woman for planning and carrying out a healthy preg-
infants, children, and families” (U.S. Department of Health nancy and birth.
and Human Services [USDHHS], 2000, p. 16-3). To meet The purpose of preconception care is to identify con-
this goal, specific objectives are identified, focusing on the ditions, whether physical, psychological, or social, that
number of women receiving prenatal care, attendance at could adversely affect a future pregnancy. By identifying
prepared childbirth education classes, delivery of low-birth- these conditions early, interventions can be initiated to
weight and very-low-birth-weight infants, preterm delivery, reduce or prevent potential complications that may be
and maternal weight gain. One of the most important ways associated with them. Although certain conditions can-
to facilitate meeting these objectives is for nurses and health not be ameliorated, it may be possible to manage or treat
care providers to promote healthy pregnancies in women them so that they have the smallest impact possible
on future pregnancies. Each time a woman of childbear-
ing age presents to her care provider for an annual gyne-
cological exam, preconception counseling should be
Box 10-1 Possible Nursing Diagnoses Related to Health included, regardless of whether or not the woman
Promotion of the Pregnant Woman and Her Fetus is planning a pregnancy now or at any time in the fore-
seeable future.
• Anxiety related to minor symptoms of pregnancy
• Disturbed Body Image related to change of appearance with
pregnancy Optimizing Outcomes— Endorsing preconception care
• Fatigue related to metabolic changes of pregnancy The past decade has shown a growing trend among clini-
• Risk for Deficient Fluid Volume related to nausea and vomiting of cians in women’s health to expand the definition of prena-
pregnancy tal care to include preconception counseling. National
• Constipation related to reduced peristalsis during pregnancy organizations such as the March of Dimes and the Centers
• Deficient Knowledge related to inadequate information regarding nutri- for Disease Control and Prevention (CDC) endorse pre-
tional needs during pregnancy conception counseling as an important component of care
• Health-seeking Behaviors related to a lack of information about child- for women contemplating pregnancy or at risk of unin-
birth and newborn care tended pregnancy (Phillips, 2007). Nurses play a major
• Ineffective Coping related to lack of support people role in endorsing preconception care for all women of
• Risk for Fetal Injury related to maternal substance abuse childbearing age.
chapter 10 Promoting a Healthy Pregnancy 259
THE HEALTHY BODY menstrual periods on the calendar (Fig. 10-2). This infor-
Preparing for pregnancy before becoming pregnant is the mation will help her to determine the length of each cycle
ideal, as it empowers women to become educated about and when to time sexual intercourse in succeeding months
the workings of their bodies and the benefits gained from to increase the likelihood of conception. When pregnancy
pregnancy planning. During the preconception visit, the does occur, one of the first questions she will be asked is,
provider reinforces the importance of early and ongoing “What was the first day of your last normal menstrual
prenatal care and counsels the woman about establishing period (LNMP)?” If she has recorded this information, she
realistic expectations for pregnancy and its outcomes can easily refer to her calendar for the accurate date.
(American College of Obstetricians and Gynecologists There are times when charting a menstrual calendar also
[ACOG], 2005) (Fig. 10-1). provides clues to menstrual and, perhaps, fertility problems.
Some women have irregular cycles that are too close together
Menstrual and Medical History or too far apart. This information, documented in a calendar,
When pregnancy is desired, the nurse can be instrumental may signal the need for referral to a reproductive specialist.
in empowering the woman to take charge of her conception A review of the family history is another important com-
care by embracing a healthy lifestyle to ensure the best pos- ponent of the preconception visit. Through the information
sible outcome. During the preconception visit, a review of gained, the woman’s and her partner’s extended families can
the menstrual history guides the nurse in identifying spe- be assessed for potential illnesses or diseases that tend to run
cific needs so that an individualized conception plan can be in families. For this reason, it is desirable for the patient’s
developed. Determining the frequency and length of men- partner to be present at the preconception visit so that he
strual periods is essential information for teaching about can accurately provide information about his family.
the fertile period and how to enhance the likelihood of
conception. The patient should be educated about the value Complementary Care: Ayurveda to enhance
of keeping an accurate menstrual calendar. She can be the preconception period
instructed to mark the first and every successive day of her
Ayurveda is a term derived from the words ayur, or life, and
veda, or science. Developed hundreds of years ago in ancient
India, Ayurveda is a system of natural and medical healing
that includes diet, herbs, massage, exercise, music therapy,
meditation, yoga, and aromatherapy. Practitioners of this
modality believe that Ayurveda is beneficial during the pre-
conception period in promoting optimal maternal and fetal
health. According to Ayruveda, a healthy lifestyle is achieved
by maintaining a mutually satisfying, harmonious emotional
relationship while avoiding stress, tobacco, alcohol and drugs,
meat, and dairy products (consume a vegetarian diet).
INSTRUCTIONS: Shade in the appropriate box for every date of menstrual bleeding
January 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
February 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 {29}
March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
April 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
May 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
June 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
July 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
August 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
September 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
October 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
November 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Figure 10-2 The menstrual calendar provides an accurate record for recording menstrual periods.
260 unit three The Prenatal Journey
The Physical Examination Finally, all adults should receive a tetanus booster
Using the patient history as a guide to help identify prob- immunization at least every 10 years. A booster can be
lems or special needs, the health care provider performs a given to the woman during the preconception period if she
complete physical examination. Along with the general has not been immunized within the previous 10 years.
physical assessment, a complete pelvic examination is also
performed to evaluate the organs and bony structures of the Exposure to Sexually Transmitted Infections
pelvis. Abnormalities in this region can be crucial during Sexually transmitted infections (STIs) may cause maternal
pregnancy and childbirth. A Papanicolaou test (Pap smear), and fetal complications during pregnancy. Routine screen-
cultures for sexually transmitted infections (STIs), and cul- ing for STIs aids in early detection and treatment. The
tures for other infections are often obtained during this Venereal Disease Research Laboratory (VDRL) test is a
exam as well. (See Chapter 9 for further discussion.) screening titer for syphilis that measures antibodies pro-
duced in mid-disease, but can produce a false positive
Laboratory Evaluation result in women who are pregnant or who have rheuma-
toid arthritis or systemic lupus erythematosus. For these
Every pregnant woman who presents for prenatal care is patients, a rapid plasma reagin (RPR) screening test may
tested for various potential problems during the first visit be used to confirm the presence of antibodies. In the event
and periodically throughout the antepartal period. The of a positive result, further testing is needed to confirm
complete blood count (CBC) serves as the primary test for the findings and to determine whether the infection is in
anemia via analysis of the hemoglobin and hematocrit. If an active or latent phase.
the woman is anemic, the indices can aid in identifying In addition to screening for syphilis, all women should
the type of anemia (e.g., iron-deficiency, etc.). The patient be screened for human immunodeficiency virus (HIV)
can also be screened for infection by the white blood cell during pregnancy (ACOG, 2004). If positive, therapy can
(WBC) count. If the WBCs are elevated, more information be initiated to decrease the likelihood of transplacental
can be ascertained via the differential analysis. Platelets, viral transmission to the fetus. An important nursing role
essential components of the clotting mechanism, are also includes educating all women about HIV and the methods
evaluated in a CBC. for decreasing the risk of infection.
Blood is also drawn for the identification of the woman’s Gonorrhea and chlamydia are cervical infections that can
blood type, Rh status, and the presence of irregular antibod- ascend through the cervix and increase the risk of prema-
ies. The blood type and Rh status are important in determin- ture rupture of the membranes and preterm labor. A cervical
ing if the woman is at risk for developing isoimmunization sample obtained during a speculum examination can be
during her pregnancy. This problem can occur if the wom- tested to determine if either of the pathogens is present.
an’s blood is Rh(D) negative and the fetus she is carrying is Hepatitis B virus is a blood-borne infection that is
Rh(D) positive. Screening identifies the presence of antibod- acquired primarily by sexual contact or through exposure
ies that have been produced in response to exposure to fetal to infected blood. The Hepatitis B Surface Antigen (HBSaG)
blood or other irregular antibodies that could potentially is used to screen for this infection. If the screening test is
cause problems. (See Chapter 11 for further discussion.) positive, further testing is indicated.
Exposure to Childhood Illnesses Now Can You— Identify essential laboratory tests during
Some of the routine maternal laboratory tests screen for preconception planning?
childhood diseases that are known to cause congenital 1. Discuss components of the CBC?
anomalies or other pregnancy complications if contracted 2. Explain the importance of identifying the woman’s blood
during early pregnancy. Rubella, or German measles, was type and Rh status?
once a common childhood disease. Today, most women 3. Identify routine screening tests performed for childhood
of childbearing age received rubella immunization during diseases?
childhood. When contracted during the first trimester, 4. Describe the processes for sexually transmitted infection
rubella causes a number of fetal deformities. Therefore, screening?
all pregnant women are screened for rubella. A positive
rubella screening test is indicative of immunity, and the
woman cannot contract the disease. If the screening test
is negative, the patient is advised to stay away from chil- Genetic Testing
dren who could possibly have the disease, and she is During the patient’s first interview and visit, the nurse
immunized for rubella after the infant is born. should ask questions that relate to the patient’s and fami-
Varicella (chickenpox) is another common childhood ly’s genetic history. Depending on the information gained,
disease that may cause problems in the developing embryo further blood work and testing may be indicated. For
and fetus. At present, an immunization for chickenpox is example, a positive family history of sickle cell disease or
available and given to most children. If a woman presents trait should be followed up with a maternal hemoglobin
for a preconception visit and her history reveals no prior electrophoresis. If the patient tests positive, her partner
chickenpox infection, she should be immunized before should also be tested.
attempting pregnancy. Pregnant women should be ques- All women should be offered screening with maternal
tioned about childhood chickenpox, and a varicella titer serum markers. Several different tests are available, such
may be obtained to confirm immunity. If nonimmune, the as the Triple Marker screen and the Quadruple Marker
patient should be advised to avoid children who could screen. Each tests for the presence of alpha-fetoprotein
potentially expose her to the chickenpox virus. (AFP), estradiol, human chorionic gonadotropin (hCG),
chapter 10 Promoting a Healthy Pregnancy 261
and other markers. These tests screen for potential neural who smoked during pregnancy are three times more likely
tube defects, Down syndrome, and trisomy 18. If the to die from sudden infant death syndrome (SIDS) than
screen is positive, the woman should be referred to a babies born to women who do not smoke (U.S. Depart-
genetics specialist for counseling, and further testing, ment of Health & Human Services [USDHHS], 2004).
such as chorionic villus sampling (CVS) or amniocentesis, Women who smoke should be encouraged to partici-
should be performed (ACOG, 2007). pate in a smoking cessation program. These programs are
While it is not possible to inquire about every inherit- 50% to 70% effective in assisting and empowering women
able disease or disorder, those most frequently encoun- who smoke to be successful in quitting (March of Dimes,
tered are addressed in Table 10-1. 2006). Smoking cessation during pregnancy reduces peri-
natal complications, even if the woman does not quit until
the second or third trimester. (See Chapter 7 for further
Optimizing Outcomes— Prenatal genetic testing
discussion.)
Prenatal nursing care is enhanced with the implementation
ALCOHOL. Alcohol consumption during pregnancy can
of interventions for early diagnosis and treatment for the
cause physical and mental abnormalities in the developing
prevention of complications related to birth defects.
fetus. Each year, more than 40,000 babies are born with
Best outcome: Provide prenatal interventions, including
complications resulting from alcohol use during preg-
folic acid supplementation for all women of reproductive
nancy (March of Dimes, 2006). The current recommenda-
age, conduct rubella screening and immunization, teach
tion is that no alcohol consumption during pregnancy is
women to avoid alcohol consumption during preconcep-
safe, as no safe level has been determined.
tion and pregnancy, offer screening and detection of pre-
Alcohol passes quickly through the placenta and reaches
natal genetic disorders and early treatment of disorders
the fetal bloodstream much more rapidly than it does in
when possible, and offer termination of pregnancy for
adults. Fetal body system functions are immature and
severe defects.
unable to metabolize alcohol, resulting in elevated alcohol
levels and damage to developing organs and tissues. The
resulting problems are manifested in the facial features
Exposures Related to Lifestyle Choices associated with fetal alcohol syndrome (FAS): a low nasal
Several factors related to lifestyle choices can have detri- bridge, short nose, flat midface, and short palpebral fis-
mental effects on the developing fetus, including use of sures. FAS is one of the most common causes of mental
tobacco, alcohol, caffeine, artificial sweeteners, marijuana, retardation. Body organs affected include the heart and the
and cocaine. brain. Children born with lesser damage are diagnosed
TOBACCO. Smoking during pregnancy causes a plethora
with fetal alcohol effects (FAEs), fetal alcohol spectrum
of problems for the woman and the developing fetus. disorder (FASD), or alcohol-related birth defects (ARBDs).
Carbon monoxide in the cigarette smoke binds more (See Chapter 19 for further discussion.)
readily than oxygen to hemoglobin, thereby decreasing Heavy maternal drinking can result in spontaneous
the oxygen-carrying capacity of the red blood cells. This abortion or a low-birth-weight infant. In fact, heavy
alteration decreases the amount of oxygen traveling to drinkers are two to four times more likely to have a spon-
the placenta, thereby decreasing the amount of oxygen taneous abortion than are nondrinkers (Centers for Dis-
available to the fetus for growth and development of ease Control & Prevention [CDC], 2002). While drinking
tissues and organs. alcohol should be discouraged for the duration of the
The nicotine in the cigarette smoke also poses a signifi- pregnancy, many women do not know they are pregnant
cant risk to the developing fetus. Depending on the during the first few weeks. During this time, occasional
amount and the frequency of smoking, nicotine can act as alcohol consumption is not believed to harm the fetus.
either a stimulant or a relaxant. Nicotine causes the (See Chapter 7 for further discussion.)
release of epinephrine, stimulating the “fight or flight”
response that results in tachycardia, hypertension, and Now Can You— Discuss complications related to alcohol
tachypnea. This response occurs in both the woman and consumption during pregnancy?
her fetus. The stimulation of the sympathetic nervous 1. Identify facial anomalies associated with FAS?
system also prompts the release of cortisol from the adre- 2. Identify fetal body organs affected by alcohol exposure?
nal glands, increasing blood glucose levels, and altering 3. Describe pregnancy complications related to alcohol
the body’s immune response. Vasoconstriction results consumption?
from stimulation of the sympathetic nervous system,
causing decreased blood flow through the arteries and
decreased oxygen transport to the placenta and the devel- CAFFEINE. Caffeine acts as a central nervous system (CNS)
oping fetus. stimulant, causing tachycardia and hypertension. Since caf-
Smoking is associated with spontaneous abortion, low feine readily passes through the placenta to the fetus, the
birth weight, intrauterine growth restriction, preterm effects of caffeine affect fetal heart rate and movement. High
labor and birth, placenta previa, placental abruption, and caffeine intake during pregnancy has been associated with
premature rupture of the membranes. Infants born to preterm labor and birth as well as intrauterine growth
mothers who smoke are more likely to be small for gesta- restriction. However, no clear causation exists.
tional age. Each of these complications predisposes the The primary sources of caffeine for most pregnant women
fetus to complications related to growth and physical and include coffee, tea, and sodas. Other lesser known sources
cognitive development. In fact, babies born to mothers include chocolate, over-the-counter medications that contain
262 unit three The Prenatal Journey
Sickle cell disease African Americans • Autosomal recessive hemolytic disease Spontaneous abortion
Persons of Mediterranean • Involves an abnormal substitution • Preterm labor
descent of an amino acid in the structure
of hemoglobin
• Red blood cells assume abnormal, sickle • Intrauterine growth restriction
shape in response to triggers, including
hypoxia, infection, dehydration
• Results in inability to oxygenate tissues • Stillbirth
• Leads to occlusion and rupture
of blood vessels
Tay–Sachs disease Ashkenazi Jews • Lipid storage disease that results from • Infants appear normal at birth, until
a deficiency in hexosaminidase about 3–6 months of age
Jewish people from • Both parents must carry and pass • Neurological system begins to deteriorate
eastern or central Europe on the trait to the child
• Death occurs between the ages of 2 and
4 years
French Canadians
Cajuns
Thalassemia Greeks • Disorder of hemoglobin synthesis • Children appear normal at birth
Italians • Thalassemia minor: person is • During first two years, become pale,
heterozygous for the trait; experiences lethargic, and develop jaundice
fewer symptoms
Southeast Asians • Thalassemia major: person is • Results in enlarged liver, spleen, and
homozygous for the trait; heart
experiences more severe symptoms
Filipinos • Death results from heart failure and
infection
Hemophilia Males affected • Mutation in the gene for coagulation • Males can have excessive bleeding when
factor VIII circumcised
Females are carriers • Causes a defect in blood clotting • Increased incidence of intracranial
hemorrhage
• Leads to frequent bleeding episodes • Easy bruising and bleeding with injuries
and hemorrhage
Glucose-6-phosphate African Americans • Causes drug-induced destruction of • Increased incidence of pathological
dehydrogenase (G6PD) red blood cells when taking certain jaundice or hyperbilirubinemia due to
deficiency Seen mostly in males medications (e.g., sulfonamides) destruction of red blood cells
Cystic fibrosis Caucasians • Autosomal recessive genetic disorder • Results in chronic obstructive lung disease
from thick mucous secretions in the lungs
• Causes exocrine gland dysfunction • Frequent lung infections occur
• Causes a deficiency in pancreatic enzymes
that prevents normal digestion
Data from: Cunningham et al., (2005); Kilpatrick & Laros (2004); & Lashley (2005).
caffeine as an ingredient, and dietary supplements. Women pregnant should limit their intake of caffeine to less than
should be counseled that coffee and tea labeled “caffeine- 300 mg/day, which is the equivalent of two (caffeinated)
free” still contain small amounts of caffeine. beverages per day (National Toxicology Program Center
Moderate intake of caffeine during pregnancy has not for the Evaluation of Risks to Human Reproduction,
been found to cause perinatal problems. Women who are 2005). (See Chapter 7 for further discussion.)
chapter 10 Promoting a Healthy Pregnancy 263
ARTIFICIAL SWEETENERS. Aspartame (Nutrasweet®, Equal®), the years with other women (Lederman, 1996). The rela-
acesulfame potassium (Sunett®), and sucralose (Splenda®) tionship with her own mother plays a significant role in
have not been shown to have any negative effects associated how she views motherhood. If the woman’s mother is
with the developing fetus. However, because aspartame con- available, accepting the pregnancy and respect for her
sists of two naturally occurring amino acids, women who daughter’s autonomy play an integral role in assisting the
have phenylketonuria (PKU) should not use this product. woman to become a successful mother. Absence of some
Saccharin, another artificial sweetener, is considered to be of these components may impede the pregnant woman’s
unsafe for use during pregnancy and should be avoided ability to develop into the motherhood role.
altogether. One way that a pregnant woman can demonstrate a
positive attitude toward her pregnancy is by educating
MARIJUANA. No studies have documented fetal terato-
herself about maternal changes during pregnancy, fetal
genic effects associated with marijuana. Women who use
growth and development, and motherhood (Fig. 10-3).
marijuana, however, may engage in other high-risk behav-
Many helpful books, brochures, online resources, and
iors (e.g., alcohol use) and the combination of effects may
community programs on pregnancy and parenting are
be associated with poor fetal outcomes. (See Chapters 7
available for mothers-to-be.
and 9 for further discussion.)
COCAINE. It is difficult to determine the effects of cocaine Psychological Changes During Pregnancy
use in pregnancy due to the high potential that the woman Hormone levels during pregnancy often play havoc with
may be using other drugs and engaging in additional high- the pregnant woman’s psyche. Progesterone exerts a
risk behaviors. Fetal exposure to cocaine is associated with depressant effect. Physical changes, changes in body
an increased risk for congenital anomalies that most fre- image and fears related to becoming a mother, the impend-
quently occur in the cardiac and central nervous systems. ing labor and birth, and the increased responsibilities that
The pregnant woman who uses cocaine is at risk for preg- accompany pregnancy and parenthood often produce
nancy complications that include stillbirth, abruptio pla- anxiety or heighten depression during pregnancy (Young-
centae, preterm labor, preterm birth, and giving birth to an kin & Davis, 2004). Providers must be aware of this
infant who is small for gestational age (SGA) (Stuart & potential and remain cognizant for signs and symptoms of
Laraia, 2005). (See Chapters 7, 9, and 11 for further mental illness in the pregnant woman. Referral to a mental
discussion.) health professional may be necessary.
Now Can You— Discuss substances to be avoided during The Healthy Relationship
pregnancy? The incidence of intimate partner violence (IPV) during
1. Name one harmful effect of caffeine during pregnancy? pregnancy is high and, statistically, as many as 20% of preg-
2. Identify women who should be counseled to avoid the nant women experience violence in the home (ACOG,
artificial sweetener aspartame? 2006). Every woman should be screened for IPV during the
3. Name three maternal/fetal complications that can result initial visit and then as necessary (e.g., if bruises or other
from cocaine use during pregnancy? injuries are present) throughout the pregnancy. (See further
discussion in Chapter 9.)
Maternal stress also has a negative effect on the devel-
oping fetus. Women who are anxious or stressed during
THE HEALTHY MIND their pregnancy are more likely to deliver preterm or to
Maternal attachment to the fetus is an important area to give birth to smaller babies. The nurse should assess all
assess and can be useful in identifying families at risk for pregnant women for stressors and coping skills during
maladaptive behaviors (Youngkin & Davis, 2004). The pregnancy. (See Chapter 9 for further discussion.)
nurse should assess for indicators such as unintended preg-
nancy, intimate partner violence, difficulties in the partner
relationship, sexually transmitted infections, limited finan-
cial resources, substance use, adolescence, poor social sup-
port systems, low educational level, and the presence of
mental conditions that might interfere with the patient’s
ability to bond with and care for the infant (ACOG, 2006).
It is important to remember that, depending on what is
going on in her life at the time of the pregnancy, any
woman has the potential for maladaptive behaviors.
IMPORTANT NUTRITIONAL ELEMENTS source of protein, and include eggs, milk, cheese, and
Many elements combine to facilitate a healthy pregnancy. yogurt. For women who do not prefer dairy sources of
Often pregnant women are told to eat as much as they want protein, or who may be lactose intolerant, soy milk and
since “they are eating for two.” However, this is not neces- soy cheese are available as protein-rich substitutes. In
sarily accurate advice. Practitioners must evaluate the addition, beans and legumes provide a rich source of pro-
amount as well as the nutritional value of the food con- tein as well as fiber to the diet and can be substituted for
sumed. Calories are an important consideration when plan- protein servings in many meals. Peanut butter is another
ning the patient’s daily food intake. Other essential nutri- source rich in protein, but potentially high in fat. Beans
tional elements are protein, water, iron, folic acid, and and legumes are combined protein sources that provide
calcium. Maternal dietary practices that may exert a nega- carbohydrates with protein to supply the essential amino
tive influence on the pregnancy must also be addressed. acids that may be missing when insufficient protein from
animal sources is consumed.
A word of caution should be provided by health care
Calories
providers to pregnant women with regard to microbial
A calorie, or unit of heat, signifies the energy expenditure foodborne illness (USDHHS, 2005). Raw, or unpasteur-
of food. A kilocalorie (kcal) is equivalent to 1000 calo- ized, milk, as well as partially cooked eggs and foods con-
ries. It is the basic unit of measurement that more accu- taining raw or partially cooked eggs should be avoided.
rately defines the amount of energy needed to metabolize Deli meats, luncheon meats, and frankfurters should be
food and provide an energy source from this food heated before consumption. In addition, raw shellfish and
(Venes, 2009). The body’s energy needs are met by car- fish high in mercury, including shark, swordfish, tilefish,
bohydrate, fat, and protein in the diet. and king mackerel should be avoided. Fresh or frozen
The Recommended Daily Allowance (RDA) for caloric tuna, red snapper, and orange roughy contain moderate
intake for nonpregnant women ranges from 1200 to amounts of mercury and women who are pregnant or
2400 kcal/day, depending on activity level. Women who are planning to become pregnant should limit their intake of
sedentary and who exercise less than 30 minutes per day these products to 12 ounces per week.
should have a daily intake of 1200 kcal/day. Women who
exercise vigorously for at least 30 minutes per day, 5 to Water
7 days per week, and engage in cardiovascular and strength Water is necessary for all body tissues and all body system
training activities, should consume 2000 to 2400 kcal/day. functions. It is essential for the maintenance of life, and must
During pregnancy, the RDA for caloric intake increases be consumed in sufficient quantity to sustain homeostasis.
only slightly, and requires only a 300 kcal/day increase from All persons should consume six to eight (8-oz.) glasses of
pre-pregnant needs. Growth during the first and second fluid daily; however, pregnant women should have an intake
trimesters occurs primarily in the maternal tissues; during of eight to ten (8-oz.) glasses of fluid per day. The increased
the third trimester, growth occurs mostly in the fetal tissues. amount needed during pregnancy is necessary to meet the
An increase in maternal caloric intake is most important changing physiology of the maternal cardiovascular system
during the second and third trimesters. In the first trimester, and to maintain adequate blood flow to the fetus.
the average maternal weight gain is 1 to 2.5 kg and thereaf- During pregnancy, blood volume increases about
ter the recommended weight gain for a woman of normal 1500 mL, which represents a 40% to 50% increase from
weight is approximately 0.4 kg per week. For overweight the pre-pregnancy blood volume. The increase in mater-
women, the recommended weekly weight gain during the nal blood volume occurs for three primary reasons: to
second and third trimesters is 0.3 kg; for underweight meet the needs of the hypertrophied vascular system of
women, it is 0.5 kg. the enlarged uterus, to adequately hydrate maternal and
Pregnant women should be counseled about healthy fetal tissues, and to provide a fluid reserve for blood loss
ways to incorporate the additional 300 kcal needed in during childbirth. In addition, adequate blood flow to the
their daily diets. For example, adding an additional serv- fetus is necessary for oxygenation of body tissues and
ing from each of the major food groups (skim milk, yogurt maintenance of a normal acid–base balance.
or cheese; fruits; vegetables; bread, cereal, rice or pasta) Water intake can be in the form of many different types
meets this need. It is essential for health care providers to of fluids, including fruit juice and vegetable juice. How-
stress to patients that the additional kilocalories should ever, at least four to six glasses of the fluid consumed each
not be met through an increased intake of “empty calo- day should be water. Patients should be cautioned to con-
ries” such as soda, candy, or simple carbohydrates. sume certain beverages, such as diet sodas (high in
sodium and contain artificial sweeteners) and caffeinated
Protein drinks (promote diuresis) in moderation. Alcohol should
Protein is necessary for tissue growth and repair. For be avoided entirely throughout the pregnancy, as no safe
pregnant women, protein is important for growth of amount has been determined.
maternal tissues, including the uterus and the breasts, and
for development of fetal tissues and organs. Only a modest Minerals and Vitamins
increase in protein is required; increasing intake of milk Women who eat a balanced diet that includes recommended
and dairy products by one or two servings per day meets servings and serving sizes may meet the recommended
the daily requirement for protein. nutritional needs during pregnancy without vitamin supple-
Protein is typically found in animal sources, specifi- mentation. However, the need for an increased intake of
cally in meat, poultry, and fish. However, other protein specific nutrients must be taken into consideration as the
sources are also available. Dairy products are a great pregnant woman plans her diet. Specifically, the daily intake
266 unit three The Prenatal Journey
of calcium, iron, and folic acid must be adequate to meet 1992). Iron can be found in a variety of food sources. Many
the maternal–fetal needs for adequate growth and individuals may not be aware that adequate amounts of iron
development. are found in fortified ready-to-eat cereals, white beans, len-
tils, spinach, kidney beans, lima beans, soybeans, shrimp,
CALCIUM AND VITAMIN D. The RDA for calcium is 1000 mg/
and prune juice. Red meats, including beef, duck, and lamb,
day in pregnant and pre-pregnant women. Calcium require-
contain moderate amounts of iron as well. Some of the best
ments are increased in pregnant adolescents, who need an
food sources for iron include oysters, organ meats (liver,
intake of 1300 mg/day. Without supplementation, most
giblets), and fortified instant cooked cereals. Interestingly,
women fail to consume adequate amounts of dietary cal-
canned, drained clams provide the highest amount of iron
cium. Calcium is essential for maintaining bone and tooth
per serving, with 23.8 mg of iron in each 3-ounce serving.
mineralization and calcification. During pregnancy, calcium
While most other necessary nutrients can be met
must be available to the fetus for the growth and develop-
through a balanced diet, it is almost impossible to meet the
ment of the skeleton and teeth.
maternal daily requirements for iron without a dietary
Dairy products, especially milk and milk products,
supplement. Consideration must be given, however, to the
constitute the best nutritional sources of calcium. Three
gastrointestinal side effects of supplemental iron, which
daily servings of dairy products are recommended for
include constipation, black tarry stools, nausea, and
women; one to two additional daily servings of milk are
abdominal cramping. These side effects may exacerbate
recommended during pregnancy (USDHHS, 2005). Other
other pregnancy-related gastrointestinal discomforts. Daily
rich sources of calcium include legumes, dark green leafy
iron supplementation is often initiated at around 12 weeks
vegetables, dried fruits, and nuts.
of gestation in order to avoid compounding the nausea
commonly prevalent during the first trimester. Adequate
Optimizing Outcomes— Teaching patients to avoid water intake helps to decrease constipation, and patients
bone meal supplements may take the iron at bedtime if abdominal discomfort is
experienced when taking iron between meals.
Bone meal, sometimes used as a calcium source, should be
avoided during pregnancy. This supplement is frequently
contaminated with lead, a toxin that readily crosses the Nursing Insight— When teaching about iron
placenta and can result in high levels in the fetus. supplements
Nurses can teach patients about substances known to decrease
Vitamin D is important in the absorption and metabolism the absorption of iron. Women should be taught to avoid con-
of calcium. Milk and ready-to-eat cereals constitute the suming bran, tea, coffee, milk, oxylates (found in Swiss chard
major food sources of vitamin D, which is also produced in and spinach), and egg yolk at the same time as they take the iron
the skin by the action of sunlight. Women who do not supplement. Also, iron is best absorbed when taken between
include milk in their diets should be taught about other vita- meals with a beverage other than tea, coffee, or milk.
min D sources such as cereals, egg yolks, liver, and seafood.
Also, since the use of sunscreens with a recommended SPF
rating of 15 reduces the skin vitamin D production by up to
99% (Scanlon, 2001), all women should be taught about the medication: Ferrous Sulfate
need for vitamin D-fortified foods or supplements.
Ferrous sulfate (fer-us sul-fate)
Vitamin C (ascorbic acid), important in tissue forma- and the brain. (See Chapter 7 for further discussion.) The
tion, also enhances the absorption of iron. Women who folic acid RDA for nonpregnant women is 400 mcg/day.
take iron supplements should consume foods or beverages During pregnancy, a minimum of 800 mcg/day of folic
that contain vitamin C. Food sources rich in vitamin C acid is recommended, and this amount is usually provided
include red and green sweet peppers, oranges, kiwi fruit, through supplementation. Childbearing aged women who
grapefruit, strawberries, Brussels sprouts, cantaloupe, have previously given birth to an infant with a neural tube
broccoli, sweet potatoes, tomato juice, cauliflower, pine- defect or those who have a positive family history of neu-
apple, and kale. Most pregnant women are able to meet ral tube defects are encouraged to consume 1 to 4 mg of
the recommended daily allowance (80 to 85 mg) by folic acid each day (ACOG, 2003a; Veterans Health
including at least one daily serving of citrus fruit or juice Administration, 2002).
or vitamin C-rich food source, although women who The neural tube develops during the first 4 weeks after
smoke need more. conception. During these early developmental weeks, the
Inadequate iron intake can lead to anemia, a decrease in majority of women do not yet know that they have con-
the oxygen-carrying capacity of the blood. Physiological ceived. Because of the strong connection between folic acid
anemia, common during pregnancy, occurs when the plasma deficiency and the subsequent development of neural tube
volume increases more than the red blood cell mass, pro- defects, all women of childbearing age should take a folic
ducing a modest decrease in the hemoglobin concentration acid supplement of at least 400 mcg/day. Research has indi-
and hematocrit. True anemia, or iron-deficiency anemia, cated that an adequate intake of folic acid during the peri-
occurs when the hemoglobin level drops below 10 g/dL. The conceptional period can reduce the incidence of neural tube
blood’s decreased oxygen-carrying capacity causes a reduc- defects by up to 50% (Krishnaswamy & Madhavan Nair,
tion in oxygen transport to the developing fetus. Decreased 2001; Lewis, Van Dyke, Stumbo, & Berg, 1998). Findings
fetal oxygen transport has been associated with intrauterine from studies also show an association between folic acid
growth restriction (IUGR) and preterm birth. deficiency, elevated homocysteine, and the development
of Down syndrome and childhood leukemia (Thompson,
Ethnocultural Considerations— Anemia Gerald, Willoughby, & Armstrong, 2001).
during pregnancy Foods that are rich in folic acid include dark leafy
greens, asparagus, Brussels sprouts, soybeans, liver, root
In the United States, maternal anemia occurs most commonly vegetables, beans, and orange juice. Since 1998, all
among adolescents, African American women, and women of enriched grain products produced in the United States
lower socioeconomic status (Siega-Riz & Savitz, 2001; contain folic acid (Lewis et al., 1998), and this nutritional
Swensen, Harnack, & Ross, 2001). supplementation has decreased the incidence of neural
tube defects by 19%. Current recommendations include
consuming folic acid with vitamin C to enhance the
In recent years, there has been some controversy sur-
absorption of iron and folic acid.
rounding the value of iron supplementation during preg-
nancy (Haram, Nilsen, & Schall, 2001; Mahomed, 2002; Now Can You— Discuss aspects of good nutrition during
Scholl & Reilly, 2000). Although iron supplementation pregnancy?
enhances maternal hematological values, its role in
improving pregnancy outcomes is unclear. However, 1. Identify two protein sources for women who wish to avoid
maternal iron supplementation is believed to improve dairy products?
fetal iron stores and reduce the risk of anemia in the infant 2. Identify three calcium sources for women who wish to avoid
during the first year of life (Haram et al., 2001). Further- dairy products?
more, women who have iron-deficiency anemia during 3. Explain why adequate intake of vitamin C and folic acid are
the early months of pregnancy are at an increased risk for important during pregnancy?
preterm birth (Scholl, 2005).
FOLIC ACID Vitamin B9, or folic acid (folate), is a water-
soluble vitamin that is closely related to iron. Working WEIGHT GAIN DURING PREGNANCY
with vitamin B12, folic acid helps to regulate red blood cell Weight gain is expected during pregnancy and results from
development and facilitates the oxygen-carrying capacity a combination of maternal physiological changes and fetal
of the blood. Folic acid is essential in the production of growth. During early pregnancy, maternal weight gain is
DNA and RNA, and helps to maintain normal brain func- related to an increased blood volume, necessary to supply
tion and to stabilize mental and emotional health. Folic the enlarging uterus and support fetal growth and develop-
acid also works with vitamins B6 and B12 to control blood ment. Dilation of the renal pelvis and ureters from increased
levels of homocysteine, an amino acid that, in elevated blood flow adds volume to the bladder and results in an
amounts, has been linked to heart disease, depression, increased production of urine. Essential nutrients pro-
and Alzheimer’s disease. vided through the maternal blood supply enable fetal
Increased estrogen production during pregnancy alters growth and development. As the pregnancy progresses,
the absorption and metabolism of folic acid, producing an enlargement of the placenta and fetal body add to the
increased maternal susceptibility for folic acid deficiency. woman’s increase in weight. By term, maternal extracellu-
Folic acid deficiency is primarily responsible for the devel- lar fluid, blood, uterine tissue, and breast tissue comprise
opment of neural tube defects, including spina bifida, cleft 35% of the gestational weight gain; the maternal reserves
lip and palate, and anencephaly. The neural tube is the comprise 27%; fetal tissue comprises 27%; and placental
embryonic structure that divides during embryo-fetal fluid comprises 11% of the total maternal weight gain
development to form the CNS, including the spinal cord (King, 2006).
268 unit three The Prenatal Journey
Factors Affecting Weight Gain States, one of the Healthy People 2010 goals (USDHHS,
In addition to maternal–fetal physiological factors, social 2000) is to increase the number of women who attain a
influences are also important predictors of gestational weight recommended weight gain during their pregnancies, in
gain (Stotland, 2006). Social factors related to an insufficient consultation with their health care provider (Table 10-2).
maternal weight gain may include an inability to purchase There are also recommendations for specific populations
food, inadequate dairy intake, unplanned pregnancy, inti- of pregnant women. Pregnant adolescents and women of
mate partner violence, anorexia nervosa, shortened time color should attempt to gain weight at the upper end of the
period between pregnancies, and lack of prenatal care. Fac- appropriate range for their pre-pregnant BMI. Women of
tors that may influence an excessive maternal weight gain short stature (less than 62 inches [1.6 m] in height) should
during pregnancy include inadequate or inconsistent physi- attempt to gain weight at the lower end of the appropriate
cal activity, a high carbohydrate or fat intake, excessive con- range for the pre-pregnant BMI. Women pregnant with
sumption of sweets, and lack of prenatal care. twins or triplets should gain a total of 35 to 45 lbs. (16 to
An adverse outcome may result when the woman gains 20.5 kg), primarily during the second and third trimesters.
too much or too little weight during her pregnancy. Health Ideally, weight management begins before the pregnancy.
care providers need to assess the patient’s weight during the At the preconception visit, women should be screened for
first prenatal visit and monitor the weight gain closely height and weight, with the BMI calculated as a beginning
throughout the pregnancy. The amount of weight that is point for determining an appropriate weight gain during
gained during the gestational period results from a combina- pregnancy (Institute for Clinical Systems Improvement,
tion of influences, including biological and social factors. 2005). The BMI and weight are then monitored at each pre-
Biological factors include genetic alleles that affect pheno- natal visit. Throughout the pregnancy, counseling, educa-
types responsible for regulating energy and fat metabolism. tional interventions, and prophylaxis are provided (Table
These, in turn, affect maternal weight and fat gain during 10-3). Since excess weight gain during early pregnancy is
pregnancy. High levels of insulin and leptin (a protein hor- associated with an increased incidence of gestational diabe-
mone that regulates energy metabolism and appetite) during tes, new recommendations indicate that complications can
the first trimester are also associated with higher maternal be decreased if screening for gestational diabetes takes place
weight and fat gain during pregnancy (Stotland, 2006). during the first trimester (Riley, 2006).
Women who gain too much weight during pregnancy
are at an increased risk for gestational diabetes. This com- PLANNING DAILY FOOD INTAKE
plication places the infant at risk for macrosomia (large While planning daily food intake is based on individual
body size), congenital anomalies, birth trauma, perinatal preferences, consideration must be given to ensure that
asphyxia, respiratory distress syndrome, hypoglycemia, adequate nutrients are provided without an excessive
hypocalcemia, cardiomyopathy, hyperbilirubinemia, and increase in caloric intake. New guidelines indicate strate-
polycythemia. Gestational diabetes also increases the risk gies for daily food consumption (USDHHS, 2005). The
for maternal preeclampsia. Preeclampsia is a condition primary recommendations include the following:
associated with a decreased blood supply to the maternal
organs and to the developing fetus and may result in pre- • Including a variety of nutrient-dense foods and fluids
term birth, premature rupture of membranes, maternal while limiting saturated and trans fats, cholesterol,
organ damage, thrombocytopenia, intrauterine growth excessive sugar, salt, and alcohol
restriction, and an altered acid–base balance in the fetus • Developing a balanced daily eating pattern, using the
(Mayo Foundation for Medical Education and Research, USDA Food Guide or the DASH Eating Plan (see below).
2005). (See Chapter 11 for further discussion.) Specific recommendations for women of childbearing
Management of Weight During Pregnancy age and women who are pregnant incorporate the follow-
ing strategies:
Classification of weight is often based on body mass
index (BMI), which is a method of evaluating the appro- • Eating iron-rich foods or iron-fortified foods
priateness of weight for height. The BMI is calculated • Including vitamin C to enhance the absorption of iron
using the formula: • Including folic acid through consumption of fortified
foods or supplemental folic acid
Weight
BMI ⫽ Height2
where the weight is recorded in kilograms and the height is Table 10-2 Recommended Total Weight Gain During
in meters. For example, the calculated BMI for a woman Pregnancy for a Single Birth
who weighed 52 kg before pregnancy and is 1.58 m tall is: Recommended Total
52 Pre-Pregnancy BMI Weight Gain
BMI ⫽ ⫽ 20.8
1.582
Underweight (⬍19.8) 28–40 lbs.
Persons with a BMI less than 18.5 are underweight;
Normal weight (19.8–26) 25–35 lbs.
those with a BMI between 25 and 29.9 are overweight. Per-
sons with a BMI between 30 and 34.9 are classified at Level Overweight (⬎26–29) 15–20 lbs.
1 obesity; those with a BMI between 35 and 39.9 are classi-
Obese (⬎29) 15⫹ lbs.
fied at Level 2 obesity. Extreme obesity, or Level 3 obesity,
includes persons with a BMI of 40 or above (Cogswell & From the National Heart, Lung and Blood Institute (2006). Body mass index.
Dietz, 2006). Given the increase in obesity in the United Retrieved from www.nhlbi.nih.gov/guidelinesbmi_tbl.htm.
chapter 10 Promoting a Healthy Pregnancy 269
The USDA Food Guide visualized by the new Food Now Can You— Plan a Daily Menu for a Woman Who Is
Pyramid is based on individual factors, including age, Pregnant?
gender, and activity level. No longer does “one size fit
all.” The new Food Pyramid is based on the guiding 1. Identify proteins that meet pregnancy needs?
principles of overall health, up-to-date research, total 2. Suggest foods to increase daily intake of potassium,
diet, usefulness, realism, flexibility, practicality, and evo- magnesium, calcium, protein, and fiber?
lution. Using the name “MyPyramid” the Guide focuses 3. Describe foods that should be avoided by women who are
the patient on developing an individual approach to pregnant?
daily dietary planning (see Fig. 4-1). The pyramid is
color-coded to provide a visual view of the types and
amounts of food that should be eaten. The bands are
wide on the bottom and narrow on the top, indicating
what nutrient-dense foods need to be consumed. The
colors indicate the following: case study Excessive Weight Gain During
Pregnancy
• Orange: Grain group—make one half of the grain
selections whole grains Tamara, a 24-year-old primigravida at 26 weeks’ gestation, has
• Green: Vegetable group—vary vegetables, and include presented for a routine second-trimester prenatal visit. During
green, red, and yellow vegetables the interview with the nurse, Tamara voices no complaints. Her
• Red: Fruit group—focus on fruits of various types vital signs and laboratory data are assessed and all are within
• Blue: Milk group—consume calcium-rich foods normal limits. However, her weight today is 155 lbs. (70.5 kg),
which represents a 30-lb. (13.6 kg) weight gain from her pre-
• Purple: Meat and bean group—consume lean protein
pregnancy weight. Tamara has no preexisting health conditions.
• Yellow: Oils—not considered a food group, but essen- She is married and lives in a mobile home. She works part time
tial as a source of essential fatty acids and vitamin E at a local fast food restaurant and readily admits that she enjoys
The DASH (Dietary Approaches to Stop Hyperten- eating the food served there.
sion) Eating Plan resulted from a study designed to Critical Thinking Questions
investigate whether the typical American diet affected
blood pressure (USDHHS, 2006). The diet plan includes 1. What are the major health concerns regarding Tamara at this
the daily consumption of whole grain products, fish, time?
poultry, and nuts. There is also a focus on reducing lean 2. What patient education should the nurse provide for
red met, sweets, and added sugar found in foods and Tamara?
beverages. The DASH Eating Plan encourages an 3. What additional care should be provided for Tamara?
increased intake of potassium, magnesium, calcium, pro-
tein, and fiber. Table 10-4 compares the daily servings ◆ See Suggested Answers to Case Studies in the text on the
and serving sizes between the USDA Food Guide and the Electronic Study Guide or DavisPlus.
DASH Eating Plan.
Adapted from: Institute for Clinical Systems Improvement (ICSI). (2005). Routine prenatal care. Bloomington, MN.
270 unit three The Prenatal Journey
Table 10-4 Comparison of USDA Food Guide and DASH Eating Plan
Food Groups and Subgroups USDA Food Guide Amount DASH Eating Plan Amount
Source: U.S. Department of Agriculture. Dietary Guidelines for Americans 2005: Sample USDA Food Guide and the DASH Eating
Plan at the 2,000-Calorie Level.
chapter 10 Promoting a Healthy Pregnancy 271
REST
Fatigue and tiredness are common symptoms associated
with the health care provider, include general health and with pregnancy. As the pregnancy progresses from one
well-being, the overall progression of the pregnancy, trimester to the next, the woman’s level of fatigue
present age, prior pregnancy complications, the type of changes along with the need for rest. An understanding
work performed, the number of hours worked, and the of the expected alterations in maternal anatomy and
environmental and safety risk factors associated with physiology empowers the woman to anticipate and
the work. make changes in her daily routine to accommodate the
necessary rest. Nurses should provide education about
Evaluation of Work and Its Impact on the Pregnancy the anticipated need for additional rest and suggest
The pregnant woman may be advised to reduce the num- strategies for managing fatigue and for promoting rest
ber of hours worked if the job requires heavy lifting, pro- and relaxation.
longed standing, extensive walking, or physical exertion.
When the nature of the work is physically demanding, Contributors to Fatigue During the First Trimester
safety concerns may require that she stop working alto- During the first trimester, the woman’s body begins to
gether. The potential for maternal exposure to toxic undergo changes that will support the developing fetus.
substances such as chemotherapeutic agents, lead, and One of the major changes is an increase in the produc-
ionizing radiation (found in laboratories and health care tion of progesterone, a hormone that causes increased
facilities) or heavy machinery and other hazardous equip- fatigue and feelings of tiredness, especially during the
ment should prompt reassignment to a different work day. The maternal blood volume also begins to increase
274 unit three The Prenatal Journey
and frequently results in physiological anemia. Women and often do not readily report this information during
with decreased iron stores may develop “true” (iron- the prenatal interview. Thus, the nurse should ask specific
deficiency) anemia. As the fetus grows, oxygen require- questions regarding prescription and OTC medications
ments increase and cause an increased workload on the and the use of any herbal therapies.
woman’s body systems. These changes, along with the
emotional stress often associated with adjustment to SAFE VERSUS TERATOGENIC MEDICATIONS
the news of the pregnancy, combine to produce fatigue.
Strategies for coping with pregnancy-related fatigue A teratogen is anything that adversely affects the normal
should routinely be discussed with patients early in cellular development in the embryo or fetus (Venes,
the pregnancy. 2009). Although some medications are safe, others are
known teratogens or the safety of their use during preg-
Contributors to Fatigue During the Second Trimester nancy has not been demonstrated. The fetus is most vul-
During the second trimester the rapid physiological nerable to the effects of teratogens from the third week of
changes that occurred in the first trimester come into bal- gestation through the third month. However, the risk for
ance with the body’s workload demands. Pregnant women fetal developmental anomalies continues to exist through-
experience increased energy and endurance during this out the pregnancy. The third trimester is the most vulner-
time and are able to focus more on planning for the able time for cognitive impairment from a teratogenic
upcoming birth. Some women, however, may continue to insult.
experience fatigue that persists into the second trimester.
Potential causes of the fatigue include depression, exter- Over-the-counter Medications
nal stressors, and anemia. Other underlying medical Nonprescription medications such as acetaminophen
causes may also be a factor and should be investigated by (Tylenol) and guaifenesin (Robitussin) are often taken
the woman’s health care provider. for minor problems such as headaches, coughs, and
colds. It is commonly assumed that a medication that
Contributors to Fatigue During the Third Trimester requires no prescription must be safe to take. However,
The pregnant woman’s level of fatigue increases as the all medications, whether available by prescription or over
fetus continues to grow and develop. The maternal weight- the counter, have side effects, and many have adverse
bearing load associated with the fetus is compounded by effects. The nurse needs to counsel women who are plan-
a corresponding increase in extracellular fluid and blood ning to become pregnant and those who are already preg-
volume, maternal reserves, placental mass, and amniotic nant not to take any medications (prescription or non-
fluid. The enlarging fetus causes the maternal diaphragm prescription) without first consulting with the primary
to be upwardly displaced, decreasing lung expansion. health care provider. The provider will make a determi-
Increased bladder pressure from the gravid uterus causes nation regarding the safety and necessity of the medica-
increased voiding, especially at night, when the woman tion. Additional information (including a physical assess-
is trying to sleep. Each of these factors plays a role in ment) may need to be obtained and an alternate medication
the overwhelming fatigue common during the third or therapy may be advised. When possible, all nonpre-
trimester. scription drugs should be avoided during preconception
Through education, the health care provider can and throughout pregnancy.
empower the expectant mother throughout the pregnancy
to better manage her rest demands and cope with fatigue. Herbal and Homeopathic Preparations
Planning and making healthy choices concerning rest One of the most important facts about herbal and
enables the woman to feel more relaxed and energetic and homeopathic preparations is that the U.S. Food and
better able to cope with and manage this common discom- Drug Administration (FDA) has not approved these
fort of pregnancy. drugs and does not regulate or control them. Further,
there are major drawbacks to the use of these substances.
Now Can You— Discuss work and fatigue during There is no regulation that controls product develop-
pregnancy? ment, the dosages are not consistent between brands,
1. Identify three situations in which women may need to stop and additives used in their composition may differ in
working during pregnancy? type and amount. Also, since herbal and homeopathic
2. Name two reasons why fatigue is especially pronounced products have not been subjected to rigorous research to
during the first and third trimesters? determine their efficacy, effectiveness, side effects, thera-
3. Identify three strategies to help women cope with fatigue peutic dosages, and adverse effects, there is no guarantee
during pregnancy? that the claims made about them are true. Although
herbal and homeopathic treatments are considered to be
“natural” because they have been developed from plants
and other natural sources, many of these products are
Medications dangerous and toxic, and may cause effects that have not
yet been discovered.
Medication use during pregnancy must be handled very Several herbal products are recognized to be danger-
carefully and the needs of the patient and her fetus should ous; others are known to have specific teratogenic effects.
always be considered on an individual basis. Nurses need These substances need to be completely avoided during
to be aware that their patients may be taking over- the periods of preconception and pregnancy. Nurses
the-counter (OTC) medications and herbal preparations should warn patients about the use of these products,
chapter 10 Promoting a Healthy Pregnancy 275
Now Can You— Discuss the use of herbal preparations and Table 10-5 Common Discomforts During Each Trimester
prescription medications in pregnancy? of Pregnancy
1. Identify two major concerns related to the use of herbal and Trimester Common Discomforts
homeopathic preparations?
2. Name four herbs that should be avoided during pregnancy? First Nausea
3. Identify two types of prescription medications that should Vomiting
not be used during pregnancy?
4. Discuss what is meant by a Category B medication?
Fatigue
Urinary frequency
Nocturia
NAUSEA Flatulence
Nausea is often one of the first symptoms of pregnancy Gum hyperplasia and bleeding
experienced. Although commonly known as “morning Leg cramps
sickness,” nausea can occur at any time of the day or night.
While the exact cause of nausea is unknown, it most prob- Dependent edema
ably is related to the increased levels of the pregnancy hor- Leg varicosities
mones. Nausea is primarily noted during the first trimester
Dyspareunia
of the pregnancy and usually resolves by 13 to 14 weeks,
although it may persist throughout the pregnancy. Nausea Nocturia
during the early weeks of pregnancy is believed to be a reas- Round ligament pain
suring indicator of embryo/fetal development with adequate
hormonal support (Youngkin & Davis, 2004). Complaints Supine hypotensive syndrome
of nausea should never be dismissed without further assess- All Trimesters Ptyalism
ment to rule out pregnancy-related complications such as
hyperemesis gravidarum, multiple gestation, gestational Nasal congestion
trophoblastic disease, or maternal gastrointestinal or eating Back pain
disorders. (See Chapter 11 for further discussion.)
Nurses can suggest strategies to help offset the nausea, Leukorrhea
such as the avoidance of “trigger foods” (foods that cause Constipation
nausea from sight or smell) and tight clothing that con-
stricts the abdomen. The use of relaxation techniques (e.g., Insomnia
slow, deep breathing, mental imagery) can also help to
decrease nausea. Other techniques that are often helpful
include consuming plain, dry crackers or sucking on pep-
permint candy before arising; adhering to small, frequent VOMITING
meals; and remaining in an upright position after eating. Vomiting in early pregnancy often accompanies the nau-
Medication is usually not necessary for the nausea of sea, although it is important to ascertain that the amount
early pregnancy, although some women have found that vomited is not excessive. During the assessment, nurses
taking vitamin B6 or ginger tablets helps to lessen nausea. should question patients about vomiting frequency and
These oral supplements can be purchased over-the-coun- amount, and their ability to consume and retain foods
ter and should be taken with meals. Acupressure bracelets, and liquids. It is important to assess for weight loss,
often used for the prevention of motion sickness, can also dehydration, urine ketones, blood alkalosis, and hypoka-
be purchased without a prescription and may be beneficial lemia, which are clinical findings that may be indicative
in reducing nausea during early pregnancy (Varney, Kriebs, of a more serious complication known as hyperemesis
& Gegor, 2004; Youngkin & Davis, 2004;). gravidarum (Youngkin & Davis, 2004). Hyperemesis
chapter 10 Promoting a Healthy Pregnancy 277
meals and avoid greasy and fatty foods, very cold foods and enlarging uterus. Tight, restrictive clothing that inhibits
consuming beverages with meals. Drinking cultured or sweet venous return from the lower extremities increases the
milk and using over-the-counter antacids may also be helpful edema. Once pathological conditions, such as gestational
(Varney et al., 2004). hypertension, renal disease, liver disease, cardiac disease,
vascular disorders, trauma, and infection have been ruled
out, the nurse can suggest relief measures. These include
avoiding constrictive clothing, elevating the legs periodi-
FLATULENCE
cally throughout the day, and assuming a side-lying position
Flatulence (excessive gas in the stomach and intestines) is when resting.
caused by decreased gastric motility that results from ele-
vated levels of progesterone during pregnancy. Pressure of VARICOSITIES
the enlarging uterus on the abdominal contents also contrib-
utes to the formation of gas. When excessive or particularly A positive family history, coupled with the normal physio-
disturbing, other causes, such as irritable bowel syndrome logical changes of pregnancy, predisposes the patient to
or lactose intolerance should be ruled out. Patients can be the development of varicose veins. Physiological changes
counseled to avoid gas-forming foods, constipation, gum of pregnancy include vascular relaxation from the effects
chewing, consuming large meals, and swallowing air. of progesterone and impaired venous circulation from
pressure exerted by the enlarged uterus. Constrictive
clothing also increases the risk for varicose veins. Nursing
CONSTIPATION
care for patients with varicosities includes regular assess-
Elevated levels of progesterone relax the smooth muscles, ment of lower extremity peripheral pulses and education.
causing decreased contractility of the lower gastrointesti- Patients should be taught to avoid crossing their legs and
nal tract and slowed movement of the stool. As the uterus the use of constrictive clothing such as knee-high stock-
enlarges, the large intestines become compressed, further ings. They should also be encouraged to elevate their legs
slowing movement of stool through the intestines. Sup- above the level of the heart at least twice a day. For some
plemental iron may also be a contributor to the develop- women, a maternity girdle may provide relief (Varney
ment of constipation. All patients should be taught about et al., 2004; Youngkin & Davis, 2004).
the importance of regular physical exercise and bowel
habits, consuming a high-fiber diet with increased liquids, DYSPAREUNIA
and to avoid straining at defecation and the use of mineral
oil and bulk-forming laxatives. Dyspareunia, or painful intercourse, may result from pel-
vic congestion and impaired circulation caused by the
enlarging uterus. Also, as the pregnancy advances, finding
DENTAL PROBLEMS a position of comfort for intercourse may become increas-
Elevations in pregnancy hormones cause the gums to ingly difficult due to the enlarging abdomen. Concerns
become edematous and friable, which can lead to bleeding that intercourse will harm the fetus may also interfere with
during brushing. Open lesions and other dental problems, sexual enjoyment and increase the likelihood of dyspareu-
such as caries, can open a direct pathway for pathogens to nia. Unless a medical condition contraindicates inter-
enter the bloodstream. Meticulous dental care during course, the patient and her partner should be reassured
pregnancy is important to prevent infections and other that intercourse is safe during pregnancy. Education about
dental complications. The dentist should be informed of sexual intimacy should include suggestions for comfort-
the pregnancy so that an abdominal shield can be used if able positions for intercourse and alternative methods for
x-ray films are needed. If treatment is indicated, most mutual sexual satisfaction (Varney et al., 2004).
local anesthetics can be used safely during pregnancy.
— When asked about sexual
LEG CRAMPS activity during pregnancy
The actual cause of leg cramps is unknown, although
Couples have many questions regarding sexual activity
decreased levels of calcium and phosphorus have been
during pregnancy. These questions relate to the safety of
implicated. As the uterus enlarges, pressure is exerted on
sexual intercourse, potential complications, when to stop
the major blood vessels, causing impaired circulation to
having intercourse, and sexual positions that facilitate
the lower extremities. It is important to rule out throm-
comfort. It is important for the health care provider to
bosed blood vessels, muscular strain, and other injuries to
address sexual activity early in the pregnancy in an
the lower extremities. The patient should be advised to
honest, open manner and to encourage the couple to
engage in regular exercise and maintain good body
communicate with each other. The nurse can address the
mechanics; elevate the legs above the heart several times
couple’s concerns with the following statements:
throughout the day; dorsiflex the foot; and consume a diet
“It is perfectly safe to continue sexual activity
that includes adequate amounts of calcium and phospho-
throughout your pregnancy unless your doctor or nurse
rus (Varney et al., 2004; Youngkin & Davis, 2004).
midwife identifies risk factors that may preclude your
activity (e.g., a risk for preterm labor). With no risk factors,
DEPENDENT EDEMA sexual activity is safe for you and your baby as long as you
Edema in the lower extremities is caused by relaxation of continue to practice safe sex behaviors as you would if you
the blood vessels (an effect of increased progesterone) and were not pregnant. As you gain pregnancy weight, some
the increased pressure placed on the pelvic veins by the sexual positions may be less comfortable; for comfort,
chapter 10 Promoting a Healthy Pregnancy 279
you can try woman on top and side-lying positions. A NUMBNESS AND TINGLING IN THE FINGERS
sexual activity to avoid during pregnancy includes oral
Numbness and tingling in the fingers may be associated
sex during which water or air is placed in the vagina.”
with hyperventilation or from nerve compression in the
median and ulnar nerves in the arm. Maintaining good
posture, elevating the hands on a pillow while sleeping, or
NOCTURIA wearing a wrist brace when sleeping may provide symp-
Nocturia, or excessive nighttime urination, is more com- tomatic relief.
mon during the first and third trimesters. When the
woman assumes a recumbent position, the gravid uterus SUPINE HYPOTENSIVE SYNDROME
no longer compresses the pelvic vessels, and blood flow to Supine hypotension is caused by pressure of the enlarging
the kidneys is enhanced. This factor, combined with an uterus on the inferior vena cava while the woman is in a
increased glomerular filtration rate, increases the need to supine position. Vena caval compression impedes venous
urinate. Although there is no remedy for nocturia, the blood flow, reduces the amount of blood in the heart, and
nurse can teach the patient about the cause of nocturia decreases cardiac output, causing dizziness and syncope.
and advise her that limiting fluids in the few hours before Pathological causes of supine hypotension include cardiac
bedtime may be helpful. or respiratory disorders, anemia, hypoglycemia, dehydra-
tion, anxiety, and stress. Once these conditions have been
INSOMNIA ruled out, the nurse should educate the patient about the
Insomnia may have a variety of causes, including physical causes of supine hypotension and advise the woman to rest
discomfort, nocturia, caffeine, or stress. The nurse can on her side and slowly move from a lying to a sitting to a
suggest strategies to enhance relaxation and comfort standing position to minimize changes in blood pressure.
before bedtime. For example, the woman may incorporate
sleep-inducing night time rituals such as taking a warm Now Can You— Discuss Common Discomforts of Pregnancy?
bath, enjoying a warm drink such as milk, engaging in a 1. Name four strategies to alleviate nausea during early
restful activity like reading, practicing meditation and pregnancy?
other forms of relaxation, and arranging the bed covers 2. Identify four pathological causes of backache during
and pillows in an inviting way that promotes rest. pregnancy?
3. Explain how you would counsel couples regarding sexual
ROUND LIGAMENT PAIN intercourse during pregnancy?
The round ligaments support the uterus as it enlarges dur-
ing pregnancy. These structures attach to the fundus on
each side, pass through the inguinal canal, and insert into Recognizing Signs and Symptoms
the upper portion of the labia majora. As the uterus enlarges,
the round ligaments stretch and produce a painful sensation of Danger
in the lower quadrants. Once pathological conditions such
as preterm labor, rupture of an ovarian cyst, ectopic preg- Complications can occur at any time during the preg-
nancy, appendicitis, gallbladder disease, and peptic ulcer nancy. Nurses need to educate the pregnant woman and
disease have been ruled out, the nurse can educate the her family about danger signs and symptoms, teach them
patient about the cause of the pain and make suggestions for about interventions that can be initiated at home, and
relief measures. Taking a warm bath, applying heat, sup- provide specific instructions about when to notify the
porting the uterus with a pillow when resting, and using health care provider.
a pregnancy girdle may help to diminish the discomfort
(Varney et al., 2004; Youngkin & Davis, 2004). FIRST TRIMESTER
Nausea and Vomiting
HYPERVENTILATION AND SHORTNESS During the first trimester, nausea and vomiting are com-
OF BREATH mon discomforts. However, when vomiting becomes
Increased metabolic activity during pregnancy increases severe, weight loss and dehydration can occur and place
the amount of carbon dioxide in the maternal respiratory both the woman and her fetus at risk. Severe, persistent
system. Hyperventilation decreases the amount of carbon vomiting is indicative of hyperemesis gravidarum. Causes
dioxide and may trigger a feeling of “air hunger.” Patients of hyperemesis gravidarum include multiple gestation;
may also experience shortness of breath related to uterine thyroid disorder; and hydatidiform mole, which is the
enlargement and the upward pressure exerted on the dia- growth of abnormal tissue that results from conception
phragm. Once pathological conditions such as upper but does not give rise to a viable fetus. Nausea and vomit-
respiratory infection, asthma, cardiac problems, and ane- ing are managed with oral fluids, small, frequent meals,
mia have been ruled out, the nurse should explain the and emotional support. Dehydration may require intrave-
cause of hyperventilation to the patient and suggest that nous fluids and hospitalization. (See Chapter 11 for fur-
she consciously attempt to regulate her breathing. Other ther discussion.)
measures that may be helpful include breathing into a
paper bag to decrease the symptoms of hyperventilation, Abdominal Pain and Vaginal Bleeding
maintaining good posture, and stretching the arms above Abdominal cramping and vaginal spotting or bleeding
the head (Varney et al., 2004; Youngkin & Davis, 2004). may indicate spontaneous abortion, or miscarriage.
280 unit three The Prenatal Journey
Spontaneous abortion is the termination of pregnancy labor must be differentiated from Braxton-Hicks contrac-
by natural causes before 20 weeks’ gestation. The major- tions (disorganized tightenings of the uterine muscles as
ity of spontaneous abortions are related to chromosomal they stretch to prepare for labor) so that appropriate inter-
defects. Approximately 10% to 20% of clinically recog- ventions may be initiated. (See Chapters 11 and 12 for
nized pregnancies end in spontaneous abortion (White further discussion.)
& Bouvier, 2005). A woman may assume she is having a
heavy period when she is actually experiencing a miscar- Fetal Complications
riage. (See Chapter 11 for further discussion.) Treatment During the second trimester the fetus is assessed for well-
includes bedrest and emotional support. If bleeding and/ being. The fundal height measurement should correlate to
or pain are excessive, the patient should contact her the weeks of gestation from approximately 22 to 34 weeks
primary health care provider or report to the emergency of gestation. A decreased fundal height may indicate intra-
department. uterine growth restriction, while increased fundal height
is suggestive of multiple gestation, fetal macrosomia, or
Infection hydramnios. The gestational age is also determined from
Generalized symptoms of infection include chills, fever, a variety of sources that include the patient’s menstrual
malaise, and anorexia. Burning on urination may indicate a history, contraceptive history, pregnancy test results, first
urinary tract infection, which is treated with antibiotics. documentation of fetal heart sounds, and ultrasonogra-
Patient education to prevent a urinary tract infection includes phy. (See Chapters 9 and 11 for further discussion.)
advising the woman to use white, unscented toilet paper; to A number of potential fetal problems may occur dur-
avoid bubble baths or the addition of “additives” in the bath; ing the second trimester. These include hypoxia from
to wear underwear with cotton crotches; to drink at least 8 maternal hypertension, irregular or absent heart rate,
to 12 glasses of liquid each day; and to urinate before going preterm birth, infection from premature rupture of mem-
to bed and before and after sexual intercourse. Diarrhea may branes, and absence of fetal movements after quickening.
indicate a gastrointestinal infection, which may be treated If the woman experiences an absence of fetal move-
with antibiotics if bacterial in origin. ments, she is instructed to drink two full glasses of
water, rest on her left side for 2 hours, and assess for
fetal movements once again. If fewer than 10 fetal move-
SECOND TRIMESTER
ments are noted after the liquid intake, the patient must
Maternal Complications be evaluated by her health care provider. (See Chapter
Preeclampsia is one of the most common pregnancy 11 for further discussion.)
complications during the second trimester. It is a preg-
nancy-specific systemic syndrome that is clinically defined THIRD TRIMESTER
as an increase in blood pressure (140/90) after 20 weeks’
gestation accompanied by proteinuria (National High Maternal Complications
Blood Pressure Education Program Working Group, During the third trimester, the patient may develop the
2000; Peters & Flack, 2004). Early signs and symptoms same problems that can occur during the second trimes-
of preeclampsia include headache, vision changes, ele- ter, such as preeclampsia, premature rupture of the mem-
vated blood pressure, and edema. Patients who experi- branes, and preterm labor. Also, gestational diabetes may
ence any of these symptoms should promptly notify their develop during this time. A Glucose Challenge Test (Glu-
health care provider. Bedrest is the first intervention cola screening) is performed between 24 and 28 weeks of
implemented in an effort to reduce blood pressure and gestation and a positive test warrants further screening
alleviate the myriad of other problems that can be associ- with a 3-hour oral glucose tolerance test (OGTT). A posi-
ated with this disorder. (See Chapter 11 for further tive OGTT indicates the presence of gestational diabetes
discussion.) and patient care involves education and a team approach
Premature rupture of the membranes, which is rup- that usually includes the obstetrician, internist, endocri-
ture of the membranes before the onset of labor, can also nologist, diabetes educator, neonatologist, dietitian, and
occur during the second trimester. Patients are taught to nurse. (See Chapter 11 for further discussion.)
promptly seek advice from their health care provider if Hemorrhagic disorders may also develop during the
vaginal discharge is present. Although increased vaginal third trimester. Placenta previa is an implantation of
discharge is normal during pregnancy, the provider will the placenta in the lower uterine segment, near or over the
determine if the vaginal discharge is normal, is associ- internal cervical os. The abnormal location of the placenta
ated with a vaginal infection, or results from the leakage can cause painless, bright red vaginal bleeding as the
of amniotic fluid. Women who have experienced prema- lower uterine segment stretches and thins during the third
ture rupture of membranes must be closely monitored trimester. Depending on the placental location, the patient
for signs of infection. (See Chapter 11 for further may need to adhere to strict bedrest and a cesarean birth
discussion.) may be necessary. Abruptio placentae, or placental
The presence of uterine contractions during the second abruption, is the premature separation of a normally
trimester may indicate preterm labor (PTL). Preterm implanted placenta from the uterine wall. An abruption
labor is defined as regular uterine contractions and cervi- results in hemorrhage between the uterine wall and the
cal dilation before the end of the 36th week of gestation placenta, causing abdominal pain and vaginal bleeding.
(ACOG, 2003b). All pregnant women are taught the signs Interventions may include hospitalization, bed rest, Tren-
and symptoms of preterm labor and instructed to contact delenburg position, intravenous fluids, and delivery. (See
their health care provider if the symptoms appear. True Chapter 11 for further discussion.)
chapter 10 Promoting a Healthy Pregnancy 281
Fetal Complications difficulty often lies in finding the right class to meet the
Leopold maneuvers are used to determine the lie, presen- specific needs of the expectant parents. Traditionally, child-
tation, and position of the fetus. (See Chapter 9 for further birth education focused on managing labor and birth. Con-
discussion.) To monitor fetal growth, the fundal height is temporary classes focus on a wide variety of topics, with the
measured and compared to the estimated date of delivery primary goal centered on facilitating a positive childbearing
at each prenatal visit during the second and third trimes- experience, including pregnancy, childbirth, postpartum,
ters. During the third trimester, non-stress tests may be and newborn care. Topics typically discussed in childbirth
performed to evaluate fetal well-being. (See Chapter 11 classes include anatomy and physiology related to preg-
for further discussion.) Fetal complications during the nancy; comfort measures during each trimester of preg-
third trimester are the same as for the second trimester nancy; the labor and birth process; relaxation and pain
although hypoxia related to poor placental perfusion may management, including pharmacological and nonpharma-
become more of a threat during this time. cological measures; complications related to pregnancy,
labor, and birth; vaginal and cesarean births; postpartum
care; newborn care; and newborn feeding, including bottle
Optimizing Outcomes— Fetal activity and well-being feeding and breastfeeding (Fig. 10-9).
Maternal involvement in activities to monitor fetal well-
being is an important component of prenatal care. Begin- METHODS OF CHILDBIRTH PREPARATION
ning in the second trimester, the patient should consis-
tently assess fetal movements. Reassuring findings include Expectant parents can choose from a variety of available
a count of at least four movements within 1 hour, during childbirth education classes. Ideally, they will select one
rest after meals. that is in harmony with their beliefs and values about the
Best outcome: Fetal well-being is maintained during childbearing experience and be able to engage in the edu-
the third trimester, labor, and birth. The neonate is full cational process without reservation and with complete
term and appropriate for gestational age. Normal physio- commitment. While different, all childbirth preparation
logical transitions in the neonate occur without difficulty. classes incorporate a holistic approach to childbearing,
which encompasses the biological, psychological, and
social factors related to the experience. For many expect-
ant parents, the experience of childbearing is more than
Now Can You— Identify danger signs during pregnancy? just a physical and biological one; the experience can have
1. Discuss the significance of abdominal cramping and vaginal emotional, mental, and spiritual meaning. This holistic
bleeding during the first trimester? approach to having a child allows the parents to assimilate
2. Identify two actions the pregnant woman should take if she all aspects of the experience in order to be prepared physi-
experiences an absence of fetal movements? cally and mentally for becoming a parent.
3. Name two placental problems that can cause hemorrhage, Many childbirth education programs in the community
especially during the third trimester? combine aspects from the traditional stand-alone methods
of childbirth preparation. Combining philosophies and
activities into the classes allows the couple to identify more
strongly with features that fit their individual and collective
needs. The most common childbirth methods include the
Using a Pregnancy Map to Guide Lamaze and the Bradley methods of natural childbirth.
Prenatal Visits
Lamaze Method
A prenatal care map that includes a timetable for prenatal The Lamaze childbirth experience was started in 1960 by
visits helps to ensure consistency of care, especially when the American Society for Psychoprophylaxis in Obstetrics
many health care professionals are involved in the woman’s (ASPO) as a way to bring families together in the labor
care. The care map can be placed in the patient’s chart and delivery process while focusing on the normality of
during the initial visit and an abbreviated version that out- birth. The concepts were founded on principles and tech-
lines the schedule for prenatal care visits may be given to niques used by Dr. Fernand Lamaze, giving rise to the
the patient. Some facilities add a grid that provides addi- familiar labeling of the association as ASPO/Lamaze. It
tional space for entering scheduled appointment dates. An was not until the 1970s that the organization officially
example of a prenatal care map is presented in Table 10-6. changed its name to Lamaze International, becoming
In other institutions, the care map consists of a comprehen- known as such throughout the United States.
sive guide with check boxes and identifies counseling and The heart of the Lamaze method is empowerment, rec-
education needs throughout pregnancy and during the ognizing the woman’s innate ability to give birth, while
postpartum period (Fig. 10-8). finding strength and support from her family and the
members of the health care team during the labor and
birth process. The Lamaze Philosophy of Birth (Box 10-3)
Childbirth Education to Promote identifies the core ideals of the organization and provides
a Positive Childbearing Experience the template for the classes. Historically, Lamaze has
focused on breathing techniques during labor and birth.
Childbirth education provides a wealth of information to As the philosophy indicates, this method incorporates the
parents who are having a baby for the first time as well as ideology of empowerment into the entire experience, pro-
to parents who have already experienced childbirth. The viding more than just instruction on breathing.
282 unit three The Prenatal Journey
First Every 4 weeks • Reason for seeking care • CBC with differential
• Presumptive signs • Blood type and Rh
• Review of systems • Rubella titer
• Medical history • VDRL or RPR
• Family history • HIV
• Gynecologic and obstetric • Hemoglobin
history electrophoresis (sickle
cell, thalassemia)
• Nutritional history • Urinalysis
• Social history • Pap test
• Drug use • Vaginal smear
• Assessment of abuse risk
• Birth plan
Second Every 4 weeks • Summary of relative • Hematocrit
events since last visit
• General emotional state • Urinalysis
• Presence of edema
• Confirmation of
gestational age
As the Lamaze method has evolved over the years, • Lamaze promises painless childbirth: Pain is a natural
many myths have continued to prevail regarding this and normal part of childbirth. Instead of attempting to
method of childbirth preparation. The organization iden- alleviate the pain, women are taught strategies for
tified and addressed these myths (Lamaze International, coping with the pain associated with labor and birth in
2005), and they include: positive ways. The strategies provide the woman with
• Lamaze is all about breathing: In fact, Lamaze classes education to understand and respond to the pain
provide education on movement and position, signals and to facilitate the process of labor and birth.
massage, relaxation, and use of heat and cold in addi- • Lamaze childbirth means you cannot have an epidural:
tion to the traditional focused-breathing techniques. Education on epidural use is provided during Lamaze
chapter 10 Promoting a Healthy Pregnancy 283
continued
Figure 10-8 Prenatal Care Guide.
284
unit three
The Prenatal Journey
they can lead to dizziness and hyperventilation, resulting FINDING INFORMATION ON CHILDBIRTH
in decreased oxygenation of the fetus. EDUCATION
Other Methods There are many ways that expectant mothers and their
While the Lamaze and Bradley methods remain the top partners can locate information on childbirth education.
childbirth education formats, with training to prepare edu- The best strategy is to begin with the health care provider,
cators to teach parents the strategies, other methods for who can provide information about potential birth loca-
childbirth exist. Prepared childbirth classes incorporate tions and childbirth education provided by the individual
approaches from diverse methods to assist expectant cou- facilities. Internet sources can also assist couples in find-
ples in developing coping skills that will work best for them. ing classes that are available to them locally. Expectant
Additional methods and techniques include the following: couples can engage in online childbirth education classes
as well as home education through the purchase of com-
• Dick-Read: The underlying philosophy in Dick-Read’s prehensive childbirth programs.
approach to childbirth still focuses on the natural In determining the childbirth preparation class that
aspect of giving birth. After witnessing a birth in the will meet the individual needs of the parents, the follow-
1920s, without the use of the traditional chloroform to ing questions should be considered:
render the laboring woman unconscious, he discovered • Who sponsors the class?
that it was possible for women to experience pain-free • How many classes will we be expected to attend?
birth. Through his study of physiology, he hypothe- • How many couples are in the class?
sized that the pain associated with childbirth was • Can I bring more than one support person to the class?
caused by fear and tension, stimulating the sympathetic • What types of teaching and learning strategies are used?
nervous system. This physiological event decreased • What topics are covered in the course?
blood flow to the uterus and created uterine muscle • Where will the classes be held?
cell hypoxia. Through various relaxation techniques • Is there a cost involved?
that consist of conscious and progressive relaxation of • Is the instructor certified? If so, with what organiza-
different muscle groups, the tension is reduced and tion is the instructor affiliated?
blood flow to the uterus is restored. Although Dick-
Read did not advocate the use of pharmacologic pain With the abundance of childbirth methods available and
management during labor and delivery, he approved of the different certifications that exist for childbirth educators,
its use when the woman was unable to relax or was it is important for expectant parents to identify the approaches
experiencing complications (Dick-Read, 1987). and methods that best meet their needs in order to make the
• HypnoBirthing: Classes using this method are based on childbirth experience as meaningful as possible to them. It
Dick-Read’s fear-tension-pain philosophy. Couples are is helpful not only to examine the questions listed above,
taught, in four sessions, relaxation techniques to elimi- but also to consider what the most important factors are
nate the pain associated with the fear and tension. with regard to personal values and beliefs. Using the list
• LeBoyer method: Using this method, the baby is born below, nurses can direct parents to the appropriate educa-
in a dimly lit room that is conducive to relaxation and tion program to meet their needs. The woman should iden-
facilitates a tranquil entrance into the world. Immedi- tify which four of the following factors are most important
ately after birth, the newborn is placed in a warm in selecting a childbirth education class:
water bath to enhance the transition from the intra- • Familiarize me with hospital routines
uterine to the extrauterine environment. The infant is • Prepare me for a natural, nonmedicated birth
then moved to the mother’s abdomen to initiate • Teach me breathing patterns and distraction techniques
bonding. Through the gentle handling and the quiet, • Give my partner the skills necessary to be an active
smooth transition, the newborn is able to open her and informed labor coach
eyes and breathe with minimal external stimulation. • Teach us as parents to be childbirth consumers and to
• Odent method: This method arose from the LeBoyer take responsibility for our child’s birth
method and includes moving the woman into a warm • Follow current medical policies
water bath for the birth. In addition to reducing labor • Represent the most common type of childbirth educa-
pain, the warm water provides a comforting atmo- tion class in our area
sphere to transition the newborn to extrauterine life. • Teach relaxation and natural breathing
The underlying concept is that the infant can safely be • Stress good nutrition and exercise
born while submersed in water, without fear of • Discuss medication options without making value
drowning, since the fetus has lived in fluid for the judgments
duration of the pregnancy. Not all women are candi-
dates for hydrotherapy. It is not an option for women
who have rupture of the membranes or other compli- CREATING A BIRTH PLAN
cations that require continuous fetal monitoring. From the moment a woman discovers that she is pregnant,
• Birthing From Within: This method views childbirth she begins to consider ideas for her birth experience.
as a rite of passage for parents and their infant. The Although the birth is usually not imminent, previous
underpinnings of this method focus on the psycholog- knowledge and experience, along with information shared
ical and spiritual aspects of birth, using art, writing, by friends and family, prompt her to seek out information
painting, and sculpting to encourage self-discovery. on options that are available and choices that she can make
The focus is not on the birth process, but on the to prepare for the birth. While the birth plan is not a
experience of birth. concrete document from which to outline every step of the
chapter 10 Promoting a Healthy Pregnancy 287
labor and birth, it provides written information that identi- Choosing a Birth Location
fies preferences for labor and birth, empowering the A hospital is the most common birth location. In this set-
expectant couple with the control that is needed to reduce ting, health care providers and patients have access to
the anxiety associated with labor. Birth plans can be tai- technology and individuals trained to manage any compli-
lored to meet the needs of expectant couples that antici- cations that may arise. Obstetricians and certified nurse
pate a hospital delivery, a birthing center delivery, a home midwives attend and facilitate childbirth in the hospital
delivery, a cesarean delivery, or a multiple delivery. Devel- setting. When choosing the facility that best meets their
oping a birth plan in conjunction with the health care pro- needs, the expectant couple should identify the type of
vider assures that the woman’s individual situation is con- setting provided by the hospital. For example, some insti-
sidered, especially important for high-risk pregnancies. tutions have separate labor, delivery, recovery, and post-
partum rooms. This arrangement requires the family to be
Birth Plan Choices moved from one location to another during their hospital
There are many issues to consider when developing a per- stay. The newest facility models place emphasis on family-
sonal birth plan. One concerns the presence of additional centered care and offer large, comfortable rooms where
people in the birthing room. The woman may wish to the woman remains for the duration of the childbirth
include her partner, friends, relatives, a doula (a woman experience.
who is experienced in childbirth and provides physical and Free-standing birthing centers were first opened in
emotional support to the mother during the prenatal period, 1974 to provide women with a more homelike atmo-
during labor, during birth, and during the postpartum sphere in which to give birth. Although these facilities are
period) or birthing coach, and children. She may desire to located near the hospital in the event of an emergency,
personalize the experience by wearing her own clothes, lis- they are recommended for women with low-risk pregnan-
tening to music, and taking pictures or videotaping the birth. cies. A major benefit of the birthing centers is that they
Fluids and food preferences can be noted, along with the have fewer restrictions and generally allow the parents
woman’s desire for a saline or heparin lock or an intravenous more freedom to make personal decisions regarding labor
line. While most hospitals utilize continuous fetal monitor- and birth.
ing, the woman can identify her wish for intermittent moni- Home births are returning as an option for women with
toring or no monitoring at all, unless an emergency develops. low-risk pregnancies and no known labor complications.
Preferences for laboring and birthing positions can also be Although obstetricians will not deliver babies at home,
noted. Choices regarding strategies for pharmacological and many CNMs are willing to do so. Many expectant couples
nonpharmacological pain management are identified, with believe that giving birth at home enriches the childbirth
the understanding that the woman has the right to change experience and allows them to better integrate the birth as
her mind and alter her plan at any time. a normal and natural event in their lives. However, the
The woman who anticipates a vaginal birth should parents must be open to transfer to a hospital if complica-
identify her preference regarding an episiotomy and the tions arise.
use of medication to augment labor contractions. The
partner’s desired level of involvement in the birth should Now Can You— Discuss childbirth preparation, birth plans,
also be identified. The woman can decide if she would like and doulas?
to hold her baby immediately after birth and, if she plans
1. Compare and contrast the Lamaze, Bradley and LeBoyer
to breastfeed, whether she wishes to do so at that time.
methods of childbirth preparation?
Women who anticipate a cesarean birth or who dis-
2. Discuss the purpose of a birth plan?
cover that they need a cesarean birth can usually maintain
3. Describe the role of a doula?
some degree of control over this procedure as well. They
may be allowed to have their partner present during the
surgery. The partner may be permitted to hold the new-
born during the first moments of life if there are no imme- summar y poi nt s
diate health concerns. The mother may also choose to ini-
◆ Preconception counseling empowers families to plan
tiate breastfeeding in the recovery room. Other preferences
for pregnancy and develop healthy bodies and minds to
regarding infant feeding, rooming-in and circumcision
optimize birth outcomes.
should be noted in the birth plan.
◆ Nurses and other health care providers must collabora-
Choosing a Health Care Provider tively provide families with prenatal education and
Selecting a health care provider for the preconception, incorporate interventions for a holistic approach to
pregnancy, and birth experience is an essential first step pregnancy.
that empowers the woman and her partner to become ◆ A balance of diet and nutrition, exercise, work, and rest
actively involved in care during the childbearing year. enhances the development of a healthy pregnancy.
Approximately 90% of pregnant women choose an obste-
◆ To determine safety of use during pregnancy, all medi-
trician as the primary care provider. Others use a certified
nurse-midwife (CNM), who is trained in both nursing and cations, including prescription, over-the-counter, and
midwifery and can provide a more personalized, less rou- herbal preparations, must be carefully evaluated. It is
tine approach to a normal, uncomplicated pregnancy and essential that the nurse obtain a comprehensive medi-
birth. It is especially important that the patient choose a cation history during each prenatal visit.
care provider with whom she can openly relate and who ◆ Ongoing prenatal education regarding pregnancy dan-
shares the same philosophical views on the management ger signs and symptoms, and appropriate home inter-
of pregnancy. (See Chapter 9 for further discussion.) ventions is key in reducing complications.
288 unit three The Prenatal Journey
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses Peters, R.M., & Flack, J.M. (2004). Hypertensive disorders of pregnancy.
(11th ed.). Philadelphia. F.A. Davis. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing,
Dick-Read, G. (1987). Childbirth without fear (5th ed.). New York: 33(2), 209–220.
Harper & Collins. Phillips, O.P. (2007). Preconceptional care: Risk reduction starts before
Encyclopedia of genetic disorders. (2008). http://health.enotes.com/ pregnancy. The Forum, 5(1), 12–18.
genetic-disorders-encyclopedia/accutane-embryopathy) (Accessed Riley, L.E. (2006). Recommended practices and policies for clinicians.
April 22, 2008). Workshop on the Impact of Pregnancy Weight on Maternal & Child
Goodheart, H.P. (2006). Accutane for severe acne. Women’s Heath Health, May 30–31, 2006. The National Academies. Retrieved from
Ob-GYN Edition, 11(12), 9–15. www.bocyf.org/053006.html (Accessed June 12, 2006).
Haram, K., Nilsen, S., & Schall, J. (2001). Iron supplementation in preg- Scanlon, K. (Ed.) (2001). Final report of the vitamin D expert panel.
nancy: Evidence and controversies. Acta Obstetrica et Gynecologica Atlanta: Centers for Disease Control and Prevention.
Scandinavica, 89, 683–688. Scholl, T. (2005). Iron status during pregnancy: Setting the stage for
Institute for Clinical Systems Improvement (ICSI). (2005). Routine pre- mother and infant. American Journal of Clinical Nutrition, 81(5),
natal care. Bloomington, MN: Author. 1218S–1222S.
Institute of Medicine. (1992). Nutrition during pregnancy and lactation: Scholl, T., & Reilly, T. (2000). Anemia, iron and pregnancy outcome.
An implementation guide. Washington, DC: National Academies Journal of Nutrition, 130(25 Supplement), 443S–447S.
Press. Siega-Riz, A., & Savitz, D. (2001). What are pregnant women eating?
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Nutrient and food group differences by race. American Journal of
Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and Obstetrics and Gynecology, 186(3), 480–486.
NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). Stotland, N.E. (2006). Gestational weight gain: Social predictors or rela-
St. Louis, MO: Mosby Elsevier. tionships. Workshop on the Impact of Pregnancy Weight on Maternal &
Kilpatrick, S., & Laros, R. (2004). Maternal hematologic disorders. In Child Health, May 30–31, 2006. The National Academies. Retrieved
R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Prin- from www.bocyf.org/053006.html (Accessed June 12, 2006).
ciples and practice (5th ed.). Philadelphia: W.B. Saunders. Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric
King, J.C. (2006). Biological determinants of gestational weight gain. nursing (8th ed.). St. Louis: C.V. Mosby.
Workshop on the Impact of Pregnancy Weight on Maternal & Child Swensen, A.R., Harnack, L.J., & Ross, J.A. (2001). Nutritional assess-
Health, May 30–31, 2006. The National Academies. Retrieved from ment of pregnant women enrolled in the special supplemental pro-
www.bocyf.org/053006.html (Accessed June 12, 2006). gram for Women, Infants, and Children (WIC). Journal of the Ameri-
Krishnaswamy, K., & Madhavan Nair, K. (2001). Importance of folate in can Dietetic Association, 101(8), 903-908.
human nutrition. British Journal of Nutrition, 85(Supplement 2), Thompson, J.R., Gerald, P.F., Willoughby, M.L., & Armstrong, B.K.
S115–S124. (2001). Maternal folate supplementation in pregnancy and protec-
Lamaze International. (2005). About Lamaze International, Inc. Retrieved tion against acute lymphoblastic leukemia in childhood: A case-
from www.lamazechildbirth.com/fact_sheet.html (Accessed April 22, controlled study. Lancet, 358, 1935–1940.
2008). U.S. Department of Health & Human Services (USDHHS). (2000).
Lashley, F. (2005). Clinical genetics in nursing practice (3rd ed.). New York: Healthy People 2010: Understanding and improving health (2nd ed.).
Springer. Washington, DC: U.S. Government Printing Office.
Lederman, R. (1996). Psychosocial adaptation in pregnancy (2nd ed.). U.S. Department of Health & Human Services (USDHHS). (2004). The
Englewood Cliffs, NJ: Prentice-Hall. health consequences of smoking: A report of the Surgeon General—2004.
Lewis, D.P., Van Dyke, D.C., Stumbo, P.J., & Berg, M.J. (1998). Drug Atlanta, GA: CDC Office on Smoking and Health.
and environmental factors associated with adverse pregnancy out- U.S. Department of Health & Human Services (USDHHS). (2005). U.S.
comes. Part II: Improvement with folic acid. Annals of Pharmacother- Department of Agriculture Dietary Guidelines for Americans, 2005.
apeutics (32), 947–961. Washington, DC: U.S. Government Printing Office.
Mahomed, K. (2002). Iron supplementation in pregnancy (Cochrane U.S. Department of Health & Human Services (USDHHS). (2006). Your
Review). The Cochrane Library, Issue 4. Oxford: Update Software. guide to lowering your blood pressure with DASH (NIH Publication No.
March of Dimes Birth Defects Foundation (2006). Smoking during 06-4082). Washington, DC: U.S. Government Printing Office.
pregnancy. Retrieved from www.marchofdimes.com/printableArti- United States Department of Health and Human Services (USDHHS), &
cles/14332_1171.asp (Accessed June 11, 2006). United States Department of Agriculture (USDA). (2005). Dietary
Mayo Foundation for Medical Education & Research. (June 1, 2005). Guidelines for Americans. Retrieved from http://www.nal.usda.gov/
Weight gain during pregnancy: What’s healthy? Retrieved from www. fnic/.Hyattsville, MD: US Department of Agriculture.
mayoclinic.com/print/pregnancy-weight-gain/PR00111/METHOD- United States Department of Labor. (1995). Fact sheet #28: The Family
⫽print (Accessed June 11, 2006). and Medical Leave Act of 1993. Retrieved from www.dol.gov/esa/regs/
Mills, M.E. (2007). More than food: The implications of Pica in preg- compliance/whd/printpage.asp?REF⫽whdfs28.htm (Accessed July
nancy. Nursing for Women’s Health, 11(3), 266–273. 16, 2006).
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing Varney, H., Kriebs, J.M., & Gegor, C.L. (2004). Varney’s midwifery (4th
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. ed.). Boston: Jones and Bartlett.
Moos, M.K. (2006). Preconception Care: Every Woman, Every Time. Venes, D. (Ed.). (2009). Tabers cyclopedic medical dictionary (21st ed.).
AWHONN Lifelines, 10(4), 332–334. Philadelphia: F.A. Davis.
NANDA International. (2007). NANDA-I Nursing Diagnoses: Definitions Veterans Health Administration. (2002). Department of Defense/Veterans
and Classifications 2007-2008. Philadelphia: NANDA-I. Administration clinical practice guideline for the management of uncompli-
National High Blood Pressure Education Program Working Group. cated pregnancy. Washington, DC: U.S. Government Printing Office.
(2000). Working group report on high blood pressure in pregnancy. White, H., & Bouvier, D. (2005). Caring for a patient having a miscar-
NHBPEP Publication No. 00-3029. Washington, DC: National Heart riage. Nursing 2005, 35(7), 18–19.
Lung and Blood Institute. Youngkin, E.Q., & Davis, M.S. (2004). Women’s health: A primary care
National Toxicology Program Center for the Evaluation of Risks to clinical guide (3rd ed.). Upper Saddle River, NJ: Pearson-Prentice
Human Reproduction (2005). Caffeine. Retrieved from http://cerhr. Hall.
niehs.nih.gov/common/caffeine.html (Accessed July 16, 2007).
CONCEPT MAP
Promoting a
Healthy Pregnancy
Healthy Body: assess Factors Affecting: • Encourage consultation Work: assess impact
• Medical/menstrual • Eating disorders: pica, with PCP to determine • What is the nature of the
history anorexia/bulimia drug safety work?
• Findings from • Cultural influences • Know teratogens • Is there exposure to toxins?
physical/lab exams • Being vegan • Assess for use of • What is the number of
• Exposure to STIs herbal/homeopathic hours?
Nursing:
• Lifestyle choices preparations and OTCs • Are there complications
• Obtain nutritional hx.
with pregnancy?
• Assess for nutritional
elements: calories, • Plan for maternity leave
Healthy Mind: assess proteins, water, minerals,
• Readiness for vitamins, calcium, iron,
motherhood/fatherhood vitamin C Exercise:
• Healthy relationship • Focus on muscle
• Social support strengthening
• Educational level • Maintain adequate
• Mental illness breathing rate; fluid intake
during
• Limit strenuous aerobics
and increased body
temperature
Common Discomforts Weight Gain Childbirth Education • Avoid exhaustion
Anticipatory guidance/care Factors Affecting: • Class harmonious Rest: tending to fatigue caused by:
strategies for: Genetic/social hx. with beliefs/values • Increased progesterone
GI: nausea, vomiting, Enlarging placenta • Goal facilitate positive production
constipation, flatulence, • Increased bladder volume birth experience • Physiological anemia
dyspepsia, ptyalism • Increased blood volume • Topics: A&P, comfort • Increased fetal oxygen needs
CV: dependent edema, • Fetal growth measures, labor and birth • Emotional stress
varicosities, supine process, childbirth
Nursing: • Decreased maternal lung
hypotensive syndrome methods, relaxation/pain
• BMI screening expansion
GU: frequency, nocturia management, types of
• Conscious planning of food births, postpartum care, • Nocturia
Pain: round ligament,
paresthesias, backache, intake: USDA food pyramid newborn care/feeding
leg cramps & DASH plan • Create a birth plan
Other: leukorrhea, • Patient education/
Complementary Care:
fatigue, shortness of counseling
• Ayurveda during
breath, dyspareunia, pre-conception period
dental issues, insomnia • Manage stress with:
massage, light and
aromatherapy,
Recognize signs of complications: Nursing Insight: reflexology, relaxation
Differentiate from discomforts • Food/drug interactions with iron
supplements
• Vegetarians at risk for B12 deficiency Optimizing Outcomes:
• Hyperemesis gravidarum • Significant teratogenic effects • Prenatal interventions to
with Accutane prevent birth defects
• Spontaneous abortion
• Food choice and positioning can • Educate re: strategies to
• Infection
decrease dyspepsia relieve back pain
• Preeclampsia
• Patient should participate in
• PROM fetal movement assessment
• Absence of fetal
movement Ethnocultural Considerations:
• Placenta previa/abruptio • Higher maternal anemia in
placentae adolescents, African American Now Can You:
women/low socioeconomic • Discuss preconception care
status • Identify substances to be avoided
• African Americans: higher • Discuss aspects of good nutrition
vitamin D deficiency rate • Discuss work, fatigue and medication use
• Pica associated with some • Identify common discomforts of pregnancy
cultural, religious beliefs • Identify danger signs in pregnancy
chapter
Caring for the Woman
Experiencing Complications 11
During Pregnancy
Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm
than exertion.
—Florence Nightengale, 1860
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Discuss the importance of ongoing assessment of the pregnant patient for potential complications
throughout her pregnancy.
◆ Describe the roles of the perinatologist, neonatologist, obstetric nurse, visiting nurse, chaplain,
nutritionist, and social worker in caring for the family experiencing complications during a pregnancy.
◆ Discuss the importance of understanding and respecting the cultural differences the nurse may
encounter when caring for a diverse population experiencing a high-risk pregnancy.
◆ Plan nursing assessments and interventions for the woman experiencing complications of pregnancy.
◆ Discuss the importance of complete and accurate documentation in caring for the patient
experiencing an obstetric emergency.
◆ Identify complications of pregnancy that require fetal surveillance.
◆ Describe fetal surveillance tests that may be warranted to evaluate fetal well-being.
◆ Relate the effects of antenatal bedrest to the physical, psychological, and social adjustment of a
high-risk pregnancy.
moving toward evidence-based practice Risk of Adverse Pregnancy Outcomes Related to Weight Changes
Villamor, E., & Cnattingius, S. (2006). Interpregnancy weight change and risk of adverse pregnancy outcomes: A population-based
study. The Lancet, 368, 1164–1170.
The purpose of this study was to explore the relationship • 1 to less than 2
between overweight or obesity and adverse pregnancy out- • 2 to less than 3
comes. The association between the pre-pregnancy body-mass • 3 or more units
index (BMI) from the first to the second pregnancy and the risk The interpregnancy interval (months between birth of the
of adverse outcomes during the second pregnancy were exam- first child and the estimated date of conception of the second
ined. The study sample consisted of data from 151,025 women child) included the following groups:
who experienced first and second consecutive singleton births
• 12–23 months
during the time interval from 1992 to 2001.
• 24–35 months
The participants’ BMI was calculated during the first antena-
• 36 or more months
tal visit of each pregnancy. Interpregnancy changes in the BMI
from the beginning of the first and second pregnancies were Based on the BMI at the beginning of the first pregnancy,
also calculated and the participants were placed in the following participants were grouped using the following categories:
categories based on changes in BMI units: • Underweight (BMI 18.4)
• less than –1 • Healthy (BMI 18.5–24.9)
• –1 to less than 1 (continued)
291
292 unit three The Prenatal Journey
fetal, and neonatal life span. Because there is a greater always be evaluated for an ectopic pregnancy. Pain increases
danger to life during this period than at any other time after rupture of the ectopic pregnancy and the woman may
during the life cycle, adverse outcomes can be expected. experience referred shoulder pain from diaphragmatic irri-
Loss of a child, whether it is an embryo, fetus, or neonate, tation caused by blood in the peritoneal cavity.
can be totally devastating not only to the woman but to the A number of factors place a woman at risk for experi-
entire family as well. Supporting the family through a peri- encing an ectopic pregnancy. These include past and cur-
natal loss can be very challenging to the obstetric nurse rent medical and gynecological problems such as:
who must be in touch with personal feelings in order to
• History of sexually transmitted infections or pelvic
help understand the family’s response to their loss. (See
inflammatory disease
Chapter 14 for further discussion.)
• Prior ectopic pregnancy
• Previous tubal, pelvic, or abdominal surgery
— Communicating with the family • Endometriosis
who has experienced a perinatal loss • Current use of exogenous hormones (i.e., estrogen,
progesterone)
The nurse approaches the family with compassion and • In vitro fertilization or other method of assisted
sincerity. Expressions of caring are conveyed in the reproduction
following statements: • In utero diethylstilbestrol (DES) exposure with
“I understand this is a very difficult time for you and abnormalities of the reproductive organs
your family, but I want you to know that I am here • Use of an intrauterine device
and willing to listen if you want to talk. You let me
know if and when you are ready.” Diagnosis
“It is normal for you to be sad and you will probably feel To prevent major morbidity or death, an ectopic preg-
like this for some time. Losing a baby, no matter how nancy should be diagnosed before the onset of hypo-
far along in your pregnancy, is very difficult. I can tension, bleeding, pain, and overt rupture. The patient’s
recommend some support groups if you think you history (e.g., unilateral, bilateral or diffuse abdominal
might be interested.” If the patient says she does not pain, missed period) and physical exam (a palpable mass
want the information at this time, continue with is present on bimanual examination in approximately
“Please do not hesitate to call us if you change your 50% of women) should alert the health care professional
mind. We can always give you the information.” to the possible presence of an ectopic pregnancy. Active
“Does your baby have a name?” The nurse would bleeding is associated with rupture; other symptoms of
then refer to the fetus by name. Do not use the term this complication may include hypotension, tachycardia,
“fetus” with the patient. To her the deceased fetus vertigo and shoulder pain. Diagnostic laboratory tests
was her baby. include a beta-human chorionic gonadotropin (-hCG)
that is low for gestational age (because an ectopic preg-
nancy has a poorly implanted placenta, the level of a
-hCG does not double every 48 hours as in normal
ECTOPIC PREGNANCY implantation) and a white blood count (WBC) that can
An ectopic pregnancy is one that implants outside of the range from normal to 15,000/mm3. Transvaginal ultraso-
uterine cavity. Implantation may occur in the fallopian nography should be performed to confirm intrauterine or
tube (99%), on the ovary, the cervix, on the outside of tubal pregnancy (Farquhar, 2005). Ultrasonographic iden-
the fallopian tube, the abdominal wall, or on the bowel tification of an intrauterine pregnancy rules out the pres-
(Fig. 11-1). Patients who present with vaginal bleeding, a ence of an ectopic pregnancy in most women (Murray,
missed period, and abdominal tenderness or pain should Baakdah, Bardell, & Tulandi, 2005).
HEMORRHAGE
IN TUBAL WALL
UTERUS
ISTHMIC
AMPULLAR
INTRALIGAMENTOUS
LUMEN OF
FALLOPIAN
UTERUS
TUBE
CHORION
AMNION
INFUNDIBULAR
OVARIAN
FETUS
FIMBRIAL
INTRAMURAL
CERVICAL
ABDOMINAL
Diagnosis
The diagnosis of a molar pregnancy is made by an ultra-
sound examination. The placental tissue appears in a
Figure 11-2 A hydatidiform mole pregnancy is one in “snowstorm” pattern due to the profuse swelling of the
which the chorionic villi degenerate into a mass of chorionic villi. When a complete mole is present no fetus
fluid-filled grapelike clusters. is identified in the uterus.
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 295
Diagnosis
PLACENTAL ABRUPTION
Vaginal bleeding in the third trimester of pregnancy is the
Placenta abruption (abruptio placentae) is the premature hallmark of placental abruption or placenta previa and
separation of a normally implanted placenta from the uter- should always prompt an investigation to determine its
ine wall. An abruption results in hemorrhage between the etiology. Diagnosis is made by clinical findings and, when
uterine wall and the placenta. Fifty percent of abruptions available, ultrasound examination. Recent advances in
occur before labor and after the 30th week, 15% occur dur- ultrasound imaging and interpretation have greatly
ing labor, and 30% are identified only on inspection of the
placenta after delivery (Cunningham et al., 2005).
Box 11-2 Classifications of Abruptio Placentae
Etiology and Classifications
At the initial point of placental separation, nonclotted Grade 1: Slight vaginal bleeding and some uterine irritability are usually
blood courses from the site of injury. The enlarging col- present. Maternal blood pressure is unaffected and the maternal fibrino-
lection of blood may cause further separation of the pla- gen level is normal. The fetal heart rate pattern is normal.
centa. Bleeding can be either concealed or revealed Grade 2: External uterine bleeding is absent to moderate. The uterus is
(apparent). A concealed hemorrhage occurs in 20% of irritable and tetanic or very frequent contractions may be present. Maternal
blood pressure is maintained, but the pulse rate may be elevated and pos-
cases and describes an abruption in which the bleeding is tural blood volume deficits may be present. The fibrinogen level may be
confined within the uterine cavity. The most common decreased. The fetal heart rate pattern often shows signs of fetal
abruption is associated with a revealed or external hem- compromise.
orrhage, where the blood dissects downward toward the Grade 3: Bleeding is moderate to severe but may be concealed. The
cervix (Fig. 11-5). Placental abruption may be broadly uterus is tetanic and painful. Maternal hypotension is frequently present
classified into three grades that correlate with clinical and and fetal death has occurred. Fibrinogen levels are often reduced or are
laboratory findings (Box 11-2). less than 150 mg/dL; other coagulation abnormalities (thrombocytopenia,
factor depletion) are present.
Perinatal and Maternal Morbidity and Mortality
Source: Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & Wenstrom,
Maternal mortality from abruptio placentae varies from K. (2005). Williams obstetrics (22nd ed.). New York: McGraw-Hill
0.5% to 5%. The degree of hemorrhage that results from
300 unit three The Prenatal Journey
improved the diagnosis rate. On ultrasound examination, Now Can You— Discuss the management of bleeding
more than 50% of patients with a confirmed placental during pregnancy?
abruption will demonstrate evidence of hemorrhage.
However, during the acute phase of placental abruption 1. Describe the difference between placenta previa and
ultrasound findings may not be reliable, so a thorough abruptio placentae?
clinical evaluation of any pregnant woman who presents 2. Name three initial steps in the management of the bleeding
with bleeding or acute abdominal pain is always indicated pregnant patient?
(Cunningham et al., 2005). 3. Explain why it may be difficult to identify an early maternal
hemorrhage?
Management
The potential for rapid deterioration (hemorrhage, dis-
seminated intravascular coagulation [DIC], fetal hypoxia)
necessitates delivery in some cases of placental abruption.
Preterm Labor
However, most abruptions are small and noncatastrophic, Preterm labor (PTL) is defined as cervical changes and regu-
and therefore do not necessitate immediate delivery. Cer- lar uterine contractions occurring between 20 and 37 weeks
tain actions, including hospitalization, laboratory studies, of pregnancy. Many patients present with preterm contrac-
continuous monitoring, and ongoing patient support tions, but only those who demonstrate changes in the cervix
should be initiated when placental abruption is suspected are diagnosed with preterm labor (ACOG, 2001).
(Box 11-3).
INCIDENCE
Optimizing Outcomes— Religious beliefs and blood
transfusions Preterm birth, which is a birth that occurs before the com-
pletion of 37 weeks of pregnancy, is considered the most
Members of Jehovah’s Witness do not receive blood prod- acute problem in maternal–child health (American College
ucts or their derivatives. When bleeding occurs during of Obstetricians and Gynecologists [ACOG]/American
pregnancy and blood is deemed necessary to save the Academy of Pediatrics [AAP], 2002). The sequelae of pre-
woman’s and/or fetus’ life, a very challenging situation term birth has a profound effect on the survival and health
exists. Non-blood products may be given but are not of about one in every eight infants born in the United States
always successful. Sometimes a court order is obtained so each year (Freda & Patterson, 2004). From 1981 to 2001,
that blood can be administered to save the life of the the rate of preterm births in the United States increased by
woman and/or fetus. The perinatal nurse must be able to 27%. In 2001, more than 476,000 infants were born at least
respect the family’s beliefs and support them during this 3 weeks before their due date (National Center for Health
very difficult time when the health of both the woman and Statistics [NCHS], 2002). In spite of advances in obstetric
her fetus as well as their religious beliefs are being care, the rate of prematurity has not decreased over the past
challenged. 40 years and in most industrialized countries, it has slightly
increased. The preterm delivery rate in the United States
is approximately 11%; in Europe the rate varies between
5% and 7%. A very preterm birth is a birth that occurs
Box 11-3 Care for the Patient Experiencing an Abruptio before the completion of 32 weeks of pregnancy. In 2003,
Placentae the very preterm birth rate in the United States was 1.97%
(Martin et al., 2005).
• Hospitalization
• Intravenous placement with a large-bore catheter (16-gauge) ETIOLOGY AND RISK FACTORS
• Labwork: Includes CBC, coagulation studies (fibrinogen, PT, PTT,
platelet count, fibrin degradation products), type and screen for 4 units The defining physiological mechanism that triggers the onset
of blood, Kleihauer–Betke for Rh-negative patients. A “clot test” may of preterm labor is largely unknown but may include decid-
be performed: a red top tube of blood is drawn, set aside, and checked ual hemorrhage (abruption), mechanical factors (uterine
for clotting. If a clot does not form within 6 minutes or if it forms and overdistention or cervical incompetence), hormonal changes
lyses within 30 minutes, a coagulation defect is probably present and (perhaps mediated by fetal or maternal stress) and bacterial
the fibrinogen level is less than 150 mg/dL. infections (ACOG, 2001). However, a number of risk factors
• Betamethasone may be given to the woman to promote fetal lung have been associated with preterm labor (Box 11-4).
maturity when delivery is not imminent.
• Rh(D)-negative patients should receive RhoGAM to prevent
isoimmunization. Collaboration in Caring— Increasing public
• Continuous evaluation of intake and output awareness of the problems of prematurity
• Continuous electronic fetal monitoring
The Association of Women’s Health, Obstetric and Neonatal
• Delivery (cesarean or vaginal birth) may be initiated depending on the Nurses (AWHONN), the American College of Obstetricians
status of the mother and the fetus.
and Gynecologists (ACOG), and the American Academy of
• Nursing care is centered on continuous maternal–fetal assessment, Pediatrics (AAP) have partnered with the March of Dimes in
with on-going information and emotional support for the patient and
a multi-million-dollar research, education and awareness
her family.
campaign to address the problem of prematurity. Educating
Source: Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & Wenstrom, all women of childbearing age about preterm labor is a crucial
K. (2005). Williams obstetrics (22nd ed.). New York: McGraw-Hill component of prevention (March of Dimes, 2005).
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 301
MORBIDITY AND MORTALITY A diagnosis of preterm labor is made when the follow-
As a result of high-tech neonatal intensive care, advanced ing criteria are met (ACOG/AAP, 2007):
technology, and improved medications, the morbidity of • A gestation of 20 to 37 weeks
babies born after 34 to 35 weeks has decreased and the defi- • Documented persistent uterine contractions (4 every
nition of viability has changed dramatically throughout the 20 minutes or 8 in 1 hour)
past several decades (ACOG, 2002b). The limits of viability • Documented cervical effacement of 80% or greater
keep moving downward in gestation time, and this factor • Cervical dilation of more than 0.4 inch (1 cm) or a
contributes to the increasing numbers of preterm births. documented change in dilation
With appropriate medical care, neonatal survival dra-
matically improves as gestational age increases, with more Infection has been implicated as a contributing factor in
than 50% of neonates surviving at 25 weeks’ gestation, and preterm labor. Prostaglandin production by the amnion,
more than 90% at 28 to 29 weeks’ gestation. Short-term chorion, and decidua is stimulated by cytokines (extracel-
neonatal morbidities associated with preterm birth are lular factors) that are released by activated macrophages.
numerous and include respiratory distress syndrome, intra- Group B streptococci, chlamydia, and gonorrhea have
ventricular hemorrhage, periventricular leukomalacia, nec- been associated with preterm labor and preterm premature
rotizing enterocolitis, bronchopulmonary dysplasia, sepsis, rupture of the membranes (Cunningham et al., 2005). It is
and patent ductus arteriosus. Long-term morbidities include always prudent for the nurse to obtain a clean-catch, mid-
cerebral palsy, mental retardation, and retinopathy of pre- stream, or catheterized urine specimen to identify and treat
maturity. The risk of these morbidities is directly related to infection if the patient presents with signs of preterm labor
the infant’s gestational age and birth weight. or preterm premature rupture of the membranes.
2003c; Cunningham et al., 2005). Tocolysis is the use of Now Can You— Care for the patient experiencing
medications to inhibit uterine contractions. Drugs used for preterm labor?
this purpose (“tocolytics”) include the beta-adrenergic
agonists (also called beta-mimetics), magnesium sulfate 1. Identify five symptoms of preterm labor?
(MGSO4), prostaglandin synthetase inhibitors (indometh- 2. Discuss the use of tocolytics in preterm labor?
acin [Indocin]) and calcium channel blockers (nifedipine 3. Develop a teaching plan about preterm labor for pregnant
[Procardia]). The most commonly used tocolytics are the women?
beta-mimetics ritodrine (Yutopar) and terbutaline sulfate
(Brethine) and magnesium sulfate, a CNS depressant.
Although ritodrine is FDA approved for tocolysis, it is not
used for this purpose as frequently as is terbutaline sulfate,
which is not FDA approved for tocolysis. The use of these Box 11-5 Contraindications to the Use of Tocolytics
medications is contraindicated under certain conditions in Preterm Labor
(Box 11-5). At present, it is believed that the best reason to
use tocolytic drugs is to allow an opportunity to begin the • Significant maternal hypertension (eclampsia, severe preeclampsia,
administration of antenatal corticosteroids to accelerate chronic hypertension)
fetal lung maturity. Also, delaying the birth provides time • Antepartum hemorrhage
for maternal transport to a facility equipped with a neona- • Cardiac disease
tal intensive care unit (ACOG, 2003b). Caring for the • Any medical or obstetric condition that contraindicates prolongation
patient receiving tocolytic therapy requires the nurse to be of pregnancy
cognizant of not only the safety aspects of administering • Hypersensitivity to a specific tocolytic agent
the medication to the pregnant woman but also to the • Gestational age 37 weeks
emotional needs of the patient as attempts to halt the pre- • Advanced cervical dilation
term labor are being made (Box 11-6).
• Fetal demise or lethal anomaly
• Chorioamnionitis
• In utero compromise
• Acute: nonreassuring fetal heart rate pattern
Family Teaching Guidelines… • Chronic: IUGR or substance abuse
Preventing Prematurity
Source: Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & Wenstrom,
Freda and Patterson (2004) suggest that nurses be proac- K. (2005). Williams obstetrics (22nd ed.). New York: McGraw-Hill
tive by educating women about preterm labor and teach-
ing them how to recognize the warning signs and
symptoms.
◆ Encourage all pregnant women to obtain prenatal care.
◆ Educate all pregnant women as to the signs and symp- Box 11-6 Nursing Care of the Patient Receiving Tocolytic
toms of preterm labor. Therapy
◆ Eliminate the term “Braxton-Hicks” from teaching • Explore the woman’s understanding of what is taking place.
(women may delay seeking treatment if they believe
• Include the woman’s partner in all discussions about medications and
they are only experiencing Braxton-Hicks contractions). their effects.
◆ Ask all pregnant women if they have had any symp- • Provide anticipatory guidance regarding what is likely to happen during
toms of preterm labor. medication administration.
◆ Screen for vaginal and urogenital infections and treat • Position the woman on her side for better placental perfusion.
appropriately. • Explain the side effects and contraindications of the drug.
• Assess blood pressure, pulse, and respirations regularly according to
◆ Teach women about the dangers of douching.
hospital policies (in many institutions every 15 minutes).
◆ Assess all pregnant women for intimate partner violence • Notify the health care provider if systolic blood pressure is 140 mm
and intervene. Hg or 90 mm Hg.
◆ Discuss stress levels early in pregnancy, and intervene. • Notify the health care provider if diastolic blood pressure is 90 mm
Hg or 50 mm Hg.
◆ Assess all pregnant women for nutritional status and
• Assess for signs of pulmonary edema (chest pain, shortness of
weight gain in pregnancy and intervene as necessary. breath).
◆ Assess for illicit drug use, and help the woman get into • Assess for the presence of deep tendon reflexes (DTRs).
treatment. • Assess output every 1 hour.
◆ Encourage women who have preterm labor symptoms • Notify provider if output is 30 mL/hr.
to drink fluids, lie down for 1 hour, and go to the • Limit intake to 2500 mL/day (90 mL/hr).
hospital for a vaginal exam if symptoms continue. • Provide psychosocial support and opportunities for the patient to
◆ Remind the woman with symptoms that she should express anxiety.
not hesitate to call her provider repeatedly if her Source: March of Dimes Nursing Module: Preterm Labor: Prevention and Nursing
symptoms recur. Management (2004).
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 303
Premature Rupture of the Membranes • The woman should be assessed for evidence of
advanced labor, chorioamnionitis (intrauterine
To facilitate an understanding of premature rupture of the infection), abruptio placentae, and fetal distress.
membranes (PROM), it is helpful to first define the vari- • Patients with advanced labor, intrauterine infection, sig-
ous terms used: nificant vaginal bleeding, or nonreassuring fetal testing
are best delivered promptly, regardless of gestational age.
• Premature rupture of the membranes (PROM) is
defined as rupture of the membranes before the onset There is further debate over the use of tocolytics, corti-
of labor at any gestational age. costeroids, and antibiotics in patients with PPROM.
• Preterm rupture of membranes is defined as rupture Tocolysis appears to be of little benefit in PPROM and
of the membranes before 37 completed weeks of gesta- may be harmful when chorioamnionitis is present. How-
tion. It is a common cause of preterm labor, preterm ever, in many hospitals, tocolytic therapy is instituted for
delivery, and chorioamnionitis. 48 hours, especially with earlier gestational ages, in order
• Preterm premature rupture of the membranes to administer a course of corticosteroids to enhance fetal
(PPROM) is defined as a combination of both terms— lung maturity (Cunningham et al., 2005).
rupture occurs before the 37th completed week of ges- Conservative management includes inpatient observa-
tation and in the absence of labor. PPROM accounts tion unless the membranes reseal and the leakage of fluid
for 25% of all cases of premature rupture of the amni- stops. This approach initially consists of prolonged contin-
otic membranes and is responsible for 30% to 40% of uous fetal and maternal monitoring combined with modi-
all preterm deliveries (Cunningham et al., 2005). fied bedrest to promote amniotic fluid reaccumulation and
spontaneous membrane sealing. Delivery of the fetus should
PATHOPHYSIOLOGY be accomplished if signs of infection are present: maternal
temperature of 100.4°F (38°C) or greater, foul-smelling
Premature rupture of the membranes is multifactorial. vaginal discharge, elevated white blood count, uterine
Choriodecidual infection or inflammation appears to play tenderness, and maternal and/or fetal tachycardia.
an important role in the etiology of PPROM, especially at Without intervention, approximately 50% of patients
early gestational ages. Other factors include decreased who have ROM will go into labor within 24 hours, and up
amniotic membrane collagen, lower socioeconomic status, to 75% will do so within 48 hours. These rates are
cigarette smoking, sexually transmitted infections, prior inversely correlated to the gestational age at the time of
preterm delivery, prior preterm labor during the current rupture of the membranes. Thus, patients with ROM
pregnancy, uterine distention (e.g., multiple gestation, before 26 weeks’ gestational age are more likely to gain an
hydramnios), cervical cerclage, amniocentesis, and vaginal additional week than those greater than 30 weeks’ gesta-
bleeding in pregnancy (Mercer, 2003). In many cases, the tion. While maintaining the pregnancy to gain further
cause is not known. fetal maturity can be beneficial, prolonged PPROM has
been correlated with an increased risk of chorioamnion-
DIAGNOSIS itis, placental abruption and cord prolapse (Cunningham
Most often, the patient reports a gush or leakage of fluid from et al., 2005).
the vagina. However, any increased vaginal discharge should The nurse’s role in caring for the patient with PPROM
be evaluated. The diagnosis is based on the patient’s history of includes explaining to the patient that she will be on full
leaking vaginal fluid and the finding of a pooling of fluid on or modified bedrest and her vital signs will be checked at
sterile speculum examination. Nitrazine and fern tests con- least every 4 hours to detect early signs of a developing
firm the diagnosis of PROM. Easily performed, these tests infection. If the patient does not exhibit signs of labor,
are used to discriminate between vaginal discharge and amni- intermittent fetal monitoring is appropriate. Frequent
otic fluid. (See Procedure 12-2.) The tampon test may also be ultrasound examinations are performed to assess amniotic
used to diagnose PROM. With this test, a blue dye (indigo fluid levels. An important component of the nursing care
carmine) is injected into the uterus via amniocentesis. A pre- plan centers on providing emotional support to the patient
viously inserted vaginal tampon is then checked in 30 min- who is understandably worried about the outcome for her
utes for the presence of blue dye. The level of amniotic fluid baby. The nurse should encourage the woman and her
in the uterus may also be checked via an abdominal ultrasound family members to ask questions and express fears and
examination. Leakage of amniotic fluid is consistent with concerns. When the nurse does not have enough informa-
findings of oligohydramnios (decreased amniotic fluid). tion to respond adequately, another health team member
who can appropriately answer the patient’s questions and
address her concerns should be contacted.
MANAGEMENT
The risk of perinatal complications changes dramatically Now Can You— Discuss the care of the patient with
according to the gestational age when rupture of the mem- premature rupture of the membranes?
branes occurs. Clinical practice varies, and, at present,
considerable controversy exists concerning the optimal 1. Name three factors associated with premature rupture of
management of PPROM. However, there is general con- membranes?
sensus in regard to the following factors: 2. Discuss three major complications that accompany
premature rupture of membranes?
• Gestational age should be established based on clinical 3. Describe the Nitrazine, fern and tampon tests?
history and prior ultrasound assessment when available. 4. Formulate a plan of care for the patient who has experienced
• Ultrasound should be performed to assess fetal premature rupture of membranes?
growth, position, and residual amniotic fluid.
304 unit three The Prenatal Journey
Hypertensive Disorders of Pregnancy then returns to nonpregnant values by the end of the
third trimester.
Hypertensive disorders are the most common medical At one time, the presence of edema was included in the
complication of pregnancy. The incidence of hypertensive definition of preeclampsia, but this criterion has been
disorders is between 5% and 10%, and this complication is removed since edema is common during pregnancy. How-
the second leading cause of maternal death in the United ever, the sudden onset of severe edema always warrants
States (embolic events are the leading cause) (Martin et al., close evaluation to rule out preeclampsia or other patho-
2005). Hypertensive disorders contribute significantly to logical processes such as renal disease. Eclampsia is the
stillbirth and neonatal morbidity and mortality (National occurrence of a grand mal seizure in a woman with pre-
High Blood Pressure Education Program Working Group eclampsia who has no other cause for seizure (ACOG,
[NHBPEP], 2000; Sibai, Dekker, & Kupfermine, 2005) 2002a; Roberts, 2004).
and can result in maternal cerebral hemorrhage, dissemi-
nated intravascular coagulation (DIC), hepatic failure, Nursing Insight— Recognizing variations in the
acute renal failure, pulmonary edema, adult respiratory onset of eclampsia
distress syndrome, aspiration pneumonia, and abruptio
placentae (ACOG, 2002a). Approximately one third of cases of eclampsia develop during
pregnancy; one third during labor and one third within
CLASSIFICATIONS AND DEFINITIONS 72 hours postpartum (Emery, 2005).
Proteinuria
Increased plasma uric acid and creatinine
Increased Glomerular damage
Oliguria
thromboxane Increased sodium retention
to prostacyclin/
increased
sensitivity to Visible edema of face, hands, and abdomen
angiotensin II Generalized edema
Pitting edema after 12 hours of bed rest
Headaches
Vasospasms Cortical brain spasms Hyperreflexia
Fluid shifts from Seizure activity
intravascular
Decreased placental perfusion
to intracellular
Placental production Pulmonary edema Dyspnea
space
of endothelin
(decreased
(a toxic substance to
plasma volume)
endothelial cells)
(increased Blurred vision
Retinal arteriolar spasms
hematocrit) Scotoma
Endothelial
cell damage
Hemolysis of red blood cells Decreased hemoglobin
(torn red blood cells) Maternal hyperbilirubinemia
Intravascular
coagulation
Elevated liver enzymes (AST and LDH)
Nausea/vomiting
Hepatic microemboli; Epigastric pain
liver damage Right upper quadrant pain
Decreased blood glucose
Liver rupture
Alpha-methyldopa Central alpha- Starting dose 250 mg Methyldopa hypersensitivity, history of Safe
(Aldomet) adrenergic inhibitor po, tid or qid. hepatitis, autonomic dysfunction, lethargy
Maximum dosage of or syncope. Can cause liver damage, fever,
2–4 g/24 hr Coombs-positive hemolytic anemia
Labetalol (Trandate, Alpha-/beta- 100–400 mg po, bid or Labetalol hypersensitivity, bradycardia, Safe
Normodyne) adrenergic blocker tid maximum dose 2400 asthma, heart block, heart failure. Can
mg a day cause maternal and fetal bradycardia,
hypotension, bronchospasm
Nifedipine (Adalat, Calcium channel 10–30 mg po tid slow Hypersensitivity to calcium channel Safe
Procardia) blocker release once a day. blockers, persistent dermatologic reactions,
Maximum of 90 mg/day congestive heart failure. Can potentiate
cardiac depressive effect of magnesium
sulfate
Furosemide (Lasix) Loop diuretic 20–80 mg po, qd or bid Hypersensitivity to furosemide, anuria, Safe
or depleted blood count. Can cause
profound diuresis with water and
electrolyte depletions, sun sensitivity to
exposure to sunlight, hyperuricemia and
gout, exacerbation of SLE, abdominal
cramping, diarrhea, tinnitus, dizziness,
pancreatitis, and cholestasis
Hydrochlorothiazide Loop diuretic 25–50 mg po, qd Anuria, renal disease, liver disease, SLE, Risk is remote, but
(HydroDIURIL) hypersensitivity to hydrochlorothiazide there are concerns
or other sulfonamide derived drugs. about potential
Can cause weakness, hypotension, thrombocytopenia
pancreatitis, cholestasis, anemia, allergic in infants.
reactions, electrolyte disturbance,
hyperglycemia, hyperuricemia, dizziness,
renal dysfunction
Source: Yankowitz, J. (2004). Pharmacologic treatment of hypertensive disorders during pregnancy. The Journal of Perinatal
& Neonatal Nursing, 18(3), 230–240. Reproduced with permission.
Labetalol hydrochloride Alpha-/beta-adrenergic blocker IV bolus 20 mg; if no response, double dose and repeat every
(Normodyne, Trandate) 15 min, up to a cumulative maximum dose of 300 mg
Hydralazine (Apresoline, Neopresol) Peripheral/arterial vasodilator IV bolus 5–10 mg every 15–20 minutes to a maximum dose of 30 mg
Nifedipine (Adalat, Procardia) Calcium channel blocker Nifedipine can be given po in doses of 10 mg repeated every
15 minutes to a maximum of 30 mg
Sodium nitroprusside (Nipride, Vasodilator 0.25 mcg/kg per minute (increase by 0.25 g/kg/min every
Nitropress) 5 minutes) to a maximum of 5 g/kg per minute
Source: Yankowitz, J. (2004). Pharmacologic treatment of hypertensive disorders during pregnancy. The Journal of Perinatal
& Neonatal Nursing, 18(3), 230–240. Reproduced with permission.
The goal of therapy is to reduce the risk of cere- 3. Invasive hemodynamic monitoring may be
bral vascular accident, while maintaining utero- required if any of the following are present:
placental perfusion. A decrease in the diastolic • Oliguria unresponsive to a fluid challenge
pressure to less than 90 mm Hg in the patient • Pulmonary edema
with severe hypertension will decrease placental • Hypertensive crisis refractory to conventional
blood flow, often with a decrease in the fetal heart therapy
rate (FHR). Management is directed at reducing • Cerebral edema
the diastolic blood pressure to a value of less than • Disseminated intravascular coagulation (DIC)
110 mm Hg, but greater than 95 to 100 mm Hg. • Multisystem organ failure
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 309
medication: Magnesium Sulfate Serum magnesium levels and renal function should be monitored
periodically throughout administration of parenteral magnesium
Magnesium sulfate (mag-nee-zhum sul-fate)
sulfate.
Pregnancy Category: D Have 10% calcium gluconate available should toxicity occur.
Indications: Administer 10 mL intravenously over 1–3 minutes until signs and
Anticonvulsant in severe eclampsia or preeclampsia symptoms are reversed.
Unlabeled Use: Preterm labor After delivery, monitor the newborn, for hypotension, hyporeflexia,
and respiratory depression.
Actions: Plays an important role in neurotransmission and muscular
excitability Data from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses
Therapeutic Effects: Resolution of eclampsia (11th ed.). Philadelphia: F.A. Davis.
Pharmacokinetics:
ABSORPTION: IV administration results in complete bioavailability; well
absorbed from IM sites
DISTRIBUTION: Widely distributed. Crosses the placenta and is present in
breast milk. clinical alert
METABOLISM AND EXCRETION: Excreted primarily by the kidneys
Accidental overdose of magnesium sulfate administration
HALF-LIFE: Unknown
can pose a significant risk to both mother and newborn
Contraindications and Precautions:
CONTRAINDICATED IN: Hypermagnesemia/hypocalcemia/anuria/heart block/ Current recommendations to prevent magnesium sulfate accidents:
active labor or within 2 hours of labor (unless used for preeclampsia • A standardized unit protocol should be consistent and include:
or eclampsia) standing orders addressing the initial bolus and maintenance
USE CAUTIOUSLY IN: Any degree of renal insufficiency dose to be administered; how the pump should be programmed;
Adverse Reactions and Side Effects: the maintenance IV solutions that will be used and the fre-
Central nervous system: Drowsiness quency that the fetus and mother will be assessed.
Respiratory system: Decreased respirations • Administer IV magnesium sulfate (including the initial bolus)
Cardiovascular system: Arrhythmias, hypotension, bradycardia only through a controlled infusion device with free-flow
Gastrointestinal system: Diarrhea protection.
Dermatology system: Flushing, sweating • Use universal standardized dose prepackaged magnesium sulfate.
Metabolic: hypothermia
• Have a second nurse check the initial magnesium sulfate IV bag
Interactions: Potentiates neuromuscular blocking agents and pump settings (and every magnesium sulfate IV bag that is
Route and Dosage (Eclampsia/Preeclampsia): Piggyback a added and each subsequent rate change).
solution of 40 g of magnesium sulfate in 1000 mL of lactated Ringer’s • Use a 100-mL (4 g) or 150-mL (6 g) IV piggyback (IVPB) for the
solution—use an infusion control device (pump) at the ordered rates; initial bolus instead of bolusing from the main bag with a rate
loading dose: initial bolus of 4–6 g over 15–30 min; maintenance change on the pump.
dose: 1–3 g/hr.
• Use color-coded tags on the lines as they go into the pumps
IM: 4–5 g given in each buttock, can be repeated at 4-hour intervals; use
and into the IV ports.
Z-track technique. (Note: IM route rarely used because the absorption
rate cannot be controlled and injections are painful and may result in • Provide 1:1 nursing care for women in labor who are receiving
tissue necrosis.) magnesium sulfate.
Time/Action Profile for Anticonvulsant Effect: • When care is transferred to another nurse, have both nurses
IM: Onset is 60 minutes with peak unknown and duration is together at the bedside review the pump settings for both the
3–4 hours IV: onset is immediate with peak unknown and duration magnesium sulfate and mainline IV fluids and review written
is 30 minutes. physician orders for magnesium sulfate infusion orders.
Nursing Implications: Remember that this is a very potent, high alert • Implement periodic magnesium sulfate overdose drills with
drug! airway management and calcium administration with the physi-
Explain purpose and side effects of the medication to the patient and cian and nurse team members participating together.
her companion. • Maintain the calcium antidote in the patient’s room in a locked
Explain that she may feel very warm and become flushed and box (Simpson & Knox, 2004).
experience nausea and vomiting, visual blurring, and headaches.
Magnesium sulfate must never be abbreviated (i.e., MgSO4 is not
acceptable) and requires a written order by the physician for
administration.
Always use an infusion pump for administration and run the medication NURSING ASSESSMENTS
piggyback, not as the main line.
Monitor pulse, blood pressure, respirations, and ECG frequently Nursing care centers on extremely accurate, astute obser-
throughout parenteral administration. Respirations should be at vations and assessments. An in-depth understanding of
least 16/min before each dose. the pharmacological regimens, management plans, and
Monitor neurological status before and throughout therapy. potential complications associated with this disease is also
Institute seizure precautions essential. The clinical manifestations of preeclampsia are
Keep the room quiet and darkened to decrease the likelihood of triggering directly related to the presence of vascular vasospasms.
seizure activity Vasospasms cause endothelial injury, red blood cell
Patellar reflexes should be tested before each parenteral dose of destruction, platelet aggregation, increased capillary per-
magnesium sulfate. If absent, no additional dose should be meability, increased systemic vascular resistance, and
administered until a positive response returns.
renal and hepatic dysfunction. Hypertension and protein-
Monitor intake and output. Urine output should be maintained at a
level of at least 100 mL/4 hr. uria are the most significant indicators of preeclampsia
(Poole, 2004b).
310 unit three The Prenatal Journey
IDENTIFYING HYPERTENSION filtration rate and renal blood flow may not occur, nor the
Preventing hypertension-induced problems in pregnancy expected decrease in serum creatinine, especially if the
requires nurses to use their assessment, advocacy, and disease is severe. Preeclampsia may be associated with a
counseling skills. Assessment begins with accurate blood profuse swelling in the kidney glomerular endothelial cell
pressure measurements. Checking blood pressures should cytoplasm. This pathological change causes glomerular
never be treated as a routine, mundane task. endotheliosis, a lesion that correlates with proteinuria
In the past, hypertension indicative of preeclampsia (ACOG, 2002a).
had been defined as an elevation of more than 30 mm Hg As an important component of hospital care, the nurse
systolic or more than 15 mm Hg diastolic above the assesses urine output every 1 to 4 hours to confirm adequate
patient’s baseline blood pressure. However, this definition renal perfusion and oxygenation. A urinary output of 25 to
has not been a good prognostic indicator of outcome. The 30 mL/hr or 100 mL/4 hr is normal; a downward trend in
frequently cited “30–15” rule is not part of the criteria for output should be reported immediately. A urimeter attached
preeclampsia according to the National High Blood Pres- to the Foley catheter tubing is useful in the accurate assess-
sure Education Program Working Group. Instead, women ment of the hourly urine output. A 24-hour urine test for
who demonstrate a blood pressure elevation of more than total protein may be ordered to monitor for an increase in
30 mm Hg systolic or more than 15 mm Hg diastolic the excretion of protein, a finding indicative of increasing
above the pre-pregnancy baseline “warrant close observa- kidney impairment. The nurse should be aware that if the
tion” (ACOG, 2002a; Peters & Flack, 2004). 24-hour urine specimen (for total protein) shows the pres-
The nurse needs to remember that blood pressure pres- ence of protein, a dipstick is not appropriate. Once protein
ents differently in women with preeclampsia. Preeclamptic is evident in a 24-hour urine collection, protein will always
patients often demonstrate labile (unstable) pressures and be present when the urine is tested by the dipstick. There-
a flattening or reversal of normal circadian blood pressure fore, no new information is obtained. The 24-hour urine
rhythms, with the highest values recorded at night (Cun- sample yields more accurate information because it shows
ningham et al., 2005). Because of this variation, hospital- whether or not the urine protein is increasing, decreasing,
ized patients should routinely have a nocturnal blood or remaining the same. When indicated, a high-protein diet
pressure assessment unless otherwise ordered by the phy- may be needed to replace the protein excreted in the urine.
sician. A daily cardiovascular assessment is also an impor-
tant monitoring component for the hospitalized patient. ASSESSING EDEMA
At one time, edema was an important component of the
Be sure to— Perform a daily cardiovascular triad considered along with hypertension and proteinuria
assessment on patients with preeclampsia to diagnose preeclampsia. However, edema is a common
finding in pregnancy. Dependent edema in the absence of
During the assessment, the nurse should include the fol- hypertension or proteinuria is generally related to changes
lowing parameters: in the interstitial and intravascular hydrostatic pressures
• Auscultation of heart sounds, lungs, and breath sounds that facilitate the movement of intravascular fluid into the
• Presence and degree of edema tissues. When preeclampsia is present, continuous capillary
• Early signs or symptoms of pulmonary edema, such as leakage combined with a decreased colloidal pressure can
tachycardia and tachypnea lead to pulmonary edema. In this situation, intravascular
• Daily weight taken at the same time of the day and on fluid leaks out through holes (caused by vasospasms) in the
the same scale endothelial lining of the blood vessels. Pulmonary edema
• Skin color, temperature, and turgor can occur very suddenly, especially if the patient receives
• Capillary refill, which may indicate decreased perfusion an overload of intravenous fluid. Because of the potential
or vasoconstriction if 3 seconds for rapid development of this life-threatening complication,
the nurse must frequently perform a careful assessment
of the patient’s pulmonary status and meticulously monitor
the total intake and output.
SIGNIFICANCE OF PROTEINURIA
Proteinuria is defined as the excretion of 300 mg or more CENTRAL NERVOUS SYSTEM ALTERATIONS
of protein every 24 hours. If 24-hour urine samples are Preeclampsia may quickly develop into eclampsia, the
not available, proteinuria is defined as a protein concen- convulsive phase of preeclampsia. Before the onset of
tration of 300 mg/L or more (1 on dipstick) in at least seizure activity, the patient may complain of headaches,
two random urine samples taken at least 4 to 6 hours visual disturbances, blurred vision, scotomata (specks
apart and no more than 7 days apart. However, studies or spots in the vision where the patient cannot see;
have shown that urinary dipstick determinations as well “blind spots”), and, in rare cases, cortical blindness
as random protein to creatinine ratios correlate poorly (August, 2004). These symptoms can be indicators of
with the amount of protein found in a 24-hour sample of increased CNS irritability that precedes the onset of sei-
women with gestational hypertension. Therefore, the zures. A retinal examination often reveals vascular con-
definitive test to diagnose proteinuria should be quantita- striction and narrowing of the small arteries. These
tive protein excretion over 24 hours (Sibai et al., 2005). changes are reflective of the widespread vasoconstric-
The purpose of the renal assessment is to identify renal tion that is occurring throughout the body. Deep tendon
compromise. Due to the vasospasm that accompanies reflexes (DTRs) are also routinely assessed for evidence
preeclampsia, the expected increases in the glomerular of irritability and clonus (rapidly alternating muscle
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 311
contraction and relaxation), two additional signs of complication of hypertension, and most maternal deaths
increased CNS irritability. attributable to hypertension occur in women with eclamp-
sia. Although patients with severe preeclampsia are at
the greatest risk for developing seizures, the onset of
Optimizing Outcomes— Grading reflexes and
checking for clonus
eclampsia-related seizures in women with mild preeclamp-
sia have been reported. Women in whom eclampsia devel-
During the assessment, grade maternal reflexes on a ops exhibit a wide spectrum of signs and symptoms, rang-
0–4 scale: ing from extremely high blood pressure, 4 proteinuria,
4 Very brisk, hyperactive; often indicative of disease; generalized edema, and 4 patellar reflexes to minimal
often associated with clonus blood pressure elevation, no proteinuria or edema, and
3 Brisker than average; possibly but not necessarily normal reflexes (Sibai, 2002).
indicative of disease Maternal complications of eclampsia include cerebral
2 Average; normal hemorrhage, aspiration pneumonia, hypoxic encephalop-
1 Somewhat diminished athy, coma, thromboembolic events, and maternal death
0 No response (incidence 0.4% to 14%) (Poole, 2004b). The perinatal
death rate in pregnancies complicated by eclampsia is 9%
If the reflexes are hyperactive, test for ankle clonus. Sup-
to 23%. Perinatal deaths are closely related to gestational
port the knee in a partly flexed position. With your other
age and most often result from premature delivery, abrup-
hand, dorsiflex and plantar flex the foot a few times while
tio placentae, and intrauterine asphyxia (Cunningham
encouraging the patient to relax, and then sharply dorsi-
et al., 2005).
flex the foot and maintain it in dorsiflexion. Look and feel
The exact cause of eclamptic seizures is unknown but
for rhythmic oscillations between dorsiflexion and plantar
many etiologies, including cerebral vasospasm with local
flexion. Normal is no reaction to this stimulus. Sustained
ischemia, hypertensive encephalopathy with hyperperfu-
clonus indicates upper motor neuron disease. The ankle
sion, vasogenic edema, and endothelial damage, have been
plantar flexes and dorsiflexes repetitively and rhythmically
proposed (Cunningham et al., 2005). Eclamptic seizures are
(Fig. 11-7) (Dillon, 2007). Clonus is usually noted as
clonic–tonic in nature and are almost always self-limiting.
“absent” or “present” but it may be rated as:
They seldom last longer than 3 to 4 minutes.
• Mild (2 movements)
• Moderate (3 to 5 movements)
• Severe (6 or more movements)
critical nursing action Care of the Pregnant
A neurological assessment of the patient with pre- Patient Post-seizure
eclampsia includes establishing her level of consciousness • Do not attempt to shorten or abolish the initial seizure. Attempts to
(LOC). Determining if the patient is alert and oriented can administer anticonvulsants intravenously without secure venous
be accomplished by asking if she knows why she is in the access can lead to phlebitis and venous thrombosis.
hospital and if she can correctly identify the name of the • Prevent maternal injury.
hospital. It is also important for the nurse to assess for any • Maintain adequate oxygenation; administer oxygen via face mask
change in the patient’s behavior or personality. Preeclamp- at 10 L/min
sia is an insidious condition and symptoms associated with • Minimize the risk of aspiration. Position the patient on her side
worsening of the disease can be very subtle. Maintaining a to facilitate drainage. Suction equipment should be ready and
quiet, darkened environment reduces stimuli that may working.
trigger seizure activity. Ensure that seizure precautions • Give adequate magnesium sulfate to control seizures. As soon
as possible following the seizure, venous access should be
(e.g., suction equipment, oxygen administration equip- secured with a 4- to 6-g loading bolus of magnesium sulfate
ment, emergency medication tray) are in place. given over 15–20 minutes. If the patient seizes following the
loading dose, another 2-g bolus may be given intravenously,
over 3–5 minutes.
Eclampsia • Correct maternal acidemia. Blood gas analysis allows monitoring
of oxygenation and pH status. Respiratory acidemia is possible after
Eclampsia is the occurrence of grand mal seizures in a seizure.
women who have either gestational hypertension or pre- • Avoid polytherapy. Maternal respiratory depression, respiratory
eclampsia (Sibia et al., 2005). It is the most common CNS arrest, or cardiopulmonary arrest is more likely in women who
receive polytherapy to arrest a seizure. Remember that
anticonvulsants are respiratory depressants and may interact.
• Be sure to check the fetus or fetuses (all must be accounted
for). After a seizure there may be loss of FHR variability and
bradycardia on the fetal monitoring tracing.
• Check the patient for ruptured membranes, contractions, and cervical
dilation.
• Prepare for delivery as indicated.
• Support the patient and her family. This is a very frightening
event for them and they will need reassurance and to be kept
aware of the plan of care and the well-being of their baby
(Poole, 2004b).
Figure 11-7 Testing for clonus.
312 unit three The Prenatal Journey
Be sure to— Document after a patient seizure bones again.” Her sister had continued to monitor the blood
pressure. According to the blood pressure log, Kimberly’s sys-
Time and length of seizure tolic blood pressure measurements had been in the 160s and
Associated symptoms the diastolic measurements were in the 60–70 range. Kimberly
Vital signs including fetal heart assessment denied headaches, visual disturbances, or abdominal pain and
Presence or absence of uterine contractions remarked that the fetus had been active. At this visit, the follow-
Any untoward results such as rupture of the membranes ing data were obtained:
Blood pressure: 158/98 (sitting); 150/100 (left side); weight:
or signs of placental abruption
160 lbs. (72.7 kg); fundal height: 27 cm; FHR: 150–170
Medications that were given. Remember to have the bpm; reflexes: 3–4 with no clonus; urinary protein: 4
physician write or co-sign any verbal orders that were (2000 mg/dL) on dipstick
given during the emergency (Poole, 2004b). Assessment: Severe preeclampsia at 29 4/7 weeks’ gesta-
tional age
At this point, Kimberly’s physician consulted with a maternal
fetal medicine specialist, who advised transferring Kimberly to a
tertiary care center located 50 miles away. Kimberly was
case study Kimberly Stallings promptly transferred to the tertiary care center and admitted to
the obstetrical service.
Kimberly Stallings is a 25-year-old white married woman preg-
nant with her first child. Kimberly’s family practice physician has Critical Thinking Questions
been caring for her since her first prenatal visit at 11.4 weeks’ 1. What are Kimberly’s risk factors for developing preeclampsia?
gestation. During the initial prenatal visit, the following data
was obtained: 2. Why did the nurse ask Kimberly about headaches, blurred
Vital signs: temperature: 98.6ºF (37.0ºC); pulse: 78 beats/ vision, and right upper quadrant (RUQ) pain?
min; respirations: 20 breaths/min; blood pressure: 110/70; 3. What signs and symptoms prompted Kimberly’s physician to
weight: 146 lbs. (66.4 kg) consult with the maternal–fetal specialist and arrange for a
A complete physical exam was performed with normal find- transfer to a tertiary care center?
ings and prenatal labs including a thyroid-stimulating hormone
level (TSH, because of a positive family history for hypothyroid- ◆ See Suggested Answers to Case Studies in the text on the
ism) were drawn. During the interview, the nurse inquired about Electronic Study Guide or DavisPlus.
any other family medical problems. Kimberly reported that both
her sister and her mother had experienced preeclampsia during
pregnancy.
An ultrasound was ordered for pregnancy dating because
Kimberly had experienced irregular menstrual periods since HELLP Syndrome
discontinuing oral contraceptives.
Kimberly was seen by her doctor every 4 weeks and the HELLP is an acronym for: Hemolysis, Elevated Liver
pregnancy progressed uneventfully until 4 months later, when enzymes and Low Platelets
she presented to the office with increased blood pressure and Due to the arteriolar vasospasms in the cardiovascular
swollen legs. Kimberly had noticed an increased swelling that system that occur in preeclampsia, the circulating red
extended up to the knees of both legs. She denied hand or facial blood cells (RBCs) are destroyed as they try to navigate
swelling, headaches, visual problems, or right upper quadrant through the constricted vessels (Hemolysis). Vasospasms
(RUQ) pain. Her sister, a chiropractor, had been checking her
decrease blood flow to the liver, resulting in tissue isch-
blood pressure and noted it to be as high as 160–170/100 to
110. At this visit, the following data was obtained:
emia and hemorrhagic necrosis (Elevated Liver enzymes).
Blood pressure: 144/96 (sitting). Repeat on left side: 130/76. In response to the endothelial damage caused by the
Weight: 172.5 lbs. (78.4 kg) vasospasms (small openings develop in the vessels),
Physical exam: General: In no acute distress; abdomen: non- platelets aggregate at the site and a fibrin network is
tender; fundus at 28–11.8 inches (30 cm) above the sym- set up, leading to a decrease in the circulating platelets
physis pubis; FHR 150 bpm; cardiovascular: 1 pedal (Low Platelets).
edema; neurological: reflexes 3 with no clonus. HELLP syndrome is a serious complication of pre-
Assessment: Mild preeclampsia. eclampsia that can manifest itself at any time during preg-
The following lab tests were ordered: CBC with platelet nancy and the puerperium, but like preeclampsia, it is rare
count; liver enzyme determination (AST, ALT, LDH), alkaline before 20 weeks’ gestation. However, unlike preeclampsia,
phosphatase (ALP); prothrombin time (PT); a chemistry panel
(electrolytes: Na, K, Cl-, HCO3-, Ca2, Mg2), blood urea nitro-
HELLP syndrome occurs more often in Caucasians, mul-
gen (BUN), creatinine (Cr), uric acid and a 24-hour urine collec- tiparas, and in women older than 35 years. One third of
tion for protein and creatinine clearance. A sonogram (ultra- all cases of HELLP syndrome occur during postpartum,
sound) was also ordered to monitor the status of the fetus. and only 80% of these patients are diagnosed with pre-
Kimberly was instructed to go home, observe modified bed eclampsia before delivery (Sibai et al., 2005).
rest, rest on her left side as much as possible, and call the HELLP syndrome is actually a laboratory diagnosis for
nurse if she experienced increased edema, headaches, visual a variant of severe preeclampsia. The primary presentation
disturbances, or RUQ pain. She was told to continue with is consistent with hepatic dysfunction evidenced by find-
twice daily blood pressure monitoring and return to the office ings from the patient’s liver function tests (ACOG, 2002a;
in 1 week.
Poole, 2004b). HELLP syndrome is characterized by
On her next office visit 8 days later, Kimberly reported that
she had been observing bedrest at home and had noticed that
rapidly deteriorating liver function and thrombocytopenia.
her leg edema was improved. She stated “I can see my ankle Liver capsule distention often produces epigastric pain.
Though rare, liver rupture is one of the most ominous
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 313
increased urinary tract infections, preeclampsia/eclampsia, physiological parameters along with ongoing surveillance
placenta previa, fetal intrauterine growth restriction is essential in developing an appropriate plan of care.
(IUGR), abnormal presentation, and umbilical cord pro-
lapse (Cunningham et al., 2005).
NURSING IMPLICATIONS
MATERNAL AND FETAL MORBIDITY Caring for the patient with a multiple pregnancy can be
AND MORTALITY challenging, especially when complications arise. Hospital-
ization may be needed due to the increased risk of compli-
Maternal morbidity is higher in women with multiple ges- cations, and the nurse needs to remain cognizant of this
tations and seems to be related to the number of fetuses fact. As an example, the patient with a multiple gestation
present. Twin pregnancies are associated with significantly who requires tocolytic therapy to prevent preterm birth
higher risks of hypertension, placental abruption, anemia, is at greater risk for complications related to the tocolytic
and urinary tract infections than are singleton pregnancies therapy than the patient with a singleton gestation. There
(Malone & D’Alton, 2004). Monochorionicity (one chorion is an increased risk of pulmonary edema due to the
instead of separate chorions surrounds the developing mul- expanded plasma volume and increased cardiac output.
tiple gestation), growth restriction, and prematurity pose Also, nutritional requirements are increased. Maternal
the main risks to fetuses and neonates in a multiple gesta- caloric needs are approximately 40% greater for a woman
tion. The mean duration of a twin gestation is 37 weeks; for expecting twins and 80% greater for a woman pregnant
triplets and quadruplets the mean duration of gestation is with triplets or higher multiples (Luke, 2005). Early in the
33 and 31 weeks, respectively. The mean gestational age at pregnancy, the patient may suffer from severe hyperemesis
delivery for multiple gestations can be misleading because gravidarum due to higher levels of pregnancy hormones
the classification does not reveal the true incidence of found in multiple pregnancies as compared to singleton
extreme prematurity, which has great clinical significance. pregnancies. This condition can lead to dehydration and
The incidence of preterm delivery prior to 28 weeks for poor nutrient intake and require hospitalization for rehy-
singletons is 0.7% in the United States. For twins, the inci- dration. At this time, the nurse can refer the patient to a
dence increases to 5% and for triplet gestations the inci- nutritionist and also review foods that might be more
dence is 14%. The perinatal mortality rate for twins is at appealing to the patient (Bowers & Gromada, 2006).
least threefold higher than with singletons (Malone & The nurse must also remain aware that the patients
D’Alton, 2004). being cared for are the woman (the primary patient) as
Perinatal morbidity is also more likely in a multiple well as each individual fetus. Serial ultrasounds, nonstress
gestation. The incidence of a severe handicap in neonatal tests, and biophysical profiles will be part of the ongoing
survivors of multiple gestation is increased from 19.7 per assessment for fetal well-being and growth. Fetal surveil-
1000 for singleton survivors to 34.0 and 57.5 per 1000 lance with electronic fetal monitoring may be difficult,
twin and triplet survivors, respectively. Twins account for especially when there are more than two fetuses. Triplet
between 5% and 10% of all cases of cerebral palsy in the monitors are available that allow for the tracing of three
United States (Malone & D’Alton, 2004). separate FHRs on a single channel, or two heart rate trac-
ings and a digital read-out for the third fetus. It is best to
DIAGNOSIS monitor all fetuses simultaneously and the nurse should
A positive diagnosis of a multiple gestation can be con- label which line corresponds to which ultrasound trans-
firmed by ultrasound examination. Sonography reveals ducer so that it is clear which fetus is being monitored.
multiple gestational sacs with yolk sacs by 5 weeks of The presenting twin is always “A,” with the remaining
gestation and multiple embryos with cardiac activity by fetuses (“B,” “C,” etc.) identified by relative ascending
6 weeks of gestation (Malone & D’Alton, 2004). Rapid positions. Although not common, late pregnancy changes
uterine growth, excessive maternal weight gain, or palpa- in fetal positions (e.g., male fetus B now in the position of
tion of three or more fetal large parts (cranium and breech) female fetus A) should be noted in the patient record. If
on Leopold maneuvers are clinical findings suggestive no recent ultrasound has been obtained, the nurse should
of multiple gestation. Laboratory tests show elevated levels identify each FHR by the appropriate abdominal quadrant
of human chorionic gonadotropin (hCG), human placen- (Bowers & Gromada, 2006).
tal lactogen (hPL), and maternal serum -fetoprotein A multiple pregnancy can cause many concerns for the
(MSAFP) (Cunningham et al., 2005). family. They often fear for the well-being of the babies,
especially since preterm labor is a major complication
with multiples. The thought of the everyday rigors of car-
MANAGEMENT ing for several newborns at one time can constitute
Since multiple gestation pregnancies are considered to be another major cause of stress. If there are other children
high risk, an appropriately trained specialist should ide- in the household, the expectant couple may question how
ally manage the obstetric care. Delivery should be planned they are going to be able to give the older siblings the care
to take place at a Level III facility that has trained person- and time they will also need. Family finances can be a
nel who are prepared to deal with maternal or neonatal great concern as well as the affordability of childcare
complications. When a pregnancy is complicated by a when it is necessary for the mother to return to work. The
multiple gestation, the normal maternal physiological nurse can be supportive in encouraging families to voice
adaptations to pregnancy are heightened. Complications their concerns and address them as appropriately as pos-
that are associated with these changes help to guide the sible. Helping the family to prepare for the birth of
clinical management. Consideration of maternal–fetal the babies can be of great benefit. The nurse may offer
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 315
suggestions that include giving the older children house- those infected will develop an acute symptomatic UTI.
hold chores appropriate for their age, alerting the partner’s Treatment includes anti-infectives such as ampicillin
employer of a potential need to adjust the work schedule (Marcillin) for a 7- to 10-day period. Screening women
in order to help out at home or finding someone to help for asymptomatic bacteriuria on the first prenatal visit
with housekeeping, grocery shopping, laundry, cleaning, constitutes a standard of obstetric care (Davison &
and/or childcare. Other team members such as social ser- Lindheimer, 2004; Savoia, 2004).
vice can also provide valuable solutions to these concerns.
Referring the couple to a “multiples” support group may Acute Cystitis
also be appropriate and welcomed. Symptomatic lower UTI occurs in 1.3% to 3.4% of preg-
nant women. Symptoms include urinary frequency,
Now Can You— Discuss care of the pregnant patient with urgency, dysuria, and suprapubic pain. The treatment is
a multiple gestation? the same as for asymptomatic bacteriuria (Savoia, 2004).
1. Name five complications associated with a multiple gestation?
2. Describe your plan of care, taking into consideration the Nursing Insight— Anti-infective medications
maternal fetal physiological parameters of the multiple contraindicated during pregnancy
gestation pregnancy?
3. Identify other team members you would include in your plan Medications including amoxicillin (Amoxil), ampicillin
of care? (Marcillin), and cephalosporins (cephalexin [Keflex]) are
safe antibiotics during pregnancy. Sulfonamides should not
be used near term because they interfere with protein binding
of bilirubin and tetracyclines should never be used because
they cause retardation of fetal bone growth and staining of
Infections fetal teeth.
URINARY TRACT INFECTION
Urinary tract infection (UTI) is the most common bacterial Acute Pyelonephritis
infection in pregnancy. The three most common clinical
syndromes associated with UTI are asymptomatic bacteri- Pyelonephritis, an inflammation of the kidney substance
uria, acute cystitis and acute pyelonephritis (Savoia, 2004). and pelvis, occurs in 1% to 2% of pregnant women. This
condition presents as flank tenderness on the affected side
Pathophysiology and is associated with nausea, vomiting, fever, and chills
The physiological dilatation of the urinary collecting sys- along with the symptoms of a lower UTI. Significant
tem that occurs normally during pregnancy is associated pyuria and bacteriuria are present. Pyelonephritis is
with an increase in ascending urinary infections. Mechan- treated aggressively with hospitalization and intravenous
ical and hormonal changes may lead to hydroureter, antibiotics. If left untreated or inadequately treated, septic
decreased peristalsis, bladder distention, and incomplete shock, adult respiratory distress syndrome and/or preterm
emptying. These events can result in urine stasis or reflux labor may result (Cunningham et al., 2005; Davison &
in the bladder and ureters (Cunningham et al., 2005; Lindheimer, 2004).
Savoia, 2004).
The most common infecting organism is Escherichia
coli (E. coli), which is responsible for 75% to 90% of all Optimizing Outcomes— When caring for the patient
bacteriuria during pregnancy. Other organisms frequently with a UTI
responsible for UTIs include Klebsiella, Proteus, Pseudo- During pregnancy, a urine specimen is more likely to be
monas, Group B streptococcus, and coagulase-negative contaminated by bacteria that originate in the urethra,
staphylococci (Davison & Lindheimer, 2004). vagina, or perineum. This occurs due to a change in pH
during pregnancy: the urine becomes more alkaline due to
Morbidity the maternal excretion of bicarbonate; the vagina also
Bacteriuria in pregnancy predisposes the patient to the becomes alkaline and the vaginal secretions have increased
development of acute pyelonephritis, a condition that poses glycogen content, which aids bacterial growth). Before
significant risk to the woman and her fetus (Savoia, 2004). collecting a mid stream specimen, the nurse should
Asymptomatic and untreated bacteriuria has been associ- instruct the patient about the importance of proper
ated with a number of complications during pregnancy cleansing.
including low birth weight, intrauterine death, preeclamp- A urinalysis and urine culture and sensitivity (C & S)
sia, and maternal anemia (Davison & Lindheimer, 2004). should be obtained on all patients who present with signs
of preterm labor and the nurse must remember that signs
Asymptomatic Bacteriuria of UTI often mimic normal pregnancy complaints (i.e.,
Asymptomatic bacteriuria is defined as the presence of urgency, frequency). It is important to remind the patient
at least 105 colony-forming units of bacteria per millili- to take all of the medication that has been prescribed, even
ter of clean, voided, midstream urine in specimens if the symptoms subside and she feels better. A Test of
obtained on two separate occasions.As the name implies, Cure (repeat urine test to evaluate whether or not bacteria
the patient does not express any symptoms of a UTI. is still present) should be obtained once the treatment has
Asymptomatic bacteriuria occurs in 2% to 11% of preg- been completed.
nancies and if left untreated, approximately 40% of
316 unit three The Prenatal Journey
Now Can You— Discuss the significance of a UTI in the Cytomegalovirus (CMV), and Herpes simplex virus type 2
pregnant patient? (HSV-2). (Some sources identify the “O” as “other”
infections, such as hepatitis B, syphilis, and human immu-
1. Describe anatomical and physiological renal system changes nodeficiency virus.) Maternal exposure to the TORCH
during pregnancy that place women at risk for UTIs? Identify infections during the first 12 weeks of gestation is associ-
the most common organism responsible for a UTI? ated with fetal developmental anomalies.
2. Explain why pyelonephritis must be treated aggressively?
3. Discuss nursing responsibilities when obtaining a urine
specimen from a pregnant patient and identify instructions SEXUALLY TRANSMITTED INFECTIONS
that should be given to the patient who is treated for a UTI? Sexually transmitted infections (STIs) can cause serious
morbidity and, in some cases, mortality in the mother,
fetus, and infant. Following perinatal exposure, newborns
Group B Streptococcal Infection
are at risk for a number of minor and major complications
that include congenital anomalies, mental impairment,
Group B streptococcus (GBS) is a frequent cause of urinary and death. Women exposed to STIs are at risk for infertil-
tract infections and chorioamnionitis during pregnancy ity, ectopic pregnancy, and pregnancy complications
and a significant cause of endometritis after the pregnancy (Cunningham et al., 2005).
has ended. It is a major pathogen in neonatal sepsis that
can result in significant neonatal morbidity and mortality. Chlamydia trachomatis
Women harbor GBS as part of the normal fecal and vaginal
flora. It is estimated that 10% to 30% of women are asymp- Chlamydia trachomatis is the most prevalent sexually trans-
tomatic carriers of the organism. However, the rates vary mitted infection in the United States. An estimated 3 million
according to the culture technique used, the number of cases occur annually (CDC, Workowski, & Berman, 2006).
samples cultured, and the nature of the populations stud- C. trachomatis causes genital infections that can be asymp-
ied. When maternal GBS colonization is present, transmis- tomatic and thus difficult to treat. However, infected women
sion to the neonate is estimated to occur in approximately who do experience symptoms usually complain of vaginal
60% of cases. The incidence is approximately 1.8 per 1000 discharge, dysuria, and, on occasion, abnormal vaginal
live births (Cunningham et al., 2005; Savoia, 2004). bleeding. On speculum examination, the cervix exhibits a
The onset of neonatal infection may be early (within distinct mucopurulent discharge along with marked inflam-
the first 6 days of life) or late. Infants with early-onset mation of the endocervix. Some women also experience an
infection generally develop signs (i.e., respiratory distress, acute urethral syndrome manifested by dysuria, urinary fre-
septic shock) during the first 12 hours of life. Exposure to quency, and the presence of pyuria in a sterile urine speci-
the organism occurs either in utero or during labor as the men. Oral anti-infectives such as erythromycin or penicillin-
fetus travels down the colonized birth canal. Risk factors based agents are used to treat Chlamydia trachomatis during
for contracting the infection include prematurity, low pregnancy (Yudkin & Gonik, 2006).
birth weight, premature rupture of the membranes, pro- Neonatal infection, most commonly manifested as con-
longed labor, maternal chorioamnionitis, multiple gesta- junctivitis and pneumonia, results from exposure to the
tion, and GBS bacteremia during pregnancy. The overall pathogen during birth. Typically, conjunctivitis occurs
rate of neonatal mortality from early onset GBS has during the first 5 to 12 days of life whereas pneumonia
declined from 50% in 1977 to approximately 6% cur- does not develop until 1 to 3 months after birth (Rawlins,
rently, although infants of low birth weight continue to be 2001). Topical antibiotic therapy, routinely administered
at a substantial risk. Late-onset GBS is community acquired during the immediate neonatal period, is inadequate
(the route of transmission is less clear and can be nosoco- for the treatment of a chlamydial infection. Since treat-
mial [acquired while in the hospital], environmental, or ment with erythromycin is only about 80% effective, the
maternal) and presents more than a week after birth. The newborn requires careful follow-up by the pediatrician
majority of infants with community-acquired GBS are full (Yudkin & Gonik, 2006).
term and 85% exhibit signs and symptoms of meningitis Neisseria gonorrhoeae
(Savoia, 2004).
In an effort to protect infants from Group B streptococ- Neisseria gonorrhoeae (gonococci [GC], gonorrhea), a
cus infections, the Centers for Disease Control and Pre- gram-negative diplococcus, is one of the oldest known
vention (CDC) has issued guidelines that advocate obtain- sexually transmitted infections. It often coexists with
ing vaginal and rectal cultures from all pregnant women chlamydia. The most common site of infection is the geni-
between 35 and 37 weeks of pregnancy. Women with tourinary tract. Infection sites unique to women include
positive cultures and those with unknown GBS, ruptured the Skene’s and Bartholin’s glands, endocervix, endome-
membranes greater than 18 hours, previous preterm deliv- trium, and fallopian tubes. Symptoms of infection include
ery (37 weeks) or a history of a previous infant with vaginal discharge, dysuria, and abnormal vaginal bleed-
GBS disease are treated with a penicillin-based anti-infec- ing. A speculum examination often reveals an inflamed,
tive agent (Savoia, 2004). friable (easy to bleed) cervix. Treatment includes either
oral or intramuscular cefixime (Suprax) or ceftriaxone
(Rocephin) (CDC et al., 2006). Infants born to untreated,
TORCH INFECTIONS infected mothers are at risk for disseminated infection
TORCH refers to a group of maternal infectious diseases (bacteremia) and ophthalmia neonatorum (an eye
that cause harm to the embryo–fetus (Table 11-3). The inflammation) that can result in permanent blindness
TORCH acronym stands for Toxoplasmosis, Rubella, from perforation of the globe of the eye.
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 317
The amniotic infection syndrome is an additional surgical excision. None of these therapies has been shown to
manifestation of gonococcal infection in pregnancy. This be superior to the others. The best approach to treatment
entity manifests as placental, fetal membrane, and umbili- during pregnancy may be the excision of the lesions by cau-
cal cord inflammation that occurs after premature rupture tery or the use of cryosurgery. Care must be taken to prevent
of the membranes (PROM) and is associated with infected extensive scarring or sloughing of tissue (CDC et al., 2006;
oral and gastric aspirate, leukocytosis, neonatal infection, Gibbs et al., 2004).
and maternal fever. The syndrome is characterized by The risk for transmission of the virus from maternal con-
PROM, premature delivery, and a high rate of infant mor- dylomata acuminata to the neonate has not been established.
bidity (Gibbs, Sweet, & Duff, 2004). HPV is present in maternal blood and can be transmitted
transplacentally to the fetus, but the incidence is very low
Syphilis according to reported studies (Gibbs et al., 2004).
Syphilis is an acute and chronic infection caused by the spi-
rochete Treponema pallidum. It has a long clinical course Nursing Insight— Preventing HPV through
that begins with an incubation period followed by primary, vaccination with Gardasil
secondary and tertiary infection. Throughout this time,
there is progressive damage to the CNS, cardiovascular sys- Nurses can be instrumental in preventing infection caused by
tem, and musculoskeletal system. Syphilis is transmitted the human papillomavirus. The American College of Obstetri-
primarily through sexual contact or fetal infection may cians and Gynecologists (ACOG) Committee on Adolescent
occur transplacentally. During pregnancy, syphilis usually Health Care and the ACOG Working Group on Immunization
occurs in women who are young and unmarried and in recommend that females 9–26 years of age receive vaccination
those who receive little or no prenatal care (Savoia, 2004). against HPV. Although obstetricians-gynecologists are not
The onset of primary syphilis is usually heralded by the likely to care for many girls in this initial vaccination group,
appearance of a chancre, a painless, round, ulcerated ACOG has recommended that the first adolescent reproduc-
lesion with a raised border and indurated (hardened) tive health care visit take place between 13 and 15 years of
base. In women, the chancre most commonly appears on age. These visits are a strategic time to discuss HPV and the
the vulva, cervix, and vagina. Penicillin is the treatment of potential benefit of the HPV vaccine and to offer vaccination
choice for all stages. If left untreated, the disease pro- to those who have not already received it (ACOG, 2006).
gresses, becomes chronic, and may lead to death.
Prompt maternal treatment eliminates most fetal syphi-
lis infections, but delayed treatment or failure to obtain HIV and AIDS
treatment may result in fetal effects that range from minor
Human immunodeficiency virus (HIV) type 1 (HIV-1)
anomalies to preterm birth or fetal death. Damage to the
infection, with rare exception, causes a slow but relentless
fetus depends on when during gestation the infection
destruction of the immune system that ultimately results
occurred and the amount of time elapsed before treat-
in acquired immunodeficiency syndrome (AIDS). HIV
ment. Neonatal infection may be present at birth, but not
type 2 (HIV-2) infection has a more variable and benign
expressed for up to 2 years (“silent infection”) (Askin,
course. HIV-2 has remained largely confined to West
2004). Manifestations of congenital syphilis include rhini-
Africa, whereas HIV-1 strains are causing increasing
tis (snuffles), macular rash on the palms and soles of the
epidemics around the world (Landry, 2004).
feet, osteochondritis (inflammation of the bony epiphy-
HIV-1 infection is an increasing problem among women
sis), perichondritis (inflammation of the membrane that
of childbearing age. AIDS is the fifth leading cause of
covers the surface of cartilage), hepatosplenomegaly,
death among women 25 to 44 years of age and has become
jaundice, anemia, and thrombocytopenia (Savoia, 2004).
a leading cause of death for young children in many parts
Human Papillomavirus Infection of the world. Without identification of HIV-infected
women and the aggressive use of preventive therapy,
Human papillomavirus (HPV) is a sexually transmitted
20%-30% of these children will become infected with
virus that causes condylomata acuminata (genital warts)
HIV (CDC, 2006a; Landry, 2004; Moran, 2004a).
and is the primary cause of cervical neoplasia (American
Cancer Society, 2006). Approximately 70% of cervical can- TRANSMISSION. Heterosexual unprotected sexual contact
cers result from infection with HPV (ACOG, 2006). Risk now poses the greatest risk to women. Because vaginal
factors associated with HPV infection include early onset of mucus can harbor the retrovirus, women are more likely
sexual activity, multiple sex partners, cigarette smoking, and than men to contract HIV infection through heterosexual
long-term use of oral contraceptives (Gibbs et al., 2004). activity. Factors that increase the risk of transmission
The prevalence of genital warts is highest among the include (Moran, 2004a):
16- to 25–year-old age group, which is also the age group
• Unprotected sexual intercourse (no condom is used)
with the highest rate of pregnancy. The warts grow more
• Sexual intercourse during menses
rapidly during pregnancy and may involve the cervix,
• Increased number of sexual contacts
vagina, or vulva so extensively that vaginal delivery is pre-
• Presence of genital sores
cluded. The reason for the increase in size and number of
• Advanced disease state
the lesions is not known but has been postulated to be the
decrease in cell-mediated immunity that occurs during The risk of vertical transmission to the fetus or newborn
pregnancy (Landry, 2004). Management of these lesions in is proportional to the concentration of virus in maternal
pregnancy presents difficult problems and treatment includes plasma (viral load). Vertical transmission occurs antepar-
trichloroacetic acid, dichloroacetic acid, cryotherapy, and tally when the virus crosses the placenta, intrapartally
Text continued on page 322
318 unit three The Prenatal Journey
Toxoplasmosis Single-celled protozoan Transplacental Serologic antibody testing Most infections in humans are
parasite Toxoplasma IgM specific antibody asymptomatic
gondii Eating raw meat,
especially pork, lamb IgG seroconversion from However, may include fatigue, muscle
or venison negative to positive pains, and sometimes
lymphadenopathy
Touching the hands Most accurate confirmation
or the mouth after of active infection is a rise in In the immunocompetent person,
handling undercooked IgG titer in two appropriately toxoplasmosis can be a devastating
meat containing spaced tests infection
T. gondii
Secreted in feces of
infected cats
Cyst is destroyed with
heat
Other HBV Direct contact with the HBsAg identified 7–14 days Course of the disease is not altered
blood or body fluids of after exposure during the pregnancy
Hepatitis B Incubation usually an infected person
60–90 days Hepatitis B surface antibody Symptoms are seen in only 30%–50%
Sexual present with HBsAg indicates of patients; these include low-grade
non infectious fever, nausea, anorexia, jaundice,
Perinatal hepatomegaly, malaise, preterm labor,
HBcAg, HBeAg, and AntiHBc and preterm birth
Percutaneous evaluate stage and
Transplacental progression of the infection No specific treatment, but may include
bedrest and a high-protein, low fat diet
Blood, stool, amniotic
fluid, and saliva Mother to child transmission of HBV
transmission occurs in 10%-20% of women who
are seropositive for HBsAg and in 90%
Shared razors, of women who are seropositive for
toothbrushes, towels, both HBsAg and HBcAg
and other personal items
Transmission to the neonate appears
to occur as a result of exposure to
infected blood and genital secretions
during delivery
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 319
Severity varies with gestational age Pyrimethamine and ACOG does not recommend routine screening People who consume raw
sulfadiazine may reduce except for pregnant women with HIV infection or poorly cooked meat
Congenital infection can occur if a incidence of congenital
woman develops acute toxoplasmosis toxoplasmosis Incidence varies throughout the world High risk gestational
during pregnancy (most likely in the (1-4 infants per 1000 live births) age 10-24 weeks
third trimester) Treatment of the mother has Toxoplasmosis is more
shown to reduce the risk of 30% of U.S. women have been exposed common in Western
May have miscarriage if acquired early congential infection Europe, particularly
Approximately 40%-50% of U.S. adults
Fetal infections more virulent the have antibody to this organism France
Pyrimethamine
earlier the infection is acquired but
less frequent Is not recommended Frequency of seroconversion during pregnancy
for use during the first is 5% and approximately 3 in 1000 infants
Sequelae include low birth weight, trimester of pregnancy show evidence of congenital infection
hepatosplenomegaly, icterus, anemia,
neurologic disease, and chorioretinitis Incidence of congenital toxoplasmosis,
infection in the U.S. is 1 in 1000–8000
Clinically significant congenital
toxoplasmosis occurs in approximately More than 60 million people in the U.S. carry
1 in 8000 pregnancies a parasite
Cook meat to a safe temperature
Peel or wash fruits and vegetables
Infants infected at birth have a 90% Mother: rest Screen all pregnant women. The incidence High risk categories:
risk of becoming chronically infected of hepatitis B in the U.S. declined by 60%
with HBV (carrier) and 25% risk of Infant: vaccine if mother is from 1985 to 1995 Pregnant women from
developing significant liver disease— carrier, infant receives HBIG China, Southeast Asia,
yet if they receive prophylaxis at birth, Estimated that 1 to 1.25 million people in Africa, Philippines, and
HBV vaccine recommended the U.S. are chronically infected with HBV Indonesia
95% can be prevented (three doses)
Increased risk of transmission to infant Estimated that 300 million people Eskimos
if mother is HBeAg-positive (indicating worldwide are chronically infected with HBV
Prostitutes
acute infection) Approximately 8000 acute HBV infections
were reported to CDC Homosexuals
Stillbirth
HBV vaccine has been available since 1982 IV drug users
Clinical illness is relatively infrequent
Acute infection occurs in 1–2 per Hemophiliacs
Most (90%-95%) of those infected
are symptomatic and become chronic 10000 pregnancies Transfusion recipients
hepatitis B carriers Minimize exposure of close physical contact People with other sexually
Infants born to women who have Heptavax-B (pregnancy does not transmitted diseases or
hepatitis B infection during pregnancy contraindicate vaccination) multiple sex partners
should be given HBIG within 12 hours CDC recommends universal
of delivery screening of all prenatal
patients
Continued
320 unit three The Prenatal Journey
Cytomegalovirus DNA virus of the Transmitted horizontally Isolation of virus from urine Most infections are asymptomatic, but
(CMV) herpesvirus group by droplet infection and or endocervical secretions approximately 15% of adults have a
contact with saliva and mononucleosis-like syndrome
urine, vertically from characterized by fever, pharyngitis,
mother to fetus-infant, lymphadenopathy, and polyarthritis
and as a sexually
transmitted disease
Intimate contact with
infected secretions
(breast milk, cervical
mucus, semen, saliva,
tears and urine).
Transplacental
Organ transplacental
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 321
Continued
322 unit three The Prenatal Journey
ACOG, American College of Obstetricians and Gynecologists; AntiHBc, antibody to hepatitis B core antigen; CDC, Centers for Disease Control;
CID, cytomegalic inclusion disease; CNS, central nervous system; DNA, deoxyribonucleic acid; HBV, hepatitis B virus;
HIV, human immunodeficiency virus; HbsAg, surface antigen to HBC; HbcAg, core antigen to HBV; HbeAg, hepatitis B early antigen;
HBIg, hepatitis B immunoglobulin; IgG, immunoglobulin G; IgM, immunoglobulin M; IUGR, intrauterine growth restriction; IV, intravenous
Source: Moran, B. (2004). Maternal infections. In S. Mattson & J. Smith (Eds.), Maternal-child nursing core curriculum (3rd ed., pp 419-448).
Philadelphia: W.B. Saunders. Reproduced with permission.
Sickle
these conditions is very different, the importance of an
en
hemoglobin
at
(HbS)
io
Etiology Management
Streptococcus pneumoniae, Mycoplasma pneumoniae, Chla- Careful monitoring along with appropriate adjustments
mydia pneumoniae, and viruses (e.g., Influenza A and Vari- in therapy may be required to maintain maternal lung
cella) are the major causative agents. function and ensure an adequate oxygen supply to the
fetus. Failure to control asthma during pregnancy may
Effects on Pregnancy result in hypoxia in both the patient and her fetus. A
Pneumonia can complicate pregnancy at any time during PO2 of less than 60 mm Hg places the fetus in jeopardy
gestation. Maternal bacteremia, empyema, a need for (National Asthma Education and Prevention Expert
mechanical intervention, and death have all been reported. Panel, 2005). Guidelines for asthma management have
Pneumonia may be associated with poor fetal growth been developed to help ensure maternal–fetal safety and
(IUGR), preterm birth, and perinatal loss (Mandel & well-being during pregnancy. Goals of therapy include
Weinberger, 2004). optimal control of asthma symptoms; attainment of nor-
mal pulmonary function; prevention and reversal of
Management asthma attacks; and prevention of maternal and fetal
The normal physiological changes in the respiratory sys- complications (Guy, Kirumaki, & Hanania, 2004).
tem that occur during pregnancy result in a loss of ventila- Asthma therapy is based on a stepwise classification
tory reserve. These changes, coupled with pregnancy- system designed to control symptoms, avoid acute
related immunosuppression, place the woman and her attacks, and help patients achieve unhampered life
fetus at an increased risk for respiratory infection. Any styles (Kennedy, 2005).
pregnant patient suspected of having pneumonia should Medications currently used for asthma are generally
be managed aggressively with appropriate laboratory test- well tolerated during pregnancy and appear to be safe
ing, clinical surveillance, and medications. for the fetus. Therefore, the management of asthma
in the pregnant woman differs little from management
in the nonpregnant patient. It is also widely accepted
ASTHMA that the fetal risk is higher with poorly controlled
Asthma is the most common form of lung disease that maternal asthma than with medications necessary to
affects pregnancy; from 0.5% to 8% of pregnant women gain optimal symptom control. Nevertheless, nurses
have this condition (Gardner & Doyle, 2004). Asthma is must be aware of available data concerning the use of
characterized by a limitation of airflow that is generally these drugs during pregnancy (Gluck & Gluck, 2005;
more marked during expiration than during inspiration. Mandel & Weinberger, 2004).
The obstruction associated with asthma is a reversible pro-
cess caused by airway inflammation and an increased CYSTIC FIBROSIS
responsiveness of the airways to a variety of stimuli (e.g.,
Cystic fibrosis (CF) is a chronic, progressive, genetic mul-
dust, pollen, grass, and cold temperature). The airway
tisystem disease. It affects nearly 30,000 children and
response to the stimuli involves contraction of the bronchial
young adults, and occurs in approximately one out of every
smooth muscle, hypersecretion of mucus, and edema of the
3000 Caucasian live births (Brennan & Geddes, 2004). One
mucosal surfaces. Collectively, these events contribute to
thousand new cases are diagnosed each year, usually by the
the pathophysiological processes associated with the revers-
age of 3; however, nearly 10% of newly diagnosed cases
ible airway obstruction characteristic of asthma (Mandel &
involve individuals age 18 or older. Since CF is a recessive
Weinberger, 2004).
disorder, a child must inherit a defective gene from each
parent. Each time two CF carriers conceive, there is a 25%
Effects on Pregnancy
chance that the child will have CF; a 50% chance that the
Asthma is associated with significant risks for both the child will be a carrier; and a 25% chance the child will be a
patient and her fetus. Maternal complications reported noncarrier. One in 20 Americans (more than 20 million
among asthmatics include hyperemesis, vaginal bleeding, total) is an unknowing carrier of the defective gene for CF
hypertensive disorders, a predisposition to infections, ges- (Cystic Fibrosis Foundation, 2005).
tational diabetes, preterm rupture of the membranes and The last several decades have witnessed a dramatic
preterm labor, and delivery of a low-birth-weight infant. increase in the survival of patients with CF. This trend is
There is little risk to the fetus with well-controlled mater- attributable in large part to earlier diagnosis and interven-
nal asthma and it is safer for pregnant asthmatics to be tion, the introduction of pulmonary therapies such as
treated with appropriate medications than to have asthma dornase-alpha and high-dose ibuprofen, new airway clear-
symptoms and exacerbations. Exacerbations that cause ance techniques, effective antipseudomonal antibiotics
hypoxia and decreased uterine blood flow increase the such as tobramycin for inhalation, improved nutritional
incidence of intrauterine growth restriction (IUGR), pre- management, and dietary recommendations (Kulich et al.,
term birth, and neonatal mortality (Yancy, 2004). 2003). In the United States, the median survival age for
persons with CF has increased to 31.1 years for men and
Signs and Symptoms 28.3 years for women (Cystic Fibrosis Foundation, 2005;
A number of classic symptoms are associated with an Yankaskas, Marshall, Sufian, Simon, & Rodman, 2004).
exacerbation of asthma. These include dyspnea, coughing, An increasing number of women with CF are now surviv-
wheezing, voice changes, chest tightening, and the pres- ing into the reproductive years and, with meticulous man-
ence of scant or copious clear sputum. Lung auscultation agement of their pulmonary function, usually maintain
usually reveals bilateral expiratory wheezing. their fertility.
330 unit three The Prenatal Journey
• There is an increasing trend toward pregnancies in multiple hospitalizations over the years and be fearful of the
older women who are susceptible to heart diseases medical environment. Some of them never expected to bear
acquired in adulthood. children. Often, women with a history of rheumatic heart
• Immigration from underdeveloped nations has reac- disease have lived outside the traditional medical care sys-
quainted Western medicine with a cohort of young tem due to conditions of poverty and cultural differences.
childbearing patients who have rheumatic heart disease. Not uncommonly, they are recent immigrants. When caring
for any patient with special needs, it is imperative for the
Signs and symptoms of cardiac disease can be similar
nurse to collaborate with other health professionals and
to physiological changes that normally occur during
community support systems to facilitate the patient’s access
pregnancy. For example, the pregnant patient may
to care and to ensure her comfort with the health care envi-
experience heart palpitations associated with the nor-
ronment (Easterling & Otto, 2002).
mal increase in blood volume. Women with heart
disease may experience heart palpitations due to an
arrhythmia. Fatigue, a common complaint during preg- Optimizing Outcomes— Caring for the pregnant
nancy, may result from poor cardiac output and myo- woman with cardiac disease
cardial ischemia in patients with heart disease. The Antepartally, continuity of care with a single provider, fre-
incidence of maternal and fetal morbidity and mortality quent prenatal visits, routine screening for bacteriuria, and
associated with cardiac disease during pregnancy prophylaxis against anemia are essential. Intrapartal care
depends on the specific cardiac lesion, the functional includes the induction of labor when cervical favorability is
abnormality produced by the lesion, and the develop- present, the avoidance of prolonged labor, second stage
ment of pregnancy-related complications, such as infec- pushing and maternal blood loss, and prophylactic anti-
tion, hemorrhage, or preeclampsia (Yancy, 2004). biotics when the woman is at risk for endocarditis. Postpar-
Categories of cardiac disease during pregnancy tal care centers on strict management of blood volume and
include congenital cardiac disease (e.g., atrial septal careful but aggressive diuresis (Easterling & Otto, 2002).
defect, ventricular septal defect, pulmonic stenosis, con-
genital aortic stenosis, coarctation of the aorta, tetralogy
of Fallot, and Eisenmenger syndrome) and acquired Labor, birth, and the immediate postpartum period pro-
cardiac disease (i.e., lesions that are rheumatic in origin vide a time of increased risk due to the rapid volume
and valvular lesions such as mitral and aortic stenosis). changes that occur. During labor and birth, epidural anes-
Rheumatic mitral stenosis is the most common clini- thesia may be used for most patients with cardiac disease,
cally significant valvular abnormality in pregnant women but care must be taken to avoid hypotension. Positioning
and may be associated with pulmonary congestion, the patient in a lateral recumbent position as well as careful
edema, and atrial arrhythmias during pregnancy and administration of intravenous fluids will help to balance the
soon after childbirth. Ischemic cardiac disease (coro- patient’s blood pressure. Continuous invasive hemody-
nary artery disease and myocardial infarction) is rare in namic monitoring is beneficial in evaluating rapid changes
pregnancy. in heart rate, cardiac output, and pulmonary capillary
The New York Heart Association (NYHA) classification wedge pressure (PCWP) (an estimation of left atrial pres-
system is often used to assess the functional ability of the sure) so that fluid, diuretic, vasodilator, or pressor therapy
pregnant cardiac patient (Criteria Committee of the NYHA, may be guided (Setaro & Caulin-Glaser, 2004).
1979). Patient cardiac function is divided into four Medications that may be indicated for the pregnant cardiac
classes: patient include diuretics (e.g., Lasix) to prevent congestive
Class I The patient is asymptomatic and there is heart failure, digitalis, nitrates (to reduce after-load, the resis-
no limitation on physical activity. tance the ventricles must overcome to eject blood during
Class II The patient is asymptomatic at rest, symp- systole), antiarrhythmic agents (e.g., lidocaine), beta blockers
tomatic with heavy physical activity, and (e.g., labetalol), calcium channel blockers (e.g., nifedipine),
requires slight limitation of activity. antibiotics and anticoagulants (heparin–warfarin [Coumadin]
Class III The patient is asymptomatic at rest, symp- is contraindicated because it crosses the placenta). As with any
tomatic with minimal physical activity, and medication being considered for the pregnant patient, a thor-
physical activity is considerably limited. ough investigation of side effects and potential fetal harm must
Class IV The patient may be symptomatic at rest, is be evaluated before administration.
symptomatic with any activity, and has
severe limitations on physical activity. Nursing Insight— Recognizing cardiac effects of
Patients classified as NYHA I and II generally do well various obstetric drugs
during pregnancy, but those classified as III or IV have a
significantly increased risk of morbidity and mortality with Obstetric medications such as tocolytics and uterine stimulants
pregnancy. However, it must be remembered that any can have a major impact on circulatory function. Terbutaline,
patient with a cardiac history, regardless of classification, administered to suppress premature uterine contractions, may
must be thoroughly assessed for any signs of decompensa- stimulate the heart. Adverse effects include chest discomfort,
tion at each prenatal visit. dyspnea, irregular pulse, EKG changes, or pulmonary edema.
The nurse should question the use of this medication with any
patient with a cardiac history. Prostaglandin is a vasodilator
MANAGEMENT
and should not be used in patients with certain cardiac condi-
Management of cardiac disease in pregnancy is frequently tions. Oxytocin can cause hypertension and fluid retention and
complicated by unique social and psychological concerns. lead to congestive heart failure.
Patients with congenital heart disease may have experienced
332 unit three The Prenatal Journey
The nurse needs to assess the patient for signs and symptoms of PERIPARTUM CARDIOMYOPATHY
decreased cardiac output: Peripartum cardiomyopathy (PPCM) is a rare syndrome
• Decreased and/or irregular pulse of heart failure that occurs in late pregnancy or within the
• Increased respiratory rate first 5 months postpartum. The patient typically has no
• Dyspnea history of cardiac disease and presents with dyspnea,
• Chest pain fatigue, and peripheral or pulmonary edema. Radiological
• Abnormal breath sounds: crackles at the base of the lungs findings are consistent with cardiomegaly. Acute treat-
• Decreased blood pressure ment is directed at improving cardiac function. Treatment
• Decreased urinary output (less than 30 mL/hr)
• Edema of the hands, face and feet
includes diuretics to decrease preload and relieve pulmo-
• Abnormal heart sounds: diastolic murmur at the heart’s apex nary congestion; digoxin to improve contractility and
• Signs of air hunger: anxiety facilitate rate control when atrial fibrillation is present;
beta-adrenergic blockers; anticoagulation with heparin if
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 333
the woman is antepartum and Coumadin if postpartum; Type 2 diabetes, the most prevalent form of the disease,
and fluid and sodium restriction (Easterling & Otto, is characterized by a combination of insulin resistance and
2002; Klein & Galan, 2004). inadequate insulin production (ECDCDM, 2003). Char-
The mortality rate associated with peripartum cardio- acteristics of type 2 diabetes include:
myopathy is reported to be 25% to 50%. Within 6 months
• It is diagnosed primarily in adults older than age 30,
after childbirth, half of the patients will demonstrate reso-
but with the current obesity epidemic, it is now seen
lution of left ventricular dilation. Of those who do not,
in children.
8.5% will die within 4 to 5 years. Death is usually due
• The disease is typically symptom free for many years,
to progressive heart failure, arrhythmia, or thromboembo-
with a slow onset and a gradual progression of
lism (Easterling & Otto, 2002).
symptoms.
• Individuals with type 2 are not ketosis prone.
Now Can You— Discuss cardiac complications during • It does not always require insulin and can often be
pregnancy? treated with diet, exercise, and/or oral hypoglycemic
agents.
1. Describe the normal anatomical and physiological changes
that occur in the cardiovascular system during pregnancy GDM is an impairment in carbohydrate metabolism
and their impact on the pregnant woman with a cardiac that first manifests during pregnancy. This category may
disease? include a small number of previously undiagnosed type 1
2. State three important factors in the management of cardiac and type 2 diabetic women. The following characteristics
disease in pregnancy? apply (ECDCDM, 2003):
3. Identify team members you would include in your plan of care?
• Estimated to occur in approximately 4% to 7% of
pregnancies; however, the prevalence may range from
1% to 14%, depending on the population studied and
Diabetes in Pregnancy the diagnostic test used (ADA, 2006).
• Develops in the latter half of pregnancy as a result of
Diabetes during pregnancy encompasses a range of disease the altered hormonal milieu (Kenshole, 2004).
entities that include gestational diabetes mellitus (GDM) • Symptoms are usually mild and not life threatening.
and overt diabetes mellitus. Diabetes complicates more • May be treated by either diet or insulin, depending on
than 200,000 pregnancies each year in the United States the blood glucose levels.
(American Diabetes Association [ADA], 2006; Wallerstedt • Women diagnosed with GDM are at an increased risk
& Clokey, 2004). Diabetes is a complex health care prob- for developing diabetes later in life.
lem that requires a comprehensive, multidisciplinary
approach to ensure a healthy outcome for both the patient RISK FACTORS FOR GESTATIONAL DIABETES
and her infant. When working with this population, peri- • Women older than 25 years of age
natal nurses are challenged to provide care and education • Obesity
that incorporates diabetes management principles into • Insulin resistance
obstetric care during all phases of childbearing, from pre-
• Polycystic ovary syndrome
conception through the postpartum period.
• History of pregnancy-related diabetes mellitus
• History of a large-for-gestational age infant,
DEFINITION AND CLASSIFICATION OF DIABETES hydramnios
MELLITUS • Stillbirth, miscarriage, or an infant with congenital
Pregestational diabetes mellitus is a chronic metabolic anomalies during a previous pregnancy
disease characterized by hyperglycemia that results from • Family history of type 2 diabetes (first-degree relative)
limited or absent insulin production, deficient insulin action, • Ethnicity
or a combination of the two (Expert Committee on the
Diagnosis and Classification of Diabetes Mellitus [ECDCDM], Ethnocultural Considerations— Gestational
2003). Diabetes is divided into two broad categories— Diabetes
type 1 and type 2—that are differentiated according to the
primary underlying etiology. Type 1 diabetes (formerly An increased incidence of gestational diabetes occurs in
termed “insulin-dependent diabetes mellitus,” or IDDM), is Native Americans, African Americans, Hispanic Americans,
characterized by an autoimmunity directed at the pancreatic Asian Americans, and Pacific Islanders (ADA, 2006).
beta cells. With Type 1 diabetes, there is an absolute insulin
deficiency and the following characteristics are typically
present (ECDCDM, 2003): PATHOPHYSIOLOGY
• It is usually diagnosed in those younger than 30 years The body requires a constant source of energy, provided
of age. mainly by glucose. Once glucose enters a cell, it may
• Acute symptoms precede the diagnosis and include undergo oxidative (glycolysis) or nonoxidative metabolism
polyuria, polydipsia, and significant weight loss. (glycogen synthesis). In response to glucose ingestion, the
• It has an abrupt onset that requires emergency medical pancreatic beta cells of the islets of Langerhans secrete insu-
attention. lin, a hormone that promotes the uptake of glucose into the
• It accounts for approximately 10% of those diagnosed cells. The regulation of plasma glucose levels and the entry
with diabetes. of glucose into the cells are of critical importance.
334 unit three The Prenatal Journey
Changes in carbohydrate, protein, and fat metabolism cesarean birth are increased. In the long term, GDM is also
in normal pregnancy are profound, mediated in part by associated with impaired insulin tolerance and the manifes-
the developing fetus and the production of placental hor- tation of diabetes in later life (Cunningham et al., 2005).
mones. The first half of pregnancy is considered an “ana- Major fetal effects associated with diabetes include a
bolic phase.” It is associated with an increased storage of fivefold increase in perinatal death and a two to threefold
fat and protein, along with an increase in the secretion of increase in the rate of congenital malformations. Early in
estrogen and progesterone. These physiological events pregnancy, the fetus is at risk for congenital malforma-
lead to maternal hyperplasia and hyperinsulinemia. The tions and poor fetal growth. The risk of major congenital
increased insulin production prompts an increased tissue defects is 4% to 8% greater with type 1 or 2 diabetes. Con-
response to insulin and the increased uptake and storage genital defects result from the teratogenic effects of hyper-
of glycogen and fat in the liver and tissues. glycemia during the time of organogenesis during the
The second half of pregnancy is characterized by a early gestational weeks. Late in pregnancy, the fetus is at
“catabolic phase” associated with the breakdown of pro- risk for growth abnormalities and sudden intrauterine
tein and fat. During this time there is also an increased death (Cunningham et al., 2005).
insulin resistance due to the heightened production of Control of maternal glucose levels (7.0% in overtly
placental hormones (insulinase and human placental lac- diabetic women) is an important factor in determining fetal
togen), cortisol, and growth hormones. These hormones outcome. The glycosylated hemoglobin A1c (HbA1c) level
are diabetogenic and act as insulin antagonists. In women is commonly assessed to guide adjustments in the treat-
who cannot meet the increasing needs for insulin produc- ment plan throughout pregnancy. Since the maternal serum
tion, this change leads to an altered carbohydrate metabo- HbA1c reflects the degree of glycemic control during the
lism and progressive hyperglycemia. preceding 5 to 6 weeks, the test is repeated every trimester.
During this time, the developing fetus continuously Good diabetic control is reflected by a HbA1c value of 2.5%
removes glucose and amino acids, substances that can eas- to 5.9%; a HbA1c value greater than 8% is indicative of poor
ily cross the placenta, from the maternal circulation. diabetic control. In the absence of pre-pregnancy and pre-
Because insulin does not cross the placenta, the fetus must natal care, the rate of perinatal mortality for the diabetic
increase its own insulin production. Fetal hyperinsu- patient and her fetus may be as high as 40%. However, with
linemia develops and acts as a growth hormone that con- close, meticulous care, the perinatal mortality rate can be
tributes to an increase in fetal size (macrosomia), and a reduced to 3% to 5% (Cunningham et al., 2005).
decrease in pulmonary surfactant production. Macroso-
mia occurs in 20% to 25% of diabetic pregnancies. When Ketoacidosis
the pregnant woman’s blood glucose levels remain abnor- Diabetic ketoacidosis (DKA) is an accumulation of ketones
mally elevated, there is a constant transport of maternal in the blood that results from hyperglycemia. This condi-
glucose across the placenta. This “glucose load” prompts tion, which can lead to metabolic acidosis, has become a
the fetus to produce insulin at a greater rate in order to less common occurrence since the implementation of
utilize the glucose. meticulous antenatal care and protocols that stress the
strict metabolic control of maternal blood glucose levels.
Early recognition of the signs and symptoms of DKA helps
Nursing Insight— Anticipating changes in to improve both maternal and fetal outcome. As occurs in
insulin needs during pregnancy the nonpregnant state, clinical signs of volume depletion
During the first trimester, maternal blood glucose levels are follow the symptoms of hyperglycemia, which include
normally reduced and the insulin response to glucose is polydipsia and polyuria. Malaise, headache, nausea, and
enhanced. The woman with well-controlled pregestational dia- vomiting are common patient complaints. A distinctive
betes may need a decrease in her insulin dosage to avoid hypo- feature of diabetic ketoacidosis during pregnancy is that it
glycemia. During the second and third trimesters, as the insulin can occur with remarkably low blood glucose levels
requirements steadily increase, the insulin dosage must be (barely exceeding 200 mg/dL, compared with 300 to
adjusted to prevent hyperglycemia. Maternal insulin resistance 350 mg/dL in the nonpregnant state) and requires emer-
begins around 14 weeks of gestation and continues to increase gency management to prevent maternal coma or death.
until it stabilizes during the final weeks of pregnancy. Ketoacidosis that occurs at any time during pregnancy
may result in fetal death and it is a common cause of pre-
term labor (Cunningham et al., 2005).
MATERNAL AND PERINATAL MORBIDITY
AND MORTALITY clinical alert
The changes in the maternal milieu that characterize the
Maternal diabetes and preterm labor
diabetic state can have profound effects on the growth and
development of the fetus, increase the risk of perinatal mor- Magnesium sulfate is the drug of choice for diabetic women who
bidity and mortality, and exert adverse effects throughout experience preterm labor. The use of terbutaline sulfate (Brethine)
or antenatal corticosteroids to accelerate fetal lung maturation can
life. The physiological adaptations induced by pregnancy cause significant maternal hyperglycemia and precipitate DKA.
can unmask latent maternal diabetes or result in transient Patients must be closely followed in an acute care setting for at
worsening of preexisting vascular compromise (Kenshole, least 48 to 72 hours after corticosteroids have been given. An
2004). Diabetic women are four times more likely to develop intravenous insulin infusion will usually be required and is adjusted
preeclampsia or eclampsia than are nondiabetic women and on the basis of frequent capillary glucose measurements (Landon,
twice as likely to experience a spontaneous abortion. The Catalano, & Gabbe, 2002).
rates of infection, hydramnios, postpartum hemorrhage, and
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 335
MANAGEMENT
The goal of modern glycemic management during the
The Thyroid Gland and Pregnancy
diabetic pregnancy is to maintain blood glucose levels as Thyroid disorders are relatively common among pregnant
close to normal (euglycemia) as possible. Euglycemia is a women. The hormonal changes and increasing metabolic
normal blood glucose level in the range of 65 to 105 mg/ demands of pregnancy bring about complex compensa-
dL preprandially. Two-hour postprandial blood glucose tory alterations in maternal thyroid function. Human
levels should be less than 130 mg/dL (ADA, 2006). Meta- chorionic gonadotropin (hCG), which is at its highest
bolic monitoring during pregnancy is directed at detecting levels in early pregnancy, possesses intrinsic, weak thy-
hyperglycemia and making all necessary pharmacological, roid-stimulating activity. Thyroid-stimulating hormone
dietary, or activity adjustments in order to minimize any (TSH) levels fall during the first trimester, and this
adverse effects to the fetus. Home blood glucose monitor- decrease parallels the rise in the production of hCG.
ing with a glucose reflectance meter or biosensor monitor
is a widely accepted method for monitoring blood glucose HYPERTHYROIDISM
levels and an essential tool for helping the woman to
assess her degree of blood glucose control. Patients moni- Signs and Symptoms
tor their blood glucose levels daily, record the findings, The signs and symptoms of mild to moderate hyperthyroid-
and bring their blood glucose logs with them to each pre- ism are common during pregnancy (heat intolerance, dia-
natal appointment. phoresis, fatigue, anxiety, emotional lability, tachycardia,
336 unit three The Prenatal Journey
Nursing Diagnosis: Nutrition, Imbalanced: Less than Body Requirements related to impaired carbohydrate
metabolism during pregnancy
Measurable Short-term Goal: The patient will plan a balanced diet and exercise program to follow during
pregnancy
Measurable Long-term Goal: The patient will obtain and metabolize sufficient nutrients for maternal and fetal
needs and to maintain appropriate blood glucose levels during pregnancy
NOC Outcomes: NIC Interventions:
Diabetes Self-Management (1619) Personal actions Nutrition Therapy (1120)
to manage diabetes mellitus and prevent disease Nutrition Counseling (5246)
progression.
Nutritional Status: Nutrient Intake (1009)
Adequacy of usual pattern of nutrient intake.
Nursing Interventions:
1. Assess the patient’s understanding of gestational diabetes and provide additional information as needed about
changes in carbohydrate metabolism during pregnancy and how these may affect the patient and her fetus.
RATIONALE: Teaching is based on the patient’s need for information to help promote active participation in self
care.
2. Refer patient to a registered dietician and reinforce the recommended diet parameters with patient at each
visit: an additional 300 calories per day are needed in the second and third trimesters; 40–50% from complex
carbohydrates, 10–20% from protein, and 30% from fats; avoid concentrated sweets; nutrients should be
divided each day between three meals and three snacks.
RATIONALE: The diet is planned to maintain a normoglycemic state during pregnancy based on the patient’s
lifestyle and individual food preferences.
3. Encourage the patient to engage in 30 minutes of daily exercise appropriate for her pregnancy such as
walking or swimming.
RATIONALE: Regular exercise helps maintain lower blood glucose levels
4. Ask patient to keep a daily log of her diet and exercise. Review at each prenatal visit and offer support and
encouragement to continue regimen.
RATIONALE: A written log allows the patient to monitor her own progress as well as providing a record of
interventions to compare with blood glucose levels.
5. Inform patient that she will need to have her blood glucose checked weekly in the office and if it is still high
after about 2 weeks of diet and exercise, she may need to begin insulin therapy.
RATIONALE: Dietary changes and exercise may not be enough to maintain carbohydrate balance. Anticipatory
guidance helps motivate the patient and prepare her for possible change.
6. Monitor fetal growth and well-being. Instruct patient in a method for fetal kick counts beginning at 28 weeks
and prepare her for weekly NSTs from 34 weeks until birth.
RATIONALE: Maternal hyperglycemia may result in fetal macrosomia. The fetus of a diabetic mother is at higher
risk for complications.
and a wide pulse pressure). However, weight loss, tachycar- prompt diagnosis of hyperthyroidism is imperative because
dia greater than 100 beats per minute, and diffuse goiter are of the potential for serious maternal and fetal complications.
clinical features suggestive of hyperthyroidism. Gastrointes- Research suggests that uncontrolled hyperthyroidism dur-
tinal symptoms (i.e., severe nausea, excessive vomiting, ing pregnancy may be associated with increased preeclamp-
and diarrhea), cardiomyopathy, lymphadenopathy, and sia, preterm labor, low birth weight, and neonatal mortality
congestive heart failure can also accompany thyrotoxicosis (Cunningham et al., 2005; Nader, 2004).
(excessive thyroid activity) in pregnancy (Cunningham
et al., 2005; Nader, 2004). Establishing a diagnosis of mater- Treatment
nal hyperthyroidism can be challenging due to the myriad of Treatment for hyperthyroidism includes the use of
metabolic and hormonal changes that normally take place antithyroid medications such as the thioamides, propyl-
during pregnancy. However, a depressed maternal serum thiouracil (PTU—the drug of choice), or methimazole
TSH concentration and an elevated free thyroxine (T4) level (Tapazole). Symptomatic improvement usually occurs
are useful in confirming the diagnosis. Although difficult, within 2 weeks after the initiation of therapy although the
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 337
Diabetes type__________________ Age @ diagnosis ____________ Expected date of confinement ________________ Educator _________________
Blood pressure ______________ Height _________ Weight __________Urine: Protein _______ Glucose_______ Ketone ______
Glucose tolerance test: Fasting blood sugar ______ 1h ______ 2h ______ 3h ____________________________________________________________
Understands effect pregnancy has on diabetes control, including role of placental hormones
Understands potential outcomes of uncontrolled blood glucose—macrosomia, polyhydramnios, respiratory distress syndrome,
preterm delivery, intrauterine fetal death, neonatal hypoglycemia, ketoacidosis, birth trauma, cesarean delivery
Understands significance of hemoglobin A1C for spontaneous abortion and congenital defects
Identifies timing of injection, injection sites, rotation and technique, and appropriate syringe disposal
Has support person with knowledge of glucagon use and appropriate administration—provided Rx with two refills
Identifies signs and symptoms of ketoacidosis; reports persistent nausea/vomiting, illness, infection, persistent hypcrglycemia,
or recurrent insulin reactions
Checks ketones daily with first void (pregestational) and with blood glucose values >180 mg/dL
Understands significance of GDM for future pregnancy, development of overt diabetes mellitus later in life, appropriate
follow-up, need for follow-up testing, preconception control, and risk-minimizing interventions
Understands significance of diabetes and development of long-term complications related to poor control
• Many women experience relapse or worsening of • Referring the woman to community resources such as
symptoms if pharmacologic treatment is not continued home health visitation and the local mental health
or instituted when necessary. (Maternal anxiety and agency
stress have been shown to have adverse effects on
pregnancy outcome, infant/child neurodevelopment, — When screening for depression
and maternal postnatal mental health.) during pregnancy
to the fetus or child (Kearney, Wellman, & Freda, 1999). ultrasound guidance, a needle is inserted through the
Nurses in prenatal care and acute care settings are respon- maternal abdomen and into the fetal umbilical cord. Use of
sible for thoroughly assessing psychosocial risks and con- a fetal blood sample for karyotyping allows for more rapid
ducting mutual goal setting with pregnant patients to test results than when fetal skin cells are used, as with
minimize the harm associated with these risks. Support amniocentesis. Complications include cord laceration,
and respect should be offered regardless of the woman’s thromboembolism, preterm labor, premature rupture of the
decisions about her health care or self-care. A nonjudg- membranes, and infection (Jenkins & Wapner, 2004).
mental, concerned, and empathetic environment should
be provided so that the patient feels encouraged to express AMNIOCENTESIS
her feelings and concerns about herself, her drug use, and
Amniocentesis is an invasive procedure that involves the
her unborn child (Kearney et al., 1999; Moran, 2004b).
removal of amniotic fluid. Under ultrasound guidance, a
needle is inserted through the maternal abdomen and into
Now Can You— Discuss issues associated with substance
abuse during pregnancy?
the amniotic sac (Fig. 11-12). Amniocentesis may be per-
formed beginning at 12 weeks’ gestation. Components of
1. Name five behaviors that may signal a substance abuse the amniotic fluid, including fetal cells, may be analyzed
problem? for chromosomal abnormalities, fetal lung maturity, infec-
2. Discuss how substance abuse can affect the course and tion, and the presence of bilirubin in Rh-sensitized preg-
outcome of pregnancy? nancies. Later in the pregnancy, amniotic fluid reduction
3. Discuss the ethical dilemmas faced by the perinatal nurse (via amniocentesis) may be performed for temporary alle-
who is caring for the pregnant woman with a substance viation of maternal symptoms associated with hydramnios
abuse problem? (excessive amniotic fluid). Complications associated with
amniocentesis include rupture of the membranes, preterm
labor, infection, fetal injury, and fetal death. If the woman
has Rho(D)-negative blood, Rho(D) immune globulin
Antepartum Fetal Assessment should be administered following the amniocentesis to
prevent isoimmunization.
Fetal assessment is an integral component of prenatal Amniocentesis is frequently performed late in preg-
care. Careful assessment of fetal well-being enhances peri- nancy to provide information concerning fetal lung matu-
natal outcome through early identification and interven- rity. Lecithin and sphingomyelin are the protein compo-
tion for fetal compromise. The goal of antepartum fetal nents of surfactant, the lung enzyme that is formed by the
surveillance is to prevent fetal death and to help ensure alveoli beginning around the 22nd week of gestation.
the best possible fetal outcome. A number of tests can be After amniocentesis, the lecithin/sphingomyelin ratio
performed during pregnancy to monitor fetal growth, (L/S ratio) may be quickly determined by a “shake test” or
development, and well-being. Antenatal assessment dur- sent to the laboratory for a quantified analysis. An L/S
ing the first and second trimester is directed primarily at ratio of 2:1, which typically occurs by 35 weeks’ gestation,
the diagnosis of fetal congenital anomalies while the goal is traditionally accepted as lung maturity (a ratio of 3:1 in
of third trimester assessment is to determine the quality of the infant of a diabetic mother).
the intrauterine environment for the maturing fetus. Phosphatidylglycerol and desaturated phosphati-
dylcholine are two other compounds that are found in
CHORIONIC VILLUS SAMPLING surfactant after approximately 35 to 36 weeks of gesta-
tion. Since these two substances are present only with
Chorionic villus sampling (CVS) is an invasive procedure
that can be used to obtain a fetal karyotype. Because the villi
arise from trophoblast cells, their chromosome structure is Amniotic
identical to that of the fetus. CVS is performed between Amniotic fluid
10 and 12 weeks’ gestation and results are available quickly cavity
due to the rapid proliferation of the chorionic villi cells. Skin Fascia Ultrasound guide
Using ultrasound guidance to locate the chorion cells, a thin 90° Uterine wall
catheter is inserted vaginally into the intrauterine cavity. An Bladder empty
alternative technique involves the abdominal or intravaginal
insertion of a biopsy needle. A small quantity of chorionic
villi is then aspirated from the placenta. The risk of compli-
cations associated with CVS is 1 in 200. Risks include infec-
tion (in 0.5% of cases), fetal loss (in 0.3% of cases), rupture
of membranes (in 0.1% of cases), Rh isoimmunization, and
possible fetal limb reduction (Gilbert & Harmon, 2003).
lung maturity, their presence in the amniotic fluid sample pregnancy), and locate the presence of an intrauterine
is another indicator that respiratory distress syndrome contraceptive device. Fetal heart rate activity can be
will not occur in the neonate. observed as early as 6 to 7 weeks via real-time echo sonog-
raphy. In the second and third trimesters, ultrasound is
ADDITIONAL INVASIVE TESTS frequently used to confirm fetal viability and gestational
age, monitor fetal growth, AFV, placental location and
Amnioscopy
maturity, and assess uterine fibroid tumors and cervical
Amnioscopy involves the use of an amnioscope (a small length. Serial measurements are useful in providing an
fetoscope) to visually inspect the amniotic fluid through accurate determination of fetal age. Ultrasound is an
the cervix and membranes. Most often this procedure is essential component of the biophysical profile and fetal
performed to detect meconium staining. It carries a risk of Doppler studies (discussed later).
membrane rupture.
Fetoscopy Optimizing Outcomes— Accurately determining fetal
Fetoscopy is a method of visualizing the fetus with a feto- age with ultrasonography
scope, an extremely narrow, hollow tube inserted through Ultrasonography examinations provide an accurate esti-
an amniocentesis technique. It is sometimes used to assess mate of fetal age during the first 20 weeks of gestation
fetal well-being, obtain fetal tissue and blood samples, and because most normal fetuses grow at approximately the
perform fetal surgery, but not before 17 weeks of gesta- same rate. Throughout the gestational period, fetal age
tion. The procedure carries a risk of premature labor and determination may be made by the following sonographic
infection. measurements: (1) gestational sac dimensions (around
8 weeks); (2) crown–rump length (CRL) (around 7–12
ULTRASONOGRAPHY weeks); (3) biparietal diameter (BPD) (after 12 weeks);
Ultrasonography is the use of high-frequency (20,000 and (4) femur length (after 12 weeks). The accuracy of
Hz) sound waves to detect differences in tissue density and gestational age assessment increases as the fetus ages
visualize outlines of structures in the body. Widely used in because more than one structure is measured.
modern obstetrics, ultrasonography is an important com-
ponent of antepartum fetal assessment and surveillance.
The examination can be done abdominally (after applica- KICK COUNTS
tion of a transmission gel, a transducer is moved over the
skin) or transvaginally (a lubricated transducer probe is Counting fetal movements or “kick counts” has been pro-
placed in the vagina) during pregnancy. The abdominal posed as a primary method of fetal surveillance for all preg-
technique is more useful after the first trimester when the nancies. This method of fetal assessment has many benefits.
gravid uterus becomes an abdominal organ. The sound It is easy to perform, readily available to the woman, and
frequencies that bounce back from the uterus are displayed has no associated costs. The patient is instructed to lie on
on an oscilloscope screen as a three-dimensional visual her side and count the number of times that she feels the
image. During the painless examination, the patient should fetus move. Many variations have been developed but there
be positioned so that she (and her support person, if pres- are two major methods for performing kick counts:
ent) can observe the images, if they wish to do so. • The first method is done while the woman lies on her
side. She counts and records 10 distinct movements in
Nursing Insight— Levels of ultrasonography a period of up to 2 hours. Once 10 movements have
been perceived, the count may be discontinued.
There are three levels of ultrasonography examinations: stan- • With the second method, the patient counts and
dard, limited, and specialized. records fetal movements for 1 hour three times
Ultrasonographers or other health care professionals who per week. The count is to be considered reassuring
have received special training may perform the standard if it equals or exceeds the woman’s previously estab-
examination, which is used to detect fetal viability, assess the lished baseline.
gestational age, determine the presentation of the fetus, locate
the placenta, assess amniotic fluid volume (AFV), and exam- DOPPLER ULTRASOUND BLOOD FLOW
ine the fetus for certain anatomic abnormalities. The limited STUDIES (UMBILICAL VELOCIMETRY)
examination is performed for a specific indication, such as
Doppler ultrasound is used to study blood flow in the
determining the fetal presentation during labor or evaluating
umbilical vessels of the fetus, placental circulation, fetal
fetal heart activity when it cannot be detected by other meth-
cardiac motion, and maternal uterine circulation. This
ods. The specialized examination is performed to evaluate a
technology is useful in managing pregnancies at risk
fetus suspected to have an anatomical or physiological abnor-
because of hypertension, diabetes mellitus, IUGR, multi-
mality. This level of examination is generally performed by
ple fetuses or preterm labor. A noninvasive Doppler wave
specialists in high-risk perinatal centers (ACOG, 2004).
measures the velocity of red blood cell movement through
the uterine and fetal vessels. Assessment of the blood flow
During the first trimester, ultrasound may be used to through the uterine vessels is useful in determining vascu-
confirm the viability and age of the pregnancy, determine lar resistance in women at risk for developing placental
the number, size, and location of the gestational sacs, insufficiency. Decreased velocity is associated with poor
identify uterine abnormalities (and rule out an ectopic neonatal outcome (Jasper, 2004).
342 unit three The Prenatal Journey
patient and her partner by encouraging them to express Prenatal medical and behavioral risk factors can severely
their emotional concerns, by keeping them informed of complicate adolescent pregnancy and result in poor birth
changes in the woman’s condition and by encouraging outcomes, particularly when late or inadequate prenatal
them to ask questions. care occurs. Prenatal medical and behavioral risks for the
Depending on the circumstances, the postpartum period adolescent population include (Gilliam, Tapia, & Gold-
may be very difficult as well, due to physical and emotional stein, 2003):
exhaustion, especially if antenatal hospitalization was
• Preterm labor and birth—especially when combined
required. Adverse symptoms associated with weeks of bed
with low socioeconomic status, single parent, smoker,
rest are often not resolved by 6 weeks postpartum (Maloni
illicit drug use, pre-pregnant weight less than 100 lbs.
& Park, 2005). The woman may not be able to care for her
(45.5 kg), poor weight gain during pregnancy, and
infant as she would like, and this situation can quickly lead
inadequate prenatal care.
to feelings of helplessness, frustration, and disappointment.
• Anemia
The nurse needs to remain supportive, conduct an ongoing
• Preeclampsia/eclampsia
assessment of the family’s coping skills, monitor the extent
• Repeated exposure to sexually transmitted infections
of maternal–infant attachment, and engage the appropriate
• Chronic or asymptomatic urinary tract infections
hospital and community resources.
• Acute pyelonephritis
• Intrauterine growth restriction
Now Can You— Discuss care for the patient on antenatal
bed rest? The nurse’s need for good communication skills when
1. State six complications of antenatal bed rest? working with adolescents cannot be overstated since these
2. Formulate a plan of care to meet the physiological, young women often lack trust in medical personnel and
psychological and social needs of the pregnant patient on fear that their behaviors might be judged. Without good
bed rest? communication, the nurse is unable to make an accurate
3. Identify team members to be included in your plan of care assessment of the adolescent’s knowledge about the
when caring for the pregnant patient on bed rest? importance of quality, consistent prenatal care. Without
4. Describe how antenatal bed rest can affect the patient after good communication, the professional nurse–patient rela-
childbirth (postpartum)? tionship is neither established nor developed and the pre-
natal plan of care is jeopardized.
trauma incidents. About 50% of fetal deaths result from teratogenic effects from the anesthetic agents. The risk
maternal trauma, and most of these are due to motor of spontaneous abortion associated with maternal surgery
vehicle accidents (Mattox & Goetzl, 2005). Blunt trauma is approximately 8% during the first trimester and 6.9%
is caused by the following conditions (Haney, 2004): in the second trimester. Extra-abdominal surgery is less
likely to be complicated by spontaneous abortion
• Motor-vehicle collisions in which force is applied to
(Burtness, 2004; Callahan, 2004).
the abdomen from direct impact or as a result of sec-
ondary injury from abdominal organs. Abruption of
the placenta and/or preterm labor may result from the CANCER DURING PREGNANCY
trauma. The incidence of cancer is low during the childbearing
• Accidental falls are usually more common in the third years. During pregnancy, the incidence of cancer is similar
trimester as the woman’s center of gravity becomes to that of nonpregnant women of childbearing age. Can-
increasingly displaced. cer complicates 1 out of 1000 pregnancies and accounts
• Assaults involving intimate partner violence (the for 5% of deaths that occur during pregnancy. Because
incidence increases during pregnancy), gunshot and more women today choose to delay childbearing, the
stabbing wounds. co-occurrence of pregnancy and cancer may increase
(Burtness, 2004). The prognosis best correlates with the
Optimizing Outcomes— Considerations when caring anatomic extent of the disease at the time of diagnosis.
for the obstetric trauma patient Cancer in the pregnant woman does not appear to metas-
tasize to the fetus because of the placenta’s effectiveness
Maternal stabilization is the initial goal in resuscitation. as a barrier against spread and also because the fetus may
Resuscitation during pregnancy proceeds as with any other be capable of resisting the invasion of malignant cells.
trauma. Trauma in pregnancy involves at least two patients During pregnancy the diagnosis of cancer can be dif-
(more in the case of multiple gestation). The fetal heart ficult for the following reasons: many of the presenting
rate is often the first vital sign to change. All pregnant symptoms of cancer are often attributed to the preg-
trauma patients need continuous fetal monitoring. Risk nancy; many of the physiologic and anatomic alterations
factors predictive of fetal death include ejection during an of pregnancy can compromise the physical examination;
automobile crash, motorcycle and pedestrian collisions, many serum tumor markers (-hCG, fetoprotein, CA
abnormal heart fetal heart rate patterns, maternal tachycar- 125) are normally increased during pregnancy; and the
dia, and maternal death (Haney, 2004). ability to perform either imaging studies or invasive
diagnostic procedures is often altered (Gabbe, Niebyl, &
Simpson, 2007).
Care of the pregnant patient with cancer is related a
Be sure to— Take care with documentation number of factors:
Document your nursing care by writing accurate and fac- • Gestational age of the pregnancy
tual notes. Make certain you have described your assess- • Stage of the cancer and the associated prognosis
ment, plan of care, interventions, and evaluation for your • Potential for the cancer treatment to have adverse
plan of care. Frequently, trauma cases involve litigation. effects on the fetus, including the potential for long-
Well-documented records protect both the patient and the term occult problems
health care system. • Risk to the patient of delaying therapy to permit fetal
viability
• Risk to the fetus of early delivery to allow more timely
cancer therapy; and the possible need to terminate an
SURGERY DURING PREGNANCY early pregnancy to allow an optimal opportunity to
Surgery for nonobstetric reasons occurs in about 1% to 2% treat the patient and cure the malignancy.
of pregnant women. This figure is most likely an underes-
timated number since many women may not know that
they are pregnant at the time of surgery (Callahan, 2004). OBESITY
Obesity has reached epidemic proportions in the United
Maternal and Fetal Risks During Surgery States, and nearly one third of reproductive-aged women
Anesthetic considerations are of prime importance when are considered to be obese. In pregnancy, obesity is associ-
surgery becomes necessary during pregnancy. General ated with a higher incidence of antepartum complications
anesthesia is a more complex issue during pregnancy such as diabetes and hypertension, and with peripartum
because of the increase in maternal blood volume and complications including macrosomia, prolonged labor,
cardiac output. Surgery risks are related to the possibility of shoulder dystocia, and higher cesarean rates. Cesarean
increased maternal morbidity associated with pregnancy- delivery is often complicated by excessive operative blood
induced changes in the cardiovascular, respiratory, hema- loss (greater than 1000 mL), difficult anesthesia intuba-
tologic, and gastrointestinal systems. Normal physiolo- tions and operative times greater than 2 hours duration.
gical changes that occur during pregnancy can adversely Postoperative wound complications, including infection,
affect the use of anesthesia and the safety of the surgical delayed healing, operative injury, the need for blood
procedure. Surgery carries a possibility of increased fetal transfusions, thromboembolism, and hysterectomy are
risks due to an intraoperative decrease in uteroplacental also increased in obese women and result in prolonged
blood flow (leading to fetal hypoxia), along with possible hospitalization and increased costs.
346 unit three The Prenatal Journey
help teenagers with violence only if they know that the 2. The perinatal nurse uses the acronym “SPASMS”
teenagers are experiencing it. Thus, nurses need to be able to teach a new nurse about preeclampsia. The “P”
to gain their young patients’ trust and confidence so that refers to:
they feel comfortable sharing their problems. Assessment, A. Pregnancy
safety planning, documentation, and follow–up are all B. Proteinuria
essential components of providing care for women who C. Pelvic circulation
are experiencing violence, no matter what their age. The D. Pressure
medical record is often the source of information that can
raise suspicions of abuse, and a number of assessment True or False
forms specifically designed to elicit information regarding 3. The perinatal nurse knows that the most common
patterns of abuse have been developed. (See Chapter 9 for medical complications of pregnancy are those related
further discussion.) to hypertension.
Now Can You— Discuss abuse during pregnancy? 4. The perinatal nurse is aware that the most accurate
determination of gestational age is based on the date
1. Explain why pregnancy is often the trigger for the beginning of the last menstrual period and an early ultrasound
or escalation of intimate partner violence? examination.
2. Describe the body areas that are usually targeted during
pregnancy? Select All that Apply
3. Discuss your nursing plan of care when you suspect that
your patient has been abused?
5. The clinic nurse recognizes that a woman’s risk
factors for an ectopic pregnancy include:
A. The use of oral contraceptive pills
B. A previous history of a dilatation and curettage
C. A history of Chlamydia trachomatis infection
s umma ry p o in t s D. A history of rubella
◆ Complications that arise during pregnancy are often 6. The perinatal nurse provides additional time for the
challenging and demand the perinatal nurse’s skills, clinic appointment for Janet and her partner. Janet
knowledge, and expertise, combined with the nursing has just experienced a spontaneous abortion. The
process, to first identify the pregnant patient at risk and perinatal nurse knows that it is critical to provide:
then formulate, implement, and evaluate an appropri- A. Time to listen to their grief
ate, holistic plan of care. B. Information about support groups
◆ Anticipatory nursing care is invaluable in preventing a C. A referral to an obstetrician if requested
complication from becoming a major health crisis. D. Appropriate contraceptive information
◆ Alterations of signs and symptoms from the expected 7. The perinatal nurse knows that risk factors for
clinical progression during pregnancy must be immedi- preeclampsia include:
ately conveyed to the primary healthcare provider so A. Maternal history of preeclampsia
that an appropriate management plan may be activated. B. Body mass index (BMI) greater than thirty
C. Nulliparity
◆ The nurse must always remain cognizant of the impor- D. History of a previous cesarean birth
tant role the patient’s family, culture, language, and
religious beliefs play in her adjustment to motherhood Fill-in-the-Blank
and overall well being.
8. As part of the surgical follow-up for removal of a
◆ By providing culturally competent care to childbearing molar pregnancy, the nurse schedules ________
families, many potential complications can be identi- hCG levels beginning at biweekly, then monthly for
fied in a timely manner to allow for effective treatment at least ________ months.
and improved outcomes.
9. The perinatal nurse completes a ________ test on
◆ Meticulous documentation of the patient’s plan of fluid obtained from a speculum examination on a
care and response to the plan of care cannot be woman at 35 weeks’ gestation who describes a
overemphasized. spontaneous rupture of the membranes.
10. The perinatal nurse knows that _________ bleeding
r e v i e w q u est io n s related to disruption in _________ attachment is the
most common presentation for _______ ________.
Multiple Choice
See Answers to End of Chapter Review Questions on the
1. The perinatal nurse describes for the woman/family Electronic Study Guide or DavisPlus.
who have experienced an 11-week miscarriage and
desire information that the majority of miscarriages
are caused by: REFERENCES
A. Nausea and vomiting in early pregnancy American Cancer Society (ACS). (2006). Cancer facts and figures 2006.
New York: Author.
B. Prenatal stress American College of Obstetricians and Gynecologists (ACOG). (1999).
C. Chromosomal abnormalities Antepartum fetal surveillance (Practice Bulletin No. 9). Washington,
D. Umbilical cord accidents DC: Author.
348 unit three The Prenatal Journey
American College of Obstetricians and Gynecologists (ACOG). (2000). Carty, E. (1998). Disability and childbirth: meeting the challenges.
Scheduled cesarean delivery and the prevention of vertical transmission of Canadian Medical Association Journal, 159(4), 363–369.
HIV infection (Committee Opinion No. 234, pp 592-602). Washington, Centers for Disease Control and Prevention (CDC). (2006a). HIV/AIDS
DC: Author. Update: A glance at the epidemic. Retrieved from www.cdc.gov/hiv/
American College of Obstetricians and Gynecologists (ACOG). (2001a). pubs/facts/at-a-glance.htm (Accessed August 7, 2007).
Gestational diabetes. (Practice Bulletin No. 30, pp. 525–538). Centers for Disease Control and Prevention, Workowski, K., & Berman, S.
Washington, DC: Author. (2006b). Sexually transmitted diseases treatment guidelines 2006.
American College of Obstetricians and Gynecologists (ACOG). (2001b). MMWR Morbidity and Mortality Weekly Report, 51(RR11), 1–23.
Assessment of risk factors for preterm birth (Practice Bulletin No. 31, Clark, S. (2004). Placenta previa and abruptio placentae. In R. Creasy,
pp. 709–716). Washington, DC: Author. R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and
American College of Obstetricians and Gynecologists (ACOG). (2002a). practice (5th ed.). Philadelphia: W.B. Saunders.
Diagnosis and management of preeclampsia and eclampsia (Practice Cockwell, H., & Smith, G. (2005). Cervical incompetence and the role
Bulletin No. 33, pp. 717–725). Washington, DC: Author. of emergency cerclage. Journal of Obstetrics and Gynecology Canada,
American College of Obstetricians and Gynecologists (ACOG). (2002b). 27(2), 123–129.
Prenatal care at the threshold of viability (Practice Bulletin No. 38, Criteria Committee of the New York Heart Association. (1979). Nomen-
pp. 751–758). Washington, DC: Author. clature and criteria for diagnosis of diseases of the heart and great
American College of Obstetricians and Gynecologists (ACOG). Committee vessels (8th ed.). New York: New York Heart Association.
on Clinical Practice. (2003a). Immunization during pregnancy (Commit- Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., &
tee Opinion No. 282, pp 434-439). Washington, DC: Author. Wenstrom, K. (2005). Williams obstetrics (22nd ed.). New York:
American College of Obstetricians and Gynecologists (ACOG). (2003b). McGraw-Hill.
Cervical Insufficiency (Practice Bulletin No. 48, pp. 793–801). Cystic Fibrosis Foundation. (2005). What is CF? Retrieved from http://
Washington, DC: Author. www.cff.org (Accessed April 6, 2008).
American College of Obstetricians and Gynecologists (ACOG). (2003c). Davison, J., & Lindheimer, M. (2004). Renal disorders. In R. Creasy,
Management of Preterm Labor (Practice Bulletin No. 43, pp. 765–773). R. Resnick, & J. Iams (Eds.), Maternal-fetal medicine: Principles and
Washington, DC: Author. practice (5th ed., pp. 901–923). Philadelphia: W.B. Saunders.
American College of Obstetricians and Gynecologists (ACOG). (2004a). Deglin, J., & Vallerand, A. (2009). Davis’s drug guide for nurses (11th ed.).
Nausea and vomiting of pregnancy.[miscellaneous] (Practice Bulletin Philadelphia: F.A. Davis.
No. 52, pp. 812–823). Washington, DC: Author. Dillon, P.M. (2007). Nursing health assessment. Philadelphia: F.A. Davis.
American College of Obstetricians and Gynecologists (ACOG). (2004b). Duffy, T. (2004). Hematologic aspects of pregnancy. In G. Burrow,
Ultrasonography in pregnancy. (Practice Bulletin No. 58). Obstetrics T. Duffy, & J. Copel (Eds.), Medical complications of pregnancy (6th ed.,
and Gynecology, 104(6), 1149–1158. pp. 69–86). Philadelphia: W.B. Saunders.
American College of Obstetricians and Gynecologists (ACOG). Committee Easterling, T., & Otto, C. (2002). Heart disease. In S. Gabbe, J. Niebyl,
Opinion (2004c). Prenatal and perinatal human immunodeficiency virus & J. Simpson (Eds.), Obstetrics normal and problem pregnancies
testing: Expanded recommendations (Committee Opinion No. 304). (4th ed., pp. 1005–1032). Philadelphia: Churchill Livingstone.
Washington, DC: Author. Emery, S. (2005). Hypertensive disorders of pregnancy: Over-diagnosis
American College of Obstetricians and Gynecologists (ACOG). Commit- is appropriate. Cleveland Clinic Journal of Medicine, 72(4),
tee Opinion (2006). Human papillomavirus vaccination (Committee 345–352.
opinion number 344). Washington, DC: Author. Epperson, C., & Czarkowski, K. (2004). Psychiatric complications. In
American College of Obstetricians and Gynecologists & American Acad- G. Burrow, T. Duffy, & J. Copel (Eds.), Medical complications of
emy of Pediatrics (ACOG/AAP). (2007). Guidelines for perinatal care pregnancy (6th ed., pp. 505–513). Philadelphia: W.B. Saunders.
(6th ed.). Washington, DC: Author. Expert Committee on the Diagnosis and Classification of Diabetes Melli-
American Diabetes Association (ADA). (2006). Diagnosis and Classification tus. (2003). Report of the expert committee on the diagnosis and
of diabetes mellitus. Diabetes Care, 29(Supplement), S543–S548. classification of diabetes mellitus. Diabetes Care, 26(Supplement 1),
Askin, D. (2004). Intrauterine infections. Neonatal Network, 23(5), 23–29. S5–S20.
August, P. (2004). Hypertensive disorders in pregnancy. In G. Burrow, Farquhar, C. (2005). Ectopic pregnancy. Lancet, 366(9485), 583–591.
T. Duffy, & J. Copel (Eds.), Medical complications during pregnancy Foley, M. (2004). Cardiac disease. In G. Dildy, M. Belfort, G. Saade,
(6th ed., pp. 43–67). Philadelphia: W.B. Saunders. J. Phelan, G. Hankins, & S. Clark (Eds.), Critical care obstetrics
Berman, M., DiSaia, P., & Tewari, K. (2004). Pelvic malignancies, ges- (4th ed.). Malden, MA: Blackwell Science.
tational trophoblastic neoplasia, and nonpelvic malignancies. In Freda, M., & Patterson, E. (2004). In R. Wieczorek (Ed.), Preterm labor:
R. Creasy, & R. Resnick (Eds.), Maternal-fetal medicine: Principles Prevention and nursing management (3rd ed.). White Plains, NY:
and practice (5th ed., pp. 1213–1242). Philadelphia: W.B. Saunders. March of Dimes.
Bernhardt, J., & Dorman, K. (2004). Pre-term birth risk assessment Gabbe, S.G., Niebyl, J.R., & Simpson, J.L. (Eds). (2007). Obstetric normal
tools. Exploring feal fibronectin and cervical length for validating and problem pregnancies (5th ed.). New York: Churchill Livingstone.
risk. AWHONN Lifelines, 8(1), 38–44. Gardner, M., & Doyle, N. (2004). Asthma in pregnancy. Obstetrics and
Bess, K., & Wood, T. (2006). Understanding gestational trophoblastic Gynecology Clinics of North America, 31(2), 385–413.
disease: How nurses can help those dealing with a diagnosis. Gibbs, R., Sweet, R., & Duff, P. (2004). Maternal and fetal infections. In
AWHONN Lifelines, 10(4), 320–326. R. Creasy, & R. Resnick (Eds.), Maternal-fetal medicine; Principles
Bowers, N., & Gromada, K. (2006). Care of the multiple birth family: and practice (5th ed., pp. 741–801). Philadelphia: W.B. Saunders.
Pregnancy and birth. March of Dimes Nursing Module. New York: Gilbert, E., & Harmon, J. (2003). Manual of high risk pregnancy and
March of Dimes. delivery (3rd ed.). St. Louis: C.V. Mosby.
Brady, T., & Ashley, O. (2005). Women in substance abuse treatment: Gilliam, M., Tapia, B., & Goldstein, C. (2003). Adolescent girls’ attitudes
Results from alcohol and drug services study (ADSS). DHHS Publica- toward pregnancy. Hispanic Journal of Behavioral Sciences, 29(1), 50-67.
tion SMA 04-3968 analytic series A 26. Rockville, MD: Substance and Givens, S., Moore, M., & Freda, M. (2004). Interviewing by the perinatal
Mental Health Services Administration, Office of Applied Studies. nurse (1st ed.). White Plains, NY: March of Dimes.
Brennan, A., & Geddes, D. (2004). Bringing new treatments to the bed- Gluck, J., & Gluck, P. (2005). Asthma in pregnancy. Obstetrics and
side in cystic fibrosis. Pediatric Pulmonology, 37(1), 87–98. Gynecology, 192(2), 369–380.
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven- Golden, L. & Burrow, G. (2004). Thyroid disease in pregnancy. In
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. G. Burrow, T. Duffy, & J. Copel (Eds.), Medical complications of
Burrow, G., Duffy, T., & Copel, J., Eds. (2004). Medical complications of pregnancy (6th ed., pp. 131–161). Philadelphia: W.B. Saunders.
pregnancy. Philadelphia: W.B. Saunders. Griebel, C., Halvorsen, J., Golemon, T., & Day, A. (2005). Management of
Burtness, B. (2004). Neoplastc diseases. In G. Burrow, T. Duffy, & spontaneous abortion. American Family Physician, 72(7), 1243–1250.
J. Copel (Eds.), Medical complications during pregnancy (6th ed., Guy, E., Kirumaki, A., & Hanania, N. (2004). Acute asthma in preg-
pp. 479–504). Philadelphia: W.B. Saunders nancy. Critical Care Clinics, 20(4), 731–745.
Callahan, L. (2004). Surgery in pregnancy. In S. Mattson, & J. Smith (Eds.), Haney, S. (2004). Trauma in pregnancy. In S. Mattson, & J. Smith (Eds.),
Core curriculum for maternal-child nursing (3rd ed., pp. 727–749). Core curriculum for maternal-child nursing (3rd ed., pp. 703–726).
Philadelphia: W.B. Saunders. Philadelphia: W.B. Saunders.
chapter 11 Caring for the Woman Experiencing Complications During Pregnancy 349
Harmon, C. (2004). Assessment of fetal health. In R. Creasy, R. Resnik, Maloni, J., & Park, S. (2005). Postpartum symptoms after antepartum
& J. Iams (Eds.), Maternal-fetal medicine: Principles and practice bedrest. Journal of Obstetric, Gynecologic and Neonatal Nursing, 34(2),
(5th ed., pp. 357–401). Philadelphia: W.B. Saunders. 163–171.
Hjartardottir, S., Leifsson, B., Geirsson, R., & Steinthorsdottir, V. Mandel, J., & Weinberger, S. (2004). Pulmonary diseases. In G. Burrow,
(2004). Paternity change and the recurrence risk in familial hyper- T. Duffy, & J. Copel (Eds.), Medical complications of pregnancy
tensive disorders in pregnancy. Hypertension in Pregnancy, 23(2), (6th ed., pp. 375–414). Philadelphia: W.B. Saunders.
219–225. March of Dimes. (2005). March of Dimes prematurity campaign. Retrieved
Hoyert, D., Mathews, T., Menacker, F., Strobino, D., & Guyer, B. (2006). from www.marchofdimes.com (Accessed August 6, 2007).
Annual summary of vital statistics: 2004. Pediatrics, 117(1), Martin, J., Hamilton, B., Sutton, P., Ventura, S., Menacker, F., &
168–183. Munson, M. (2005). Births: Final data for 2003. National Vital Statis-
Hunter, L.P., Sullivan, C.A., Young, R.E., & Weber, C.E. (2007). Nausea tics Report, 54(2), 1–115.
and vomiting of pregnancy: Clinical management. The American Mason, E., & Lee, R. (2004). Substance abuse. In G. Burrow, T. Duffy,
Journal for Nurse Practitioners, 11(8), 57–67. & J. Copel (Eds.), Medical complications of pregnancy (6th ed., pp.
Iams, J., & Creasy, R. (2004). Preterm labor and delivery. In R. Creasy, 515–537). Philadelphia: W.B. Saunders.
R. Resnik, & J. Iams (Eds.). Maternal-fetal medicine: Principles and Mattox, K., & Goetzl, L. (2005). Trauma in pregnancy. Critical Care
practice (5th ed.). Philadelphia: W.B. Saunders. Medicine, 33(10S), S385–S389.
Jasper, M. (2004). Antepartum fetal assessment. In S. Mattson, & J. Smith Mattson, S. (2004). Intimate partner violence. In S. Mattson, & J. Smith
(Eds.), Core curriculum for maternal-child nursing (3rd ed., pp. 161–200). (Eds.), Core curriculum for maternal-child nursing (3rd ed., pp. 537–553).
Philadelphia: W.B. Saunders. Philadelphia: W.B. Saunders.
Jenkins, T., & Wapner, R. (2004). Prenatal diagnosis of congenital dis- McPhedran, P. (2004). Venous thromboembolism during pregnancy. In
orders. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal G. Burrow, T. Duffy, & J. Copel (Eds.), Medical complications of
medicine: Principles and practice (5th ed.). Philadelphia: W.B. pregnancy (6th ed., pp. 87–101). Philadelphia: W.B. Saunders.
Saunders. Mercer, B. (2003). Preterm premature rupture of the membranes. Obstet-
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., rics and Gynecology, 101(1), 178–193.
Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and Moise, K. (2004). Hemolytic disease of the fetus and newborn. In R.
NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Princi-
St. Louis, MO: Mosby Elsevier. ples and practice (5th ed., pp. 537–561). Philadelphia: W.B.
Kearney, M., Wellman, L., & Freda, M. (1999). Perinatal impact of Saunders.
alcohol, tobacco and other drugs (1st ed.). White Plains, NY: March Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing
of Dimes. outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V.
Kennedy, M.S. (2005). Stepwise approach to managing asthma in pregn Mosby.
ancy.[miscellaneous]. AJN, American Journal of Nursing, 105(4), 20. Moran, B. (2004a). Maternal infections. In S. Mattson, & J. Smith (Eds.),
Kenshole, A. (2004). Diabetes and pregnancy. In G. Burrow, T. Duffy, & Core curriculum for maternal-newborn nursing (3rd ed., pp. 592–629).
J. Copel (Eds.), Medical complications during pregnancy (6th ed., pp. St. Louis: W.B. Saunders.
15–42). Philadelphia: W.B. Saunders. Moran, B. (2004b). Substance abuse in pregnancy. In S. Mattson, &
Kilpatrick, S., & Laros, R. (2004). Maternal hematologic disorders. In R. J. Smith (Eds.), Core curriculum for maternal-child nursing (3rd ed.,
Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Princi- pp. 750–770). Philadelphia: W.B. Saunders.
ples and practice (5th ed., pp. 975–1021). Philadelphia: W.B. Murray, H., Baakdah, H., Bardell, T., & Tulandi, T. (2005). Diagnosis
Saunders. and treatment of ectopic pregnancy. Canadian Medical Association
Klein, L., & Galan, H. (2004). Cardiac disease in pregnancy. Obstetrics Journal, 173(8), 905–912.
and Gynecology Clinics of North America, 31(2), 429–459. Nader, S. (2004). Thyroid disease in pregnancy. In R. Creasy, R. Resnik,
Kulich, M., Rosenfeld, M., Goss, C., & Wilmott, R. (2003). Improved & J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th
survival among young patients with cystic fibrosis. The Journal of ed., pp. 1063–1081). Philadelphia: W.B. Saunders.
Pediatrics, 142(6), 631–636. NANDA International. (2007). NANDA-I Nursing Diagnoses: Definitions
Labelle, C., & Kitchens, C. (2005). Disseminated intravascular coagula- and Classifications 2007-2008. Philadelphia: NANDA-I.
tion: Treat the cause, not the lab values. Cleveland Clinic Journal of National Asthma Education and Prevention Expert Panel. (2005). Man-
Medicine, 72(5), 377–397. aging asthma during pregnancy: Recommendations for pharmaco-
Landon, M., Catalano, P., & Gabbe, S. (2002). Diabetes mellitus. In S. logic treatment—2004. The Journal of Allergy and Clinical Immunol-
Gabbe, J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem ogy, 115(1), 34–46.
pregnancies (4th ed., pp. 1081–1116). Philadelphia: Churchill National Center for Health Statistics (NCHS). (2002). Report of final
Livingstone. mortality statistics, 2000.
Landry, M. (2004). Viral infections. In G. Burrow, T. Duffy, & J. Copel National High Blood Pressure Education Program Working Group.
(Eds.), Medical complications of pregnancy (6th ed., pp. 347–374). (2000). Working group report on high blood pressure in pregnancy
Philadelphia: W.B. Saunders. No. NHBPEP Publication No. 00-3029. Washington, D.C.: National
Laros, R. (2004). Thromboembolic disease. In R. Creasy, R. Resnik, & Heart Lung and Blood Institute.
J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th ed., Norwitz, E., Hsu, C., & Repke, J. (2002). Acute complications of pre-
pp. 845–857). Philadelphia: W.B. Saunders. eclampsia. Clinical Obstetrics and Gynecology, 45, 308–329.
Laskin, C. (2004). Pregnancy and the rheumatic diseases. In G. Burrow, Parry, B. (2004). Management of depression and psychoses during preg-
T. Duffy, & J. Copel (Eds.), Medical complications of pregnancy (6th nancy and the puerperium. In R. Creasy, R. Resnick, & J. Iams
ed., pp. 429–449). Philadelphia: W.B. Saunders. (Eds.), Maternal-fetal medicine: Principles and practice (5th ed.,
Lawrence, R., & Lawrence, R. (2005). Breastfeeding: A guide for the medi- pp. 1193–1200). Philadelphia: W.B. Saunders.
cal profession (6th ed.). Philadelphia: C.V. Mosby. Peters, R.M., & Flack, J.M. (2004). Hypertensive disorders of pregnancy.
Longo, S., Dola, C., & Pridjian, G. (2003). Preeclampsia and eclampsia JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing,
revisited. Southern Medical Journal, 96(9), 891–898. 33(2), 209–220.
Luke, B. (2005). Nutrition in multiple gestations. Clinics in Perinatology, Pigarelli, D., Kraus, C., & Potter, B. (2005). Pregnancy and lactation:
32(2), 403–429, vii. Therapeutic considerations. In J. DiPiro, R. Talbert, G. Yee, G.
Malone, F., & D’Alton, M. (2004). Multiple gestation: Clinical character- Matzke, B. Wells, & M. Posey (Eds.), Pharmacotherapy: A pathophysi-
istics and management. In R. Creasy, R. Resnik, & J. Iams (Eds.), ologic approach (6th ed., pp 72–76). New York: McGraw-Hill.
Maternal-fetal medicine: Principles and practice (5th ed., pp. 513–536). Poole, J. (2003). Thalassemia and pregnancy. The Journal of Perinatal &
Philadelphia: W.B. Saunders. Neonatal Nursing, 17(3), 196–208.
Maloni, J.A. (2002). Astronauts & pregnancy bed rest: What NASA is Poole, J. (2004a). Hemorrhagic disorders. In S. Mattson & J. Smith (Eds.),
teaching us about inactivity. AWHONN Lifelines, 6(4), [318–319], Core curriculum for maternal-child nursing (3rd ed., pp. 630–659).
320–323. St. Louis: W.B. Saunders.
Maloni, J.A., Brezinski-Tomasi, J.E., & Johnson, L.A. (2001). Antepar- Poole, J. (2004b). Hypertensive disorders in pregnancy. In S. Mattson, &
tum bed rest: Effect upon the family. JOGNN: Journal of Obstetric, J. Smith (Eds.), Core curriculum for maternal-newborn nursing (3rd
Gynecologic, and Neonatal Nursing, 30(2), 165–173. ed., pp. 554–591). St. Louis: W.B. Saunders.
350 unit three The Prenatal Journey
Rawlins, S. (2001). Nonviral sexually transmitted infections. Journal of Simpson, K., & Knox, G. (2004). Obstetrical accidents involving intra-
Obstetrical, Gynecological and Neonatal Nursing, 30(3), 324–331. venous magnesium sulfate: Recommendations to promote patient
Records, K., & Rice, M. (2007). Psychosocial correlates of depression safety. The American Journal of Maternal/Child Nursing, 29(3),
symptoms during the third trimester of pregnancy. Journal of Obstet- 161–171.
ric, Gynecologic and Neonatal Nursing, 36(3), 231–242. Smith, J. (2004). Age-related concerns. Core curriculum for maternal-
Refuerzo, J.S., Hechtman, J.L., Redman, M.E., & Whitty, J.E. (2004). child nursing (3rd ed., pp. 147–160). Philadelphia: W.B. Saunders.
Venous thromboembolism during pregnancy: Clinical suspicion war- Tucker, S.M. (2004). Pocket Guide to fetal monitoring and assessment
rants evaluation. Obstetrical & Gynecological Survey, 59(4), 239-240. (5th ed.). St Louis: Elsevier Health Sciences.
Riordan, J. (2005). Breastfeeding and human lactation (3rd ed.). Boston: Wallerstedt, C., & Clokey, D. (2004). Endocrine and metabolic disor-
Jones & Bartlett. ders. In S. Mattson, & J. Smith (Eds.), Core curriculum for maternal-
Roberts, J.M. (2004). Pregnancy-related hypertension. In R. Creasy, & newborn nursing (3rd ed., pp. 660–702). St. Louis: W.B. Saunders.
R. Resnik (Eds.), Maternal-fetal medicine: Principles and practice (5th Weinberg, L., Steele, R., Pugh, R., Higgins, S., Herbert, M., & Story, D.
ed., pp. 859–899). Philadelphia: W.B. Saunders. (2005). The pregnant trauma patient. Anaesthesia and Intensive Care,
Rubin, R. (1976). Maternal tasks of pregnancy. Journal of Advanced Nurs- 33(2), 167–180.
ing, 1, 367–376. White, H., & Bouvier, D. (2005). Caring for a patient having a miscar-
Rust, O., Atlas, R., Kimmel, S., Roberts, W., & Hess, I. (2005). Does the riage. Nursing 2005, 35(7), 18–19.
presence of a funnel increase the risk of adverse perinatal outcome in Whitty, J., & Dombrowski, M. (2004). Respiratory diseases in preg-
a patient with a short cervix? American Journal of Obstetrics and Gyne- nancy. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medi-
cology, 192(4), 1060–1066. cine: Principles and practice (5th ed.). Philadelphia: W.B. Saunders.
Rust, O., & Roberts, W. (2005). Does cerclage prevent preterm birth? Yancy, M. (2004). Other medical complications. In S. Mattson, & J.
Obstetrics and Gynecology Clinics of North America, 32(3), 441–456. Smith (Eds.), Core curriculum for maternal-newborn nursing (3rd ed.,
Savoia, M. (2004). Bacterial, fungal, and parasitic disease. In G. Burrow, pp. 771–817). St. Louis: W.B. Saunders.
T. Duffy, & J. Copel (Eds.), Medical complications of pregnancy (6th Yankaskas, J., Marshall, B., Sufian, B., Simon, R., & Rodman, D. (2004).
ed., pp. 305–345). Philadelphia: W.B. Saunders. Cystic fibrosis adult care: Consensus conference report. Chest,
Setaro, J., & Caulin-Glaser, T. (2004). Pregnancy and cardiovascular dis- 125(1), 1–39.
ease. In G. Burrow, T. Duffy, & J. Copel (Eds.), Medical complications Yudkin, M., & Gonik, B. (2006). Perinatal infections. In R. Martin, A.
in pregnancy (6th ed., pp. 103–129). Philadelphia: W.B. Saunders. Fanaroff, & M. Walsh (Eds.). Fanaroff & Martin’s neonatal-
Sibai, B.M., Dekker, G., & Kupfermine, M. (2005). Preeclampsia. The perinatal medicine: Diseases of the fetus and infant (8th ed., pp. 118–131).
Lancet. 365(9461), 785–799. Philadelphia: C.V. Mosby.
CONCEPT MAP
The Birth
Experience
chapter
The Process of Labor and Birth
12
To my labor and delivery nurse:
On February 24th you helped us welcome our darling daughter into the world. In fact you
practically delivered her yourself. My labor and delivery moved along quite quickly. Through
it all you somehow managed to always say and do the right thing. I have taken great
pleasure in telling people what a really good labor and birth experience I had. You played a
key role in that. While we know it’s your job and all that, we thought you still deserved to
know that your contribution to our daughter’s birth was important and will always be a
part of our memory. Years from now when we are telling her about her birth, your name is
sure to come up. Thanks again!
—Anonymous
LEARNING T A R GE T S At the completion of this chapter, the student will be able to:
◆ Discuss various theories concerning the onset of labor.
◆ Describe signs and symptoms of impending labor.
◆ Distinguish between true and false labor.
◆ Contrast advantages and disadvantages of various childbirth settings.
◆ Describe the “5 P’s” and how each influences labor and birth.
◆ Differentiate among the four stages of labor according to the duration and work accomplished,
contraction patterns, and maternal behaviors.
◆ Identify nursing interventions for each stage of labor.
◆ List five nursing diagnoses applicable to childbearing women.
The literature, as reported by the researchers, states that there Physicians were asked whether they had ever performed a
has been a 42% increase in the number of elective cesarean patient-requested cesarean section and, if so, how many were per-
procedures performed from 1999 to 2002, which accounted formed during the previous year. They were also asked what they
for 1.5–2.21% of all live births during that period. considered as acceptable reasons for performing the procedure.
The purpose of this study was to examine obstetricians’ atti- In addition, the physicians were also asked whether they
tudes and practices with respect to patient choice of elective would prefer this method of childbirth for themselves (if female)
cesarean section. Questionnaires were sent to all (110) American or for their partner (if male) and reasons for their choice.
College of Obstetricians and Gynecologists (ACOG) practicing If the respondent physicians had not performed any patient-
Fellows and Junior Fellows in one northeastern state. requested cesarean deliveries, they were asked if they would be
(continued)
355
356 unit four The Birth Experience
During contraction
Before contraction
Beginning of contraction
Beginning of contraction
Acme
t Interval
n
Dec
between
eme
Another method to measure the intensity of uterine Now Can You— Evaluate uterine contractions?
contractions is an invasive procedure that involves the use
of an internal monitor. If the amniotic membranes have 1. Discuss what is meant by the “powers” of labor?
ruptured, an internal pressure catheter is inserted through 2. Describe the terms used to evaluate contractions?
the cervix and into the uterus to measure the internal 3. Identify two methods used to assess the intensity of
pressure generated during the contraction. Normally, the contractions?
resting pressure in the uterus (between contractions) is
10 to 12 mm Hg. During the acme, contraction intensity The coordinated efforts of the contractions help to bring
ranges from 25 to 40 mm Hg during early labor, 50 to about effacement and dilatation of the cervix. Effacement
70 mm Hg during active labor, 70 to 90 mm Hg during is the process of shortening and thinning of the cervix. As
transition, and 70 to 100 mm Hg during maternal pushing contractions occur, the cervix becomes progressively
in the second stage. Internal uterine pressure monitoring shorter until the cervical canal eventually disappears. The
is most often used with high-risk pregnancies when accu- amount of cervical effacement is usually expressed as a
rate measurement of uterine activity is required. Since percentage related to the length of the cervical canal, as
internal monitoring is an invasive procedure, it is associ- compared to a noneffaced cervix. For example, if a cervix
ated with a slight risk of infection. (See Chapter 14 for has thinned to half the normal length of a cervix it is con-
further discussion.) sidered to be 50% effaced. Dilation is the opening and
During early labor, uterine contractions are charac- enlargement of the cervix that progressively occurs through-
teristically weak and irregular. They usually last for out the first stage of labor. Cervical dilation is expressed in
about 30 seconds and occur every 5 to 7 minutes. As the centimeters and full dilation is approximately 10 cm. With
labor pattern becomes established, the uterine contrac- continued uterine contractions, the cervix eventually opens
tions typically become regular in frequency, longer in large enough to allow the fetal head to come through. At
duration, and increased in intensity. The duration of this point, the cervix is considered fully dilated or com-
contractions increases to about 60 seconds, and they pletely dilated and measures 10 cm (Fig. 12-2).
occur every 2 to 3 minutes. The contractions are invol- The first stage of labor, which begins with the onset of
untary and are most efficient when there is a regular, true labor, concludes when cervical effacement and dila-
rhythmic, coordinated labor pattern. The woman in tion are complete. Effacement and dilation occur concur-
labor is unable to control contraction frequency, dura- rently but at different rates. In a nulliparous patient, most
tion, or intensity. cervical effacement is completed early during the process
Uterine contractions also bring about changes in the of cervical dilation whereas the multiparous cervix is
pelvic floor musculature. The forces of labor cause the often patulous (distended) before effacement begins.
levator ani muscles and fascia of the pelvic floor to draw Effacement and dilation are evaluated by a vaginal exami-
the rectum and vagina upward and forward. During nation performed by a qualified practitioner such as a mater-
descent, the fetal head exerts increasing pressure and nity nurse who has received specialized training in this pro-
causes thinning of the perineal body from 5 cm to less cedure (Procedure 12-1). The vaginal examination provides
than 1 cm in thickness. Continued pressure causes the important information regarding the diameter of the opening
maternal anus to evert and the interior rectal wall is of the cervix, which ranges from 1 cm (not dilated) to 10 cm
exposed as the fetal head descends forward (Cunningham (fully dilated), the status of the amniotic membranes (rup-
et al., 2005). tured or intact), and the fetal presentation and the station, or
chapter 12 The Process of Labor and Birth 359
Amniotic sac
Amniotic fluid Amniotic
fluid
Internal os
Cavity of cervix Internal os
External os External os
A B
Amniotic
Figure 12-2 Cervical effacement and fluid
dilation. The membranes are intact.
Internal Internal os
A. Before labor. B. Early effacement.
os Amniotic fluid
C. Complete (100%) effacement. The
fetal head is well applied to the cervix. External os
D. Complete dilation (10 cm). Note the External
C os D
overlapping of the cranial bones.
the extent of the fetal descent through the maternal pelvis. A & P review The Fetal Skull
Once the cervix is fully dilated and retracted up into the
lower uterine segment, it can no longer be palpated. The fetal skull, or cranium, consists of three major com-
ponents: the face, the base of the skull, and the vault of
Maternal Pushing Efforts the cranium (roof). The facial bones and the cranial base
After the cervix has become fully dilated, the laboring are fused and fixed. The cranial base is made up of two
woman usually experiences an involuntary “bearing down” temporal bones and each has a sphenoid and ethmoid
sensation that assists with the expulsion of the fetus. At bone.
this time, the woman can use her abdominal muscles to aid The cranial vault is composed of five bones: two frontal
in the expulsion. It is important to remember that the cer- bones, two parietal bones, and the occipital bone. These
vix must be fully dilated before the patient is encouraged bones, which are not fused, meet at the sutures. The
to push. Bearing down on a partially dilated cervix can sutures of the fetal skull are composed of strong but flexi-
cause cervical edema and damage and adversely affect the ble connective tissue that fills the spaces that lie between
progress of the labor. For most women, the urge to bear the cranial bones.
down generally occurs when the fetal head reaches the The sagittal suture lies between the parietal bones and
pelvic floor. Women who have a strong urge to push often runs in an anteroposterior direction between the fonta-
do so more effectively than women who force themselves nels, dividing the head into a right and a left side. The
to push without experiencing any sensations of pressure. lambdoidal suture extends from the posterior fontanel
and separates the occipital bones from the parietal bones.
PASSAGEWAY The coronal sutures are located between the frontal and
parietal bones. They extend from the anterior fontanel
The passageway consists of the maternal pelvis and the soft laterally and separate the parietal from the frontal bones.
tissues. The bony pelvis through which the fetus must pass The frontal (mitotic) suture lies between the frontal bones
is divided into three sections: the inlet, midpelvis (pelvic cav- and extends from the anterior fontanel to the prominence
ity), and outlet. Each of these pelvic components has a between the eyebrows.
unique shape and dimension through which the fetus must Two membrane-filled spaces are present where the
maneuver to be born vaginally. In human females, the four suture lines meet. These spaces are referred to as the
classic types of pelvis are the gynecoid, android, platypelloid, anterior and posterior fontanels. The anterior fontanel is
and anthropoid. (See Chapter 5 for further discussion.) the larger of the two and measures approximately 0.8
1.2 inch (2 3 cm). It is diamond shaped and is posi-
PASSENGER tioned where the sagittal, frontal, and coronal sutures
The passenger is referred to as the fetus and the fetal intersect. The anterior fontanel remains open until
membranes. In the majority (96%) of pregnancies, the approximately 18 months of age to allow normal brain
fetus presents in a head-first position. The fetal skull, usu- growth to occur. The posterior fontanel is triangular in
ally the largest body structure, is also the least flexible shape and is much smaller than the anterior fontanel. It
part of the fetus. However, because of the sutures and measures approximately 0.8 inch (2 cm) at its widest
fontanels, there is some flexibility in the fetal skull. These point. The posterior fontanel is positioned where the
structures allow the cranial bones the capability of lambdoidal and sagittal sutures meet. Shaped like a small
movement and they overlap in response to the powers of triangle, it closes at approximately 6 to 8 weeks after
labor. The overlapping or overriding of the cranial bones birth. The location of the fontanels assists the examiner
is called molding. in determining the position of the fetal skull during a
360 unit four The Birth Experience
Suboccipitobregmatic Bregma
(9.5 cm) (anterior fontanelle) Vertex
Submentobregmatic
(9.5 cm)
Sinciput
(brow) Posterior
Occipitofrontal fontanelle
Sphenoid
(11.75 cm) Glabella fontanelle
(bridge of
the nose)
Occiput
Mastoid
Occipitomental Mentum fontanelle
(13.5 cm) (chin)
Frontal
suture Frontal
bone
Coronal
suture
Bregma Bitemporal
(anterior (8 cm)
Sagittal fontanelle)
suture
Parietal
bone
Lambdoid Biparietal
suture Posterior (9.25 cm)
fontanelle
Occipital
bone
Figure 12-3 Bones, fontanels, and sutures of the fetal head. An understanding of the
placement and relationships of these structures is essential in making an accurate
assessment during the labor process.
362 unit four The Birth Experience
Fetal Attitude A B C
The fetal attitude describes the relationship of the fetus’
body parts to one another. The fetus normally assumes an Figure 12-5 The fetal attitude describes the
attitude of flexion. In this attitude, the fetal head is flexed relationship of the fetal body parts to one another.
so that the chin touches the chest, the arms are flexed and A. Flexion (vertex). B. Moderate flexion (military).
folded across the chest, the thighs are flexed on the abdo- C. Extension.
men, and the calves are flexed against the posterior
aspects of the thighs. This is commonly referred to as the
“fetal position.”
or shoulder. The part of the fetal body first felt by the
In moderate flexion, the fetal chin is not touching the
examining finger during a vaginal examination is the
chest but is in an alert of “military position.” This posi-
“presenting part.” The presenting part is determined by
tion causes the occipital frontal diameter to present to
the fetal lie and attitude.
the birth canal. An attitude of moderate flexion usually
does not interfere with labor because during descent and CEPHALIC PRESENTATION. A cephalic presentation iden-
flexion the fetal head flexes fully. The fetus in partial tifies that the fetal head will be first to come into contact
extension presents the brow or face of the head to the with the maternal cervix. Cephalic presentations consti-
birth canal. tute the most desirable position for birth and occur in
Flexion of the fetal head (where the chin touches the approximately 95% of pregnancies. There are four types of
chest) is the preferred position for birth because it allows cephalic presentations (Fig. 12-6):
the smallest anteroposterior diameter of the fetal skull to Vertex. The fetal head presents fully flexed. This is the
enter into the maternal pelvis. Any other position of the most frequent and optimal presentation as it allows the
fetal head (other than that of complete flexion) will pres- smallest suboccipitalbregmatic diameter to present. It is
ent with a larger anteroposterior diameter, which can called a “vertex presentation.”
ultimately contribute to a longer, more difficult labor Military. In the military position, the fetal head pres-
(Fig. 12-5). ents in a neutral position, which is neither flexed nor
extended. The occipitofrontal diameter presents to the
Fetal Presentation maternal pelvis and the top of the head is the present-
The fetal presentation refers to the fetal part that enters ing part.
the pelvic inlet first and leads through the birth canal dur- Brow. In the brow position, the fetal head is partly
ing labor. The fetal presentation may be cephalic, breech, extended. This is an unstable presentation that converts to
Figure 12-6 There are four types of cephalic presentation; the vertex presentation with
complete flexion is optimal. Fetal presentation refers to the fetal body part that first enters
the maternal pelvis.
chapter 12 The Process of Labor and Birth 363
Station
Station refers to the level of the presenting part in rela-
tion to the maternal ischial spines. In the normal female
pelvis, the ischial spines represent the narrowest diame-
ter through which the fetus must pass. The ischial
Figure 12-8 Shoulder presentation. spines, blunted prominences located in the midpelvis,
have been designated as a landmark to identify station
zero. To visualize the location of station zero, an imagi-
nary line may be drawn between the ischial spines.
Engagement has occurred when the presenting part is at
where research and practice meet: station zero. When the presenting part lies above the
The Planned Vaginal Breech Delivery maternal ischial spines, it is at a minus station. There-
The American College of Obstetricians and Gynecologists (ACOG) fore, a station of minus 5 (–5) cm indicates that the
published a Committee Opinion in July 2006, advising that in presenting part is at the pelvic inlet. Positive numbers
light of recent published studies that further clarify the long-term indicate that the presenting part has descended past
risks of vaginal breech delivery, “the mode of delivery should the ischial spines. A presenting part below the level of
depend on the experience of the health care provider…Cesarean the ischial spines is considered to be a positive station. A
delivery will be the preferred mode for most physicians because of station of 4 cm indicates that the presenting part is at
the diminishing expertise in vaginal breech delivery”. A Random- the pelvic outlet (Fig. 12-9). During labor, the present-
ized Controlled Trial (RCT) that included 2088 women found that ing part should continue to descend into the pelvis,
perinatal mortality, neonatal mortality, or serious neonatal mor- indicating labor progress. As labor advances and the pre-
bidity was significantly lower for the planned cesarean section
group than for the planned vaginal birth group (Hannah et al.,
senting part descends, the station should also progress to
2000). Currently, the standard of care in most practices is to a numerically higher positive station. If the station does
deliver all breeches by cesarean section to avoid the potential not change in the presence of strong, regular contrac-
complications of vaginal breech deliveries such as cord prolapse, tions, this finding may indicate a problem with the rela-
head entrapment, birth asphyxia and birth trauma (Hacker, tionship between the maternal pelvis and the fetus
Moore, & Gambone, 2004). (“cephalopelvic disproportion”).
Position
Position refers to the location of a fixed reference point
on the fetal presenting part in relation to a specific quad-
Now Can You— Discuss the breech and shoulder rant of the maternal pelvis (Fig. 12-10). The presenting
presentations? part can be right anterior, left anterior, right posterior,
1. Identify three types of breech presentations? and left posterior. These four quadrants designate whether
2. Explain three disadvantages of a breech presentation? the presenting part is directed toward the front, back,
3. Describe how the nurse could identify a shoulder right, or left of the passageway.
presentation?
PASSAGEWAY ⫹ PASSENGER
The passageway and the passenger have been identified as
two of the factors that affect labor. The next “P” is the Iliac Iliac
relationship between the passageway (maternal pelvis) crest crest
and the passenger (fetus and membranes). The nurse
assesses the relationship between the two when determin-
ing the engagement, station, and fetal position.
Engagement –5
–4
Engagement is said to have occurred when the widest –3
–2
–1
diameter of the fetal presenting part has passed through 0
1
Ischial Ischial
the pelvic inlet. In a cephalic presentation, the largest 2
3
spine 4 spine
diameter is the biparietal; in breech presentations, it 5
Right occiput anterior (ROA) Right occiput transverse (ROT) Right occiput posterior (ROP)
Left occiput anterior (LOA) Left occiput transverse (LOT) Left occiput posterior (LOP) Right mentum anterior (RMA)
Right mentum posterior (RMP) Left mentum anterior (LMA) Left sacrum anterior (LSA) Left sacrum posterior (LSP)
Figure 12-10 Fetal presentations and positions. The position refers to how the presenting
fetal part is positioned in relation to a specific quadrant of the maternal pelvis: front, back,
or side.
Four landmarks of the fetus are used to describe the of a malpresentation may signal the need for a cesarean
relationship of the presenting part to the maternal pelvis. delivery. Identification of a posterior lie may identify the
In a vertex presentation, the occiput (O) is used. For a potential for a longer labor as the fetus may attempt to
face presentation, the chin (M for mentum) is used. In rotate to an OA position. In addition, the nurse must be
a breech presentation, the sacrum (S) is used, and for a aware that the fetal position will vary as the fetus changes
shoulder presentation, (A) for acromion process of the position to move through the different diameters of the
shoulder is used. Fetal position may be described as: maternal pelvis.
In some situations, the physician may have the option
• Right (R) or left (L) side of the maternal pelvis to attempt a fetal rotation. Prenatally, an external cephalic
• The landmark of the presenting part: occiput (O), version may be performed in an attempt to rotate an identi-
mentum (M), sacrum (S), acromion process (A) fied breech presentation. A forceps rotation from a trans-
• Anterior (A), posterior (P), transverse (T): This desig- verse or posterior position to an anterior position may also
nation depends on whether the landmark is in the be indicated during a prolonged second stage of labor.
front, back, or side of the maternal pelvis However, as with any procedure, these maneuvers are
It is important for the nurse to assess the position of associated with risks and benefits that must be presented
the fetus to identify whether the fetus is in an optimal to the patient for informed consent. (See Chapter 14 for
position for a vaginal birth. To do so, the nurse uses further discussion.)
inspection and palpation of the maternal abdomen and
vaginal examination. Use of the abbreviated notations critical nursing action Determining and
(listed above) helps to convey essential information to
other members of the health care team. For example, Documenting Fetal Position
when the fetal occiput is directed toward the maternal During the assessment, the nurse determines that the fetal occiput is
back (a posterior lie) and to the right of the birth passage- in the right anterior quadrant of the maternal pelvis. The position is
way, the nurse would chart “ROP,” to indicate right correctly documented as ROA. If the fetus were presenting in the frank
occiput–posterior. The fetal position most common, and breech position with the buttocks positioned to the left maternal pos-
most favorable for birth, is the right occiput–anterior terior quadrant, the position would be correctly documented as LSP
(ROA). Identification of a malpresentation such as a foo- (left sacrum posterior).
tling breech or transverse lie is important, as the presence
366 unit four The Birth Experience
Now Can You— Discuss the passageway and passenger? Now Can You— Discuss the psychosocial influences
1. Define engagement and identify when engagement has of labor?
occurred? 1. Describe why maternal psyche and cultural influences are
2. List the four fetal landmarks used to describe the important factors during labor?
relationship of the presenting part? 2. Identify three culturally oriented nursing assessments for the
3. Discuss why it is important for the nurse to assess fetal laboring woman?
position during labor? 3. Discuss how maternal emotions can adversely affect the
process of labor?
PSYCHOSOCIAL INFLUENCES
The first four P’s discussed address the physical forces of Signs and Symptoms of Impending
labor. The last “P” (psychosocial influences) acknowl- Labor
edges the many other critical factors that have an effect on
parents such as their readiness for labor and birth, level of Before the onset of labor, a number of physiological
educational preparedness, previous experience with labor changes occur that signal the readiness for labor and birth.
and birth, emotional readiness, cultural influences, and These changes are usually noted by the primigravid
ethnicity. Transition into the maternal role, and most woman at about 38 weeks of gestation. In multigravidas,
likely, into the paternal role as well, is facilitated by a they may not take place until labor begins. It is important
positive childbirth experience. A number of internal and for nurses to empower pregnant women and their families
external influences can affect the woman’s psychological by teaching them about the signs and symptoms of
well-being during labor and birth. impending labor. Providing guidelines about when to
Culturally oriented views of childbirth help to shape contact the health care provider or come to the birth facil-
the woman’s expectations and ongoing perceptions of the ity helps to demystify the sometimes confusing events that
birth experience. The nurse’s understanding of the cul- surround birth and lessen the anxieties that can accom-
tural values and expectations attached to childbirth pro- pany the onset of labor.
vide a meaningful framework upon which to plan and
deliver sensitive, appropriate care. Cultural considerations LIGHTENING
for the laboring woman encompass many elements of the
birth experience including choice of a birth support per- At about 38 weeks in the primigravid pregnancy, the pre-
son, strategies for coping with contractions, pain expres- senting part (usually the fetal head) settles downward into
sion and relief and food preferences. the pelvic cavity, causing the uterus to move downward as
well. This process, called lightening, marks the beginning
of engagement. As the uterus moves downward, the
Nursing Insight— Assessing cultural influences woman may state that her baby has “dropped.” She may
of the laboring patient also report changes in the appearance of her abdomen
such as a flattening of the upper area and an enhanced
To provide culturally sensitive care to the laboring patient,
the nurse should consider:
protrusion of the lower area. This downward settling of
the uterus may decrease the upward pressure on the dia-
• The patient’s and family’s level of comfort with the nurse’s phragm and result in easier breathing. The downward set-
“language” and whether an interpreter is needed tling may also lead to the following maternal symptoms:
• Who is the designated birth support person and what will
be the extent of this person’s role • Leg cramps or pains
• The patient’s level of comfort with touch • Increased pelvic pressure
• If any special rituals or practices will be used during the • Increased urinary frequency
childbirth experience • Increased venous stasis, causing edema in the lower
extremities
• Increased vaginal secretions, due to congestion in the
Studies have revealed that marked anxiety, fear, and vaginal mucosa
fatigue can adversely affect the woman’s ability to cope
with the demands of labor. A negative childbirth experi-
ence can have far-reaching implications, interfering with BRAXTON-HICKS CONTRACTIONS
bonding and maternal role attainment. As the pregnancy approaches term, most women become
Emotional factors can have physiological implications more aware of irregular contractions called Braxton-Hicks
as well. Maternal catecholamines (chemicals that affect contractions. As the contractions increase in frequency
the nervous and cardiovascular systems, metabolic rate, (they may occur as often as every 10 to 20 minutes), they
temperature, and smooth muscle) are often stimulated as may be associated with increased discomfort. Braxton-Hicks
a response to anxiety and fear and can inhibit uterine contractions are usually felt in the abdomen or groin region
contractions and impede placental blood flow. During and patients may mistake them for true labor. It is believed
labor, the nurse’s ongoing assessment of the maternal that these contractions contribute to the preparation of the
psyche along with appropriate interventions can help cervix and uterus for the advent of true labor. Braxton-Hicks
facilitate therapeutic communication to decrease or elimi- contractions do not lead to dilation or effacement of the
nate anxiety and fear through discussion and support. cervix, and thus are often termed “false labor.”
chapter 12 The Process of Labor and Birth 367
Childbirth Settings and Labor Support partner before, during, and immediately after the birth.
She does not function in a clinical role but instead special-
The decision about where to give birth is influenced by izes in providing comfort measures to decrease the
several factors: geographical location, socioeconomic sta- woman’s anxiety. Breathing techniques, application of hot
tus, the patient’s preference, and the absence or presence and cold, and massage are strategies often used to enhance
of pregnancy complications. The size of the community comfort and the progress of labor.
often dictates the type and number of maternity health The doula assists the family in gathering information
care facilities and the available primary care providers concerning the labor process and available options before
who may include family physicians, obstetricians, and childbirth. If a cesarean birth is required, the doula may
certified nurse midwives (CNMs). accompany the laboring woman into the surgical suite.
Large urban centers have hospitals with birthing units Doulas also provide some postpartum services. In some
or birthing centers. Some of the units may offer labor situations, the family hires the doula. Doulas can be paid
options such as whirlpool baths. Other settings may hospital employees or volunteer doulas may be available
provide a home-like environment for the expectant cou- in certain settings. When needed, the bilingual doula
ple. Taking a tour of the available birth settings as part of can be an essential team member in helping to promote
prenatal education classes can help the pregnant woman a positive childbirth experience for the woman and her
and her partner develop an understanding of what to family.
expect during the childbirth experience.
The woman’s socioeconomic status and whether or not Now Can You— Discuss childbirth settings and support
she has health insurance also affect the choices available persons?
for labor and birth. Some pregnant women who have no
pregnancy complications may choose to have their prena- 1. Discuss various childbirth settings and factors that may
tal care and birth managed by a CNM, and they may also influence the woman’s choice?
plan for a home birth. 2. Describe the role of a doula?
The patient usually determines whether or not a sup-
port person accompanies her to the birthing unit and
remains throughout the labor and birth. This decision is
based on personal preferences, and may reflect cultural Routine Hospital and Birth Center
or religious practices. The woman’s partner or the baby’s
father is the most common labor support person, Admission Procedures
although the woman’s mother or friend may also serve
In the third trimester it is important for the prenatal care
as a support person especially if the patient is single.
nurse to explain the differences between true and false
The nurse can identify the patient’s preference for a
labor, and to teach the patient about when to go to the
support person by asking a question such as, “Who is
birthing center. Table 12-2 summarizes the circumstances
the main person that you want to stay with you
that warrant going to the birthing center. The nurse
during labor?”
should reinforce this information during each prenatal
In some centers, women may use a doula as a labor
visit.
support person. The doula is a woman who has received
professional training and is experienced in childbirth. The
doula’s role is to provide continuous information and Be sure to— Understand federal regulations that
physical and emotional support to the woman and her relate to obstetric care
The federal regulation known as The Emergency Medical
Treatment and Active Labor Act (EMTALA) was created to
ensure that all women receive emergency treatment or
where research and practice meet: active labor care whenever such treatment is sought.
Home-like Birth Settings Under the EMTALA regulation, true labor is considered to
In this Cochrane review of home-like versus conventional institu- be an emergency medical condition. Thus the nurse work-
tional settings for birth, Hodnett, Downe, Edwards, and Walsh ing in a birthing unit must be familiar with the full range
(2005) reviewed six trials of 8677 women. The findings revealed of responsibilities included in the EMTALA regulations:
a number of benefits associated with home-like settings for (1) provide services to pregnant women when an urgent
childbirth: increased maternal satisfaction with the intrapartum pregnancy problem such as labor, rupture of the mem-
care; increased initiation and continuation of breastfeeding; an branes, decreased fetal movement, or recent trauma is
increased incidence of spontaneous vaginal births; and a reduced experienced and (2) fully document all relevant informa-
likelihood of medical interventions including analgesia/anesthesia
tion to include assessment findings, interventions imple-
and episiotomies. Despite these positive findings, the review also
demonstrated an association between home-like birth settings mented and the patient’s response to the care provided.
and increased perinatal mortality. The authors concluded that Any pregnant woman who presents to an obstetric triage is
although a home-like birth setting with its focus on normality is considered to be experiencing “true labor” until a qualified
associated with modest benefits, care providers need to monitor health care provider determines that she is not (Angelini &
patients closely for complications, regardless of the setting for Mahlmeister, 2005; Caliendo, Millbauer, Moore, &
labor and birth. Kitchen, 2004).
370 unit four The Birth Experience
Table 12-2 Providing Patient Guidelines for Reporting to the Birthing Center
Questions to Ask the Patient Guidelines for Admission
Describe your contractions: frequency, duration, Primigravida: Contractions are regular, occur about every 5 minutes for at least 1 hour.
and intensity?
Multipara: Contractions are regular, occur about every 10 minutes for at least 1 hour.
Have your membranes ruptured? Any gush of fluid needs to be evaluated, even if there are no contractions.
Is there any vaginal bleeding? The mucus plug or “bloody show” is usually pink or dark red. Any bright red bleeding
requires immediate evaluation.
Has there been a decrease in the movement of the baby? Any decrease in fetal movement signals the need to report to the birthing center.
Has there been any change in your health? Any cause for worry or anxiety in the pregnant woman needs to be explored by the
nurse and may lead to admission.
Once the woman arrives at the birthing center, the role The admission interview provides the nurse with infor-
of the nurse is twofold: to establish a positive relationship mation about the woman’s reason for coming to the birth-
with the patient and her family and support person and to ing center, her understanding and expectations of the
assess the status of the patient and her fetus. labor and birth process, her subjective experience of the
labor, as well as psychosocial and cultural factors that can
ESTABLISHING A POSITIVE RELATIONSHIP impact her birth experience. The fetal assessment, includ-
ing presentation, fetal heart rate (FHR), and movement
The onset of labor is a time of many emotions for the provides essential data regarding fetal well-being. Mater-
woman and her family. There can be excitement, fear, and nal vital signs, particularly blood pressure and tempera-
anxiety. The role of the nurse in recognizing these emo- ture, as well as the assessment of current labor status
tions and creating a caring, trusting relationship is para- (uterine contraction patterns, cervical dilatation, and
mount to a positive birth experience. The nurse needs to effacement, fetal station, rupture of membranes) provide
respect individual differences in the woman’s knowledge important baseline labor data. A systematic physical
and understanding of childbirth, as well as recognize the assessment provides the nurse and other care providers
cultural or religious practices that may influence the expe- with overall health data, and various laboratory tests, such
rience. The nurse needs to remain nonjudgmental, partic- as hematocrit, blood glucose, and HIV status, give further
ularly with patients who have not had adequate prenatal direction for the individual plan of care.
care or who have made unhealthy lifestyle choices during
the pregnancy.
To foster a positive and therapeutic relationship, the Initial Admission Assessments
nurse creates an atmosphere that encourages questions
and the sharing of information. Some women have pre- For women who have received prenatal care, the prenatal
pared written childbirth plans that describe their expecta- care record is sent to the birthing center prior to the
tions of the experience. Getting to know each patient’s expected due date. The information is stored and readily
expectations for her childbirth experience constitutes an available when the laboring patient reports there for care.
important element in the relationship. The nurse must Women without a prenatal care record require a more
also recognize when an interpreter is needed to assist in extensive assessment upon admission to the birth
the understanding and exchange of information. setting.
Touch is an integral aspect of the nurse–patient rela-
tionship during labor and birth. Touch can convey caring THE FOCUSED ASSESSMENT
and provide comfort. The nurse continuously assesses the
patient’s response to touch and provides intimate care that On admission to the birthing unit, the nurse initiates a
is culturally sensitive. focused assessment to determine the condition of the
mother and fetus and the progression of the labor. The
data collected answers these critical questions and helps
COLLECTING ADMISSION DATA the nurse to establish priorities for care:
The nurse uses multiple sources and data collection meth-
• Is this true labor, and if so, is birth imminent?
ods to compile a comprehensive database to plan and
• Are there any factors that increase risk to the mother
deliver individualized care to the woman in labor. The
or fetus?
prenatal record provides data regarding the current preg-
nancy and previous pregnancies and birth outcomes for The nurse assesses the fetus’ well-being by recording
the multiparous woman. Measurements such as maternal the FHR and noting the FHR in response to uterine con-
weight gain, fundal height, blood pressure, fetal heart rate tractions. The nurse also assesses fetal movement. If the
patterns, laboratory values such as blood type and Rh fac- woman reports that her membranes have ruptured, the
tor, results from diagnostic tests such as amniocentesis, nurse validates the presence of amniotic fluid using Nitra-
non-stress tests, and ultrasound examinations provide the zine tape (see Procedure 12-2), and examines the amni-
basis for determining intrapartal risk. otic fluid for color and odor.
chapter 12 The Process of Labor and Birth 371
The nurse assesses the patient’s vital signs to establish and sexually transmitted infections are often embarrass-
a baseline for comparison during the labor and birth. An ing. The nurse can facilitate the sharing of this informa-
elevation in blood pressure may be a sign of pregnancy- tion through the establishment of a caring and nonjudg-
induced hypertension (PIH). An elevated temperature may mental relationship with the patient.
signal infection. The nurse also assesses the progression of
the labor by monitoring the pattern of uterine contractions — Asking the difficult questions
for frequency, duration, and intensity. The nurse further
assesses the labor status by evaluating cervical dilatation and Asking closed-ended questions such as “Do you drink
effacement, and fetal station, presentation, and position. alcohol?” may elicit a quick “No” response. Asking more
A patient who states “I feel like pushing” may be indi- directed and open questions such as “How many drinks
cating that the birth is imminent. Important questions to do you have each day?” may encourage a more detailed
ask this patient upon admission include the following: response. The nurse should remember that a caring and
nonjudgmental attitude, in a private, nonthreatening
• What is your name? Your support person’s name?
environment, helps to foster a trusting nurse–patient
• Have you received prenatal care? Who is your care
relationship.
provider?
• How many pregnancies and births have you had?
Were the deliveries vaginal or cesarean? Were there
any difficulties with previous deliveries? THE CULTURAL ASSESSMENT
• What is your due date? When was your last normal To provide care that is culturally relevant, the nurse must
menstrual period? assess the patient’s cultural preferences, practices, and
• Have your membranes ruptured? What time? Describe values related to labor and childbirth. Issues such as care
the fluid. provider gender preference, comfort level with intimate
• Have you had any complications with this pregnancy? touch, and the presence or absence of a labor support
• Do you have any allergies? person may be culturally determined. The woman’s
• Describe your contractions—mild, moderate, or responses to the labor pain, her acceptance or rejection of
intense. When did your contractions begin? How are labor support interventions, and her emotional responses
you coping? to the newborn can be culturally based.
• Are you taking any medications—prescribed and/or
over-the-counter? Do you use illegal/street drugs?
LABORATORY TESTS
Do you smoke? Do you drink alcoholic beverages?
• When did you last eat or drink anything and what Laboratory testing is a routine component of the admission
was it? process. Tests for blood type and Rh factor, complete blood
• Have you prepared a birth plan? Do you have any count, hemoglobin and hematocrit, and blood glucose are
cultural preferences related to your labor and birth? generally obtained. Blood tests for syphilis, hepatitis B, and
HIV are also collected. The urine specimen is tested for the
If the nurse determines that the fetal or maternal presence of protein, glucose, and ketones.
assessments are not normal, or that the birth is imminent,
the physician or primary care provider is notified immedi-
ately. If the assessments are normal, and birth does not Documentation of Admission
appear to be imminent, the nurse can then complete a
more thorough admission assessment, which would Each birth setting has documentation forms and set proto-
include a systematic physical assessment. cols to be completed with patient admissions. Collecting
a complete health and childbirth history and performing a
THE PSYCHOSOCIAL ASSESSMENT physical examination of the patient and her fetus provide
an essential foundation for the care and support to be
An important, yet sometimes challenging part of the data
given during labor and birth. Once the admission assess-
collection is the psychosocial assessment. Understanding
ments have been completed, the nurse documents the
the woman’s behavioral responses to the pregnancy and
information using the birth setting’s recording procedures,
childbirth experience allows the nurse to support and
notifies the patient’s primary care provider of the admis-
strengthen the identified coping mechanisms. Obtaining
sion status, and receives orders. Critical information to
information that addresses questions such as “What was
relay to the physician or nurse-midwife includes:
the previous birth experience like?” “How is the patient
handling the labor pain?” and “Who is providing labor • Patient’s name and age
support for her?” helps the nurse to better meet the • Gravidity and parity
patient’s and her support person’s needs. • Gestational age and estimated date of delivery
The nurse completes a social assessment, collecting • Labor status: pattern of contractions, cervical dilata-
information about the woman’s family and support sys- tion and effacement, fetal presentation and station
tems and living conditions. Questions about family vio- • Status of membranes
lence can be particularly difficult. If the nurse suspects • Fetal heart rate and response to contractions
partner abuse, the patient should be interviewed alone in • Patient’s vital signs, especially blood pressure and
a private place where she feels safe. temperature
Assessing the woman’s social and lifestyle habits can • Any identified risk to maternal or fetal well-being
also be difficult. Questions about drug and alcohol use • Patient’s coping ability in response to labor
372 unit four The Birth Experience
After admission, the patient and her fetus are assessed 90 seconds on average. Fortunately, this phase often
frequently to monitor both the progression of labor and does not take long because dilation usually progresses at
the responses of both to the labor. Throughout each stage a pace equal to or faster than active labor (1 cm/hr for a
of labor, ongoing maternal assessments include vital signs, nullipara and 1.5 cm/hr for a multipara). During the
intake and output, pattern of contractions, cervical dilata- transition phase, the laboring woman may feel that she
tion and effacement, and response to labor. Fetal assess- can no longer continue or she may question her ability
ments, which primarily center on the response to labor, to cope with much more. Other sensations that a woman
involve intermittent or continuous FHR monitoring. may feel during transition include rectal pressure, an
increased urge to bear down, an increase in bloody show,
and spontaneous rupture of the membranes (if they have
First Stage of Labor not already ruptured). Table 12-3 presents a summary
of the characteristics of the first and second stages of
The first stage of labor is often referred to as the stage of labor.
dilation. This stage begins with the onset of regular uterine A labor curve assessment tool, often referred to as a
contractions and ends with complete dilation of the cervix. “Friedman curve,” is a graph used to help identify
The onset of labor is often made retrospectively since the whether a patient’s labor is progressing in a normal pat-
woman may not always recognize when true labor actually tern (Fig. 12-11). Composite normal labor patterns are
begins. The contractions often start slowly and are fairly graphically presented for the multiparous and nullipa-
tolerable. Over time, contractions tend to increase in fre- rous patient. The labor curve assessment tool contains
quency, duration, and intensity as the first stage of labor categories that include the time of day, amount of cervi-
progresses. The first stage of labor is most often the longest cal dilation, and effacement and hours of labor that have
stage and its duration can vary considerably among women. elapsed. The patient’s own labor progress is plotted on
The first stage of labor is divided into three distinct phases: the graph to allow a comparison between her progress
latent, active, and transition. Multiparous women tend to and the norm.
progress through the childbirth process much more rap-
idly than do nulliparous women. Factors such as analgesia,
Now Can You— Identify characteristics of the first and
maternal and fetal position, the woman’s body size and her
second stages of labor?
level of physical fitness can also affect the length of labor.
1. Define the characteristics of the first and second stages of
LATENT PHASE labor including contractions, dilation, and maternal
response?
The latent phase of labor begins with the establishment 2. Describe the three phases of the first stage of labor and the
of regular contractions (labor pains). Labor pains are changes that occur during each phase?
often initially felt as sensations similar to painful men- 3. Explain the value of using a labor curve assessment tool?
strual cramping and are usually accompanied by low back
pain. Contractions during this phase are typically about
5 minutes apart, last 30 to 45 seconds, and are considered
to be mild. During this phase, the woman is usually NURSING CARE DURING THE FIRST STAGE
excited about labor commencing and she remains chatty OF LABOR
and sociable. Often this phase of labor is completed at
home. During the latent phase cervical effacement and Cunningham and associates (2005) noted that there are
early dilation (0 to 3 cm) occurs. The latent phase of labor two opposing priorities in the ideal management of
can last as long as 10 to 14 hours as the contractions are labor:
mild and cervical changes occur slowly. • Birthing should be recognized as a normal physiologi-
cal process and should be treated as such.
ACTIVE PHASE • Intrapartum complications can arise quickly and unex-
The active phase of labor is characterized by more active pectedly and therefore should be anticipated.
contractions. The contractions become more frequent There are several key roles for the nurse who is provid-
(every 3 to 5 minutes), last longer (60 seconds), and are ing care for the woman in labor. It is essential that the
of a moderate to strong intensity. During the active labor nurse continually assess the patient and her fetus to
phase, the woman becomes more focused on each con- ensure a safe delivery, help to facilitate a positive birth
traction and tends to draw inward in an attempt to cope experience, assist in the satisfactory management of pain,
with the increasing demands of the labor. Cervical dila- and advocate for the patient’s needs.
tion during this phase advances more quickly as the con- It is important to remember that nursing interventions
tractions are often more efficient. While the length of the must first be safe and consistent with the current standard
active phase is variable, nulliparous women generally of care. Interventions are also tailored to meet the individual
progress at an average speed of 1 cm of dilation per hour needs and preferences of the woman in labor. The patient’s
and multiparas at 1.5 cm of cervical dilation per hour. needs may quickly change throughout the process of labor.
For example, during early labor the woman may be very
TRANSITION PHASE independent and in little need of assistance. During active
The transition phase is the most intense phase of labor. labor or transition, the needs often become very different.
Transition is characterized by frequent, strong contrac- Research has shown that during labor, support by nurses
tions that occur every 2 to 3 minutes and last 60 to has a positive effect on maternal and fetal outcomes.
chapter 12 The Process of Labor and Birth 373
Definition Commences with the onset of regular contractions and ends Begins with full dilation of the cervix (10 cm) and ends
with full dilation (10 cm) of the cervix with the expulsion (birth) of the fetus.
Contractions Latent: 5–10 minutes, may be irregular in frequency, duration Contractions continue at a similar rate as during the
30–40 seconds, mild to moderate strength transition phase; 2–3 minutes apart lasting 60 seconds
and strong by palpation.
Active: Regular pattern established (2–5 minutes apart),
40–60 seconds duration and moderate to strong by palpation
Transition: 2–3 minutes apart lasting 60–90 seconds, strong
by palpation.
Dilation Latent: 0–3 cm Fully dilated
Active: 4–7 cm
Transition: 8–10 cm
Physical Latent: Contractions often begin as painful menstrual-like cramps May have an urge to push that increases as the fetal head
discomforts or low back ache descends.
Active: Increasing discomfort as contractions become stronger Many women prefer to push so that they can use the
and more regular. May have backache. contractions and work with them.
Transition: Increasing discomfort as contractions are very strong When head is crowning may feel intense pain, burning.
with little time for relaxation in between. As the fetal head
descends there may be an increase in rectal pressure and the
urge to push.
Maternal Latent: Pain often well controlled; various behaviors may be Often during this stage many women get a “second wind”
behaviors present: excited, talkative, confident, anxious, withdrawn as they see that they are making progress and are
Stage may be completed at home. embarking on a new (labor) phase.
Active: Needs to focus more on staying in control and managing Intense concentration with pushing efforts.
the pain; often requires coaching at this stage; quieter and more
inwardly focused
Transition: Most intense phase. Often difficult to cope; may
experience various emotions: irritable, agitated, hopeless
(“can’t do it”); tired (sleeps between contractions)
-4 9
-3 8
Multiparous Nulliparous
(composite) (composite)
-2 7
Dilatation
Station
-1 6
0 5
+1 4
+2 3
Figure 12-11 A labor curve
assessment tool, often +3 2
referred to as a “Friedman
curve,” helps to identify Effacement %
whether a patient’s labor is and/or position
progressing in a normal Hours of labor 4 5 6 7 8 9 10 11 12 13
pattern.
374 unit four The Birth Experience
Now Can You— Provide comforting nursing care during items such as towels and washcloths, kitchen supplies (ice
labor? chips), and the restroom.
Assessment of the degree of involvement the support
1. List four examples of nursing interventions that patients have person would like to assume is also important. It is help-
identified as helpful in promoting comfort and relaxation? ful to determine whether or not the patient and labor
2. Identify three beneficial positions for the laboring woman partner have attended childbirth preparation classes and
who is confined to bed rest? give respect to the support person for their identified
3. Describe what is meant by “presence”? wishes and or limitations. In some cultures, assistance at
the birth might be considered “woman’s work” and the
laboring woman instead seeks support from a sister,
ANTICIPATORY GUIDANCE mother, and aunt while the husband stays at home or
assumes more of an observational role.
Providing anticipatory guidance for the woman and her
family constitutes an essential role of the obstetric nurse. ENSURING CULTURE-CENTERED CARE
Regardless of whether or not they have attended prenatal
classes, most women and their families have many ques- Providing care that is culturally appropriate is as important
tions. Anticipatory guidance should be provided through- in caring for laboring women and their families as with any
out the childbirth experience. Women and families usually other patients. It is unrealistic to expect nurses to be
want to know what to expect. While the nurse cannot pre- knowledgeable about the cultural traditions and customs
dict exactly what will happen, helpful information can be of all patients. However, it is important for nurses to
provided in general terms. For example, a woman in early remain open minded and aware that there are a myriad of
active labor may comment: “These contractions are getting values, attitudes, beliefs, and practices regarding childbear-
stronger, how strong will they get?” The nurse can empower ing that vary among cultures just as there may be wide
the woman by identifying the progress she has made to variations within cultures. Body language and communica-
that point. Explaining how the contractions have gradually tion approaches provide examples of how differences in
become stronger and emphasizing how successful the cultural practices can be applied when caring for a woman
patient has been in adjusting to the changes provides fac- and her family during the childbirth experience.
tual feedback and positive reinforcement of the progress
made. In addition, the nurse may suggest comfort mea- Ethnocultural Considerations— Cultural
sures such as relaxing in a whirlpool bath or shower for differences in communication
later on when the contractions become stronger.
Eye contact: North American nurses have been taught that
eye contact is an integral part of the communication process
— Positive, encouraging words when communicating with patients. Some cultures do not
during labor maintain eye contact as they consider eye contact to be impo-
lite or aggressive.
During labor the patient needs encouragement with
Silence: Some individuals find silence to be uncomfortable
positive words regarding what she is doing well even
and may make efforts to communicate when there are gaps in
when she may not be coping at her optimal ability.
a conversation. However, labor may be a time where it is inap-
Nurses must be careful not to use language that may be
propriate to be carrying on a conversation. Silence can be seen
discouraging for the woman such as “This is just the
as a sign of respect for the laboring woman and the effort that
beginning. It is going to get much worse.” Instead,
she may be using to stay focused.
nurses should offer comments such as “Try focusing on
Touch: Often during the care of laboring women, nurses
one contraction at a time” or “See if you can concentrate
will use touch as a sign of caring and empathy. Wide varia-
on relaxing more between the contractions” followed by
tions in meaning can be attributed to touch among cultures. It
“That is really great, keep going, excellent, now let’s try
is recommended to always ask the patient prior to touching
that again with the next one.”
her and assess her response to being touched.
Space: The concept of personal space varies among indi-
Keeping the woman and her family informed about the viduals and cultures. An awareness of personal space bound-
process of labor and birth is a constant and ever changing aries is essential; the individual patient will help the nurse to
task. For example, during the transition phase the nurse identify what she finds acceptable.
may be teaching the woman breathing techniques to avoid Care provider and labor support gender: Variations exist
pushing with a partially dilated cervix. In a matter of min- within cultures regarding norms relating to gender. Some cul-
utes, the patient can reach full cervical dilation. The nurse tures require a female care provider for the woman in labor.
then teaches her how to push and may need to assist the Other cultures require that a female labor companion accompany
woman into an effective pushing position. the woman in labor while the husband assumes a passive role.
Sick role behavior: Sick role behavior can vary among indi-
CARING FOR THE BIRTH PARTNER viduals and cultures. In some cultures it may be unacceptable to
shout out during labor and the woman may be very stoic even
Obviously, most of the nurse’s attention focuses on the though she is in extreme pain. Other cultures consider the child-
woman in labor. Efforts also should be made to help bearing year to be a time that requires intense assistance. In
the support person feel welcome and included whenever these situations, it is appropriate for the mother or sister to come
possible according to the woman’s wishes. Orientation to live with the family to help care for the mother and infant.
the birth unit is helpful in identifying where to locate
chapter 12 The Process of Labor and Birth 377
Assessment of the Fetus During Labor her contraction frequency, and the effectiveness of her
support person. However, the nurse is unable to use direct
and Birth observation skills to assess the status of the fetus. There-
fore, it is critical that fetal assessment be a priority when
Assessment of the fetus during labor and birth is a funda- the patient enters the intrapartal unit.
mental component of caring for a woman in labor. Intra-
partal assessment of the fetus should be included in the
maternal assessments at admission and remain ongoing FETAL POSITION
throughout the intrapartal period. Fetal assessments There are four central ways to identify fetal position and
include the identification of fetal position and presenta- some methods are more accurate than others. The nurse
tion, and the evaluation of the fetal status. may attempt to identify the fetal presentation in the fol-
Nurses use a variety of assessment techniques includ- lowing ways:
ing observation, palpation, and auscultation. When assess-
ing a woman in labor, the nurse is able to use observation • Abdominal palpation (Leopold maneuvers)
and interview skills from the moment the woman comes • Location of the point of auscultation of the FHR
through the door. Astute observation assists the nurse in • Vaginal examination
assessing the patient’s level of pain, her coping abilities, • Ultrasound
378 unit four The Birth Experience
Leopold Maneuvers and Point of FHR Auscultation ASSESSMENT OF THE FETAL HEART RATE
Leopold maneuvers are a systematic way of palpating the Much debate exists regarding the optimal method for
maternal abdomen to assess the fetal position. In addition, evaluating the FHR in labor with the use of continuous or
through the identification of fetal position, Leopold maneu- intermittent electronic fetal monitoring and intermittent
vers can also assist the nurse to identify the location in auscultation. In addition, there is considerable variation
which to auscultate the fetal heart tones. Performing Leop- among the methods of fetal monitoring used routinely in
old maneuvers is a skill that requires practice and is not practice and the scientific evidence to support clinical
always accurate in identifying fetal position. Factors such as practice. There is no consensus in the literature that elec-
maternal obesity, hydramnios, and multiple gestation can tronic fetal monitoring provides superior assessment over
increase the difficulty of identifying fetal position by Leop- intermittent auscultation (IA) in low-risk women. How-
old maneuvers. (See Chapter 9 for further discussion.) ever, in practice, many low-risk women continue to be
electronically monitored during labor. In addition, there
is evidence to support the assertion that continuous elec-
Critical Nursing Action Prevent Supine Hypotension tronic fetal monitoring can be associated with negative
outcomes (Thacker, Stroup, & Chang, 2005).
Much of the fetal assessment involves the maternal abdomen. Avoid
positioning the patient flat on her back. Instead, slightly elevate the
head of the bed or place a wedge under the patient’s hip to prevent
compression of the maternal vena cava caused by the gravid uterus.
Across Care Settings: Variations in practice
environments for perinatal nurses
Since diverse policies are found in different practice
Vaginal Examination environments, nurses are encouraged to seek relevant
policies and procedures within their individual health care
Another method of assessing the fetal position is by vaginal organizations to guide their practice. It is important that the
examination (see Procedure 12-1). The examiner may be nurse practice within the standards set by the employer
able to palpate the fontanels or cranial suture to identify that institution. The nurse is professionally accountable and has a
the fetus is in a cephalic presentation. The landmarks may legal responsibility to be knowledgeable of the current
also be used to further identify the degree of flexion and the standards that affect practice. Perinatal nurses should be
specific presentation such as vertex. If the membranes are fully cognizant of the institutional policies concerning fetal
intact or if the cervix is minimally dilated the examiner may heart surveillance during labor. Pertinent information
not be able to identify the position of the fetus. generally includes the method of assessment, qualifications
Ultrasound Examination for those performing the technique, nurse to patient ratio,
frequency and duration of assessment for specific stages of
Ultrasound may be used when the practitioner is unable to labor and defined risk categories, indications for specific
identify the position by abdominal palpation or when it is methods, when to notify the primary care provider, and
necessary to determine the fetal position with the most accu- documentation (Goodwin, 2000).
racy. If a breech presentation is suspected during labor, an Table 12-4 identifies recommendations for fetal monitoring
ultrasound examination may be performed to confirm the generated by various professional organizations. This
fetal presentation prior to performing a cesarean section. information further underscores the diversity of professional
standards related to the issue of FHR monitoring.
Now Can You— Discuss determination of fetal position
during labor?
1. Identify and describe three methods used to determine fetal
Auscultation of Fetal Heart Sounds
position?
2. Outline the major steps involved in performing an intrapartal Fetal heart sounds are best heard over the fetal back when
vaginal examination? the fetus is in the flexed position, as this is the part in clos-
est contact with the uterine wall. Where to auscultate the
AWHONN (Association of Women’s Health, Obstetric Supports both the use of IA and uterine palpation as an appropriate method of fetal
and Neonatal Nurses, 2000, 2003b) assessment for both antepartum and intrapartum patients and the judicious, appropriate
application of EFM intrapartally.
Risk assessment of the mother and fetus should guide the use of technology.
ACOG (American College of Obstetrics and Recommends that either EFM or electronic IA be used during the labors of low-risk
Gynecology, 2005) pregnant women.
SOGC (Society of Obstetricians and Gynaecologists Recommends IA as the preferred method of fetal surveillance of low-risk pregnancies and
of Canada, 2005) that there is insufficient evidence to justify the use of continuous EFM in routine practice.
fetal heart sounds depends on the fetal position (back to LSA LOP
maternal left or right side; breech versus cephalic)
(Fig. 12-13). Finding the best location to auscultate fetal
heart sounds facilitates another method to identify or con-
firm fetal position. Typically, with a cephalic presentation,
the fetal heart sounds are heard below the level of the
maternal umbilicus. In a ROA position, the heart sounds
RSA
are heard loudest in the right lower quadrant. Conversely,
with a breech presentation, the fetal heart sounds are
often auscultated above the level of the umbilicus. In a ROP
LSA position, the fetal heart sounds should be heard loud-
est in the upper left quadrant.
Regardless of the method used to assess fetal well-being
in labor, nurses need to be extremely attentive to the fetal
heart sounds. In addition, nurses must be knowledgeable
regarding the identification of reassuring versus non- RMA LMA
ROA LOA
reassuring FHR sounds and the appropriate interventions
that may be required. Figure 12-13 Identifying where to auscultate fetal
heart sounds depends on the fetal position.
INTERMITTENT AUSCULTATION. Intermittent auscultation
(IA) of the fetal heart rate is frequently the recom-
“intermittent” fetal monitoring. However, the evidence base
mended method for evaluating fetal status in women
supporting this practice has not demonstrated improved
who have been identified as low risk. The fetal heart rate
outcomes (Thacker, Stroup, & Chang, 2005). Thacker and
can be auscultated with a fetoscope or Doppler instru-
colleagues (2005) reported that EFM, as compared to IA,
ment and should be assessed for the baseline FHR, regu-
has not been associated with a decrease in neonatal mortal-
lar or irregular rhythm pattern, and the presence of
ity or morbidity although EFM has been associated with
accelerations (discussed later). In addition, the nurse
increased rates of cesarean section, operative vaginal birth
should be able to identify reassuring and non-reassuring
and the use of obstetrical anesthesia. At present, more than
FHR patterns and recognize the implications and inter-
85% of laboring women in the United Sates are monitored
ventions that may be required. Intermittent auscultation
electronically for at least part of their labor (Martin et al.,
is conducted using a fetoscope or Doppler instrument
2005). The continued use of EFM over intermittent FHR
(Procedure 12-3).
auscultation is believed to be related to concerns about lia-
bility and the increased nurse-to-patient ratio required with
Optimizing Outcomes— Recognizing reassuring and IA (Wood, 2003). In view of the fact that all fetal surveil-
non-reassuring FHR patterns lance methods have limitations, some professionals assert
that the current evidence supports a return to the use of IA
The use of intermittent auscultation to monitor FHR dur-
for low-risk laboring women (Dildy, 2005).
ing labor requires the nurse to recognize characteristics of
Situations where EFM is recommended continuously for
reassuring and non-reassuring patterns.
assessing fetal well-being include the presence of a high-
Reassuring FHR characteristics:
risk pregnancy, induction of labor with oxytocin, when IA
• Normal FHR baseline (110–160 bpm) identifies a non-reassuring FHR or if the institution is
• Presence of accelerations unable to provide IA. EFM can be performed externally or
Non-reassuring FHR characteristics: internally. The external EFM involves a process that is very
• Abnormal FHR baseline (110 or 160 bpm) similar to the non-stress test (NST) (see Chapter 11). The
• Presence of decelerations (ACOG, 2005) external monitor is composed of a Doppler ultrasound
transducer and tocodynanometer that is applied to the
maternal abdomen to monitor and display the FHR and
contractions (Fig. 12-14). Although the use of an external
Now Can You— Assess FHR by auscultation? transducer requires that the woman remain confined to a
1. Describe situations in which intermittent auscultation of the bed or chair, portable telemetry units allow patients to
FHR is indicated? ambulate during electronic monitoring. The nurse is able to
2. List the characteristics of a reassuring FHR monitored by observe the FHR and uterine contraction patterns at a cen-
intermittent auscultation? trally located electronic display station. Some facilities are
equipped with monitoring units that can be used when the
woman is submerged in water.
The internal fetal monitor is composed of a spiral elec-
Electronic Fetal Monitoring trode that must be inserted into the fetal scalp or presenting
Electronic fetal monitoring (EFM) may be conducted on an part during a vaginal examination (Fig. 12-15). The cardiac
intermittent or continuous basis. In a large number of signal is transmitted through the spiral electrode and a fetal
American and Canadian hospitals, women are routinely electrocardiogram tracing is produced. Uterine activity is
monitored on admission for a short period of time to assess assessed by a solid or fluid-filled intrauterine pressure cath-
fetal well-being and then the monitoring is conducted peri- eter (IUPC) that is introduced into the uterine cavity. The
odically throughout labor. This practice is referred to as IUPC can measure contraction frequency, duration, and
380 unit four The Birth Experience
intensity. The internal method is a more accurate form of regarding interpretation of fetal heart patterns. Often, nurses
fetal monitoring. However, owing to the invasive nature of who practice in labor and delivery units obtain advanced
the procedure, internal EFM is often reserved for high-risk training and education regarding fetal monitoring to aid in
pregnancies (situations in which external fetal monitoring accurate interpretation.
is insufficient in obtaining the FHR or in situations where
there is evidence of a non-reassuring fetal heart rate). The Optimizing Outcomes— Standards for the
application of an internal electrode requires that the mem- interpretation of FHR patterns
branes be ruptured and that the cervix has sufficiently
dilated. In 1997, the National Institute of Child Health and Human
The interpretation of the fetal heart rate pattern requires Development (NICHD) published a proposed nomencla-
a holistic assessment of the maternal risk factors, uterine ture system for EFM interpretation. Standardized defini-
activity, and FHR patterns including baseline, variability tions for FHR monitoring were presented (NICHD, 1997).
and the presence of accelerations, and the identification of Concerns regarding enhancing communication among
any decelerations. Members of the obstetrical team must various caregivers and patient safety (Simpson, 2004) as
maintain close communication and reach mutual consensus well as concerns about research validity have led to the
chapter 12 The Process of Labor and Birth 381
Ultrasound
Toco transducer transducer
(uterine contractions) (FHR)
Source: Simpson, K.R., and Creehan, P.A. (2001). AWHONN Perinatal Figure 12-18 Top. Early decelerations. Bottom.
Nursing (2nd ed.). Philadelphia: Lippincott. Uterine contractions.
chapter 12 The Process of Labor and Birth 383
Early decelerations are considered benign and are usu- • Continuation of a baseline at a lower level that before
ally well tolerated by the fetus. They are believed to be the deceleration
related to fetal head compression and the resulting vagal • The presence of fetal tachycardia
stimulation that slows the FHR. They may occur during
vaginal examinations, uterine contractions, and during
placement of the internal mode of fetal monitoring. Early Optimizing Outcomes— Amnioinfusion to relieve
decelerations are viewed as a reassuring FHR pattern cord compression
when accompanied by normal baseline FHR and normal Amnioinfusion is the infusion of warmed normal saline
variability. into the uterus via sterile catheter (IUPC). Amnioinfusion
Variable Decelerations may be used in an attempt to reduce the severity of variable
decelerations caused by cord compression. The nurse
Variable decelerations, as the name implies, are decelera- assists with the procedure by assembling the equipment;
tions that are variable in terms of their onset, frequency, monitoring the FHR, contraction status, and maternal tem-
duration, and intensity. The decrease in FHR below the perature; and by verifying that the infused fluid is exiting
baseline is 15 bpm or more, lasts at least 15 seconds, and the uterus.
returns to the baseline in less than 2 minutes from the
time of onset (NICHD, 1997) (Fig. 12-19). The decelera-
tion is unrelated to the presence of uterine contractions.
Variable decelerations are thought to be a result of umbili- Late Decelerations
cal cord compression. Thus, the degree by which the cord
The patterns of late decelerations typically mirror the
is compressed (partially versus completely) can affect the
contraction, and this characteristic is similar in appear-
severity of the deceleration. For example, a cord that is
ance to early decelerations. With late decelerations, the
briefly compressed by the fetus may be manifest as a very
deceleration has a late onset and begins around the
abrupt decrease in the FHR with a rapid return to base-
peak of the contraction (Fig. 12-20). This type of decel-
line. Conversely, a cord that is tightly wrapped around the
eration does not resolve until after the contraction has
fetal neck (nuchal cord) progressively becomes more
ended. Late decelerations indicate the presence of
compressed as the fetus descends into the maternal pelvis.
uteroplacental insufficiency, a decline in placental
This situation is most likely to result in longer, more
function. Normally, the fetus can withstand repeated
severe decelerations. In general, brief, occasional decelera-
contractions with sufficient oxygenation. However, in
tions are often considered benign whereas repetitive,
this circumstance a decrease in blood flow from the
worsening variable decelerations are cause for concern
uterus to the placenta results in fetal hypoxia and late
and always warrant further investigation.
decelerations.
The American College of Obstetricians and Gynecolo-
Late decelerations require prompt attention and
gists (ACOG, 2005) classifies variable decelerations as
reporting. The longer the late decelerations persist, the
significant when the FHR falls below 70 bpm and lasts
more serious they become. Immediate attempts should
longer than 60 seconds. In addition, the Society of Obste-
be made to correct the cause of the late decelerations if
tricians and Gynaecologists of Canada (SOGC, 2005)
possible. For example, late decelerations in the presence
concurs and further identifies “non-reassuring” or “atypi-
of an oxytocin infusion may signal a need to immedi-
cal” variable decelerations as:
ately discontinue the oxytocin infusion, especially if
• Deceleration to less than 70 bpm lasting greater than uterine hyperstimulation is suspected. Nursing inter-
60 seconds ventions that should be implemented immediately
• Loss of variability in the baseline FHR and in the include reporting the late decelerations, changing the
trough of the deceleration maternal position, discontinuing the oxytocin infusion,
• Biphasic deceleration increasing the intravenous fluids, and administering
• Slow return to baseline oxygen by mask.
Figure 12-19 Top. Variable decelerations. Figure 12-20 Top. Late decelerations. Bottom. Uterine
Bottom. Uterine contractions. contractions.
384 unit four The Birth Experience
critical nursing action Interpreting Fetal Monitor Optimizing Outcomes— Communicating about FHR
Tracings patterns
In clinical practice, various guidelines exist concerning the
To aid in the interpretation of EFM tracings, the nurse should consider
the following parameters: management of FHR tracings. Accurate, consistent, and
timely communication among health care providers is
• Uterine activity: What is the frequency, duration, and always required to optimize outcomes for the patient and
intensity of contractions?
her fetus.
• Labor progress: What is the stage of labor? What is the
dilation, effacement, station, presentation, and position?
• Baseline FHR: What is the baseline FHR? Is tachycardia or
bradycardia present?
• Baseline variability: What is the variability of the FHR Be sure to— Use appropriate terminology during
(absent, minimal, moderate, marked, or other)? documentation of FHR auscultation
• Periodic changes in FHR: Are there any FHR changes from
the baseline? Are accelerations present? Are any decelerations When documenting the findings from FHR auscultation,
present? If decelerations are present are they early, variable, late, descriptive terms associated with EFM such as “marked
or prolonged? variability” or “variable deceleration” should be avoided
• Maternal history and condition: Are there any pre- because these terms reflect visual descriptions of the pat-
existing conditions that increase risk for this pregnancy? Are there terns produced on the monitor tracing. Terms that are
any intrapartum high-risk factors (e.g., meconium) that should numerically defined (i.e., “bradycardia,” “tachycardia”)
be noted? may be used. When auscultated, FHR must be described as
a baseline number or range and as having a regular or
irregular rhythm. The presence or absence of accelerations
Based on a systematic interpretation, FHR tracings or decelerations that occur during and after contractions
are generally classified as reassuring or non-reassuring should be noted (AWHONN, 2000; 2003b).
(Box 12-4). This classification helps to determine the
need for interventions. In general, a reassuring (normal)
FHR tracing is generally associated with fetal well-
being. Routine assessment of the fetal heart rate is NURSING INTERVENTIONS AND DIAGNOSES
conducted according to the birth center protocol. A Early decelerations are considered to be benign and no
non-reassuring tracing indicates an urgent need to notify action is necessary. However, it is important to identify
the physician (or nurse midwife) and implement appro- them so that they can be differentiated from late or vari-
priate interventions. able decelerations. Depending on the cause, interventions
chapter 12 The Process of Labor and Birth 385
for variable and late decelerations include lateral position support person are crucial at this stage. The woman is not
changes (to displace the weight of the gravid uterus off the to be left alone during this time, and continuous support
inferior vena cava), oxygen administration at 8 to 10 L per should be provided. It is important to encourage the
minute by face mask, palpation of the uterus for hyper- patient to rest between pushing in order to maintain her
stimulation, discontinuation of oxytocin if infusing, energy throughout the second stage.
increasing the rate of the maintenance intravenous The duration of the second stage is variable and may be
solution, and assisting with fetal oxygen saturation moni- influenced by several factors such as parity; the type and
toring if ordered. Possible nursing diagnoses include amount of analgesia or anesthesia administered; the fre-
impaired fetal gas exchange related to umbilical cord com- quency, intensity, and duration of contractions; maternal
pression or placental insufficiency; decreased maternal efforts in pushing, and the support the patient receives.
cardiac output related to supine hypotension secondary to For nulliparous women, the second stage often involves 1
position; and anxiety related to lack of knowledge con- to 2 hours of pushing. Multiparous women typically expe-
cerning fetal monitoring/fetal well-being during labor. rience a much shorter second stage and childbirth may
occur within minutes following full cervical dilation.
Now Can You— Assess FHR patterns detected by EFM?
1. Describe situations when electronic fetal monitoring instead PROMOTING EFFECTIVE PUSHING
of intermittent auscultation is indicated?
2. Define the following frequently used terminology: baseline Women push most effectively when they experience the
fetal heart rate, variability, acceleration, deceleration? urge to bear down and push. The urge to push is believed
3. Describe the assessment of a reassuring and a non- to be stimulated by the Ferguson reflex as the presenting
reassuring fetal heart rate? part stretches the pelvic floor muscles. Thus, the maternal
4. List four nursing interventions for variable and late urge to push may be more related to the station of the
decelerations? presenting part rather than to the dilation of the cervix.
Differing practices exist regarding the promotion of
pushing during the second stage. Many practitioners believe
that pushing should be encouraged only when the woman
Second Stage of Labor has the urge to push, instead of when full cervical dilation
has been reached. Some women (i.e., those with an epidu-
The second stage of labor commences with full dilation of ral analgesia or other types of anesthesia) may have no urge
the cervix and ends with the birth of the infant. Often the to bear down. When this situation occurs, a process called
woman or nurse may suspect that the woman has entered “laboring down” may be used. “Laboring down” allows the
the second stage of labor because of the patient’s urge to woman to rest as the fetus descends. Pushing is postponed
push or the presence of involuntary bearing down efforts. until the urge to push is experienced. Research suggests
The contractions often remain very similar to those expe- that there is a decrease in maternal fatigue and an increase
rienced during the transition stage. They continue to in fetal oxygenation when women delay pushing until they
occur frequently and are very intense. The woman may feel the urge (Minato, 2000; Roberts, 2003). It has been
exhibit varying emotions during the second stage. Some proposed that the decision concerning when to initiate
patients may get a spurt of energy or a “second wind” to pushing should be based on the individual maternal
help them get through the second stage. Others may be response rather than on standardized routine practices.
nervous or fearful of the new sensations that they are feel- Furthermore, the duration of active maternal pushing has
ing. Encouragement and support from the labor nurse and been found to be more closely related to the neonate’s con-
dition at birth than the duration of the second stage of labor
(Cesario, 2004; Minato, 2000; Roberts, 2002).
There are generally two methods of pushing during the
where research and practice meet: second stage of labor: closed-glottis and open-glottis
Use of EFM pushing. Closed-glottis pushing, also referred to as
“directed pushing,” is the traditional method, in which
Researchers evaluated nine randomized controlled trials that
included 18,561 low- and high-risk pregnant women from diverse
women are encouraged to begin pushing at full cervical
countries to compare the efficacy and safety of routine continuous dilation regardless of the urge to bear down. The woman
EFM during labor with intermittent auscultation. Overall, there was is encouraged to take a deep breath and hold it for at least
a statistically significant decrease in the incidence of neonatal sei- 10 seconds while pushing as hard and as long as she is
zures in infants subjected to EFM. They found no significant differ- able throughout the contraction. Simpson and Creehan
ences between patients who received electronic fetal monitoring or (2001) identify this practice as outdated and physiologi-
intermittent auscultation during labor on: Apgar scores of infants at cally inappropriate. They assert that there is a lack of sci-
1 minute of less than 7 or less than 4, rate of admission to neonatal entific evidence to support closed-glottis pushing and
intensive care units, perinatal deaths, or the development of cerebral point out that this practice has been associated with
palsy. However, there was an increased rate of cesarean delivery adverse outcomes including fetal hypoxia, acidemia, and
and operative vaginal delivery with the use of EFM. Implications for
clinical practice include the following: (1) EFM may exert a preventa-
lower neonatal Apgar scores. The poor outcomes are
tive effect on neonatal seizures and (2) the use of EFM appears to believed to result from prolonged maternal breath holding
increase the rate of maternal operative deliveries, a factor that may that ultimately affect uteroplacental blood flow.
balance or outweigh the potential benefits of its use (Thacker, Open-glottis pushing, also referred to as “involuntary
Stroup, & Chang, 2005). pushing”, is another method of pushing. With this tech-
nique, the laboring woman is encouraged to hold her
386 unit four The Birth Experience
breath for only 5 to 6 seconds during pushing and to take introitus, often appears to recede between contractions. As
several breaths between each bearing down effort. In addi- the contractions and maternal pushing efforts continue, the
tion, women are allowed to exhale throughout the bearing presenting part descends farther.
down attempts. This process is believed to produce no Crowning, which means that birth is imminent, occurs
compromise to the uteroplacental blood flow and there- when the fetal head is encircled by the vaginal introitus
fore is thought to invoke less stress on the fetus. (Fig. 12-21). Some women may complain of a burning
Variations in pushing techniques are found in clinical sensation as the perineum is stretched. This experience
practice. Regardless of the process used for second-stage can be frightening for the woman and it is important for
pushing, laboring women require continuous support and the nurse to identify it as a normal sensation. The woman
encouragement from their health care provider(s). It is may also feel intense pressure in the rectum and a need to
important to calmly provide easy-to-understand, consis- evacuate her bowels. Again, the nurse should confirm the
tent information to avoid confusion. It is also important to normalcy of these sensations and continue to offer encour-
remember that the patient and her partner can become agement and support. If the woman does pass stool, she
anxious and confused if several people attempt to give should be cleaned in a timely manner. Some women may
directions at the same time. feel as though they are losing control and a variety of emo-
tions (e.g., irritability, fear, embarrassment, and helpless-
ACHIEVING A POSITION OF COMFORT ness) may be displayed. These behaviors can be frighten-
ing to the support person as well. The nurse needs to
During the second stage, comfort measures remain equally continue to encourage and reinforce to the woman and
important and many of the interventions and positioning her support person that these reactions are normal and
identified for the first stage of labor can be implemented that progress is being made.
during the second stage as well. Many factors (e.g., the
woman’s personal preferences, the use of analgesia or anes-
EPISIOTOMY
thesia, the preferences of the health care practitioner, and
the imminence of birth) have an influence on the optimal Episiotomy is a surgical incision of the perineum that is
maternal position during this stage. When pushing, women performed to enlarge the vaginal orifice during the second
are encouraged whenever possible to maintain an upright stage of labor (Carroli & Belizan, 2006). The frequency of
or semi-upright position, such as squatting, sitting, stand- routine episiotomy has decreased over the last 20 years as
ing, kneeling, on all fours, or sitting on the toilet. the benefits of performing routine episiotomy began to be
Pushing when in an upright position allows the use of questioned. In the 1980s, the episiotomy rate was reported
gravity to promote fetal descent and has been associated to be approximately 64 out of 100 births. At that time,
with a shortened labor. Positions such as squatting and many physicians routinely performed episiotomies based
kneeling may also help to increase the dimensions of the on the belief that surgical enlargement of the vaginal
maternal pelvis. Assuming a hands and knees position or opening would prevent intrapartal complications such as
leaning over a table or chair helps to take pressure off the protracted second stage of labor, fetal trauma, and severe
maternal spine and often reduces backache commonly lacerations, and later maternal problems such as cysto-
associated with a fetal occipital–posterior position (see cele, rectocele, dyspareunia, and uterine prolapse.
Fig. 12-12). Many women questioned the use of routine episiotomy
and current practices have changed to reflect existing evi-
Now Can You— Discuss comfort measures and pushing dence that routine episiotomy has not been associated
techniques for the second stage of labor? with better outcomes over selective episiotomy. In studies
where episiotomy had been performed for medical indica-
1. List three comfort measures used during the first stage of tions, the results demonstrated positive benefits. When
labor that would also be effective during the second stage medically indicated, episiotomy was associated with
of labor? decreased posterior perineal trauma and suturing and
2. Discuss how the nurse can advocate for a patient who does
not have the urge to push in the second stage?
3. List two positions for pushing and provide one advantage
of each?
fewer complications. No differences were found in mater- birth in an “all fours” position. In addition, women who received
nal pain experience or the incidence of severe vaginal regional anesthesia also demonstrated an increased need for
perineal trauma when routine and selective episiotomies suturing than women who gave birth in a lateral position.
were compared. There was an increased risk of anterior Nurses should be aware of the potential benefits and risks
perineal trauma associated with selective episiotomy (Car- associated with various techniques intended to help minimize
roli & Belizan, 2006). Many practitioners currently reserve perineal trauma. It is important for nurses to remain open-
the use of episiotomy for medical indications, which minded, encouraging, and supportive of patients who wish to
include instrumentation during birth (forceps or vac- utilize alternate methods to help facilitate perineal stretching.
uum), a need to expedite the birth (evidence of fetal com-
promise), or in the event of maternal exhaustion.
Two different methods are used for the episiotomy. The Now Can You— Discuss factors associated with impending
most common method is the midline or median episiotomy. childbirth?
An incision is made from the vaginal opening downward
toward the rectum. A midline episiotomy is easily repaired, 1. Explain the significance of crowning?
heals quickly, and is associated with less postoperative pain 2. Discuss the controversies surrounding routine episiotomy?
than a mediolateral episiotomy. However, the primary dis- 3. Identify three strategies that may be effective in reducing
advantage of a midline episiotomy is the risk of third- and perineal trauma during childbirth?
fourth-degree lacerations with extension through the rectal
sphincter. The mediolateral episiotomy is less common.
An incision is made from the vagina to the 5 o’clock or
7 o’clock position (the maternal left mediolateral or right Birth
mediolateral position). Compared to a midline incision, the
mediolateral episiotomy is associated with a smaller risk of As the fetal head is crowning, the perineum is stretched
fourth-degree lacerations although third-degree lacerations very thin and the anus stretches and protrudes. With con-
may occur. The amount of blood loss is usually greater, the tinued maternal pushing efforts, the fetal head extends
surgical repair is more difficult, and there is increased pain under the symphysis pubis and is born. The practitioner
postpartum (Fig. 12-22). assisting at the birth may prefer to coach the patient
regarding pushing and breathing, as the birth of the head
Complementary Care: Methods to decrease should occur in a controlled manner in an attempt to limit
perineal trauma injury to the perineum. Once the anterior shoulder reaches
the pelvic outlet, it rotates to the midline and is delivered
Various strategies to decrease the risk of perineal trauma during from under the pubic arch. The posterior shoulder is
the second stage of labor have been implemented and evaluated. guided over the perineum, and the body follows.
These include perineal massage (antenatal and intrapartal),
application of warm compresses, use of lubricating oils, and
THE CARDINAL MOVEMENTS
manual support. However, research has demonstrated variable
results and further investigation is indicated. Maternal position- The cardinal movements, or mechanisms of labor, have
ing for birth has also shown variable results regarding its effect been used to describe how the fetus (in a vertex presenta-
on perineal trauma. Soong and Barnes (2005) found that women tion) passes through the birth canal and the positional
who gave birth in a semirecumbent position had an increased changes required to facilitate birth (Fig. 12-23). The cardi-
need for sutures for perineal lacerations than women who gave nal movements are presented in the order in which they
occur.
Descent
Four forces facilitate descent, which is the progression of
the fetal head into the maternal pelvis: (1) pressure of the
amniotic fluid; (2) direct pressure of the uterine fundus
on the fetal breech; (3) contraction of the maternal
abdominal muscles; and (4) extension and straightening
of the fetal body. The fetal head enters the maternal inlet
in the occiput transverse or the oblique position because
the pelvic inlet is widest from side to side. The sagittal
suture is equidistant from the maternal symphysis pubis
and sacral promontory. The degree of fetal descent is mea-
Fetal
Mediolateral sured by stations.
head
Perineal Midline Flexion
body
Flexion occurs as the fetal head descends and comes into
Figure 12-22 An episiotomy is a surgical incision of contact with the soft tissues of the pelvis, the muscles of
the perineum that is performed to facilitate birth. the maternal pelvic floor, and the cervix. The resistance
The most common method is the midline or median encountered with these structures causes the fetal chin to
episiotomy. An incision is made from the vaginal flex downward onto the chest. This position allows the
opening downward toward the rectum. smallest fetal diameters to enter the maternal pelvis.
388 unit four The Birth Experience
may also contribute to polycythemia and potential • Impaired fetal gas exchange related to umbilical cord
hyperbilirubinemia. compression
The primary care provider places two Kelly clamps on • Deceased maternal cardiac output related to supine
the umbilical cord, and may invite the father or birth hypotension secondary to maternal position
support person to cut the cord between the two clamps.
Either the primary care provider or the nurse then places
a plastic clamp on the umbilical cord approximately 0.5 Now Can You— Discuss cardinal movements and umbilical
to 1 inch (1.2 to 2.5 cm) from the newborn’s abdomen, cord clamping?
being careful to not catch the abdominal skin in the 1. Describe what is meant by the cardinal movements?
clamp. The nurse observes the cut cord for the presence 2. Compare and contrast early versus late clamping of the
of three blood vessels: two arteries and one vein. Samples umbilical cord?
of cord blood are collected for laboratory analysis. Some
parents request to have their newborn’s cord blood
“banked” in the event that the stem cells in the cord
blood may be required in the future for the treatment of
a family illness. A vaginal birth sequence is presented in
Figure 12-24. Third and Fourth Stages of Labor
Nursing care during the third and fourth stages of labor
is focused on providing immediate care for the newborn
Possible Nursing Diagnoses in the adjustment to extrauterine life, assisting with the
for the Intrapartal Patient delivery of the placenta, monitoring and assisting the
mother with the physiological adjustments of labor and
Examples of common nursing diagnoses during labor and birth, and facilitating the attachment between the
birth are listed below. It is important to be cognizant of mother and baby. Characteristics of the third and fourth
individual differences among patients. While these are com- stages of labor are presented in Table 12-6.
mon nursing diagnoses, they will vary among individuals
and stages of labor.
Third Stage of Labor
• Pain related to increasing frequency, duration, and
intensity of contractions The third stage of labor is the period of time from the
• Knowledge deficit related to pain management birth of the baby to the complete delivery of the placenta.
techniques for active labor This stage usually lasts 5 to 10 minutes, and may last up
• Anxiety related to the previous birth experience to 30 minutes. Once the baby is born, the uterine cavity
• Fatigue related to a prolonged latent phase labor immediately becomes smaller. The change in the interior
• Risk for infection related to prolonged rupture of dimension of the uterus results in a reduction in the size
membranes of the placental attachment site. This event leads to the
Description Begins with the birth of the infant and ends with the A time of physiological adaptation that begins following delivery
delivery of the placenta. Usually takes 5–10 minutes, of the placenta and lasts 1–2 hours.
and may take up to 30 minutes.
Contractions The uterus should be firmly contracted. The uterus should be firmly contracted.
Assessment Uterus becomes globelike. Uterus remains firmly contracted.
Uterus rises upward. Lochia rubra, bright red blood flow with occasional small clots.
Umbilical cord descends further. Vital signs return to prelabor values.
Gush of blood as placenta detaches.
Physical discomforts Some discomfort or cramping as the placenta Some experience perineal discomfort usually related to trauma from
is expelled. the episiotomy or tearing, or hemorrhoids.
Maternal behaviors Focus on infant well-being. Excited, tired.
Crying common. Expressions of relief. Bonding and attachment with infant.
Culturally influenced. Initiation of breastfeeding.
Culturally influenced.
390 unit four The Birth Experience
A B
separation of the placenta from the uterus. The following medication: Oxytocin
clinical indicators signal that separation of the placenta
from the uterus has occurred: Oxytocin (ox-i-toe-sin)
Pitocin, Syntocinon
• The uterus becomes spherical in shape.
• The uterus rises upward in the abdomen due to the Pregnancy Category: X (intranasal), UK (IV, IM)
descent of the placenta into the vagina. Indications:
• The umbilical cord descends further through the Induction of labor at term
vagina. Facilitation of uterine contractions at term
Facilitation of threatened abortion
• A gush of blood occurs once the placenta detaches
Control of postpartum bleeding after expulsion of placenta
from the uterus.
Actions: Stimulates uterine smooth muscle producing uterine
The placenta is expelled in either the Schultze or Dun- contractions similar to those in spontaneous labor (administered intrave-
can manner (Fig. 12-25). The Schultze mechanism nously). Stimulates mammary gland smooth muscle facilitating lactation
(“shiny Schultze”) occurs when the placenta separates (administered intranasally). Has vasopressor and diuretic effects.
from the inside to the outer margins with the shiny, fetal Therapeutic Effects: Induces labor. Reduces postpartum bleeding.
side of the placenta presenting first. It is the most com- Induces breast milk letdown.
mon method of placental expulsion. The Duncan mecha- Pharmacokinetics:
nism occurs when the placenta separates from the outer ABSORPTION: Well-absorbed from the nasal mucosa when administered
margins inward, rolls up, and presents sideways. Since the intranasally.
placental surface is rough, the Duncan mechanism is com- DISTRIBUTION: Through extracellular fluid. Small amounts reach fetal
monly called “dirty Duncan.” circulation.
As the placenta separates from the uterine wall, it is METABOLISM: Metabolized rapidly in kidneys and liver.
EXCRETION: Small amounts excreted in urine, half-life 3–9 minutes.
important that the uterus continues to contract. The con-
tractions minimize the bleeding that results from the open Contraindications and Precautions:
blood vessels left at the placental attachment site. Failure Contraindicated in CPD or deliveries that require conversion (i.e., transverse
of the uterus to contract adequately with separation of the lie). Use with caution in first and second stages of labor.
placenta can result in excessive blood loss or hemorrhage. Adverse Reactions and Side Effects: Maternal adverse reactions are
To enhance the uterine contractions after expulsion of the associated with IV use only. Painful contractions and increased uterine
placenta, oxytocic medications are often given. Oxytocin motility most common. May contribute to maternal coma, seizures,
hypotension. May contribute to fetal asphyxia or arrhythmias.
is administered either by the intravenous (IV) route or by
intramuscular (IM) injection. Route and Dosage: May be added to IV for labor induction or given IV
or IM to control postpartum bleeding (do not administer IM and IV
routes simultaneously). Intranasal spray is administered 2–3 minutes
before planned breastfeeding.
NURSING CARE OF THE MOTHER DURING
Nursing Implications:
THE THIRD STAGE OF LABOR Fetal maturity, presentation, and maternal pelvic adequacy should be
After the birth of the infant, the nurse observes for signs assessed before administration to induce labor.
that the placenta has separated from the wall of the uterus. Monitor contractions, resting uterine tone, and FHR frequently.
The uterus is palpated to determine the rise upward as Monitor uterus for firmness and early detection of bogginess.
well as the characteristic change in shape from one resem- Monitor lochia for signs of excessive bleeding.
bling a disk to that of a globe. The nurse may ask the Adapted from Deglin, J.H., and Vallerand, A.H. (2009). Davis’s drug guide for
woman to push again, to facilitate in the delivery of the nurses (11th ed.). Philadelphia: F.A. Davis.
placenta. If 30 minutes have elapsed from completion of
B
Figure 12-25 Third stage of labor: separation and expulsion of the placenta. A. Schultze
mechanism. B. Duncan mechanism.
392 unit four The Birth Experience
the second stage of labor and the placenta has not yet been accomplishment, and amazement. The nurse can support
expelled, it is considered to be “retained”. (See Chapter 14 the mother and birth partner by promoting contact with
for further discussion.) the infant. The stable newborn can be placed on the
Oxytocic medications such as Pitocin and Syntocinon maternal abdomen, and as soon as possible, the nurse
are often administered at the time of the delivery of the can help the mother into a comfortable position to hold
placenta. These drugs are used to stimulate uterine con- the infant.
tractions, thereby minimizing the bleeding from the pla-
cental attachment site and reducing the risk of postpartum Initiating Infant Attachment
hemorrhage. The nurse administers oxytocic medications Once the birth has taken place, the time that immediately
according to institutional protocol. If a peripheral intrave- follows is ideal for fostering attachment between the
nous infusion has been established, oxytocin 10 to 20 units mother, her birth partner, and the newborn. The infant is
may be added to the intravenous infusion. If no intrave- in a stage of alertness during the first hour after birth and
nous infusion is present, 10 units of oxytocin may be is responsive to voice, touch, and gaze. The nurse can
administered intramuscularly. In situations where there is facilitate eye-to-eye contact between the patient and her
excessive blood loss, the physician may order up to 40 neonate by dimming the room lights. This occasion also
units of oxytocin per liter of intravenous infusion fluid. provides an excellent time to initiate breastfeeding if the
Other medications such as methylergonovine maleate mother wishes to do so.
(Methergine) or carboprost tromethamine (Hemabate)
may be given intramuscularly to control blood loss. During
this time the nurse continues to assess the volume of blood Immediate Nursing Care
loss and monitor the patient’s vital signs, paying close
attention to the blood pressure and heart rate.
of the Newborn
Once the placenta has been delivered, the nurse care- Once the newborn has been born, the primary care pro-
fully examines it to ensure that all cotyledons are intact vider (physician or certified nurse midwife) places the
(Fig. 12-26). If any part of the placenta is missing, the infant on the mother’s abdomen (if the infant is stable), in
nurse immediately reports this finding to the attending a modified Trendelenburg position. This immediate con-
physician. Because retained placental fragments can con- tact between mother and newborn provides reassurance to
tribute to postpartum hemorrhage or infection, the physi- the mother regarding the overall well-being of the baby,
cian may perform a manual exploration of the uterus to and begins the attachment process.
remove any remaining placental tissue. Birth signals the transition from fetus to newborn.
Emotional Support
Several physiological adaptations must occur to facilitate
the adjustment of the newborn to the extrauterine envi-
The birth of the newborn is an emotional experience for ronment. Of primary importance is the initiation of the
the patient and her support person. Hearing the infant’s newborn’s respirations, a process that results in the
first cry can evoke tears, laughter, and feelings of relief, replacement of fetal lung fluid with air. In most situa-
tions, the actions of drying the newborn and performing
nasopharyngeal suctioning, if needed, provide adequate
stimulation to initiate the newborn’s respiratory effort.
While respirations are being established, the newborn’s
cardiovascular system is also undergoing major adapta-
tions to allow the flow of deoxygenated blood into the
lungs for gas exchange. Fetal circulation transitions to
neonatal circulation after closure of the ductus arterio-
sus, the foramen ovale, and the ductus venosus. (See
Chapter 17 for further discussion of the physiological
transitions in the newborn.)
The modified Trendelenburg position facilitates the
drainage of mucus from the newborn’s nasopharynx and
trachea. The nurse suctions the newborn’s nose and
mouth with a bulb syringe as needed. Preventing heat loss
in the neonate constitutes an important nursing role.
Before the infant is placed on the mother’s abdomen, the
nurse dries the infant, discards the wet linens, and applies
warm blankets. Skin-to-skin contact between the mother
and baby also helps to maintain the newborn’s
temperature.
five signs of newborn cardiopulmonary adaptation and While the newborn rests upon the mother’s abdomen,
neuromuscular function: heart rate, respiratory effort, the nurse performs a head-to-toe assessment to detect
muscle tone, reflex irritability, and color (Table 12-7). any abnormalities. The nurse observes the infant’s over-
all size relative to the gestational age, noting the shape
HEART RATE. The priority assessment of the newborn is
and size of the head and chest. The color of the skin,
the heart rate. On auscultation or palpation, the nurse
presence of vernix and lanugo, and any evidence of
recognizes an absent heart rate or heart rate less than 100
trauma are also noted. (See Chapter 18 for further
bpm as a signal for resuscitation.
discussion.)
RESPIRATORY EFFORT. The newborn’s vigorous cry best
indicates adequate respiratory effort, the next most impor- Now Can You— Discuss essential nursing actions during
tant assessment after birth. A weak or absent cry is a signal the third stage of labor?
for intervention. 1. Name three clinical indicators that signal placental
MUSCLE TONE. The nurse determines the newborn’s separation during the third stage of labor?
muscle tone by assessing the response to the extension of 2. Explain what is meant by “shiny Schultze” and “dirty
the extremities. Good muscle tone is noted when the Duncan”?
extremities return to a position of flexion. 3. Describe essential nursing actions concerning the
oxytocin infusion, placenta inspection, and immediate
REFLEX IRRITABILITY. The nurse assesses reflex irritability newborn care?
by observing the newborn’s response to stimuli such as a
gentle stroking motion along the spine or flicking the
soles of the feet. When this stimulation elicits a cry, the
score is 2. A grimace in response to stimulation scores 1, Fourth Stage of Labor
and no response is a score of 0.
COLOR. The nurse assesses skin color for pallor and The fourth stage of labor is the period of maternal physio-
cyanosis. Most newborns exhibit cyanosis of the extremi- logical adjustment that occurs from the time of delivery of
ties at the 1-minute Apgar check, and this normal finding the placenta through the first 1 to 2 hours after birth.
is termed acrocyanosis. A score of 2 indicates that the Monitoring of the mother and infant takes place fre-
infant’s skin is completely pink. Newborns with darker quently during this time.
pigmented skin are assessed for pallor and acrocyanosis.
NURSING CARE DURING THE FOURTH STAGE
IDENTIFICATION OF THE NEWBORN OF LABOR
Another important nursing action involves placing match- While the physician examines the mother’s perineum,
ing identification bands on the infant and the mother. cervix, and vagina for evidence of tears, the nurse assesses
Some hospitals also provide identification bands for the the uterus for firmness, height, and position. To perform
father or other designated birth support person. The fundal palpation, the left hand is placed directly above
infant’s identification bands are placed snugly enough so the symphysis pubis and gentle downward pressure is
that when the initial weight loss occurs, the ID band does exerted. The right hand is cupped around the uterine
not fall off. Agency protocols may also direct the nurse to fundus (Fig. 12-27). On palpation, the uterus is expected
footprint the newborn. (See Chapter 18 for further to feel firm and be positioned in the midline, at or just
discussion.) below the umbilicus. It can be described as closely
Physiological Score
Parameter 0 1 2
Society of Obstetricians and Gynaecologists of Canada (SOGC). (2005). Database of Systematic Reviews, No. 4. Chichester, UK: John Wiley
Clinical Practice Guidelines: Fetal health surveillance in labor. Jour- & Sons, pp 73–86.
nal of Gynecology Canada, 24(3), 250–262. Tucker, S.M. (2004). Pocket Guide to Fetal Monitoring and Assessment
Soong, B., & Barnes, M. (2005). Maternal position at midwife-attended birth (5th ed.). St Louis: C.V. Mosby.
and perineal trauma: Is there an association? Birth, 32(3), 164–169. Wood, S. (2003). Should women be given a choice about fetal assess-
Thacker, S., Stroup, D., & Chang, M. (2005). Continuous electronic ment in labor? MCN American Journal of Maternal/Child Nursing,
heart rate monitoring for fetal assessment during labor. Cochrane 28(5), 292–298.
CONCEPT MAP
Complementary Care:
• Perineal massage, warm compresses, lubricating oils, semi-recumbent
position potentially decrease perineal trauma
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Describe the unique characteristics of pain associated with childbirth.
◆ Discuss sociocultural factors that shape the woman’s pain experience during labor and
childbirth.
◆ Identify nonpharmacological methods to promote comfort during labor and birth.
◆ Compare pharmacological interventions used for discomfort and pain during different stages of
labor.
◆ Summarize the possible complications associated with regional and general anesthesia.
◆ Discuss the nurse’s role in ensuring maternal-fetal safety while promoting comfort during labor and
birth.
Previous meta-analysis of randomized clinical trials have found The onset of regular contractions was determined by the
that there is a reduction in the number of cesarean deliveries, nurse or reported by the patient. The actual time of birth
length of labor, and use of analgesia along with increased infant was obtained from the woman’s medical record.
Apgar scores in women who receive continuous support during • Type of birth
labor. One form of support can be provided by a doula, who is a • Type and timing of administration of analgesia or anes-
female support for women in labor. She is not a physician, nurse, thesia
or midwife and does not provide medical treatment. In addition, • Apgar scores at 1 and 5 minutes.
her presence is not intended to take the place of the male partner The study took place in a tertiary perinatal care hospital that
or other family members who may be present during labor. provides care for underinsured low-income women. A conve-
The purpose of the study was to compare labor outcomes of nience sample of 600 nulliparous women met the criteria for the
nulliparous women accompanied by a doula with the labor out- study: low-risk, singleton pregnancy. Male partners and/or addi-
comes of nulliparous women who received standard care and tional family members were allowed to provide support during
did not have the support of a doula, regardless of support from labor.
the male partner or other family members. The outcomes under Three hundred women who were randomly assigned to the
investigation included: experimental group identified a female friend or family member
• Length of labor, which was defined as the time from the who was willing to serve as a lay doula.
onset of regular contractions to the birth of the neonate. (continued)
399
400 unit four The Birth Experience
Introduction People 2010 national goals relate to pain relief during labor.
One such goal is:
When a laboring woman experiences discomfort and • Reduce the maternal mortality rate to no more than
pain, there are many interventions that nurses can 3.3 per 100,000 live births from a baseline of 7.1 mater-
implement to help reduce anxiety and promote comfort. nal deaths in 1998.
There is an increasingly accepted perspective that certain Nurses can help the nation achieve this goal by educat-
physiological processes are normally associated with a ing women about the benefits of prepared childbirth. Dur-
certain level of pain, and that the pain serves a useful ing labor, nurses can educate, reassure, and continuously
purpose. The pain of childbirth, for example, may serve monitor patients and assist them in the use of nonpharma-
to warn the woman to seek a safe haven and obtain help. cological pain relief methods to enhance comfort and
Ideally, these actions help to ensure that the birth takes reduce the total amount of analgesics needed.
place in safe surroundings and facilitate a positive out-
come, whether childbirth takes place at home, in a free-
standing birth center, or at a hospital. However, this
perspective should not be confused with the belief that The Physiology of Pain During Labor
childbirth should not be painful. To deny that discom-
fort or pain exists during childbirth is patently unrealis- and Birth
tic. The nurse, the laboring woman, and her support
person(s) all benefit from an understanding of the physi- DEFINING PAIN
ological and psychological processes that underlie the Pain is a complex, multidimensional experience. Accord-
experience of pain. Becoming familiar with strategies for ing to Padfield and colleagues (2003), pain is defined as
managing or diminishing the pain of childbirth empow- whatever the person who is experiencing it says it is. The
ers the laboring woman to make informed decisions International Association for the Study of Pain defines
about the various pain management measures she will pain as an unpleasant sensory and emotional experience
use. This chapter discusses the physiology of childbirth arising from actual or potential tissue damage or described
pain, theories related to pain perception, cultural and in terms of such damage. Pain includes not only the per-
psychological factors that affect childbirth pain, non- ception of an uncomfortable stimulus but also the response
pharmacological and pharmacological pain management to that perception (Venes, 2009). The expression of pain
interventions, and implications for nursing care. is influenced by a number of psychosocial and cultural
factors. For example, in some cultures it is permissible for
Optimizing Outcomes— Helping to achieve Healthy the woman in labor to freely verbalize her pain. In others,
People 2010 national goals
the laboring woman must be stoic and keep her emotions
to herself.
Because the use of anesthesia and analgesia during child- The pain experienced during childbirth is an unpleas-
birth can increase maternal mortality, several of the Healthy ant sensation that is usually localized to the back and the
chapter 13 Promoting Patient Comfort During Labor and Birth 401
abdomen. For most, the pain associated with childbirth abdominal wall, the lumbosacral area of the back, the
intensifies an already highly emotional experience for iliac crests, the gluteus maximus, and down the thighs.
both the laboring woman and her support person. How Usually, the discomfort is felt only during contractions. A
well the laboring woman is able to cope with her pain sig- period of pain relief occurs between contractions although
nificantly affects the overall birth experience. some women report continued nonremitting pain even
During the assessment, the nurse may identify physiolog- during the interval between contractions (Lowe, 2002).
ical and psychological changes that are indicative of mater- Somatic pain, a faster, well localized intense, sharp,
nal pain. These include an increased pulse rate and blood burning, prickling pain, occurs during the second stage of
pressure, changes in mood, increased anxiety and stress, labor. Somatic pain is associated with stretching and disten-
marked agitation, confusion, decreased urine output, tion of the perineal body to allow for birth. It is also related
decreased intestinal motility, and guarding of the target area to distention and traction placed on the peritoneum and
of discomfort. Pain affects the patient’s physiologic, behav- uterocervical supportive tissue during contractions and can
ioral, sensory, and cognitive responses. It is frequently result from soft tissue lacerations that frequently occur in
intensified by fear, anxiety, and fatigue. the cervix, vagina, or perineum. Somatic pain may also
The experience of pain is shaped by many factors such occur from the maternal expulsive forces during the sec-
as the patient’s age, educational background, state of well- ond, or “pushing” stage of labor or by fetal pressure on the
ness, prior experiences, sociocultural background, degree bladder, bowel, or other pelvic structures. During the sec-
of family and social support, and mastery of coping mecha- ond stage of labor, pain impulses are transmitted via the
nisms. Nurses must simply accept what the patient says pudendal nerve through S2 to S4 spinal nerve segments and
about her pain experience. The pain is real for each woman the parasympathetic system (Lowe, 2002).
and occurs wherever she reports it to hurt. Despite the During the third stage of labor, and in the early post-
presence or absence of physiological indicators of pain, partum period, discomfort is associated with uterine con-
only the patient can validate with certainty her present tractions. The pain experienced during this time is similar
level of discomfort. to that associated with the first stage of labor.
practices and pain behaviors. However, the nurse should pharmacological methods of pain relief. When cervical
be cautious not to stereotype patients and must remain changes (softening, some dilation and effacement) have
sensitive to individual variations in women’s choices for occurred before the onset of labor, the cervix opens more
dealing with pain during the childbirth process. Approach- readily. Theoretically, fewer contractions are needed to
ing each woman’s response to her labor and pain with achieve dilation and effacement.
acceptance and support is key to a therapeutic nursing When the fetus is in an unfavorable position, the labor
relationship. is likely to be longer and associated with a greater amount
of discomfort. For example, when the fetus is in an
occiput posterior position, the woman experiences intense
Ethnocultural Considerations— Realities of pain during contractions as the fetal occiput is pressed
the cultural model
against the maternal sacrum. The pain associated with
When caring for women, nurses must be aware that a “back labor” persists between contractions and is unre-
potential limitation of relying solely on a cultural perspective mitting until the fetus rotates to a more favorable position
comes from neglecting to recognize women’s individuality in (e.g., occiput anterior). The size and shape of the maternal
how they conform to traditional values and norms. Cultural pelvis influences the progress, and thus the level of dis-
models of health care frequently stereotype women who share comfort and pain associated with the labor. Structural
the same cultural heritage. In so doing, they may immobilize abnormalities may cause the labor to be prolonged and
health providers who seek to change unfavorable health care may contribute to fetal malpresentation.
situations in the name of protection of the cultural heritage Maternal fatigue adversely affects the ability to tolerate
(Meleis, 2003). pain and the effective use of coping techniques and strate-
gies to remain in control. Fatigue can hamper the woman’s
ability to concentrate and prevent her from using imagery,
Pain is expressed in a number of physiological and affec- focal points, breathing techniques, and other methods of
tive ways. During labor and childbirth, the sympathetic distraction. Lack of refreshing sleep is not unusual during
nervous system responds to pain with increased levels of the last weeks of pregnancy; a well-rested woman who
catecholamines (e.g., epinephrine and norepinephrine— experiences a prolonged labor can quickly become
biologically active substances that produce a marked effect exhausted long before the birth takes place.
on the nervous and cardiovascular systems, metabolic rate, Certain care provider interventions, such as intrave-
temperature, and smooth muscle). There is a rise in blood nous and fetal monitoring equipment, can intensify the
pressure and heart rate. Increased maternal oxygen con- discomfort naturally associated with labor. At times,
sumption results in an altered respiratory pattern that may these methods may also interfere with maternal mobility
produce hyperventilation and respiratory alkalosis. The and the ability to assume a position of comfort. Labor
woman may become diaphoretic, and nausea and vomiting induction and augmentation, amniotomy and vaginal
are common during the active phase of labor. Throughout examinations may also be associated with intensifying
this process, decreased placental perfusion and uterine labor discomfort.
activity can potentially prolong labor and adversely affect
fetal well-being. Physiological Factors
Visceral and somatic pain has been described as burning, Physiological forces influence the laboring woman’s pain
prickling, stabbing, heavy, pulling, pointing, sharp, stinging, response. If there is a history of dysmenorrhea, increased
and throbbing. On an emotional, or affective level, maternal childbirth pain may be related to higher levels of circulat-
pain during childbirth has been characterized as exhausting, ing prostaglandins. Laboring in an upright, instead of
nauseating, annoying and sickening (Lowe, 2002). Outward supine, position may help alleviate discomfort. Freedom
signs of suffering tend to be universal and are exhibited in to ambulate and assume a position of comfort during
varying degrees. Patients in pain cry, scream, clench and labor has been shown to be beneficial in reducing pain
wring their hands, moan, groan, clench their jaws, and in and muscle tension. Furthermore, the opportunity to
other ways demonstrate increasing anxiety with a reduced choose positions for labor empowers the woman with a
perceptual field. greater sense of control over her situation. In addition, the
fetal size in relation to the maternal pelvic dimensions
FACTORS THAT AFFECT MATERNAL PAIN may also affect the level of pain intensity (Lowe, 2002;
RESPONSE Simkin & O’Hara, 2002).
Although the physiological role is not well under-
Physical, physiologic, and psychological influences affect stood, the level of circulating endorphins is believed to
the laboring woman’s perception and tolerance of pain. have an important effect on the laboring woman’s sense
Physical factors include labor intensity, cervical readiness, of well-being. Endorphins are endogenous opioids
fetal position, pelvic dimensions, fatigue, and medical secreted by the pituitary gland. Endorphins act as opiates
interventions. and produce analgesia by binding at opiate receptor sites
involved in pain perception. In this manner, endorphins
Physical Factors increase the threshold for pain. Beta-endorphin is the
A brief, intense labor is often associated with a greater most active compound. When present in higher levels,
level of discomfort and pain because the contractions are endorphins are believed to increase the laboring woman’s
highly efficient in accomplishing cervical changes (efface- ability to tolerate pain; increased endorphin levels have
ment and dilation) and fetal progress (descent). Also, a been demonstrated with spontaneous, natural childbirth
shortened labor may diminish the woman’s options for (Righard, 2001).
chapter 13 Promoting Patient Comfort During Labor and Birth 403
Psychological Factors
Now Can You— Discuss characteristics of pain during labor
A number of psychological forces such as anxiety, fear, and birth?
previous experiences, support systems, and childbirth
preparation influence perception of and response to pain. 1. Identify three distinct characteristics of childbirth pain?
Maternal anxiety during labor triggers the release of cate- 2. Differentiate among visceral, somatic, and referred pain and
cholamines, which increase the amount of pelvic pain discuss when these pain types are most likely to occur
stimuli sent to the brain, resulting in an intensified per- during labor?
ception of pain (Lowe, 2002). As muscle tension increases, 3. Discuss the physical, physiological, and psychological factors
the effectiveness of the uterine contractions decreases that influence the laboring woman’s experience of pain?
and maternal discomfort and pain are intensified. Over
time, the cycle of anxiety → tension → pain diminishes
the progress of labor. At the same time, the woman’s self-
confidence in her ability to cope with the pain erodes and
THE EFFECTS OF PREPARED CHILDBIRTH
therapeutic interventions to help reduce pain and dis-
ON PAIN PATHWAYS
comfort become less effective. Prepared childbirth provides the patient and her partner
The woman’s previous experience with pain and with an understanding of what to expect during childbirth
childbirth also influences her pain perception and abil- and empowers them to become knowledgeable consumers
ity to cope during labor. For most young, healthy of health care who can make informed choices concerning
women, childbirth often represents the first exposure to their childbearing experience. Accessible through many
prolonged, intense pain. During early labor, sensory avenues, childbirth education is offered by most care pro-
pain tends to be more pronounced in the nulliparous viders, and may also be obtained in written or online mate-
patient because the reproductive tract structures are less rials, or through participation in formal childbirth educa-
pliant and flexible. Multiparous patients may experience tion classes. In most areas, a variety of classes are available
greater sensory pain during the transition phase of the to provide general or specialized information. Prenatal
first stage of labor because their pliable reproductive classes focus on fetal growth and maternal changes and
tract structures allow for a more rapid fetal descent often place emphasis on health promotion through nutri-
accompanied by a heightened intensity in pain. During tion, exercise, stress reduction, and adequate rest. Other
the first stage of labor, affective pain is usually greater classes are intended to prepare the expectant couple for the
for nulliparous women but is decreased for both nullip- labor process, and much time is spent exploring nonphar-
arous and multiparous women during the second stage macological and pharmacological measures for pain relief.
(Lowe, 2002). These classes generally focus on educating the woman and
The patient’s personal experience with a previous her support person(s) about strategies such as position
childbirth also influences her pain perception. A prior changes, breathing techniques, massage, and other meth-
negative experience marked by misery and pain may pro- ods to achieve relaxation and enhance comfort during
duce an expectation of a repeated negative experience labor. Classes for women with a planned cesarean birth are
that is filled with fear and dread. A woman whose prior also available, and for those who wish to breastfeed, hospi-
childbirth experience was satisfying is more likely to tal maternity programs and local lactation support groups
approach the present birth with a positive attitude and frequently provide focused breastfeeding classes.
confidence in her ability to cope with the pain and To enhance understanding of how methods learned
discomfort. through prepared childbirth work to promote comfort
The physical environment that envelops the birth during labor, it is helpful to review pain pathways and the
experience should be considered as well. “Environment” gate control theory of pain. Pain may be viewed as a multi-
encompasses those present as well as the physical space dimensional phenomenon that encompasses the following
where the labor takes place. When indicated, labor sup- five dimensions: affective, physiologic, behavioral, sen-
port persons should be encouraged to serve as the patient’s sory, and cognitive. The neural pathway for pain involves
advocate in communicating desires, expectations and con- four processes: transduction, transmission, perception,
cerns and in providing physical comfort measures. Women and modulation. Transduction is the conversion of a
prefer to be cared for in a home-style setting by trusted, mechanical, thermal, or chemical stimulus into a neuronal
familiar caregivers (Hodnett, 2002). action potential. Transduction occurs at the nociceptors,
nerves that receive and transmit painful stimuli. Stated
another way, incoming noxious stimuli are converted to
electrical activity at the sensory endings of the peripheral
Nursing Insight— Environmental strategies nerves. Transmission is the movement of the pain impulse
to enhance comfort during labor
from the site of transduction (e.g., uterine contractions) to
The labor environment should provide privacy, comfort, the brain. Perception is the development of the sensory,
and a sense of security. Allowing patients to determine the subjective and emotional experience identified by the indi-
amount of noise, light, and temperature in their room fosters vidual as pain. Perception occurs when the patient feels
relaxation and a sense of control over their situation. Ideally, the pain and responds to it, and modulation involves the
the room has an abundance of space that freely allows for activation of descending pathways that exert either inhibi-
patient and staff mobility, equipment (preferably hidden from tory or facilitatory effects on the transmission of pain
view unless needed) and comfort measures such as birth balls, (Lowe, 2002).
reclining chairs, tubs, and showers. Sometimes it is possible for painful stimuli to be
ignored. Groups of certain nerve cells located in the spinal
404 unit four The Birth Experience
cord, brainstem, and cerebral cortex have the ability to interventions and pain relief measures during labor and
modulate, or alter, pain impulses through a blocking birth report a greater sense of satisfaction with their birth
mechanism. According to the gate-control theory of pain experience (Hodnett, 2002). When support is perceived to
control (Melzack & Wall, 1965), pain sensations travel be ongoing and individualized throughout labor, women
along sensory nerve pathways to the brain—but only a require fewer pain medications and interventions and expe-
certain number of sensations, or “messages” can pass rience improved outcomes (Simkin & O’Hara, 2002).
through the nerve pathways at one time. Methods of dis-
traction learned and practiced in prepared childbirth Optimizing Outcomes— Assessment of pain during
classes such as breathing patterns, massage, music, and labor
the use of focal points and imagery reduce or completely
block the capacity of the nerve pathways to transmit pain. Throughout the process of labor and birth, the nurse con-
It is believed that these physical and psychological distrac- tinuously assesses the patient and addresses her needs for
tions work by “shutting the gate” in the spinal cord so that comfort measures. Conducting an initial and ongoing pain
pain signals are unable to reach the brain. assessment lays the foundation for intrapartal nursing care.
When the laboring woman is actively involved in neuro- Once the beginning assessment has been completed, the
muscular and motor activity, there is an increase in spinal nurse uses the information to develop an individualized
cord activity that further modifies the transmission of pain. plan of care that includes pain relief interventions accept-
For example, the cognitive effort channeled into concentra- able to the patient. A number of tools have been developed
tion on breathing patterns, focal points, and imagery requires to facilitate pain assessment during labor; these may be
selective and directed cortical activity that activates and modified or adapted as needed (Fig. 13-1).
closes the gating mechanism. The gate-control theory helps
to explain how methods such as hypnosis and the various
pain relief techniques taught in childbirth education classes
help to diminish the laboring woman’s perception of pain. Providing Comfort and Pain Relief
Methods to provide comfort and relieve pain are of para-
BENEFITS OF COMFORT AND SUPPORT mount importance for the childbearing couple. The wom-
ON PAIN PERCEPTION an’s perception of her overall birth experience is greatly
In the traditional medical model, pain and discomfort dur- influenced by her ability to cope with pain in whatever man-
ing labor have largely been viewed as a negative component ner is acceptable to her. Nonpharmacological pain relief
that should be eliminated. An alternative approach views measures are for the most part inexpensive, easy to use, safe,
labor as a natural process that challenges women to seek and readily available. They also allow the patient to gain an
activities of comfort that will allow them to transcend the enhanced sense of control over her childbirth experience.
pain to achieve the satisfaction and contentment of birth. Despite their effectiveness, however, none of the various
Feeling safe, secure, comforted, and in control empowers techniques are more effective than methods of epidural anal-
the laboring woman to find strength in dealing with her gesia. Nurses play a key role in educating women and their
discomfort and pain. Nurses can facilitate comfort by pro- support persons about the various nonpharmacological and
viding a caring, supportive, therapeutic presence. pharmacological pain relief methods available. During labor,
Support during labor and birth has a major impact on the women should be encouraged to try a variety of pain relief
woman’s birth experience. Support includes both nonphar- measures, including pharmacological methods, if needed.
macological and pharmacological measures. The nurse’s Factual information and ongoing support empowers the
attitude, expressions of caring, and supportive actions play patient to make informed choices and to participate fully in
a significant role in the woman’s perception of pain and in the decision-making process.
her overall childbearing experience. Patients who feel they Another important component of childbirth prepara-
have control over their situation (self-efficacy) and who are tion concerns the choice of the birth setting. Many com-
actively engaged in the decision-making process concerning munities offer several options for where the childbirth
Diagnosis__________________________________ Physician/Midwife________________________________
What has the patient done at home to cope with the pain?___________________________________________
What comfort measures would the patient like to use now? __________________________________________
Other ____________________________________________________________________________________
Signature of Nurse completing form ____________________________________________________________ Figure 13-1 Assessment tool to gauge
pain during labor.
chapter 13 Promoting Patient Comfort During Labor and Birth 405
will take place. Often during the first prepared childbirth squatting position helps to open the pelvic outlet, which
class, expectant couples are encouraged to explore com- facilitates the fetus’ downward movement. Assuming a
munity options for the childbirth setting that best “fits” hands and knees position is comforting for women who
with their desired childbirth experience. have back labor or whose fetus is in a posterior position.
The hands and knees position decreases the patient’s back
pressure and helps the fetus to rotate into an anterior posi-
Across Care Settings: Childbirth options in tion. Many hospital birthing suites offer wireless telemetry
the local community units that provide continuous monitoring while the patient
Encouraging expectant couples to explore options for the ambulates at her leisure (Fig. 13-2).
childbirth setting is an important component of prenatal The “birth ball” may be also used to promote comfort
education. As consumers of health care, patients should seek during labor. Essentially, the birth ball is a large, firm yet
a primary care provider and facility that will safely meet their pliable physical therapy ball or gymnastic ball that pro-
childbirth needs. Depending on the locale, the community vides support for the laboring woman. The patient care-
may have a large city hospital, a small community hospital, fully sits on the birth ball and rhythmically rocks back and
a birth center, or a practicing group of certified nurse forth or moves the ball around in a circular motion.
midwives (CNMs) that provides care during home births. Assuming a sitting position on the birth ball facilitates a
When considering a birth facility, the woman may wish to supported squatting position that opens the pelvis to allow
ask the following questions: fetal descent in preparation for birth. Warm compresses
1. Where does my primary care provider have childbirth applied to the back and perineum while balancing on the
privileges? ball enhance relaxation and promote comfort (Fig. 13-3).
2. Does the facility offer personal Jacuzzis? Traditional The birth ball should be large enough to allow the woman
bathtubs? Showers? to sit comfortably on it with her knees bent at a 90-degree
3. Does the facility have birth balls? Could I bring my own angle with her feet flat on the floor and approximately
birth ball? 2 feet apart (Perez, 2000). The woman may also place the
4. Would the facility allow me to play my own music during birth ball against the wall behind the small of her back and
labor and birth? gently lunge from side to side to open the pelvis. When
5. How many labor support persons may be with me when I needed, assuming a kneeling position while leaning for-
give birth? ward on the birth ball may encourage the rotation of the
6. Does the facility permit the use of aromatherapy? fetus from a posterior to an anterior position.
7. Does the facility have transcutaneous electrical nerve
Breathing Techniques
stimulation (TENS) units available?
8. At what point would I be allowed to receive an epidural? During childbirth education classes, the pregnant woman
9. What medications would be available during my labor? and her labor coach learn about conscious breathing pat-
terns that involve slowed respirations to enhance relaxation.
Specific breathing methods are also taught as attention
Now Can You— Discuss a pain control theory, pain
perception, and considerations for the
childbirth setting?
1. Discuss the basic premise of the gate control theory of pain
control?
2. Explain how comfort and support during labor decrease the
woman’s perception of discomfort and pain?
3. Identify four questions the expectant couple may wish to
ask to help determine their choice of childbirth setting?
Effleurage, taken from the French word effleurer (to water provides welcomed relief from labor discomfort
touch lightly) is a gentle stroking technique performed in and pain. The production of maternal catecholamines is
rhythm with contractions. The patient or her labor sup- decreased, prompting an increase in the release of oxyto-
port person massages the abdomen using light circular cin (stimulates uterine contractions) and endorphins
motions. Effleurage is helpful in distracting the patient (reduces the perception of pain). If the woman is experi-
from her contractions. Massage of the hands, feet, and encing “back labor” from a fetal occiput posterior or
back may be effective in diminishing tension and in transverse position, she may be assisted into a side-lying
enhancing comfort. Throughout the labor experience, or hands-and-knees position in the tub. These positions
patients and their partners should be encouraged to enhance comfort and help to facilitate fetal rotation into
experiment with various techniques to determine what an occiput anterior position.
methods work best for them. Whirlpool tubs (“jet hydrotherapy”) are available in
Counterpressure is often effective in enhancing the many birth settings, although some institutions require
woman’s ability to cope with discomfort from internal prior approval for use from the patient’s primary care pro-
pressure and lower back pain. This technique involves use vider. The pulsating flow of warm water from the whirl-
of the labor support person’s fist or heel of the hand to pool jets is soothing and delivers continuous massage to
apply steady pressure to the sacral area. Counterpressure the patient’s legs, abdomen, and back. The rhythm of the
is especially helpful when maternal back pain results from water flowing in the shower or whirlpool tub provides a
pressure of the occiput against spinal nerves when the soothing sound that aids in relaxation.
fetal head is in a posterior position. This technique brings During hydrotherapy, fetal heart rate (FHR) monitoring
pain relief as the counterpressure lifts the occiput off of may be intermittent or continuous. It may be conducted
the spinal nerves. via Doppler technique, fetoscope, or use of a wireless
Therapeutic touch is based on the use of “prana,” the external monitor device. Internal electrode placement may
body’s energy fields. Prana is believed to be deficient in not be used with whirlpool baths. In some settings, women
some individuals who experience pain. Specially trained with ruptured membranes are allowed to use jet hydro-
persons use laying-on of hands to provide therapeutic therapy, provided that the amniotic fluid is clear.
touch to redirect the energy fields thought to be associated Patients may stay in the tub as long as desired; most
with the pain (Scheiber & Selby, 2000). Although the remain for 40 to 60 minutes. During that time, if the mater-
benefits of therapeutic touch in enhancing relaxation and nal temperature or FHR increase, if the labor slows or
in reducing anxiety and pain have been documented becomes too intense, or if the comforting effects of the water
(Marks, 2000), the effectiveness of this modality for pain are diminished, patients may come out of the tub and return
relief during labor is not known. at a later time. For many, repeated immersions are more
Healing touch is also based on use of the body’s effective in relieving pain than a long, continuous exposure
energy fields. This modality employs a combination of to the water. During tub hydrotherapy, the nurse or labor
techniques from multiple disciplines. Persons trained in partner can offer comforting, cool washcloths for the face
healing touch are taught energetic diagnosis and treat- and fluids to promote hydration (Mackey, 2001; Simkin &
ment forms and how to document the patient’s response O’Hara, 2002). To avoid overheating, the water temperature
and progress. It is believed that the various techniques should be maintained at 96.8º to 100.4ºF (36º to 38ºC)
align and balance the human energy field, enhancing the (Florence & Palmer, 2003).
body’s ability to heal itself. Although healing touch has
been used during labor, no studies have been published Hypnotherapy
to document its effectiveness (Hover-Kramer, Mentgen, Hypnotherapy is a structured technique that enables the
& Scandrett-Hibdon, 2001). patient to achieve a state of heightened awareness and
focused concentration that can be used to alter the percep-
Hydrotherapy tion of pain. With this modality, emphasis is placed on
Hydrotherapy (water therapy) is the use of warm water promoting maternal relaxation while decreasing fear, anx-
to promote comfort and relaxation. Hydrotherapy may iety, and the perception of pain. To accomplish this, the
involve showering or soaking in a regular tub or whirlpool woman may be given direct suggestions about pain relief
bath. When showering is the selected method of hydro- or indirect suggestions that she is experiencing decreased
therapy, the patient stands in a warm shower and allows discomfort (Ketterhagen, VandeVusse, & Berner, 2002).
the water to gently glide over her abdomen. Alternatively, Education about the method and continued practice dur-
she may wish to sit in a shower chair. The nurse or labor ing the prenatal period are essential in the successful use
coach may use a hand-held sprayer to direct a steady of hypnotherapy during labor and birth (Gentz, 2001).
stream of water over the abdomen or back. Throughout Hypnotherapy involves the induction of a state of great
this time, the support person provides reassurance and mental and physical relaxation that can be therapeutic in
encouragement, assists with breathing techniques during the management of pain control (Potter, 2006).
contractions, and offers touch and massage. The flow of
warm water enhances feelings of relaxation and helps to Aromatherapy
decrease muscle tension. Reduced discomfort and Aromatherapy is the use of essential oils, derived from
increased relaxation often empowers the woman to have plants, flowers, herbs, and trees, whose aroma is thought
more control over her labor. to have a therapeutic effect in treating illnesses and pro-
Immersion in a tub of warm water filled up to shoul- moting health and well-being. The fragrances of rose, lav-
der level is also beneficial in promoting comfort and ender, frankincense, and bergamot oils are believed to
relaxation. For most, the buoyancy provided by the promote comfort and relaxation and decrease pain. Patients
chapter 13 Promoting Patient Comfort During Labor and Birth 409
clinical alert
When using aromatherapy
Nurses must be aware that the essential oils used in aromatherapy
should never be applied to the skin in a full-strength form. Instead,
the oils must be diluted, usually in a vegetable oil base, before
application. Patients should be cautioned that not all aromatherapy
oils are safe to use during pregnancy; some oils, when inhaled,
cause side effects such as nausea and headache (Gentz, 2001). Figure 13-5 A cool washcloth placed on the forehead
provides comfort during labor.
Complementary Care: Yoga to reduce Optimizing Outcomes— When using heat and cold
discomfort during labor for pain relief during labor
Prenatal yoga classes, which focus on breathing techniques Nurses should avoid the application of heat or cold over
and enhanced relaxation, are becoming increasingly popular. body areas that have been anesthetized because of the risk
Physiologically, yoga increases the efficiency of the heart, slows for tissue damage. Hot and cold packs should be used only
the respiratory rate, and lowers blood pressure. For many, yoga after one to two layers of cloth have been placed between the
helps decrease stress and anxiety during the prenatal period and pack and the patient’s skin (Simkin & Bolding, 2004).
provides coping strategies that can be used during labor. The
practice of yoga during pregnancy helps women learn to
decrease the urge to tighten muscles in response to pain. This
Biofeedback
response promotes the release of oxytocin to enhance the prog-
ress of labor. Poses used in prenatal yoga also facilitate the Biofeedback has been used for many years to enhance relax-
descent of the fetus and often decrease back pain. Women ation and help patients to gain control over their pain. It is
should always check with their primary care provider before based on the concept that the mind controls the body: if one
beginning prenatal yoga. For many, attending a prenatal yoga can recognize physical signals, certain internal physiological
class in the community is a healthy way to meet other women events can be changed. During the prenatal period, the
who are beginning a new chapter in their life. woman is taught body awareness, how to recognize responses
to stimuli, and various relaxation techniques. She practices
using strategies such as concentration, focal points, and
breathing to control her response to uncomfortable stimuli.
Application of Heat and Cold The labor partner learns to recognize cues (e.g., grimacing,
The application of heat and cold can promote comfort and tensing, frowning, moaning, and breath holding) indicative
help decrease pain during labor and birth. The two modal- of pain and uses verbal feedback and touch to help the
ities may be used alternately to enhance their effects. Heat woman to achieve relaxation. Formal biofeedback, which
exerts a therapeutic effect by relieving muscle ischemia involves the use of a recording device to measure physiolog-
and increasing blood flow to the area of discomfort. Warm ical responses, requires special training by a skilled biofeed-
washcloths applied to the perineum help to relieve the back therapist. Body signals (e.g., skin temperature, blood
discomfort associated with stretching. Socks or bags that flow, and muscle tension) that indicate pain and stress are
are sewn from cloth can be filled with uncooked rice and sent via attached electrodes back to the biofeedback unit.
heated in a microwave oven. Once warmed, the bags radi- The unit then alerts the patient who uses various techniques
ate soothing heat that helps to diminish pain. The rice to decrease the tension and discomfort.
bags may be placed on the patient’s neck, back, or wher-
ever the discomfort is felt. When desired, lavender oil, a Transcutaneous Electrical Nerve Stimulation
comforting aroma to many, may be added to the home- Transcutaneous electrical nerve stimulation (TENS)
made rice bag before heating. involves the delivery of an electric current through elec-
Cold washcloths or ice packs placed on the forehead, trodes that are applied to the skin over the painful region
chest, or face may be comforting to laboring women who of a peripheral nerve (Simkin & Bolding, 2004). The
feel warm (Fig. 13-5). Cold packs may also be applied to TENS unit relieves pain by producing counterirritation on
areas of pain where they exert a therapeutic effect by the nociceptors. Normally, two pairs of flat electrodes are
reducing muscle temperature and relieving muscle spasms. placed on either side of the patient’s thoracic and sacral
The nurse should be aware that some patients’ cultural spine. Continuous low-intensity electrical impulses are
beliefs may not permit the use of cold therapy during delivered through a battery-operated device. During a
labor (Simkin & Bolding, 2004). contraction, patients are instructed to turn the knobs on
410 unit four The Birth Experience
Nursing Interventions:
1. Review the birth plan with Ann and Raul, answering any questions and providing additional information as
needed. Inform other caregivers of the couple’s plans for their labor and birth.
RATIONALE: Appraisal of the couple’s expectations allows the opportunity to provide factual information and
offer support in an accepting environment.
2. Ensure a comforting environment: offer warmed blankets, an electric or hand held fan; adjust the room
thermostat as needed.
RATIONALE: A comfortable environment enhances relaxation and increases the patient’s ability to focus on her
coping skills.
3. Provide Ann’s preferred music as desired; use soft lighting; ensure the focal point is within easy view; avoid
conducting assessments and procedures during contractions; ensure that bed linens are soft, clean, and dry.
RATIONALE: Listening to favorite music may distract the patient from discomfort and external noises.
Environmental distractions and unnecessary stimulants interfere with the successful use of learned techniques
to manage labor discomfort.
4. Assist Raul in helping Ann to find a position of comfort; encourage position changes every 30–60 minutes and
unless contraindicated, encourage ambulation, sitting in a chair or use of a birth ball.
RATIONALE: Assistance empowers Raul to participate actively in the labor and birth experience. Position
changes enhance maternal comfort by reducing muscle tension and facilitate fetal descent.
5. Encourage Raul to perform back rubs or provide counterpressure as learned in childbirth classes, according to
Ann’s desires.
RATIONALE: Back rubs and counterpressure provide comfort from pain associated with back labor by
stimulating the large-diameter fibers and interfering with the transmission of pain impulses to the brain.
6. Keep Ann and Raul informed of the progress of labor.
RATIONALE: Ongoing information helps to decrease anxiety and fear, which increase the perception of pain and
decrease pain tolerance; news of labor progress provides an incentive to continue with efforts to cope with labor.
to her; and the patient’s consent must be given freely thick and rest has been prescribed for the patient. Seda-
without coercion or manipulation from her health care tives may also be used to augment analgesics and reduce
provider (Lowe, 2004). nausea after the administration of opioids. Sedatives
induce sleep for a few hours. Once the woman awakens,
either the contractions have ceased (i.e., the patient had
experienced false labor) or regular, effective contrac-
SEDATIVES AND ANTIEMETICS tions that produce cervical change occur. Sedatives
Sedatives are agents that relieve anxiety and induce should not be used during active labor because they can
sleep. They are primarily used during the early latent cause respiratory depression in the neonate (Faucher &
phase of labor, when the cervix is long, closed, and Brucker, 2000).
412 unit four The Birth Experience
Hydromorphone hydrochloride (Dilaudid) IV: 1 mg q3h prn Monitor vital signs, FHR pattern and uterine activity prior
to and during administration; observe for maternal
IM: 1–2 mg q3–6h prn respiratory depression; encourage voiding q2h, palpate
for bladder distention; if birth occurs within 1–4 hours
after administration, observe neonate for respiratory
depression
Meperidine hydrochloride (Demerol) IV: 25 mg q1–3h prn
IM: 50–100 mg q1–3h prn
Fentanyl citrate (Sublimaze) IV: 25–50 mg; 1–2 mg with 0.125%
bupivacaine at rate of 8–10 mL/hr
epidurally
Sufentanil citrate (Sufenta) IV: 1 mg with 0.125% bupivacaine
at rate of 10 mL/hr
chapter 13 Promoting Patient Comfort During Labor and Birth 415
Table 13-2 Commonly Used Regional Blocks for Labor and Birth
Type of Block; Areas Affected When Used During Labor and Birth Nursing Implications
Local Perineal Infiltration Immediately before birth for episiotomy; after Assess patient’s knowledge and
birth for repair of lacerations understanding; provide information as
Affected area: Perineum needed. Observe perineum for bruising or
discoloration during the recovery period.
Pudendal Nerve Block Late in the second stage for episiotomy, Assess patient’s level of knowledge and
forceps, or vacuum extraction; during third understanding; provide additional information
Affected areas: Perineum and lower vagina stage for repair of episiotomy or lacerations as needed.
Spinal Anesthesia Block First stage for both elective and emergent Assess patient’s level of knowledge and
cesarean births; low spinal anesthesia block understanding; provide additional information
Affected areas: Uterus, cervix, vagina, and may be used for vaginal birth—not suitable as needed. Monitor maternal vital signs and
perineum for labor FHR status.
Lumbar Epidural Block First and second stages Assess patient’s level of knowledge and
understanding; provide additional information
Affected areas: Uterus, cervix, vagina, and as needed. Monitor maternal blood
perineum pressure—major side effect is hypotension.
Provide ongoing support.
Combined Spinal–Epidural Spinal analgesia may be administered during Assess patient’s level of knowledge and
the latent phase for pain relief. understanding; provide additional information
Affected areas: Uterus, cervix, vagina, and as needed. Monitor maternal vital signs and
perineum Epidural is given when active labor begins FHR status. Provide ongoing support.
Ischial
spine
Pudendal
nerve
Sacrospinous
A ligament
B
Figure 13-6 A. Administration of a pudendal block. B. The areas of the perineum affected
by a pudendal block.
chapter 13 Promoting Patient Comfort During Labor and Birth 417
Pia mater
L1
L2
Ending of
spinal cord
L3
Spinal Subarachnoid
block L4 space
Epidural Epidural
block L5 space
Dura mater
Vaginal birth
A B Cesarean birth
Figure 13-7 A. The spinal column: levels of the sacral, lumbar, and thoracic nerves. B. Levels
of anesthesia necessary for vaginal and cesarean births.
anesthesia (Bucklin et al., 2005). The differences in the excellent muscular relaxation; allows for maintenance
levels of spinal anesthesia for vaginal and cesarean of maternal consciousness; and is associated with mini-
birth are created by the dosage of the anesthetic agent mal blood loss. However, because uterine contraction
administered, and the position of the patient after sensation is lost, the patient must be instructed when to
placement of the medication in the dural sac. For vagi- bear down during a vaginal birth. Since voluntary
nal birth, a low spinal anesthesia block provides anes- maternal expulsive efforts are compromised, there is an
thesia from level T10 (hips) to the feet; patients remain increased likelihood of an operative (e.g., episiotomy,
in a sitting position for a brief period of 1 to 2 minutes forceps-assisted; vacuum-assisted) birth. After child-
after administration to facilitate downward migration birth, there is an increased incidence of bladder and
of the anesthetic solution toward the sacral area. For uterine atony and postdural puncture headache.
cesarean birth, the level of anesthesia coverage extends Nursing care during administration of a spinal anesthe-
from the nipples (T6) to the feet; after administration sia block includes proper positioning of the patient in a
of the anesthetic solution, patients are immediately lateral or sitting position with the back curved outward to
assisted to a supine position with a left lateral tilt to widen the intervertebral space (Fig. 13-8). After injection
enhance a cephalad spread of the anesthesia (and a of the anesthetic solution, the patient is positioned upright
higher level of sensory blockade). The anesthetic agent to allow downward flow of the solution to provide a lower
may be “weighted” with glucose to make it heavier level of anesthesia suitable for a vaginal birth. For a cesar-
than CSF. This prevents the medication from rising too ean birth, the patient is placed in a supine position with
high in the spinal canal and interfering with motor the head and shoulders slightly elevated with a wedge
control of the uterus or with the maternal respiratory placed under one of the hips to displace the uterus (to
muscles (Fig. 13-7). obtain a higher level of anesthesia coverage). Effects from
Spinal anesthesia block has several advantages: it is the anesthesia occur within 1 to 2 minutes after injection
easy to administer; has an immediate onset of anesthe- and last 1-3 hours, depending on the anesthetic agent
sia; requires a smaller volume of medication; produces used (Hawkins et al., 2002) (Procedure 13-1).
outside the dura mater; beyond the epidural space, the systolic pressure does not fall below 100 mm Hg or
ligamentum flavum, which extends from the base of the decrease 20 mm Hg in a hypertensive patient. A drop
skull to the end of the sacral canal, provides another pro- greater than this may be life-threatening to the fetus
tective layer. With epidural anesthesia, an anesthetic agent unless effective interventions (e.g., maternal position
is placed just inside the ligamentum flavum in the epidu- change; administration of antihypotensive agents) are
ral space (Figs. 13-9 and 13-10). ◆ instituted.
Other disadvantages include limited mobility due to
medical interventions such as the intravenous infusion
Nursing Insight— Methods for administering an and electronic monitoring equipment. Patients may
epidural block
experience orthostatic hypotension, dizziness, sedation,
Epidural blocks, administered by a nurse anesthetist or and lower extremity weakness. The accidental injection
anesthesiologist, may be given in different ways. For analgesia of a local anesthetic into a blood vessel can cause CNS
and anesthesia during labor, the block may be administered as effects including bizarre behavior, disorientation, excita-
a single dose with an epidural needle. It may also be adminis- tion, and convulsions. Severe maternal hypotension
tered as a single dose through an epidural catheter, with addi- resulting from sympathetic blockade can cause a signifi-
tional doses (“top-offs”) given as needed, or given as a continu- cant decrease in uteroplacental perfusion and the deliv-
ous epidural. Patients may be required to remain in bed; other ery of oxygen to the fetus (Anim-Somuah, Smyth, &
blocks allow ambulation (“walking epidural”) (Mayberry, Howell, 2005).
Clemmens, & De, 2002).
with her legs slightly flexed or she is asked to sit on the contractions but does not feel pain—thus she is able to
edge of the bed. She is instructed to drop her shoulders, bear down during the second stage of labor; and her
round out the small of her back (“arch the back like a motor power remains intact.
cat”), and put her chin into her chest. The medication is Opioids such as fentanyl, sufentanil (short-acting
injected between contractions to minimize the risk of agents—effects last 1.5 to 4 hours) and preservative-free
tachycardia that can occur if the drug is unintentionally morphine (long-acting—effects last up to 7 hours) may be
injected directly into a vessel. The diffusion of the epidu- used. A drawback of this method concerns the potential
ral anesthesia is dependent on the placement of the cathe- need for a pudendal nerve block or local perineal infiltration
ter tip, the dose and volume of medication used, and the anesthesia since intrathecal opioids do not provide adequate
patient’s position (e.g., horizontal or upright). Once the anesthesia for second-stage labor pain, episiotomy, or birth
epidural has been administered, a side lying position for most women (Cunningham et al., 2005). More often,
(alternating sides each hour) is maintained to prevent epidural and intrathecal opioids are used for postoperative
compression of the vena cava. Depending on the degree of pain control. After cesarean birth, women are comfortable
motor impairment, ambulation may be encouraged. enough to freely ambulate and care for their newborns.
Early ambulation is associated with enhanced bladder emp-
tying, more rapid return of peristalsis, and a decreased risk
Nursing Insight— Methods for epidural of respiratory complications and thrombophlebitis. Side
anesthesia block effects are more common when preservative-free morphine
is used. These include nausea and vomiting, pruritus, uri-
Most often, a continuous epidural anesthesia block, a nary retention, and delayed respiratory depression.
method achieved by the use of a pump to infuse solution into
an indwelling catheter, is used. In many areas, patients are
allowed to control the dosing with a programmed pump Optimizing Outcomes— When epidural and
(patient-controlled epidural analgesia [PCEA]). This method intrathecal opioids are administered
empowers the patient to achieve some degree of control over The nurse should monitor and record the patient’s respira-
her labor comfort and has been shown to decrease the total tory rate every hour for 24 hours (or per institutional proto-
amount of medication needed. A lock-out period after each col) after administration of epidural or intrathecal opioids.
self-administration prevents overdosage. Less commonly, an Naloxone (Narcan) should be administered if the maternal
intermittent block that relies on repeated injections of anes- respiratory rate decreases to less than 10 breaths per minute
thetic solution is performed. or if the maternal oxygen saturation rate decreases to less
than 89%. Oxygen may be administered by face mask and the
anesthesiologist should be notified.
COMBINED SPINAL–EPIDURAL ANALGESIA. A combination of
spinal–epidural analgesia may be used to block pain trans-
mission without interfering with motor ability. Pain relief
is immediate, unlike the 20- to 30-minute delay associated Now Can You— Discuss epidural and intrathecal
with an epidural alone. With the combined approach, an anesthesia?
opioid such as fentanyl or sufentanil is injected into the 1. Name six advantages of epidural anesthesia and identify the
subarachnoid space to rapidly activate the opioid recep- most common complication associated with this method?
tors. A catheter inserted in the epidural space extends the 2. Describe the benefits of combined spinal–epidural anesthesia?
duration of the analgesia by using a lower dose of a local 3. Identify an essential component of nursing assessment after
anesthetic agent alone or in combination with an opioid the administration of epidural or intrathecal opioids?
agonist analgesic (Hawkins et al., 2002). Although patients
may ambulate, they often choose not to do so because of
fatigue, sensations of weakness in the legs, and a fear of
falling. They should be encouraged to change positions GENERAL ANESTHESIA
frequently and assisted to an upright position to enhance
General anesthesia (induced unconsciousness) may be
bearing-down efforts. Because this method is associated
used for unplanned, rapid (emergency) cesarean birth,
with puncture of the dura and placement of a catheter in
when there are contraindications to an epidural or spinal
the epidural space, there is a greater risk for infection and
block, or when surgical intervention is required for cer-
postdural puncture headache (Lieberman & O’Donoghue,
tain obstetric complications (Box 13-3). The major risks
2002; McCool et al., 2004). A combined spinal–epidural
block may be used for both labor analgesia and for cesar-
ean birth; the anesthetic and analgesic agents used vary
according to the purpose of the procedure. Additional Box 13-3 Contraindications to Spinal/Epidural Block
medication may be added to increase its effectiveness or if Anesthesia
an instrument-assisted or cesarean birth is needed.
EPIDURAL AND INTRATHECAL OPIOIDS. Another approach • Maternal refusal
for nerve block analgesia/anesthesia involves the use of • Local or systemic infection
opioids alone. This method eliminates the effects of a local • Coagulation disorders
anesthetic. Advantages of epidural or intrathecal (injected • Actual or anticipated maternal hemorrhage
into the subarachnoid space) opioids without local anes- • Allergy to specific anesthetic agents
thetics include the following: there is no maternal hypo- • Lack of trained staff available (Cunningham et al., 2005)
tension or alteration in vital signs; the patient is aware of
422 unit four The Birth Experience
anesthesia chosen is determined by the ______ of Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
_______ and the woman’s available __________ at tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
Caton, D., Corry, M., Frigoletto, F., Hopkins, D., Lieberman, E.,
the birth facility. Mayberry, L., et al. (2002). The nature and management of labor
pain: Executive summary. American Journal of Obstetrics and
True or False Gynecology, 186(5), S1–S15.
7. Childbirth education is encouraged by the perinatal Colin, J.M., & Paperwalla, G. (2003). Haitians. In St. Hill P., Lipson, J.G.,
& Meleis, A.I. (Eds.), Caring for women cross-culturally (pp. 172–187).
nurse as it increases the information that women and Philadelphia: F.A. Davis.
families have about labor, birth, and options for pain Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., &
relief. Wenstrom, K. (2005). Williams’ obstetrics (22nd ed.). New York:
McGraw-Hill.
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses
Case Study (11th ed.). Philadelphia: F.A. Davis.
8. The perinatal nurse assists Teresa, a laboring woman, Faucher, M., & Brucker, M. (2000). Intrapartum pain: Pharmacologic
and her partner between contractions to increase management. Journal of Obstetric, Gynecologic and Neonatal Nursing,
29(2), 169–180.
their knowledge and ability to use breathing methods Florence, D., & Palmer, D. (2003). Therapeutic choices for the discom-
during the contractions. Teresa’s use of breathing forts of labor. Journal of Perinatal and Neonatal Nursing, 37, 238.
techniques during a contraction may decrease Gentz, B. (2001). Alternative therapies for the management of pain in
pain by: labor and delivery. Clinical Obstetrics and Gynecology, 44(4),
A. Reducing the capacity of nerve pathways to 704–732.
Hawkins, J., Chestnut, D., & Gibbs, C. (2002). Obstetric anesthesia.
transmit pain In Gabbe S., Niebyl, J., & Simpson, J. (Eds.), Obstetrics: Normal
B. Increasing the capacity of nerve pathways to and problem pregnancies (4th ed.). Philadelphia: Churchill
transmit endorphins Livingstone.
C. Decreasing her anxiety about labor Hodnett, E. (2002). Pain and women’s satisfaction with the experience
of childbirth: A systematic review. American Journal of Obstetrics and
D. Decreasing her distraction during her contractions Gynecology 186(5), S160–172.
Hover-Kramer, D., Mentgen, J., & Scandrett-Hibdon, S. (2001). Healing
Select All that Apply touch; A resource for health care professionals. Albany, NY: Delmar.
9. The perinatal nurse is aware that one of the Healthy Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
Maas, M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and
People 2010 goals is to: NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.).
A. Educate women in the use of nonpharmacological St. Louis, MO: Mosby Elsevier.
pain management in labor. Ketterhagen, D., VandeVusse, L., & Berner, M. (2002). Self-hypnosis:
B. Decrease mortality related to pharmacological Alternative anesthesia for childbirth. MCN American Journal of
methods of pain relief in labor. Maternal/Child Nursing, 27(6), 335–340.
Kulig, J.C. (2003). Cambodians. In St. Hill, P., Lipson, J.G., & Meleis, A.I.
C. Increase informed use of pharmacological (Eds.), Caring for women cross-culturally (pp. 78–91). Philadelphia:
methods of pain relief in labor. F.A. Davis.
D. Increase availability of pharmacological pain Lagana, K., & Gonzalez-Ramirez, L. (2003). Mexican Americans. In
relief in labor. St. Hill, P., Lipson, J.G., & Meleis, A.I. (Eds.), Caring for women cross-
culturally (pp. 218–235). Philadelphia: F.A. Davis.
10. The perinatal nurse understands that the advantages Lehne, R. (2006). Pharmacology for nursing care (6th ed.). Philadelphia:
to a spinal anesthetic for a woman in labor include: Saunders.
A. Easy administration Leighton, B., & Halpern, S. (2002). The effects of epidural analgesia on
labor, maternal, and neonatal outcomes: A systematic review. American
B. Immediate pain relief Journal of Obstetrics and Gynecology, 186(5), S69–S77.
C. Minimal blood loss Lieberman, E., & O’Donoghue, C. (2002). Unintended effects of epidural
D. Good voluntary maternal expulsive efforts anesthesia during labor: A systematic review. American Journal of
Obstetrics & Gynecology, 186(5), S31–S68.
See Answers to End of Chapter Review Questions on the Lowe, N. (2002). The nature of labor pain. American Journal of Obstetrics
Electronic Study Guide or DavisPlus. and Gynecology, 186(5), S16–S24.
Lowe, N. (2004). Context and process of informed consent for pharmaco-
logic strategies in labor pain care. Journal of Midwifery & Women’s
REFERENCES Health, 49(3), 250–259.
Allaire, A.D. (2001). Complementary and alternative medicine in the Mackey, M. (2001). Use of water in labor and birth. Clinical Obstetrics
labor and delivery suite. Clinical Obstetrics and Gynecology, 44(4), and Gynecology, 44(4), 733–749.
681–691. Mahlmeister, L. (2003). Nursing responsibilities in preventing, prepar-
Anim-Somuah, M., Smyth, R., & Howell, C. (2005). Epidural versus non- ing for, and managing epidural emergencies. Journal of Perinatal and
epidural or no analgesia in labor. The Cochrane Database of Systematic Neonatal Nursing, 17(1), 19–32.
Reviews, 2006, No. 3. Chichester, UK: John Wiley & Sons. Marks, G. (2000). Alternative therapies. In Nichols, F., & Humernick,
Association of Women’s Health, Obstetric, and Neonatal Nurses S. (Eds.), Childbirth education: Practice, research and theory (2nd ed.).
(AWHONN). (2001). Evidence-based clinical practice guidelines: Philadelphia: W.B. Saunders.
Nursing care of the woman receiving regional analgesia/anesthesia in Maternity Center Association. (2002). Listening to mothers: Report of the
labor. Washington, DC: Author. first national U.S. survey of women’s childbearing experiences executive
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). summary and recommendations issued by the Maternity Center Associa-
(2002). The role of the registered nurse (RN) in the care of pregnant women tion. New York: Maternity Association. Retrieved from http://www.
receiving analgesia/anesthesia by catheter techniques (epidural, intrathecal, maternitywise.org (Accessed April 11, 2008).
spinal, PCEA catheters). Clinical Position Statement. Retrieved from Mayberry, L., Clemmens, D., & De, A. (2002). Epidural anesthesia side
http://www.awhonn.org (Accessed April 12, 2008). effects, co-interventions, and care of women during childbirth: A
Bricker, L., & Lavender, T. (2002). Parenteral opioids for labor pain relief: systematic review. American Journal of Obstetrics and Gynecology 186
A systematic review. American Journal of Obstetrics and Gynecology, (5) Supplement S, S81–93.
186(5), S94–S109. McCool, W., Packman, J., & Zwerling, A. (2004). Obstetric anesthesia:
Bucklin, B., Hawkins, J., Anderson, J., & Ulrich, F. (2005). Obstetric changes and choices. Journal of Midwifery & Women’s Health, 49(6),
workforce survey. Anesthesiology, 103(3), 645–653. 505-513.
chapter 13 Promoting Patient Comfort During Labor and Birth 425
Meleis, A. (2003). Theoretical considerations of health care for immigrant Righard, L. (2001). Making childbirth a normal process. Birth, 28(1),
and minority women. In St. Hill, P., Lipson, J.G., & Meleis, A.I. (Eds.), 1–4.
Caring for women cross-culturally (pp. 1–10). Philadelphia: F.A. Davis. Scheiber, B., & Selby, C. (Eds.). (2000). Therapeutic touch. New York:
Metzack, R., & Wall, P. (1965). Pain mechanisms: A new theory. Science, Prometheus Books.
150(2), 971–982. Simkin, P., & Bolding, A. (2004). Update on nonpharmacologic approaches
Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing to relieve labor pain and prevent suffering. Journal of Midwifery &
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. Women’s Health, 49(6), 489–504.
NANDA International (2007). NANDA-I nursing diagnoses: Definitions Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain dur-
and classifications 2007–2008. Philadelphia: NANDA-I. ing labor: Systematic reviews of five methods. American Journal of
Padfield, D., Hurwitz, B., & Pither, C. (2003). Perceptions of pain. Stock- Obstetrics and Gynecology, 186(5), 5131–5159.
port, England: Dewi Lewis Publishing. Smith, C., Collins, C., Cyna, A., & Crowther, C. (2005). Complemen-
Perinatal Education Associates. (2006). Breathing. Retrieved from http:// tary and alternative therapies for pain management in labour. The
www.birthsource.com (Accessed April 6, 2007). Cochrane Database of Systematic Reviews, 2006, Issue 3. Chichester,
Perez, P. (2000). Birthballs: The use of physical therapy balls in maternity UK: John Wiley & Sons.
care. Johnson, VT: Cutting Edge Press. Venes, D. (Ed.). (2009). Taber’s cyclopedic medical dictionary (21st ed.).
Potter, G. (2006). RN teaches expectant parents the power of hypnosis. Philadelphia: F.A. Davis.
Nursing Spectrum (Greater Philadelphia/Tri-State Edition), 5(3),
14-15.
CONCEPT MAP
Types of Pain
Visceral: 1st stage of labor Physical:
• r/t change in cervix, lower Perception/Expression:
• Influenced by • Duration/intensity of labor
uterine segment, uterine
- Primary social group; culture; • Position of fetus
ischemia
ethnicity; past experience • Pelvic size/shape
• radiates to abdominal
wall/lumbosacral area/ • Psychological/emotional response: Influencing • Maternal fatigue
gluteus maximus/thighs - crying; screaming; quiet; factors • Presence of equipment
Somatic: 2nd stage of labor exhaustion; clenching teeth; • Induction of labor
• r/t stretching/distention of • Multidimensional groaning; wringing hands Psychological:
perineal body; traction on experience • Physiological response: • Anxiety/fear
peritoneum; soft tissue • Unique to each individual - elevated BP, heart rate, • Previous experience/childbirth
lacerations; expulsive • Includes perception of and respirations; diaphoresis preparation
forces; fetal pressure response to nausea/vomiting+ • Support systems
PAIN
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Differentiate critical factors associated with nursing care of women experiencing dysfunctional labor
patterns.
◆ Discuss pharmacological and nonpharmacological interventions used for the induction and
augmentation of labor.
◆ Discuss collaborative care of the woman experiencing an induction of labor.
◆ Compare and contrast methods of instrumentation assistance of birth.
◆ Describe the management of selected maternal complications during the intrapartal period.
◆ Discuss how fetal malpresentation and malposition affect labor and birth.
◆ Compare and contrast the intrapartal management for placenta previa and abruptio placentae.
◆ Describe emergency nursing care for various uterine, placental, umbilical, and amniotic
complications during labor and birth.
◆ Plan appropriate nursing care for a family experiencing a fetal loss.
◆ Discuss maternal and fetal factors associated with cesarean birth.
◆ Describe the controversies associated with vaginal birth after cesarean birth.
moving toward evidence-based practice Maternal placental syndrome as it relates to cardiovascular health
Ray, J.G., Vermeulen, M.J., Schull, M.J., & Redelmeier, D.A. (2005). Cardiovascular health after maternal placental syndromes
(CHAMPS): Population-based retrospective cohort study. The Lancet, 366, 1797–1803.
Research indicates that the presence of maternal placental syn- through multiple databases, consisted of women admitted to the
dromes, which include hypertensive disorders of pregnancy and hospital for the first obstetrical delivery of a live or stillborn infant
abruption or infarction of the placenta, probably originate from after 20 weeks of gestation. Women younger than age 14, older
diseased placental vessels. These conditions occur more often in than age 50, and those with a preexisting diagnosis of cardiovas-
women with metabolic risk factors for cardiovascular disease cular disease in the 24 months preceding the birth were
such as obesity, hypertension, diabetes, and hyperlipidemia. The excluded.
purpose of this study was to assess for the risk of premature Maternal placental syndrome included preeclampsia, gesta-
vascular disease in women who experienced maternal placental tional hypertension, placental abruption, and placental infarction.
syndrome during pregnancy. A history of hospitalization for cardiovascular, coronary artery, or
The population-based retrospective cohort study included peripheral artery disease a minimum of 90 days after the delivery
1.03 million women who had no evidence of cardiovascular dis- discharge date was identified as the point for determining the
ease before their first documented delivery. The sample, obtained composite for the development of cardiovascular disease.
(continued)
427
428 unit four The Birth Experience
mm Hg 100
75
50
25
0
1 2 3 4 5 6 7 8 9 10
A
Minutes
100
mm Hg
75
50
25
0 Increased resting tone
Figure 14-1 Uterine
1 2 3 4 5 6 7 8 9 10
B contraction patterns.
Minutes
A. Normal uterine
100
contraction pattern.
mm Hg
hydromorphone (Dilaudid), and morphine (Cunningham a 10-minute period. The uterus can be easily indented,
et al., 2005). Natural labor with effective contractions often even at the peak of the contraction, and the intrauterine
resumes after this simple intervention. Nonpharmacological pressure (IUP) is insufficient for the progression of cervi-
techniques to reduce anxiety such as relaxation techniques, cal effacement and dilation (Gilbert, 2006).
massage, a warm shower or tub bath, and increased emo- Hypotonic labor may be associated with a number of
tional support are also helpful for some women. maternal and fetal factors that produce excessive uterine
For a woman whose fetus is in an occiput–posterior stretching and overdistention. For example, fetal macro-
position, the major goal of care is to facilitate rotation of somia, multiple gestation, and hydramnios are all risk
the fetal head into a more favorable position. The nurse factors for hypotonic labor. Grand multiparity may also be
can encourage the laboring woman to walk and change a contributing cause.
positions frequently throughout the course of labor. The Fetal macrosomia occurs in one fourth of all pregnan-
descent of the fetus into an anterior lie creates a better cies and is the leading cause of uterine hypotonia. Macro-
environment for normal labor progression. somia, defined as a fetus whose birth weight is above the
Nursing care begins with a thorough assessment. It is 90th percentile on an intrauterine growth chart for that
critical to identify factors that contribute to increased gestational age, often results from a fetal imbalance between
maternal anxiety. Careful monitoring of contractions may glucose and insulin in women diagnosed with any type of
provide early information regarding poor labor progres- diabetes. Over time, as increased amounts of glucose are
sion and lead to timely interventions. While frequent absorbed from the mother, the fetus produces pancreatic
checks for cervical dilation are not advisable, this assess- insulin which results in an increase in fat deposits.
ment, when performed at proper intervals, provides a Maternal obesity unaccompanied by diabetes also con-
strong indicator of labor progression. Along with contin- tributes to a larger fetus. Hall and Neubert (2005) define
ued assessment of the contraction pattern, the nurse can obesity as a woman who has a body mass index (BMI) of
use this information to validate the finding of hypertonic greater than 30 kg/m2. In their review of studies that
labor. Once any intervention has occurred, the nurse examined obesity and pregnancy, direct links were found
evaluates the plan of care and, depending on the results, between maternal obesity and fetal macrosomia. The
initiates appropriate measures. study findings are consistent with data from Young’s and
Woodmansee’s (2002) research, which demonstrated a
Ethnocultural Considerations— positive relationship between an increased maternal BMI
Communication difficulties during labor and fetal macrosomia.
Pharmacological agents used to alleviate pain during
Nurses need to be sensitive to cultural differences among labor may also contribute to the risk of uterine hypotonia.
women experiencing hypertonic labor—those who are unable If a labor pattern is not well established, these medications
to speak or understand the English language may have diffi- often halt or significantly slow down the progress of labor.
culty communicating their feelings. Various studies have produced conflicting data concerning
a clear link between the use of analgesia, anesthesia, and
the progress of labor. After administration of epidural anes-
thesia, some women may experience a longer second stage
HYPOTONIC LABOR of labor. The effects of the epidural may make it difficult for
Hypotonic labor is a more common type of uterine dys- the patient to identify when to push and how long to push
functional pattern that contributes to poor labor progres- because the contractions are not always detected. However,
sion. With hypotonic dystocia, the uterine contractions nulliparous women who experience long and painful labors
decrease in frequency and intensity. A hypotonic labor are more likely to choose epidural anesthesia for pain relief.
pattern usually occurs during the active phase of labor. It Often it is difficult to document which factors contribute
is defined as fewer than two to three contractions during most significantly to a protracted labor.
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 431
the lower segment of the fetal membranes; following rup- and the indication for the amniotomy. The patient may
ture, the fluid is allowed to drain slowly (Fig. 14-2). The request analgesia or epidural anesthesia before the proce-
rupture of the membranes causes a release of arachidonic dure. If she has not requested any medication, the nurse
acid, which converts to prostaglandins, known inducers of assists her with relaxation and breathing techniques dur-
labor through the stimulation of oxytocin in the uterus ing the contractions following the amniotomy because
(Gilbert, 2006). Labor usually commences within 12 hours they are likely to be stronger.
after artificial rupture. However, if labor does not ensue,
there is an increased risk of infection; other risks include Be sure to— Monitor and document FHR during
fetal injury and umbilical cord prolapse. Because of the risk AROM
for infection, amniotomy is frequently used in combination
with oxytocin induction to facilitate delivery. The nurse needs to assess the FHR immediately before and
The nurse carefully monitors the patient who will after the artificial rupture of membranes. Changes such as
undergo an amniotomy. Vital signs, cervical effacement and transient fetal tachycardia may occur and are common.
dilation, station of the presenting part, FHR, and contrac- However, other FHR patterns such as bradycardia and vari-
tions are documented. The presenting part must be engaged able decelerations may be indicative of cord compression
and well applied to the cervix to prevent umbilical cord or prolapse.
prolapse (protrusion of the umbilical cord in advance of
the presenting part). There should be no evidence of active
Maternal temperature is assessed frequently (at least
infection of the genital tract (e.g., herpes) or human immu-
every 2 hours) after amniotomy to rule out infection. A
nodeficiency virus (HIV) infection (Norwitz, Robinson &
temperature of 100.4°F (38°C) may be indicative of an
Repke, 2002).
infection and the health care provider should be notified.
Other signs and symptoms of infection include the presence
Optimizing Outcomes— Preparing the Patient for an of chills, uterine tenderness on palpation, foul-smelling vag-
Amniotomy inal discharge, and fetal tachycardia (Simpson, 2005b).
The nurse provides information, assesses the woman’s
understanding of the procedure, and assures her that the
membrane rupture will be painless to her and her fetus Pharmacological Induction of Labor
although she may experience some discomfort when the
instrument is inserted through the vagina and cervix. The INDICATIONS FOR INDUCTION
nurse ensures that the necessary equipment has been assem-
Induction of labor describes the use of chemical or
bled: sterile gloves, lubricant, and the Amnihook or Allis
mechanical modalities to initiate uterine contractions
clamp. After placing hip pads under the buttocks to absorb
(before their spontaneous onset) to bring about child-
the fluid, the nurse positions the woman on a padded bed-
birth. Induction of labor is considered when either a
pan or with rolled up linens to elevate the hips. The nurse
maternal or fetal condition exists that dictates the need
assists the health care provider performing the procedure by
for medical intervention in the labor process. According
unwrapping and passing the equipment.
to Simpson and Atterbury (2003), labor induction often
leads to an increase in interventionist care including the
Immediately after the artificial rupture, the nurse notes use of intravenous therapy, amniotomy, internal moni-
and records the FHR and pattern. The color, odor, consis- toring, epidural anesthesia, and a longer stay in the labor
tency, and clarity (and amount, if unusual) of the amniotic unit. Martin et al. (2005) reported that since the year
fluid are also documented, along with the time of rupture 1989, when data were first collected, there has been a
125% increase in labor induction and a 75% increase in
labor augmentation. Interestingly, non-Hispanic white
women experience the highest rate of inductions. In
Amniotic 2003, the rate was 24.7%, while Asian or Pacific Islanders
membrane
(14%) and Hispanic women (13.8%) experienced the
lowest induction rates.
According to the American College of Obstetricians
and Gynecologists (ACOG) the following maternal/fetal
conditions serve as some of the indications for induction
(ACOG, 1999):
• Postterm pregnancy
• Maternal medical conditions (e.g., diabetes mellitus,
renal disease, chronic pulmonary disease, chronic
hypertension)
• Pregnancy-induced hypertension (PIH)
• Fetal demise
• Chorioamnionitis
• Premature rupture of membranes
• Fetal compromise (e.g., severe fetal growth restriction,
Figure 14-2 An Amnihook is used to rupture the isoimmunization)
membranes. • Preeclampsia, eclampsia
434 unit four The Birth Experience
Since induction carries certain risks, it is not per- Dinoprostone, marketed as Cervidil Insert and Prepidil
formed without careful consideration and evaluation of Gel, is an analogue of (PGE2). This cervical ripening
the maternal–fetal status. However, due to the rise in the agent makes the cervix softer, causing it to begin to dilate
U.S. cesarean rate over the last two decades, medical and efface and stimulate uterine contractions. PGE2 is
management of labor is commonly practiced in many used for preinduction cervical ripening when the Bishop
hospitals to prevent the need for surgical delivery. This score is 4 or less. Cervidil is applied into the posterior
practice often involves admission of the patient with vaginal fornix; Prepidil is inserted through a syringe into
complete cervical effacement, rupture of the membranes, the cervical canal just below the internal cervical os or
or expulsion of the mucus plug who is begun on a series into the posterior fornix. Cervidil acts more quickly.
of protocols that frequently include amniotomy com- Uterine contractions usually begin in 5 to 7 hours after
bined with oxytocin infusion. administration. When necessary, induction with oxyto-
Induction of labor is more successful when the cervix is cin can be initiated 30 to 60 minutes after removal of the
“favorable,” or inducible. The Bishop score is a rating Cervidil insert. When using Prepidil gel, oxytocin induc-
system that may be used to determine the level of cervical tion must be delayed until 6 to 12 hours after the last
inducibility. A series of points is awarded to cervical dila- instillation of the medication. Cervidil has an added
tion, effacement, station, consistency, and position (Table advantage—the insert can be removed if uterine hyper-
14-1). In general, labor induction is more likely to be suc- stimulation occurs. Dinoprostone is FDA approved for
cessful with a higher score (9 or more for nulliparous cervical ripening.
women; 5 or more for multiparous women) (Cunningham Contraindications to the PGE1 and PGE2 cervical rip-
et al., 2005; Gülmezoglu, Crowther, & Middleton, 2006). ening agents include the presence of a non-reassuring
FHR pattern, maternal fever, infection, vaginal bleeding,
Cervical Ripening Agents hypersensitivity, regular, progressive uterine contrac-
If it is determined that the cervix is not favorable for oxy- tions, and a history of cesarean birth or uterine scar. The
tocin induction, a chemical cervical ripening agent using medications should be cautiously used in women with a
prostaglandin E1 (PGE1) (Misoprostol) or prostaglandin history of asthma, glaucoma or renal, hepatic, or cardio-
E2 (PGE2) (Dinoprostone [Prepidil, Cervidil]) may be vascular disorders. After insertion, the nurse should
prescribed (Table 14-2). These agents are most beneficial clearly document all assessment findings and adminis-
when the patient’s Bishop score is greater than 6, although tration procedures.
they are commonly used when the Bishop score is 4 or
less. Before administration, informed consent may be Mechanical Methods
required, according to agency protocol.
Mechanical methods provide another approach to cervi-
Misoprostol (Cytotec) is an analogue of prostaglandin
cal ripening. Dilators placed in the cervix cause cervical
E1. Available in tablet form, the medication is inserted into
ripening by stimulating the release of endogenous pros-
the posterior vaginal fornix. Misoprostol ripens the cervix,
taglandins. Rai and Schreiber (2005) cite the use of a
causing it to begin to dilate and efface. The U.S. Food and
balloon catheter (e.g., Foley catheter) placed into the
Drug Administration (FDA) has not approved the use of
intracervical canal to increase pressure exerted on the
misoprostol for cervical ripening. Wing (2002) found miso-
lower uterine segment. Hydroscopic dilators (those that
prostol to be an effective agent for cervical ripening and
enlarge as they absorb moisture from the surrounding
induction of labor that also decreases the amount of oxyto-
tissue) such as laminaria tents (made from desiccated
cin required. Culver et al. (2004) concurred that misopros-
seaweed) and synthetic dilators containing magnesium
tol is an effective cervical ripening agent but cited higher
sulfate (Lamicel) may be inserted into the endocervix
failure rates in nulliparous women with a low Bishop score
without rupturing the membranes. The dilators remain
and reported an increased incidence of uterine hyperstimu-
in place for 6 to 12 hours before removal for assessment
lation with the medication. At least 4 hours after the last
of cervical dilation. Fresh dilators may then be inserted
dose, oxytocin may be initiated for the induction of labor if
if necessary. Amniotomy and membrane stripping (the
cervical ripening has occurred and labor has not begun.
physician or midwife inserts a gloved finger into the cer-
vical os to gently “strip” the membranes) can be also be
used to ripen the cervix.
Table 14-1 The Bishop Score
Score
Oxytocin
0 1 2 3 Oxytocin, a hormone produced by the pituitary gland,
stimulates uterine contractions. (See Chapter 12.) It can be
Dilation (cm) 0 1–2 3–4 5 used to induce labor or augment a labor that is progressing
Effacement (%) 0–30 40–50 60–70 80 slowly due to ineffective uterine contractions. Administra-
tion of the medication is closely monitored according to
Station (cm) –3 –2 –1 1, 2
institutional protocols. An intravenous infusion of 0.5 to
Cervical Firm Medium Soft 2 milliunits per minute of oxytocin is used for labor induc-
consistency tion or augmentation. The dose is increased 1 to 2 milli-
Cervix position Posterior Midposition Anterior units per minute at intervals no less than 30 to 60 minutes
until adequate labor progress is achieved. The patient
Adapted from Rai, J., & Schreiber, J.R. (2005). Cervical ripenning. EMedicine. should be reevaluated if the dose reaches 20 milliunits per
Retrieved from http://www.emedicine.com. minute (Deglin & Vallerand, 2009).
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 435
Prostaglandin E1 Induces labor contractions Diarrhea, abdominal pain, Intravaginally: 25 mcg—repeat every
headaches, fever, tachysystole, 4–6 hours until Bishop score equals
Misoprostol (Cytotec) uterine hyperstimulation 8 or greater.
Prostaglandin E2 Promotes initiation of cervical Uterine hyperstimulation, fever, Cervidil Insert:
ripening back pain, headache, nausea and
Dinoprostone vomiting, diarrhea, hypotension, (10 mg dinoprostone gradually
tachysystole released over 12 hours). Remove
(Cervidil Insert, Prepidil Gel) after 12 hours or at labor onset.
May stimulate labor contractions Adverse effects are more Keep insert frozen until ready
common with intracervical to use.
administration.
Prepidil Gel:
(2.5-mL syringe containing 0.5 mg
of dinoprostone). Repeat gel
insertion in 6 hours as needed
(maximum 1.5 mg or 3
doses/24 hr).
Allow gel to reach room temperature
before administration; do not heat.
Continue administration until
maximum dose is reached, or
uterine contractions are established
(3/10 min) or Bishop score equals
8 or greater or adverse reactions
occur.
Teaching: Patient Education
Lock
Shank Handle
Piper forceps
(aftercoming head in breech)
Now Can You— Discuss issues surrounding the use of following fetal scalp blood sampling. The suction pres-
forceps? sure can cause excessive bleeding at the sampling site. It
is also not recommended for preterm fetuses whose
1. Identify three maternal indications and three fetal indications skulls are extremely soft.
for a forceps-assisted birth? To prepare the patient for a vacuum-assisted birth, the
2. Describe maternal–fetal complications associated with the nurse provides education and support and encourages the
use of forceps instrumentation? woman’s continued participation in childbirth by pushing
3. Discuss key information the nurse provides the parents during contractions. The FHR is assessed before and
regarding a forceps-assisted birth? throughout the procedure. The nurse assists the woman
to a lithotomy position to allow sufficient traction. The
primary care provider applies the cup to the fetal head and
Vacuum-Assisted Birth a caput (swelling of the soft tissue) develops inside the
Vacuum-assisted birth, also termed vacuum extraction, is cup as the pressure is initiated. Gentle traction is applied
an alternative method used in an assisted vaginal delivery to facilitate descent of the fetal head. An episiotomy may
(Fig. 14-4). The vacuum extractor consists of a soft plas- be performed as the head crowns.
tic cup that is attached to the fetal head over the posterior
fontanel and a suction apparatus that uses negative pres-
Be sure to— Assume nursing responsibilities
sure to facilitate the birth of the head. This modality is
associated with a vacuum-assisted birth
used for a patient who is unable to voluntarily push dur-
ing the second stage of labor (most often due to exhaus- The nurse is responsible for management of care during a
tion or pharmacological agents), fetal distress or failure vacuum-assisted procedure. Although the physician applies
to progress. The same conditions apply to the use of the the vacuum to the infant head, the nurse controls the vac-
vacuum as for forceps: vertex presentation, ruptured uum gun and the pressure and is responsible for all of the
membranes, and absence of CPD. Vacuum-assisted birth required documentation. The perinatal team must com-
has certain advantages over forceps-assisted birth: little municate frequently during the procedure as they each
anesthesia is required (the fetus is less depressed at birth) assess progress or the lack of progress. The nurse, follow-
and it is associated with fewer lacerations of the maternal ing protocols, can advocate for cesarean birth if maternal
birth canal. Vacuum extraction should not be used exhaustion and/or failure of descent indicates that the
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 439
The caput that has formed on the neonate’s scalp Box 14-3 Factors that May Necessitate Immediate
begins to disappear in several hours but may persist for Intervention to Facilitate Birth in Patients
up to 7 days after birth. Appropriate education of the with Hypertensive Disorders
parents before the vacuum application helps them to
understand that the caput swelling is not harmful to the • Uncontrolled severe hypertension
infant and the markings will decrease rapidly. Neonatal • Eclampsia
complications include cephalhematoma, scalp lacera- • Persistent oliguria ( 500 mL/24 hr)
tions, and subdural hematoma. The infant should be • Abruptio placentae
carefully observed for signs of trauma and infection at the • Platelet count less than 100,000/mm3
application site. • Elevated liver enzyme levels with epigastric pain or right upper quad-
rant tenderness
• Pulmonary edema
Maternal Conditions that Complicate • Persistent severe headache or visual changes
Childbirth • Spontaneous labor
• Fetal death
HYPERTENSIVE DISORDERS • Rupture of the membranes
Management of hypertensive disorders during parturition • Gestational age less than 34 weeks (an observational period may be
is based on two goals: preventing further deterioration of initially attempted as a conservative management approach)
affected organs and fostering a positive maternal-infant • Evidence of fetal compromise
outcome. Women who have been diagnosed with severe
440 unit four The Birth Experience
monitor each fetus. The tocodynamometer needs to be Now Can You— Discuss aspects of various maternal
placed at the height of fundus to ensure the best interpreta- conditions that complicate childbirth?
tion of the labor contractions (Simpson, 2004).
1. Discuss critical aspects of intrapartal care for the woman
with diabetes?
Optimizing Outcomes— Providing pain relief during 2. Describe one critical nursing responsibility in the patient
preterm labor and birth experiencing a nonarrested preterm labor?
The length of the first stage of labor for a woman who is pre- 3. Identify three teaching needs for the patient experiencing
term is essentially the same as for a woman with a full term preterm labor and birth?
gestation although the second stage may be shorter—the
smaller fetal size can be pushed through the dilated cervix
more easily. Maternal analgesia is used cautiously due to the
immaturity of the fetus, who may have considerable diffi-
culty breathing without the additional burden of sedative Complications of Labor and Birth
effects from maternal analgesic agents. If the patient desires Associated with the Fetus
analgesia, the nurse can explain why epidural pain relief is
most likely preferable. An episiotomy is often performed at FETAL MALPRESENTATION
the time of birth to lessen trauma on the fragile fetal head; Fetal malpresentation is the second most commonly
forceps may also be used. reported complication of labor and birth. In 2003, it
occurred at a rate of 38.5 per 1000 live births (Martin et al.,
Because of the patient’s medical complications and 2005). The fetal occiput is the most favorable presenting
related fetal issues, she and her support person often part for a vaginal birth. Face, brow, shoulder, compound,
experience increased anxiety and fear during the labor and breech constitute malpresentations. A breech presen-
and birth. The nurse is there to offer clinical expertise; tation, in which the buttocks or legs present first, occurs in
provide a calming presence; and inform, support, and approximately 3% of all births and is considered the most
assist the patient and her partner throughout the birth common malpresentation. (See Chapter 12.) It is impor-
experience. A careful assessment of the patient’s psycho- tant that these conditions be identified during the antepar-
logical status can help direct the care. Expressions of car- tum period since a malpresentation may place the woman
ing coupled with dialog that includes specific questions and fetus at risk for complications during labor and birth.
help to identify the patient’s main concerns. Diagnosis is made by abdominal palpation (i.e., Leopold
maneuvers) and vaginal examination and is usually con-
firmed by ultrasonography.
Optimizing Outcomes— Exploring concerns of the During labor, descent of the fetus in a breech presenta-
woman experiencing preterm labor tion may be slow. This is because the breech is not as
The nurse should use active listening and remain nearby. effective as a dilating wedge as the fetal head. There is an
The patient should be encouraged to participate in decision increased risk of prolapsed cord if the membranes rupture
making as much as possible throughout the labor process. during early labor (Fig. 14-5).
Women who have anticipated an uncomplicated labor and
birth experience often feel out of control when events occur Nursing Insight— Breech presentation and
that differ from their expectations. The nurse can play a vital meconium in the amniotic fluid
role in keeping the patient informed and helping her to
remain an active participant throughout the birth process. When the fetus is in a breech presentation, the presence of
One approach involves teaching the patient and her partner meconium in the amniotic fluid may not be indicative of fetal
what to expect during each phase and how they can help distress. Pressure exerted on the fetal abdomen during the birth
one another throughout the process. If the patient so wishes, process may cause the passage of meconium. It is important to
the nurse involves the support person in the care as much as assess the FHR and pattern to ensure there are changes indica-
possible. tive of fetal hypoxia. When the fetus is in a breech position, the
FHR is best auscultated at or above the maternal umbilicus.
expected). Face and brow presentations hyperextend the uterine anomalies, CPD, placenta previa, multifetal gesta-
neck and increase the overall circumference of the presenting tion, and oligohydramnios (Cunningham et al., 2005).
part. These presentations are uncommon and are usually Before the version, ultrasonography is obtained to con-
associated with fetal anomalies (i.e., anencephaly), macroso- firm the fetal position, locate the umbilical cord; rule out
mia, CPD, and contractures of the maternal pelvis. Vaginal placenta previa; assess the maternal pelvic dimensions
birth may be accomplished if the fetus flexes to a vertex pre- and the amniotic fluid volume, fetal size and gestational
sentation. Forceps are often used. Cesarean birth is indicated age, and the presence of anomalies. Before the version, a
if the presentation persists, if there is evidence of fetal non-stress test (NST) is performed to confirm fetal well-
compromise, or if there is an arrest in the progression of being, or the FHR may be electronically monitored for a
labor. Shoulder and compound presentations (e.g., a hand brief period (e.g., 10 to 20 minutes).
combined with the head) contribute to fetal and vaginal Ultrasound guidance is used as the physician slowly
trauma and usually require cesarean birth (Cunningham applies gentle, steady pressure over the fetal head and but-
et al., 2005). tocks to rotate the position. Complications associated
with version include umbilical cord compression, placen-
tal abruption, maternal hemorrhage, and fetal bradycardia
VERSION (Vadhera & Locksmith, 2004).
Version (turning of a fetus from one presentation to The procedure of rotating the fetus (version) requires
another) may be done either externally or internally by uterine relaxation. Tocolytic agents such as magnesium
the physician. sulfate or terbutaline are used to facilitate this process.
Acoustic stimulation of the fetus has also resulted in suc-
External Version cessful versions (Vadhera & Locksmith, 2004).
An external cephalic version (ECV) is used as an attempt
to turn the fetus from a breech presentation to a vertex
Optimizing Outcomes— Assisting with ECV
presentation to allow a vaginal birth (Fig. 14-6). Since
cesarean birth is a major surgical procedure associated The nurse is responsible for obtaining written informed
with numerous maternal and fetal risks, ECV may offer an consent from the patient after physician explanation,
alternative to surgery. The procedure, performed in a providing teaching regarding the procedure, administer-
birth unit, may be attempted after 37 weeks’ gestation. ing medications as ordered, and conducting constant
Contraindications to ECV include previous cesarean birth, surveillance of the maternal–infant dyad. The patient
444 unit four The Birth Experience
Intravenous
tocolytic
drug
Figure 14-6 External cephalic version is a maneuver performed through the maternal
abdominal wall in an attempt to change the fetal position from a breech to a cephalic
presentation.
needs to know not only that the version attempt might indicators: slowed labor progression and formation of a
not be successful; she must also be aware of the associ- caput succedaneum that increases in size. When the fetal
ated complications that may occur such as rupture of the head emerges on the perineum (crowning), it retracts
membranes, fetal bradycardia, and discomfort. During instead of protruding with subsequent contractions
the version, if there is any indication of significant fetal or (termed the “turtle sign”), and external rotation does not
maternal compromise, the nurse prepares the woman for occur (ACOG, 2002b; Bowes & Thorp, 2004; Jevitt,
a cesarean birth. Women who are Rh-negative are given 2005). Fetal/neonatal injuries are related to birth asphyxia;
Rh immune globulin because the manipulation may cause damage to the brachial plexus; and fractures, usually of
fetomaternal bleeding (Bowes & Thorp, 2004; Vadhera & the humerus or clavicle. Maternal injury is most com-
Locksmith, 2004). monly associated with excessive blood loss that results
from uterine atony or rupture; other risks include lacera-
tions, extension of the episiotomy, and postpartum
endometritis.
Internal Version A number of maneuvers have been attempted to free
With internal version, the physician rotates the fetus by up the anterior shoulder and facilitate delivery. The
inserting a hand into the uterus and changes the fetal McRoberts maneuver is one approach. The woman is
presentation to cephalic (head) or podalic (foot). Inter- placed in a dorsal lithotomy position, and her thighs
nal version is used with multifetal gestations to deliver are sharply flexed on her abdomen. This position
the second fetus. However, the safety of this procedure increases the angle between the symphysis pubis and
has not been documented. Cesarean birth is usually per- the sacral promontory, allowing for greater room in
formed for malpresentation in multiple gestations. Nurs- fetal descent. Suprapubic pressure applied immediately
ing responsibilities center on maternal–fetal monitoring above the symphysis pubis may be needed along with
and providing support to the woman. the McRoberts maneuver to loosen the trapped shoul-
ders (Baxley & Gobbo, 2004; Camune & Brucker,
2007) (Fig. 14-7).
SHOULDER DYSTOCIA Other methods of delivery assistance for shoulder dys-
Shoulder dystocia is an uncommon obstetric emergency tocia center on maternal positional changes: a hands-and-
that occurs in 0.5% to 1.5% of all births (Jevitt, 2005). In knees position, a squatting position, or a lateral recumbent
this type of dystocia, the head is born but the anterior position (Bowes & Thorp, 2004; Camune & Brucker,
shoulder cannot pass under the maternal pubic arch. The 2007; Jevitt, 2005).
problem is often not identified until the head is born. Risk
factors for shoulder dystocia include maternal pelvic
Optimizing Outcomes— When birth is complicated
abnormalities, a history of shoulder dystocia in a previous
by shoulder dystocia
pregnancy, obesity, diabetes, prolonged labor, postdate
pregnancy, and fetal macrosomia (greater than 4000 g) When childbirth is complicated by shoulder dystocia, the
(Gherman, 2005). nurse’s role is to assist the woman in assuming the posi-
Although there are no methods to predict or prevent tions, assist the physician with the maneuvers, and to doc-
shoulder dystocia, the nurse should be alert to clinical ument all procedures. The nurse also provides careful
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 445
separation after the birth of the first fetus. Because of these onset of labor. Epidural anesthesia is considered a safe
problems, the risk for long-term disabilities such as cere- method for providing relief of pain and it allows prompt
bral palsy is greater among multiple births. intervention in case the second twin requires an external
Women who present at 38 weeks with a twin pregnancy version or a cesarean birth (Vadhera & Locksmith, 2004).
are less likely to experience fetal morbidity and mortality The woman may experience an unmedicated birth provided
and may be appropriate candidates for a vaginal birth. It is she understands that if it is necessary to proceed to a
recommended, although it is not always possible, that cesarean birth she will receive a general anesthetic to
women with a multiple gestation, particularly triplets or facilitate uterine relaxation.
higher-order multiples, deliver at a tertiary care center
where facilities are available in the event of an emergency. There is controversy over the medical management in
Birthing centers must have transport ready for infant trans- twin births where the second twin is not in a vertex
fer to neonatal intensive care units. Patients who will position. Data from a retrospective cohort study with
undergo labor or a trial of labor require careful monitoring. 15,185 participants that studied twin births of vertex,
Ultrasound is used to determine position and presentation nonvertex pairs showed that there is a higher risk of
of the fetal parts. Electronic fetal monitoring (EFM) is neonatal mortality and morbidity with vaginal birth of
applied. It is important to identify each of the individual the nonvertex twin (Yang et al., 2005). The acknowl-
FHRs and the use of a separate monitor for each fetus is edged limitations of large cohort studies lies in the fact
preferable. Interventions, such as analgesia, anesthesia, and that they are chart reviews and therefore do not examine
intravenous infusions are determined on a case-by-case complications associated with the birth of the second
basis. The stimulation of labor with oxytocin, and epidural twin (Wen et al., 2004).
anesthesia, forceps, and vacuum assistance and fetal version Triplets and higher order multiples generally require a
may all be used to facilitate the vaginal birth of twins. cesarean birth. This mode of birth decreases the risk that
Women in good health and with no evidence of fetal distress the second fetus will experience anoxia as well as other
should be given the opportunity to participate in medical complications such as cord entanglement and premature
decision management. placental separation. While there are reports of triplet
When the woman is fully dilated and ready to push, she vaginal births, these successes are tempered with the
is moved to the birthing suite, where personnel, equipment, strong possibility that both the second and the third neo-
and supplies are readily available in the event there is a need nates may be in breech presentations and require opera-
for a cesarean birth. The woman may safely give birth in a tive interventions. If it is deemed possible for the woman
labor, delivery, recovery, postpartum (LDRP) suite provided to give birth to triplets vaginally, the medical team must
there is quick access to the surgical area. The nurse prepares be on ready standby for an immediate cesarean surgery
the woman and her support for the possibility that she may (Cunningham et al., 2005).
experience both a vaginal and a cesarean birth depending on
the fetal presentation. The nurse also explains the external
version procedure in case this intervention is necessary. Now Can You— Discuss birth options for a woman with a
Patient education is carried out in a timely manner when the multiple gestation?
patient is capable of participation. 1. Identify what factors determine whether a woman with
The majority (approximately 80%) of vertex, vertex multiple gestation may be allowed to attempt a vaginal
twins are delivered with success vaginally. The first birth?
infant born is identified as “A” and neonatal care is initi- 2. Describe the primary recommendations concerning the
ated. Oxytocin, usually given to halt contractions and childbirth options available for a woman with a multiple
minimize bleeding, is withheld to avoid compromising gestation?
circulation to the unborn fetus. In the vertex, breech 3. Discuss controversies that surround the medical
presentation, an external version of the second twin is management of twin births?
attempted provided that the conditions are favorable. If
the second fetus is a footling breech, has a hyperex-
tended head, or exhibits signs of compromise, a cesarean
birth is considered the better option. The birth of the NON-REASSURING FHR PATTERNS
second twin normally occurs within 15 minutes of the Fetal heart monitoring is one type of assessment that pro-
birth of the first twin. Although there has been concern vides the nurse, the patient, and her support(s) feedback
over complications associated with a longer time period concerning the well-being of the fetus. Families often
between births, studies have shown that with proper request to increase the volume of the fetal monitor so that
fetal monitoring and maternal surveillance, a safe vaginal they hear the reassurance of a strong heartbeat. It is essen-
birth can take place in an indefinite amount of time tial that the nurse understand actions that should be taken
(Cunningham et al., 2005; Vadhera & Locksmith, 2004). when decelerations or other ominous FHR patterns are
The nurse documents the time of birth for the first infant detected. (See Chapter 12.)
and all subsequent infants who are born.
Optimizing Outcomes— Responding to a non-
Across Care Settings: Planning the multiple reassuring FHR pattern
gestation birth
• Provide information to the woman; assist her to a lateral
Together, the obstetrician, anesthesiologist, and patient position.
discuss the anesthetic options available for childbirth. This • Encourage relaxation and mental imagery to reduce
collaborative meeting is best done in an office visit before the anxiety.
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 447
• Assess for and correct maternal hypotension by elevating applying pressure with the fingers to the fetal scalp during a
the legs. vaginal examination. Vibroacoustic stimulation is accom-
• Increase the rate of the maintenance IV fluids. plished by placing an artificial larynx or fetal acoustic stimu-
• Assess for hyperstimulation by palpating the uterus. lation device on the maternal abdomen directly over the
• Discontinue oxytocin if infusing. fetal head for 1 to 2 seconds. Acceleration of the FHR in
• Administer oxygen at 8-10 L/min by mask. response to the stimulation is usually indicative of fetal well-
• Consider internal monitoring to obtain more accurate being; lack of a FHR acceleration does not necessarily indi-
fetal/uterine assessments. cate fetal compromise but warrants further evaluation.
• Apply fetal scalp or acoustic stimulation.
• Assist with fetal oxygen saturation monitoring if Fetal Oxygen Saturation Monitoring
ordered. Fetal pulse oximetry (FPO), or continuous monitoring of
• Assist with birth (cesarean or vaginal-assisted) if a non- fetal oxygen saturation, is similar to pulse oximetry used in
reassuring FHR pattern cannot be corrected. children and adults. A small sensor designed to assess oxy-
gen saturation is inserted next to the fetal cheek or temple
area. The sensor is connected to a monitor; incoming data
It is important that the nurse immediately notifies the are continuously displayed on the uterine activity panel of
physician or certified nurse midwife and initiate appropri- the fetal monitor tracing. The normal range for oxygen satu-
ate interventions for non-reassuring FHR patterns. (See ration in the healthy fetus is 30% to 70%. Before this modal-
Chapter 12.) A prolonged deceleration is the presence of ity can be used, certain criteria (e.g., 36 weeks’ gestation or
a decrease in the FHR below the baseline 15 beats per min- greater; singleton fetus; vertex presentation; non-reassuring
ute or more that lasts more than 2 minutes, but less than FHR pattern; ruptured membranes; fetal station less than or
10 minutes. A deceleration that lasts more than 10 minutes equal to –2) must be met. The American College of Obstetri-
is considered a baseline change (National Institute of Child cians and Gynecologists (ACOG) has not endorsed FPO in
Health and Human Development [NICHD], 1997). Benign clinical practice and recommends further clinical research
causes of prolonged FHR decelerations include pelvic for this assessment modality (ACOG, 2005).
examination, application of a fetal spiral electrode, rapid
fetal descent, and prolonged maternal Valsalva maneuver. Fetal Scalp Blood Sampling
Less benign causes include progressive severe variable Fetal scalp blood sampling is conducted to assess the fetal
decelerations, umbilical cord prolapse, hypotension asso- pH, PO2 and PCO2. A small sample of capillary blood is
ciated with spinal or epidural analgesia/anesthesia, para- taken from the fetal scalp as it presents at the dilated cer-
cervical anesthesia, tetanic uterine contractions, placental vix. If the fetus is hypoxic, there is a drop in the pH (aci-
hemorrhage, uterine rupture, and maternal hypoxia. A dosis). A scalp blood pH greater than 7.25 is considered
prolonged FHR deceleration that occurs late in the course normal for a fetus during labor; a scalp blood pH below
of severe variable decelerations or a series of prolonged 7.20 is acidotic and is recognized as an indicator of fetal
decelerations may occur immediately before fetal death. distress. However, because of the frequent variations in
fetal blood gas values associated with transient circulatory
changes, fetal blood sampling is rarely performed except
in tertiary centers that have a capability for repetitive sam-
critical nursing action Assisting with Intrauterine
pling and the rapid report of results.
Resuscitation Depending on the situation, watchful waiting with con-
tinuous monitoring conducted by the nurse may provide the
Intrauterine resuscitation, a term used to describe interventions
initiated when a non-reassuring FHR pattern is detected, centers on
best option for assessment of fetal well-being. Since non-
improving uterine and intervillous space blood flow and cardiac output reassuring FHR patterns constitute a risk indicator for cesar-
(Simpson & James, 2005). When intrauterine resuscitation is underway, ean birth, the nurse and all members of the health care team
nursing priorities are: (1) to open the maternal and fetal vascular must be ready for this outcome at all times. It is important
systems; (2) to increase the blood volume; and (3) to optimize oxygen- to provide ongoing support for the laboring woman and
ation of the circulating blood volume. These interventions are accom- keep her informed of her labor progress and fetal status.
plished by maternal positional changes, increasing the rate of the
primary IV, and providing oxygen by face mask. — When a non-reassuring FHR
pattern is detected via electronic monitoring
When non-reassuring FHR patterns are detected by When electronic monitoring reveals a non-reassuring
EFM, other methods of assessment may be initiated: FHR pattern, the nurse needs to maintain a calming
presence and offer factual, simple explanations for all
• Fetal scalp and vibroacoustic stimulation
actions. For example, the nurse may say:
• Fetal oxygen saturation monitoring
“We are concerned about your baby’s heart rate pattern.”
• Fetal scalp blood sampling
“I am going to change your position to your side to
increase oxygen flow to your baby.”
Fetal Scalp and Vibroacoustic Stimulation
“I am also going to place this oxygen mask on your
Fetal stimulation is done to elicit an acceleration of the FHR face to increase the oxygen flow to you and to your baby,
(15 beats per minute for at least 15 seconds) that occurs in and increase your IV rate.”
response to a tactile stimulus (Tucker, 2004). Acceleration “Do you have any questions?”
of the FHR will not occur in the presence of fetal distress “I am here to help in any way and I will stay here
and acidosis; thus, fetal stimulation is an assessment of the with you. Please let me know what concerns you have.”
fetal acid–base balance. Scalp stimulation is conducted by
448 unit four The Birth Experience
Vital Signs Establish maternal stability. Take every 5 minutes if unstable, or every Vital signs are within normal range.
15 minutes if stable.
Use pulse oximetry. Pulse is between 60 and 120 beats/
min.
Auscultate respirations. Respirations are between 14 and
26 breaths/min.
Temperature is less than 100.4ºF
(38.0ºC).
Blood pressure is greater than
90/60.
Bleeding Resolve hemorrhage. Start two large-bore IV sites. Bleeding is minimized.
Prevent shock. Infuse normal saline and lactated Ringer’s Homeostasis is established.
solution.
Estimate blood loss
(1 g 1 mL) for replacement.
Infuse blood products as necessary.
Monitor circulatory volume using CVP/
Swan-Ganz catheter as needed for extreme
bleeding.
Send blood sample to lab for analysis
of gases.
Document blood loss.
Intake/Output Prevent volume depletion. Insert indwelling urinary catheter. Urine output will be greater than
30 mL/hr.
Measure and record output every hour.
Measure and record input every hour.
Fetal Status Prevent fetal injury. Continuous electronic fetal monitoring Fetal heart rate tracings remain
between 120 and 160 beats/min.
No evidence of abnormal tracings.
Emotional Response Assist patient to cope with Educate the patient regarding all Patient verbalizes an understanding
condition. procedures. of her condition.
Inform the patient of her status throughout Face displays no grimace.
the bleeding crisis.
Provide relaxation and breathing Muscles remain relaxed.
techniques.
Provide spiritual support as necessary.
Pain Reduce pain. Provide relaxation and breathing Patient reports pain on a scale of
techniques. 1–10 as between 3 and 5.
Use guided imagery.
Offer massage.
Monitor contractions.
Offer limited pain medication as ordered.
Adapted from MacMullen et al. (2005); Curran (2003); and Mandeville & Troiano (1999).
450 unit four The Birth Experience
assessed for indicators of hemorrhage (decreasing blood separated placenta and the uterine wall) and DIC. Although
pressure, tachycardia, changes in the level of conscious- a Couvelaire uterus is rare, its implications are severe. The
ness (LOC), and oliguria). Continuous EFM is used to uterus takes on a bluish tinge as blood extravasates from the
assess the fetus for signs of hypoxia. clot into the myometrium. Contractility is lost. The condi-
There is an increased risk for postpartal hemorrhage tion is so severe that a hysterectomy may be necessary to
because the placental site is in the lower uterine segment, control the bleeding (Cunningham et al., 2006).
which does not contract as efficiently as the upper segment. If DIC has developed, surgery poses a major maternal risk
Also, because the uterine blood supply is less in the lower due to the possibility of hemorrhage during surgery and later
uterine segment, the placenta tends to grow larger than from the incisional site. The administration of intravenous
when implanted in the upper segment. Thus, a larger fibrinogen or cryoprecipitate (which contains fibrinogen)
denuded surface area is exposed after removal of the pla- may be given to increase the maternal fibrinogen level.
centa. Nursing care throughout the intrapartal course cen- The maternal prognosis depends on how quickly inter-
ters on providing emotional support for the woman and her ventions are initiated and how effective they are in halting
family and collaborating with and supporting medical the hemorrhage. Death can occur from massive hemor-
management. rhage that leads to shock or renal failure from circulatory
collapse. The fetal prognosis depends on the extent of the
abruption and the severity of the accompanying hypoxia.
PLACENTAL ABRUPTION
Placental abruption (abruptio placentae), which tends to
occur in late pregnancy, may occur as late as the first or
second stage of labor. Although the primary cause of pre- case study A Pregnant Adolescent in
mature placental separation is unknown, predisposing the Emergency Department
factors include maternal hypertension, cocaine use (asso-
ciated with vasoconstriction), direct trauma, and a history Maria Selles is a 14-year-old girl who arrives in the emergency
or previous placental abruption (Ananth, Oyelese, Yeo, department (ED) complaining of severe abdominal pain. She is
Pradhan, & Vintzileos, 2005). pale and diaphoretic. A small amount of bright red blood is slowly
trickling from her vagina. On assessment, her blood pressure is
Treatment for abruptio placentae depends on the sever-
120/70; pulse, 100; respirations 22 breaths/minute; temperature
ity of maternal blood loss and the fetal maturity and status. 99ºF (37.2ºC). Her physical examination reveals an enlarged
If the abruption is mild and the fetus is less than 36 weeks abdomen, which is rigid and board-like with extreme tenderness.
and not in distress, expectant management may be imple- Maria is known to the ED because of a history of repeated drug
mented. (See Chapter 11.) When the fetus is at term gesta- abuse including cocaine. She has been living on the street since
tion or if the bleeding is moderate to severe and the woman she was kicked out of her house several months ago.
or fetus is in jeopardy, delivery is facilitated. Nursing care
includes continuous maternal-fetal monitoring and emo- critical thinking questions
tional support. The patient is maintained in a lateral posi- 1. Based on this initial information, what is the nurse’s assess-
tion to prevent pressure on the vena cava and to facilitate ment of the possible problem?
placental blood flow. To avoid further damage to the 2 Since Maria is in such extreme distress, the nurse is aware of
injured placenta, no vaginal or pelvic examinations are a need to limit the number of questions asked. What critical
performed and no enemas are administered. questions should be asked at this point?
Blood and fluid volume replacement are implemented
3. What laboratory tests would be important to check?
to maintain the urine output (assessed by indwelling
Foley catheter) at 30 mL/hr or more and the hematocrit at ◆ See Suggested Answers to Case Studies in the text on the
30% or more. Hemodynamic monitoring may be neces- Electronic Study Guide or DavisPlus.
sary. If the premature placental separation occurs during
active labor, the physician may elect to rupture the mem- The nurse’s further assessment reveals dark red vaginal
branes or augment the labor with intravenous oxytocin to bleeding and clinical signs consistent with pregnancy (the pres-
ence of abdominal enlargement, deeply pigmented areolae,
hasten birth. Rupturing the membranes prevents large
linea nigra, and striae gravidarum). The young patient has said
amounts of blood from collecting in the myometrium, very little in response to the questions but Maria does admit to
which can interfere with uterine contractions. Artificial sexual intercourse and no recent periods.
rupture of the membranes allows a slow, steady escape of Given this information, the nurse formulates the care pri-
amniotic fluid, preventing a sudden change in intrauterine orities for Maria. Although her physical condition and that of the
pressure that may encourage further placental separation. fetus warrant immediate priority, the nurse needs to support this
Vaginal birth is desirable, especially in cases of fetal death. young girl psychologically in order to proceed with any plan. Any
If birth does not appear to be imminent, a cesarean birth support people who have come with her to the ED should be
is the delivery method of choice. However, cesarean birth identified. If there is no one with her, the nurse explains the plan
should be reserved for cases of fetal distress or other of care and describes what she should expect. The nurse places
Maria on the electronic fetal monitor and immediately notifies the
obstetric indications and should not be attempted if the
physician of her condition. Because cocaine is associated with
woman has severe and uncorrected coagulopathy (i.e., placental abruption, the nurse must identify any recent drug use.
disseminated intravascular coagulation [DIC]). The care plan should be developmentally oriented. The nurse
The patient with unresolved bleeding from a placental implements strategies to keep Maria warm, provides emotional
abruption is most vulnerable to severe complications. Mater- support and a calming presence, and continues to monitor her
nal problems resulting from abruptio placentae include a vital signs and her vaginal flow until the physician arrives.
Couvelaire uterus (the accumulation of blood between the
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 451
Nursing Diagnosis: Deficient Fluid Volume related to active losses from premature separation of the placenta.
Measurable Short-term Goal: The patient and her fetus will maintain fluid balance during the intrapartum
period.
Measurable Long-term Goal: The patient and newborn will have stable homeostatic conditions upon
discharge.
NOC Outcomes: NIC Interventions:
Fluid Balance (0601) Water balance in the Fluid Management (4120)
intracellular and extracellular compartments of Bleeding Reduction: Antepartum Uterus (4021)
the body Electronic Fetal Monitoring: Intrapartum (6772)
Blood Loss Severity (0413) Severity of internal or
external bleeding/hemorrhage
Fetal Status Antepartum (0111) Extent to which
fetal signs are within normal limits from
conception to the onset of labor
Nursing Interventions:
1. Monitor vital signs every 5–15 minutes with active bleeding or if the vital signs are not stable.
RATIONALE: The vital signs provide important information about the response of the cardiac system to active
bleeding and possible development of shock.
2. Provide continuous monitoring of the FHR and pattern.
RATIONALE: The fetus reacts directly to an assault on the mother’s system. Bleeding from the placenta places
the fetus in distress, which is manifested by changes in the FHR.
3. Observe the perineum and behind the patient’s back at least every hour for signs of active bleeding. Weigh
pads as needed to estimate losses.
RATIONALE: Observation of active bleeding may indicate the need for an emergency cesarean delivery. One
gram of weight can be estimated to equal 1 mL of blood lost.
4. Assess for abdominal pain, palpate fundal tone, and measure abdominal girth at the umbilicus at least
each hour.
RATIONALE: Concealed bleeding into the myometrium may result in a painful, rigid, board-like uterus that
becomes enlarged over time.
5. Review baseline and ongoing laboratory data including: complete blood count (CBC), clotting studies, serum
electrolytes, and renal function tests.
RATIONALE: Baseline information is used to alert the care providers to changes in the patient’s condition as
additional lab tests are obtained.
6. Maintain intravenous access with a large-bore catheter and administer intravenous fluids as directed.
RATIONALE: Intravenous access is required to maintain and replace fluid volume. Large catheters facilitate the
infusion of large volumes of fluid quickly.
7. Administer blood replacement products in a timely manner as directed.
RATIONALE: The hematocrit level should be 30% or greater to prevent severe shock.
8. Assess hourly intake and output with an indwelling urinary catheter.
RATIONALE: A decrease in urine output below 30 mL/hr indicates that the patient may be developing shock.
9. Monitor for development of abnormal clotting studies, bleeding from gums, oozing from injection sites,
bruising, or petechiae and notify caregiver.
RATIONALE: The patient is at risk for developing DIC because of excessive bleeding. Fibrinogen levels should
be greater than 150 mg/dL.
10. Facilitate delivery as necessary to prevent maternal–fetal injury.
RATIONALE: If the patient is actively bleeding, or there is any indication that she has concealed bleeding, she
must be delivered to prevent hemorrhage, shock, and death.
Adapted from Gilbert, E., & Harmon, J. (2003). High-risk pregnancy and delivery (3rd ed.). St. Louis, MO: C.V. Mosby.
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 453
A B C
Figure 14-9 Umbilical cord prolapse. A. Occult. The cord cannot be seen or felt during a vaginal
examination. B. Complete. During a vaginal examination, the cord is felt as a pulsating mass.
C. Frank. The cord precedes the fetal head or feet and can be seen protruding from the vagina.
454 unit four The Birth Experience
It is imperative that the nurse recognizes indicators nurse or other care provider continues to manually
of umbilical cord prolapse: fetal bradycardia with vari- maintain upward pressure on the presenting part (using
able decelerations during contractions; observing or a hand in the vagina) until a cesarean birth can be
palpating the cord in the vagina; woman’s statement accomplished.
that she “feels the cord” after membrane rupture. Pro-
longed cord compression causes fetal hypoxia; occlu-
critical nursing action After Prolapse of the
sion of blood flow to and from the fetus for greater than
5 minutes is likely to result in central nervous system Umbilical Cord
damage or fetal death.
After prolapse of the umbilical cord, immediate nursing interventions
To relieve pressure on the cord, the examiner places a are essential:
sterile gloved hand into the vagina and manually lifts the
presenting part off of the umbilical cord. The patient is • Call for assistance; notify the primary health care provider.
assisted into a position such as a modified Sims, extreme • Using the gloved examining hand, insert two fingers into the vagina
to the cervix. Place one finger on either side of the cord or both
Trendelenburg, or knee–chest position, which uses grav- fingers to one side and quickly exert upward pressure against the
ity to cause the presenting part to fall back from the cord presenting part to relieve compression of the cord.
(Fig. 14-10). The nurse administers oxygen at 10 L/min • Assist the woman into an extreme Trendelenburg, modified Sims, or
by face mask to improve oxygenation to the fetus; the knee–chest position.
physician may order administration of a tocolytic agent • If the cord is protruding from the vagina, wrap it loosely in a sterile
to reduce uterine activity and relieve pressure on the towel saturated with a warmed, sterile normal saline solution.
fetus. If the cord is protruding from the vagina, the expo- • Administer oxygen at 10 L/min by face mask.
sure to room air will cause drying, which leads to atro- • Increase the IV fluids; administer a tocolytic agent as ordered.
phy of the umbilical vessels. No attempts should be • Continuously monitor the FHR by internal fetal scalp electrode if
made to place the cord back into the vagina. Instead, the possible.
• Provide information and support to the woman and her birth
nurse should cover the exposed segment of umbilical partner.
cord with warm, sterile saline compresses to prevent • Prepare for an immediate vaginal birth if the cervix is fully dilated or
drying. Prompt delivery, often with forceps assistance, is for cesarean birth if it is not.
facilitated if the cervix is fully dilated. Otherwise, the
C
Figure 14-10 Interventions to relieve pressure on a prolapsed umbilical cord until birth can
be effected. A. A gloved hand is placed in the vagina to lift the presenting part off the
cord. B. The maternal hips are elevated with two pillows; this intervention is often
combined with a Trendelenburg position. C. The knee–chest position uses gravity to shift
the fetus out of the maternal pelvis.
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 455
A B C D
Figure 14-11 Variations related to umbilical cord insertion in the placenta. A. Velamentous
insertion of the umbilical cord. B. Circumvallate placenta. C. Succenturiate placenta. D.
Battledore placenta.
456 unit four The Birth Experience
AMNIOTIC FLUID EMBOLISM given consideration over the fetus. While there are no easy
Amniotic fluid embolism (AFE) (obstruction of a blood answers to these dilemmas, the nurse can serve as a leader
vessel by amniotic fluid) is a rare complication of the by organizing regular meetings during which issues of this
intra- and postpartum periods that is associated with a nature can be discussed in a calm, open manner. The
high incidence of maternal and fetal death. For mothers, nurse is in a key position to help create an environment
the mortality rate is as high as 80%; approximately 50% of where health professionals can resolve or work through
neonates who survive this event have neurological impair- difficult dilemmas.
ment (Schoening, 2006). The origins of the problem are
not clear, but it is hypothesized that amniotic fluid con-
taining particles of fetal debris (meconium, hair, vernix, Collaboration in Perinatal Emergencies
skin cells) escapes into the maternal circulation and
causes the release of endogenous mediators such as hista- Approximately 1% to 2% of pregnancies are complicated
mine, prostaglandins, and thromboxane. Obstruction of by an obstetrical emergency and require a multidisci-
the pulmonary vessels leads to respiratory distress and plinary approach to provide an effective, rapid response.
circulatory collapse. Hemorrhage, disseminated intravas- Communication is an essential component in all patient
cular coagulation, and pulmonary edema are present to environments but it is critical in emergency obstetrical
some extent in women who experience an amniotic fluid nursing. Team members need to collaborate to provide
embolism. AFE is not preventable because it cannot be timely interventions that promote patient safety. Learn-
predicted although maternal factors (including multipar- ing how to present information in a way that is non-
ity, abruptio placentae, tumultuous labor) and fetal prob- threatening but effective is key to promoting positive
lems (including macrosomia, meconium passage, death) communication patterns (Clements, Flohr-Rincon, Bom-
have been associated with an increased risk for develop- bard, & Catanzarite, 2007).
ment (Cunningham, 2005). Miller (2005) identifies the hierarchical communication
The nurse must recognize the rapidly deteriorating that often exists between physicians and nurses as detri-
maternal condition and seek immediate help. Frequently, mental to good perinatal outcomes. The need to employ
the first symptom is acute dyspnea, followed by severe healthy communication patterns to effect safe and healthy
hypotension. Other symptoms include restlessness, cyano- outcomes for the patient is tantamount. Effective commu-
sis, tachycardia, respiratory arrest, shock, and cardiac arrest nication does not mean that there are no followers of
(Schoening, 2006). orders or directives. Instead, it is important for both the
leaders and the followers to employ critical thinking skills.
Use of the word “we” promotes collaboration and under-
critical nursing action When Amniotic Fluid scores the nurse’s role as a patient advocate in this effective
Embolism Develops communication style.
Perinatal Fetal Loss infant may not always be in the most favorable condition.
The maternity unit should always have a supply of clothing
The World Health Organization definition of perinatal and new blankets available for these infants.
death is death of the offspring “occurring during late To provide the family as much privacy as possible from
pregnancy (at 22 completed weeks gestation and greater), hospital workers who might not know that the family has
during childbirth and up to seven completed days of life” experienced a loss it is best to have some sort of indicator
(Smith, 2005, p. 17). Perinatal deaths can occur during outside of the room. One hospital unit places a single red
the antepartum, intrapartum, or postpartum periods. A rose across the door. Another places a special “remem-
variety of causes may lead to the death of the fetus or the brance card” outside the doorframe. Both provide an
newborn and these are often related to obstetric complica- immediate identification to any hospital worker entering
tions such as placental abruption or neonatal prematurity the room that the patient and her family have experienced
related to genetic disorders or congenital malformations a loss.
(Smith, 2005). Perinatal death is rare because the majority All of these practices stem from the development of
of the childbearing population consists of young healthy hospital protocols regarding bereavement. The team
women who expect to give birth to healthy babies. This develops a list of critical actions and specific plans to
prevailing expectation among the general population con- respond to each point. There is flexibility to allow the
stitutes a major reason why it is so difficult for all involved parents to be active participants in the decision making
when a perinatal death occurs. but it is also organized so that as nursing and hospital
Nursing practice has changed over the years in regard personnel change, there is consistency in the approach.
to caring for families who are dealing with a perinatal loss. Communication is another critical factor in providing
During the 1960s through the 1980s, women who experi- care for the family who has experienced a fetal or neonatal
enced a perinatal loss were often placed on a medical– loss. Parents report that comforting words, touch, and
surgical unit to prevent them from hearing the sounds of directed speech are helpful to them. Nurses need to avoid
infants crying. One problem with this approach lies in the using phrases such as:
fact that the most experienced professionals in perinatal
• “It’s God’s will.”
nursing are not located in the medical–surgical areas. The
• “You can always have another.”
patient who has suffered a loss still requires all assess-
• “There was a problem with this baby.”
ments and interventions involved in normal postpartum
• “There’s always next time.”
care. A nurse in the perinatal practice area can better focus
on therapeutic interventions to assist the woman and her Parents respond better to acknowledgment of the
family in the grieving process. infant’s death than to avoidance. A simple “I’m sorry” and
The nurse organizes and coordinates a team approach a touch of the hand can convey the nurse’s care and con-
to bereavement. Different members may participate but cern when the right words are hard to find. It is also
there should be key individuals such as spiritual or reli- important for the nurse to sit and listen. Parents often
gious representatives, social workers, and physicians, in have multiple feelings, which they need to share. The
addition to the nurse. It is important to identify which nurse, as the objective individual, can help interpret feel-
hospital routines associated with perinatal death might ings and recommend resources to assist the family as they
interfere with allowing the family to have options con- deal with their grief. It is essential that the perinatal care
cerning decisions made regarding their infant. As an team remain sensitive to the cultural and spiritual beliefs
example, in some cases, the infant’s body might be moved and practices of the bereaved parents and families. (See
to the funeral home before the family has had the oppor- Chapter 11 for further discussion.)
tunity to hold him or her. Many parents wish to hold their
child prior to an autopsy, and they should be encouraged
to do so. Before presenting the parents with their infant, — To the mother whose newborn
the nurse should make certain the infant has been cleaned has died
and is wrapped in a soft blanket. Depending on the cause When caring for the mother whose infant has died, the
of death, it may also be prudent to give the parents an idea nurse conveys compassion by simply being available.
of their infant’s appearance. Usually, parents’ precon- Often, the mother finds comfort in talking about the
ceived perceptions concerning how their infant will look birth experience, her infant, and how she will cope with
is much worse than the reality. Individuals from the hos- her loss. The nurse can gain insights into the mother’s
pital morgue or a funeral home who are involved with support systems by asking the following questions:
regular bereavement team meetings can be instrumental “What are you most worried or fearful about?”
in developing a perinatal bereavement plan that is “How supportive is the baby’s father and your family
grounded in compassion and sensitivity. or friends?”
When healthy infants are discharged, it is common prac- “What coping techniques have been helpful for you in
tice to take their picture. Photographs should also be taken the past?”
when an infant has died. Parents should always be encour- (Gilbert, 2006)
aged to view, touch, and hold the deceased infant. How-
ever, if they do not wish to see the infant while in the hos-
pital, the picture provides a way for them to see their infant A perinatal loss might be the first experience a family has
at a future time when they are ready. Photographs can be with death. It is a confusing, anxiety-provoking time that
stored in a file and given to the parents upon their request. often creates a fear that it will happen again. Death of a
Use of an experienced photographer is preferred, since the child of any age is also viewed as unnatural. Parents expect
458 unit four The Birth Experience
the best interest of the patient, the patient should be (sometimes called a “midline” incision). The skin incision
informed and given the right to select another physician. may or may not be the same type of incision that is made
However, the issue is far more complex than this simple into the abdomen. After the skin incision, the surgeon
example. carefully moves through the tissue layers to the uterus. An
Williams and Shah (2003) plead for a return to common incision is made into the uterus and the fetal head is gen-
sense. Birth is a normal and natural event. These authors tly elevated through the opening. A patent airway is estab-
raise the following questions: “Have we become a nation so lished and the rest of the fetus is delivered. The cord is
obsessed with expediency and control that we are willing to clamped and the newborn is placed, depending on the
relinquish our humanity to technology? Are we truly will- circumstances, either in the arms of the parent or in the
ing to sacrifice our health and future childbearing for the neonatal warmer. After removal of the placenta, the inci-
lure of ‘birth by appointment’? Are our demands for perfec- sion is sutured at each layer and a sterile bandage is placed
tion or compensation unnecessary interventions (p. 284)?” over it (Cunningham et al., 2005; Porter & Scott, 2003).
All women are entitled to unbiased information and a safe, The nurse documents all components of patient care
supportive environment. Continued studies that examine including the time of birth and offers ongoing encourage-
the myriad issues concerning aspects of benefit versus harm ment and support to the mother. Once the birth has taken
including the economic ramifications of elective cesarean place, the nurse facilitates attachment with the new fam-
birth are in order. ily. When complications are present, the nurse provides
information including a description of the newborn to the
SURGICAL PROCEDURES family. If the newborn requires resuscitation or a transfer
to the neonatal intensive care unit, the family is allowed
There are two main types of cesarean operations: the clas- to view the neonate in the isolette before transport. When
sic (vertical) incision and the lower-segment transverse the newborn’s condition is satisfactory, the newborn is
(LST) incision (Fig. 14-12). The surgeon chooses the inci- presented to the parent or support person to hold.
sion type based on the patient’s condition and the fetal Although the mother is restrained by surgical equipment,
status. Rarely used today, the classic cesarean incision is the parent or support person can hold the baby close to
reserved for some cases of shoulder presentation, placenta the mother’s face so that she can see her child. This initial
previa, and when birth must take place immediately. Since bonding experience can usually take place while the sur-
this type of uterine incision is associated with complica- geon completes the suturing process. The family is then
tions including considerable blood loss, infection, and moved to the recovery room for post-surgical care.
uterine rupture with subsequent pregnancies, women
who undergo classic cesarean births may not attempt
future vaginal births. NURSING CARE
The lower segment cesarean (preferred by women for In most instances, the patient scheduled for a planned
cosmetic reasons) may involve either a vertical or a trans- cesarean birth is admitted on the day of surgery. When the
verse uterine incision. The transverse incision, more com- need for an emergency or unplanned cesarean arises, the
monly performed, is associated with less blood loss, fewer patient undergoes the same procedures but in a more
postoperative infections, and a decreased likelihood of timely manner. Blood work, including type and cross
uterine rupture during subsequent pregnancies (Bowes & match and a complete blood count, is obtained before
Thorp, 2004; Cunningham et al., 2005). The skin incision admission and the results are entered in the chart. The
made into the abdomen is either transverse (sometimes woman has been instructed to remain NPO since midnight
called a “Pfannenstiel” or “bikini” incision) or vertical before admission. The nurse orients the patient to the unit,
reviews the prenatal history, and responds to any ques-
tions or concerns. An informed consent is signed. A fetal
monitor is placed on the patient’s abdomen for a 20- to
30-minute baseline assessment. Vital signs are taken and
charted. In preparation for the surgery, the abdomen is
cleaned and shaved, an intravenous line is placed, and an
indwelling urinary catheter is inserted to keep the bladder
empty during the operation. Medications are administered
according to the physician’s orders. If an epidural anes-
A Vertical Transverse
thetic is to be used, the nurse properly positions the
patient and supports her during its administration. If a
general anesthetic is to be used, an oral antacid may be
prescribed to neutralize gastric secretions in the event of
aspiration. The woman is then transported to the operative
suite (Simpson & Creehan, 2001).
experience, the type of anesthesia used depends on factors reported that research conducted during that time pro-
such as the maternal medical history and current status, and vided evidence that a VBAC was safe and a more cost-
how quickly the birth needs to take place. In addition, the effective birth alternative. This movement also coincided
woman is a factor—she may harbor fears about having an with the growing concern in the United States over the
anesthetic injected into her back. Patients should be given dramatic increase in cesarean birth rates, especially among
information including the risks and benefits associated with women requiring a repeat cesarean birth.
the different types of anesthesia to empower them to make In 1988, the American College of Obstetricians and
an informed decision whenever there is a choice. Gynecologists (ACOG), having concluded that women
with a low transverse incision could safely be allowed a
trial of labor and possible vaginal birth, released a state-
ment in support of VBAC. ACOG endorsed the practice
SURGICAL CARE of oxytocin administration, epidural anesthesia, and early
The nurse’s role varies during the surgical procedure. ambulation for women with previous cesarean births who
Depending on the hospital setting and protocols, one nurse met certain criteria. A standby team prepared to perform
assists the physician during the procedure while another a cesarean birth in the event of an emergency was to be
nurse circulates. A team consisting of a neonatal nurse and available at all times (Dauphinee, 2004). Numerous stud-
a neonatologist or nurse skilled in neonatal resuscitation is ies supported the success of VBAC. During the 1990s,
in attendance to provide care for the infant. The patient is approximately 60% to 80% of women who underwent a
placed on the surgical table with a hip wedge to slightly trial of labor following a previous cesarean were able to
elevate the hips. The fetal heart rate is continuously moni- give birth vaginally with minimal complications (Porter
tored until the patient’s abdomen is ready for surgical prep- & Scott, 2003). Safety concerns arose although data
aration according to hospital protocol. The support person, showed that uterine rupture, the most serious of compli-
dressed in appropriate surgical attire, may be present at any cations, was a rare event. In response to these concerns,
point in the process but is usually asked to wait until the physicians began to more closely restrict the types of
surgical drapes are in place before being seated by the patients allowed to attempt a trial of labor. Criteria for
patient’s head. The anesthesiologist monitors the maternal the selection of candidates for a trial of labor have been
vital signs and the intravenous solutions. developed (Box 14-6). A critical point confirmed by the
When the woman remains awake during the procedure, studies was that VBACs needed to be performed in large
the nurse and other members of the care team provide infor- hospitals or tertiary level centers since these institutions
mation about the events taking place and sensations that the offer continued 24-hour anesthesia coverage necessary to
woman may be experiencing. Continued support and exp- prevent perinatal mortality and morbidity if uterine rup-
lanations help to decrease anxiety, enhance feelings of com- ture occurs (Porter & Scott, 2003).
fort, and help the woman to maintain a sense of control in
the unfamiliar and perhaps frightening, environment. NURSING IMPLICATIONS
To provide safe, effective care, it is essential that nurses
POSTOPERATIVE CARE who care for patients in the labor and birth suite have
After the completion of the surgery, the woman is trans- received extensive training in fetal monitoring interpreta-
ferred to a recovery room or to her labor room. According tion. At the first sign of any abnormality in the fetal heart
to agency protocol, the nurse assesses various aspects of rate tracing, the nurse must alert the physician or certified
the recovery progress, including effects from the anesthe- nurse midwife. Meticulous documentation is critical, as it
sia, the status of the postoperative/postbirth uterus, and provides essential information to other members of the
the degree of pain. If a general anesthetic was used, special health care team. For the elective cesarean birth, informed
attention is given to maintenance of a patent airway. The consent is obtained in the physician’s office before admis-
patient is positioned to prevent aspiration and vital signs sion and the nurse confirms this with the patient. Once
are assessed every 15 minutes for the first 2 hours, or until patients actually experience labor, it is possible for them
stable. The nurse frequently inspects the incisional dress-
ing and assesses the fundus, the amount of lochia, the
intravenous infusion, and the urinary output. The woman
Box 14-6 Selection Criteria for Vaginal Birth After
is assisted to turn, cough, deep breathe, and perform leg
Cesarean Birth (VBAC)
exercises. Pain medications are administered as needed.
If the neonate is with the mother and her labor sup- • One previous low-transverse cesarean birth (If two prior cesarean
port, time is provided to facilitate family bonding and births, only those who have also had a vaginal birth as well should be
attachment. If the woman wishes to breastfeed, she is considered candidates for a spontaneous labor)
encouraged to do so. Patients generally remain in the • Clinically adequate pelvis in relation to fetal size
recovery area for 1 to 2 hours before transfer to the post- • No other uterine scars, anomalies, or previous rupture
partum unit for continued care. (See Chapter 15.) • Physician immediately available throughout active labor capable of
monitoring labor and performing an emergency cesarean birth
VAGINAL BIRTH AFTER CESAREAN • Availability of anesthesia and personnel for emergency cesarean birth
There is an old adage, “once a cesarean, always a cesar-
Source: American College of Obstetricians and Gynecologists (ACOG). (2004a).
ean.” During the 1970s and 1980s, women challenged this Vaginal birth after previous cesarean delivery (Practice Bulletin No. 54).
rule and fought for the opportunity to attempt a vaginal Washington, DC: Author.
birth after a cesarean birth (VBAC). Dauphinee (2004)
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 461
to change their minds and, depending upon the circum- of factors that contribute to the rise in cesarean births. The
stances, they may choose not to have a vaginal birth. As in results of such studies may lead to a decrease in the overall
other situations, the nurse responds to questions and con- cesarean birth rate, which has risen steadily throughout the
cerns and ascertains the patient’s understanding of the last decade. Nurse educators in the community can provide
associated benefits and risks (Dauphinee, 2004). supportive interventions for all of these issues. Counseling
During the entire labor process the nurse is alert for any during the prenatal period to allay anxieties and fears is
changes in the maternal–fetal condition. The FHR pattern critical. Families also need realistic plans for the childbirth
and uterine activity are usually monitored electronically along with thorough explanations of procedures and what
during the active phase of labor. Non-reassuring FHR pat- they should expect (Tillett, 2005).
terns such as prolonged decelerations, late decelerations, Prepared childbirth classes have increased in numbers
and variable decelerations, may precede uterine rupture or and variety in the United States. Although many health
herald its occurrence. The nurse continuously evaluates educators serve an important role, the nurse with a clinical
the woman’s level of pain. Uterine rupture may be accom- practice in obstetrics and women’s health is in an ideal
panied by abdominal, shoulder, or back pain even when position to offer constructive guidance to families. Fami-
epidural anesthesia has been administered. However, the lies need to learn to advocate for themselves through
nurse should frequently palpate the uterus for signs of increased knowledge and understanding of the issues sur-
rigidity since the patient may report no pain. Since there is rounding operative deliveries. If women’s fears concerning
always the possibility of an emergency at any time, the childbirth are lessened, they become more open to teach-
nurse must be prepared to react in a calm manner. As the ing and can begin to function as collaborators in their own
labor progresses, the patient and her support(s) should care. For example, perinatal education and selective
receive reassurance and information regarding any change tension-reducing labor techniques may reduce the wom-
in the plan of care (Dauphinee, 2004). an’s fear of labor and birth. Perhaps women who are able
to overcome their fear of labor will choose to attempt vagi-
Now Can You— Discuss VBAC? nal birth instead of an elective cesarean birth. Nurses who
serve as childbirth educators have a unique opportunity to
1. Name five criteria for a patient to be allowed to attempt a empower women and their families through education and
vaginal birth after a previous cesarean birth? this new knowledge and self confidence may translate into
2. Discuss possible patient concerns regarding VBAC and how a reduction in the rate of cesarean births.
the nurse should appropriately respond to them?
3. List three specific nursing implications associated with the
care of the woman who is experiencing a VBAC?
Postterm Pregnancy/Prolonged
Pregnancy
RESEARCH FINDINGS AND IMPLICATIONS A postterm pregnancy is defined as one that extends
The rising rate of cesarean births and the decrease in the beyond 294 days or 42 weeks past the first day of the last
number of vaginal births after cesarean births (VBAC) are normal menstrual period. Stated another way, a postterm
related. The higher the number of first-time mothers who pregnancy has gone at least 1 day past 42 completed
experience a cesarean delivery, the higher the number of weeks (gestational age 421). A similar term, postdate,
women who may not have a choice for a vaginal delivery identifies a pregnancy that has gone past the estimated
the next time if their physician is reluctant to attempt a date of birth. It is estimated that postterm pregnancies
VBAC. Medical studies currently question the rising cesar- occur in approximately 3% to 12% of all pregnancies.
ean birth rate. Kabir and colleagues (2004) evaluated a Prolonged pregnancies are at risk for a number of prob-
large database of U.S. patients and concluded that a high lems including fetal macrosomia associated with shoulder
proportion of unnecessary cesarean births occur. For study dystocia and fetal injury, oligohydramnios, meconium
purposes, an “unnecessary cesarean birth” was defined as aspiration, intrapartum fetal distress, and stillbirth. Neo-
one that occurred when there were no identified medical natal problems may include asphyxia, meconium aspira-
risks or adverse circumstances. The adverse consequences tion syndrome, hypoglycemia, polycythemia, respiratory
of higher cesarean birth rates contribute to an increase in distress, and dysmaturity syndrome (Gilbert, 2006).
maternal morbidity and mortality. In addition, there are Maternal risks such as trauma, hemorrhage, infection,
significant economic costs related to the prolonged hospi- and labor abnormalities are also associated with postterm
tal stays and the increased need for expensive surgery- pregnancy. Labor interventions including induction with
related technologies. Although the greatest concern cen- prostaglandins or oxytocin, forceps- or vacuum-assisted
ters on the health and safety of the mother and her fetus, birth and cesarean birth are more likely to be needed. In
burgeoning health care costs cannot be discounted as a addition, the woman may experience fatigue and psycho-
problem (Kabir et al., 2004). logical responses such as depression, frustration, loss of
Nurse researchers should continue to examine evidence control, and feelings of inadequacy as the pregnancy
to provide a better understanding of the factors that impact extends beyond the estimated date of birth (ACOG,
the cesarean birth rate. A few of the modifiable variables 2004b; Moore & Martin, 2003).
include maternal obesity, fear of labor and delivery, physi- The exact cause of postterm pregnancy is unknown.
ological pushing techniques, fear of injury, and conve- However, a possible cause may be related to a deficiency
nience in planning a birth. Nurses need to engage in clinical of placental estrogen and the continued secretion of pro-
research designed to offer evidence identifying the myriad gesterone. Low levels of estrogen may result in a decrease
462 unit four The Birth Experience
in prostaglandin precursors and the reduced formation of increased anxiety when their due date has passed and they
myometrial oxytocin receptors (Gilbert, 2006). A woman are still pregnant. The nurse is in a position to provide a
with a history of one postterm pregnancy is more likely consistent presence and respond to any questions or con-
to experience another with subsequent pregnancies cerns. If induction is decided as the treatment option, the
(Divon, 2002). nurse explains the procedure to the patient and again
Because the placenta ages rapidly past the fortieth week responds to questions and concerns.
of gestation, it becomes inefficient and cannot adequately Intrapartal nursing care centers on close maternal–fetal
support the fetus. A decrease in oxygen and nutrients surveillance and continued emotional support. During labor,
results in fetal hypoxic episodes. Hypoxic events that the fetus should be monitored electronically to obtain an
occur on a regular basis stress the fetus. When labor com- accurate assessment of the FHR and pattern. Umbilical cord
mences, the postterm compromised fetus is at a greater compression, which is more likely to occur in the presence
risk for severe distress than the nonstressed term infant of decreased amniotic fluid, results in fetal hypoxia. Variable
(Gilbert, 2006). or prolonged deceleration patterns and the passage of meco-
Antenatal testing combined with careful expectant nium are reflective of fetal hypoxia. If oligohydramnios is
management is used to monitor fetal status beyond the present, amnioinfusion may be performed to restore the
fortieth week of gestation. Antenatal testing is not viewed amniotic fluid volume to provide a fluid cushion for the
as a predictor of an untoward event but as a way to iden- umbilical cord (Cunningham et al., 2005).
tify the fetus that demonstrates signs of compromise. The
antenatal assessments most often obtained include non-
stress tests (NST), biophysical profiles (BPP), amniotic summar y poi nt s
fluid volume (AFV) measurements and maternal daily
fetal movement counts. Other tests include the contrac- ◆ The nurse serves in many capacities when managing
tion stress test (CST), which relies on oxytocin-stimulated the care of women experiencing a complicated labor
contractions to identify FHR decelerations associated with and birth; a strong theoretical background provides a
fetal hypoxia and Doppler flow measurements. The tests foundation for the necessary critical decision-making
are usually performed on a weekly or twice-weekly basis
◆ Dystocia, a long, difficult or abnormal labor, may arise
(Cunningham et al., 2005; Divon, 2002). (See Chapter 11
for further discussion.) from any of the three major components of the labor
process: the powers, passenger or passageway
MEDICAL MANAGEMENT ◆ During a trial of labor, nursing responsibilities center
on assessment of maternal vital signs and fetal heart
If a woman does not experience spontaneous labor by the rate and pattern
42nd week (sometimes earlier), induction is considered
the primary medical management choice. Expectant man- ◆ Oxytocin used during labor induction and augmenta-
agement, including daily kick counts, weekly monitoring tion should always be administered as a “piggyback”
of the amniotic fluid index, and non-stress testing provide solution, and a uterine and FHR monitor should be
information regarding fetal well-being but are not always used continuously during the infusion
conclusive. If the gestational age is documented by ultra- ◆ Forceps and vacuum extraction are methods to assist
sound to be beyond 42 weeks and the cervix is favorable, birth; the mother and the infant require special obser-
most physicians proceed with labor induction. A cervix vation during and after these procedures
that is favorable (i.e., one that has begun to efface and
◆ The management of hypertensive disorders during intra-
dilate) is more conducive to the induction. If the cervix is
not favorable, a cervical ripening agent (e.g., prostaglan- partum is focused on preventing further deterioration of
din insert or gel) may be administered, followed by oxyto- affected organs and fostering a positive maternal–fetal
cin induction (ACOG, 2004b; Resnik & Resnik, 2004). outcome
Some women with an unfavorable cervix may choose to ◆ Cesarean birth, which may be a scheduled or emer-
continue with careful daily monitoring instead of the gency procedure, is associated with increased risk for
induction. As long as the physician considers the surveil- the mother and her infant and should be undertaken
lance to be a safe option, the patient may be allowed to only when medically necessary
continue with the process of expectant management. ◆ Perinatal loss necessitates a collaborative response from
However, if spontaneous labor does not begin by the 42nd all professionals involved in the care of the patient
or 43rd week, most physicians proceed with induction
(Beckman et al., 2002).
r evi ew quest i ons
NURSING IMPLICATIONS
The nurse conducts the non-stress and nipple stimulation Multiple Choice
contraction stress tests in the antepartum clinical setting, 1. When reviewing hypotonic labor, the perinatal nurse
interprets information for the patient and provides reas- explains to a student nurse that the leading cause of
surance. The nurse must be cautious in providing only the this dysfunctional labor pattern is:
factual information. Since there is a possibility of false A. Fetal macrosomia
readings, the nurse must avoid offering unfound reassur- B. Maternal android pelvis
ances and immediately notify the physician if test results C. Inadequate uterine pacemakers
are not normal. Understandably, patients often experience D. Fetal occiput posterior position
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 463
2. The perinatal nurse is aware that the minimal amount American College of Obstetricians and Gynecologists (ACOG). (2001).
of fluid that would be infused for an amnioinfusion is: Gestational diabetes (Practice Bulletin No. 30, pp 695–708). Washington,
DC: Author.
A. 500 mL American College of Obstetricians and Gynecologists (ACOG). (2002a).
B. 300 mL Diagnosis and management of preeclampsia and eclampsia (Practice
C. 250 mL Bulletin No. 33). Washington, DC: Author.
D. 800 mL American College of Obstetricians and Gynecologists (ACOG). (2002b).
Shoulder dystocia (Practice Bulletin No. 40). Washington, DC: Author.
3. The perinatal nurse understands that one of the risks American College of Obstetricians and Gynecologists (ACOG). (2003a).
of oxytocin infusion includes fetal heart rate changes Management of preterm labor (Practice Bulletin No. 43). Washington,
related to: DC: Author.
American College of Obstetricians and Gynecologists (ACOG). (2003b).
A. Decreased placental perfusion New ACOG opinion addresses elective cesarean controversy, ACOG
B. Oligohydramnios news release, October 31, 2003. Washington, DC: Author.
C. Maternal hypotonic contractions American College of Obstetricians and Gynecologists (ACOG). (2004a).
D. Maternal hypotension Vaginal birth after previous cesarean delivery (Practice Bulletin
No. 54). Washington, DC: Author.
American College of Obstetricians and Gynecologists (ACOG).
True or False (2004b). Management of postterm pregnancy (Practice Bulletin
4. The perinatal nurse understands the definition of No. 55). Washington, DC: Author.
hypotonic labor to be one that has fewer than five American College of Obstetricians and Gynecologists (ACOG). (2005).
Intrapartum fetal heart rate monitoring (Practice Bulletin No. 70).
contractions in a 10-minute period. Washington, DC: Author.
5. The perinatal nurse is aware that clinical signs that Ananth, C., Oyelese, Y., Yeo, L., Pradhan, A., & Vintzileos, A. (2005).
require discontinuation of an amnioinfusion include Placental abruption in the United States, 1979 through 2001: Tem-
poral trends and potential determinants. American Journal of Obstet-
maternal shortness of breath or tachycardia. rics and Gynecology, 192(1), 191–198.
6. The perinatal nurse recognizes that the presence of Baxley, E., & Gobbo, R. (2004). Shoulder dystocia. American Family
Physician, 69(7), 57–68.
hydramnios, which occurs when there is an excessive Beckman, C., Ling, F., Laube, D., Smith, R., Barzansky, B., & Herbert,
amount of amniotic fluid, may increase the risk of W. (2002). Obstetrics and Gynecology (4th ed.). Philadelphia: Lippincott
prolapsed umbilical cord following rupture of Williams & Wilkins.
membranes. Belfort, M. (2003). Operative vaginal delivery. In J.R. Scott, R.S. Gibbs,
B.Y. Karlan, & A.F. Haney (Eds.), Danforth’s obstetrics and gynecology
Fill-in-the-Blank (9th ed., pp. 419–447). Philadelphia: Lippincott Williams & Wilkins.
Bernasko, J. (2004). Contemporary management of type I diabetes mel-
7. The perinatal nurse knows that fetal macrosomia is litus in pregnancy. Obstetrical and Gynecological Survey, 59(8),
significantly related to maternal __________ 628–636.
measurement and _____________ _______________. Bowes, W., & Thorp, J. (2004). Clinical aspects of normal and abnormal
labor. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medi-
8. After a precipitous birth, the perinatal nurse carefully cine: Principles and practice (5th ed.). Philadelphia: W.B. Saunders.
assesses the mother and her neonate for signs or Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
symptoms of _________. Camune, B., & Brucker, M.C. (2007). An overview of shoulder dystocia.
9. In providing information to a woman in labor who is Nursing for Women’s Health, 11(5), 490–498.
to have an amniotomy, the perinatal nurse identifies Canavan, T., Simhan, H., & Cartis, S. (2004). An evidenced-based
approach to the evaluation and treatment of premature rupture of
______________ to be one of the procedure’s risks, membranes. Part II. Obsterical & Gynecological Survey, 59(9),
which means that there will be a commitment to 678–689.
have this birth occur in a timely manner. Centers for Disease Control and Prevention (CDC). (2007). Quick Stats:
Percentage of all live births by cesarean delivery—National vital sta-
Case Study tistics system, United States, 2005. MMWR Morbidity and Mortality
Weekly Report, 56(15), 1–2.
10. The perinatal nurse is caring for Christy, a 22-year-old Chan, P., & Winkle, C. (2006). Gynecology and obstetrics: Current clini-
G3 TPAL 1011, who is 9 cm. dilated and contracting cal strategies. Laguna Hills, CA: CCS Publishing.
every 2 to 3 minutes. Her labor has been rapid and she Church, S., & Hodgson, T. (2003). Disordered uterine action In J.R. Scott,
R.S. Gibbs, B.Y. Karlan, & A.F. Haney (Eds.), Danforth’s obstetrics and
has been admitted in the last 30 minutes. Christy’s gynecology (9th ed., pp. 876–883). Philadelphia: Lippincott Williams
membranes rupture spontaneously and the perinatal & Wilkins.
nurse is not able to auscultate the fetal heart. The most Clark, S. (2004). Placenta previa and abruptio placentae. In R. Creasy,
immediate nursing action is to: R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and
A. Check the perineum for the possibility of a practice (5th ed.). Philadelphia: W.B. Saunders.
Clements, C.J., Flohr-Rincon, S., Bombard, A.T., & Catanzarite, V.
prolapsed umbilical cord. (2007). OB team stat: Rapid response to obstetrical emergencies.
B. Reposition the Doppler to attempt to auscultate Nursing for Women’s Health, 11(2), 194–198.
the fetal heart rate. Culver, J., Strauss, R., Brody, S., Dorman, K., Timlin, S., & McMahon, M.
C. Reposition Christy to a left lateral position. (2004). A randomized trial of intracervical Foley catheter with con-
current oxytocin compared to vaginal misoprostol for labor induction
D. Reassure Christy that her labor is progressing well. in nulliparous women [Supplement]. American Journal of Obstetrics &
See Answers to End of Chapter Review Questions on the Gynecology, 185(6), S203.
Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., &
Electronic Study Guide or DavisPlus. Wenstrom, K. (2005). Williams’ obstetrics (22nd ed.). New York:
McGraw-Hill.
REFERENCES Curran, C. (2003). Intrapartum emergencies. Journal of Obstetric, Gyne-
American College of Obstetricians and Gynecologists (ACOG). (1999). cologic, and Neonatal Nursing, 32(6), 802–813.
Induction of labor (Practice Bulletin No. 10, pp 603–612). Washington Dauphinee, J. (2004). VBAC: Safety for the patient and the nurse. Journal
DC: Author. of Obstetric Gynecologic and Neonatal Nursing, 33(1), 105–115.
464 unit four The Birth Experience
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses Norwitz, E., Robinson, J., & Repke, J. (2002). Labor and delivery. In
(11th ed.). Philadelphia: F.A. Davis. S. Gabbe, J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and
Divon, M. (2002). Prolonged pregnancy. In S. Gabbe, J. Niebyl, & problem pregnancies (4th ed.). New York: Churchill Livingstone.
J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (4th ed.). Oyelese, Y., Catanzarite, V., Prefumo, F., Lashley, S., Schachter, M.,
New York: Churchill Livingstone. Tovbin, Y., et al. (2004). Vasa previa: The impact of prenatal diagno-
Dudley, D. (2003). Complications of labor. In J.R. Scott, R.S. Gibbs, sis on outcomes. Obstetrics and Gynecology, 103(5), 937–942.
B.Y. Karlan, & A.F. Haney (Eds.), Danforth’s obstetrics and gynecology Parer, J., & Nageotte, M. (2004). Intrapartum fetal surveillance. In
(9th ed., pp. 397–417). Philadelphia: Lippincott Williams & Wilkins. R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine:
Fraser, W.D., Hofmeyr, J., Lede, R., Faron, G., Alexander, S., Goffinet, F., Principles and Practice (5th ed.). Philadelphia: W.B. Saunders.
Ohisson, A., et al. (2005). Amnioinfusion for the prevention of meco- Patel, R., & Murphy, D. (2004). Forceps delivery in modern obstetric
nium aspiration syndrome. New England Journal of Medicine, 353(9), practice. British Medical Journal, 328(7451), 1302–1305.
909–917. Porter, F., & Scott, J. (2003). Cesarean delivery. In J.R. Scott, R.S. Gibbs,
Gherman, R.B. (2005). Shoulder dystocia prevention and management. B.Y. Karlan, & A.F. Haney (Eds.), Danforth’s obstetrics and gynecology
Obstetrics and Gynecology Clinics of North America, 32, 297–305. (9th ed., pp. 449–460). Philadelphia: Lippincott Williams & Wilkins.
Gilbert, E.S. (2006). Manual of high risk pregnancy and delivery. Rai, J., & Schreiber, J.R. (2005). Cervical ripening. EMedicine. Retrieved
St. Louis, MO: C.V. Mosby. from http://www.emedicine.com (Accessed September 19, 2005).
Gilbert, E., & Harmon, J. (2003). High-risk pregnancy and delivery (3rd ed.). Resnik, J., & Resnik, R. (2004). Post-term pregnancy. In R. Creasy,
St. Louis, MO: C.V. Mosby. R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and
Gülmezoglu, A.M., Crowther, C.A., & Middleton, P. (2006). Induction practice (5th ed.). Philadelphia: W.B. Saunders.
of labor for improving birth outcomes for women at or beyond term. Schoening, A.M. (2006). Amniotic fluid embolism: Historical perspec-
Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: tives and new possibilities. MCN: The American Journal of Maternal
CD004945. DOI: 10.1002/14651858.CD004945.pub2 Child Nursing, 31(2), 78-83.
Hall, L., & Neubert, A. (2005). Obesity and pregnancy. Obstetrical and Sibai, B., Dekker, G., & Kuperminic, M. (2005). Pre-eclampsia. Lancet,
Gynecological Survey, 60(4), 253–260. 365(9461), 785–799.
Hamilton, B., Martin, J., Ventura, S., Sutton, P., Menaker, F., & Division Simpson, K. (2004). Monitoring the preterm fetus during labor. American
of Vital Statistics. (2005). Births: Preliminary data from 2004. Journal of Maternal Child Health, 29(6), 380–390.
National Vital Statistics Report, 54(8), 1–18. Simpson, K. (2005a). Failure to rescue: Implications for evaluating qual-
Hannah, M. (2004). Planned elective cesarean section: A reasonable choice ity of care during labor and birth. Journal of Perinatology & Neonatal
for some women? Canadian Medical Association Journal, 170(5), 1–7. Nursing, 19(1), 24–36.
Institute of Medicine. (2003). The future of the public’s health in the Simpson, K. (2005b). The context and clinical evidence for common
21st century. Washington, DC: National Academy Press. nursing practices during labor. MCN American Journal of Maternal/
Jevitt, C. (2005). Shoulder dystocia: Etiology, common risk factors and Child Nursing, 30(6), 356–363.
management. Journal of Midwifery & Women’s Health, 50(6), 485–497. Simpson, K., & Atterbury, J. (2003). Trends and issues in labor induc-
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., tion in the United States: Implications for practice. Journal of Obstet-
Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and ric Gynecologic and Neonatal Nursing, 32(6), 767–779.
NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). Simpson, K., & Creehan, P. (2001). Perinatal nursing. Philadelphia:
St. Louis, MO: Mosby Elsevier. Lippincott.
Kabir, A., Steinmann, W., Myers, L., Khan, M.M., Herrera, E.A., Yu, S., Simpson, K., & James, D. (2005). Efficacy of intrauterine resuscitation
& Jooma, N. (2004). Unnecessary cesarean delivery in Louisiana: An techniques in improving fetal oxygen status during labor. Obstetrics
analysis of birth certificate data. American Journal of Obstetrics and and Gynecology, 105(6), 1362–1368.
Gynecology, 190(1), 10–19. Simpson, K., & Thorman, K. (2005). Obstetric “conveniences”: Elective
Labelle, C., & Kitchens, C. (2005). Disseminated intravascular coagula- induction of labor, cesarean birth on demand, and other potentially
tion: Treat the cause, not the lab values. Cleveland Clinic Journal of unnecessary interventions. The Journal of Perinatal & Neonatal Nurs-
Medicine, 72(5), 377–397. ing, 19(2), 134–144.
MacMullen, N., Dulski, L., & Meagher, B. (2005). RED ALERT: Perina- Smith, G. (2005). Estimating risks of perinatal death. American Journal
tal hemorrhage. The American Journal of Maternal Child Health, 30(1), of Obstetrics and Gynecology, 192(1), 17–22.
46–51. Tenore, J. (2003). Methods for cervical ripening and induction of labor.
Mahlmeister, L. (2005). Nursing responsibilities in preventing, prepar- American Academy of Family Physicians, 67(10), 2123–2128.
ing for and managing epidural emergencies. Journal of Perinatal and Tillett, J. (2005). The labor progress handbook: Early interventions to
Neonatal Nursing, 17(1), 19–34. prevent and treat dystocia. Journal of Perinatal & Neonatal Nursing,
Mandeville, L., & Troiano, N. (1999). High-risk and critical care: Intra- 14(3), 97.
partum nursing (2nd ed.). Philadelphia: Lippincott. Tucker, S.M. (2004). Pocket guide to fetal monitoring and assessment
Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Menacker, F., (4th ed.). St. Louis, MO: C.V. Mosby.
& Munson, M.L. (2005). Births: Final data for 2003. (Electronic ver- Turkoski, B.B., Lance, B.R., & Bonfiglio, M.F. (2004). Lexi comp’s drug
sion). National Vital Statistics Report, 52(10), 1–114. information for nursing: Including assessment, administration, monitoring
Miller, L. (2005). Patient safety and teamwork in perinatal care: guidelines, and patient education (6th ed.). Hudson, OH: Lexi-Comp.
Resources for clinicians. The Journal of Perinatal & Neonatal Nursing, U.S. Department of Health and Human Services (USDHHS). (2000).
19(1), 46–51. Healthy People 2010. Washington, DC: Author.
Moore, L., & Martin, J. (2003). Prolonged pregnancy. In J.R. Scott, Vadhera, R., & Locksmith, G. (2004). Breech presentation, malpresen-
R.S. Gibbs, B.Y. Karlan, & A.F. Haney (Eds.), Danforth’s obstetrics tation, and multiple gestation. In S. Datta (Ed.), Anesthetic and
and gynecology (pp. 219–223). Philadelphia: Lippincott Williams & obstetrics management of high-risk pregnancy (3rd ed., pp. 67–85).
Wilkins. Boston: Springer.
Moore, M. (2003). Preterm labor and birth: What have we learned in the Vain, N., Szyld, E., Prudent, L., Wiswell, T., Aguilar, A., & Vivas, N.
past two decades? Journal of Obstetric Gynecological and Neonatal (2004). Oropharyngeal and nasopharyngeal suctioning of meconium-
Nursing, 32, 638–649. stained neonates before delivery of their shoulders: Multicentre,
Moore, T. (2004). Diabetes in pregnancy. In R. Creasy, R. Resnik, & randomized, controlled trial. Lancet, 364(9434), 597–602.
J. Iams (Eds.), Maternal-fetal medicine: Principles and practice (5th ed.). Wax, J. (2004). Gravid uterus exteriorization at cesarean delivery for
Philadelphia: W.B. Saunders. prenatally diagnosed placenta previa-accreta. American Journal of
Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing Perinatology, 21(6), 311–313.
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Wax, J., Cartin, A., Pinette, M., & Blackstone, J. (2004). Patient choice
Mosby. cesarean: An evidence-based review. Obstetrical & Gynecological
NANDA International. (2007). NANDA-I nursing diagnosis: Definitions Survey, 59(8), 566–567.
and classifications 2007–2008. Philadelphia: NANDA-I. Wen, S., Rusen, I., Walker, M., Liston, R., Kramer, M., Baskett, T., et al.
National Institute of Child Health and Human Development (NICHD) (2004). Comparison of maternal mortality and morbidity between trial
Research Planning Workshop. (1997). Electronic fetal heart rate of labor and elective cesarean section among women with previous
monitoring: Research guidelines for interpretation. American Journal cesarean delivery. American Journal of Obstetrics and Gynecology,
of Obstetrics and Gynecology, 177(6), 1385–1390. 191(4), 1263–1269.
chapter 14 Caring for the Woman Experiencing Complications During Labor and Birth 465
Williams, D. (2005). The top 10 reasons elective cesarean section should the vertex second twin after normal vaginal delivery of the first twin.
be on the decline. AWHONN Lifelines, 9(1), 23–24. American Journal of Obstetrics and Gynecology, 192(1), 178–184.
Williams, D., & Shah, M. (2003). Soaring cesarean section rates: A cause Young, T., & Woodmansee, B. (2002). Factors that are associated with
for alarm. Journal of Obstetric Gynecological and Neonatal Nursing, 32, cesarean delivery in a large private practice: The importance of pre-
283–284. pregnancy body mass index and weight gain. American Journal of
Wing, D.A. (2002). A benefit-risk assessment of Misoprostol for cervical Obstetrics & Gynecology, 187(2), 312–320.
ripening and labour induction. Drug Safety, 25(9), 665-676. Zelop, C., & Heffner, L. (2004). The downside of cesarean delivery: Short-
Yang, Q., Wen, S., Chen, Y., Krewski, D., Fung, K., & Walker, M. and long-term complications. Clinical Obstetrics and Gynecology, 47(2),
(2005). Occurrence and clinical predictors of operative delivery of 386–393.
CONCEPT MAP
Care of the
New Family
chapter
Caring for the Postpartal
Woman and Her Family 15
Within a period of one day, most of what has been carefully accumulated over nine
months is eliminated as no longer necessary by the body.
—Rubin, 1984, p. 753
LEA R NING T AR G ET S At the completion of this chapter the student will be able to:
◆ Discuss the physiological and psychological changes that occur in the postpartal woman.
◆ Assess the physiological and psychosocial status of the postpartal woman.
◆ Plan holistic nursing care for the postpartal woman and her family that includes strategies for home
follow-up.
◆ Implement nursing interventions to promote positive breast and formula feeding outcomes for the
mother and her infant.
◆ Describe effective maternal self-care measures to be implemented during the puerperium.
◆ Discuss methods for assessing and treating pain in the postpartal period.
◆ Conduct appropriate nursing assessments and plan interventions for the patient who has
experienced a cesarean birth.
◆ Discuss dimensions of postpartal care for the multicultural family.
◆ Plan postpartal nursing care with interventions to assess and foster maternal/infant/family bonding.
The purpose of this study was to investigate the subjective ing during this period was examined. The researchers also
norms of new mothers in relation to the decision to breast or explored the views held by significant persons in the women’s
bottle feed. Norms were defined as “group identity-based codes environment (partner, own mother, and nurses) in relation to
of conduct that are understood and disseminated through group the mother’s decision about a method of feeding.
interaction” (Rimal & Real, 2003). The Theory of Planned An initial interview and self-administered questionnaire were
Behavior (TPB), a social cognition model, was used as a frame- completed by 203 new mothers after childbirth. At 6 weeks
work for the study, which explored how attitudes, norms, and postpartum, 118 of the participants completed a follow-up
perceived behavior control (PBC) predicted mothers’ feeding questionnaire. The sample included primiparous and multipa-
behaviors at birth. rous women who experienced a vaginal or cesarean birth. At
Specifically, the research was designed to measure changes the time of delivery, 103 participants planned to breastfeed;
in norms and attitudes on the selected infant feeding method 100 planned to bottle feed.
from birth to 6 weeks postpartum. Follow-up for both breast- (continued)
and bottle-fed infants and a decision to discontinue breastfeed-
469
470 unit five Care of the New Family
assess, assist, and educate new mothers about matters Hospital personnel are typically required to wear visible
concerning personal, newborn, and family health. Infor- photo identification when working in the maternal child
mation provided by the postpartum nurse can protect the unit. All employee photo badges should be similar in
newborn and his family from unnecessary morbidity and appearance to facilitate the ready identification of individ-
mortality. uals posing as hospital employees. Visitors may be required
Fears surrounding infant abductions have long been a to wear identification badges while on the unit. Hospital
common concern among hospital staff and families. These staff should be empowered to question any suspicious
concerns have created the need for the electronic tracking activity or individuals who are present on the maternal
of infants. The growing need for fail-proof mechanisms to child unit.
ensure infant safety has prompted the development of a
variety of systems designed to foil infant abduction
attempts. In response to increased litigation and pressure
from The Joint Commission, it has become mandatory for Now Can You— Discuss strategies to ensure maternal–
hospitals to offer state-of-the-art security protection for infant safety?
their patients, mother/baby units, and visitors.
1. Identify three measures the hospital nurse can implement to
To meet The Joint Commission mandatory infant
ensure the safety of both the infant and the mother?
safety requirements, hospitals have instituted policies and
2. Suggest a strategy to decrease the potential for confusing
procedures that nurses and mothers must follow to
infants whose last names are similar or identical?
ensure their newborn’s safety. Infant security experts
3. Describe two actions that hospital personnel can take to
agree that an informed mother is the baby’s first line of
help prevent infant abduction?
defense while in the hospital as well as after returning
home. It is essential that nurses educate new mothers
about measures designed to protect their newborns from
potential abductors. Early Maternal Assessment
VITAL SIGNS
Be sure to— Check identification bracelets
During the postpartum period, vital signs are a reflection
The safety and security of the infant must be maintained at of the body’s attempts to return to a pre-pregnant state.
all times during hospitalization. This process involves the Vital signs can alert the nurse to the presence of hemor-
placement of identification bands on both the mother and rhage or infection and should be monitored according to
infant shortly after birth. On bringing the infant to the hospital policy. After a vaginal birth, vital signs are typi-
mother, it is essential for the nurse to verify that the brace- cally monitored every 15 minutes during the first hour
lets match. At discharge, it may be necessary for the nurse after childbirth, then every 30 minutes during the sec-
to retain both the infant’s and parent’s identification brace- ond hour, once during the third hour, and then every
lets as part of the permanent record. This safety measure 8 hours until discharge or until they are stable. A differ-
serves a twofold purpose: to prevent the unauthorized ent protocol is followed for vital sign assessment after a
removal of the infant from the hospital unit and to prevent cesarean birth (e.g., q30min 4 hours; then q1h 3;
the inadvertent mix-up or switching of newborns. then q4–8h).
Temperature
During the first 24 hours postpartum, some women expe-
Be sure to— Protect the infant from abduction rience an increase in body temperature up to 100.4°F
Protecting the infant from abduction is an extremely impor- (38°C). The exertion and dehydration that accompany
tant consideration during hospitalization. Personnel, par- labor are the primary causes for the temperature elevation,
ents, and significant others must be educated regarding the and increased fluids usually return the temperature to a
various measures implemented to protect the safety of the normal range. Increased breast vascularity may also cause
infant. Any time the infant is transported from the nursery a transient increase in temperature. After the first 24 post-
to the mother’s room, it is essential for staff to follow the partal hours have passed, however, the patient should be
hospital’s protocol. In most facilities, infants may be trans- afebrile. A temperature above 100.4°F (38°C) at this time
ported only in a bassinet and parents are prohibited from may be indicative of infection. (See Chapter 16 for further
carrying the infant in the halls. When identification brace- discussion).
lets are used, they are matched before giving the infant to
the mother. Mothers should be instructed to release the Pulse
infant only to properly identified hospital personnel. After Heart rates of 50 to 70 beats per minute (bradycardia)
birth, admission photographs and footprints are most likely commonly occur during the first 6 to 10 days of the post-
taken and affixed to the permanent record. When two or partum period. During pregnancy, the weight of the
more infants have a similar or same last name, it is common gravid uterus causes a decreased flow of venous blood to
practice for the infants’ cribs and charts to indicate the the heart. After childbirth, there is an increase in intravas-
mother’s first name, and bear a label that designates a cular volume. The elevated stroke volume leads to a
“NAME ALERT.” When there are multiple births, the decreased heart rate. Postpartal tachycardia may result
infants’ cribs may be labeled with the infant’s name fol- from a complication, prolonged labor, blood loss, temper-
lowed by a letter of the alphabet (i.e., A, B, C, or D). ature elevation, or infection.
472 unit five Care of the New Family
may also be present. The nurse should note and document Table 15-2 BUBBLE-HE: Components of a Postpartum
the number, appearance, and size (in centimeters) of the Assessment
hemorrhoids.
Letter Assess Assessment Includes
HEMORRHOIDS B Breasts Inspection of nipples: everted, flat,
Hemorrhoids that may be present before pregnancy or inverted? Breast tissue: soft, filling,
develop during pregnancy can become enlarged due to firm? Temperature and color: warm,
pressure on the lower bowel during the second stage of pink, cool, red streaked?
labor. The application of ice packs and/or pharmaceutical U Uterus Location (midline or deviated to right
preparations such as topical anesthetic ointments or witch or left side) and tone (firm, firm with
hazel pads helps to relieve discomfort. Frozen tea peripads massage, boggy)
may also be used as a comfort measure for hemorrhoids B Bladder Last time the patient emptied her
and labial swelling. The tannic acid decreases edema and bladder (spontaneously or via
is soothing. Other actions to minimize hemorrhoidal dis- catheter)? Palpable or nonpalpable?
comfort include assisting the patient to a side-lying posi- Color, odor, and amount of urine?
tion in bed and teaching her to sit on flat, hard surfaces
B Bowels Date/time of last BM; presence of flatus
and to tighten her buttocks before sitting. Soft surfaces and hunger (unless the colon was
and pillows such as donut rings should be avoided manipulated, do not need to auscultate
because they separate the buttocks and decrease venous for bowel sounds)
flow, intensifying the pain. If the hemorrhoids are severe,
the patient can be taught how to manually reposition the L Lochia Color, amount, presence of clots, any
hemorrhoids back into the rectum. Hemorrhoids that free flow?
developed during pregnancy generally disappear within a (I) E (Incision) Type as well as other tissue trauma
few weeks after childbirth. Episiotomy (lacerations, etc.) Assess using REEDA
L/H Legs Pain, varicosities, warmth or
Now Can You— Discuss postpartum vital signs and (Homans’ sign) discoloration in calves; presence of
perineal assessment? pedal pulses; sensation and movement
1. Describe the expected vital sign findings during the (after cesarean birth)
postpartum period? E Emotions Affect, patient-family interaction,
2. Identify potential causes for increased blood pressure, pulse, effects of exhaustion
and respirations during the postpartum period?
3. Explain what is meant by the REEDA acronym to facilitate (B) Bonding Interaction with infant—”taking in”
phase—presence of finger tipping,
the perineal assessment?
gazing, enfolding, calling infant by
name, identifying unique characteristics
Stool softener Docusate sodium (Colace) 50 mg to 500 mg by mouth daily until bowel Used in the treatment of
movements are normal. constipation
Not contraindicated in breastfeeding mother.
Stool softener Bisacodyl (Dulcolax) 10 mg to 30 mg by mouth until bowel movements are Used in the treatment of
normal. constipation
Not contraindicated in breastfeeding mother.
Topical anesthetic Lidocaine spray Spray to perineal area after sitz bath or perineum care. Used on the skin to relieve pain and
Not contraindicated in breastfeeding mother. itching
Hemorrhoid care Witch hazel (Tucks) Apply to perineal area after sitz bath or perineum care. Used on the skin to relieve the
Not contraindicated in breastfeeding mother. itching, burning, and irritation
associated with hemorrhoids
Nonsteroidal anti- Ibuprofen (Motrin) 400 mg by mouth every 4–6 hours as needed for pain. Used for the treatment of mild to
inflammatory drugs Not contraindicated in breastfeeding mother. moderate pain
Opioid analgesics Darvocet (propoxyphene Take one tablet by mouth every four hours as needed Used for the treatment of moderate
and acetaminophen) for pain. to severe pain
Not contraindicated in breastfeeding mother.
Opioid analgesics Percocet (oxycodone and Take one to two tablets every 4-6 hours as needed for Used for the treatment of moderate
acetaminophen) pain. to severe pain
Not contraindicated in breastfeeding mother.
Source: Deglin, J.H., & Vallerand, A.H. (2009). Davis’s Drug Guide for Nurses (11th ed.). Philadelphia: F.A. Davis.
By the time the breasts are fully formed, typically by the feed. Tense, painful breasts in a breastfeeding mother are
age of 15, breast tissue extends medially from the second or indicative of poor transfer of milk to the infant. This find-
third rib to the sixth or seventh rib, and laterally from the ing should prompt a breastfeeding assessment and, when
breastbone to the edge of the axillae. Although genetic fac- appropriate, referral to an international board-certified
tors, body size and ethnicity account for some variations, lactation consultant. (See discussion later in this chapter.)
on average, the breasts weigh approximately 200 grams. Occasionally, small, firm nodules can be palpated in
During pregnancy, each breast increases in size and weight the filling breasts. The nodules result from incomplete
to reach approximately 600 grams and 600 to 800 grams emptying of the breasts during the previous feeding. Usu-
during lactation (Lawrence & Lawrence, 2005). ally, a nodule arises from a blocked milk duct or from
Until menopause, when menstrual periods cease, the milk contained in a gland that is not flowing forward to
woman’s breast tissue continues to respond to the chang- the nipple. Although the nodules typically disappear after
ing hormonal environment that accompanies each men- a satisfactory feeding, their location should be noted and
strual cycle. Throughout the majority of the woman’s life, monitored. Persistence of any breast mass may be indica-
the breasts remain in a resting state except for the time tive of fibrocystic disease or malignant growths unrelated
during pregnancy and lactation. ◆ to the pregnancy. The nurse also documents the appear-
ance of the nipples, noting the presence of fissures, cracks,
Regardless of whether the woman plans to breast or blood, or dried milk, and whether they are erect or
bottle feed, the breasts require careful assessment. After inverted.
ensuring privacy, the nurse asks the patient to remove her
bra. The chest area is covered with a sheet or towel and Uterus
the woman is instructed to raise her arms and rest her Involution is a term that describes the process whereby
hands on her head. The nurse inspects and palpates each the uterus returns to the nonpregnant state. The uterus
breast for size, shape, tenderness, and color. During the undergoes a dramatic reduction in size although it will
first 2 postpartal days, the breast tissue should feel soft to remain slightly larger than its size before the first preg-
the touch. By the third day, the breasts should begin to nancy. Immediately after expulsion of the placenta, the
feel firm and warm. This change is described as “filling.” uterus rapidly contracts to prevent hemorrhage. The
On the fourth and fifth days postpartum, breastfeeding uterus weighs approximately 1000 g in the immediate
mothers’ breasts should feel firm before infant feeding, postpartal period and by the end of the first week, its
then become soft once the baby is satiated. The noticeable weight has diminished to 500 g. Uterine size and weight
changes in breast firmness are indicative of milk transfer. continue to decrease and on average, the uterus weighs
The process of lactation is established in all postpartum 300 g by the end of the second week and thereafter the
women, regardless of their intention to breast or formula weight is 100 g or less (Cunningham et al., 2005).
chapter 15 Caring for the Postpartal Woman and Her Family 475
After the birth of the infant, placental expulsion spon- To perform the uterine assessment, the nurse assists
taneously occurs within 15 minutes in approximately 90% the patient to a supine position so that the height of the
of women. To prevent hemorrhage, rapid uterine contrac- uterus is not influenced by an elevated position. The
tions seal off the placental site, effectively pinching off the patient’s abdomen is observed for contour to detect dis-
massive network of maternal blood vessels that were tention and the presence of striae or a diastasis (separa-
attached to the placenta (Cunningham et al., 2005). tion), which appears as a slightly indented groove in the
The original site of placental implantation covers a midline. When present, the width and length of a diastasis
surface area that is approximately 8 to 10 cm in size. By are recorded in fingerbreadths. The uterine fundus is pal-
the end of the second postpartal week, the site has shrunk pated by placing one hand immediately above the sym-
to about 3 to 4 cm; complete healing takes approximately physis pubis to stabilize the uterus and the other hand at
6 to 7 weeks. The uterus is predominantly composed of a the level of the umbilicus (Fig. 15-1). The nurse presses
muscle layer, the myometrium. The myometrium is cov- inward and downward with the hand positioned on the
ered by serosa and lined by the decidua basalis. The pro- umbilicus until the fundus is located. It should feel like a
cess of uterine involution results from a decrease in the firm, globular mass located at or slightly above the umbi-
size of the myometrial cells rather than from a decrease in licus during the first hour after birth.
the number of myometrial cells. The decrease in cell size
results in myometrial thickening and ischemia from
reduced blood flow to the contracted uterus. clinical alert
Phagocytosis (the engulfment and destruction of cells)
Proper technique for uterine palpation
contributes to the process of uterine involution by remov-
ing elastic and fibrous tissue from the uterus. The process The uterus should never be palpated without supporting the lower
uterine segment. Failure to do so may result in uterine inversion
is further hastened by autolysis (self-digestion) that results
and hemorrhage.
from migration of macrophages to the uterus.
Subinvolution is the failure of the uterus to return to
the nonpregnant state. Uterine involution may be inhibited
by multiple births, hydramnios, prolonged labor or diffi- FUNDUS. Immediately after childbirth, the uterus rapidly
cult birth, infection, grand multiparity, or excessive mater- contracts to facilitate compression of the intra myometrial
nal analgesia. In addition, a full bladder or retained placen- blood vessels. The uterine fundus can be palpated midline,
tal tissue may prevent the uterus from sustaining the midway between the umbilicus and symphysis pubis.
contractions needed to prevent hemorrhage or to facilitate Within an hour, the uterus settles in the midline at the
involution. (See Chapter 16 for further discussion.) level of the umbilicus. Over the course of days, the uterus
The placental site heals by a process called exfoliation. descends into the pelvis at a rate of about 1 cm/day (one
Exfoliation is the scaling off of dead tissue. New endome- fingerbreadth) (Fig. 15-2). After 10 days, the uterus has
trial tissue is generated at the site from the glands and tis- descended into the pelvis and is no longer palpable.
sue that remain in the lower layer of the decidua after The fundus is assessed for consistency (firm, soft, or
separation of the placenta. This physiological process boggy), location (should be midline), and height (mea-
results in a uterine lining that contains no scar tissue, sured in finger breadths). During the fundal assessment,
which could impede implantation in future pregnancies. the nurse notes whether it is located midline or deviated
Regeneration of the endometrium is complete by the to one side. On occasion, the fundus can be palpated
16th postpartum day, except at the placental site, where slightly to the right because of displacement from the sig-
regeneration is usually not complete until approximately moid colon during pregnancy. Assessment of the fundus
6 weeks after childbirth. should be made shortly after the patient has emptied her
bladder. A full bladder prevents the uterus from contract-
Table 15-4 Assessment and Documentation Now Can You— Discuss changes in the breasts and uterus
of Uterine Involution during the postpartum period?
Time Location of Fundus Documentation 1. Name each component of the BUBBLE-HE mnemonic for the
postpartum assessment?
Immediately Midline, midway between 2. Explain normal breast changes that occur during the first
after birth umbilicus and symphysis pubis few postpartal days?
3. Explain what is meant by “involution”?
1–2 hours At the level of the umbilicus at U (umbilicus)
12 hours 1 cm above umbilicus U1
(1 fingerbreadth) Bladder
24 hours 1 cm below umbilicus U1 After childbirth, spontaneous voiding should occur within
2 days 2 cm below umbilicus U2
6 to 8 hours and the first few voiding amounts should be
(2 fingerbreadths) monitored. Urinary output of at least 150 mL/hr is neces-
sary to avoid urinary retention or stasis. Generalized
3 days 3 cm below umbilicus U3 edema is often present in the early puerperium. It is
(3 fingerbreadths) related to the fluid accumulation that normally occurs
7 days Palpable at the symphysis pubis during pregnancy combined with intravenous fluids fre-
quently administered during labor and birth. Maternal
10 days Not palpable diuresis occurs almost immediately after birth and urinary
output reaches up to 3000 mL each day by the second to
fifth postpartum days.
Decreased bladder tone is normal during pregnancy,
and results from the effects of progesterone on the smooth
ing and instead pushes the uterus upward and may deviate muscle, edema from pressure of the presenting part, and
it from the midline, due to laxness of the uterine liga- mucosal hyperemia from the increase in blood vessel size.
ments. A flabby, noncontracted, boggy uterus is associ- Prolonged labor, the use of forceps, analgesia, and anes-
ated with increased bleeding. A well-contracted fundus is thesia may intensify the changes in the immediate post-
firm, round, and midline. The nurse documents the loca- partum period. Pressure caused by the fetal head pressing
tion of the fundus according to fingerbreadths above or on the bladder during labor can result in trauma and a
below the umbilicus (Table 15-4). transient loss of bladder sensation during the first few
Afterpains (afterbirth pains) are intermittent uterine postpartal days or weeks. These changes can result in
contractions that occur during the process of involution. incomplete bladder emptying and overdistention.
Patients often describe the sensation as a discomfort Bladder and urethral trauma is not uncommon during
similar to menstrual cramps. The primiparous woman the intrapartal period and may be associated with a
typically has mild afterpains, if she notices them at all, decreased flow of urine immediately after a vaginal birth.
because her uterus is able to maintain a contracted state. An increase in the voided volume, the total flow time
Multiparas and patients with uterine overdistention (e.g., (how long it takes to empty the bladder) and the time to
large baby, multifetal gestation, hydramnios) are more peak urine flow (the maximum urinary flow rate) begins
likely to experience afterpains, due to the continuous to occur during the first postpartum day. Urine volume
pattern of uterine relaxation and vigorous contractions. and flow time should return to pre-pregnant levels by 2 to
When the uterus maintains a constant contraction, the 3 days after childbirth. Epidural anesthesia, catheteriza-
afterpains cease. Breastfeeding and the administration of tion before birth, and an instrument-facilitated birth are
exogenous oxytocin usually produce pronounced after- associated with an increased risk of postpartum urinary
pains because both cause powerful uterine contractions. retention. Urethral and bladder trauma and lacerations
Afterbirth pain is often severe for 2 to 3 days after child- may accompany vaginal or cesarean birth.
birth. Nursing interventions for discomfort include Urinary retention can also result from bladder hypoto-
assisting the patient into a prone position with a small nia after childbirth since the weight of the gravid uterus
pillow placed under her abdomen, initiating sitz baths no longer limits bladder capacity. Assessment of the
(for warmth), encouraging ambulation, and administrat- maternal bladder is an extremely important component of
ing mild analgesics. the nursing evaluation (Table 15-5). An overdistended
bladder, which displaces the uterus above and to the right
of the umbilicus, can cause uterine atony and lead to hem-
Optimizing Outcomes— Breastfeeding and orrhage. Other assessment findings may include presence
afterpains of the bladder palpated as a hard or firm area just above
Analgesics such as ibuprofen (Advil, Motrin) or naproxen the symphysis pubis and a urinary output that is dispro-
(Aleve, Anaprox) are frequently administered to lessen portionate to the fluid intake. Bladder percussion enhances
the discomforts of afterpains. Breastfeeding women should the assessment. To percuss the bladder, the nurse places
take pain medication approximately 30 minutes before one finger flat on the patient’s abdomen over the bladder
nursing the baby to achieve maximum pain relief and to and taps it with the finger of the other hand. A full bladder
minimize the amount of medication that is transferred in produces a resonant sound. An empty bladder has a dull,
the breast milk. thudding sound. Patients may express an urge to void but
be unable to void. Fortunately, spontaneous voiding typi-
chapter 15 Caring for the Postpartal Woman and Her Family 477
Table 15-5 Nursing Assessment and Interventions Box 15-1 Nursing Interventions to Facilitate Normal
for the Urinary System Bowel Function During the Puerperium
Patient’s Signs and
To facilitate the return of normal bowel function in the puerperium, the
Symptoms Nursing Interventions
nurse should:
• Location of fundus above • Promote hydration • Encourage the patient to drink at least six to eight 8-oz. glasses of
baseline level water every day to help keep the stool soft.
• Promote ambulation
• Fundus displaced from midline • Encourage the patient to eat a high-fiber diet that includes an abun-
• Administer an analgesic dance of fruits and vegetables, oat and bran cereal, whole-grain bread,
• Excessive lochia before voiding, as prescribed and brown rice.
• Bladder discomfort • Place ice on perineum to • Encourage the patient to avoid ignoring the urge to defecate.
• Bulge of bladder above reduce swelling and pain • Encourage the patient to avoid straining to have a bowel movement.
symphysis pubis • Encourage the use of a sitz • Encourage the patient to initiate early ambulation.
• Frequent voiding of less than bath
• Administer stool softeners and/or laxatives as ordered.
150 mL of urine; urinary • Provide privacy • Explain that after hospital discharge, over-the-counter medications may
output disproportionate to • Turn on the bathroom faucet be helpful for hemorrhoidal symptoms of pain, itching, or swelling but
fluid intake encourage the patient to consult with her caregiver before using such
medications.
medication: Methylergonovine
Methylergonovine (meth-ill-er-goe-noe-veen)
Scant: Blood only on tissue when Methergine
wiped or 1- to 2-inch stain Pregnancy Category: C
Indications: Prevention and treatment of postpartum and postabortion
hemorrhage caused by uterine atony or subinvolution
Actions: Directly stimulates uterine and vascular smooth muscle.
Therapeutic Effects: Uterine contraction
Light: 4-inch or less stain
Pharmacokinetics:
ABSORPTION: Well absorbed after oral or IM administration
ONSET OF ACTION: Oral: 5–10 minutes; IM: 2–5 minutes; IV: Immediately
DISTRIBUTION: Oral: 3 hours; IM: 3 hours; IV: 45 minutes. Enters breast
milk in small quantities.
Moderate: Less than 6-inch stain METABOLISM AND EXCRETION: Probably metabolized by the liver
HALF-LIFE: 30–120 minutes
Contraindications and Precautions
CONTRAINDICATED IN: Hypersensitivity. Should not be used to induce labor.
USE CAUTIOUSLY IN: Hypertensive or eclamptic patients (more susceptible
to hypertensive and arrhythmogenic side effects); severe hepatic or renal
Heavy: Saturated pad
disease; sepsis
Figure 15-3 Assessment of lochia flow in one hour. EXERCISE EXTREME CAUTION IN: Third stage of labor
Adverse Reactions and Side Effects:
CENTRAL NERVOUS SYSTEM: Dizziness, headache
EYES, EARS, NOSE, THROAT: Tinnitus
respirations 21 breaths/minute; temperature 98.9°F
RESPIRATORY: Dyspnea
(37.1°C). The nurse’s first action is to assess the fundus. With CARDIOVASCULAR: Hypotension, arrhythmias, chest pain, hypertension,
the cupped palm placed directly over the uterine fundus, palpitations
the nurse uses palpation to assess for the state of contraction GASTROINTESTINAL: Nausea, vomiting
(e.g., soft, boggy, or firmly contracted), along with the loca- GENITOURINARY: Cramps
tion and height of the fundus. If soft, the fundus is massaged DERMATOLOGICAL: Diaphoresis
in a circular motion with the cupped palm until the uterus is Route and Dosage:
well contracted. The nurse inspects the peripad for the lochia PO: 200–400 mcg (0.4–0.6 mg) q6–12h for 2–7 days
amount and color, and the presence of odor. The physician IM, IV: 200 mcg (0.2 mg) after delivery of fetal anterior shoulder, after
or nurse midwife is notified of the findings. If excessive blood delivery of the placenta, or during the puerperium; may be repeated as
loss has occurred or if the uterus is not well contracted, the required at intervals of 2–4 hours up to five doses.
nurse administers appropriate prn medication(s) (e.g., Nursing Implications:
Methylergonovine [Methergine]) as ordered. 1. Physical assessment: Monitor blood pressure, heart rate and uterine
response frequently during medication administration. Notify the
primary health care provider if uterine relaxation becomes prolonged
or if character of vaginal bleeding changes.
Episiotomy 2. Assess for signs of ergotism (cold, numb fingers and toes, chest pain,
An episiotomy is a 1- to 2-inch surgical incision made in nausea, vomiting, headache, muscle pain, weakness)
the muscular area between the vagina and the anus (the
Data from Deglin, J.H, and Vallerand, A.H. (2009). Davis’s drug guide for
perineum) to enlarge the vaginal opening before birth. nurses (11th ed.). Philadelphia: F.A. Davis.
The midline episiotomy is a straight incision extending
toward the anus. A mediolateral episiotomy extends
downward and to the side. (See Chapter 12.) Typically,
the episiotomy edges have become fused (the edges have
sealed) by the first 24 hours after birth. Although the
patient’s perineal folds may interfere with full visualiza- To assess for perineal hematoma, the nurse should:
tion of a midline episiotomy, it is important for the nurse
to carefully assess the episiotomy for redness, edema, 1. Look for discoloration of the perineum.
ecchymosis, discharge, and approximation (REEDA) and 2. Listen for the patient’s complaints or expression of severe peri-
then document all findings. neal pain.
3. Observe for edema of the area.
4. Listen for the patient’s expression of a need to defecate (the
clinical alert hematoma may cause rectal pressure).
Hematoma after an episiotomy 5. Don sterile gloves, gently palpate the area, and observe for the
patient’s degree of sensitivity to the area by touch.
Severe hemorrhage after an episiotomy is possible. Maternal com-
plaints of excessive perineal pain should alert the nurse to the pos- 6. Call the physician or nurse-midwife to report the findings imme-
sibility of a perineal, vulvar, vaginal, or ischiorectal hematoma diately. The bleeding that has produced the hematoma must be
(a blood-filled swelling that occurs from damage to a blood vessel). promptly identified and halted.
chapter 15 Caring for the Postpartal Woman and Her Family 479
for taking a sitz bath include sitting in a tub filled with 4–6
Optimizing Outcomes— Early episiotomy care inches of warm water or the use of a nonportable sitz bath
The nurse should apply an ice bag or commercial cold pack unit (similar to a toilet that fills up with warm water). A
to the perineum during the first 24 hours after childbirth. sitz bath may be used for either healing or hygiene pur-
The ice bag should be wrapped in a towel or disposable paper poses. The water may contain medication. Sitz baths are
cover to prevent a thermal injury. Application of cold pro- used to relieve pain, itching, or muscle spasms.
vides local anesthesia and promotes vasoconstriction while
reducing edema and the incidence of peripheral bleeding. The patient likely has expectations regarding pain man-
Later (after 24 hours), the nurse encourages the use of moist agement during the postpartum phase. She should be
heat (sitz bath) between 100o and 105oF (37.8–40.5oC) for encouraged to express her requests or concerns regarding
20 minutes three to four times per day. The sitz bath increases pain control. Education regarding the available modalities is
circulation to the perineum, enhances blood flow to the tis- essential and will likely enhance the patient’s perception of
sues, reduces edema, and promotes healing. Dry heat, in the control, as well as her level of satisfaction with the nursing
form of a commercial perineal “hot pack,” may also be used. care received. The nurse should regularly assess for pain and
The packs are “cracked” to generate heat. Women should be medication side effects and actively involve the patient in
cautioned to apply a washcloth or gauze square between the her pain management regimen. Use of a standardized pain
hot pack and their skin to prevent a potential burn. rating scale enhances the assessment by allowing the patient
to select the pain intensity level being experienced.
ASSESSMENT OF PAIN. Pain, sometimes considered the
The nurse assesses and documents the patient’s pain
fifth “vital sign,” must be recognized as an important behavior regarding the:
assessment focus throughout the postpartum period. Nurses • Location of the pain
play an important role in assessing, planning, and imple- • Type of pain: stabbing, burning, throbbing, aching
menting interventions to manage maternal pain effectively. • Duration of pain: intermittent or continuous
Pain should be recognized and treated in a timely manner.
The failure to manage pain effectively has been associated Nursing interventions include the administration of
with numerous complications, including prolonged recov- analgesics and patient education about other measures to
ery, increased length of hospital stay, depression, anxiety, promote comfort.
poor coping, and altered sleep patterns. • Suggest nonpharmacological methods for pain relief
Discomfort and pain may occur from several sources. such as imagery, therapeutic touch, relaxation, distrac-
Afterpains, which most commonly occur in the multipa- tion, and interaction with the infant.
rous patient, can be quite intense, especially after breast- • Provide pain relief by administering prescribed
feeding. Analgesics such as acetaminophen (e.g., Tylenol) agents such as ibuprofen, propoxyphene napsylate/
or nonsteroidal anti-inflammatory agents (NSAIDs) such acetaminophen (Darvocet-N), or oxycodone/
as ibuprofen (e.g., Motrin, Advil) are effective and safe for acetaminophen (Percocet).
use. Heat is not applied to the abdomen because of the • Suggest over-the-counter medications and alternative
potential for uterine relaxation and bleeding. therapies such as tea tree oil for self-care after hospital
Muscular aches and cramps related to the physical exer- discharge. Teach the patient that medications such as
tion expended during labor and birth may be relieved with acetaminophen or ibuprofen may be equally as effec-
back rubs and massage. When necessary, acetaminophen tive as narcotic analgesics.
(e.g., Tylenol) may be used to alleviate the discomfort. • Reassure the patient that the pain and discomfort
Pain occurring in the calf of the leg must be carefully eval- should not persist beyond 5 to 7 days and that since
uated for thromboembolic disease. Episiotomy pain and the episiotomy sutures are made of an absorbable
discomfort may be associated with sitting, walking, bend- material, they will not need to be removed.
ing, urinating, and defecating. It may interfere with the
woman’s ability to comfortably hold and feed her infant.
Interventions to decrease discomfort from the episiotomy Complementary Care: Tea tree oil to facilitate
include the application of cold (first 24 hours) and heat, episiotomy healing
and the use of topical anesthetic creams, sprays, and sitz Tea tree (Melaleuca alternifolia) oil applied to the perineum
baths. The sitz bath is a portable unit with a reservoir that is believed to be beneficial in facilitating healing of the episi-
fits on the toilet. When filled with warm water, the swirl- otomy site. Melaleuca alternifolia oil has been in use as a
ing action of the fluid soothes the tissue, reduces inflam- botanical medicine in various forms for centuries. For hun-
mation by promoting vasodilation to the area, and provides dreds of years, the Australian aboriginal people have used tea
comfort and healing. The nurse prepares and assists the tree oil as an antiseptic, antimicrobial, and anti-inflammatory
patient to the sitz bath, which should be used for 20 min- agent. The anti-inflammatory properties are believed to be
utes three to four times a day (Procedure 15-1). particularly helpful in promoting incisional healing (Halon &
Milkus, 2004) although allergic contact dermatitis may occa-
Optimizing Outcomes— Enhancing comfort and sionally occur (Stonehouse & Studdiford, 2007).
healing with a sitz bath Postpartum women with episiotomies may be taught to fill
an applicator with tea tree oil and then apply the oil directly
A sitz bath is a warm-water bath taken in the sitting posi- to the wound. A few drops of the oil provide cooling to the
tion that covers only the perineum and buttocks. It can be wound, relieve pain, enhance comfort, and promote healing.
placed in the toilet, with the seat raised. Other mechanisms
480 unit five Care of the New Family
Teach the Patient Caution: The nurse must check the temperature of
1. The benefits of using the sitz bath, which include the water before administration of the sitz bath to
enhanced hygiene, comfort, and improved ensure that it is not too warm.
circulation
Documentation
2. To use the sitz bath as often as recommended—
usually three to four times per day or as needed 6/29/09 1500 Patient reported perineal discomfort. Mild
for discomfort perineal edema noted. Patient assisted into bathroom
3. To contact the nursing staff immediately if she for sitz bath. Tolerated sitz bath with warm water
becomes light-headed or dizzy
for 20 minutes. She denied any discomfort or syncope
4. To check the temperature of the solution before
use. Applying water or solution that is too warm throughout treatment. Perineal care was provided and a
may result in local trauma or burns to the area new peripad was applied. The patient was assisted back
Note into bed. She denies perineal pain at present.
If the patient prefers to prepare a sitz bath in the tub —Olga Sanchez, RN
at home, she should be instructed not to use the
same water for bathing. Instead, fresh water should
be drawn for washing to diminish the potential for
infection.
result of diuresis. The 500-mL blood loss that typically returns to normal values within 6 days. Levels of plasma
accompanies a vaginal birth (1000 mL for a cesarean fibrinogen tend to remain elevated during the first few
birth) usually results in a 1 gram (2 grams for a cesarean postpartal weeks. Although this alteration exerts a protec-
birth) drop in hemoglobin. It is important for the nurse to tive effect against hemorrhage, it increases the patient’s
remember that as the body’s excess fluid is excreted, the risk of thrombus formation. Overall, the hematologic sys-
hematocrit may rise due to hemoconcentration. However, tem has usually returned to a nonpregnant status by the
the hematocrit should have returned to pre-pregnancy third to fourth postpartal week.
levels by 4 to 6 weeks postpartum. Circulating levels of estrogen and progesterone decrease
The white blood cell (WBC) count, which increases dramatically after delivery of the placenta. The decline in
during labor and in the immediate postpartum period, these two hormones signals the anterior pituitary gland to
chapter 15 Caring for the Postpartal Woman and Her Family 483
produce prolactin in readiness for lactation. In nonlactat- lyte balance has been restored to a nonpregnant homeo-
ing (formula feeding) women, prolactin levels return to static state by the third postpartal week.
normal by the third to fourth postpartal week. After childbirth, a decrease in levels of oxytocin and
After childbirth and expulsion of the placenta, circulat- estrogen naturally occurs and contributes to diuresis. As
ing levels of other hormones, including placental lactogen, the serum levels decline, the diuresis becomes more pro-
cortisol, growth hormone, and insulinase, also fall. During nounced. Nurses often note a maternal urinary output
the early postpartum period, the decline in the serum levels that reaches 3000 mL excreted in a 24-hour period. For
of these substances reduces the anti-insulin effects that the postpartum patient, a single voiding may contain
occur during pregnancy. Hence, insulin requirements are 500 to 1000 mL of urine.
reduced for insulin dependent women during this time,
sometimes termed a “honeymoon phase.” For many insulin- Now Can You— Describe early postpartal physiological
dependent diabetics, glucose levels remain in a normal adaptations in the metabolic, neurological,
range (without intervention) during the first few days after and renal systems?
childbirth (Chan & Winkle, 2006). 1. Explain what is meant by the “honeymoon phase” and why
this may occur?
NEUROLOGICAL SYSTEM 2. Identify possible causes and describe appropriate nursing
Fatigue and discomfort are common complaints after assessments for patients who complain of headache?
childbirth. The demands of the newborn frequently create 3. Discuss physiological adaptations in the renal system and
altered sleep patterns that contribute to increased maternal identify one patient teaching need related to these
fatigue. Anesthesia and analgesia received during labor and adaptations?
birth may cause transient maternal neurological changes
such as numbness in the legs or dizziness. When these
changes are present, the nursing priority is to safeguard the RESPIRATORY SYSTEM
patient and her infant and prevent injury from falls. Respiratory alkalosis and compensated metabolic acidosis
Complaints of headaches require further nursing occur during labor and may persist into the postpartum
assessment. Patients who received epidural or spinal anes- period. In most situations, however, after delivery of the
thesia may experience headaches, especially when they placenta and the decline in levels of progesterone, the
assume an upright position. After spinal or epidural anes- respiratory system quickly returns to a pre-pregnant state.
thesia, headaches may result from the leakage of cerebro- In addition, the immediate decrease in intra-abdominal
spinal fluid into the extradural space. Labor-induced pressure associated with the birth of the baby allows for
stress or gestational hypertension may also cause head- increased expansion of the diaphragm and relief from the
aches. It is essential that the nurse assess the quality and dyspnea usually associated with pregnancy. By the third
location of the headache and carefully monitor maternal postpartal week, the respiratory system has returned to a
vital signs. Headaches that are accompanied by double or pre-pregnant state.
blurred vision, photophobia, epigastric or abdominal pain,
and proteinuria may be signs of a developing or worsening
INTEGUMENTARY SYSTEM
preeclampsia. Report these findings immediately to the
primary health care provider. Implement environmental Changes in the skin during pregnancy and in the postpar-
interventions such as reducing the room lighting and tum period are related to the major alterations in hormones.
noise levels and limiting visitors. The physiological edema Women may experience alterations in pigmentation, con-
of pregnancy is dramatically reversed during postpartum nective and cutaneous tissue, hair, nails, secretory glands,
diuresis. Patients who experienced medial nerve compres- and pruritus. Most pregnancy-related skin changes disap-
sion and carpel tunnel syndrome during pregnancy often pear completely during the postpartum period although
obtain relief of symptoms. some, such as striae gravidarum (stretch marks) fade but
may remain permanently.
RENAL SYSTEM, FLUID, AND ELECTROLYTES
The renal plasma flow, glomerular filtration rate (GFR), Ethnocultural Considerations— Pregnancy-
plasma creatinine and blood urea nitrogen (BUN) return to related skin changes in the puerperium
pre-pregnant levels by the second to third month after
Although abdominal stretch marks (striae gravidarum) appear
childbirth. Urinary glucose excretion increases in preg-
more pronounced immediately after childbirth, they tend to
nancy by 100-fold over nonpregnant values. These values
fade over the following 6 months. In Caucasian women, striae
return to nonpregnant levels after the first postpartal week.
become pale and white in color; in African American women,
Pregnancy-associated proteinuria (up to 1 on a urine
they will appear as a slightly darker pigment.
dipstick or less than 300 mg in 24 hours) is common dur-
ing pregnancy and generally returns to pre-pregnancy val-
ues by 6 weeks postpartum (Cunningham et al., 2005).
During the postpartum period, there is a rapid, sus- CARDIOVASCULAR SYSTEM
tained natriuresis (excessively large amount of sodium in During pregnancy, the heart is displaced slightly upward
the urine) and diuresis as the sodium and water retention and to the left. As involution of the uterus occurs, the
of pregnancy is reversed. The physiological reversal is heart returns to its normal position. Dramatic changes in
particularly pronounced during the second to fifth puer- the maternal hemodynamic system result from birth of the
peral days. In most women, the body’s fluid and electro- baby, expulsion of the placenta, and loss of the amniotic
484 unit five Care of the New Family
fluid. These abrupt alterations can create cardiovascular tion, which ensures that the placental site heals without
instability during the immediate postpartum period. leaving a fibrous scar. Formation of scar tissue would limit
Despite the usual blood loss (500 mL with a vaginal birth; areas for future implantation and adversely affect the poten-
1000 mL with a cesarean birth), the maternal cardiac out- tial for future pregnancies. After a vaginal birth, the vagina
put is significantly elevated above prelabor levels for 1 to often appears edematous or bruised and superficial lacera-
2 hours postpartum and remains high for 48 hours post- tions may be present. Although swelling is resolved during
partum. The cardiac output returns to pre-pregnant levels the healing process, the vagina does not return to its nul-
within 2 to 4 weeks after childbirth. liparous size and the labia majora and labia minora remain
On average, a 3-kg weight loss occurs during the first more flaccid in the multiparous woman (Cunningham et
postpartal week. Diuresis takes place between the second al., 2005).
and fifth day. A major fluid shift involves the movement During the postpartum phase, the return of ovulation
of extracellular fluid back into the venous system for and menstruation varies according to the individual.
excretion through urine and perspiration. If the physio- Menstruation usually resumes within 6 to 8 weeks after
logic diuresis does not occur, there is an increased risk of childbirth in women who are not breastfeeding. Seventy-
pulmonary edema. The cardiac output and stroke volume five percent menstruate by the twelfth postpartal week.
remain elevated for at least 48 hours after childbirth. The first cycle is often anovulatory. The return of ovula-
Within 2 weeks, the cardiac output has decreased by 30% tion and menstruation is typically prolonged in lactating
and then reaches pre-pregnant values by 6 to 12 weeks women. Those who exclusively breastfeed may not ovu-
postpartum in most women (Cunningham et al., 2005). late or menstruate for 3 or more months. It is important
to educate patients that since ovulation can precede
IMMUNE SYSTEM menstruation, breastfeeding is not a reliable method of
contraception.
The WBC count is increased during labor and birth and
remains elevated during the early postpartum period,
gradually returning to normal values within 4 to 7 days GASTROINTESTINAL SYSTEM
after childbirth. Depending on the patient’s blood type and Owing to hormonal effects, gastric motility is decreased
immune status, administration of RhoGAM (see below) during pregnancy. It is further decreased during labor and
may be indicated. Women who are rubella susceptible dur- in the first few postpartal days due to decreased abdomi-
ing pregnancy should receive the MMR (measles–mumps– nal wall tone. Abdominal discomfort results from gaseous
rubella) vaccine at the time of hospital discharge; varicella distention related to decreased motility and abdominal
vaccine should also be encouraged (American College of muscle relaxation. Constipation, a common nursing diag-
Obstetricians and Gynecologists [ACOG], 2003). nosis for the postpartal patient, is associated with abdomi-
nal discomfort and decreased hunger. Straining to pass
Rho(D) Immune Globulin hard stool can cause hemorrhoids and tear episiotomy
Nonsensitized women who are Rho(D)-negative and have sutures. Although spontaneous bowel movements usually
given birth to an Rh(D)-positive infant should receive resume by the second or third day after childbirth, it is
300 mcg of Rho(D) immune globulin (RhoGAM) within important to educate the patient about strategies to pre-
72 hours after giving birth. RhoGAM should be given vent constipation. Stool softeners may be necessary. Addi-
whether or not the mother received RhoGAM during the tional nursing diagnoses for the postpartal patient focus
antepartum period. In some situations, depending on the on a variety of other problems such as pain, fatigue, and
extent of hemorrhage and exchange of maternal–fetal sleep disturbances, infant feeding difficulties and knowl-
blood, a larger dose of RhoGAM may be indicated. (See edge deficit (Box 15-2).
Chapter 11 for further discussion.)
Rubella Vaccine
Before discharge, the patient needs to be assessed for
rubella immunity. If nonimmune (rubella titer less than
1:8, or antibody negative on the enzyme-linked immuno- Box 15-2 Common Nursing Diagnoses During
sorbent assay [ELISA]), the MMR vaccine should be the Puerperium
administered. The nurse should counsel the patient about
• Breastfeeding, ineffective/effective
the need to avoid pregnancy for 1 month after receiving
the vaccine (due to the teratogenic effects associated with • Risk for constipation
congenital rubella syndrome) and advise her that she may • Sleep-pattern disturbed
briefly experience rubella-type symptoms such as lymph- • Fatigue
adenopathy, arthralgia, and a low-grade fever. The vaccine • Pain, acute
may be safely given to breastfeeding mothers. A signed • Activity intolerance
consent form must be obtained before administration of • Skin integrity, risk for impaired
the vaccine (ACOG, 2003). • Knowledge, deficient regarding self-care or care of infant
• Risk for infection
REPRODUCTIVE SYSTEM • Family processes parenting impaired
The uterus undergoes a rapid reduction in size (involution) • Risk for situational low self-esteem related to body image changes
and returns to its pre-pregnant state in about 3 weeks. The • Risk for urinary retention
former site of the placenta heals by the process of exfolia-
chapter 15 Caring for the Postpartal Woman and Her Family 485
• Avoiding the consumption of ice water or cold water. patients should be encouraged to obtain adequate sleep
These cold beverages are believed to cause weakness and frequent rest periods to help facilitate an optimal
and delay healing. recovery.
• Avoiding cold temperatures, which are thought to be
detrimental to the mother’s recovery. To maintain NOURISHMENT
warmth, the mother dresses warmly and stays in bed
A weight loss of approximately 10 to 12 lbs. (4.5 to
for several days. Bathing, showering, and washing the
5.5 kg) occurs immediately after childbirth, and this
hair is delayed for 40 days because water cools the
amount is directly related to the collective weights of the
body.
baby, placenta, and amniotic fluid. An additional 5 lbs.
• Avoiding drafts by keeping doors and windows closed
(2.3 kg) is lost over the following week as a result of puer-
and avoiding fans and air-conditioning.
peral diuresis and uterine involution. How quickly the
woman returns to her pre-pregnancy weight depends on
CLINICAL IMPLICATIONS OF CULTURALLY her physical activity level, eating habits, and lifestyle.
APPROPRIATE CARE Olson, Strawderman, Hinton, and Pearson (2003) noted
To provide sensitive, appropriate care, nurses need to that women whose weight increase was within the recom-
adopt a flexible approach when caring for women who mended limit of 25 to 30 lbs. (11.4 to 13.6 kg) during
embrace non-Western health beliefs and practices. Inquir- pregnancy could anticipate a return to the pre-pregnancy
ing about cultural beliefs, and, when possible, incorporat- weight by 6 to 8 weeks postpartum. Factors associated
ing the beliefs into the plan of care are important strate- with weight changes during the postpartum period include
gies to help achieve this goal. For example, to demonstrate gestational weight gain, frequency of exercise, dietary
sensitivity to beliefs regarding hot and cold, the nurse may intake, and breastfeeding for longer than 1 year.
offer a warm sponge bath instead of a shower, adjust the Because of the restriction of food during labor, most
thermostat in the room and provide extra blankets for patients demonstrate a hearty appetite after childbirth. All
warmth; offer warm drinks instead of cold beverages; and parturient women should be encouraged to eat a bal-
allow female family members as much access to the anced, nutritious diet with multivitamin supplements.
mother as possible. Iron is recommended only if the patient’s hemoglobin
is low.
Now Can You— Provide culturally sensitive postpartal
care? ELIMINATION
1. Identify at least five ways that health care providers can Voiding should occur within 4 hours of childbirth. Patients
enhance cultural sensitivity before conducting a cultural should be encouraged to empty the bladder every 4 to
assessment? 6 hours and to expect to excrete large volumes of urine.
2. Describe several cultural beliefs concerning “hot” and In addition to the extra- to intravascular fluid shift that
“cold” and identify specific nursing interventions that allow follows childbirth, there is a decrease in the production of
women to adhere to these beliefs? the adrenal hormone aldosterone. Declining levels of
aldosterone are associated with a decrease in sodium
retention and an increase in urinary output.
Promoting Recovery and Self-Care An intake and output record should be maintained
to monitor the volume of urine passed during the first
in the Puerperium 24 hours. The woman who has recently given birth is prone
to urinary stasis and retention. Incomplete bladder empty-
ACTIVITY AND REST ing or urinary retention may result from trauma to urethral
In the postpartum period, it is important for the new tissue sustained during the “pushing phase” of a vaginal
mother to begin ambulating as soon as her condition per- birth. Also, patients who were catheterized or who received
mits. Despite recent advances in diagnosis and treatment, regional anesthesia during childbirth sometimes experience
deep vein thrombosis after birth continues to constitute a an absence of the sensation to void. Bladder hypotonia dur-
leading cause of maternal morbidity and mortality. Venous ing labor may also lead to postpartal urinary retention or
stasis and hypercoagulation, conditions that exist in preg- stasis, factors that increase the risk of infection.
nancy, are continued into the postpartum period. Early Incomplete emptying of the bladder is suspected when
postpartum ambulation is key in preventing maternal the patient experiences urinary frequency and passes
thromboembolic events. 100 to 150 mL of urine with each voiding. The nurse’s
The type of birth and overall health status determines assessment includes careful palpation of the lower abdo-
how soon the patient is allowed to resume exercise. The men to identify a distended or displaced uterus. The uter-
woman should be taught to begin with mild exercises, ine fundus is felt above the symphysis pubis with a lateral
such as Kegel exercises, to strengthen the pelvic floor displacement of the uterus. The nurse also notes an
muscles. Nonambulating patients may begin with leg exer- increase in the amount of lochia since the uterus is unable
cises. All exercise methods should be increased gradually. to contract effectively. The bladder is displaced, bulges
Many women enter labor fatigued from the discomforts above the symphysis pubis, and feels “boggy” on palpa-
of pregnancy and lack of satisfying sleep associated with tion. Patients experiencing urinary retention due to
the third trimester. The length of labor and demands of absence of the urge to void can be helped by assisted early
the new mothering role further increase the feelings of ambulation to the toilet and other measures such as run-
exhaustion. During the hospital stay and later at home, all ning the water from the lavatory faucet. If ambulation is
chapter 15 Caring for the Postpartal Woman and Her Family 487
not possible, the nurse can pour warm water over the may be beneficial in helping the patient expel additional
vulva and perineal area to help relax the urethral sphinc- blood or clots. The nurse uses a peri-bottle filled with warm
ter. Owing to the risk of urinary infection associated with water (or other solution used according to hospital policy)
urinary stasis, catheterization may be necessary if the and gently squirts the perineum from front to back while
patient is unable to void. allowing the water to collect in the bedpan. The labia are
Constipation commonly occurs because of slowed peri- not separated because they prevent the solution from enter-
stalsis associated with pregnancy hormones and childbirth ing the vagina. The perineal area is then gently dried and a
anesthesia. In addition, perineal discomfort, fear of suture clean peripad is applied from front to back.
separation at the episiotomy site, and incisional pain (after
a cesarean birth) may contribute to decreased frequency in Optimizing Outcomes— Teaching about perineal
bowel movements. To prevent constipation, nurses should care
encourage patients to consume foods high in fiber and
roughage. Adequate fluid intake that includes drinking at To enhance the patient’s understanding about proper peri-
least six to eight glasses of water or juice daily is another neal care, the nurse provides the following instructions:
important strategy to prevent constipation. Early ambula- 1. Fill the squeeze/peri bottle with tap water. The water
tion is also encouraged to improve peristalsis and relieve should feel comfortably warm on your wrist.
abdominal gas pain. If these measures are not effective, the 2. Sit on the toilet with the bottle positioned between your
primary care provider may prescribe a stool softener, sup- legs so that water can be squirted directly on the
pository, or enema to alleviate the symptoms. perineum. Aim the bottle opening at your perineum and
spray so that the water moves from front to back. Do not
PERINEAL CARE separate the labia and do not spray the water into your
vagina. Empty the entire bottle over the perineum— this
The perineum is susceptible to infection because of should take approximately 2 minutes.
impaired tissue integrity resulting from bruising, lacera- 3. Gently pat the area dry with toilet paper or cotton
tion, or an episiotomy. The proximity of the perineum to wipes. Move from front to back, use each wipe once,
the anus increases the risk of the incision becoming con- then drop it in the toilet.
taminated with fecal material; continuous drainage of 4. Grasping the bottom side or ends of a clean perineal
blood creates a favorable medium for the proliferation of pad, apply it from front to back.
bacteria. To minimize infection, patients should be taught 5. Stand before flushing the toilet to prevent the water
about perineal hygiene. A teaching approach that incorpo- from the toilet from spraying onto your perineum.
rates a return demonstration, encouragement, and posi-
tive reinforcement is most likely to be successful. Instruc-
tions should be given about properly cleansing the perineal Ice Packs
area and the value of sitz baths, which not only cleanse To reduce perineal swelling and pain that result from
but also provide relief from discomfort during the first bruising, ice packs may be applied every 2 to 4 hours.
24 to 48 hours postpartum. Application of cold is beneficial because of its vasocon-
Patients should be educated about the importance of striction and numbing effects. The ice pack should always
cleansing the perineum after each voiding and bowel move- be covered and applied from front to back. It should be
ment. Hand washing before and after perineal care (“peri- left in place for no longer than 20 minutes to minimize the
care”) is essential for the prevention of infection. The nurse complications associated with prolonged vasoconstric-
instructs the patient to gently rinse her perineum with fresh tion. Patients obtain the most relief when ice packs are
warm water after use of the toilet and before a new perineal applied within the first 24 hours after childbirth.
pad is applied. The patient is taught to fill the peri-bottle
(hand-held squirt bottle) with warm tap water and gently DISCOMFORT RELATED TO AFTERPAINS
squirt the water toward the front of the perineum and allow
Afterbirth pains describe intermittent uterine contractions
the water to flow from front to back. Consistent use of the
that occur during the process of involution. In general,
peri-bottle is soothing, cleansing, and helps to relieve dis-
the pains are more pronounced in patients with decreased
comfort. Peri-pads should be changed often and secured in
uterine tone due to overdistention. Uterine overdistention
the underwear to allow for free drainage of the lochia. Tam-
is associated with multiple gestation, multiparity, macro-
pons are contraindicated due to the risk of infection.
somia, and hydramnios. Afterpains also tend to be more
The nurse provides pericare for patients recovering from
intense in breastfeeding women because infant suckling
cesarean births until they are ambulatory and able to per-
and/or pumping the breasts triggers an endogenous release
form personal self-care. To provide pericare for the bed-
of oxytocin, the hormone that initiates the milk-ejection
bound patient, a plastic-covered pad is placed under the
reflex. Oxytocin causes powerful uterine contractions.
patient’s buttocks to protect the bed during the procedure.
Afterbirth pain maybe severe for 2 to 3 days after child-
With the woman in a supine position, the nurse carefully
birth. Mild analgesics should provide relief.
removes the perineal pad in a front-to-back direction. This
prevents the portion of the pad that touched the rectal area
from sliding forward and contaminating the vagina. Next, a SPECIAL CONSIDERATIONS FOR WOMEN
bedpan is positioned under the buttocks. The movement WITH HIV/AIDS
associated with lifting the buttocks helps to expel clots Women who have the human immunodeficiency virus
and/or pooled blood in the vaginal canal. This also serves as (HIV) or acquired immunodeficiency syndrome (AIDS)
a good time to assess the fundus for tone. Uterine palpation require special precautionary care during the puerperium.
488 unit five Care of the New Family
All personnel who come in close contact with the patient extreme disappointment, feelings of inadequacy, guilt,
should wear latex gloves (unless the patient has a latex and personal failure. They may also harbor hostilities
allergy). In that situation, nonlatex gloves are used, as directed toward the medical and nursing staff. (See Chap-
well as safety glasses to prevent the transmission of blood ter 16 for further discussion.)
and body fluids. Patients need to be taught to avoid con- After a cesarean birth, especially when unplanned,
tact of personal body fluids with the infant’s mucous nurses must be aware of the myriad of potential psycho-
membranes and open skin lesions. Breastfeeding is not logical issues that may arise. Research suggests that
advised due to the risk of transmission of HIV to the women may perceive cesarean birth to be a less positive
infant. (See Chapter 11 for further information.) experience than a vaginal birth. Vaginal birth has been
shown to be associated with enhanced maternal satisfac-
Now Can You— Promote recovery and self-care in the tion and perceptions of greater personal control over the
puerperium? birth. Women who experience vaginal birth describe feel-
1. Identify factors that determine how quickly patients should ings of empowerment, elation, and achievement (Laven-
return to the pre-pregnant weight? der, Hofmeyr, Nielson, Kingdon, & Gyte, 2007). Particu-
2. Describe the essential components of patient teaching about larly for unplanned or emergent cesarean deliveries, the
perineal care? experience of cesarean birth may be associated with more
3. Describe special precautions that should be taken for negative perceptions of the birthing experience. However,
postpartal HIV-positive women? research regarding the psychological outcomes associated
with cesarean birth remains mixed (Patel, Murphy, &
Peters, 2005).
The benefits of maternal–child interaction during the
Care of the Postpartal early postpartal hours are well documented. The first few
Surgical Patient hours after childbirth constitute a critical time for the ini-
tiation of a healthy maternal–infant interaction. For most
PERMANENT STERILIZATION (TUBAL mothers, a successful vaginal birth is psychologically bet-
LIGATION) ter tolerated and avoids the need for additional recovery
A postpartum tubal ligation is a procedure that blocks the time that is necessary after a cesarean birth. In addition,
fallopian tubes to prevent the woman from becoming early breast feeding (for those who wish to breast feed) is
pregnant. When requested, the procedure, called a mini- more easily implemented after a vaginal birth.
laparotomy, is performed after childbirth while the mother Additional challenges faced by patients during recovery
is still hospitalized. The size and position of the uterus from a cesarean birth include recovery from the anesthe-
during the early puerperium facilitates the surgical proce- sia, a need to cope with incisional and gas pain, and slow
dure. When a cesarean birth has been performed, the ambulation. Mother–infant bonding may be delayed and
tubal ligation may be done at the same time. Patients need patients are at an increased risk for hemorrhage, surgical
to be informed that while it is typically considered to be a wound infection, urinary tract infections, and DVT. (See
permanent form of fertility control, there is a small chance Chapter 16 for additional information.)
that a future pregnancy may occur. (See Chapter 6 for
further discussion.) CARE OF THE INCISIONAL WOUND
Patients scheduled for a tubal ligation are NPO before
the surgical procedure. If epidural anesthesia was used for The surgical incision requires ongoing nursing assessment
childbirth, the catheter is often left in place so that the after a cesarean birth. The nurse should assess for approx-
patient can be re-anesthetized easily. When no epidural imation of the wound edges, and make note of any red-
ness, discoloration, warmth, edema, unusual tenderness,
was previously placed, general anesthesia will most likely
or drainage. If a dry sterile dressing has been applied, the
be used during surgery.
surrounding tissue should be carefully evaluated for evi-
dence of a reaction to the tape used to secure the dressing.
CARE OF THE PATIENT AFTER Assessing for and effectively treating incisional pain is also
A CESAREAN BIRTH of paramount importance.
Nursing care of the postoperative postpartum patient is
similar to the care provided to all postoperative patients.
The nurse must complete the BUBBLE-HE assessment RECOVERY FROM ANESTHESIA
previously discussed. Because the woman is confined to Ambulation is encouraged as soon as the patient’s vital
bed until full sensation has returned to the lower extremi- signs are stable. If a spinal or epidural anesthesia was
ties, interventions for the prevention of deep vein throm- used, ambulation is delayed until full sensation has
bosis (DVTs) must be implemented. Preventive strategies returned to the lower extremities. Common side effects of
include leg exercises (flexion and extension of the knee) anesthesia include paresthesias (sensation of pins and
and application of compression boots as ordered by the needles in the legs) and headache. Assistance is required
physician. when the patient gets out of bed for the first time. Nurses
How the patient reacts to her surgery is often tied to should administer pain medication 30 minutes before the
the circumstances surrounding the birth—that is, whether patient attempts ambulation. To minimize dizziness from
the cesarean section (“c-section”) was a planned proce- orthostatic hypotension, the nurse should instruct the
dure or an emergency event. Women who experience an patient to sit on the side of her bed for several minutes
emergency or unplanned cesarean birth may suffer from before moving into a standing position.
chapter 15 Caring for the Postpartal Woman and Her Family 489
channels that serve the chest wall and are continuous with and continues until breastfeeding ceases. The “weaning”
the superficial lymphatics of the neck and abdomen. A stage, sometimes referred to as “Stage 4,” begins when
rich network of lymphatics is also present deep in the breast stimulation ceases. This stage is characterized by a
breasts. The primary deep lymphatics drain laterally significant reduction in milk volume.
toward the axillae. A lack of breastfeeding (in breastfeeding or non breast-
feeding mothers), or a failure to empty the breasts by
The Physiology of Lactation pumping, results in an accumulation of inhibiting pep-
MILK PRODUCTION AND LET-DOWN. Lactogenesis, the pro- tides, or hormones released from the hypothalamus.
cess by which the breasts secrete milk, is dependent on Inhibiting peptides act on the breast secretory cells, caus-
the release of the hormones prolactin and oxytocin. The ing a gradual decrease in milk volume and the eventual
process of milk synthesis begins after the delivery of the death of the epithelial cells.
placenta. This event results in a dramatic decrease in
plasma progesterone and estrogen and an increase in the ASSISTING THE MOTHER WHO CHOOSES
secretion of prolactin from the anterior lobe of the pitu- TO BREASTFEED: STRATEGIES FOR
itary gland. Prolactin stimulates the alveoli, or milk- BREASTFEEDING SUCCESS
producing cells, to secrete milk. Stimulation from infant
suckling or pumping the breasts triggers the release of The most important information that the nurse can give to
oxytocin from the posterior lobe of the pituitary gland. a mother is that breastfeeding should not be painful.
Oxytocin prompts contraction of the smooth muscle myo- When the baby is feeding at the breast, the woman should
epithelial cells surrounding the alveoli to eject milk from experience a strong tugging sensation and occasional mild
the alveoli into the lactiferous (main) ducts (Fig. 15-7). discomfort. However, pain associated with breastfeeding
Movement of milk into the large lactiferous ducts for is not a normal finding. The nurse should refer women
removal is called the “milk ejection reflex” or the “let- who experience breastfeeding pain or other difficulties to
down” reflex. Lactating mothers describe “let-down” as a a board-certified lactation consultant (IBCLC) for help
tingling or pins and needles sensation that occurs imme- and assistance. Although the pediatrician is responsible
diately before or during breastfeeding. Frequent stimula- for the health care of the infant, the IBCLC is a lactation
tion and release of milk from the breasts are necessary for expert who offers the most current, up-to-date, accurate
the continued release of prolactin. information on breastfeeding using a “hands-on” approach.
The initiation of milk production is divided into three Mothers should be encouraged to consult with an IBCLC
stages. Stage 1 occurs in late pregnancy and is character- when they have any questions, are having difficulty with
ized by the maturation of the alveoli, the proliferation of the latch-on process, or express concerns about their milk
the secretory alveoli ductal system, and the increase in production. Ideally, all breastfeeding mothers should be
size and weight of the breast. Stage 2 begins during the discharged with an appointment to an IBCLC.
postpartum period. Reduced plasma progesterone levels
lead to an increase in prolactin levels that cause a copious Collaboration in Caring— Partnering with
milk production by the fourth to fifth postpartal day. an IBCLC and other community resources
Stage 3, the establishment and maintenance of the milk
supply, is governed by a principle of “supply and demand” An IBCLC is a health care professional who specializes in
the clinical management of breastfeeding. IBCLCs are
certified by the International Board of Lactation Consultant
Hypothalamus Examiners Inc. under the direction of the US National
Commission for Certifying Agencies. IBCLCs work in a
Posterior variety of health care settings including hospitals, pediatric
Anterior
pituitary offices, public health clinics, and private practice. The
pituitary
IBCLC credential is primarily an add-on qualification that
brings together health professionals from different
disciplines who share a common knowledge base in human
lactation. Among those who become IBCLCs are midwives,
nurses, family practitioners, pediatricians, obstetricians,
educators, dietitians, and occupational, speech, and physical
therapists. Most of these health care professionals have
Sucking stimulus
spent at least 4 years acquiring the experience and
Prolactin
education required for certification.
Milk production Costs for services provided by IBCLCs depend upon the
Oxytocin environments in which they work. Charges for inpatients
Milk let-down are typically incorporated into the hospital stay. Follow-up
visits in a hospital-based lactation department may or may
not be included as a benefit for giving birth at that facility.
Other consultations are fee-for-service. Most insurance
companies do not pay for lactation services unless the
service is provided within a physician’s office under the
supervision of the physician. Under these circumstances,
Figure 15-7 Mechanism for milk production. the office visit charges may apply.
492 unit five Care of the New Family
Initiating the Feeding Figure 15-8 When properly latched-on, the tip of the
The optimal time to breastfeed is when the baby is in a infant’s nose, cheeks and chin should all be touching
quiet alert state. Crying is usually a late sign of hunger and the breast.
achieving satisfactory latch-on at this time is difficult.
Latch-on is proper attachment of the infant to the breast The nurse may ask:
for feeding. The neonate is most alert during the first 1 to • Have you tried to unwrap the baby’s swaddling?
2 hours after an unmedicated birth, and this is the ideal Doing this will increase skin-to-skin contact and
time to put the infant to the breast. Bathing the neonate help to awaken the infant and promote feeding.
before the first breastfeeding should be avoided. The smell
of the amniotic fluid on the infant matches the smells of • Have you tried to rest with the baby by your breast?
Doing this may allow the infant to feel and/or smell
the mother and serves as a “homing device” for the baby.
the breast, which may promote feeding.
Cesarean deliveries and medicated births, including those
with epidural anesthesia, may require more mother–infant • Are you familiar with feeding cues? Watching for
skin to skin contact before a successful latch-on occurs. feeding cues may help you to recognize when your
To assist the breastfeeding mother, the nurse must baby is ready to breastfeed. Examples of infant feeding
understand that a baby latched on to the breast is not cues are vocalizations, movements of the mouth, and
necessarily transferring milk. A baby that breastfeeds moving the hand toward the mouth. Hunger-related
effectively cues (shows readiness) for feedings, is in a crying is a late sign of hunger and should not be used
good feeding position, latches-on (attaches) deeply at the as the cue for feeding.
breast, and moves milk forward from the breast and into
the mouth. When the infant is properly latched-on to the
An optimal breastfeeding experience begins with the
breast, the tip of his nose, cheeks and chin should all be
mother’s prompt response to her infant’s feeding readiness
touching the breast (Fig. 15-8).
cues (Cadwell et al., 2006). The mother should hold the
To feed effectively, the infant must awaken and let his
baby so that his nose is aligned with the nipple and watch
mother know that he wants to eat. When possible,
mother-baby rooming-in creates an optimal situation for
breastfeeding. When the infant is in the mother’s room at
all times, she is able to observe “feeding-readiness cues” Box 15-4 Infant Feeding-Readiness Cues
that signal the infant’s readiness to feed (Box 15-4).
The infant demonstrates readiness for feeding when she:
• Begins to stir.
— To assist the mother whose • Bobs the head against the mattress or mother’s neck/shoulder.
infant won’t awaken to breastfeed
• Makes hand-to-mouth or hand-to-hand movements.
During hospitalization, nurses provide much information • Exhibits sucking or licking.
and coaching regarding breastfeeding. One new mother • Exhibits rooting.
expresses her concern that her infant is too sleepy to • Demonstrates increased activity; arms and legs flexed; hands in a fist.
breastfeed.
chapter 15 Caring for the Postpartal Woman and Her Family 493
A B
C D
Figure 15-9 Infant latch-on. A. Nipple is aligned with the baby’s nose. B, C. As the baby
latches to the nipple, the baby’s mouth is placed one to two inches beyond the base of the
nipple. D. To remove the baby from the breast, the mother inserts her finger into the
corner of the baby’s mouth to break the seal.
494 unit five Care of the New Family
Feedings that last less than 10 minutes or continue for lon- in the arm, close to the maternal breast. The infant’s
ger than 40 minutes are not satisfactory and require consul- abdomen is placed against the mother’s abdomen with
tation and assessment by a lactation consultant. the mother’s other hand supporting the breast. The cross
Optimal feeding results in the infant coming off the cradle hold is similar to the cradle hold, although in this
breast without assistance. Once the feeding has ended, the hold, the infant is laying in the opposite direction. In the
infant should be in a relaxed state with hands open; he may
or may not be asleep. After a successful breastfeeding experi-
ence, mothers often describe their baby as having a “drunken
stupor” look. The nipple should be everted and round,
never flat or pinched on any side. The mother should report
no pain and the infant should appear satiated.
football hold, the infant’s back and shoulders are held in and vary from minimally engorged (patients complain of
the palm of the mother’s hand. The infant is tucked up breast fullness and discomfort) to severe engorgement,
under the mother’s arm, keeping the infant’s hip, shoul- characterized by symptoms of pain, tenderness, hardness
der, and ear in alignment. The mother supports the breast and warmth to the touch. With severe engorgement,
to touch the infant’s lips. Once the infant’s mouth is swelling of the breasts is profuse and extends from the
open, the mother pulls the infant toward the breast. In clavicle to the tail of Spence and the lower rib cage. The
the side-lying position, both the mother and the infant breasts may have a shiny, taut appearance. The areolae
lay on their sides. Facing one another, the mother should become very firm and the nipples may flatten, making it
place a pillow behind the infant’s back for support. The difficult for the infant to latch-on. Back pressure exerted
nipple should be placed within easy reach for the infant on full milk glands inhibits milk production. Thus, if
with the mother guiding the nipple into the infant’s milk is not removed from the breasts, the milk supply
mouth (Lawrence & Lawrence, 2005). may decrease. Treatment involves relieving the patient’s
discomfort by removal of the milk (via breast feeding or
Now Can You— Discuss the physiology of lactation and pumping) to decrease stasis, which reduces the swelling
assist the breastfeeding mother? and discomfort.
1. Describe the four stages involved in the process of lactation? Because the infant is very efficient in the removal of
2. Discuss techniques the breastfeeding mother can use to milk, frequent feeding (at least every 2 to 3 hours) is
promote proper “latch-on”? advised to minimize the stasis of milk. The infant
3. Explain what the mother should be taught regarding the should feed at each breast at least 15 to 20 minutes until
infant’s weight? at least one breast softens after the feeding. To help
4. Demonstrate four common breastfeeding positions? reduce the swelling and enhance milk flow, the nurse
should instruct the mother to use warm compresses and
perform hand expression before nursing. This action
PROBLEMS THAT RESULT IN INEFFECTIVE softens the areola, initiates the let-down reflex, and
BREASTFEEDING allows the infant to more easily grasp the areola. Mas-
Sore nipples are related to an incorrect latch-on and posi- saging the breasts during feedings is also beneficial.
tioning of the infant at the breast. If a mother complains Other methods to enhance milk flow and help facilitate
of pain when the infant is nursing, it is important to infant latch-on include taking a warm shower or leaning
observe the baby for correct latch-on during feeding. The over a bowl of warm water and hand-expressing some
nurse can assess for proper latching by making the fol- milk before nursing. Since breast swelling is related to
lowing observations when the infant is at the breast: increased blood flow, cold ice packs may be used after
maternal–infant positioning is optimal for feeding; the breastfeeding or pumping to constrict blood flow and
infant exhibits a flanged lower lip, there is a good seal reduce the edema.
between the mouth and nipple, and an audible swallow.
Successful latch-on is essential to prevent trauma to the Complementary Care— Cabbage leaves to
nipple. The shape of the nipple at the conclusion of the diminish breast swelling
feeding also provides a good indicator for correct latch-
ing. If the nipple shape has changed at the end of the Patients can be taught to place raw cabbage leaves over
feeding, the nurse should troubleshoot for specific prob- their breasts between feedings to help reduce swelling. First,
lems and teach the mother about correct latch and posi- several large cabbage leaves are washed, then stored in the
tioning techniques. refrigerator until they become cool. The leaves are then
crushed and placed directly on the breasts for 15 to 20 min-
utes. This process may be repeated two to three times only;
Optimizing Outcomes— Breast shells for flat,
frequent application of the cabbage leaves may decrease the
inverted, or sore nipples
milk supply. Women who are allergic to cabbage, sulfa drugs,
Breast shells, which are plastic “nipple cups,” or inserts that or who develop a skin rash should not use cabbage leaves
fit into the bra, are useful for women with flat or inverted (Lactation Education Resources, 2004).
nipples because they help the nipples to become more pro-
tuberant. They may also be used to prevent sore nipples
A nonprescription anti-inflammatory medication such
from making contact with the woman’s clothing or bra.
as ibuprofen (e.g., Motrin, Advil) may be taken for the
pain and swelling related to engorgement. It may be par-
Breast engorgement is described as excessive swelling ticularly helpful for the mother to take the medication
and overfilling of the breast and areola and is a physio- before breastfeeding in anticipation of postfeeding dis-
logical response to an increase in blood flow and an comfort. Because of the significant increase in breast size
increase in milk production. Engorgement, which may during lactation, patients should be advised to wear well-
occur from infrequent feeding or ineffective emptying of fitting supportive bras with no underwire for comfort.
the breasts, results in congestion and overdistension of Bras that are too small may compress the ducts and
the collecting ductal system and obstruction of lym- obstruct milk flow. If the infant is unable to breastfeed,
phatic drainage. It typically lasts about 24 hours. Symp- warm soaks, breast massage and the use of a manual or
toms of engorgement usually occur between the third electric pump for the expression of milk help to reduce
and fifth day after childbirth (when the milk “comes in”) milk stasis and swelling.
496 unit five Care of the New Family
Now Can You— Discuss breast milk storage and assist the
mother who is bottle feeding her infant?
1. Explain what the breastfeeding mother should be taught
about pumping and storing breast milk?
2. Discuss appropriate cleaning techniques for bottles and
nipples?
3. Describe special precautions to be used with powdered
formulas?
First 1–2 days Second and/or third day First 2–6 weeks postpartum
The mother is recovering from the immediate The mother starts to initiate action and to This is the time during which the mother
exhaustion of labor. begin some of the tasks of motherhood. redefines her new role.
She is relatively dependent on others to meet her She may: She:
physical needs. a) Ask for help with self-care a) Moves beyond the mother–infant symbiosis of
Characteristics of her behavior include: b) Begin caring for the baby pregnancy and early postpartum and begins
a) Physical exhaustion c) Be anxious about her mothering to see her infant as an emerging individual.
b) Elation, excitement, and/or anxiety and abilities. b) Starts to focus on issues larger than those
confusion. associated directly with herself and her
newborn. (She begins to focus on her partner,
c) Reliving, verbally and mentally, the events of other children, and family issues.)
her labor and birth.
Adapted from Rubin R. (1975). Maternal tasks in pregnancy. MCN: The Amercian Journal of Maternal-Child Nursing, 4(3), 143–153.
transitions through each phase. Today, however, with ties of parenthood. Maladjustment during this phase may
shortened hospital stays, women seem to move through occur with an overprotective mother who has difficulty
the transitions much more rapidly and often there is over- accepting help with infant care from others and who
lapping of the phases. excludes the partner from her affections.
In the first day or two after birth, the mother is
exhausted and should be encouraged to rest. During this Across Care Settings: Successful maternal
time she is reflecting and clarifying, or “taking-in” her
birth experience. Many mothers want to talk about their transition into the letting-go phase
labor, discuss with family members the detailed events of During the letting-go phase, the mother may have difficulty
the labor, seek clarification if unexpected events occurred, with the tasks associated with viewing the infant as a
and share joys or disappointments associated with the separate individual. This phase occurs after the mother has
birth. Mothers who hold specific expectations for their been discharged from the hospital or birthing center.
birth experience and are unable to follow a birth plan or Postpartum and community health nurses who suspect that
who are required to transfer from a birth center to a hos- patients may have difficulty making a successful transition
pital setting may experience feelings of loss and mourn for into this phase must communicate their concerns with the
the hoped for birth experience. infant’s pediatric care team so that appropriate assessments
As the mother’s physical condition improves, she and interventions can be carried out.
begins to take charge, and enters the taking-hold phase
where she assumes care for herself and her infant. At this
time, the mother eagerly wants information about infant
care and shows signs of bonding with her infant. During Bonding and Attachment
this phase, the nurse should closely observe mother–infant
interactions for signs of poor bonding and if present, Bonding is described by Klaus (1982) as the promotion of
implement actions to facilitate attachment. a unique and powerful relationship between the parent
and the infant. Attachment refers to the tie that exists
between the parent and infant and is recognized as a feel-
critical nursing action Assessing for Maternal– ing that binds one person to another.
Infant Attachment
MATERNAL
When observing the mother with her newborn, the nurse should look
for clues that indicate successful bonding. The nurse should assess for Bonding begins at the moment the pregnancy is confirmed
the following indicators: and continues through the birth experience, during the
postpartal period and throughout the early years of the
Does the mother show eagerness to care for her infant?
child’s life. Bonding is critical for the infant’s survival and
What is her response when the baby cries? development. Providing parents with a model of caring
Does she make eye contact when holding and feeding her baby? during labor, birth, and in the early postpartum period
enhances the bonding process and helps to lay the foun-
dation for the nurturing care that the child will later
In the letting-go phase, seen later in the mother’s recov- receive.
ery, the woman begins to see the infant as an individual Touch is recognized as an important communication
separate from herself. At this point, she can leave the baby tool between humans. Touch is an essential element in
with a sitter, set aside more time for herself, become more the creation of a loving relationship and lasting attach-
involved with her partner, and begin adapting to the reali- ment between the parents and their child. Nurses can be
500 unit five Care of the New Family
2. Describe strategies to facilitate maternal and paternal birth. The symptoms associated with this condition are
bonding? often insidious and include sleep disturbances, guilt,
3. Discuss five specific activities that parents can use to help fatigue, and feelings of hopelessness and worthlessness. In
older siblings adjust to the newborn? severe instances, suicidal ideation may occur. Patients
who demonstrate symptoms of post partum depression
must be promptly referred for evaluation and interven-
Emotional and Physiological tion. (See Chapter 16 for further discussion.)
Adjustments During the Puerperium Postpartum Psychosis
EMOTIONAL EVENTS Postpartum psychosis develops in approximately one or
two women for every 1000 births and is unlikely to mani-
Many mothers experience a roller coaster of emotions fest itself during the early postpartum period. Symptoms
after childbirth. These feelings stem from a number of include delusions; hallucinations; agitation; inability to
influences and are often linked to perceptions concerning sleep; and bizarre, irrational behavior. Before hospital dis-
the fulfillment of expectations surrounding the childbirth charge, patients with a history of mood disorders or
experience. A complicated birth, a premature birth or a depression should be referred to appropriate resources for
sick infant, as well as the woman’s parity, age, marital sta- community support and follow-up. (See Chapter 16 for
tus and stability of family finances are some of the many further discussion.)
factors known to shape emotions experienced during the
postpartum period.
The first 3 months after birth are recognized as the PHYSIOLOGICAL RESPONSES
most vulnerable emotional period for mothers. Insecurity TO EMOTIONAL EVENTS
about infant care, the constant demands associated with Tiredness and Fatigue
caring for the baby, sleep deprivation, and minimal social Postpartum tiredness and fatigue have long been consid-
support create the potential for frequent and dramatic ered a natural physiological and psychological response
mood changes. Rapid hormonal changes during the first to the stresses of labor and childbirth coupled with the
few postpartal days and weeks may give rise to mood dis- additional responsibilities of motherhood. Although new
orders. The most common of these is often termed “the mothers are often confident that tiredness will improve
blues.” Other less common puerperal mood disorders upon returning home, this phenomenon is not supported
include post partum depression and post partum psycho- by the nursing literature. Rather, the multiplicity of
sis. (See Chapter 16 for further discussion.) demands associated with motherhood augments the expe-
Maternity Blues/Baby Blues/Postpartum Blues
rience of physical and mental exhaustion. While changes
in societal trends in the care of children suggest that
The “maternity blues” are considered to be a normal reac- fathers are taking a more active role, mothers continue to
tion to the dramatic changes that occur after childbirth hold the main responsibility for care. Thus, it is essential
including abrupt withdrawal of the hormones estrogen, for the nurse to encourage new mothers to enlist the sup-
progesterone and cortisol. Women experience a range of port and assistance of family and friends in an effort to
symptoms that include tearfulness, mood swings, insomnia, promote time for rest and recovery (Runquist, 2007).
fatigue, anxiety, difficulty concentrating, irritability and
poor appetite. The symptoms usually begin during the first
few postpartal days, peak on the fifth day, and then subside Nursing Insight— Persistent fatigue during the
over the next several days. Blues do not affect the woman’s puerperium
ability to care for herself or her newborn and family.
Feelings of fatigue that extend beyond the 6-week postpar-
The “blues” are treated with support and reassurance
tal period may be indicative of a more serious condition. Per-
(Beck, Records, & Rice, 2006). Proactive education to pre-
sistent, pervasive fatigue may be indicative of postpartum
pare the woman and her family for the possibility of post-
depression (Troy, 2003). The woman and her family should
partum blues is important. The nurse needs to explore what
be provided with guidelines about normal feelings and reac-
resources the new mother will have available when she goes
tions during the puerperium and encouraged to report exces-
home. The discussion should focus on whether the patient
sive tiredness or fatigue to the health care provider.
has adequate food, clothing, shelter, and transportation,
and whether there are relational concerns that need to be
addressed before discharge. Incorporating community Contributors to fatigue and tiredness in the postpartum
resources such as the woman’s church, a Mother’s Day Out period include physical, psychological, and situational
group, a hobby club, or La Leche League can help the new variables. Physical contributors include the length of labor,
mother realize she is not alone in the experience of nurtur- maternal hormone shifts, maternal anemia, episiotomy or
ing a newborn, while also caring for herself and her family. surgical incision healing, breast feeding, and pain. Psycho-
Referral to a health care provider is appropriate for women logical contributors include difficulty sleeping, depression,
whose symptoms persist for more than ten days, as this pat- and a non supportive partner. The challenge of managing
tern is suggestive of postpartum depression. multiple roles, cultural influences and expectations, a lack
of assistance with housework or childcare, having more
Postpartum Depression than one child under the age of 5 in the home, and
Postpartum depression, which affects 10% to 13% of returning to outside employment are situational variables
women, usually appears around two weeks after child- that can readily lead to fatigue. Insights into the multiple
chapter 15 Caring for the Postpartal Woman and Her Family 503
contexts that shape the patient’s environment allow nurses nificant vaginal bleeding. The infant must also meet certain
to provide anticipatory guidance regarding fatigue and its criteria (i.e., full term, normal vs and physical examination,
relationship with diminished quality of life in the postpar- feeding, urinating, stooling, laboratory/screening tests com-
tum period (Runquist, 2007). pleted). Early follow-up visits are an essential component of
safe care for mothers and their infants (AAP Committee on
Fetus and Newborn, 2004; Meara, Kotagal, Atherton, &
Postpartal Discharge Planning Lieu, 2004).
and Teaching
PROMOTING MATERNAL SELF CARE COMPONENTS OF MATERNAL
SELF-ASSESSMENT
Because of early postnatal discharge, all postpartal women
must be taught strategies for self-care. A self-assessment Fundus
sheet completed before discharge helps to identify areas of The woman is taught how to locate and palpate the fundus
deficits. When possible, parents are encouraged to attend and how to determine the progression of the fundal height
a discharge teaching class. Topics reviewed usually include as it involutes into the pelvis. After months of abdominal
infant bathing, breastfeeding, perineal hygiene, physical enlargement, many women are delighted to be able to rest
activity, rest and expected emotional changes. This infor- in a prone position. Nurses can explain that lying on the
mation is useful because it empowers the family to iden- abdomen is beneficial because this position supports the
tify normal events and to promptly recognize complica- abdominal muscles and aids involution because the uterus
tions that should be reported to the health care provider. is tipped into its natural forward position.
Many institutions also distribute home care booklets that
provide written information about maternal and newborn
care and available community resources. Often, home vis- clinical alert
itation by a community health nurse is arranged before Avoiding the knee–chest position
the patient’s discharge. The community health nurse visit
The nurse teaches the patient to avoid a knee-chest position until
typically includes an examination of the mother and at least the third postpartal week. This position causes the vagina
infant, an opportunity for discussion about problems or to open. Since the cervical os is still open to some extent, there is
concerns and breastfeeding or formula feeding support. a danger that air can enter the vagina, pass into the cervix and
Additional areas of focus during the postpartal visit enter the open blood sinuses inside the uterus. Entry of air into the
include education regarding basic maternal and infant circulatory system can cause an air embolus.
care, plans for follow up visits and contraception counsel-
ing (Fig. 15-15).
Lochia
Optimizing Outcomes— When early postpartum The nurse reinforces to the patient that the lochia (vaginal
discharge is planned discharge) may continue for 3 to 6 weeks after birth. Dur-
ing this time, it is important for her to examine the peri-
Women and their families may have the option of early dis- pads for color, amount and odor each time she visits the
charge with postpartum home care. Maternal criteria for toilet. The woman should be provided with guidelines
early discharge includes an uncomplicated perinatal course, concerning the anticipated color and amount of the lochia
no evidence of PROM, no difficulties with voiding or ambu- and reminded to promptly report abnormal findings such
lation, normal vital signs, hemoglobin 10 g and no sig- as heavy bleeding, the passing of large clots and foul
smelling odor.
Hygiene
The patient is advised to continue to use her perineal
squeeze bottle until the bleeding stops and to use the pre-
scribed medications and/or sitz bath for episiotomy dis-
comfort. After each visit to the toilet she is reminded to
carefully wipe from front to back and thoroughly wash
her hands before and after changing the peri pads.
Abdominal Incision
Nurses should instruct the post operative patient to
shower as normal and to carefully pat the incision dry. If
staples were applied at the incision site, the obstetrician
will inform her when to come into the office for removal.
Steri-strips used for incision closure should remain undis-
turbed until they eventually fall off. The woman is advised
Figure 15-15 The postpartum home visit usually to avoid the application of cream or powder to the inci-
involves an examination of the mother and baby. It sion site and to notify her obstetrician if she experiences
provides an opportunity for teaching and promotes fever or develops signs of incisional infection such as red-
continuity of care. ness, offensive odor or discharge.
504 unit five Care of the New Family
Body Temperature half of the weight gained during the previous nine
Some women experience a transient increase in body tem- months. On average, the weight loss amounts to 10 to
perature along with breast heaviness on the third to fourth 12 lbs. (4.5 to 5.5 kg). This loss comes from the infant,
postpartum day when the milk supply is established. They the placenta, amniotic fluid, and blood. Rapid diuresis
should be reminded that temperatures above 100.4°F and diaphoresis occur during the second to fifth post-
(38.0°C) and flu-like symptoms (e.g., chills, body aches, partum days and result in an additional weight loss of
severe pain) may indicate infection and should be promptly about 5 lbs. (2.3 kg). By the sixth to eighth postpartal
reported to the health care provider. week, many women will have returned to their pre-
pregnant weight. The amount of weight lost during the
Urination puerperium is primarily related to the amount of weight
Before discharge, all patients should be able to pass urine gained during pregnancy and the woman’s level of
without difficulty. Women should be taught the signs and physical activity.
symptoms of a urinary tract infection (UTI). Specifically,
Exercise
burning on urination (dysuria), frequent voiding with only
a small amount of urine passed, the presence of a “fishy” The patient is advised to resume activities gradually,
odor to the urine and lower abdominal or flank pain are beginning with Kegel exercises to strengthen the pelvic-
symptoms that must be reported to the health care provider. floor muscles. After a vaginal birth, patients may begin
To reduce the likelihood of a urinary tract infection, patients modified sit-ups to strengthen the abdominal muscles and
are advised to drink at least eight 8-oz. glasses of water each perform knee and leg roll exercises to firm the waist.
day, avoid delays in emptying the bladder, wipe the perineum Modified sit-ups are especially beneficial for women with
from front-to-back after each use of the toilet, change peri- diastasis recti.
pads after toileting, and to wash their hands frequently.
Optimizing Outcomes— Postnatal exercises to
Bowel Function promote physical fitness
The nurse teaches about the importance of maintaining
good hydration and consuming a healthy diet abundant in Teaching patients about exercises to help return the body
fiber and roughage. An exploration of the woman’s dietary to its pre-pregnant state is an important component of
preferences facilitates discussion about specific types of postpartal care. Exercises to strengthen the back, abdomi-
foods (e.g., fruits, vegetables, whole-grain cereals) that nal muscles, thighs, and shoulders are particularly benefi-
promote bowel regularity. The patient should consult cial at this time.
with her obstetrician or certified nurse midwife if laxa- Supple Spine
tives or other medications become necessary. Stool soften- Begin on all fours. Inhale. Lift your head, keeping your
ers are usually prescribed for women with third or fourth back straight or arching slightly (avoid strain). Then
degree episiotomies or vaginal lacerations. exhale, round your back, tighten abdominals, tuck in tail
and head. Repeat the sequence eight times. This exercise
Nutrition strengthens the back and abdominals.
Most women are concerned about weight increase dur-
ing the pregnancy and how quickly they can expect to
return to their pre-pregnancy weight. A well-balanced
diet that includes high-energy foods is essential to recov-
ery in the puerperium. Patients should be counseled
about the need for adequate protein to promote tissue
repair and healing and encouraged to select a healthy,
low-fat diet that contains protein along with carbohy-
drates, fruits, and vegetables. Tighter Abdominals
Lie on your back in a straight line. Then exhale, lower-
Fatigue
ing the back, vertebra by vertebra. Repeat sequence five
Patients should be reminded that since the first six post- times. This exercise helps develop a strong back and
partal weeks are devoted to infant care and recovery from abdominals.
childbirth, energy depletion, usually manifested as extreme
tiredness and fatigue, often occurs. They should be encour-
aged to limit visitors and whenever possible to rest when
the baby sleeps. Patients may wish to cook easily prepared
meals in advance and freeze foods for later use. When pos-
sible, the new mother should solicit help from her part-
ner, family members and friends to assist with the house-
hold chores, shopping and child care.
Weight Loss
Weight loss at the time of childbirth is precipitous.
Within minutes after birth, the parturient woman loses
chapter 15 Caring for the Postpartal Woman and Her Family 505
Stronger Back
Sit upright, knees bent, feet flat on the floor, back Box 15-5 Postpartum Discharge Teaching: Danger Signs
straight, arms forward at shoulder level. Inhale, then exhale to Be Reported
and lean back halfway. Inhale again and sit up slowly.
An important component of discharge teaching focuses on alerting
Repeat five times. This exercise strengthens the back and
patients to signs and symptoms that must be reported to the health care
abdominals. provider. The nurse should ensure that the patient is given written infor-
mation and knows how to reach her care provider. The patient should
immediately report:
• Temperature greater than 100.4°F (38.0°C), chills, or flu-like symptoms
• Abdominal incision that is red, tender to touch, or painful, or if edges
of the incision have separated.
• Difficulty initiating urination, urinary frequency or painful urination
• Increased vaginal bleeding with or without clots, or foul-smelling vagi-
nal discharge
Flexible Body • Persistent pain or marked swelling at the site of a perineal laceration or
Stand upright with arms raised, elbows slightly relaxed. episiotomy
Inhale, then exhale and bend forward, keeping back straight • Swelling or masses in the breasts, red streaks, shooting pain in the
and swinging arms down and back. Then relax your head breasts, or cracked, bleeding nipples.
and stretch your arms up behind you. Inhale as you swing • Swelling, warmth, tenderness or painful areas in the legs
arms and body up again, returning to your original posi- • Blurred vision or persistent headache that is not relieved by pain
tion. Repeat eight times. Go carefully and do not strain. medication
This exercise is good for thighs, hips, back, arms, shoul- • Overwhelming feelings of sadness or an inability to care for self or
ders, and neck. the baby
Exploring previously used methods of contraception Fatigue and sleep deprivation, common in all new moth-
may be helpful in identifying a starting place for the discus- ers, coupled with the responsibility of caring for an infant
sion. The couple’s religion and cultural background often who requires constant attention often results in limited
dictates their contraceptive choice. Discussing contracep- time for social activities and subsequent social isolation
tion options with the patient and her partner (if present) from their peers.
before discharge allows the couple time to make informed Nurses who care for the adolescent mother must be
decisions before resuming sexual intercourse. The breast- cognizant of personal prejudices or feelings of disapproval
feeding mother should be warned that she can become and avoid expressing negative feelings toward the teen
pregnant during lactation and that breastfeeding is not a mother. It is important for the nurse to provide emotional
substitute for birth control. If the breastfeeding patient support for the postpartum adolescent that will help her
wishes to use an oral contraceptive the nurse must inform adjust to role changes, foster feelings of positive self-
the healthcare provider so that a progesterone-only pill can esteem and assist her in developing a new identity and
be prescribed. (See Chapter 6 for further information.) sense of self (Logsdon & Koniak-Griffin, 2005). The
nurse must create a supportive environment by recogniz-
PLANNING FOR THE FOLLOW-UP ing the adolescent as the infant’s primary caregiver, irre-
EXAMINATION spective of her age. The nurse models and facilitates infant
caring behaviors that will promote bonding and teaches
Most health care providers schedule a 6-week follow-up about infant care and child safety. Before discharge,
appointment (“postpartal check”). Women who have had arrangements should be made for a community health
cesarean births are often scheduled for a return visit to the nurse follow-up visit within a week.
physician’s office 2 weeks after hospital discharge. It is
helpful to indicate the date and time of the return appoint-
ment in the patient’s discharge instructions. — When planning the adolescent
The nurse can explain that during the 6-week follow- mother’s hospital discharge
up visit, fundal palpation and a vaginal examination will
The adolescent mother has unique needs for discharge
be performed to evaluate the size of the uterus. The episi-
planning. The nurse can best explore the young patient’s
otomy or abdominal incision site will be evaluated for
immediate plans for herself and the baby by initiating
healing and a breast examination will be performed. If
dialog in a supportive, nonthreatening environment.
desired, a contraceptive method or prescription will also
Examples of appropriate questions that the nurse may
be given. The nurse should encourage the patient to dis-
ask include the following:
cuss any concerns during this visit.
The parents should also schedule a newborn follow-up “Do you have someone available to offer you help and/or
appointment before hospital discharge. Most physicians support?”
and clinics wish to see the infant within the first week or “Do you feel a sense of closeness or attachment to your
by age 2 weeks. baby?”
“After you leave the hospital, will anyone be helping you
Now Can You— Promote self-care for the puerperium? to care for your baby?”
1. Outline postpartal teaching guidelines that include “Will anyone be taking care of the baby so that you can
information about self-assessment of the fundus, lochia, go back to school?”
hygiene, incisional site, body temperature, and elimination?
“Where will you take the baby for follow-up care?”
2. Demonstrate appropriate exercises for the postpartal
patient?
3. Identify at least six symptoms indicative of poor emotional To facilitate a supportive home and family environ-
adjustment that, if present for more than 2 weeks, should ment, the community health nurse will conduct a social
be reported to the healthcare provider? support assessment to identify the significant family mem-
ber or other person who will be assisting with parenting
responsibilities and financial support. If the adolescent’s
Patients with Special Needs During mother is identified as the primary support person, the
nurse explores the mother’s and grandmother’s expecta-
the Puerperium tions in caring for the newborn in order to provide antici-
patory guidance regarding each person’s new role before
CARE OF THE ADOLESCENT discharge.
The period of adolescence is a time to form important A supportive family environment is the single most
relationships with peers–these close connections help to important element in facilitating the adolescent mother’s
facilitate self-growth and development. Adolescents who successful transition to motherhood. When appropriate,
are thrust into an untimely motherhood role must also referrals should be made for social services and other
deal with their own personal and social development. community resources such as home health nursing care,
Adjusting to pregnancy and impending motherhood can pastoral care, teen parent support groups, and economic
be emotionally and physically challenging for a mature assistance. Guidance and support provided by these pro-
woman; the adolescent requires special assistance from fessionals help to reinforce infant care skills and identify
the nurse. additional resources to enable the young mother to com-
Many adolescents enter motherhood with unrealistic plete her education. Professional and family support has
expectations. They lack mothering and child care skills. proven to be effective in helping adolescents delay a sub-
chapter 15 Caring for the Postpartal Woman and Her Family 507
s um m a ry po i n ts True or False
◆ During the postpartum period, the nurse assumes the 7. The perinatal nurse teaches the student nurse about
responsibility of facilitating the integration of the new- the use of the acronym REEDA for wound assess-
born into the family unit. ment. The “R” stands for Redness and the “A” stands
for Approximation of the wound edges.
◆ The postpartum patient has unique assessment needs
that include physical and psychosocial considerations. Select All that Apply
◆ The new mother should be given the opportunity to 8. The perinatal nurse teaches a new nurse about the
discuss her birth experience. Healthy People 2010 initiative, which includes post-
◆ The postpartum woman who has experienced a cesar- partum teaching that focuses on:
ean birth is also considered to be a surgical patient who A. Warning signs during the postpartum period
has special needs for additional nursing care. B. Benefits of breastfeeding
C. Use of infant soothers
◆ Effective pain management should be an integral com- D. Contraceptive methods
ponent of the postpartal nursing assessment.
9. The postpartum nurse recognizes that after birth, the
◆ The breastfeeding mother should be provided with suf- patient is at risk for decreased bladder tone and func-
ficient support to facilitate success. tion if her labor/birth included:
◆ The nurse should provide anticipatory guidance that A. Forceps
includes family members whenever possible. B. Vacuum extraction
C. Prodromal labor
r e v i e w q u est io n s D. Prolonged second stage
Case Study
Multiple Choice
10. The perinatal nurse is assessing Ruth, who has given
1. In the preadmission clinic, the perinatal nurse describes birth 2 hours ago. The nurse notes a discoloration of
the advantages to a short hospital stay as including: the perineum and Ruth complains of pain and rectal
A. Decreased risk of nosocomial infection pressure. The most appropriate action for the nurse
B. Increased rest and recuperation is to:
C. Increased opportunity to initiate successful A. Call the health care provider to assess immediately.
breastfeeding B. Increase IV fluids and request an order for ergo-
D. Increased teaching about infant care novine (Ergotrate).
2. In the immediate postpartum period, the perinatal C. Reassure Ruth and her family that postpartum
nurse knows that the postpartum woman most often pain is normal and medication is available.
has a: D. Apply ice packs to the perineum as quickly as
A. Bradycardia possible.
B. Tachycardia
See Answers to End of Chapter Review Questions on the
C. Pulse within the normal adult range
Electronic Study Guide or DavisPlus.
D. Tachycardia then a pulse rate that returns to nor-
mal in 4 hours
3. The postpartum nurse expects a postpartum wom- REFERENCES
an’s bladder function to return to normal within American Academy of Pediatrics (AAP) Committee on Fetus and New-
which length of time: born. (2004). Hospital stay for healthy term infants. Pediatrics,
A. 4–6 hours 113(5), 1434–1436.
American College of Obstetricians and Gynecologists (ACOG). (2003).
B. 6–8 hours ACOG Committee Opinion No. 282. Immunization during preg-
C. 2–4 hours nancy. Obstetrics and Gynecology, 101(4), 207–212.
D. 8–12 hours Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN). (1999). Clinical position statement: The role of the nurse
Fill-in-the-Blank in the promotion of breastfeeding. Washington, DC: Author.
Beck, C., Records, K., & Rice, M. (2006). Further development of the
4. The perinatal nurse knows that the first 6 weeks after postpartum depression predictors inventory-revised. Journal of
birth is described as the ______. Obstetric, Gynecologic, & Neonatal Nursing, 35(6), 735–745.
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
5. The perinatal nurse works with the healthcare facil- tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
ity’s unit council to develop policies to promote Cadwell, K., Turner-Maffei, C., O’Conner, B., Cadwell-Blair, A., Arnold,
patient safety. The policy on infant safety particularly L., and Blair, E. (2006). Maternal and infant assessment for breastfeed-
focuses on the challenge of two infants/families with ing and human lactation: A guide for the practitioner (2nd ed.). Sud-
bury, MA: Jones and Bartlett.
the same ______ to ensure that there are specific Chan, P., & Winkle, C. (2006). Gynecology and obstetrics: Current clini-
strategies to protect each family. cal strategies. Laguna Hills, CA: CCS Publishing.
6. The perinatal nurse recognizes that it is common for Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & Wen-
strom, K. (2005). Williams’ obstetrics (22nd ed). New York: McGraw-
women using insulin to have ______ insulin require- Hill.
ments postpartum. This finding is due to a ______ in Dabrowski, G.A. (2007). Skin to skin contact: Giving birth back to
levels of placental lactogen and insulinase. mothers and babies. Nursing for Women’s Health, 11(1), 64–71.
chapter 15 Caring for the Postpartal Woman and Her Family 509
Davis, R. (2001). The postpartum experience for Southeast Asian women Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing
in the United States. The American Journal of Maternal Child Nursing, outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
26(4), 208–213. NANDA International (2007). NANDA-I nursing diagnoses: Definitions
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses and classifications 2007–2008. Philadelphia: NANDA-I.
(11th ed.). Philadelphia: F.A. Davis. Olson, C., Strawderman, M., Hinton, P., & Pearson, T. (2003). Gesta-
Gartner, L., Morton, J., Lawrence, R., Naylor, A., O’Hare, D., Schanler, tional weight gain and postpartum behaviors associated with weight
R., et al. (2005). Breastfeeding and the use of human milk. Pediatrics, change from early pregnancy to 1 year postpartum. International
115(2), 496–506. Journal of Obesity, 27(1), 117–127.
Halon, L., & Milkus, K. (2004). Staphylococcus aureus and wounds: A Patel, R.R., Murphy, D.J., & Peters, T.J. (2005). Operative delivery and
review of tea tree oil (Melaeuca alternifolia) as a promising antimi- postnatal depression: A cohort study. British Medical Journal, 330(4),
crobial. American Journal of Infection Control, 32(7), 402–408. 879–886.
Horowitz, J.A., & Goodman, J.H. (2005). Identifying and treating post- Ramsay, D., Kent, J., Harmann, R., & Harmtann, P. (2005). Anatomy of
partum depression. Journal of Obstetric, Gynecologic & Neonatal the lactating human breast redefined with ultrasound imaging. Jour-
Nursing, 34(5), 264–273. nal of Anatomy, 206(6), 525–534.
International Childbirth Education Association (ICEA). (2003). Siblings Riordan, J. (2005). Breastfeeding and human lactation (3rd ed.). Sudbury,
and the new baby. (Brochure). Minneapolis, MN: Author. MA: Jones and Bartlett.
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Maas, Rubin, R. (1984). Maternal identity and the maternal experience. New
M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and NIC York: Springer.
linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). Rubin, R. (1975). Maternal tasks in pregnancy. MCN: The American
St. Louis, MO: Mosby Elsevier. Journal of Maternal-Child Nursing, 4(3), 143–153.
Johnston, M.L., & Esposito, N. (2007). Barriers and facilitators for Runquist, J. (2007). Persevering through postpartum fatigue. Journal of
breastfeeding among working women in the United States. Journal of Obstetric, Gynecologic & Neonatal Nursing, 36(1), 28–37.
Obstetric, Gynecologic & Neonatal Nursing, 36(1), 9–20. Secco, M.L., Profit, S., Kennedy, E., Walsh, A., Letourneau, N., & Stew-
Klaus, M. (1982). Parent-infant bonding (2nd ed.). St. Louis, MO: C.V. art, M. (2007). Factors affecting postpartum depressive symptoms of
Mosby. adolescent mothers. Journal of Obstetric, Gynecologic & Neonatal
Lactation Education Resources. (2004). Breast engorgement. Retrieved from Nursing, 36(7), 47–54.
www.leron-line.com/handouts/Breast_Engorgement.htm (Accessed St. John, W., Cameron, C., & McVeigh, C. (2005). Meeting the challenge
December 2, 2006). of new fatherhood during the early weeks. Journal of Obstetric, Gyne-
Lavender, T., Hofmeyr, G.J., Nielson, J.P., Kingdon, C., & Gyte, G.M. cologic & Neonatal Nursing, 34(2), 180–189.
(2007). Depressive symptoms in mothers of prematurely born Stonehouse, A., & Studdiford, J. (2007). Allergic contact dermatitis from
infants. Journal of Developmental and Behavioral Pediatrics, 28(1), tea tree oil. Consultant, 42(4), 781.
36–44. Taylor, R. (2005). Addressing barriers to cultural competence. Journal
Lawrence, R., & Lawrence, R. (2005). Breastfeeding: A guide for the medi- for Nurses in Staff Development, 21(4), 135–142.
cal profession (6th ed.). Philadelphia: Elsevier Mosby. Troy, N. (2003). Is the significance of postpartum fatigue being over-
Logsdon, M.C., & Koniak-Griffin, K. (2005). Social support in postpar- looked in the lives of women? MCN American Journal of Maternal/
tum adolescents: Guidelines for nursing assessments and interven- Child Nursing, 28(4), 252–257.
tions. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(6), Tully, M.R. (2005). Working & Breastfeeding. AWHONN Lifelines 9(3),
761–768. 198–203.
Meara, E., Kotagal, U., Atherton, H., & Lieu, T. (2004). Impact of early U.S. Census Bureau. (2001). Mapping Census 2000: The Geography of
newborn discharge legislation and early follow-up visits on infant out- U.S. Diversity. Retrieved from http://www.census.gov/ (Accessed
comes in a state Medicaid population. Pediatrics, 113(6), 1619–1627. August 21, 2007).
Miller, L.C., Cook, J.T., Brooks, C.W., Heine, A.G., & Curtis, T.K. U.S. Department of Health and Human Services. (2000). Healthy People
(2007). Breastfeeding education: Empowering future health care 2010. Washington, DC: Author.
providers. Nursing for Women’s Health, 11(4), 375–380.
CONCEPT MAP
Physiological Adaptations/Con’t Assessments Promoting Recovery/Self-Care Discharge: Planning/Teaching
• Decreased blood volume/elevated cardiac output • Early ambulation; adequate sleep/frequent rest; • Maternal self-care
• WBC: increased with labor, decreased after 6 days balanced and nutritious diet • Infant bathing, breastfeeding,
• Estrogen/progesterone decrease; prolactin released • Promote bowel and bladder function: monitor for activity/rest, perineal hygiene,
• Fatigue/discomfort: further assess headaches urinary retention, possible catheterization prn, emotional changes
• GFR/creatinine/BUN decreased by 2–3 months stool softeners/enemas prn • Teach self-assessment
• Decreased urine protein and glucose • Peri-care: ice packs, sitz bath • Teach: nutrition, weight loss,
• Natriuresis/diuresis/possible urinary retention • Analgesics for afterpains exercise, pain management,
• Stretch marks • Routine post-op care for patient having sexual activity, follow-up exams
• Involution/uterine contractions; in 6–8 wks resump- sterilization/cesarean birth: wound care, anesthesia • Identify community resources
tion of menstruation and ovulation recovery, pain control, Foley catheter; psychological
• Muscle/body aches; rectus abdominis diastasis issues with cesarean
Family–Infant Bonding Multicultural Family Care Nutrition Be Sure To: Critical Nursing Action:
• Create positive • Holistic and flexible • Check ID bands • Assessing for maternal–
environment approach • Prevent abduction infant attachment
• Provide emotional • Know and understand
support/accurate rites/customs/beliefs
information • Cultural assessment
• Maternal: taking-in/ • Affects: longevity of Promoting Breastfeeding: Formula Feeding
taking-hold/letting-go; confinement/activity • Teach: lactation/lactogenesis • Correct, safe preparation
promote bonding/ during/degree of family
• Success strategies: IBCLC • Cleaning bottles/nipples
attachment involvement
• ID feeding readiness cues • No microwaving or propping
• Paternal: encourage • Hot/cold beliefs: affect
participation diet and environmental • Facilitate latching-on/suckling • Skin-to-skin/full eye contact
• Siblings: formulate temperature • Proper positioning • Watch for large emesis
strategies to increase • Care: sore nipples/breast of formula
acceptance engorgement
• Grandparents: • Teach about collection/storage
involvement linked to of breast milk and weaning
culture
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Describe the causes and collaborative management of postpartum hemorrhage.
◆ Discuss the signs and symptoms of postpartum hematoma; describe nursing care for a patient
experiencing a postpartum hematoma.
◆ Describe the collaborative management for infections during the puerperium.
◆ Discuss the collaborative management of thrombophlebitis and thrombosis in postpartum women.
◆ Describe the signs, symptoms, and management of a pulmonary embolism.
◆ Summarize important interventions in meeting psychosocial needs of postpartum women and their
families.
◆ Describe current community and governmental services that are available to vulnerable postpartum
women and their families.
Through the replication of a previous study, the purpose of this obtained through the input of public health nurses during the
longitudinal study was to examine the relationship among standard 48-hour discharge telephone call to new mothers. Partici-
infant sleep patterns, maternal fatigue, and the development of pation was voluntary and included mothers who were at least
postpartum depression in women with no major depressive 18 years of age and at more than 32 weeks of gestation. Data
symptomatology. was obtained through an initial questionnaire and follow-up
Depression was defined in the previous study as either meet- questionnaires at 4 and 8 weeks postpartum. From a potential
ing the criteria for the diagnosis of a major depression or scoring population of 857 candidates, 667 agreed to participate. Of that
above 15 on the Edinburgh Postnatal Depression Scale. Vari- total, 585 returned the questionnaire at 1 week, with 505 (86.3%)
ables in the original study and considered to be predictive of scoring less than 13 on the Edinburgh Postnatal Depression Scale
depression included maternal age, depression during preg- (EPDS), qualifying them to participate in this study.
nancy, thoughts of death and dying at 1 month postpartum, and The EPDS assessed symptoms of depression through ratings
difficulty falling asleep at 1 month postpartum. Prenatal partici- of 10 items on a four-point scale; a high score indicated a more
pants in the study were recruited through family physician, obste- depressed mood. Depressive symptomatology was defined as a
trician, and nurse midwife offices. Postnatal participants were score 12.
(continued)
511
512 unit five Care of the New Family
TISSUE
Careful examination of the placenta after delivery is a com- HYPOVOLEMIC SHOCK
ponent of standard care. Hence, retained placental tissue is Hypovolemic (hemorrhagic) shock can result if PPH is
an uncommon cause of early PPH. If the pregnancy included not managed aggressively. Most women can tolerate a
problems with placental implantation (e.g., previa, accreta), 1000 mL blood loss because they are healthy, have a 35%
the primary care provider is aware of these risks before the to 45% increase in the plasma and red blood cell (RBC)
birth takes place. Should the practitioner note that lobes of volume (2 pints of blood), and give birth in positions that
the placenta are missing during the placental examination, “pool blood” in the pelvis (Cunningham et al., 2005).
the physician or certified nurse midwife explores the
patient’s uterus to remove them. More often, a soft uterus
with bright red bleeding later in the postpartum course clinical alert
identifies the source of a late postpartum hemorrhage
(Cunningham et al., 2005; MacMullen et al., 2005). Blood loss and vital signs
Normal physiological adaptations in pregnancy mean that a large
loss of blood can occur before changes in vital signs (decreased
THROMBIN blood pressure and increased pulse) are evident. The lack of objec-
Thrombin refers to problems with maternal coagulation. tive signs and symptoms may lead to a delay in treatment.
Disorders of the coagulation system and platelets do not
usually result in excessive bleeding during the immediate
postpartum period. Preexistent maternal factors such as The nurse, physician, or midwife may not see the usual
low fibrinogen levels and idiopathic thrombocytopenia signs of shock—restlessness, anxiety, pallor, cool, clammy
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period 515
• The patient’s circulating blood volume will be maintained and/or the critical nursing action Immediate Intervention
blood volume will be restored to a physiologically adequate level. for Uterine Atony
• Peripheral pulses and oxygenation will be maintained.
• The patient/family will express their fears. As soon as excessive blood loss is noted, the nurse’s most important
• The patient’s pain will be managed at a level acceptable to her. intervention is to begin fundal massage. Support the lower uterine
• The patient will maintain normal vital signs and laboratory values. segment by placing a hand in a slight “C” position just above the
symphysis pubis. Do not express clots if the uterus does not become
Adapted from Wilkinson, J.M. (2005). Nursing diagnosis handbook. Upper firm with massage. The clots may protect the patient from an even
Saddle River, NJ: Pearson Education. greater blood loss.
516 unit five Care of the New Family
3. Place the other hand around the top of the fundus. the umbilicus. Procedure tolerated well by the patient.
RATIONALE: This location helps to locate and assess the —Sejal Patel, RNC
fundus and the fundal height.
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period 517
Oxytocin (Pitocin) Stimulates uterine smooth 10 units IM if no IV access; Hypersensitivity Monitor uterine response. DO NOT
muscle and produces 10–40 units in 1000 cc administer a bolus of undiluted
contractions similar to crystalloid IV fluid (lactated oxytocin, as it can cause hypotension
those that occur during Ringer’s or normal saline) and cardiac arrhythmias. Consider
spontaneous labor administration of pain medication for
uterine cramping.
Methylergonovine Causes uterine 0.1–0.2 mg IM followed by Hypersensitivity Keep refrigerated. DO NOT add it to
(Methergine) contractions by 0.2 mg PO q4–6h 24 hours History of, or current IV solutions or mix in a syringe with
stimulating uterine and elevation of blood other medications.
vascular smooth muscles. pressure
Carboprost* Stimulates contractions 250 mcg IM or directly into Asthma or glaucoma Do not administer if patient
(Hemabate) of the myometrium the uterus (by MD or CNM) demonstrates shock, as it will not
may repeat dosage be well absorbed.
Keep refrigerated.
This medication is VERY expensive.
Misoprostol Acts as a prostaglandin 400–1000 mcg rectally Hypersensitivity to Stable at room temperature.
(Cytotec) analogue; stimulates prostaglandins
powerful contractions Rectal absorption is likely slower
of the myometrium than IV medication.
Monitor uterine response.
*Eighty to ninety percent effective in stopping postpartum hemorrhage when patient is unresponsive to Pitocin or Methergine
(Smith & Brennen, 2006).
Data from Adams et al. (2005); Cunningham et al. (2005); Smith & Brennan (2006); and Tucker (2004).
If the patient has a distended bladder, an indwelling Labs: Findings with DIC
urinary catheter needs to be inserted and all intake and
output carefully recorded. The nurse also needs to Low hemoglobin Low fibrinogen
weigh pads, linens, and other bloody items on a gram Low hematocrit Elevated fibrin split/degradation products
scale to obtain an accurate picture of blood loss. It may Low platelets
be necessary to administer oxygen at 10 to 12 L/min
to treat compromised tissue perfusion. Additional base-
line information that should be obtained includes a The physician or midwife may also perform bimanual
complete blood count (CBC) and coagulation studies compression in an effort to empty the uterus of clots and
(PT [prothrombin time] partial thromboplastin time restore its tone. To perform this procedure, the physician
[PTT], fibrinogen, and fibrin degradation products). inserts one hand in the vagina while pushing against the
The physician or nurse midwife orders the blood tests, fundus through the abdominal wall with the other hand
along with a type and cross match for replacement (Fig. 16-1). If these interventions fail to stabilize the
blood as an anticipatory measure in the event a trans- patient by restoring tone to the uterus and decreasing the
fusion is necessary. The patient is carefully assessed blood loss, an invasive procedure performed in the operat-
for indicators of disseminated intravascular coagulation ing room will be necessary. Invasive procedures include
(DIC). the placement of uterine packing, embolization (occlu-
DIC is a diffuse clotting pathology that involves the sion of a vessel with a clot, usually in a radiological pro-
consumption of large amounts of clotting factors cedure), or uterine artery ligation (a simple, highly effec-
including platelets, fibrinogen, prothrombin, and fac- tive treatment to control bleeding that involves stitching
tors V and VII. The pathological process may cause the artery/vein to narrow its lumen and significantly
both internal and external bleeding. Vascular occlu- decrease blood flow to the involved organ).
sion of small vessels occurs as small clots form in
the microcirculation. Although DIC may occur during
the postpartum period, it is most likely to be associ- Optimizing Outcomes— Holistic care during
ated with abruptio placentae, severe preeclampsia, management of a PPH
amniotic fluid embolism, septicemia, cardiopulmonary Best outcome: The nurse provides physiologic care in a
arrest, hemorrhage, and dead fetus syndrome (a com- timely manner and also serves as an advocate for the
plication that may occur when the fetus has died and patient’s pain control and reassures the patient and her
is retained in the uterus for 6 or more weeks). Diagno- family by explaining interventions as they occur. These
sis is made according to clinical findings and labora- actions help control not only the blood loss but also the
tory results. (See Chapters 11, 14, and 33 for further patient’s pain and the patient’s/family’s anxiety.
discussion.)
518 unit five Care of the New Family
Hematomas
DEFINITION, INCIDENCE, AND RISK FACTORS
A hematoma is a localized collection of blood in connec-
tive or soft tissue under the skin that follows injury of or
laceration to a blood vessel without injury to the overlying
tissue. At the time of injury, pressure necrosis and inade-
quate hemostasis occurs. This complication can result in
a large amount of blood loss and patient discomfort if not
recognized rapidly. Risk factors for hematoma formation
include genital tract lacerations, episiotomies, operative
vaginal deliveries, a difficult or prolonged second stage of
labor, and nulliparity. Hematomas occur most frequently
in the vulva, but they can also occur in the vagina and in
the retroperitoneal area (Figs. 16-2 and 16-3).
Figure 16-3 Vaginal wall hematoma. case study Patient Experiencing a Vulvar
Hematoma
Molly is a 20-year-old gravida 1, para 1 who gave birth to a
Box 16-5 Possible Nursing Diagnoses and Goals for term, healthy baby boy, weighing 9 lbs 1 oz (4.1 kg) at 23:32
Patients with a Postpartum Hematoma hours. She received an epidural for labor pain control, pushed
for 3 hours, and required a vacuum assisted delivery. Her
Pain related to tissue trauma and pressure. perineum required repair of a third-degree laceration. After
Patient’s pain will be managed to an acceptable level. birth, the nurse discontinued the continuous epidural pump,
Anxiety and/or fear related to knowledge deficit of procedures and plan placed ice on the perineum, completed the required 15-minute
of care. checks ( 5), helped Molly breastfeed, and assisted Molly’s
Patient will express her fears. boyfriend in holding the baby and taking pictures. On arrival
Altered family processes related to physiological crisis. to the mother–baby unit, Molly requests pain medication
Patient and her family will support one another verbally and and states that the ice is helping some but that she wants to
behaviorally. “stay on top of it.” She rates the pain as a 5 on a 10-point
Powerlessness related to loss of control of physiological functions. scale. The admission vital signs and fundal location are within
Patient will make choices over which she has control. normal limits. An examination of Molly’s perineum reveals
At risk for infection related to invasive procedures. mild swelling and a normal amount of vaginal bleeding. Molly
Patient will remain afebrile and her WBC will be within normal limits. is tired and asks that she be allowed to sleep. Her boyfriend
Patient’s perineum will heal without evidence of drainage or goes home to sleep, and the baby is taken to the nursery.
separation. Two hours later, Molly calls for her nurse and complains of
At risk for fluid volume deficit. intense burning, pain, and pressure “where I had my stitches.”
Patient’s blood loss will be minimized. You examine her perineum and note an 8 cm bulging mass on
At risk for altered attachment related to separation from infant. her left vulva. When you touch it with a gloved hand, Molly says,
Patient will demonstrate concern for and care of infant before “Oh, that is so tender! That hurts!”
discharge.
critical thinking questions
1. What factors during birth placed Molly at risk for develop-
ment of a hematoma?
If findings from the assessment are strongly suggestive
of a hematoma, the nurse needs to immediately notify the 2. Name two appropriate nursing diagnoses for Molly.
physician or nurse midwife and implement pain relief 3. What are the expected outcomes for Molly?
measures. If the hematoma is less than 3 to 5 cm in diam-
4. List four nursing interventions along with rationales.
eter, the physician usually orders palliative treatments
such as ice to the area for the first 12 hours along with ◆ See Suggested Answers to Case Studies in the text on the
pain medication, and close observation of the area for Electronic Study Guide or DavisPlus.
extension of the hematoma. After 12 hours, sitz baths are
prescribed to replace the application of ice. Sitz baths are
therapeutic in providing comfort and in facilitating reab-
sorption of the clot. A hematoma larger than 5 cm may
require incision and drainage with the possible placement Now Can You— Discuss implications of a postpartum
of a drain. This invasive procedure is performed in the hematoma?
operating room while the patient is sedated with an 1. Describe the classic signs and symptoms of a puerperal
anesthetic. hematoma?
The health care team must be particularly sensitive to 2. Identify the most common anatomical locations for a
the fact that large hematomas can lead to shock. In this postpartum hematoma?
case, the physician orders aggressive treatment that 3. Differentiate between the collaborative management for
includes intravenous fluids, oxygen, frequent measure- a small and a large hematoma?
ment of vital signs, urinary catheter placement, and strict
520 unit five Care of the New Family
Puerperal (Postpartum) Infections infant’s mouth through a fissure in the nipple. The infection
involves the ductal system, causing inflammatory edema,
DEFINITION AND INCIDENCE enlarged axillary lymph nodes, and breast engorgement with
obstruction of milk flow (Fig. 16-5). Without treatment,
Puerperal infection is a bacterial infection of the genital mastitis may progress to a breast abscess. Symptoms include
tract, usually of the endometrium (endometritis) that fever, malaise and localized breast tenderness. Management
occurs within 28 days after miscarriage, induced abortion, centers on antibiotic therapy (e.g., cephalosporins and van-
or childbirth. The presence of fever often indicates puer- comycin), application of heat or cold to the breasts, hydra-
peral infection. In the United States, the definition contin- tion, and analgesics. To maintain lactation, the woman may
ues to be a temperature of 100.4°F (38°C) or greater on empty the breasts every 2 to 4 hours by breast feeding, man-
2 successive days of the first 10 postpartum days (omitting ual expression, or breast pump. Since mastitis usually occurs
the first 24 hours) measured orally at least four hours after hospital discharge, an important component of nursing
apart. A fever of 102.2°F (39°C) or greater within the first care includes teaching the breastfeeding mother about signs
24 hours is often associated with severe pelvic sepsis, usu- of mastitis and strategies to prevent cracked nipples.
ally resulting from Group A or B Streptococcus (Cunning-
ham et al., 2005; Table 16-2).
Throughout the world, puerperal infection probably NURSING ASSESSMENT
constitutes the major cause of maternal morbidity and mor- Assessment is central to the delivery of safe, effective postpar-
tality; in the United States, the postpartum infection rate is tal nursing care. Ongoing, careful attention must be paid to
1% to 8%, with a mortality of 4% to 8% from complications the patient’s mental status and to her vital signs, breasts, fun-
(Kennedy, 2007). Cesarean birth mothers have a greater dus, lochia, incisions, and urinary status. Temperature eleva-
incidence (5% to 15%) of postpartum infection than do tion may be the first indication of an infection. If an elevated
mothers who give birth vaginally (1% to 3% incidence) temperature is combined with any of the following signs and
(Franzblau & Witt, 2006). If a cesarean birth mother expe- symptoms, the nurse must notify the primary care provider
riences a prolonged labor prior to delivery, the incidence of immediately: tachycardia, uterine or fundal tenderness or
postpartum infection increases to 30% to 35%. pain, foul-smelling lochia, an absence or decrease in lochia,
chills, decreased appetite, malaise, elevated white blood cell
count (WBC), back pain (costovertebral angle tenderness
Optimizing Outcomes— Educating patients about
[CVAT]), generalized aching, headache, dysuria, urinary fre-
risk factors for puerperal infection
quency or retention, wound drainage, erythema, edema.
Shorter hospital stays after birth make the nurse’s role in Early, ongoing collaborative treatment can then be initiated.
educating the new mother and her family about signs and
symptoms of postpartum infection vitally important. The
Optimizing Outcomes— Tests to help identify a
nurse should alert the patient about antepartum or intra-
postpartum infection
partum events that are risk factors for the development of
a postpartum infection and make certain the family under- To detect sources of puerperal infection, the nurse can antici-
stands the importance of promptly notifying their care pate that the following samples are likely to be obtained:
provider if any symptoms occur. • Complete blood count (CBC) with differential
• Blood cultures if sepsis is suspected
• Urinalysis with culture and sensitivity
TYPES OF PUERPERAL INFECTIONS • Cervical, uterine, or wound culture as needed
Infections during the puerperium most commonly involve
the endometrium (endometritis), operative wound (cesarean
incision; episiotomy), urinary tract, and breasts (mastitis).
Septic pelvic thrombophlebitis may also occur. COLLABORATIVE MANAGEMENT
All bacterial puerperal infections require treatment with
Endometritis antibiotics. The nurse can encourage rest and increased
During the immediate postpartum period, the most common fluid intake and instruct the patient about the importance
site of infection is the uterine endometrium (Fig. 16-4). This of increasing protein and vitamin C in her diet. In many
infection presents with a temperature elevation over 101°F hospitals, a nurse can refer a patient to a dietitian for
(38.4°C), often within the first 24 to 48 hours after childbirth, instruction without a physician’s order.
followed by uterine tenderness and foul-smelling lochia. Comfort measures are as important in facilitating the
Since urinary tract infections can occur during any part of the patient’s full recovery as the administration of antibiotics.
pregnancy and puerperium, differentiating the various signs Cool showers, sitz baths, warm compresses applied to the
and symptoms is important. As noted in Tables 16-2 through breasts, therapeutic touch and massage, soothing music,
16-6, other infections are more likely to occur following dis- relaxation techniques, pain medications, and antipyretics
charge from the hospital. Therefore, follow-up in the home or are all strategies to promote patient well-being. Because of
clinic by a nurse or primary care provider may offer the first their anti-inflammatory effect, many physicians order a
opportunity to identify infectious processes. nonsteroidal anti-inflammatory medication (NSAID) to
serve as an antipyretic and analgesic. Throughout the
Mastitis course of treatment, health care team members also need
Mastitis is usually unilateral and develops after the flow of to provide education to the patient and her family regard-
milk has been established. The most common causative ing her diagnosis and prognosis, treatment plan, measures
organism is Staphylococcus aureus, introduced from the to promote good hygiene, and follow-up care.
Table 16-2 Postpartum Infection: Endometritis
Causative Diagnosis Prognosis and
Type of Infection Risk Factors Onset Signs and Symptoms Organisms Based on Collaborative Treatment Complications
Endometritis Cesarean birth 2–4 days Prolonged fever Normal vaginal Clinical signs and 1. MD/CNM: order 90–95% improvement
(inflammation and Prolonged rupture of the following 100.4ºF (38ºC), foul flora and symptoms. antibiotics within 48–72 hours after
infection of the membranes, multiple vaginal childbirth smelling lochia, uterine or enteric bacteria treatment.
inner lining of the examinations, internal Vaginal and 2. Treat symptoms:
abdominal tenderness, bimanual May be discharged on
uterus) electronic FHR monitoring, chills, poor appetite, ` a. Rest
low socio-economic status, examination. oral antibiotics
Incidence: malaise, increased pulse
poor nutrition, young age, rate, cramping pain, Laboratory test b. Antipyretics Complication:
vaginal birth diabetes, prior genital increased white blood cell results: culture of c. Increase fluid intake
1–3% and infection, lapse in aseptic count (WBC) (above lochia; elevated Extension of infections via
cesarean birth technique, anemia, smoking, 20–30,000 mm3) white blood cell d. Encourage high lymphatic system to
10–20% nulliparity, operative vaginal count (WBC) protein, high vitamin connective tissues (pelvic
(Kennedy, 2005) delivery, poor postpartum C foods infection)
perineal care (Must also rule out
urinary tract infection) e. Promote uterine Dehiscence of cesarean
drainage via section incision or
ambulation and episiotomy
Fowler’s position Peritonitis
f. Instruct in perineal
care
3. Explain treatments to
patient/family
4. Home antibiotic therapy
may need to be arranged
with follow-up by a home
care nurse.
5. Promote infant
attachment.
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period
521
Data from American Academy of Pediatrics & American College of Obstetricians and Gynecologists (2002); Cunningham et al. (2005); and Gibbs et al. (2004).
522 unit five Care of the New Family
Wound infections Endometritis (infected Early: 48 hours Pain, foul smelling Polymicrobial, Clinical signs and 1. Antibiotics per order Improvement usually within
lochia), poor hygiene, discharge, edema, normal vaginal symptoms, 24–48 hours;
Perineal fecal contamination, Late: 6–8 days low grade fever flora subjective 2. May require incision and may require long term
hematoma complaints drainage with placement antibiotic therapy
Incidence: Sudden chills, high Staphylococcus of drain to facilitate healing
0.35–10% ALL wound infections: fever, abdominal aureus, aerobic Clinical signs and by secondary intention.* Complication:
Cesarean incision obesity, diabetes, tenderness, erythema, streptococci, symptoms, along If packing has been placed
hypertension, edema, warmth of aerobic and with a poor in the wound to keep it open Necrotizing fasciitis, abscess,
Incidence: 3–5% immunosuppression, incision, drainage anaerobic bacilli response to and maintain drainage, wound dehiscence
malnutrition, anemia, from the incision antibiotics given for alert the patient to exercise
hemorrhage, endometritis. caution when changing her
prolonged labor, perineal pads to avoid
chorioamnionitis Laboratory test dislodging the packing.
prolonged rupture results:
of membranes, 3. Perineal: sitz baths; instruct
elevated white in perineal care
hematoma blood cell count
(WBC) 4. Cesarean: wet to dry dressing
changes 3 times/day
5. Pain medication per order
(usually nonsteroidal
anti-inflammatory drugs
[NSAIDs])
6. Instructions to patient and
family about wound care.
7. Possible referral for home
health or community health
nurse visits
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period
*Secondary intention: healing from the inside of the wound out to the skin.
523
Data from Cunningham et al. (2005); Franzblau & Witt (2006); Gibbs et al. (2004); and Kennedy (2007).
524
Urinary tract Catheterization, multiple Any time during May have none Most common: Clinical signs 1. Antibiotics per order (usually Improvement within
infections vaginal exams, poor pregnancy or and symptoms. sulfonamides, aminopenicillins, 48–72 hours following
postpartum hygiene, after birth Dysuria (painful Escherichia coli anti-infectives, nitrofurantoin, or initiation of antibiotic
Incidence: genital tract trauma, urination), frequency, (60–90% of all UTIs); Laboratory test cephalosporins 3–10 days depending therapy
burning on urination, Proteus mirabilis, results: urine
unit five
Data from Cunningham et al. (2005); Franzblau & Witt (2006); and Kennedy (2007).
Table 16-5 Postpartum Infection: Mastitis
Type of Risk Signs and Causative Diagnosis Collaborative Prognosis and
Infection Factors Onset Symptoms Organisms Based on Treatment Complications
Mastitis Milk stasis, plugged 3–4 weeks Warm, tender, Most common: Clinical signs 1. Notify MD/CNM Improvement within
milk duct, infrequent postpartum hardened area on Staphylococcus and symptoms 24–48 hours following
breastfeeding, breast (usually only aureus; also: Laboratory test 2. Initiate antibiotics. initiation of antibiotics
fatigue, nipple one), enlarged axillary Haemophilus results: culture 3. Continue breastfeeding or manual/electrical
trauma, primiparity lymph nodes, fever parainfluenzae of breast milk Complication:
expression of milk to maintain lactation. May be
(up to 102ºF [38.9ºC]), (from infant’s instructed to discard the milk. Breast abscess
chills, generalized mouth and nose),
aching, headache, Candida 4. Promote rest. If breast abscess occurs:
malaise albicans, must discontinue
5. Increase fluid intake. breastfeeding on the
Streptococcus
viridans 6. Pump breast after infant feeding to ensure affected side—may lead to
breast is empty. decreased maternal-infant
attachment, low self-
7. Warm compress or ice to breast for comfort. esteem and feelings of
8. Antipyretics disappointment and guilt
Data from Lawrence, R., & Lawrence, R. (2005). Breastfeeding: A guide for the medical profession (6th ed.). Philadelphia: C.V. Mosby.
525
526
Septic pelvic Cesarean birth, genital 48 hours to Fever 102.2ºF Normal vaginal Clinical signs and 1. MD/CNM: prescribe antibiotics Improvement usually
thrombophlebitis tract lacerations, 4–6 weeks (39ºC) with spikes flora and enteric symptoms. within 48–72 hours of
history of varicosities, postpartum after initiation of bacteria—is 2. Add heparin therapy to increase heparin initiation; may
immobility, operative antibiotic therapy, usually an Pelvic CT or MRI to APTT (activated partial thrombo- need to continue
confirm the clinical plastin time) to 1.5–2 times the
unit five
attachment; prolonged
7. Complementary therapies: heat, hospitalization
cold, relaxation, music, touch, etc.
8. Explain treatments.
9. Promote infant attachment.
pregnancy and may extend from the foot to the iliofemo- If the result of this test is equivocal, magnetic resonance
ral region. It is associated with unilateral leg pain, calf imaging (MRI) (a diagnostic test that uses electromag-
tenderness, and swelling. However, up to 50% of all indi- netic energy to provide images of the heart, large blood
viduals with a DVT are asymptomatic. Signs and symp- vessels, brain, and soft tissues) may be ordered to deter-
toms depend on the size, location, degree of vessel occlu- mine the extent of any pelvic vein involvement (Colman-
sion, and development of collateral circulation around the Brochu, 2005; Cunningham et al., 2005).
clot. The classic presentation of DVT involves pain, ten-
derness, edema, redness, and localized heat. The presence COLLABORATIVE MANAGEMENT
of a palpable cord, changes in skin color (“milk” or “blue
leg”), a decreased peripheral pulse, and a circumference Routine interventions for either superficial or DVT include
that is 2 cm larger (or more) in the affected extremity the administration of analgesics; rest with elevation of the
assists in the DVT diagnosis. Dorsiflexing the woman’s affected extremity; elastic support to the affected leg;
foot while her knee is extended may elicit a positive increased fluid intake; and the local application of moist,
Homans’ sign (pain in the foot or leg) in the presence of warm packs. The nurse should ensure that the weight of
thrombophlebitis and thrombosis (Colman-Brochu, 2005; the warmed pack does not rest on the leg, causing obstruc-
Cunningham et al., 2005) (Fig. 16-6). tion of blood flow. Analgesics are prescribed for pain.
• Pain
• At risk for injury
• Altered peripheral tissue perfusion
• Altered family processes
• Self-care deficit
• Fear
• Altered individual/family coping
Figure 16-6 Deep vein thrombophlebitis.
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period 529
Box 16-8 Possible Nursing Diagnoses for Postpartum Box 16-9 Medications Used to Treat Postpartum
Depression Depression
Nursing Diagnosis: Ineffective Individual Coping related to multiple factors, including hormonal changes,
addition of a newborn to the family, and time management constraints
Measurable Short-term Goal: The patient will acknowledge that she is depressed and agree to participate in
individual and family therapy.
Measurable Long-term Goal: The patient will participate in activities she previously enjoyed and her affect will
demonstrate positive feelings.
NOC Outcome: NIC Interventions:
Coping (1302) Personal actions to manage Coping Enhancement (5230)
stressors that tax an individual’s resources Counseling (5240)
Medication Management (2380)
Nursing Interventions:
1. Approach the patient in a calm, nonthreatening, and concerned manner.
RATIONALE: This approach may encourage the patient to be open about her thoughts and feelings.
2. Ask open-ended questions and wait for a response.
RATIONALE: Open-ended questions require more than a one-word answer, which may encourage verbalization.
Waiting for an answer indicates that what she says is worth the silence.
3. Affirm the woman’s feelings and allow her to cry should she desire.
RATIONALE: These responses demonstrate genuine concern.
4. Notify the patient’s primary caregiver about the patient’s depressed affect.
RATIONALE: PPD may require medication or therapy.
5. Provide information about PPD and gently correct any misinformation or misconceptions the patient has
about depression.
RATIONALE: Correct information may instill hope and encourage the woman to continue therapy.
6. Provide instructions about medications (antidepressants) that may be ordered.
RATIONALE: The patient needs to know the effects and side effects of medications so that she can report
unusual symptoms.
7. Ask the patient what activities she no longer enjoys that were previously enjoyable.
RATIONALE: This baseline information allows you and the patient to establish some goals for therapy.
8. Involve the family in helping the patient cope with her feelings and assisting with infant care.
RATIONALE: Involvement of the patient’s support system is vitally important. She needs to know that she is not
alone in her struggle with depression.
9. Help the patient/family establish an activity goal that she can achieve within the next week.
RATIONALE: This intervention involves the patient in her care, allows her some control, and encourages her to
focus on a positive action/behavior.
than they do at any other time in their lives. Its onset may
be dramatic, often occurring within the first 24 to 48
Nursing Insight— Recognizing behavioral cues
that signal postpartum psychosis
hours following birth, but it always appears within the
first 8 postpartum weeks. Women with preexisting When providing hospital and community care for postpartum
psychosis, especially bipolar disorder, are at the greatest women, the nurse should be alert to behavioral cues that may
risk for postpartum psychosis (Sadock & Sadock, 2004; signal psychosis:
Nonacs, 2005).
• Hyperactivity
Postpartum psychosis may present with symptoms of
• Agitation
PPD. However, the distinguishing signs of psychosis are
• Confusion
hallucinations, delusions, agitation, confusion, disori-
• Suspiciousness
entation, sleep disturbances, suicidal and homicidal
• Excessive complaints
thoughts, and a loss of touch with reality. This condi-
tion may also resemble a sudden manic attack. Mothers
who are in a manic state require constant supervision
when caring for their infant; they are frequently too Collaborative Management
preoccupied to tend to their infant’s needs (Franzblau Infanticide (the killing of an infant) is as high as 4% in
& Witt, 2006; Nonacs, 2005). women with postpartum psychosis. Because of this danger
534 unit five Care of the New Family
and the loss of touch with reality, postpartum psychosis is expanded family present challenges that require maturity
a true emergency. The woman must be hospitalized, and and flexibility. The nurse can become involved with the
mental health experts must become involved in her care as childbearing family during the first prenatal visit. As the
quickly as possible. Immediate treatment usually includes pregnancy progresses, the nurse becomes increasingly
a mood stabilizer (lithium [Lithobid] or valproic acid familiar with the woman and her family’s lifestyle, stressors,
[Depakene]), antipsychotic medications (Thorazine, Mel- successes, disappointments, and challenges. The postpar-
laril, Serentil), and anti-anxiety medications (benzodiaze- tum nurse is at a distinct disadvantage because of the
pines—Xanax, Libruim, Tranxene, Lorazepam). If required, limited time a woman remains hospitalized after birth.
electroconvulsive therapy (ECT) often leads to rapid However, any nurse, regardless of care setting or time con-
improvement. Long-term psychotherapy and pharmaco- straints, can develop an attentive ear and sensitivity. By
logical treatment follows the immediate care (Adams et al., doing so, the nurse is then able to promote health and well-
2005; Franzblau & Witt, 2006; Nonacs, 2005). being for the new mother, her newborn, and the family.
Women who are taking mood stabilizers need extensive During the postpartum period, the nurse can provide
counseling about the side effects associated with these information that stresses the importance of asking for
medications. Patients on lithium must have serum lithium help if the patient feels overwhelmed. Promoting care
levels drawn every 6 months. Most antipsychotic medica- and activities that allow the new mother and her family
tions can cause orthostatic hypotension and sedation, side to attach to the infant is vitally important. Examples of
effects that pose a major risk for mothers providing child bonding-oriented nursing care include rooming-in,
care. Because the woman’s thought processes may be decreasing sensory stimuli so that the family can focus on
altered, the nurse should share specific information about one another, and limiting visitors (if the patient desires).
medication side effects with a close family member. If the The postpartum nurse should note negative comments
mother wishes to breast feed, some sources recommend the patient makes about herself, her family, or the new-
that no pharmacological agents be prescribed (Sadock & born and encourage the patient to talk about her expecta-
Sadock, 2004), while others advise caution when prescrib- tions for both herself and the family. If the pregnancy and
ing some medications (Schatzberg & Nemeroff, 2004). birth were difficult, the patient may be disappointed in
Current recommendations are that although most medica- herself and “blame” the baby for the difficulties.
tions pass into breast milk, there are very few instances in Moreover, if the patient is exhausted and requires extra
which breastfeeding must be discontinued (Pigarelli, Kraus, rest, the nurse can help her inform her friends and family
& Potter, 2008). The infant’s daily dose of medications is about this need. The nurse should give the patient permis-
less than the maternal daily dose. With lithium, however, sion to send her newborn to the nursery without feeling
serum concentrations in the infant may reach 50% of guilty, so that when she awakens, she can enjoy the new-
maternal levels. Thus, breastfeeding is usually discouraged born rather than becoming frustrated by his demands. It
in mothers who are taking lithium; the American Psychiat- is paramount for the nurse to remain sensitive to patients
ric Association considers lithium incompatible with breast- who are not coping well in the hospital, and advocate for
feeding (Fankhauser & Freeman, 2005). Long-term neu- follow-up by a home health nurse or social worker.
robehavioral effects on the infant related to exposure to After discharge, the nurse in the office or clinic can
psychotropic medications in breast milk are unknown. utilize waiting time for conversation and make note of any
physical characteristics that may indicate the need for
Prognosis some respite time from the demands and responsibilities
Women with postpartum psychosis have a 25% to 50% of parenthood. The nurse should become familiar with
chance of reoccurrence in future pregnancies (APA, 2000; available community support services such as a Mother’s
Nonacs, 2005). These women are also at greater risk for a Day Out to which the mother can be referred. It is also
future psychotic event unrelated to pregnancy. Counsel- important to involve the collaborative team—the physi-
ing and educational roles of the health care team for these cian, lactation consultant, social worker, and spiritual
patients and their families is paramount to health promo- advisor—in the patient’s care.
tion and maintenance.
Now Can You— Discuss postpartum blues, depression Postpartum Nursing for Vulnerable
and psychosis? Populations
1. State the difference between postpartum blues and
postpartum depression? While caring for women and their families after birth, the
2. Discuss what you would tell a woman with a history of postpartum nurse may be informed about or discover that
postpartum depression about future pregnancies and the special needs exist. If the woman received prenatal care,
probable plan of care? the prenatal history and physical examination may con-
3. Describe the signs and symptoms of postpartum psychosis? tain information that indicates the patient is in an abusive
relationship, is living in a homeless shelter, has no trans-
portation, is a migrant worker, or did not initiate care
until the second or third trimester. These social risk fac-
SUMMARIZING POSTPARTUM PSYCHOSOCIAL tors are of concern and always require follow-up. In addi-
NURSING CARE tion, a woman who gives birth with no prenatal care
Perinatal nursing offers an opportunity to develop a thera- requires support from health care professionals to ensure
peutic relationship with a woman and her family during that both she and her newborn will have their basic needs
one of the most vulnerable times in their lives. Most preg- of food, clothing, and shelter met. Though many in the
nancies are both planned and desired, but physiological world view the United States as an international social
and psychosocial adaptations to the pregnancy, birth, and welfare agency and wish to live here, some American
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period 535
When a postpartum nurse determines that a postpartum states that border Mexico (Texas, New Mexico, Arizona,
patient and her infant are possibly returning to an abusive and California) routinely fund and provide care for undoc-
environment, several interventions can occur. The nurse umented immigrants. Wrongly, many Americans believe
must first confirm the suspicions by asking direct ques- that the primary reason Latinos come to the United States
tions. If the patient confirms that she is a victim of intimate is to receive free medical care, which can include deliver-
partner violence (regardless of the form), the nurse needs ing a baby in this country in order to have a United States
to immediately enlist the help of a social worker and a citizen in the family. Berk, Schur, Chavéz, and Frankel
chaplain. These professionals are more knowledgeable (2000) studied undocumented Latinos in Houston and El
about community resources such as safe houses, churches, Paso, Texas and in Fresno and Los Angeles, California.
and child protective services to which the patient can be They studied Latinos because this group represents an
referred. The health care team can help empower the estimated 70% of all undocumented immigrants. The
patient to have an action plan to escape the abuse at a later sample size began with 7352 households and eventually
time, should she choose to delay this decision. resulted in 973 participants. From surveying and inter-
It is important to remember that if the patient chooses viewing one member of each household, the investigators
to return to the abusive environment, the nurse’s role does found that the primary reason undocumented Latinos
not end. Follow-up after discharge may include a home come to the United States is to find jobs. Only in El Paso
visit or a well baby checkup, during which time further was this not the primary reason. In El Paso, 49% of
interventions can occur. When a patient has only herself respondents cited “uniting with family members and
to think about, she may be less likely to take protective friends” as their main reason for immigrating, and this
action. However, maternal instincts may empower the primary reason was followed by “finding work” (p. 49).
woman to protect her baby and other children from abuse Recently, the Centers for Medicare and Medicaid Ser-
or violence. Even if the nurse is only able to be a therapeu- vices (CMS) proposed a plan whereby those states bearing
tic listener, this role may allow the patient to rehearse her the highest cost of health care services for undocumented
action plan, ask questions, share information, and affirm immigrants under EMTALA (Emergency Medical Treat-
her decisions regarding the future. ment and Active Labor Act) requirements would receive
Lack of personal contact does not mean that interven- reimbursement over 4 years for these services. Though this
tions cannot occur. McFarland et al. (2004) used tele- plan would help defray state costs for these services, health
phone interviews to conduct a longitudinal study on care providers would be expected to document the immi-
abused women. After an initial personal contact with gration status of their patients. Immediately after this pro-
abused women to ask about inclusion in the study and to posal, the American Nurses Association leadership shared
obtain informed consent, researchers contacted the women its concerns with CMS officials. Requiring this documenta-
with either six intervention and four follow-up calls tion would likely lead to illegal immigrants avoiding health
(experimental group) or four follow-up calls only (control care settings, even when seriously ill or injured (Trossman,
group). During the phone calls, the interviewers asked 2004). While intended to help state budgets with the high
women in the experimental group to answer yes or no to a cost of emergency health care for undocumented immi-
series of safety promoting behaviors. These behaviors grants, many providers have also expressed concern. They
included such actions as hiding money, hiding house and assert that the need to establish immigration status may
car keys, removing weapons from the house, asking neigh- create not only a public health crisis, but also a greater
bors to call police if violence begins, establishing a code financial burden, since preventative care (including prena-
with family and friends, and obtaining items such as birth tal care) would not be included in the reimbursement plan.
certificates, important phone numbers, identification cards, Statistically, immigrant and minority women have higher
and rent and utility receipts. The research findings indi- rates of disability and mortality, and their overall health
cated that women in the intervention group (those who status is lower than that of white women (AHRQ, 2006).
received six additional phone calls) practiced more safety- The nurse needs to provide unbiased, excellent care to
promoting behaviors than did those in the control group all patients, regardless of immigration or minority status.
and that the required nursing time was minimal. Such A new mother and her family’s immigration status or
research findings are significant in supporting the impor- nationality does not change her needs or her family’s need
tant role that nurses and other members of the health care for compassionate, holistic, and quality care. If the patient
team can have in helping victims of intimate partner has received minimal or no prenatal care, physical and
violence take control of their environments and practice psychosocial needs may be greater and may result in com-
positive behaviors that can break the cycle of abuse. plications that require greater skill on the part of every
involved individual. Direct care nurses are not primarily
policy experts, nor do many desire this role. A vital factor
UNDOCUMENTED IMMIGRANTS in being able to provide ongoing perinatal care is to
AND MINORITY HEALTH CARE ensure women and their families they can trust those with
As a nurse provides care for postpartum women and their whom they share information and concerns. While the
families, ethical and legal concerns inevitably arise. One of United States and individual state politicians debate the
these issues often concerns undocumented immigrants financial implications and resources required to provide
and minority health. The United States continues to health care for those in this country who need it, the man-
attract a cosmopolitan population and to be viewed as a date for nurses is that they be one of the most valuable
haven for those in search of a better life. Not all who come resources available to meet the needs of all new mothers
to the United States seek American citizenship or a legal and families for whom they care. Nursing is as much a
visa for employment purposes. In particular, citizens in “calling” as it is a profession.
chapter 16 Caring for the Woman Experiencing Complications During the Postpartal Period 537
Now Can You— Discuss issues related to the care of minority and chaplain. The physician caring for the mother and
and undocumented immigrant women? baby needs to satisfy legal requirements before discharg-
ing the patient and newborn. Often, the nurse needs to
1. State the most common reason undocumented immigrants collect newborn urine and/or meconium samples for
come into the United States? drug screening. If the hospital or birthing center employs
2. Describe a major nursing role when caring for immigrant a nurse who conducts a follow-up visit to check on the
and minority women? new mother and baby and immediate housing is avail-
3. State some potential outcomes for women and their babies able, the physician may elect to discharge them with an
who obtain minimal or no prenatal care? early visit arranged.
If the woman has absolutely nowhere to go after dis-
charge, the nurse and others have an ethical and legal
responsibility to ensure that the newborn is adequately
HOMELESSNESS AND LIMITED ACCESS fed and clothed. Child Protective Services, the United
TO CARE Way Agency, or church-affiliated social programs may be
Women and newborns who are homeless and without an sources of help for this family. Immediate solutions are
established health care provider for follow-up constitute a required. Longer-term arrangements will take additional
particularly vulnerable population after childbirth. Better resources and time. Ultimately, because the newborn is
health care outcomes are positively correlated with having a completely dependent on others for his needs to be met,
usual or principal source of care. Black and Hispanic Ameri- the best situation for the baby often drives the final
can women are much less likely than others to have a pri- decisions.
mary source of care, and this population is also more likely
to be uninsured (Partnership for the Homeless, 2008). POSTPARTUM CARE OF VULNERABLE
Often these same women are those who are homeless. POPULATIONS
Whether migrant workers who follow the crops they
Most commonly, postpartum nurses care for women and
help to harvest or individuals with socioeconomic and
families who are functional and healthy (physically, psy-
interpersonal challenges, homeless women and their
chosocially, spiritually). If the nurse knows a couple or
children represent a population that requires sensitive,
family who is unable to have children and who is explor-
skilled discussions, so that they can receive appropriate
ing the option of adoption, handling dilemmas such as
follow-up care. The fact that the pregnancy rate among
abuse or homelessness may be especially difficult. When
homeless women is almost twice that of the general
a childbearing woman faces difficult challenges and
population (Gelberg et al., 2001) is a statistic that
requires additional support, her only source of this sup-
requires action. The Healthy People 2010 indicators
port may be the health care community. Regardless of
include access to prenatal care for all women as a major
personal impressions, the nurse needs to be receptive to
initiative.
lessons that can be learned from this patient’s situation.
Studies designed to address barriers to perinatal care
Most new mothers want the best life possible for their
have noted similar findings. The research of both Mikhail
newborns. Armed with this fact, nurses can grow in their
(1999) and Bloom et al. (2004) examined barriers
ability to understand and respond with sensitivity to all
among homeless, pregnant women (in California and
families for whom they care.
Florida, respectively). There are several barriers preg-
nant, homeless women face when considering whether
Now Can You— Discuss strategies in caring for vulnerable
to begin or continue prenatal care (e.g., waiting time to
populations?
see a practitioner, especially when compared to the time
the practitioner actually spent with the patient; lack of 1. List important members of the health care team to involve in
transportation, care for older children, or encourage- the continuum of care for vulnerable pregnant women or
ment to get prenatal care from family members; concern new mothers and their babies?
about having their children removed from their care; 2. State a Healthy People 2010 goal for pregnant women?
and finances). Maupin, Fatsis, and Prystowiski (2004) 3. List characteristics of pregnant women who are most
described women who give birth with no prenatal care unlikely to get prenatal care?
as those who are more likely to be multiparous, living
with at least one child, less educated, uninsured, and
tobacco or recreational drug users. Most pregnant,
homeless women surveyed did not intend to become summar y poi nt s
pregnant. Ethnically, more African American and His-
panic women are likely to bypass prenatal care than are ◆ Postpartum hemorrhage may occur early (within the
their white counterparts (Bloom et al., 2004; Frisbie, first 24 hours after birth) or late (after the first 24 hours
Echevarria, & Hummer, 2001). but within 6 weeks after childbirth).
If a woman presents to a hospital in labor and has not
◆ Puerperal infections may involve the uterus, urinary
received prenatal care, EMTALA requires that a physi-
cian and hospital staff members deliver her baby and system, incisions, and breasts. Each type of infection
provide her and her newborn with care until they can be has common and unique risk factors, onset, signs and
safely discharged. If it is determined that the mother is symptoms, causative organisms, and complications.
homeless, once again the nurse must solicit the help of ◆ Thrombophlebitis is an inflammation of the venous
the interdisciplinary team, including the social worker circulation and blood clot formation that typically
538 unit five Care of the New Family
Clemmens, D., Driscoll, J.W., & Beck, C.T. (2004). Postpartum depres- MacMullen, N.J., Dulski, L., & Meagher, B. (2005). Red alert: Perinatal
sion as profiled through the postpartum depression screening scale. hemorrhage. The American Journal of Maternal/Child Nursing, 30(1),
The American Journal of Maternal/Child Nursing, 29(3), 180–185. 46–51.
Colman-Brochu, S. (2005). Deep vein thrombosis in pregnancy. The Magann, S.E., Hutchinson, M., Collins, R., Howard, B.C., & Morrison,
American Journal of Maternal/Child Nursing, 29(3), 186–192. J.C. (April, 2005). Postpartum hemorrhage after vaginal birth: An
Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Gilstrap, L., & analysis of risk factors. Southern Medical Journal 98(4), 419–424.
Wenstrom, K.D. (2005). Williams’ obstetrics (22nd ed.). New York: Retrieved from http://80-galenet.gale-group.com (Accessed May 12,
McGraw-Hill. 2005).
Davey, S.J., Dziurawiec, S., & O’Brien-Malone, A. (2006). Men’s voices: Mass, S. (2004). Breast pain: Engorgement, nipple pain, and mastitis.
Postnatal depression from the perspective of male partners. Qualita- Clinical Obstetrics and Gynecology, 47(3), 676–682.
tive Health Research, 16, 206–220. Maupin, R., Fatsis, J., & Prystowiski, E. (2004). Characteristics of
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses women who deliver with no prenatal care. Journal of Maternal-Fetal
(11th ed.). Philadelphia: F.A. Davis. and Neonatal Medicine 16(1), 45–50.
Family Violence Prevention Fund. (2008). Domestic violence and health McCosker, H., Barnard, A., & Gerber, R. (Nov. 21, 2003). A phenom-
care. Retrieved from www.endabuse.org (Accessed April 17, 2008). enographic study of women’s experiences of domestic violence dur-
Fankhauser, M., & Freeman, M. (2005). Bipolar disorder. In J. DiPiro, ing the childbearing years. Online Journal of Issues in Nursing.
R. Talbert, G. Yee, G. Matzke, B. Wells, & M. Posey (Eds.), Pharma- Retrieved from http://www.ana.org/ojin/topic17/tpc17_6.htm
cotherapy: A pathophysiologic approach (6th ed., 216–233). New (Accessed May 4, 2005).
York: McGraw-Hill. McFarland, J., Malecha, A., Gist, J., Watson, K., Batten, E., Hall, I., &
Flamm, B.L. (Nov. 15, 2003). Postpartum hemorrhage (Clinical Pearls). Smith, S. (2004). Original research: Increasing the safety promoting
ObGyn News. 38(22), 39. Retrieved from http://80-galenet.galegroup. behaviors of abused women. American Journal of Nursing, 104(3),
com (Accessed May 12, 2005). 40–51.
Foster, C. (2007). Factor V Leiden Mutation: What is it? What are the Meyer, G., & Lavin, M.A. (2005). Vigilance: The essence of nursing.
implications for clinical practice? The American Journal for Nurse Online Journal of Issues in Nursing. Retrieved from http://nursing-
Practitioners, 11(6), 35–46. world.org/ojin/topic22/tpc22_6.htmon (Accessed October 5, 2006).
Franzblau, N., & Witt, K. (June 26, 2006). Normal and abnormal puer- Mikhail, B.I. (1999). Perceived impediments to prenatal care among low-
perium. Retrieved from http://www.emedicine.com/med/topic3240. income women. Western Journal of Nursing Research, 21(3),
htm (Accessed October 1, 2007). 335–348.
Frisbie, W.P., Echevarria, S., & Hummer, R.A. (March, 2001). Prenatal Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing
care utilization among non-Hispanic whites, African-Americans, and outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
Mexican Americans. Maternal and Child Health Journal, 5(1), 21–33. NANDA International. (2007). NANDA-I nursing diagnoses: Definitions
Gelberg, L., Leake, B.D., Lu, M.C., Anderson, R.M., Wenzel, S.L., & and classifications 2007-2008. Philadelphia: NANDA-I.
Morgenstern, H. (2001). Use of contraceptive methods among home- National Center for Injury Prevention and Control. (2008). Intimate
less women for protection against unwanted pregnancies and sexu- partner violence: Fact sheet. Retrieved from http://www.cdc.gov/
ally transmitted diseases: Prior use and willingness to use in the ncipic/factsheets/ipvfacts.htm (Accessed April 17, 2008).
future. Contraception, 63, 277–281. Nonacs, R.M. (August 8, 2005). Postpartum depression. Retrieved from
Gibbs, R., Sweet, R., & Duff, P. (2004). Maternal and fetal infectious http://www.emedicine.com/med/topic3408.htm (Accessed October
disorders. In R. Creasy, R. Reznik, & J. Iams (Eds), Maternal-fetal 1, 2007).
medicine: Principles and practice (5th ed., 955–986). Philadelphia: Partnership for the Homeless. (2008). The Partnership’s programs work
W.B. Saunders. to break the cycle of homelessness. Retrieved from http://www.
Goodman, J.H. (2004). Postpartum depression beyond the early postpar- partnershipforthehomeless.org/ (Accessed April 17, 2008).
tum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing, Pigarelli, D., Kraus, C., & Potter, B. (2008). Pregnancy and lactation:
33(4), 410–420. Therapeutic considerations. In J. DiPiro, R. Talbert, G. Yee, G.
Healthy People 2010: Understanding and improving health. (2000). Matzke, B. Wells, & M. Posey (Eds.), Pharmacotherapy: A pathophysi-
Retrieved from http://www.health.gov/healthypeople/Publications ologic approach (7th ed., pp 1297–1312). New York: McGraw-Hill.
(Accessed September 23, 2005). Reuters Health (2005). Trauma common feature of American Indian life.
Hobbins, J.C. (April 1, 2005). The length of the third stage of labor and risk From American Journal of Public Health, May, 2005. Retrieved from
of postpartum hemorrhage. OB/GYN Clinical Alert (Comment). Retrieved http://www.nlm.gov/medlineplus/news/fullstory_24951.html
from http://80-galenet.galegroup.com (Accessed May 12, 2005). (Accessed June 9, 2005).
Jesse, D.E., & Graham, M. (2005). Are you often sad and depressed: Sadock, B.J., & Sadock, V.A. (2004). Kaplan & Sadock’s comprehensive
Brief measures to identify women at risk for depression in pregnancy. textbook of psychiatry. Philadelphia: Lippincott Williams &
The American Journal of Maternal/Child Nursing, 1(1), 40–45. Wilkins.
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Schatzberg, A., & Nemeroff, C. (Eds.). (2004). The American Psychiatric
Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and Publishing textbook of psychopharmacology. (3rd ed.). Washington,
NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). DC: American Psychiatric Publishing.
St. Louis, MO: Mosby Elsevier. Smith, J.R., & Brennan, B. (June 13, 2006). Postpartum hemorrhage.
Kennedy, E. (August 8, 2007). Pregnancy, postpartum infections. Retrieved from http://emedicine.com (Accessed June 13, 2006).
Retrieved from http://www.emedicine.com/emerg/topic482.htm Stoops, J., & Mann, N. (2004). Psychological/emotional wellness and
(Accessed October 1, 2007). illness. In M. Condon (Ed.), Women’s health: An integrated approach
Lawrence, R., & Lawrence, R. (2005). Breastfeeding: A guide for the medi- to wellness and illness (pp. 538–556). Upper Saddle River, NJ:
cal profession (6th ed.). Philadelphia: C.V. Mosby. Pearson Education.
Lincoln, V., & Kleiner, K. (2004). Holistic health: Complementary thera- Trossman, S. (November–December, 2004). No easy answers: Address-
peutic disciplines and remedies. In M.Condon (Ed), Women’s health: ing the needs of undocumented immigrants. The American Nurse,
An integrated approach to wellness and illness (pp. 195–225). Upper November–December, 2004. Retrieved from http://www.Nursing-
Saddle River, NJ: Pearson Education, Inc. World.org (Accessed May 4, 2005).
Linter, N., & Gray, B. (2006). Childbearing and depression: What nurses Walters, K.C., & Wing, D.A. (2007). Misoprostol and postpartum hem-
need to know. AWHONN Lifelines, 10(1), 50–57. orrhage. The Female Patient, 32(7), 53–60.
Logsdon, M.C., Birkimer, J.C., Simpson, T., & Looney, S. (2005). Post- Wilkinson, J.M. (2005). Nursing diagnosis handbook. Upper Saddle River,
partum depression and social support in adolescents. Journal of NJ: Pearson Education.
Obstetric, Gynecologic & Neonatal Nursing, 34(1), 46–54. Yost, N., Bloom, S., McIntire, G., & Leveno, K. (2005). A prospective
Luegenbiehl, D.L., Brophy, G., Artigue, G., Phillips, K., & Flack, R. observational study of domestic violence during pregnancy. Obstet-
(1990). Standardized assessment of blood loss. MCN: American Jour- rics and Gynecology, 106(1), 61–65.
nal of Maternal-Child Nursing, 15(4), 241–244.
CONCEPT MAP
Collaborative Management
• Assess for c/o unremitting pain and pressure;
Physical Hematoma vital signs; examine perineum/vulva; assess for
shock; notify MD or CNM; ice for 12 hours then
sitz bath; analgesics; greater than 12 cm I&D
Caring for the Woman
Experiencing
Complications During Collaborative Management
the Postpartal Period • Locate source of bleeding;
Early: within first 24 hours; establish IV access
higher in first 4 hours • Assess for: hypovolemic shock;
Psychosocial Postpartum vital signs; MAP; LOC
hemorrhage • Fundal massage; bladder palpation
• Observe rate of pad saturation;
Late: within first 6 weeks calculate I&O
Postpartum Blues
• Monitor for bleeding
• Common, self-limiting
• Possible surgical intervention
• Teary, moody, sadness
• Related to abrupt
hormone changes
Nursing
• Education; Assess Collaborative Management
resources • Assess for: fever, tachycardia,
• Rest, reassurance, uterine/fundal pain or tenderness,
therapeutic listening Puerperal infections foul smelling lochia, chills, malaise,
dysuria, inflammatory breast edema
• Antibiotic therapy; analgesics
• Encourage rest
• Increase fluids, protein, vitamin C
Postpartum Depression
• Decreased interest in
infant or overconcern
• Panic attacks
• Inability to make
decisions
Nursing Best Outcome
• Prenatal screening • Weigh pads for accurate blood loss
• Assess mother–infant • Explain interventions; control pain
interaction, bonding,
prior risk factors Across Care Settings:
• Continue assessment • Communicate risk for infection
during well baby to family and community health
providers Clinical Alert:
checkup; negativity,
neglect, social needs • Firm uterus plus slow steady
blood trickle = significant loss
• Large blood loss can occur
without change in vital signs
Postpartum Psychosis
Where Research And Practice Meet:
• Rare, severe mental illness
• Education regarding puerperal
• Involves hallucinations,
infections r/t early discharges
delusions, agitation, confusion,
suicidal/homicidal thoughts • Jesse/Graham 2 item depression
screen Critical Nursing Action:
Management • Fundal massage for
• Mental health emergency: uterine atony
hospitalize
• Immediate and long term
pharmacotherapy
Now Can You:
• Discuss holistic care of the woman experiencing postpartum hemorrhage
• Discuss routine care of the postpartum patient hospitalized with a DVT
• Describe the signs and symptoms of postpartum psychosis
chapter
Physiological Transition
of the Newborn 17
Our journey begins and ends with the development of a family. Becoming a mother is the
beginning of a wondrous journey… The transition of that little living being within you to that
amazing, beautiful newborn you will love and loves you back unconditionally…
—D. Teeple
LEAR NING T AR GETS At the completion of this chapter, the student will be able to:
◆ Explain the importance of the development of surfactant and its role in the successful transition of
the neonate.
◆ Identify the four factors that influence the initiation of respirations.
◆ Discuss how the four anatomical structures that enable in utero survival must undergo significant
transition following birth.
◆ Explain the importance of administering vitamin K to the neonate after birth and describe its effect
on the hematopoietic system.
◆ Describe the process of nonshivering thermogenesis and the importance of brown adipose tissue in
the neonate.
◆ List neonatal liver functions that allow for successful physiological transition.
◆ Name the enzymes present in the neonate’s gastrointestinal system and describe their role in
digestion.
◆ Identify the factors that influence kidney adaptation to allow for the management of bodily fluids
and urine excretion.
◆ Identify the three primary immunoglobulins that are important in strengthening the neonate’s
immunological system.
◆ Discuss normal neonatal patterns of behavior during the first several hours after birth.
The purpose of this study was to explore with first-time moth- by Nugent, Keefer, O’Brien, Johnson, and Blanchford (Brazel-
ers the feasibility and desirability of the Newborn Behavioral ton Institute, n.d.; Nugent et al., in press) as a tool to pro-
Observation (NBO) system as a nursing intervention in assist- mote positive parent–infant relationships that could be
ing mothers to establish engagement with their newborn. included as part of routine maternal–child care. The tool
Engagement was defined as “the social process of maternal assists the nurse in orientating parents to the characteristics
transition that enables growth and transformation and is and competencies of the newborn through neurobehavioral
linked to attachment and bonding.” The NBO was developed assessment items.
(continued)
541
542 unit five Care of the New Family
flow (necessary while in utero) and facilitates the carbon dioxide levels (PCO2) begin to rise and prompt the
initiation of air breathing (Hernandez, Zabloudil, & respiratory center within the medulla to initiate breathing.
Hernandez, 2004). During a vaginal birth, approxi- This brief period of asphyxia occurs in all newborns during
mately one third of the fetal lung fluid is expelled due the birth process. However, prolonged asphyxia that
to the “thoracic squeeze” that occurs during passage accompanies a traumatic birth is abnormal and may cause
through the birth canal. Infants of cesarean births are a central nervous system (CNS)-mediated respiratory
at a higher risk for pulmonary transitional difficulties depression.
because they do not receive the lung compression ben-
efits associated with a vaginal birth. Sensory Factors
Lung expansion after birth stimulates the release of sur- The newborn experiences a vast amount of stimuli when
factant, a slippery, detergent-like lipoprotein. Surfactant leaving a familiar, comfortable, warm environment to enter
causes a decreased surface tension within the alveoli, which into an extremely sensory overloaded one—filled with a
allows for alveolar re-expansion after each exhalation. multitude of tactile, visual, and auditory stimuli. These
Under normal circumstances, by the 34th to 36th weeks of sensory experiences aid in the initiation of respirations.
gestation, surfactant is produced in sufficient amounts to
maintain alveolar stability (Bloom, 2006). Thermal Factors
Many factors such as acidemia, hypoxia, shock, After months of development in a warm (98.6ºF [37ºC])
mechanical ventilation, and hypercapnia (an increased fluid-filled environment, the newborn abruptly enters
level of serum carbon dioxide) may interfere with surfac- into a thermal environment that ranges from 70 to 75ºF
tant metabolism. Surfactant production is decreased in (21 to 23.9ºC). The drastic change in temperature helps
infants of diabetic mothers (classes A, B, and C), infants to stimulate the initiation of respirations. Sensors in the
with hemolytic disorders (e.g., erythroblastosis fetalis), skin respond to the temperature changes and send signals
and in multiple gestations. Conversely, surfactant produc- to the respiratory system in the brain. Physiological
tion may be accelerated in other infants such as those of changes in the neonate’s temperature may occur and as
mothers with class D, F, and R diabetes, hypertension, long as the temperature remains within the normal range
and heroin addiction. Fetal exposure to maternal infec- of 97.7 to 98.6ºF (36.5 to 37.0ºC), no problems related
tions and placental insufficiency may also accelerate the to the thermal environment should develop. However, to
production of surfactant. prevent cold stress and respiratory depression, it is
imperative for the nurse to immediately dry and either
THE FIRST BREATH place the infant (skin to skin) with the mother or in a
Four factors influence the initiation of the newborn’s radiant warmer.
first breath. These include internal stimuli: the chemical
changes; and external stimuli: the sensory, thermal, and Mechanical Factors
mechanical changes (Fig. 17-1). Each factor stimulates Removal of fluid from the lungs with the subsequent
the respiratory center located within the medulla of replacement of air constitutes the primary mechanical
the brain. factors involved in the initiation of respirations. The
fetal chest compression that occurs during a vaginal
Chemical Factors birth increases the intrathoracic pressure and helps to
Chemical factors that initiate respirations are hypercarbia, push fluid out of the lungs. Recoil of the chest wall after
acidosis, and hypoxia. These conditions, brought about by delivery of the neonate’s trunk creates a negative intra-
the stress of labor and birth, stimulate the respiratory cen- thoracic pressure. This facilitates a small, passive inspi-
ter in the brain to initiate breathing. Hypoxia causes blood ration of air, which replaces the fluid that has been
oxygen levels (PO2) and pH to drop. Subsequently, blood squeezed out.
Stimulate
Message sent respiratory center
to respiratory
center in medulla Touch
Sound
Activate Light
chemoreceptors Cool air
Onset of Respirations
O2 Levels
Ductus arteriosus (ligamentum pressure; and closure of the foramen ovale, the ductus
arteriosum when ductus closes) arteriosus, and the ductus venosus (Hernandez &
Superior
vena cava Aortic arch Pulmonary artery Hernandez, 2004) (Fig. 17-4). A summary of the struc-
Fossa ovale tural changes in circulation that take place in the neonate
Pulmonary Pulmonary is presented in Table 17-1.
artery veins
Right Closure of the Foramen Ovale
lung
Right Left The foramen ovale is a flap in the septum of the fetal heart
atrium atrium that allows blood flow between the left and right atria.
Left
Oxygen-rich blood returning to the heart from the inferior
Inferior vena cava crosses from the right atria to the left atria across
lung
vena
cava
the foramen ovale. This pathway allows most of the oxygen-
Left ventricle ated blood to bypass the nonfunctioning lungs and supply
Hepatic
veins Right ventricle
the aorta and vessels of the heart and head with oxygen.
Liver
Blood flowing through the foramen ovale accounts for
Abdominal aorta approximately one third of the fetal cardiac output; less than
Ductus 10% is used for lung perfusion (Barzansky et al., 2006).
venosus Oxygen saturation
(closes- The right-to-left shunting ceases once the umbilical
of blood
becomes cord has been clamped. The ventricular and aortic pres-
High
ligamentum
Portal sures in the left side of the heart rise. The systemic vascu-
venosum) Low
vein lar resistance increases while pressure in the right side
decreases. The pulmonary blood vessels respond to the
Common increase in PO2 during lung expansion and aeration with
Umbilical vein iliac artery
(closes- vasodilation and a decrease in pulmonary vascular resis-
becomes Internal tance. These changes cause an increase in blood flow
ligamentum iliac artery through the pulmonary veins to the left atrium and lead to
teres) External an increased left atrial pressure that results in closure of
Umbilical
iliac artery the foramen ovale (MacDonald et al., 2005). Since the
cord foramen ovale is capable only of shunting from right to
Umbilical arteries left, this physiological event closes the shunt. Because of
Figure 17-4 Neonatal circulation. unequal pressures within the heart, the foramen ovale is
functionally closed within 1 to 2 hours after birth. Depos-
its of fibrin and cells seal the shunt and it is physiologi-
cally closed by 1 month of age. Permanent closure occurs
by the sixth month of life. If the infant experiences diffi-
Cardiovascular Adaptation culties such as asphyxia, acidosis, or cold stress during the
CHANGES AFTER PLACENTAL EXPULSION physiological transition period, the shunt may reopen and
allow for continued right to left shunting due to the
Expulsion of the placenta following childbirth triggers increased pressure in the right atria.
important physiological events in the transition process.
In utero, the placenta serves as the exchange organ for Closure of the Ductus Arteriosus
oxygen and nutrients and for the excretion of fetal waste In utero, most of the fetal blood flow occurs across the
products such as carbon dioxide. Maternal oxygenated ductus arteriosus. This structure functions as the pathway
blood enters the fetal circulation via the umbilical vein. between the pulmonary artery and the descending aorta.
Approximately 40% to 60% of the blood perfuses the fetal Blood flow through the ductus arteriosus occurs in a
liver while the remaining volume of blood passes through right-to-left direction due to a high pulmonary vascular
the ductus venosus and enters the right atrium via the resistance and low placental resistance. Once the umbili-
inferior vena cava. cal cord is clamped, placental blood flow ceases and there
During gestation, the placenta is the organ primarily
responsible for gas exchange in the fetus although there is
a small amount of blood flow to the lungs. As a “low resis-
tance circuit,” the placenta receives approximately 50% of Table 17-1 Structural Changes in Circulation After Birth
the fetal circulation (Hernandez, Zabloudil, & Hernandez, Fetus Neonate
2004). The fetal pulmonary circulation is a low flow,
“high pulmonary resistance circuit” that receives only Umbilical vein Ligamentum teres
approximately 10% of the ventricular output (MacDonald Ductus venosus Ligamentum venosum
et al., 2005). (See Chapter 7 for further discussion.)
After placental separation at birth, the umbilical arter- Foramen ovale Closed atrial septum
ies and vein constrict as the fetal circulatory system is Ductus arteriosus Ligamentum arteriosum
interrupted. Successful cardiopulmonary adaptation in
the neonate involves five major changes: an increased Umbilical artery Superior vesical (bladder) artery
aortic pressure and decreased venous pressure; an Lateral vesicoumbilical ligaments
increased systemic pressure and decreased pulmonary
chapter 17 Physiological Transition of the Newborn 547
is an increase in the systemic blood pressure and vascular should decline to 120 to 160 beats per minute. This nor-
resistance. At this point, the lungs oxygenate the blood mal fluctuation occurs in response to the cardiovascular
and the increased PaO2 stimulates the closure of the duc- transition and the newborn’s behavioral states.
tus arteriosus. On assessment, the systemic circulation is deemed
During pregnancy, the placenta produces prostaglan- adequate if the newborn exhibits a brisk capillary refill
din E2 (PGE2), a hormone-like substance that causes vaso- and stable blood pressure. Capillary refill in less than
dilation of the ductus. After birth, declining PGE2 levels 3 seconds is considered adequate. A refill time greater
contribute to the closure of the ductus arteriosus. In the than 4 seconds may be indicative of an underlying condi-
neonate, a small amount of blood flowing through the tion such as sepsis, hypoxia, or cardiovascular or central
ductus may produce a soft murmur. When present, it can nervous system compromise.
be auscultated at the left sternal border in the area of the
second intercostal space. Considered innocent, the func- Across Care Settings: Facilitating newborn
tional murmur occurs in the absence of any cardiac
anomalies and is generally asymptomatic (Miller & New- transition in a birth center
man, 2005). It is essential that the nurse who assists with an unexpected
Functional closure of the ductus arteriosus in a term birth in a nonhospital setting such as a minor care clinic or
infant typically occurs within the first 72 hours of life. physician office be able to recognize behaviors associated with
Once permanent closure occurs at 3 to 4 weeks, the struc- normal and abnormal physiological transition in the newborn.
ture is termed the ligamentum arteriosum. Permanent Since resources outside of the hospital are usually limited, the
closure results from endothelial destruction, connective nurse must be alert to signs of transitional difficulties. As
tissue formation and subintimal proliferation (MacDonald much as is possible, the environment should be manipulated
et al., 2005). to provide immediate care for the newborn during transition
The infant whose birth transition has been complicated from the intra- to the extrauterine environment. After
by factors such as asphyxia or prematurity has an increased ensuring effective respirations, facilitating a neutral thermal
risk of a return to fetal circulation. This event results from environment is an essential nursing action. Ideally, a supply of
continued blood flow through the partially opened ductus warm, dry linens should be available to prevent neonatal cold
arteriosus. Low levels of oxygenated blood flowing stress. In the optimal situation, the nurse has time to evaluate
through the shunt cause it to dilate, creating a serious the mother prior to delivery and can be alert to any potential
transitional complication (MacDonald et al., 2005). maternal complications during childbirth. A reliable
mechanism for the safe transport of the mother and her
Closure of the Ductus Venosus
newborn to the hospital should be established as soon as
The ductus venosus links the inferior vena cava with the possible. The nurse must manage care of the neonate and the
umbilical vein. The umbilical vein delivers approximately mother until the transport team arrives.
50% of the placental blood flow through the ductus veno-
sus into the inferior vena cava and then mixes with the
systemic venous drainage from the lower body. Blood flow
through the left hepatic vein mixes with blood in the infe-
rior vena cava and flows toward the foramen ovale. Oxy- Thermogenic Adaptation
genated blood traveling through the umbilical vein enters Neonatal thermoregulation is essential for life sustaining
the left ventricles and supplies the carotid arteries with physiologic adaptation. The newborn’s ability to maintain
oxygen (Barzansky et al., 2006). Once the umbilical cord a normal body temperature after birth is dependent on
is clamped, cessation of umbilical venous blood return, factors in the external environment as well as internal
along with mechanical pressure changes, lead to closure physiologic processes. Newborns are characteristically
of the ductus venosus. Closure of the bypass route forces homeothermic—that is, they attempt to regulate and
enhanced blood flow to the liver. Fibrosis occurs in the maintain their internal core temperature regardless of
nonfunctional ductus venosus and the structure, which is varying external environmental temperatures.
termed the ligamentum venosum, usually closes by the
end of the first week.
THE NEUTRAL THERMAL ENVIRONMENT
Now Can You— Discuss cardiopulmonary transitions in the Thermogenic adaptation is closely related to the infant’s
neonate? rate of oxygen consumption and metabolism. The neutral
1. Explain characteristics of periodic breathing in the neonate? thermal environment (NTE) is the range of temperature in
2. Identify when the ductus venosus functionally closes? which the newborn’s body temperature can be maintained
3. Describe the physiological event that causes closure of the with minimal metabolic demands and oxygen consump-
foramen ovale? tion. To maintain a neutral thermal environment, the neo-
nate may need to make certain vasomotor adjustments,
such as vasoconstriction to conserve heat or vasodilation to
release heat.
ASSESSING THE CARDIOVASCULAR TRANSITION Factors such as the infant’s body size and gestational
It is important to continually monitor the newborn’s car- age can affect the ability to maintain a neutral thermal
diovascular status during transition. Immediately after environment. Although the term newborn’s protective
birth, the newborn’s pulse rate may reach 160 to 180 beats subcutaneous fat helps to maintain a barrier for preven-
per minute but during the first 30 minutes of life, the rate tion of heat loss, neonates have less than half of the
548 unit five Care of the New Family
FACTORS RELATED TO COLD STRESS vessels, cells, and nerve endings that cause it to appear
Exposure to low environmental temperatures, especially dark in color. The masses of brown fat cells accelerate
for a prolonged period of time, causes an increase in oxy- triglyceride metabolism, triggering a process that pro-
gen consumption and an increased rate of metabolism. duces heat. Rapid metabolism, along with the generation
These metabolic events lead to cold stress. All newborns of heat, quickly sends heat to the peripheral circulation.
are at high risk for cold stress and ineffective thermal reg- However, fatty acids are released from metabolized BAT
ulation due to the following factors: and can cause a life-threatening metabolic acidosis.
• Large body area in relation to body mass When the elevated fatty acids are released into the
• Limited subcutaneous fat blood stream, the infant is at risk for jaundice due to
• Limited ability to shiver interference with the transport of bilirubin to the liver
• Their skin is thin and their blood vessels are close to (Sedin, 2006).
body surface
Optimizing Outcomes— Preventing cold stress in the
PHYSIOLOGICAL ADAPTATIONS FOR HEAT newborn
PRODUCTION An important factor in neonatal resuscitation is the pre-
When the infant is exposed to a cold environment, several vention of cold stress. Several body systems are affected
physiological adaptations help him to increase heat pro- when the infant has difficulty maintaining a normal tem-
duction. These include increasing the basal metabolic rate perature and becomes hypothermic. During nonshivering
and muscle activity to generate heat, peripheral vasocon- thermogenesis, the newborn metabolizes brown fat, a pro-
striction to conserve heat, and nonshivering (or chemical) cess that increases the metabolic rate and oxygen con-
thermogenesis (NST) (heat production). Unlike children sumption. Over time, the newborn uses all available glu-
and adults, newborns are unable to shiver to generate heat. cose and glycogen stores while attempting to maintain a
Instead, they must produce heat via NST and this process neutral thermal environment. Utilization of the brown fat
becomes the key mechanism for maintaining a neutral stores places the infant at risk for metabolic acidosis.
thermal environment. Decreased oxygen causes peripheral vasoconstriction and
The sympathetic nervous system responds to skin increases the likelihood of respiratory distress. Peripheral
receptors programmed to recognize a drop in the envi- vasoconstriction can lead to increased pulmonary vascular
ronmental temperature. Once low temperatures are resistance and a return to fetal circulation as a compensa-
detected, the receptors alert the sympathetic nervous tory mechanism. Elevated fatty acids can interfere with the
system. Nonshivering thermogenesis utilizes the new- transport of bilirubin to the liver and increase the risk of
born’s stores of brown adipose tissue (BAT) to provide jaundice (Sedin, 2006) (Fig. 17-6).
heat in the cold-stressed newborn. Formation of brown
adipose tissue in the fetus begins at around 26 to 30
weeks of gestation. The deposits of BAT steadily increase
until 2 to 5 weeks after birth unless they have been MECHANISMS FOR NEONATAL HEAT LOSS
depleted by cold stress. Stores of brown adipose tissue The nurse’s role in preventing neonatal cold stress is criti-
are located in the midscapular area, around the neck, cal. Supporting thermoregulation after birth allows the
and in the axillae. Deeper deposits are found around the newborn to have a successful transition from intrauterine
trachea, esophagus, abdominal aorta, kidneys, and adre- to extrauterine life. Thorough assessments of all of the
nal glands (Fig. 17-5). newborn’s systems should be aimed at maintaining a neu-
Brown adipose tissue, also known as “brown fat,” is a tral thermal environment. The newborn has four mecha-
unique highly vascular fat found only in newborns. BAT nisms by which heat is lost after birth: evaporation, con-
derives its name from the rich abundance of blood duction, convection, and radiation (Fig. 17-7).
chapter 17 Physiological Transition of the Newborn 549
Convection
O2 consumption Convection is the loss of heat from the warm body surface
to the cooler air currents. Convective heat loss occurs
Respirations when the neonate is exposed to drafts and cool circulating
air. The nurse can help minimize neonatal heat loss
Pulmonary
through convection by preventing drafts in the birth area
Peripheral
vasoconstriction vasoconstriction (e.g., no ceiling fans) and by placing the newborn away
from doors or windows. Also, depending on the environ-
ment, the neonate should be warmly clothed and possibly
O2 uptake by lungs O2 to tissues
swaddled to prevent cooling from air currents.
Skin temperature
Dry air
Heat
Heat
Temperature
A B of base
Surface
Air current
Heat
Heat
also result from an ambient environment that is too hot Blood volume in the newborn varies according to ges-
for the newborn to successfully maintain a neutral tem- tational age, a factor that determines the amount of circu-
perature. Other causes of hyperthermia include infection, lating volume, and the occurrence of prenatal or postnatal
CNS impairment, dehydration, and medications. hemorrhage (Bloom et al., 2005). Maternal prenatal or
Radiant warmers, essential equipment in the birth area, perinatal hemorrhage can have a dramatic impact on the
must be monitored closely to ensure they are in proper infant’s hematopoietic system; following a significant
working order with reliable heating mechanisms. Caution hemorrhage the infant may exhibit decreased hemoglobin
must be exercised with the use of servo-controlled radiant and hematocrit levels along with a risk of hypovolemia.
warmers since they may cause an undesirable elevation in
the neonate’s temperature if not monitored correctly. In BLOOD COMPONENTS
addition, if programmed to maintain a set temperature,
these units may the mask the signs and symptoms of an Erythrocytes and Hemoglobin
infection if the neonate is not appropriately assessed. On At birth, the neonate has a greater number of erythro-
discharge, the nurse needs to teach parents to closely cytes and higher hemoglobin and hematocrit levels than
monitor body temperature when placing the newborn in a those found in an adult. During early fetal development,
sunny location to decrease elevated bilirubin levels. (See erythropoiesis (formation of red blood cells) occurs pri-
Chapters 18 and 19 for further discussion.) marily in the liver. At approximately 6 months of gesta-
tion, the bone marrow becomes the site for hematopoiesis
Now Can You— Discuss thermoregulation in the newborn? (formation of blood cells). During the later stages of fetal
development, fetal hemoglobin (HbF) is slowly replaced
1. Define nonshivering thermogenesis and discuss its effect on
by adult hemoglobin (HbA) (MacDonald et al., 2005).
thermoregulation in the newborn?
Fetal hemoglobin carries 20% to 50% more oxygen than
2. Identify three nursing interventions to prevent heat loss by
adult hemoglobin.
evaporation and convection after birth?
The process of erythropoiesis is stimulated by the renal
3. Explain how depletion of the brown adipose tissue stores
hormone erythropoietin. Red blood cell (RBC) produc-
places the term newborn at risk for respiratory distress?
tion increases in response to a rise in erythropoietin after
low fetal oxygen saturation. This physiological event
facilitates adequate tissue perfusion and oxygenation.
After the initiation of normal respirations at birth, the
Hematopoietic Adaptation neonate’s oxygen saturation rises, causing an inhibition in
the secretion of erythropoietin. This event inhibits the
As with most of the neonate’s other body systems, the production of red blood cells. The neonate’s erythrocytes
hematopoietic system is not fully mature at birth. Instead, (fetal RBCs) have a shorter lifespan (90 days) than do
in the days following birth, the neonate’s hematopoietic adult erythrocytes (120 days). As the neonate’s red blood
system transitions from an in utero oxygenation pathway cell count decreases from deterioration of the fetal eryth-
to an extrauterine perfusion pathway. rocytes, physiological anemia of infancy may develop and
persist for 2 to 3 months. The lifespan of erythrocytes in
BLOOD VOLUME the full term neonate is 60 to 70 days; for the preterm
The full-term infant’s average blood volume ranges from neonate, the RBC lifespan is only 35 to 50 days. In the
80 to 90 mL/kg of body weight, as compared with a blood event of hemolysis, the hemoglobin is broken down and
volume of 90 to 105 mL/kg of body weight in the preterm bilirubin is released into the systemic circulation. If large
infant. The neonate’s blood volume is determined in large numbers of RBCs are involved, blood levels of bilirubin
part by the timing of umbilical cord clamping. At birth rise and the newborn becomes jaundiced (Pagana &
there is a transfer of blood from the placenta to the neo- Pagana, 2006). (See Chapter 19 for further discussion.)
nate: approximately one fourth of the fetal blood volume
is transferred within the first 15 seconds; approximately Hematocrit
one half of the fetal blood volume is transferred by the end Hematocrit is defined as a percentage of red blood cells
of the first minute of life. The umbilical vessels carry within a certain unit volume of blood. Normal neonatal
approximately 75 to 125 mL of blood at birth and the neo- blood values vary according to gestational age and the
nate’s total blood volume may be increased by as much as volume of placental blood that was transfused at the time
61%, depending on a delay in cord clamping (MacDonald of birth (i.e., delayed cord clamping) (Table 17-2). Hema-
et al., 2005). tocrit levels are generally higher in peripheral blood sam-
Currently, much debate surrounds the issue of how ples due to peripheral vasoconstriction and the stasis of
long the umbilical cord should be allowed to pulsate blood cells. A peripherally drawn hematocrit for a normal
before it is clamped. Holding the neonate below the level infant ranges from 48% to 64%. If the hematocrit drawn
of the placenta and delaying the clamping of the cord may from a central site is greater than 65%, the infant is con-
allow up to a 100 mL/kg increase in the neonate’s total sidered to be polycythemic. Polycythemia, an abnormally
blood volume. The increase in blood volume may facili- high erythrocyte count, is a condition that can place the
tate an improved transition due to enhanced pulmonary infant at high risk for jaundice and organ damage due
perfusion and the gain of additional iron stores. A disad- to increased viscosity of the blood cells. Polycythemic
vantage of this practice concerns the increased risk of infants are also at an increased risk for hypoglycemia and
jaundice due to the higher volume of erythrocytes and respiratory distress. Under routine circumstances, unless
possible resultant polycythemia. the infant exhibits signs and symptoms associated with
chapter 17 Physiological Transition of the Newborn 551
Table 17-2 Laboratory Values for the Normal Term an allergic and anaphylactic response. Basophils play an
Neonate: Blood important role as responders to allergic and inflammatory
reactions. Lymphocytes respond to graft versus host aller-
Blood Component Normal Range gic diseases and allergic reactions. Monocytes clean up old
blood cells and cellular debris and remove activated clot-
Albumin 3.6–5.4 g/dL ting factors from the circulation.
Amylase 0–1000 IU/hr An elevated leukocyte count in a normal newborn does
not always indicate infection. During the first 12 hours
Bicarbonate 20–26 mmol/L
after birth, the leukocyte count typically remains elevated
Bilirubin, direct Less than 0.5 mg/dL before it begins to decline. The average white blood cell
count in the term newborn is 18,000/mm3, but ranges
Bilirubin, total Less than 2.8 mg/dL (cord blood)
from 9000 to 30,000/mm3 are considered to be within
0–1 days 2.6 mg/dL (peripheral blood) normal limits. Infection is usually associated with a
1–2 days 6–7 mg/dL (peripheral blood) decrease in the leukocyte count. Neonatal sepsis is accom-
panied by an increased number of immature leukocytes
3–5 days 4–6 mg/dL (peripheral blood) along with a decrease in the total platelet count (Roberts,
Bleeding time 2 Minutes 2005). (See Chapter 19 for further discussion.)
Arterial blood gases Platelets
pH 7.35–7.45 Due to the absence of vitamin K at birth, the neonate is at
risk for developing a blood clotting deficiency during the
PaCO2 35–45 mm Hg
first few days of life. To facilitate clotting, the following
PaO2 50–90 mm Hg blood factors must be present: factor II (prothrombin) and
Venous blood gases factors VII, IX, and X. Vitamin K, synthesized in the
infant’s intestinal tract, is not produced in the intestines
pH 7.35–7.45 until food and normal intestinal flora are present.
PaCO2 41–51 mm Hg The infant is given an intramuscular injection of
vitamin K1 phytonadione (AquaMEPHYTON) during the
PaO2 20–49 mm Hg initial care and assessment to prevent hemorrhagic disease
Calcium, ionized 2.5–5 mg/dL of the newborn. (See Chapter 19 for further discussion.)
The normal newborn’s platelet (thrombocyte) levels range
Calcium, total 7–12 mg/dL from 150,000 to 300,000/mm3 and are essentially the
Glucose 30–125 mg/dL same as in adults. Small for gestational age (SGA) infants
may have platelet counts up to 25% lower than those
Hematocrit 48%–64%
found in appropriate for gestational age neonates. Circu-
53% (cord blood) lating platelets are hypoactive during the first few days of
life. Although this physiological phenomenon prevents
Hemoglobin 17–18.4 g/dL
the newborn from developing thrombosis, there may be
16.8 g/dL (cord blood) an increased risk for bleeding and coagulopathy (Pagana
Platelets 150,000–300,000/mm3 & Pagana, 2006).
The stressful events associated with the birth process Labs: Neonatal Blood Glucose Assessment
prompt the conversion of fats and glycogen to glucose.
After delivery, an increase in circulating catecholamines Capillary blood obtained from the neonate’s heel is commonly
triggers the release of glycogen from the neonate’s liver. used to assess blood glucose. When available, a heel warmer is used to
Glycogen provides a ready source of glucose to the brain increase blood flow to the sample site. The area is cleansed with a sterile
alcohol pad and the heel is gently punctured, taking care to avoid the
and other vital organs. During the first three hours of life,
middle area where there is a risk for nerve damage or puncture of the
a healthy term newborn may utilize up to 90% of his liver’s plantar artery. A large drop of blood is placed on the test strip and a
glycogen stores (Hernandez & Hernandez, 2004). Although sterile bandage is used to apply pressure on the sample site.
the brain’s primary source of fuel is glucose, ketones, lactic
acids, fatty acids, and glycerol can also be utilized if neces-
sary to maintain an adequate supply of energy. The liver’s
ability to adequately convert glycogen to glucose for fuel is IRON STORAGE
essential for a successful physiologic transition. During the last few weeks of pregnancy, iron is stored in
The blood glucose of a term infant should be 70% to the fetal liver. As RBCs are destroyed after birth, the neona-
80% of the maternal blood glucose level. The maternal tal liver stores additional iron until needed for the produc-
glucose level is influenced by a number of factors includ- tion of new RBCs. At term, the newborn has approximately
ing the timing and contents of the last meal consumed, the 270 mg of iron, and of this amount, 140 to 170 mg of iron
duration and mode of delivery and the components of any is contained in the hemoglobin. Adequate maternal iron
intravenous fluids or medications administered during intake during pregnancy ensures that a sufficient amount of
labor and birth. iron is available in the infant to last up to 6 months of age.
During the first 4 to 6 hours of life, the newborn’s main Term infants who are exclusively breastfed do not need
source of energy is glucose. The serum blood glucose level additional iron until at least 6 months of age. However,
drops during the first 3 hours of life and then gradually formula-fed infants should be given an iron-fortified for-
rises over the next 3 to 4 hours to reach a steady state of mula, and beginning at 6 months, all infants should receive
40 to 80 mg/dL. Glycogenolysis, the breakdown of glyco- iron supplements or iron-rich foods to prevent anemia
gen into the more usable form of glucose within the body (Luchtman-Jones, Schwartz, & Wilson, 2006).
tissues, can occur if the newborn does not receive any
exogenous glucose before the initial hepatic and skeletal
glycogen stores have been depleted. This process prompts CONJUGATION OF BILIRUBIN
the release of glucose into the bloodstream as needed to Conjugation of bilirubin constitutes a major function of
maintain normal blood levels. the newborn’s liver. Conjugation is a process that converts
the yellow lipid-soluble (nonexcretable) bilirubin pig-
Hypoglycemia ment (present in bile) into a water-soluble (excretable)
Hypoglycemia can occur after any stressful events (e.g., pigment. Jaundice is a condition characterized by a yel-
hypothermia, hypoxia) that increase metabolic demands. low (icteric) coloration of the skin, sclera, and oral
Nurses must be aware of risk factors associated with neo- mucous membranes. Jaundice results from the accumula-
natal hypoglycemia (Box 17-1). For example, preterm and tion of bile pigments associated with an excessive amount
SGA infants may not have accumulated the glycogen stores of bilirubin in the blood (hyperbilirubinemia). This con-
necessary to maintain serum glucose levels required for dition occurs in approximately 60% of full-term infants
energy needs. Large for gestational age (LGA) and infants and in up to 80% of preterm infants. The presence of jaun-
of diabetic mothers (IDM) may produce too much insulin dice is directly related to the liver’s maturity and its ability
postnatally and rapidly metabolize their glucose stores to conjugate bilirubin (MacDonald et al., 2005).
(Kalhan & Parimi, 2006). Postterm or intrauterine growth Bilirubin is produced from the hemolysis (breakdown)
restricted (IUGR) fetuses can develop hypoglycemia related of erythrocytes. Removal of bilirubin begins in the reticu-
to poor intrauterine nourishment from a deteriorating pla- loendothelial system, where mononuclear phagocytes
centa. Consequently, they have depleted glucose stores remove aging RBCs from the circulation. Heme, the oxygen-
before birth. Neonates exposed to postbirth stressors such carrying component of hemoglobin, is broken down into
as asphyxia, infection, or cold stress rapidly utilize their
glucose stores to assist with the transition process (Hertz,
2005). (See Chapter 19 for further discussion.)
Box 17-1 Risk Factors for Hypoglycemia in the Neonate
three elements: iron, carbon monoxide, and biliverdin. able to convert the fat-soluble (nonexcretable) bilirubin into
Iron, stored in the hemoglobin, is used for a number of a water-soluble (excretable) form by way of conjugation.
essential bodily functions. Carbon monoxide is exhaled Elevated blood levels of unconjugated bilirubin can be toxic
through the lungs as a waste product, and biliverdin is fur- and result in kernicterus, a life-threatening condition
ther broken down into lipid-soluble bilirubin. caused by the deposition of unconjugated bilirubin in the
During the process of normal conjugation, bilirubin brain and spinal cord. (See Chapter 19 for further
attaches to the blood albumin and is transported to the discussion.)
liver. In the liver, the unbound bilirubin detaches from the The total serum bilirubin level (TSB) is a measurement
albumin, and is conjugated with glucuronide in the pres- of both the conjugated and unconjugated bilirubin. At
ence of the enzyme glucuronyl transferase. This process birth, the normal total serum bilirubin level is 3 mg/dL or
produces water-soluble direct bilirubin, which is excreted less. Before birth, the fetus does not need to conjugate bil-
into the common duct and duodenum. Normal intestinal irubin; instead, unconjugated bilirubin is transferred
flora reduce the direct bilirubin into urobilinogen and ster- across the placenta for maternal excretion. After birth, the
cobilinogen. This product is then excreted as a yellow- neonate’s liver must be able to satisfactorily conjugate bili-
brown pigment in the stools, and a small amount is rubin (MacDonald et al., 2005).
excreted through the kidneys. The physiological pathway
for the excretion of bilirubin is presented in Figure 17-8. Nursing Insight— Maternal medications may
The breakdown of 1 gram of hemoglobin yields approx- decrease neonatal albumin-binding sites
imately 34 mg of bilirubin. The normal term newborn
produces 6 to 10 mg of bilirubin per kilogram per day. In Maternal ingestion of medications such as aspirin and sulfa
comparison, adults produce 3 to 4 mg of bilirubin per drugs may reduce the number of albumin-binding sites in the
kilogram per day. The increased bilirubin production in infant and result in neonatal hyperbilirubinemia.
the newborn is related to the high concentration of RBCs
at birth and the shortened life span of fetal erythrocytes
(Hernandez & Hernandez, 2004). Risk Factors for Hyperbilirubinemia
Conjugated or “direct” bilirubin has been converted from
a lipid-soluble, nonexcretable pigment into a water-soluble, Neonatal jaundice that occurs during the first week of life
excretable pigment. Unconjugated, or “indirect” bilirubin is most often results from excessive levels of unconjugated
fat-soluble and nonexcretable. The newborn’s liver must be bilirubin. Unlike pathologic jaundice (present at birth or
occurring during the first 24 hours), the signs of physio-
logic jaundice do not occur until after the first 24 hours
of life. Jaundice is usually first noted on the face and sclera
Neonatal bilirubin when the serum bilirubin levels reach approximately 4 to
increases with
6 mg/dL. The yellow coloration then progresses caudally
RBC destruction as the total serum bilirubin level rises to 6 to 7 mg/dL
physiological or pathological RBC destruction (Bhutani, Johnson, & Keren, 2005). Many maternal and
(most common) neonatal factors such as ethnicity, diabetes, prematurity,
-Liver immaturity and delay in feeding place the infant at risk for hyperbili-
-Lack of intestinal flora Reticuloendothelial
system rubinemia (Box 17-2). (See Chapter 18 for further
-Delayed feeding discussion.)
-Hypothermia -Phagocytosis of RBC
-Asphyxia
Unconjugatated
bilirubin released Box 17-2 Factors that May Influence Bilirubin Levels
in the Neonate
Unconjugatated
bilirubin combined with • Cultural background: Chinese, Japanese, Korean, and Native American
glucuronic acid to form neonates exhibit higher bilirubin levels than do European and American
Conjugated bilirubin Caucasian neonates. The elevated levels of bilirubin persist for a longer
GI tract period of time and cause no apparent adverse effects.
Bile duct
Reabsorbed • Perinatal events (i.e., delayed cord cutting, breech presentation, the use
urobilinogen of Pitocin)
from GI tract • Prematurity
• Maternal diabetes
Urobilinogen Stercobilinogen
Liver • Excess bilirubin production (e.g., hemolytic diseases such as Rh isoim-
munization and ABO incompatibility; sepsis; metabolic disorders)
Stool
• Delayed feedings
• Liver immaturity (i.e., prematurity; glucose-6-phosphate dehydrogenase
deficiency)
Urine • Birth trauma
Kidney
(urobilinogen) • Family history of jaundice or previous child with jaundice
• Neonatal complications (i.e., asphyxia neonatorum, cold stress,
Figure 17-8 Physiological pathway for the excretion hypoglycemia)
of bilirubin.
554 unit five Care of the New Family
week, bilirubin levels associated with breast milk jaundice Production of pancreatic lipase gradually increases dur-
continue to rise and peak at 2 to 3 weeks of life. Mean- ing the first few weeks of life.
while, infants typically are thriving, stooling appropri-
ately, and gaining weight without any evidence of hemo- INTESTINAL PERISTALSIS
lysis (Hertz, 2005).
At one time, it was thought that breast milk jaundice Fetal peristalsis can be influenced by anoxia, which trig-
was related to an enzyme in the breast milk that inhibited gers the expulsion of meconium into the amniotic fluid.
the action of glucuronyl transferase. Today the appear- Immediately after birth, air enters the stomach and reaches
ance of breast milk jaundice is believed to be related to a the small intestine within 2 to 12 hours. Bowel sounds are
factor in human milk that increases the intestinal absorp- present within the first 15 to 30 minutes of life due to the
tion of bilirubin. In most circumstances, no intervention air that has entered the stomach and small intestines. The
is necessary. If the infant continues to breastfeed, the TSB gastrocolic reflex is stimulated when the stomach fills, and
gradually declines over the course of a few weeks. Some this process helps to enhance intestinal peristalsis. The
experts recommend temporarily halting breast feeding stomach empties intermittently, usually at the beginning
for 48 hours to allow the serum bilirubin levels to decline. of a feeding and up until 2 to 4 hours after a feeding. The
It is important to carefully monitor infants and provide salivary glands are immature at birth; little saliva is pro-
phototherapy or supplemental nutrition when needed duced for the first 3 months of life. The cardiac sphincter
(Verklan & Walden, 2004). (See Chapter 18 for further (located between the esophagus and the stomach) is
discussion.) immature, and it is not unusual for newborns to regurgi-
tate small amounts following feedings (Hertz, 2005).
Compared to the overall body size, the newborn’s intes-
COAGULATION OF BLOOD tines are long, a feature that provides an increased surface
Another important function of the liver involves the pro- area for the absorption of nutrients. However, if diarrhea
duction of coagulation factors to enable the newborn to occurs, the additional surface area places the infant at an
effectively clot blood after birth. The coagulation factors increased risk for dehydration and water loss. Infants born
are activated by vitamin K (AquaMEPHYTON), given to at term generally pass their first meconium stool within
the newborn within one hour following birth. An intra- 8 to 24 hours of life. An important nursing function
muscular injection of Vitamin K (AquaMEPHYTON) includes documentation of the first meconium stool.
given prophylactically within this first hour of life pre- Absence of passage of a bowel movement by 72 hours of
vents hemorrhagic diseases of the newborn. Coagulation age may be indicative of an obstructive bowel problem
factors synthesized in the liver include prothrombin and (Miller & Newman, 2005).
factors II, VII, IX, and X. Circulating levels of the coagula- Meconium consists of particles found in the amniotic
tion factors vary according to the gestational age of the fluid such as vernix, skin cells, hair, and cells that have been
infant (MacDonald et al., 2005). shed by the intestinal tract. Meconium stools, which are
characteristically greenish-black and viscous, gradually
Now Can You— Discuss neonatal jaundice? change to transitional stools that are thinner and greenish-
1. Identify two factors that may place an infant at risk for brown to yellowish-brown. The newborn may pass stools
physiological jaundice? from one to ten times a day over a 24-hour period. Following
2. Explain why infants of Mediterranean descent are at a the transitional stools, stool appearance and frequency var-
higher risk for jaundice? ies, depending on whether the infant is breast or bottle fed.
3. Discuss why delayed cord clamping at birth can affect the
development of jaundice? Now Can You— Discuss gastrointestinal functioning in the
newborn?
1. Describe the fetal to newborn transition process that takes
place in the gastrointestinal tract?
Gastrointestinal Adaptation 2. Identify the enzymes that aid in digestion and those that are
deficient at birth?
STOMACH AND DIGESTIVE ENZYMES 3. Identify when bowel sounds become present in the newborn?
The neonate’s stomach capacity is approximately 6 mL/kg
at birth and by the end of the first week of life, the capac-
ity has increased to hold approximately 90 mL. In utero,
the fetal gastrointestinal system reaches maturity around Genitourinary Adaptation
36 to 38 weeks of gestation when there is sufficient enzy-
matic activity for digestion and the transport of nutrients KIDNEY FUNCTION
throughout the body. To nutritionally thrive, newborns
In the term newborn, the following three major physio-
must be able to digest essential carbohydrate disaccha-
logical factors enable the kidneys to manage bodily fluids
rides that include lactose, maltose and sucrose. Lactose,
and excrete urine:
the primary carbohydrate in breast milk, is easily digested
and readily absorbed (Hertz, 2005). A deficiency of pan- • The nephrons are fully functional by 34 to 36 weeks
creatic amylase, the only enzyme lacking at birth and of gestation.
during the first few months of life, makes it difficult for • The glomerular filtration rate is lower than that of the
infants to digest fats efficiently. Newborns also have adult.
a decreased production of pancreatic lipase and bile • There is a limited capacity for the reabsorption of
acids, which further limits their ability to absorb fats. HCO3– and H⫹.
556 unit five Care of the New Family
Although the fetal kidneys contain working nephrons may not void for up to 24 hours. On average, approxi-
by 34 to 36 weeks of gestation, the kidneys are not mature mately 68% of normal newborns void within the first
and fully functional until after birth when the newborn 12 hours, 93% by 24 hours, and 100% will have voided by
becomes responsible for the elimination of waste prod- 48 hours. Recording the neonate’s first voiding is an
ucts. The neonate’s elevated hematocrit (related to the important nursing action. If voiding has not occurred by
high concentration of RBCs) and low blood pressure may 24 hours of life, the nurse must alert the pediatrician or
lead to a decreased glomerular filtration rate (GFR) (the neonatal nurse practitioner. The infant may be experienc-
volume of glomerular filtrate that is formed over a specific ing hypovolemia related to an insufficient fluid intake.
period of time). With a low GFR, the newborn’s kidneys Failure to void during the first 24 hours of life may also
are unable to dispose of fluid rapidly and tend to reabsorb indicate the presence of an obstruction in the urinary out-
excess sodium. As the kidneys mature and enlarge, the flow system and the infant should be carefully assessed for
GFR rapidly increases during the first 4 months of life. bladder distention, restlessness, and symptoms of pain
Adult GFR values are reached at around 2 years of age (Hernandez & Hernandez, 2004).
(MacDonald et al., 2005). Initially, the newborn’s bladder capacity ranges from
In the neonate, urine specific gravity normally ranges 6 to 44 mL of urine. During the first 2 days of life, infants
from 1.002 to 1.010. Term newborns are unable to ade- normally void two to six times in a 24-hour period, with
quately concentrate urine (reabsorb water back into the a total output of 15 mL/day. Urine output is significantly
blood) because the kidney tubules are short and narrow. higher in infants with edema. By the fourth day, the fre-
This alteration may lead to an inappropriate loss of sub- quency of voiding should have increased to more than six
stances such as amino acids and glucose. By 3 months of voids in a 24 hour period. Since the kidneys have diffi-
age, infants are able to fully concentrate their urine (Modi, culty concentrating urine and removing waste products
2005). Normal laboratory values for components in the from the blood immediately after birth, small amounts of
neonate’s urine are presented in Table 17-3. protein and glucose are frequently present in the urine.
Along with the lungs and circulatory system, the kid- Urate crystals, which are pink-red in color, are excreted in
neys perform an important function in helping the body the urine and can be mistaken for blood. The crystals
maintain a normal acid–base balance. Several factors can (sometimes referred to as “brick dust spots”) disappear
interfere with the newborn’s ability to maintain homeosta- after the first few days of life as kidney function matures.
sis in this system. The limited capacity for tubular reab- During the first 24 to 48 hours, full-term newborns
sorption of HCO3– and H⫹ can lead to a loss of essential require 60 to 80 mL/kg of fluids to maintain an adequate
substances (e.g., amino acids, bicarbonate, glucose, fluid balance. This requirement increases to 100 to 150 mL/
sodium) in the filtrate. Due to immaturity of the new- kg per day after the first few days, and a urine output of 1 to
born’s kidneys, there is a greater capacity for glomerular 3 mL/kg per hour is indicative of adequate fluid mainte-
filtration than for tubular reabsorption and secretion nance (Hertz, 2005). Because the neonate’s kidneys are
(Cloherty, Eichenwald, & Stark, 2004). unable to tolerate large changes in volume, careful moni-
It is important for the nurse to carefully monitor the toring of fluid balance is essential. Large changes in fluid
newborn’s intake and output to prevent overhydration balance can create a problem if the infant becomes ill and
and/or dehydration. Most newborns void immediately needs to receive intravenous fluids during that time. Nurs-
after birth or within the first few hours, although some ing diagnoses for the neonate experiencing difficulty during
the transitional period may be related to the specific organ
system(s) involved, environmental factors, or medical inter-
ventions (Box 17-3).
Table 17-3 Laboratory Values for Urine in the Normal Assessing the appearance of the newborn’s urine is
Term Neonate important when evaluating genitourinary system func-
tion. When necessary, the nurse may need to apply a urine
Urine Component Normal Range
collection bag to obtain a urine sample from the infant.
Casts, WBC Normal to be present for the first
2–4 days
Osmolality (maximum 800 mOsmol/L
concentration ability) Box 17-3 Possible Nursing Diagnoses Related
to Newborn Physiological Transitions
(Maximum diluting ability) 25–30 mOsmol/L
pH 4.5–8.0 • Altered Health Maintenance related to separation from the maternal
support system.
Phenylketonuria No color changes • Risk for Infection related to the newborn’s immature immunological
Specific gravity 1.002–1.010 system.
• Risk for Ineffective Airway Clearance related to excessive fluid present
Protein May be present during first 2–4 days in lungs during neonatal transition.
Glucose Negative • Risk for Pain related to increased environmental stimuli.
• Risk for Ineffective Thermoregulation related to the newborn’s imma-
Blood Negative ture temperature regulation systems.
Leukocytes Negative • Altered Nutrition: Less than Body Requirements related to limited nutri-
tional and fluid intake and increased caloric expenditure.
Adapted from Cloherty, Eichenwald, & Stark (2004) and Nettina (2007).
chapter 17 Physiological Transition of the Newborn 557
Nursing Diagnosis: Readiness for Enhanced Organized Infant Behavior related to effective modulation of the
physiological and behavioral systems of functioning
Measurable Short-term Goal: The newborn will transition to necessary extrauterine cardiorespiratory, feeding,
and elimination functions without complications.
Measurable Long-term Goal: The newborn and mother (family) will experience successful interactions and
psychosocial adaptation to each other.
NOC Outcomes: NIC Interventions:
Newborn Adaptation (0118): Adaptive response Newborn Monitoring (6890)
to the extrauterine environment by a Environmental Management (6480)
physiologically mature newborn during the Breastfeeding Assistance (1054) or
first 28 days. Bottle Feeding (1052)
Parent–Infant Attachment (1500): Parent and Attachment Promotion (6710)
infant behaviors that demonstrate an enduring
affectionate bond.
Nursing Interventions:
1. Before birth, review maternal record for antenatal or intrapartal complications, events, or medications that
may affect the neonate. Prepare room and equipment for the birth.
RATIONALE: Review allows anticipation and preparation for complications that may occur at birth.
2. Dry newborn with prewarmed blankets while on mother’s abdomen. Assess respiratory effort, clear airway
and stimulate as needed. Discard wet blankets, cover mother and infant with a warm, dry blanket, and place
a cap on the infant’s head.
RATIONALE: Prevents heat loss by evaporation and convection and helps open the airway and initiate respirations.
3. Assess newborn’s heart rate and color. Complete Apgar scoring at 1 and 5 minutes of age. If the score is 7 or
greater, continue to monitor infant.
RATIONALE: Heart rate and color provide information about cardiovascular transition to extrauterine function.
Infants with Apgar scores of 7 or higher are considered stable.
4. Once the umbilical cord has been cut, assess the number of cord vessels and encourage mother to put the
baby in kangaroo care (skin-to-skin) at the breast.
RATIONALE: It is easiest to note the cord vessels in a freshly cut cord. Kangaroo care helps the newborn
maintain temperature and facilitates breastfeeding.
5. Offer instruction about breast feeding if needed and give praise and encouragement. Provide time and space
for first feeding.
RATIONALE: During the first period of reactivity, the unmedicated infant is alert and ready to breastfeed. The
mother should not be overwhelmed with teaching and nursing activity but encouraged to get to know her baby.
6. Continue to monitor infant’s vital signs per protocol. Encourage stable infant to remain with mother in
kangaroo care for first period of reactivity.
RATIONALE: The stable infant benefits most from maternal contact. Vital signs can be monitored in the
mother’s arms.
7. At a convenient time during the first 2 hours, place the infant under a radiant warmer with a servo-controlled
skin probe in place. Perform a brief physical exam and administer vitamin K and eye prophylaxis as ordered.
Place identification bands on the infant and mother.
RATIONALE: The radiant warmer and probe provide a safe source for external heat as the infant is examined.
Vitamin K prevents neonatal hemorrhage and eye prophylaxis is required to prevent eye infection. Two forms
of identification applied before separation help ensure that the right mother and infant are together.
8. Monitor for passage of urine and first meconium and document. Teach parents about elimination and
diapering as needed.
RATIONALE: The passage of urine and meconium provides information about the normal newborn’s anatomy
and physiology. Every opportunity for teaching should be appreciated during the short hospital stay.
9. Observe the parents’ interactions with the newborn: eye contact, stroking, talking to baby. Point out attractive
features and infant’s responses to parents. Offer encouragement to fathers to touch and hold their newborn.
RATIONALE: Observation helps the nurse identify appropriate behaviors related to attachment and bonding
with the newborn. Encouragement provides the novice father with “permission” to parent.
560 unit five Care of the New Family
phases: drowsy or semidozing, wide awake, active awake, r evi ew quest i ons
and crying (Brazelton, 1999).
Multiple Choice (Select all that apply.)
Drowsy or Semidozing
Physical manifestations include open or closed eyes; flut- 1. The perinatal nurse explains to the new nurse that
tering eyelids; semidozing appearance; and slow, regular some infants have increased surfactant production
movement of the extremities. There is a delayed response prior to birth that facilitates their transition
to external stimuli. including:
A. Infants of mothers with gestational hypertension
Wide Awake B. Infants of mothers with placental insufficiency
The infant is alert and follows and fixates on attractive C. Infants of mothers with abruptio placentae
objects, faces, or auditory stimuli. There is minimal motor D. Infants of mothers with a multiple gestation
activity and a delayed response to external stimuli. 2. The perinatal nurse describes a typical newborn
breathing pattern to the new parents as:
Active Awake A. Shallow
The eyes are open, motor activity is intense and the infant B. Irregular
displays thrusting movements of the extremities. Environ- C. About 40 to 60 breaths per minute
mental stimuli increases the motor activity. D. About 60 to 80 breaths per minute
Crying
3. The perinatal nurse understands that many factors
stimulate the newborn to begin breathing
Jerky movements accompany intense crying. Crying often including:
serves as a distraction from unpleasant stimuli such as A. Hypercarbia, acidosis and hypoxia
hunger and pain. It allows the infant to discharge energy B. Sensory stimuli
and elicits a helpful response from the parents. C. Decreased temperature in the environment
D. Cutting the umbilical cord
Now Can You— Discuss psychosocial adaptation in the
newborn? 4. The perinatal nurse recognizes that the infant that
develops respiratory distress syndrome is at risk for
1. Compare and contrast the first period of reactivity and the further complications such as:
period of inactivity/sleep? A. Loss of functional residual capacity
2. Identify two behavioral characteristics associated with deep, B. Atelectasis
quiet sleep and REM sleep? C. Poor lung compliance
3. Name four phases of the quiet alert state and identify two D. Hypoglycemia
behavioral characteristics of each phase?
5. The perinatal nurse is caring for Sarah, a primigravid
antenatal patient at 32 weeks gestation. Betamethasone
12 mg IM q24h ⫻ 2 is ordered. Appropriate nursing
s um m a ry po i n ts care includes:
A. Assessing Sarah’s temperature and white blood
◆ Surfactant, a lipoprotein that reduces surface tension, count
is essential in keeping the lungs expanded during B. Conducting continuous fetal monitoring for
expiration. 30 minutes pre and post injection
C. Providing information to Sarah and her family
◆ Initiation of the neonate’s first breath is influenced by about the benefits of this medication as well as
chemical, sensory, thermal, and mechanical factors. information about the signs and symptoms of
◆ Successful cardiopulmonary adaptation in the neonate is pulmonary edema
dependent on five major changes related to aortic, venous, D. Monitoring Sarah’s intake and output
and pulmonary pressures and closure of the foramen
ovale and ductus arteriosus and ductus venosus. Fill-in-the-Blank
◆ A number of factors, including body size and gesta- 6. The perinatal nurse understands that pulmonary
tional age, affect the neonate’s ability to maintain a ventilation in the newborn takes place on three
neutral thermal environment. levels: __________ respiration, ________ respiration
and at the _________ level.
◆ Heat loss may occur through the processes of evapora-
tion, conduction, convection, and radiation. 7. The perinatal nurse explains to the student nurse
that _______ ______ is a brief pause between breaths
◆ The neonate’s liver has essential roles in iron storage,
of 5 to 15 seconds while _________ is cessation of
carbohydrate metabolism, bilirubin conjugation, and
breathing for _________ seconds or more.
blood coagulation.
◆ The neonate receives immunity through active acquired True or False
immunity and passive acquired immunity. 8. The perinatal nurse explains to the woman who has
◆ The newborn exhibits two periods of reactivity and two given birth to a preterm infant that part of the infant’s
behavioral states that may be divided into sleep states care is to provide a dose of surfactant, a phospholipid
and alert states. that increases lung compliance.
chapter 17 Physiological Transition of the Newborn 561
9. The perinatal nurse prepares for newborn care at a Hernandez, P., & Hernandez, J. (2004). Physical assessment of the new-
cesarean birth. The nurse knows that this infant is at born. In P. Thureen, D. Hall, J. Deacon, & J. Hernandez. Assessment
and care of the well newborn (2nd ed., pp. 114–125). St. Louis, MO:
a higher risk for pulmonary transition difficulties W.B. Saunders.
due to the absence of a “thoracic squeeze” during Hertz, D. (2005). Care of the newborn, A handbook for primary care.
birth. Philadelphia: Lippincott.
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Maas,
10. The perinatal nurse assesses the newborn at 2 hours of M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and NIC link-
age. The findings include: respiratory rate of 48 breaths ages: Nursing diagnoses, outcomes, & interventions (2nd ed.). St. Louis,
per minute, irregular, no abdominal or chest retractions MO: Mosby Elsevier.
or grunting. These findings would be normal. Kalhan, S., & Parimi, P. (2006). Metabolic and endocrine disorders. In
R. Martin, A. Fanaroff, & M. Walsh (Eds.), Fanaroff and Martin’s
See Answers to End of Chapter Review Questions on the neonatal-perinatal medicine: Diseases of the fetus and infant (8th ed.,
pp. 1254–1272). Philadelphia: C.V. Mosby.
Electronic Study Guide or DavisPlus. Kapur, R., Yoder, M., & Poplin, R. (2006). Developmental immunology.
In R. Martin, A. Fanaroff, & M. Walsh (Eds.), Fanaroff and Martin’s
REFERENCES neonatal-perinatal medicine: Diseases of the fetus and infant (8th ed.,
Barzansky, B., Beckmann, C., Herbert, W., Laube, D., Ling, F., & Smith, pp. 806–824). Philadelphia: C.V. Mosby.
R. (2006). Obstetrics and gynecology (5th ed.). Philadelphia: Luchtman-Jones, L., Schwartz, A., & Wilson, D. (2006). Hematologic prob-
Lippincott. lems in the fetus and neonate. In R. Martin, A. Fanaroff, & M. Walsh
Bhutani, V., Johnson, L., & Keren, R. (2005). Treating acute bilirubin (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the
encephalopathy – before it’s too late. Contemporary Pediatrics, 22(5), fetus and infant (8th ed., pp. 756–789). Philadelphia: C.V. Mosby.
57–70. MacDonald, M., Mullett, M., & Seshia, M. (2005). Avery’s neonatology,
Bloom, R. (2006). Delivery room resuscitation of the newborn: Part 1: pathophysiology & management of the newborn (6th ed.). Philadelphia:
Overview and initial management. In R. Martin, A. Fanaroff, & M. Lippincott.
Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Miller, C., & Newman, T. (2005). Routine newborn care. In H. Taeusch,
Diseases of the fetus and infant (8th ed., pp. 483–489). Philadelphia: R. Ballard, & C. Gleason (Eds.), Avery’s diseases of the newborn
C.V. Mosby. (8th ed., pp. 239–246). Philadelphia: W.B. Saunders.
Bloom, S., Cunningham, F., Gilstrap, L., Hauth, J., Leveno, K., & Wen- Modi, N. (2005). Fluid and electrolyte balance. In J. Jennie (Ed.), Robertson’s
strom, K. (2005). Williams’ obstetrics (22nd ed.). New York: textbook of neonatology (4th ed.). Philadelphia: Churchill Livingstone.
McGraw-Hill. Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008). Nursing
Brazelton, T.B. (1999). Behavioral competence. In G.B. Avery, M.A. outcomes classification (NOC) (4th ed., pp 264–275). St. Louis, MO:
Fletcher, & M.G. MacDonald (Eds.), Neonatology: Pathophysiology C.V. Mosby.
and management of the newborn (5th ed, pp. 321–332). Philadelphia: NANDA International. (2007). NANDA-I nursing diagnoses: Definitions
Lippincott. and classifications 2007-2008. Philadelphia: NANDA-I.
Brazelton Institute. (n.d.). The Newborn Behavioral Observations (NBO) Nettina, S. (2007). Lippincott manual of nursing practice. Philadelphia:
system: What is it? Retrieved from http://www.brazelton-institute. Lippincott Williams & Wilkins.
com/cinbas.html (Accessed September 28, 2008). Nugent, J.K., Keefer, C.H., O’Brien, S., Johnson, L., & Blanchard, Y.
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven- (in press). Handbook for the newborn behavioral observations (NBO)
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. system. Baltimore: Paul H. Brookes.
Cant, A., & Gennery, A. (2005). Neonatal infection. In J. Rennie (Ed.), Pagana, K., & Pagana, T. (2006). Mosby’s manual of diagnostic and labo-
Robertson’s textbook of neonatology (4th ed., pp. 509–522). Philadelphia: ratory tests (3rd ed.). St. Louis, MO: C.V. Mosby.
Churchill Livingstone. Roberts, I. (2005). Haematological values in the newborn. In J. Rennie
Cloherty, J., Eichenwald, E., & Stark, A. (2004). Manual of neonatal care (Ed.), Robertson’s textbook of neonatology (4th ed., pp. 204–222).
(5th ed.). Philadelphia: Lippincott. Philadelphia: Churchill Livingstone.
Deglin, J.H., & Vallerand, A.P. (2009). Davis’s drug guide for nurses Sedin, G. (2006). Physical environment: Part 1. The thermal environment
(11th ed.). Philadelphia: F.A. Davis. of the newborn infant. In R. Martin, A. Fanaroff, & M. Walsh (Eds.),
Dillon, P.M. (2007). Nursing health assessment: A critical thinking, case Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus
studies approach. Philadelphia: F.A. Davis. and infant (8th ed., pp. 146–158). Philadelphia: C.V. Mosby.
Hayes, E., Kee, J., & McCuistion, L. (2006). Pharmacology: A nursing Verklan, M., & Walden, M. (2004). Core curriculum for neonatal intensive
process approach (5th ed.). St. Louis, MO: W.B. Saunders/Elsevier. nursing (3rd ed). St. Louis, MO: Elsevier/W.B. Saunders.
Hernandez, J., Zabloudil, C., & Hernandez, P. (2004). Adaptation to Wong, R., DeSandre, G., Sibley, E., & Stevenson, D. (2006). Neonatal
extrauterine life and management during transition. In P. Thureen, jaundice and liver disease. In R. Martin, A. Fanaroff, & M. Walsh
D. Hall, J. Deacon, & J. Hernandez. Assessment and care of the well (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of
newborn (2nd ed., pp. 83–100). St. Louis, MO: W.B. Saunders. the fetus and infant (8th ed., pp. 578–586). Philadelphia: C.V. Mosby.
CONCEPT MAP
Optimizing Outcomes:
Physiological Transition • Proper infant position to enhance
Intrauterine BIRTH of the Newborn bonding with breastfeeding
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Identify the components of the immediate newborn assessment.
◆ Describe methods for determining the gestational age of the neonate.
◆ Discuss how to perform a newborn behavioral assessment.
◆ List at least four actions to assess the neonate’s transition to extrauterine life.
◆ Identify three sources of heat loss in the neonate and suggest strategies to prevent the heat loss
for each.
◆ Describe strategies to prevent neonatal infection.
◆ Describe four activities to promote early infant bonding.
◆ Develop a discharge teaching plan for the mother and her newborn infant.
The purpose of this cross-sectional study was to evaluate current • No state program had specific rules or regulations about
rules and regulations for educating parents about newborn screen- how to inform parents about newborn screening before
ing. The sample included 51 newborn screening program coordi- birth although 36 state programs indicated the parents
nators from all 50 states and the District of Columbia. A 20-item should be informed by the obstetrician.
telephone survey was used to obtain data about policies, rules, • Thirty state programs indicated that parents should
and regulations along with specific topics, such as types of infor- be offered information prenatally and again after
mation given to families, and strategies for informing the general delivery.
public and primary care providers about newborn screening. • Five state programs require parental consent before infant
Data analysis revealed the following information about new- screening.
born screening programs: • Thirty-three state programs do not routinely screen for all
• Fifty state programs use standard information to inform conditions recommended by the March of Dimes and the
parents about newborn screening. National Newborn screening and Genetic Resource Center.
• Thirty-two state programs offer the information in lan- These conditions include but are not limited to phenylketon-
guages other than English. uria (PKU), congenital hypothyroidism (CH), galactosemia
• Twenty-five state programs have specific requirements for (GALT), maple sugar disease, sickle cell disease, and cystic
informing parents about the screening; of these, 12 state fibrosis.
programs specified who should inform the family and • No state program has requirements that parents should be
9 state programs were unclear about how parents should informed about the availability of additional screening.
be informed. (continued)
563
564 unit five Care of the New Family
• Thirty-eight state programs have a formal process for information is provided and there is much variation in policy
parents who wish to refuse screening. Of these, 15 state language among the screening programs. Although the majority
programs do not require that parents be informed of their of programs have educational outreach efforts, little information
right to refuse; 29 state programs have a standardized is available regarding the effectiveness of those efforts and how
refusal form; and 6 state programs offer the (refusal) form the information can be disseminated to increase the parents’
in languages other than English. Among state programs understanding of newborn screening. The investigators suggest
with no standardized refusal form, documentation of the that parent education about newborn screening should be initi-
refusal is left to the individual agency. ated during the prenatal period. Providing information at this
• Thirty-nine state programs use outreach education (i.e., critical time offers a unique opportunity and challenge for
press releases, agency Web site) to inform the general nurses in both obstetric and public health settings.
public about newborn screening. All but one state pro-
gram direct educational efforts toward physicians through 1. What might be considered as limitations to this study?
mailings, medical education activities, and information 2. How is this information useful to clinical nursing practice?
posted on the agency website. See Suggested Responses for Moving Toward Evidence-Based
The researchers concluded that although standardized infor- Practice on the Electronic Study Guide or DavisPlus.
mation is available for parents, few agencies specify how this
Teach Parents
• Proper technique for use of the bulb syringe; ask
for return demonstration.
• Proper care of the bulb syringe: wash in warm,
soapy water each day and after each use.
• Store the bulb syringe at the infant’s bedside.
Note
Instruct the parents to position the infant’s head
to the side or downward if he is vomiting or
RATIONALE: To prevent stimulation of the gag reflex. gagging.
5. Gently release compression of the bulb syringe Caution: The nurse must emphasize to the parents
and allow it to fill with oral secretions. that the bulb syringe must be compressed first and
6. Gently remove the bulb syringe; expel drainage then inserted into the infant’s nostril or mouth. If
into a tissue. they insert the bulb syringe and then compress the
7. Repeat the process on the other side of the bulb syringe, they may actually force secretions
infant’s cheek. further back into the nose or throat and possibly
cause an obstruction.
8. Repeat as needed.
Optimizing Outcomes— Placing the infant under the Table 18-1 Normal Neonatal Parameters at Birth
radiant heater Parameter Normal Finding
Best outcome: The nurse dries the infant before placing
Respirations Rate 30–60 breaths per minute, irregular
him unclothed on a clean, dry blanket under the radiant-
heater unit. Since the generated heat from the unit warms No retractions or grunting
only the outer surface of objects, it is counterproductive to
Apical pulse Rate 120–160 beats per minute
cover or clothe the infant, as he will get no benefit from the
radiant heat. Temperature 97.8°F (36.5°C)
Skin color Pink body, blue extremities
While performing these actions, the nurse observes Umbilical cord Contains two arteries and one vein
the infant’s respiratory effort, color, and muscle tone, and
makes sure that the activities underway are stimulating Gestational age Full term: 37 completed weeks (should be
the neonate to breathe deeply and cry. If needed, lightly 38–42 weeks to remain with parents for an
extended time period)
flicking the infant’s soles prompts a crying response.
Weight 2500–4300 grams
appropriate labeling. Most institutions employ a system of gonorrheal or chlamydial infection contracted during
waterproof matching identification bracelets that show the passage through the mother’s birth canal. Medications
mother’s name, the baby’s gender, the name of the physician most often used are erythromycin, tetracycline, or silver
or nurse midwife of record, and the date and time of birth. nitrate.
Two bracelets are worn by the neonate while the mother and
her partner wear the others. Careful and continuous moni- Optimizing Outcomes— Eye prophylaxis to prevent
toring of infants is essential to prevent misidentification, ophthalmia neonatorum
baby switching, or abduction. Alerting staff about mothers
who share identical last names helps to decrease the likeli- In some birth facilities, neonatal eye prophylaxis is delayed
hood of mistakes, and special security measures such as sens- up to an hour to allow eye contact to facilitate parent-
ing devices, video cameras, and door alarms on all mother- infant bonding. However, the Centers for Disease Control
baby units helps allay parents’ concerns about their infants’ and Prevention (CDC) recommends that the medication
safety. (See Chapter 15 for further discussion.) be administered as soon as possible after birth. If instilla-
tion is delayed, the facility should have a monitoring sys-
INFECTION AND INJURY PREVENTION tem in place to ensure that all infants receive the prophy-
laxis (CDC, Workowski, & Berman, 2006).
The prevention of infection and injury constitute impor-
tant aspects of newborn care. Hand washing is essential
in preventing cross contamination by all individuals car- During the first few days of life, the newborn has low
ing for the newborn. In many facilities, nursery personnel levels of vitamin K due to sterile intestinal contents. Vita-
are required to wear scrub clothes, remove nail polish, min K acts as a catalyst to synthesize prothrombin, needed
and keep fingernails trimmed. Other measures to prevent for blood clotting, in the liver. To prevent the neonatal
infection include infant bathing, umbilical cord care, care injury caused by hemorrhage, a single dose (0.5 to 1.0 mg)
of the circumcision, and eye care. Soon after birth, the of vitamin K1 phytonadione (AquaMEPHYTON) is admin-
newborn receives a prophylactic ophthalmic agent to istered via an intramuscular injection in the vastus lateralis
prevent ophthalmia neonatorum, eye inflammation from or the ventrogluteal muscle.
568 unit five Care of the New Family
Actions: Suppresses protein synthesis at the level of the 50S ribosome Pregnancy Category: UK
Therapeutic Effects: Bacteriostatic action against susceptible bacteria Indications: Prevention and treatment of hypoprothrombinemia, which
spectrum: Streptococci, staphylococci, gram-positive bacilli may be associated with excessive doses of oral anticoagulants, salicy-
lates, certain anti-infective agents, nutritional deficiencies, and prolonged
Pharmacokinetics: total parenteral nutrition. Prevention of hemorrhagic disease of the
ABSORPTION: Minimal absorption may follow topical or ophthalmic use.
newborn.
Contraindications and Precautions: Action: Required for hepatic synthesis of blood coagulation factors II
CONTRAINDICATED IN: Hypersensitivity
(prothrombin), VII, IX, and X. Therapeutic effects: Prevention of bleeding
Adverse Reactions and Side Effects: Irritation due to hypoprothrombinemia
Route and Dosage: Apply a thin strip to each eye as a single dose. Pharmacokinetics:
Nursing Implications: ABSORPTION: Well absorbed after oral, IM, or subcutaneous administration
DISTRIBUTION: Crosses the placenta; does not enter breast milk.
• Inform parents of medication administration.
Metabolism and excretion: Rapidity metabolized in the liver
• Prepare to administer the eye ointment to the infant 1 hour after birth.
HALF-LIFE: Unknown
• Apply a thin strip to each eye as a single dose.
• Start at the inner canthus and move to the outer canthus. Contraindications and Precautions:
• Dab excess medication off gently; do not wash away the medicine. CONTRAINDICATED IN: Hypersensitivity, hypersensitivity or intolerance to
benzyl alcohol (injection only)
Adapted from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for USE CAUTIOUSLY IN: Impaired liver function
nurses (11th ed). Philadelphia: F.A. Davis. EXERCISE EXTREME CAUTION IN: Severe life-threatening reactions have
occurred after IV administration; use other routes unless IV is justified.
Adverse Reactions and Side Effects:
GASTROINTESTINAL: Gastric upset, unusual taste
DERMATOLOGICAL: Flushing, rash, urticaria
HEMATOLOGICAL: Hemolytic anemia
Optimizing Outcomes— Newborn immunization to
LOCAL: Erythema, pain at injection site, swelling
prevent hepatitis B MISCELLANEOUS: Allergic reactions, hyperbilirubinemia (large doses in very
Vaccination for hepatitis B, given in a series of three doses premature infants), kernicterus
beginning at birth, is recommended for all infants. Before Route and Dosage: IV use of phytonadione should be reserved for
administration, the nurse obtains written parental con- emergencies.
sent. After injection of hepatitis B vaccine (Recombivax Prevention of hemorrhagic disease of the newborn:
HB, Enerix-B) into the vastus lateralis muscle, the nurse IM (NEONATES): 0.5–1 mg, given within 1 hour of birth. May be repeated in
massages the site with a gauze square to enhance absorp- 2–3 weeks if the mother received previous anticonvulsant/anticoagulant/
tion. Additional doses are administered at 1 and 6 months anti-infective/antitubercular therapy. 1–5 mg may be given IM to the
of age. mother 12–24 hours before delivery.
Nursing Implications:
• Inform parents of medication administration.
Assessment of blood glucose helps to prevent newborn • Prepare to administer the injection to the infant 1 hour after birth.
injury related to hypoglycemia. In healthy term infants • Administer IM injection into the anterolateral muscle of the newborn’s
after an uneventful pregnancy and delivery, blood glucose thigh.
monitoring often takes place within the first hour after • Report any symptoms of unusual bleeding or bruising (bleeding gums;
birth. During the early newborn period of a term infant, nosebleed; black, tarry stools; hematuria; bleeding from the base of
hypoglycemia is defined as a blood glucose concentration the umbilical cord or other open wounds).
• A decrease in hemoglobin and hematocrit levels or any bleeding may
of less than 35 mg/dL or a plasma concentration of less
indicate that the effects of the medicine have not been achieved and
than 40 mg/dL. Infants with a low blood glucose level or that more vitamin K may be necessary. Call the physician for further
those who exhibit signs and symptoms of hypoglycemia instruction.
(jitteriness, apnea, seizures or lethargy) require immedi-
ate attention to prevent brain cell damage. Hypoglycemia Adapted from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for
is usually resolved with feeding. If the newborn continues nurses (11th ed). Philadelphia: F.A. Davis.
to display signs and symptoms of hypoglycemia along
with low blood glucose laboratory results, transfer to the
neonatal intensive care unit for intravenous administra-
tion of glucose may be necessary. Polycythemia may be related to excessive blood flow
A heel stick blood sample for hematocrit and hemoglo- from the umbilical cord into the infant at birth. A normal
bin may be performed to detect anemia or polycythemia hematocrit at 1 hour of life is 50% to 55%. A normal
(an excess number of red blood cells). Anemia can result hemoglobin is 14.5 to 22.5 g/dL. Early detection of
from hypovolemia associated with complications such as abnormal laboratory results can ensure immediate
placenta previa, abruptio placentae, or cesarean birth. treatment.
chapter 18 Caring for the Normal Newborn 569
The neonate’s weight, recorded in grams, and the To obtain the head circumference, the tape measure is
length, recorded in centimeters, are measured in the placed on the area immediately above the eyebrows and
birthing room and again during the transitional period pinna of the ears and then wrapped around to the occipital
(Figs. 18-2 and 18-3). On average, a term newborn infant prominence at the back of the head. This location repre-
weighs 3400 grams, with a normal range of 2500 to 4300 sents the area of the greatest head circumference. After
grams. Recumbent length is a crown-to-heel measurement obtaining the head measurement three times, the nurse
taken with the infant in a supine position (Procedure records the largest finding. The normal head circumfer-
18-2). The recumbent length is recorded on a regular ence for a full-term neonate ranges from 13 to 15 inches
basis until the infant reaches 24 months of age. Normal (33 to 38 cm). Measurement of the head circumference is
length parameters for newborns are approximately 18 to repeated at subsequent physical exams until the infant
22 inches (45 to 55 cm). reaches 36 months of age.
The nurse also obtains and records the frontal–occipital To obtain the chest measurement, the paper tape mea-
circumference (FOC), or head measurement (Fig. 18-4). sure is placed on the nipple line and then wrapped
A paper tape measure with increments marked in tenths of around the entire thoracic area (Fig. 18-5). The head
a centimeter is used to ensure an accurate measurement. and chest measurement may be equal during the first
Figure 18-2 Weighing the infant. Figure 18-4 Measuring the head circumference.
Figure 18-3 Measuring the infant’s body length. Figure 18-5 Measuring the chest circumference.
chapter 18 Caring for the Normal Newborn 573
few days of life. A normal chest measurement is 12 to In 1967, the American Academy of Pediatrics recom-
13 inches (30.5 to 33 cm). The abdominal circumference mended that all newborns be classified by birth weight
may be obtained by encircling the infant’s body with the and gestational age. Since that time, a scoring system
paper tape measure placed directly above the umbilicus developed by Ballard and colleagues (1991), which repre-
(Fig. 18-6). The abdomen should be approximately the sents a modification of the Dubowitz system, has been the
same size as the chest (Dillon, 2007). Once all measure- most commonly used method for determining the neo-
ments have been obtained, the nurse plots the weight, nate’s gestational age. With this assessment system, the
length, and head circumference against the infant’s ges- infant examination yields a score of neuromuscular and
tational age to determine the appropriate size category physical maturity that can be extrapolated onto a corre-
(Fig. 18-7). Size categories are small for gestational age sponding age scale to reveal the infant’s gestational age in
(SGA), appropriate for gestational age (AGA), and large weeks. Additional methods used to determine gestational
for gestational age (LGA). If at any time the physical age are fundal height measurement before delivery, ultra-
measurements fall outside of the normal growth param- sonography, and eye lens vascularity. A rough approxi-
eters, the physician should be notified. Information con- mation of the gestational age at birth can be calculated
cerning normal growth parameters for infants, children according to the date of the mother’s last normal men-
and adults is available at the CDC National Center for strual period. Since these other sources of age determina-
Health Statistics Web site: http://www.cdc.gov/nchs/ tion are not as accurate as the neonatal physical examina-
about/major/nhanes/growthcharts/charts.htm. tion, gestational age assessments are frequently performed
by the nurse and recorded on the infant’s chart.
Nursing Insight— Understanding classifications
for newborn weight Optimizing Outcomes— Use of the Ballard
Large for gestational age (LGA): Weight is above the 90th Gestational Age by Maturity Rating tool
percentile at any week. The Ballard Gestational Age by Maturity Rating tool
Appropriate for gestational age (AGA): Weight falls includes a neuromuscular maturity and a physical matu-
between the 10th and 90th percentiles for the infant’s age. rity component (Fig. 18-8) that contains six characteris-
Small for gestational age: (SGA): Weight falls below the tics to be assessed. At the conclusion of the examination,
10th percentile for the infant’s age. the scores from each component are added together, then
mathematically extrapolated onto the maturity rating scale
to determine the infant’s gestational age by examination.
The scoring system is designed to identify the decreased
levels of muscle and joint flexibility characteristic of the
premature infant, as well as the mature term infant’s abil-
ity to return to the original position after movement. The
nurse usually performs this assessment within the first
12 hours of the infant’s life. The Ballard scoring system is
more accurate when conducted on term infants who are
between 10 and 36 hours of life. The order in which the
assessment is conducted is unimportant.
Interestingly, gestational age maturity may occur at dif-
ferent rates among the various categories. For example, a
Figure 18-6 Measuring the abdominal circumference. score of 4 (full maturity) in one category does not indicate
5000
4750 90th percentile Large for gestational age
4500 50th percentile Average for gestational age
4250 10th percentile Small for gestational age
4000
3750
3500
3250
Birth weight (g)
3000
2750
2500
2250
2000
1750
1500
1250
1000
750
500
250
0
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Figure 18-7 Gestational age assessment. Gestational age (weeks)
574 unit five Care of the New Family
Neuromuscular Maturity
-1 0 1 2 3 4 5
Posture
Square
Window
(Wrist) -90° 90° 60° 45° 30° 0°
Arm Recoil
180° 140°-180° 110°-140° 90°-110° <90°
Popliteal
Angle
180° 160° 140° 120° 100° 90° <90°
Scarf Sign
Heel To Ear
that all subsequent categories must also reflect a score of 4. be initiated if the infant is crying or appears to be upset.
“Half-scores” are often recorded if the examiner believes Instead, it is best to postpone the assessment until the
that the infant exhibits a characteristic that falls between infant is calm. Infant registration and documentation
two scoring options during the assessment. It is important of findings from the physical examination, along with
to remember that the infant’s maturity scoring does not other pertinent information (i.e., site and dosage of the
directly translate to the gestational age in weeks. vitamin K and hepatitis B vaccine injections, instillation of
medication for eye prophylaxis) must be completed for
each infant before hospital discharge.
Now Can You— Obtain neonatal measurements
and determine gestational age? ASSESSMENT OF THE NEONATE: A SYSTEMS
1. Describe and demonstrate how to obtain neonatal body APPROACH
measurements? Once the assessment of the infant’s general physical growth
2. Identify two maturity components that are assessed in the parameters and gestational age has been completed, the
Ballard tool? Describe when and why the Ballard assessment nurse systematically examines each body system, beginning
should be performed? with the skin and proceeding in a head-to-toe direction.
3. Discuss whether or not the Ballard maturity score should be This assessment may take place in the nursery with the
identical to the gestational age of the neonate? infant resting comfortably in a crib, under a radiant warmer
(to maintain temperature stability), or if stable, in the
mother’s room. Carrying out the assessment by the moth-
er’s bedside has several advantages. For most, the bedside is
Conducting and Documenting a nonthreatening environment where the mother and the
the Neonatal Physical Assessment nurse can “explore” the baby’s special and unique charac-
teristics. Also, conducting the evaluation in this relaxed
The nurse conducts the neonatal physical examination setting gives the nurse an opportunity to observe the
with the review of systems following the general nursing mother’s ease in interacting with and touching and holding
assessment of the newborn. This examination should not her infant. Appropriate positive reinforcement by the nurse
chapter 18 Caring for the Normal Newborn 575
affirms and validates the mother’s actions, enhances her delivered by forceps or vacuum extraction may have skin
sense of maternal worthiness, and strengthens the bonding disruptions or bruising on the scalp and face. Often, infants
relationship. For the infant, the evolving sense of trust and are born with pustular melanosis, a condition in which
perception of a secure environment are two essential devel- small pustules are formed prior to delivery. As the pustule
opmental milestones first established during these early disintegrates, a small residue or “scale” in the shape of the
contacts with caregivers. These experiences lay the founda- pustule is formed. This lesion later develops into a small
tion for the child’s life-long development of self-esteem (1 to 2 millimeter) macule, or flat spot. Macules, which are
and self-love. A spiritual health promotion strategy for the brown in color, appear similar to freckles and are frequently
family with a newborn centers on encouraging the parents located on the chest and extremities. Pustular melanosis
and caregivers to shower their infants and toddlers with occurs more commonly on African American infants than
love and comfort (Tucker, 2002). on Caucasian infants (Miller & Newman, 2005).
With the infant in a supine position, the nurse follows Another common skin condition is milia, small white
the steps of inspection, light palpation, deep palpation, and papules or sebaceous cysts on the infant’s face that resemble
auscultation to facilitate the examination. When assessing pimples (Fig. 18-9). Inclusion cysts may be seen singularly
the abdomen, the proper sequence is inspection, ausculta- or in pairs on the penis or scrotum of male infants or on the
tion, and light palpation followed by deep palpation. areola of female infants. Acne, a skin condition common in
adolescents, may also be present in newborns and is related
Assessment of the Integumentary System to excessive amounts of maternal hormones. Over time,
Wearing gloves, the nurse examines the neonate’s skin, neonatal acne disappears spontaneously from the infant’s
scalp and body hair, and nails for color, texture, distribu- cheeks and chest. Erythema toxicum, a transient rash that
tion, disruptions, eruptions, and birthmarks. It is important covers the face and chest with spread to the entire body, is
that the assessment take place in a well-lit room and addi- the most common normal skin eruption in term neonates.
tional light sources may be needed to confirm accuracy of It is also called “erythema neonatorum,” “newborn rash,”
findings. The infant’s skin should be pink, a finding that or “flea bite” dermatitis. Typically, the rash consists of
indicates adequate peripheral cardiac perfusion. Blanching small, irregular, flat red patches on the checks that develop
the skin over bony prominences should yield a pink-white into singular, small yellow pimples appearing on the chest,
color before returning to natural pigmentation. abdomen, and extremities. The cause of this skin condition
As previously described, acrocyanosis, a bluish color- is unknown, and it may persist for up to 1 month of life.
ation to the hands and feet, is a normal condition related There is no treatment available to hasten the resolution of
to vasomotor instability and poor peripheral circulation. the rash, which, because of its frequently unsightly appear-
To differentiate between acrocyanosis and true cyanosis, ance, can be quite disturbing to parents.
the nurse can vigorously rub the sole of the neonate’s foot. Blisters related to repetitive sucking may form on the
If the sole turns pink, the diagnosis is acrocyanosis. If the fingers, wrists, and upper lips of infants who often per-
sole remains blue, it is true cyanosis. Also, acrocyanosis petuate a habit begun in utero. Although these lesions
disappears when the infant cries. Visual inspection of the may appear to be serious, parents can be assured that they
infant’s mouth, tongue, and gums confirms the skin color will resolve over time without intervention.
assessment, as these areas should be pink-red in color and Many neonatal skin variations are characterized by
darken to bright red with crying. True cyanosis produces a color changes that are different from normal pigmentation.
bluish coloration and pallor (paleness) of the lips and on For example, Mongolian spots are areas that appear gray,
the area around the mouth. dark blue, or purple and are most commonly located on the
Careful, daily assessment of the newborn’s skin consti- back and buttocks, although they may also be found on
tutes an important nursing action that may lead to early the shoulders, wrists, forearms, and ankles (Fig. 18-10).
detection of potential problems. If pallor, plethora (a deep
purplish color related to an increased number of circulat-
ing red blood cells), petechiae (pinpoint hemorrhagic
areas), central cyanosis, or jaundice is detected, further
evaluation is warranted. The nurse describes and records
in the infant’s medical chart the location of any birth inju-
ries such as forceps marks or fetal monitoring lesions.
Infants born with a nuchal cord (umbilical cord around
the neck) or those who assumed a face presentation com-
monly exhibit bruises or petechiae on the head, neck, and
face. If extensive bruising is present, the infant’s bilirubin
level may be elevated. Although focal petechiae may be
related to injury from increased pressure, the presence of
petechiae scattered throughout the infant’s body can be
indicative of an underlying problem such as a low platelet
count or infection. Periauricular papillomas, or skin tags,
are a benign common finding that often run in families and
usually are insignificant and require no intervention.
The term infant’s skin should feel smooth and soft. In the
postterm infant, the skin is often tough and leathery, with
cracking and peeling. Disruptions or breaks in the skin
may be related to electrode marks or lacerations. Infants Figure 18-9 Milia.
576 unit five Care of the New Family
Figure 18-12 The face is examined for symmetry, Figure 18-14 Palpating the fontanel borders.
noting placement of the eyes, nose, lips, mouth,
and ears.
size. The nurse can readily determine this dimension by
palpation of the fontanel borders with use of the finger
for measurements (the distance from the tip of the finger
one ear slightly lower than the other is a common finding to the first finger joint is roughly 1 inch, or 2.5 cm).
that generally has no clinical significance. Nostrils should Variations in anterior fontanel size are common and
be open bilaterally and the nasal bridge should be range from 0.4 to 2.8 inches (1 to 7 cm). The posterior
centered with no lateral deviations. Lip color should fontanel, located toward the back of the cranium, is a
be consistent with the tongue and buccal mucosa of the small, triangular-shaped space formed by the sagittal
mouth. The upper and lower lips should be approximately suture and the posterior lateral suture. At its widest
uniform in size. The infant’s chin should be readily appar- point, the posterior fontanel is usually only 0.4 inch
ent when viewed in a profile position. Micrognathia, or (1 cm) and may be closed at initial examination. The
small jaw, may interfere with tooth development, sucking, anterior fontanel must remain open during the first year
swallowing and tongue movement inside the mouth dur- of life to accommodate skull bone expansion that accom-
ing speech (Dillon, 2007). panies normal brain growth. Open spaces between the
The nurse carefully palpates the infant’s head to assess suture lines result from cranial molding during the birth
the fontanels, the cranial suture lines, and the presence of process. Assessment of the fontanels for intracranial pres-
any birth-related edema. The anterior fontanel is readily sure is an important component of the examination.
identifiable as a diamond-shaped open space formed by Normal intracranial pressure is characterized by a finding
the anterior–posterior sagittal and frontal sutures and the of fontanel fullness without bulging, either on visual
lateral coronal suture (Fig. 18-14). Assessment of the inspection or palpation. Bulging, tense fontanels in an
fontanel includes an estimation of the overall fontanel infant with a large head circumference are indicative of
increased intracranial pressure, often associated with
hydrocephalus.
The nurse may note the presence of swelling or soft
tissue edema of the head that has resulted from trauma
during the birth process. Caput succedaneum is diffuse
edema that crosses the cranial suture lines and disappears
without treatment during the first few days of life. Ceph-
alhematoma, a more serious condition, results from a
subperiosteal hemorrhage that does not cross the suture
lines (Fig. 18-15). It appears as a localized swelling on one
side of the infant’s head and persists for weeks while the
A tissue fluid is slowly broken down and absorbed. During
this time, the infant may exhibit signs of jaundice related
to the metabolism of damaged red blood cells from the
subperiosteal hemorrhage.
The nurse next palpates the neonate’s eyes, ears, and
nose to confirm shape and size. The eyelids are manually
opened and the iris, sclera, and conjunctiva are examined.
It is not unusual to detect tiny pinpoint scleral hemor-
rhages (related to birth trauma) in the outer canthus of
the eyes. Swollen eyelids and a yellow discharge that
B C adheres to the eyelashes may provide evidence of eye pro-
phylaxis medication. The nurse uses an ophthalmoscope
Figure 18-13 To determine ear placement, an to check for bilateral red reflexes and records the findings
imaginary line is drawn from the inner to the outer on the infant’s chart. Absence of bilateral red reflexes con-
canthus of the eye and then to the ear. A. Normal stitutes a medical emergency; this finding warrants imme-
ear position. B. Low-set ear. C. Slanted low-set ear. diate attention.
chapter 18 Caring for the Normal Newborn 579
Skull
Brain
Suture line
Scalp
Periosteum
Blood Figure 18-16 Natal teeth.
Skull
Brain
apparent when the head is positioned on one side while ears, an enlarged tongue, high arched palate, and a small
the chin points to the opposite side. Torticollis or the chin. Open separations of the lip, mouth, nose, and hard or
presence of a congenital cervical spine defect are two seri- soft palate are indicative of cleft lip or cleft palate. Since facial
ous conditions that may produce limitations in neck disfigurement accompanies these defects, nurses should be
movement and should be reported immediately. extremely sensitive to the feelings of parents and other family
The nurse palpates and inspects the neonate’s ears to members who interact with the infant.
determine the thickness of the ear lobe and pinna. Ear pits The eye examination may provide an early indicator of
and ear tags are common preauricular ear malformations. several conditions that can affect the infant’s well-being. For
Ear pits, tiny pinholes found near the upper curved border of example, sclera, normally white, may appear to be blue or
the pinna, arise from the imperfect fusion of the tubercles of yellow in color. Bluish colored sclera may signal a congeni-
the first and second brachial arches during early fetal devel- tal condition known as osteogenesis imperfecta, which is
opment. Since they may signal a small sinus tract between characterized by a loss of bone structure and integrity.
the skin and underlying structures, they should be carefully Infants with this condition must be handled with extreme
evaluated to determine whether a layer of skin covers the gentleness, and may have already suffered fractures during
opening or if the pit is open at the bottom. When signs of the birth process. Yellowing of the sclera, related to elevated
infection (i.e., redness, edema, draining fluid) are present, bilirubin levels, is a late manifestation of jaundice in the
the ear pits should be surgically repaired. Ear tags, fleshy neonate. The nurse should seek immediate medical assis-
bulb-shaped growths that project from the surface of the tance for the infant and plan for rapid intervention such as
skin, should be removed for cosmetic purposes by a plastic intravenous fluids and phototherapy. A disruption in the
surgeon since they frequently contain microcapillaries that iris, called a coloboma, appears as a keyhole in the circle of
bleed when cut. The ear canals are assessed for patency and the iris and pupil and will affect vision in that eye. Congeni-
gross hearing may be evaluated by softly ringing a bell near tal cataracts are noted when white or pale yellow tissue cov-
each ear. ers the pupil and iris and occludes the red reflex. This find-
Most states in the United States require routine hear- ing warrants prompt referral. Occasionally, the red reflex
ing screening before a newborn’s discharge from the (normally red or reddish orange in color) appears to be
hospital. The goal of newborn screening is to identify white, a finding that requires immediate attention since it
congenital hearing loss and to refer those affected for may signal the presence of a neuroblastoma. Congenital
early intervention. Screening is done using automated glaucoma is an ophthalmic emergency that requires the
auditory brainstem response (AABR) in which elec- timely instillation of eye drops to prevent blindness caused
trodes are placed on the forehead and neck and soft ear- by increased intraocular pressure. This condition is charac-
phones on the ears of a sleepy, calm infant. A series of terized by protuberant eyes that appear to extend beyond
clicks are introduced, usually at the 30- to 40-decibel the orbits and feel firm on gentle palpation.
level. If an infant has normal hearing, the response is Careful examination of the infant’s facial features may
detected by the electrodes (Kaye, 2007). Infants whose provide evidence of birth defects associated with maternal
test results are unsatisfactory should be referred for alcohol use. Characteristic findings include short palpe-
repeated testing to take place no later than 8 weeks of bral fissures; a flattened nasal bridge with a small, upturned
age. Early hearing screening allows for timely identifica- nose; flat midface, thin upper lip and smooth philtrum.
tion of problems and reduces the age at which affected Alcohol-related birth defects (ARBD) also include poor
infants may be treated (Johnson et al., 2005; Joint Com- growth, mental retardation (often associated with micro-
mittee on Infant Hearing, 2000; U.S. Preventive Services cephaly, or small head), and small chin (micrognathia).
Task Force, 2001). This condition, also called fetal alcohol syndrome (FAS)
Assessment of the nose begins with an observation of or fetal alcohol effects (FAE), describes the range of physi-
the placement of the nose, normally located in the mid- cal and mental effects that are related to the mother’s
dle of the face. The nurse can draw an imaginary line alcohol use during fetal growth and development. After
from the center of the bridge of the nose downward to birth, affected infants are often jittery, irritable, and poor
the notch of the upper lip. The nose should lie exactly feeders. Nursing interventions focus on providing a calm-
vertical to this line. Each side of the nose should be sym- ing, quiet, nurturing environment with minimal stimula-
metrical. It is important to note any deviation to one tion. (See Chapter 19 for further discussion.)
side, as well as asymmetry in relation to the size and The nurse’s careful assessment of the infant’s head, face,
dimensions of the nostrils. Remember that the bridge of eyes, ears, nose, and throat constitutes an essential compo-
the nose in African American or Asian children is nor- nent of the neonatal physical examination. Since infants are
mally flat. frequently bundled in blankets when presented to parents
and loved ones, initial impressions are often formed based
CONDITIONS THAT MAY WARRANT FURTHER ASSESSMENT. When on the appearance of the neonate’s face and head. Because
conducting an assessment of the head, ears, eyes, nose, and many congenital malformations affect these body parts, the
throat, the nurse is alert to findings of asymmetry, unusual nurse must be sensitive to parents’ feelings and approach
shape or evidence of defects in underlying structures or con- the initial “viewing” prepared to provide immediate emo-
genital syndromes. Generally, findings that are immediately tional support and subsequent referral to appropriate
apparent to the nurse examiner pose the greatest problems resources as indicated. It is important to remember that a
for the neonate. For example, Down syndrome is frequently wide range of normal variations (i.e., birth marks, hair pat-
identified during the assessment of the head when the nurse terns, large eyes, nose, or ears) commonly occur and result
notes a flattened (instead of round) occiput, a broad nasal from familial characteristics and inheritance patterns rather
bridge, upward slanted eyes with epicanthal folds, low-set than from congenital syndromes.
chapter 18 Caring for the Normal Newborn 581
Now Can You— Describe the assessment related to the infant’s chest confirms that the nasal passageway is open
infant’s head? and air has been inhaled. The assessment may be repeated
with the other naris. If the infant demonstrates difficulty
1. Describe the location of the fontanels? Explain why it is with this maneuver, he may have a developmental anomaly
important to assess them? known as choanal atresia (a malformation of the bucco-
2. Differentiate between caput succedaneum and nasal membrane). When present bilaterally, cyanosis is
cephalhematoma and discuss how each is treated? noted when the infant’s mouth is closed but disappears
3. Describe how to conduct an assessment of the neonate’s when the mouth is open. An inability to pass a small cath-
mouth and explain why this assessment is important? eter into the nares confirms the diagnosis. Since choanal
4. Identify neonatal features that are characteristic of Down atresia may be associated with other developmental anom-
syndrome and maternal alcohol use? alies, a positive finding should be reported immediately.
With the infant in a supine position, the nurse can read-
ily assess his ease with overall breathing efforts. Respirations
are counted and the pattern and any use of accessory mus-
case study Baby Boy Goldman cles are noted. Slight sternal retractions may occur; this is a
normal finding. Prominence of the xiphoid process is not
Baby Boy Goldman was born via a normal spontaneous vaginal unusual and with normal growth and development, the
birth 4 hours ago. His parents are of eastern Mediterranean prominence will diminish. The lungs are auscultated anteri-
descent. His mother’s prenatal care was initiated during the third orly and posteriorly (Fig. 18-18). Infants may exhibit irregu-
month of gestation and the pregnancy was uncomplicated. He is lar breathing patterns accompanied by periods of apnea that
awake and resting quietly in the nursery bassinet. During a
can persist for up to 15 to 20 seconds. While not worrisome,
review of the infant’s medical record, the nurse notes the follow-
ing information, recorded approximately 1 hour earlier: axillary it is important to alert parents that a brief cessation in respi-
temperature: 98.0ºF (36.7ºC) pulse: 136 beats per minute; respi- rations is common in neonates. The nurse also teaches the
rations: 40 breaths per minute; weight: 8 lbs. 2 oz. (17.7 kg); infant’s caregivers how to recognize signs of respiratory dis-
length: 20.5 inches (8.1 cm). At birth, Baby Goldman’s heart rate tress: flaring of the nares, retractions (in-drawing of tissues
was 92 beats per minute and he was crying and moving all between the ribs, below the rib cage or above the sternum
extremities. The nurse now observes that the infant’s hands and and clavicles), or grunting with expirations. For healthy
feet are bluish in color and his face contains several white full-term neonates, a respiratory rate below 60 breaths per
“bumps” that are scattered over his nose and forehead. Dark minute is considered normal. To obtain an accurate respi-
gray areas are seen on his lower back and buttocks. On palpation ratory rate, it may be necessary to count the infant’s respira-
of Baby Goldman’s head, the nurse notes a small degree of
tions at several different times during the physical assess-
swelling that is symmetrical and crosses the suture lines.
ment. If the respiratory rate remains above 60 to 70 breaths
critical thinking questions per minute during rest, further evaluation is warranted.
1. Are these findings normal or pathological?
2. What actions should the nurse take?
Purpose
To assess for developmental dysplasia of the hips
Equipment
None
Steps
1. Place the infant supine on a flat surface. 4. Using gentle but firm pressure, rotate the
2. Place your thumbs on the infant’s inner thighs hips outward so that the knees touch the flat
and your fingers on the outside of the greater surface. No clicking or crepitus should be
trochanters of the hips. detected.
3. Flex the infant’s knees and move the legs inward RATIONALE: The presence of clicking or crepitus indi-
until your fingers touch. cates joint instability.
Documentation
3/4/10 1500 – Barlow-Ortolani maneuver negative
—J. Yamoto, RN
CONDITIONS THAT MAY WARRANT FURTHER ASSESSMENT. webbing of the skin between the digits and toes (syndac-
Before performing the musculoskeletal assessment, the tyly). On the hand, the extra digits often are located
nurse first must determine that there are no broken bones. below the fourth finger and are attached to the palm by a
It is important that the infant not be moved or reposi- thin line of skin. They may resemble the fourth finger and
tioned until this has been accomplished. In the neonate, may even contain a fingernail. The nurse should palpate
the clavicle is the bone most commonly fractured. The all extra digits for the presence of bone, which must be
injury occurs during birth when the infant’s shoulders do surgically removed. If no bone is present, the digit may
not readily rotate. The nurse should palpate the clavicles be tied off with suture silk to occlude the capillary to
to check for a separation between the bone ends or for the cause necrosis and loss of the digit. Polydactyly is often a
presence of crepitus. Signs and symptoms of fractures family characteristic and parents may recall other family
include swelling at the fracture site, bruising, or discolor- members who were born with extra digits or toes. Web-
ation of the affected area and the infant’s expression of bing of the toes does not interfere with balance or walk-
discomfort when moved. Other common sites for neona- ing, and parents may not wish to have their infant’s toes
tal fractures are the ribs, humerus, and skull. An x-ray surgically released from one another. Webbing of the fin-
exam is used to confirm the diagnosis. Clavicular frac- gers is often surgically corrected to facilitate dexterity and
tures heal over time without intervention and the nurse for cosmetic reasons.
can teach the parents to position the infant on the side The nurse inspects the palms of the hands for the pres-
opposite the injury and how to hold and support the ence of palmar creases. The hands of a normal neonate
infant’s head and shoulders until healing is complete. usually contain three or four curved palmar creases. A
Casts are usually applied to humeral fractures while rib simian crease is a single, straight crease that appears in
fractures are generally wrapped. Infants with skull frac- the middle of the palm on one or both hands (Fig. 18-25).
tures are most often cared for in the intensive care unit When unaccompanied by other findings, the simian crease
where they can be continuously monitored. is insignificant. However, when detected along with other
Sometimes, infants are born with extra digits (fingers) symptoms, a simian crease may be associated with other
and toes (polydactyly) or with what appears to be syndromes, such as Down syndrome.
chapter 18 Caring for the Normal Newborn 589
The infant curls his toes around an object that has been placed
at the sole of the foot.
Stroke the infant’s cheek and watch him turn toward the finger,
open his mouth and suck on an object placed in his mouth.
Extrusion Reflex
Touch the tip of the infant’s tongue and the tongue will protrude
outward.
Table 18-2 Newborn Reflexes—cont’d
Stepping Reflex
Hold the infant in an upright position with the legs flexed. The
soles of the feet are lightly brushed against a flat surface. In
response to the stimulation, the infant lifts his feet and then
places them back down in a stepwise pattern that imitates
walking.
Observe the infant, in a supine position, extend his arm and leg
on the side to which his head and jaw is turned while flexing his
arm and leg on the opposite side.
Glabellar Reflex
Tap on infant’s forehead and observe him blink for the first few
taps.
Babinski Reflex
Lightly stroke the plantar surface of the foot from the heel
toward the toes. The infant responds to this stimulation by first
incurving the toes, then uncurling and stretching them out.
Moro Reflex
Continued
592 unit five Care of the New Family
With the infant in a supine position, flex the leg and apply
pressure to the soles of the feet. Observe the infant extend his
legs against the pressure.
Crawling Reflex
Crossed Extension
In utero development of the brain and spinal cord is a importance of timely metabolic screening for the newborn,
process initiated during the embryonic period. During the since many life-threatening problems can be detected early
first 30 days of gestation, the primitive neural tube closes. enough for effective intervention.
A failure of the tube to close at the posterior end results in
an open area that may be filled with fluid or with a section TEMPERATURE ASSESSMENT
of the spinal cord. This condition, called spina bifida, is
To prevent dangerous heat loss in the infant, nurses, moth-
usually detected during routine maternal–fetal antenatal
ers, and other caregivers need to understand how to protect
testing. When the infant is born, the lesion of spina bifida
the infant from extreme temperature fluctuations during
resembles a skin-covered sac located between the fifth
bath time. In the hospital before the bath is given, it is impor-
lumbar and first sacral vertebrae. The sac, which may con-
tant to take the newborn’s temperature to ensure stability.
tain the dura mater and spinal fluid, is called a meningo-
Temperature may be assessed by several methods. The
cele. This condition usually does not cause any loss of
axillary skin method, which is reflective of the infant’s
motor function, or paralysis, below the waist. A more seri-
core temperature and the body’s compensatory response
ous lesion is the myelomeningocele. When present, a
to the environment, is the preferred noninvasive method
myelomeningocele is a sac that contains dura mater, spi-
that provides a close estimation of the rectal temperature.
nal fluid and a portion of the spinal cord. Individuals with
Although rectal temperature represents the closest approx-
a myelomeningocele have no bladder or bowel control
imation of core temperature, this route is not recom-
and there is a loss of motor function below the waist.
mended because of the possibility of irritation and perfo-
Treatment of spina bifida is related to the location and
ration of the rectal mucosa. The infant’s temperature may
extent of the lesion. Most often, the sac is surgically closed
also be assessed with a continuous skin probe (especially
to prevent infection. Spina bifida occulta is a mild varia-
useful with small newborns or infants placed in incuba-
tion of spina bifida. In this condition, there is a small
tors or under radiant warmers) or via tympanic thermom-
defect in the spinal vertebrae. However, since there is no
eter, a portable sensor probe that is placed in the ear canal.
protrusion of the dura mater, spinal fluid, or spinal cord,
This method employs infrared technology to measure the
all motor activity remains intact.
temperature of the internal carotid artery blood flow. As
An incomplete closure of the anterior portion of the
long as the temperature is maintained between 97.5º and
neural tube causes a condition known as anencephaly.
99ºF (36.4º–37.2ºC), the bath can be given. At home, it is
Lack of closure in this location causes portions of the
not necessary to take the temperature before bath time.
brain, forehead, skull, and occiput to be missing. Infants
born with anencephaly are usually placed on respirators
and monitored to assess viability. When caring for the BATHING THE NEWBORN
mother and her family, the nurse must be extremely sensi- When bathing the newborn, the bath should take place in
tive to the emotional impact associated with this condi- a warm area free from drafts. The newborn can be given a
tion and offer the parents privacy and support. sponge bath using only warm water for the first few days of
life. After the cord stump has dried completely and fallen
Now Can You— Complete a neonatal neurological off in approximately 2 weeks, the infant can be immersed
assessment? in a small tub filled with about 4 to 5 inches of water.
1. Identify the major and minor reflexes in a neonate?
2. Demonstrate how the Moro reflex is elicited and describe Optimizing Outcomes— Ensuring safety for the
why this assessment is performed? newborn
3. Recognize the signs of a brachial plexus injury?
4. Describe two types of neural tube defects? It is paramount to remember that wet newborns are slip-
pery! The nurse and parents must keep a firm hold on the
baby, and continuously support the head up out of the
water. When instructing new parents about the bath it is
Enhancing the Neonate’s Transition important that they understand that it is never acceptable
to Extrauterine Life to leave any child unattended near water, even a small
amount of water. Submersion injury is the second leading
The newborn’s adaptation to extrauterine life is an amazing cause of accidental death in children.
and complex process. In the early days of adjustment as
well as through infancy, newborns need significant physi-
cal, emotional, and spiritual care. Mothers and other care- Newborns do not require a daily bath; bathing them once
givers must learn the essential aspects of newborn care in a week is adequate. However, the face and hands can be
order to promote optimal infant growth and development. wiped off daily. The infant’s bottom and genital area should
Critical aspects of physical care include bathing, clothing, be cleansed several times during the day. Because the new-
diapering, and feeding the infant. It is also important that born’s skin may be sensitive, a mild, unscented soap is rec-
parents’ discharge instructions provide easy to understand ommended for the bath. The initial bath after birth takes
information about the proper care of the infant’s nails, place after temperature stabilization. The procedure for the
umbilical cord, and, when appropriate, the circumcision. bath after birth and at home is fairly simple. The bath should
Bonding with the newborn is essential for emotional care proceed from head to toe. Parents must understand that
and the beginnings for spiritual development are estab- good hygiene, including clean clothes, hair, nails, and teeth
lished by building trust through relationships with the is important in promoting proper growth and development
primary caregiver. Parents must be educated about the for their infant. At home, newborns can be placed in 4 to
594 unit five Care of the New Family
petrolatum gauze dressing is applied for 1 to 2 days to the immune system and enhance overall feelings of well-
prevent the diaper from adhering to the surgical site. being. Touch is a basic human expression that conveys caring
Another method involves use of the PlastiBell device, and nurturing. The mother intuitively places a comforting
which is fitted over the glans and remains there until it hand to her child’s feverish head, pinched finger, or scraped
falls off in approximately 5 to 7 days (Fig. 18-27). No pet- knee. Friends instinctively reach out to touch one another in
rolatum gauze dressing is used after circumcision with a an expression of caring and compassion. Nurses have long
PlastiBell device (Glass, 2005). Nursing care for the cir- recognized and embraced the value of touch as an important
cumcised newborn focuses on alleviation of pain and the therapeutic tool useful with patients of all ages.
prevention of infection. Parent/caregiver education is also For the neonate, life’s initial impressions, wrapped in a
an important component of care. Therapeutic touch is a halo of warmth, love, and pleasure, are all conveyed through
beneficial comfort measure for all infants and is especially touch. The infant’s growing knowledge and awareness of
useful following painful procedures. those around him is directly shaped by the way in which he
is handled. His sense of comfort, security, and well-being are
powerfully influenced by the nature of his mother’s or care-
Complementary Care: Therapeutic touch giver’s touch. Touch experiences occurring during the hours
enhances comfort
and days after birth, and the infant’s feelings that are shaped
The use of touch to promote healing and comfort dates back by these experiences, serve to set the foundation for feelings
to more than 5000 years ago, when Asian therapists used a about people throughout life. Premature and sick infants in
variety of touching methods as an important strategy in the the intensive care unit can also benefit from a light, calming
healing ritual. Over the ages, other ancient cultures, such as touch that promotes a sense of security and warmth.
the East Indians and Native Americans, also found value in
the power of “hands on” healing. Many spiritual traditions, Reasons for not circumcising a newborn may be related
including the Judeo–Christian doctrine, view healing by the to the surgical risks and/or pain associated with the pro-
“laying on of hands” as a key element in the promotion and cedure. If the parents choose not to have their son circum-
restoration of physical and mental health. cised, they need to receive information about how to keep
Touch plays an important role in fostering healthy human their son’s penis clean.
development. It has been shown to boost the functioning of
— Teaching parents who choose
not to have their son circumcised
When parents who have decided against infant
circumcision inquire about personal hygiene for their
son, the nurse may make the following suggestions:
“When your son is 4–5 years old, he can learn how to
keep his penis clean just as he will learn to keep other
parts of his body clean. The foreskin usually does not
fully retract for several years and should not be forced.
For an infant, the uncircumcised penis is easy to keep
clean by gently washing the genital area while bathing.
You do not need to do any special cleansing, such as
with cotton swabs or antiseptics.
Around the age of 4–5 years, when the foreskin fully
retracts, boys should be taught how to wash underneath
the foreskin every day. Teach your son to clean his
foreskin by gently pulling it back away from the head of
the penis and then rinsing the head of the penis and
inside fold of the foreskin with soap and warm water.
A After washing, the foreskin should be pulled back over
the head of the penis.”
the entire family. Two feeding choices are available for Infants up to 20 pounds must be placed in a rear-facing
newborns: breastfeeding with the mother’s natural milk or position in the back seat of the car. Infants must not be
bottle-feeding with a commercially prepared cow’s milk placed in the front seas as inflating front seat air bags may
formula. It is paramount that the infant’s diet be sufficient cause suffocation (AAP Committee on Safety, 2002).
to optimally meet his rapidly changing physical and psy-
chosocial needs and adhere to the current recommended Across Care Settings: Car seat safety
dietary allowances. The diet must include essential nutri-
ents such as protein to support rapid cellular growth, car- The nurse can assist the new family by providing information
bohydrates to provide energy, and fat to supply the and guidance to resources on car seat safety:
needed calories, regulate fluid and electrolyte balance, and • When purchasing a car seat, parents need to be aware
sustain development of the brain and neurological system. that the seat must meet certain federal guidelines. A
Water intake, essential for tissue hydration, should amount label on the seat tag or packaging box states whether
to 140 to 160 mL/kg per day. Because the bioavailability the product has met these guidelines. The American
of iron in breast milk is much greater than in formula Academy of Pediatrics Web site (www.AAP.org) also
preparations, full-term infants who are breastfed do not lists the guidelines. It is important to emphasize that
need supplemental iron until they reach 6 months of age. the car seat instructions must be followed when installing
At that time, breastfed babies require iron-fortified for- the car seat.
mula in combination with the breast milk. Infants who are • Several community resources are available to the family
bottle-fed should be given a commercial formula fortified that will rent or loan a car seat for the initial dismissal.
with iron from the beginning. Adequate calories are also The hospital or birthing center may have a car seat
necessary and daily requirements of 105 to 108 kcal/kg program. Other resources include the American Red
per day have been established. (See Chapter 15 for further Cross, the Local Health and Safety Council, and the State
discussion about infant feeding.) Department of Health.
• The infant must be dressed so that the clothing facilitates
ease of positioning and strap placement. To ensure
Discharge Planning for the Infant correct fit, the infant can wear a single layer of clothing,
and Family preferably pants, so that the strap can fit between the legs.
Sack sleepers are not recommended and bundling is
The new family is discharged from the hospital or birthing discouraged because the strap may not fit snugly. Head
center as early as 24 hours after birth, so early initiation of support is recommended. Parents can use a commercially
the discharge planning process is crucial. If this is the made product or place a rolled-up receiving blanket
couple’s first child, discharge planning becomes even around the head and neck area. To protect the infant
more important. The nurse must use every opportunity, from burns and overheating in warm weather, parents
beginning during the prenatal period, to teach the family should check the temperature of the car seat by touching
about newborn care. The astute nurse gathers cues about the surface.
family adaptation to the new baby by observing how the • Trained professionals may be available to perform safety
members interact with one another and their level of com- checks to help parents with proper car seat installation
fort when holding, feeding, diapering, and dressing the and use. New cars are required to be equipped with
newborn. Questions such as “Tell me how you will care tethers and lower anchors to ensure child safety.
for your new baby?” or “Who is available to help you care
for your new baby?” may give the nurse insight as to the
type of information the family may need. CHILD CARE
When the new family arrives home, they have many deci-
Across Care Settings: Providing parenting sions to make about the new baby. One important deci-
information sion is who will care for the child when the parent(s)
return to work.
Offering essential information in any setting through
Over the past 35 years, caring for children has shifted
individual instruction, educational videos, or parenting
from home care to care away from the home. It is essential
classes about such topics as health promotion, growth and
that the child care facility offer an environment of trust
development, handling, nasal and oral suctioning, hygiene,
along with safe and competent care. In addition, the child
diapering, dressing, comforting, nutrition and elimination,
care provider must offer ways to stimulate growth and
rest and sleep, safety and anticipatory guidance may help the
development as well as meet the physical and psychosocial
mother and family gain confidence about caring for their
needs of the developing child. The nurse’s responsibility is
baby. It is also helpful to educate parents about routine
to help guide the family when choosing a child care facil-
laboratory screening tests that may be performed in the
ity. There are several options available for families today.
hospital, home, doctor’s office, or community clinic.
In-home care refers to a child care provider such as a
nanny, baby sitter, family member, or friend who comes
Discharge from the hospital or birthing center is an into the family home. Work-based group care occurs when
ideal time to discuss and implement car seat safety mea- the child is placed in a facility that is directly associated
sures as automobile accidents are a safety concern for new with the parent(s)’ employment. Another child care option
parents. In moving vehicles, infants and older children involves placement of the child in another family’s home.
must always be transported in a safe seating device. This type of care can be licensed or unlicensed and may be
chapter 18 Caring for the Normal Newborn 599
considered more informal. Established business day care Under state law requirements, screening of neonates has
centers offer more formal licensed care settings that com- been routinely performed in the United States since the
ply with set standards and follow state regulations. These 1960s. However, no universal screening policy has been in
day care centers have specific policies that include mini- place to assure uniformity. Instead, policies concerning
mum child to worker ratios. Sick-child care may also be routine neonatal screening vary from state to state and are
available to the family in times of illness. These care facili- frequently based on local demographics, cost, reimburse-
ties are often offered in community or hospital settings. ment, politics, and ready availability of resources. To
address the lack of uniformity in screening practices, the
American Academy of Pediatrics (AAP) convened a national
Collaboration in Caring— Child care for Task Force on Newborn Screening. An important outcome
new families
of this work was the directive that each newborn have a
The nurse can encourage the family to: medical home. A medical home means that every newborn
should receive the benefit of a pediatrician or other primary
• Communicate their needs and express their concerns
about child care.
care health professional who works in partnership with the
newborn’s family to ensure that appropriate screening is
• Interview the facility director along with other individuals
who may be involved in the child’s care.
completed, test results are reported, and appropriate fol-
low-up is conducted (AAP, 2000; AAP, 2005b).
• Evaluate the educational programs related to qualification
of teachers and structure of the learning environment
On the federal level, members of congress recently
(structured or unstructured).
directed the U.S. General Accounting Office to compile
information related to newborn screening programs and
• Investigate the provision of meals, nutrition, and related
sanitation.
state variations. The report revealed that most states
screen newborns for only eight or fewer disorders. Fur-
• Visit the child care facility on a few occasions, announced
and unannounced.
thermore, most states selected the disorders for screening
according to whether or not they were treatable. Based on
• Identify practical aspects of child care such as location,
hours of operation, fee requirements and payment
these findings, the Department of Health and Human Ser-
schedule, child to worker ratio, environmental safety,
vices (DHHS) suggested that a common set of disorders be
indoor and outdoor space, sick day policies, and
established for all states, along with selection criteria for
availability of care during a holiday or inclement weather.
which disorders would be tested (U.S. General Account-
• Evaluate the infection control and injury prevention
ing Office, 2003).
measures.
It is essential that nurses recognize that early detection
• Gain broader information about the facility related to
of various disorders allows for timely intervention that
breast feeding, discipline, nurturing, diapering/toileting,
can prevent or minimize complications. Before mothers
stimulating growth and development, play, nap/rest time,
and their infants are discharged from the hospital or birth-
and field trips.
ing center, the nurse should educate the family about the
• Discover state regulations and read the care facility’s
importance of newborn screening. Emphasis should be
policies and related public records.
placed on the long-term benefits of neonatal screening
• Become familiar with early childhood program that offer
since early detection can allow for the initiation of timely
voluntary accreditation such as the National Academy of
treatment and the development of a plan for ongoing
Early Childhood Programs.
follow-up care. From a community perspective, universal
screening and timely intervention can lead to a national
reduction in infant disabilities, morbidity, and mortality.
While a positive screening test may indeed indicate
Newborn Metabolic Screening Tests that the newborn has a disorder, a diagnosis is generally
not made from a single laboratory result. Instead, subse-
Newborn screening, designed to identify newborns with quent testing is conducted since “false positives” (a posi-
genetic, metabolic, and/or infectious conditions, is an tive finding although the infant does not have the disor-
essential part of preventative care. Through screening, der) can occur. A false-negative result can occur if the
many life-threatening problems can be detected early specimen was collected at too young of an age, or if the
enough for effective intervention. Conditions commonly quality of the specimen was in some way jeopardized.
discovered through early screening include biotinidase
deficiency, hemoglobinopathies, medium-chain acyl Co-A
dehydrogenase deficiency, phenylketonuria (PKU), galac- Optimizing Outcomes— Newborn metabolic
tosemia, cystic fibrosis, congenital adrenal hyperplasia, screening
congenital hypothyroidism, sickle cell anemia, and phe- Best Outcome: Understand the effects of various disor-
nylketonuria (PKU). PKU, which occurs in approximately ders detected by metabolic screening and advocate for
1 in 10,000 to 25,000 births, is a genetic metabolic disor- universal routine screening of all newborns. At present,
der. It is characterized by a deficiency of the enzyme phe- the minimum mandatory newborn screening tests in most
nylalanine hydroxylase, which the body needs to convert states in the United States are for inborn errors of metabo-
phenylalanine to tyrosine. A lack of proper conversion lism such as PKU, galactosemia, hemoglobinopathy (sickle
results in a build-up of toxic blood levels of phenylala- cell disease and thalassemias), and hypothyroidism. In
nine, a condition that causes central nervous system Canada, newborn screening testing varies by province
(CNS) damage (Edwards, Howell, & Lloyd-Puryear, (CDC, 2005).
2006). (See Chapter 19 for further discussion.)
600 unit five Care of the New Family
American Academy of Pediatrics (AAP). (2002). Policy Statement: Hisley, S.M. (2006). Care of the mother and neonate during the postpar-
Selecting and using the most appropriate car safety seats for growing tum period. In Lippincott manual of nursing practice (8th ed.,
children – guidelines for counseling parents. Pediatrics, 109(3), pp. 1233–1258). Philadelphia: Lippincott Williams & Wilkins.
550–553. Johnson, J., White, K., Widen, J., Gravel, J., James, M., Kennalley, T.,
American Academy of Pediatrics (AAP). (2003). Controversies concern- et al. (2005). A multicenter evaluation of how many infants with
ing vitamin K and the newborn: committee on fetus and newborn: permanent hearing loss pass a two-state otoacoustic emissions/
Policy statement. Pediatrics 112(1), 191–192. automated auditory brainstem response newborn hearing screening
American Academy of Pediatrics (AAP). (2005a). The changing concept protocol. Pediatrics, 116(3), 663–672.
of sudden infant death syndrome: Diagnostic coding shifts, contro- Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
versies regarding the sleeping environment and new variables to Maas, M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and
consider in reducing risk. Pediatrics, 116(5), 1245–1255. NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.).
American Academy of Pediatrics (AAP). (2005b). The national center of St. Louis, MO: Mosby Elsevier.
medical home initiatives: Metabolic/genetic screening activities. Joint Committee on Infant Hearing, American Academy of Audiology,
Retrieved from http://www.medicalhomeinfo.org/screening/newborn. American Academy of Pediatrics, American Speech-Language-
html (Accessed September 6, 2007). Hearing Association, and Directors of Speech and Hearing Programs
American Academy of Pediatrics (AAP) Task Force on Circumcision. in State Health and Welfare Agencies. (2000). Year 2000 position
(1999). Circumcision policy statement. Pediatrics, 103(3), statement: Principles and guidelines for early hearing detection and
686-693. intervention programs. Pediatrics, 106(4), 798–817.
American Academy of Pediatrics (AAP) Committee on Fetus and New- Kaye, C.I. (2007). Introduction to the newborn screening fact sheets.
born & American College of Obstetricians and Gynecologists Pediatrics, 118(3), 1304–1312.
(ACOG) Committee on Obstetrics (2002). Guidelines for perinatal Lund, C., Kuller, J., Lane, A., Lott, J., Raines, D., & Thomas, K. (2001).
care (5th ed.). Evanston, IL: Author. Neonatal skin care: evaluation of the AWHONN/NANN research-
American Academy of Pediatrics (AAP) and American College of Obste- based practice project on knowledge and skin care practices. JOGNN,
tricians and Gynecologists (ACOG). (2007). Guidelines for perinatal 30, 30–40.
care (6th ed.). Elk Grove Village, IL: AAP. Lund, C., & Osborne, J. (2004). Validity and reliability of the neonatal
Anand, K., Johnston, C., Oberlander, R., Taddio, A., Lehr, V., & Walco, G. skin condition score. JOGNN, 23(3), 320–327.
(2005). Prevention and management of pain and stress in the neonate. Lund, C., Osborne, J., Kuller, J., Lane, A.T., Lott, J.W., & Raines, D.A.
Pediatrics, 27(6), 884–876. (2001). Neonatal skin care: Clinical outcomes of the AWHONN/
Association for Women’s Health, Obstetric and Neonatal Nurses NANN evidence-based clinical practice guideline. JOGNN, 30, 41–51.
(AWHONN). (2001). Evidence-based clinical practice guideline: Neo- Miller, C., & Newman, T. (2005). Routine newborn care. In H. Taeusch,
natal skin care. Washington, DC: Author. R. Ballard, & C. Gleason (Eds.), Avery’s diseases of the newborn (8th
Askin, D.F. (2007). Physical assessment of the newborn. Parts 1 and 2. ed., pp. 239–246). Philadelphia: W.B. Saunders.
Nursing for Women’s Health, 11(3), 294–315. Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing
Ballard, J.L., Khoury, J.C., Wedig, K., Wang, L., Eilers-Waisman, B.L., & outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
Lipp, R. (1991). New Ballard score, expanded to include extremely NANDA International (2007). NANDA-I nursing diagnoses: Definitions
premature infants. Journal of Pediatrics, 119, 417–423. and classifications 2007–2008. Philadelphia: NANDA-I.
Brazelton, T.B. (1973). Neonatal behavioral assessment scale. Philadelphia: National Newborn Screening and Genetic and Resource Center; National
Lippincott. newborn screening status report. Retrieved from http://genes-r-us.
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven- uthscsa.edu/nbsdisorders.pdf (Accessed April 18, 2008).
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. Recommended Childhood and Adolescent Immunizations Schedule—
Centers for Disease Control and Prevention (CDC). National Center for United States (2007). Approved by the Advisory Committee on
Health Statistics. (2007). National health and nutrition examination Immunization Practices (www.cdc.gov/nip/acip), the American
survey. Retrieved from http://www.cdc.gov/nchs/about/major/nhanes/ Academy of Pediatrics (www.aap.org), and the American Academy of
growthcharts/charts.htm (Accessed April 20, 2008). Family Physicians (www.aafp.org). http://www.cdc.gov/vaccines/
Centers for Disease Control and Prevention (2005). Retrieved from recs/acip/default.htm (Accessed September 9, 2007).
http://www.phppo.cdc.gov (Accessed August 9, 2007). Ressler-Maerlender, J., & Sorensen, R. (2005). Circumcision: An
Centers for Disease Control and Prevention, Workowski, K., & Bergman, informed choice. AWHONN Lifelines, 9(2), 146–150.
S. (2006). Sexually transmitted disease treatment guidelines, 2006. Scanlon, V.C. (2007). Essentials of anatomy and physiology (5th ed.).
MMWR Morbidity and Mortality Weekly Report, 55(RR-11), 1–94. Philadelphia: F.A. Davis.
D’Avanzo, C., & Geissler, E. (2003). Pocket guide to cultural assessment Tucker, B.A. (2002). Promoting health of the infant and child. In J.A.
(3rd ed.). St. Louis, MO: C.V. Mosby. Maville, & C.G. Huerta (Eds.), Health promotion in nursing. Albany,
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses (11th NY: Delmar.
ed.). Philadelphia: F.A. Davis. U.S. General Accounting Office (2003). Report to congressional requestors:
Dillon, P.M. (2007). Nursing Health Assessment: A critical thinking, case Newborn screening characteristics of state programs. Retrieved from
studies approach (2nd ed.). Philadelphia: F.A. Davis. www.gao.gov/new.items/do3449.pdf (Accessed August 9, 2005).
Edwards, S.E., Howell, R.R., & Lloyd-Puryear, M.A. (2006). A look at U.S. Preventive Services Task Force (USPSTF) (2001). Screening for new-
newborn screening: Today and tomorrow. Pediatrics (Supplement), born hearing. Recommendation statement. Retrieved from www.ahrq.
117(5), i gov/clinic/uspstf/uspsnbhr.htm (Accessed April 19, 2008).
Glass, S. (2005). Circumcision. In P. Thureen, J. Deacon, J. Hernandez, Verklan, M., & Walden, M. (2004). Core curriculum for neonatal intensive
& D. Hall (Eds.), Assessment and care of the well newborn (2nd ed., nursing (3rd ed.). St. Louis, MO: Elsevier/Saunders.
pp. 456–464). St. Louis, MO: W.B. Saunders. Weise, K., & Nahata, M. (2005). EMLA for painful procedures in infants.
Journal of Pediatric Health Care, 19(1), 42–47.
CONCEPT MAP
Be Sure To:
• Complete birth
Ethnocultural Considerations: documentation/registration
• Color
• Diapering Family Education
• Customs/traditions related to
health beliefs
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Identify the criteria for classification of high-risk newborns such as gestational age factors, birth
weight, and intrauterine growth restricted parameters.
◆ Describe the conditions for a small for gestational age newborn.
◆ Describe the conditions for a large for gestational age newborn.
◆ Discuss the physical assessment of the premature infant.
◆ Explain the conditions affecting the premature newborn.
◆ Explain the conditions affecting the postmature newborn.
◆ Describe other conditions affecting the high-risk newborn.
◆ Prioritize nursing care interventions for the high-risk newborn.
◆ Develop a discharge-teaching plan for the parents of the high-risk newborn.
The purpose of this integrative review of the literature was to The sample consisted of more than 800 participants. The
synthesize existing empirical research about neonatal end-of-life following were practices for withdrawing or withholding
care. The neonatal period was defined as the time from birth to life-sustaining treatment:
27 days of life. Articles published before 1997 and those that “Withholding of treatment” was defined as refusing to
dealt with ethics or considered to be clinical in nature were not administer cardiopulmonary resuscitation. The decision to with-
included in the review. hold treatment has increased in the recent past and occurred in up
Two readers reviewed all of the research studies and mutually to 69% of the cases reviewed. Decisions to withhold treatment
agreed on a total of 10 articles that met the study criteria, based were made in situations where treatment attempts were believed
on the definitions of palliative and end-of-life care in neonates. to have been futile (74%), and these cases primarily involved a
Prematurity was the most common infant diagnosis for end-of-life diagnosis of extreme prematurity and/or extreme neurological
care. The following four categories were included in the synthesis: damage.
• Practices for withdrawing or withholding life-sustaining “Withdrawal of treatment” was defined as the removal of
treatment mechanical ventilation. Decisions to withdraw treatment pri-
• Pain management during ventilator withdrawal marily included situations where continued support was consid-
• Parents and the decision-making process ered to be futile (74%). Most deaths occurred after the decision
• The dying process to withdraw treatment had been made.
(continued)
603
604 unit five Care of the New Family
GA >/= 36 Wks 32–36 6/7 Wks 28–31 6/7 Wks </= 28 Wks
Behavioral state Active/awake Quiet/awake Active/sleep Quiet/sleep
0–4 beats/ 5–14 beats/ 15–24 beats/ 25 beats or
HR
minute Inc minute Inc minute Inc > Inc
0–2.4% 2.5–4.9% 5–7.4% 7.5% or
O2 Sats
Decrease Decrease Decrease Decrease
Brow bulge None Minimum Moderate Maximum
Eye squeeze None Minimum Moderate Maximum Figure 19-3 A commonly used pain assessment
Nasolabial furrow None Minimum Moderate Maximum in the NICU is the Premature Infant Pain
Profile (PIPP).
chapter 19 Caring for the Newborn at Risk 609
first 24 hours of life. Exact hematocrit values at which complications Large-for-Gestational–Age Infants
will occur are difficult to determine since different newborns become
symptomatic at different levels. Nursing care should include monitor- Newborns who are large for gestational age (LGA) are over
ing questionable hematocrit levels via venous blood because capillary the 90th percentile on the growth chart (this is a newborn
hematocrits are less exact. Assess the newborn for neurological symp- who weights approximately 3750 grams or 8 pounds and
toms such as high-pitched cry, feeding problems, irritability, and 4 ounces at 40 weeks gestation). A macrosomic newborn
apnea. Testing urine for blood and macroscopic analysis is also recom- weighs more than 4050 grams and is always LGA. Exces-
mended (Klaus & Fanaroff, 2005). sive fetal size is found in 9% to 13% of all deliveries. LGA
newborns have a higher morbidity rate than AGA
newborns.
There are two reasons why newborns may grow to a
Optimizing Outcomes— Preventing hemolysis larger than average size in utero. They can be genetically
large or, more commonly, they are exposed to an imbalance
Best outcome: To prevent hemolysis, transport the blood of nutrients in utero. The most common energy and growth
specimen to the lab as soon as possible. source in utero is glucose. It is easily transported by diffu-
sion across the placental barrier. If the maternal circulation
contains excessive glucose levels the fetus’ circulation will
have a higher than normal glucose level also. The intrauter-
nursing diagnoses The SGA Newborn ine conditions that place a newborn at risk for LGA are
listed in Box 19-5. Delivery of a LGA newborn places the
• Risk for activity intolerance related to increased metabolic needs newborn at a greater risk for complications (Box 19-6).
• Possible ineffective feeding pattern related to increased metabolic needs Infants of diabetic mothers are often LGA. LGA new-
• Nutritional imbalance related to hypoglycemia
borns are also at risk for transient tachypnea, hypoglycemia,
• Risk for impaired parenting related to increased care needs
• Caregiver role strain related to increased care needs hypocalcemia, hypomagnesemia, birth injuries, brachial
• Risk for growth and developmental delays related to intrauterine plexus injuries, and fractures (Klaus & Fanaroff, 2005).
nutritional and oxygenation status
• Risk for imbalanced body temperature related to decreased
subcutaneous tissue and brown fat (Doenges, Moorhouse, & Geissler-
Murr, 2005)
Box 19-5 Risk Factors Contributing to LGA Newborns
• Increasing parity
Box 19-4 Conditions that May Produce Polycythemia
• Increased maternal age
in the Newborn
• Increased maternal height
• Placental insufficiency • History of other LGA newborns
• Maternal hypertension • Prolonged pregnancy
• Pregnancy at high altitudes • Maternal obesity
• Maternal diabetes • Maternal glucose intolerance
• Trisomies • Large pregnancy weight gain
chapter 19 Caring for the Newborn at Risk 611
Observation of Retractions
Upper chest Lower chest Xiphoid Nares Expiratory
retractions dilation grunt
Grade 0
Table 19-3 The Relationship Between pH and Concentration of Arterial Blood Gases
pH PCO2 PaO2 PHCO3-
Measures blood acidity. Partial pressure of carbon Partial pressure of Partial presure of
dioxide in blood. oxygen in blood. bicarbonate (alkaline
or base) in blood.
Normal Neonatal Values pH 7.25–7.45 Pco2 35–40 mm Hg PaO2 50–80 mm Hg PHCO3- 20–22 mEq/L
Respiratory Acidosis ↓ pH ↑ PCO2 WNL WNL
(due to poor ventilation)
Metabolic Acidosis ↓ pH WNL WNL ↑ PHCO3-
(anaerobic metabolism
from hypoxia, diarrhea
or kidney disease)
Respiratory Alkalosis ↑ pH ↓ PCO2 ↑ PaO2 WNL
(hyperventilation)
Metabolic Alkalosis ↑ pH WNL WNL ↑ PHCO3-
(vomiting, diarrhea,
hypocalcemia)
along with hypoglycemia. Other reasons for hypocalcemia Brachial Plexus Injuries
in the newborn are trauma, hemolytic disease, asphyxia, Brachial plexus injuries (BPI) affect 5400 newborns in the
and maternal hypocalcemia (Taeusch et al., 2005). United States each year. The brachial plexus is a complex
SIGNS AND SYMPTOMS. Symptoms of hypocalcaemia can nerve supply that is responsible for the movement of the
range from asymptomatic to seizures and are similar to shoulders, chest, and arms. Shoulder dystocia in labor is
the symptoms of hypoglycemia and often difficult to dif- the leading cause of BPI.
ferentiate. Often a hypoglycemic newborn may also be SIGNS AND SYMPTOMS. BPI is classified by type and
hypocalcemic. Other symptoms may include jitteriness, degree. A first-degree injury consists of stretching of the
hyperalertness, increased tone, poor feeding and high- nerve fibers called neurapraxia, and recovery is usually
pitched cry. complete within a few days. Second-degree BPI is called
DIAGNOSIS. The diagnosis is made by laboratory study. axonotmesis and the nerve is compressed and becomes
Where the calcium level is below 7.5 mg/dL in preterm edematous. Recovery of second-degree BPI takes longer
newborns and 8 mg/dL in term newborns (Klaus & but is often complete. In third-degree injuries, axonotme-
Fanaroff, 2005). sis, the sheath is damaged and full recovery is never
achieved. Fourth-degree injury is caused by formation of
NURSING CARE. The nurse understands that return to a a neuroma that prevents full nerve regeneration, and fifth-
normal calcium level is facilitated by feeding the infant degree injury is a disruption of the nerve at the spinal cord
soon after birth. Other treatment can include physiologi- and results incomplete loss of nerve function.
cal correction of hypoparathyroidism, administration of
calcium supplements, and in severe cases the administra- DIAGNOSIS. Diagnosis is made through a complete neu-
tion of 10% calcium gluconate. rological assessment to determine the exact damage
including the type and degree as well as the extent of
Hypomagnesemia nerve impairment.
Magnesium is necessary for proper parathyroid function. NURSING CARE. Nursing care focuses on assessment, res-
Hypomagnesemia frequently coexists with hypocalcaemia. olution of the trauma, and addressing any complications.
SIGNS AND SYMPTOMS. The decreased magnesium in the The nurse can assess the Moro, biceps, and radial reflexes.
blood is usually accompanied by increased neuromuscu- The grasp reflex is usually intact. It is important to prevent
lar irritability. contractures that usually involve limb immobilization. The
limb is gently placed across the abdomen where the hand
DIAGNOSIS. Hypomagnesemia is present when the mag- cuff of the T-shirt is pinned so that the arm is in a flexed
nesium levels are below 1.5 mg/dL (normal newborn position to produce a loose splint. Passive range-of-motion
range is 1.5 to 2.8 mg/dL). It can be caused by low mater- (ROM) exercises usually begin soon. This condition usu-
nal magnesium levels, SGA or LGA growth patterns, and ally improves rapidly without long-term consequences.
hypoparathyroidism.
NURSING CARE. Nursing care consists of magnesium Nursing Insight— Erb’s or Erb-Duchenne palsy
replacement by giving magnesium sulfate. Magnesium
may be given orally (PO) in the form of citrate, gluconate, Upper root injuries produce Erb’s or Erb-Duchenne palsy
and chloride. Levels should be checked every 24 hours to and the newborn usually holds the affected arm limp and
prevent hypomagnesaemia that can produce hypotonia, turned inward often called the “waiter’s tip” position. Lower
poor feeding, and respiratory distress (Klaus & Fanaroff, root injury is called Klumpke’s palsy and produces a weak
2005). turned out arm and limp hand. Complete nerve injury is
called Erb-Klumpke’s or total paralysis. An assessment will
Birth Injuries reveal lack of flexion and movement in the affected arm. The
A thorough physical assessment is warranted for the LGA position in which the newborn holds his arm may indicate the
newborn to assess for birth injuries related to difficult sight of the BPI (Benjamin, 2005).
deliveries. Birth injuries or traumas are usually one of two
types: neurological injuries or bone fractures.
SIGNS AND SYMPTOMS. Signs and symptoms are directly Fractures
related to the specific birth injury or trauma. Fractures are also common birth injuries and usually
involve the clavicle, humerus, or femur.
DIAGNOSIS. Diagnosis can be made by a thorough nurs- CLAVICLES. Broken clavicles are the most common frac-
ing assessment, x-ray exam, or appropriate laboratory tures from birth (2 to 35:1000 births) Fractured clavicles
studies. can occur alone, with brachial plexus injury or with a frac-
NURSING CARE. Nursing care includes neurological tured humerus. Risk factors for a broken clavicle include
assessment for intracranial bleeding and includes assess- LGA newborns, forceps use, and shoulder dystocia.
ing posture, cry, seizure activity, and coordination of Signs and Symptoms. Symptoms of a broken clavicle
sucking and swallowing. Any abnormalities in these signs include asymmetrical arm movement, asymmetrical Moro
must be reported immediately. Head circumference should reflex, swelling, and “crepitus” detected on palpation of the
be measured in centimeters every hour if neurological bone. Crepitus describes the assessment of bone rubbing
symptoms are present. The nurse also assesses for bone against bone which can be felt and sometimes even heard on
fractures and can suggest an x-ray exam to the pediatri- examination. Clavicles heal spontaneously with very little
cian if suspicious. intervention.
614 unit five Care of the New Family
Skin tags Irregular shaped head, molding Funnel or pigeon chest Apical heart rate is assessed for a
after delivery, caput full minute
succedaneum cephalhematoma
Translucent Large anterior and posterior Supernumerary nipples or The heart rate may normally be
fontanels present nipples are flat on the chest wall above 160 bpm but it should not
be above 180 bpm.
Fused sutures
Bulging or depressed fontanels
Lanugo covering the shoulders, Ear pinnas are flat and readily Ribs are visible Heart auscultation is done in the
back, thighs, forehead and ears fold upon themselves second and fourth right and left
intercostal spaces as well as the
apex and axillae area
Little subcutaneous fat Eyes are fused before 24 weeks Grunting, nasal flaring or Auscultation of heart sounds should
gestation retractions (subcostal, sternal be done routinely to detect
or suprasternal) are signs of murmurs which may or may not be
respiratory distress innocent
Fragile and easily injured Nose flattened or bruised Auscultate anterior, posterior Blood pressures on all four
and at the sides of the chest extremities are done to determine
Nasal patency any wide variations that may be
Low placement of ears indicative of a ductal defect
Mottled related to poor peripheral Facial anomalies Auscultate respiratory rate for a Persistent central cyanosis
perfusion full minute
Prominent veins Respiratory rate is between 60 Displacement of apex
and 80 respirations per minute
Covered in vernix Respiratory rate above 80 Cardiomegaly
respirations per minute are not
within normal limits
Cord does not have two arteries No flexion of extremities resulting in Male scrotum has no rugae and Marked head lag in all positions
and 1 vein increased susceptibility to heat loss the testes are often
and skin breakdown undescended
Palpate for masses Assess for fractures or Female clitoris is often Consistent caregivers read the cues
Developmental Hip Dysplasia or prominent and not covered by and notice subtle changes
fractured clavicle the labia minora. The labia
majora is also small
Auscultate bowel sounds Inguinal hernias are common Sucking and gagging reflexes are
often absent until 32 to
34 weeks gestation
Abdominal circumference is Female absence of vaginal or Moro reflex may be absent to weak
done to assess for distention male urethral opening covered
that may indicate necrotizing by prepuce
enterocolitis (NEC)
Meconium found in the vaginal Any signs or symptoms of increased
opening intracranial may be related to
cerebral insults
NURSING CARE. Most preterm newborns are on a cardio- the nurse of an impending apnea or bradycardic spell or
respiratory (C-R) monitor (Fig. 19-7). The C-R monitor is combined A&B episode.
attached to the newborn by three electrodes. Two elec- Preterm apnea usually resolves at 37 to 38 weeks postcon-
trodes are placed on either side of the chest and the third ceptual age (PCA) but may last longer. Many preterm new-
on the abdomen. The electrodes are changed often based on borns are sent home on home monitoring systems that alarm
NICU protocol. Every time the electrodes are changed they if respirations stop longer then 20 seconds or the heart rate
are applied to a new area of skin to prevent breakdown drops (Stokowski, 2005). If newborns are discharged with-
from the adhesive. The C-R monitor is set to alarm if the out monitors they usually need to be A&B spell free in the
newborn fails to breathe spontaneously for 20 seconds, the hospital for at least 5 to 7 days (Hummel & Cronin, 2004).
respiratory rate falls below a certain rate (usually 20 respi- The pulse oximeter is a small plastic light-emitting
rations/min) or the heart rate drops below a certain rate probe that is a noninvasive and can be secured to the
(usually 80 to 100 beats per minute). An alarm notifies newborn’s extremity. The newborn is maintained on
618 unit five Care of the New Family
Figure 19-7 Most preterm newborns are on a cardio- extended period of time, sometimes up to a few years, in order
respiratory monitor. to properly oxygenate their growing bodies. Newborns with
BPD are often sent home on O2 after the parents have been
educated in oxygen administration. The amounts of oxygen
continuous pulse oximeters to guard against desaturation needed through the cannula vary with the severity of the BPD
episodes. Oxygen saturation is calculated from the hemo- but often it is a small flow at anywhere from ¼ to 1 liter flow
globin flowing under the light and then the percent is dis- rate with anywhere from 21% to 30% of oxygen.
played on the monitor. It is easy to use and the saturation
measurements are fairly reliable when compared to arte-
rial samples of blood. The saturation should be main- Jaundice
tained above 92% (Klaus & Faranoff, 2005). Newborn physiological jaundice (hyperbilirubinemia) is
The pulse oximeter is also set to alarm during a low common and occurs because of the newborn’s immature
peripheral O2 saturation (usually below 88%). If the new- liver (especially the preterm newborn). The liver cannot
born desaturates without a corresponding A&B spell is conjugate the bilirubin as quickly as needed. The excess bili-
called a desaturation episode. An apneic, bradycardic, or rubin in the circulatory system moves into the skin, sclerae,
desaturation episode requires immediate attention. There nails, body fluids, as well as other body tissues resulting in
are different severities of A&B spells. Some newborns take jaundice. Jaundice that appears on the second or third day
a deep breath and regulate themselves back into a normal of life usually peaks on day four and declines on day five.
cardiorespiratory pattern without intervention, which is
often called a self-limiting episode. Some newborns con- Nursing Insight— Jaundice
tinue the apnea, bradycardia, and desaturation spell and
need mild stimulation to induce them to take a deep Bilirubin is a byproduct of the breakdown of hemoglobin.
breath and regain a normal cardiorespiratory pattern. Newborns have higher levels of fetal hemoglobin at birth
Stimulation is done by rubbing their backs or flicking which breaks down faster because it has a shorter life span
their feet. Periodically, newborns need aggressive stimula- then adult hemoglobin.
tion to regain cardiorespiratory control which includes The fetal hemoglobin is broken down by the reticuloendo-
increasing existing oxygen flow or using positive pressure thelial system and bilirubin is released into the circulation.
through bag and mask ventilation (Fig. 19-8). The circulating bilirubin or total serum bilirubin (TSB) binds
to plasma albumin. This circulating bilirubin is unconjugated
Nursing Insight— Bronchopulmonary Dysplasia (UCB) and not water soluble. The bilirubin is then is con-
verted in the liver to conjugated (water-soluble) bilirubin. The
Bronchopulmonary dysplasia (BPD) or Chronic lung disease conjugated bilirubin is excreted in the bile by the gastrointes-
(CLD) is a condition in which the newborn becomes oxygen tinal tract and then excreted in the stool.
dependent past 36 weeks gestation (Sahne et al., 2005). BPD is The two categories of jaundice are physiological and
a complication produced by long-term oxygen use. Although pathological.
oxygen is needed by the preterm to maintain proper tissue per- Premature infants develop physiological jaundice at a rate of
fusion until the maturing lungs can resume that function, sup- 90% compared to 60% of full-term newborns due to the extreme
plemental oxygen can also damage lung tissue by suppressing immature live functions and polycythemia. Physiological jaun-
compliancy. Because oxygen is administered, the lungs fail to dice occurs in the first 24 hours of life and lasts about 5 days.
develop the normal compliancy needed to force adequate levels The infant does not display any other signs of illness.
of air in and out. Sometimes the preterm newborn ends up with Pathological jaundice usually happens at less than 24
noncompliant lungs that need oxygen via cannula for an hours of age and lasts for longer than the first week of life.
chapter 19 Caring for the Newborn at Risk 619
µmol/L
one
Hig te Risk Z
cal doctor’s order. media
w Inter
Lo
Transcutaneous bilirubinometry (TcB) is a noninvasive 10 171
way of monitoring bilirubin in the skin. Over time, multiple
Low-Risk Zone
readings at a consistent site (forehead or sternum) provide the 5 85
most accurate measurement of the bilirubin. However, once
phototherapy has begun the TcB monitor is no longer a useful
0 0
screening tool and serum blood specimens must be drawn 0 12 24 36 48 60 72 84 96 108 120 132 144
every 6 to 12 hours. Postnatal Age (hours)
In addition, other laboratory samples, such as liver Figure 19-9 Laboratory evaluation of the jaundiced
enzymes (GGT), alkaline phosphatase, prothrombin time infant of 35 or more weeks’ gestation.
(PT), and partial thromboplastin time (PTT) are drawn. If a
more serious abnormality is suspected a radiological evalua-
tion is done.
DIAGNOSIS. Jaundice is diagnosed in term infants with a The nurse must remember that when a newborn is under photother-
serum bilirubin level greater than 12.9 mg/dL and in pre- apy the eyes must be shielded by an opaque mask. The nurse
term infants with a serum bilirubin greater than 15 mg/dL. assesses the newborn’s eyes every 4 hours to assess for discharge or
In addition to serum blood levels other factors that help corneal irritation. It is important to remove the mask during feedings
so the infant can receive visual stimulation. The infant’s genitalia area
determine the extent of the jaundice is evidence of hemoly-
must also be covered. Also, during phototherapy or use of the Bili-
sis, gestational age at birth, family history (including mater- blanket, the newborn should be kept warm. The infant is susceptible
nal Rh factor), timing of the appearance, and method of to hypothermia due to skin exposure and the temperature needs to
feeding. If jaundice appears, a bilirubin level to determine be monitored closely. In addition, it is important that the infant
the bilirubin risk factor is plotted on the bilirubin graph in receive proper nutrition to ensure the clearance of the bilirubin.
relation to hours of age (American Academy of Pediatrics The breast or formula feeding mother can be encouraged to feed the
[AAP], 2004) (Fig. 19-9). child as often as every 2 hours. These treatment measures must be
explained to parents to help decrease their anxiety. Parents need to
NURSING CARE. Treatment of jaundice is based on the report any changes in the infant’s condition such as an increase in
underlying cause. Infants who are plotted on the graph in the jaundice, poor feeding, lethargy, or vomiting.
high-risk zone on the bilirubin risk chart undergo photo-
therapy (bilirubin lights). Phototherapy uses daylight, cool
white, blue, or “special blue” fluorescent light tubes. Fluores- Other treatments for hyperbilirubinemia include hydra-
cent lights are the most effective form of phototherapy and tion with an electrolyte solution if the newborn shows
are placed around and above the newborn (Fig. 19-10). The signs of dehydration such as dry skin and mucus mem-
level of bilirubin in the blood determines if the newborn is branes, poor intake, concentrated urine, or limited urine
placed under single, double, or triple phototherapy. Fiber- output and irritability (AAP, 2004).
optic systems (Bili-blanket) can also deliver phototherapy in Without appropriate screening and treatment of hyper-
a blanket form placed under or around the newborn. bilirubinemia in the newborn, complications can occur.
620 unit five Care of the New Family
Bilirubin encephalopathy describes the clinical findings develop retinopathy of prematurity have stages I or II. If
when the serum bilirubin level is so elevated that the cen- ROP is untreated it will destroy the infant’s vision (National
tral nervous system is affected. The newborn becomes Eye Institute, 2008). Cryotherapy is used to treat ROP
lethargic, hypotonic, and has feeding difficulty. This is a (Kraus & Fanaroff, 2005).
severe hyperbilirubinemic condition that warrants
exchange transfusions to prevent a condition called ker-
nicterus (AAP, 2004). critical nursing action Retinopathy of Prematurity
An infant with untreated jaundice is at risk for kernic-
terus. If bilirubin crosses the blood–brain barrier it can per- Because retinopathy of prematurity (ROP) may be a complication of
manently damage a newborn’s brain (Shapiro, 2005). Not all oxygen therapy, the nurse must maintain the lowest level of oxygen as
newborns with bilirubin encephalopathy progress to kernic- possible to maintain the pulse oximeter reading above 92%.
terus, and the exact level of serum bilirubin require to cause
damage in not yet known. The damage caused by kernic-
terus can be cerebral palsy, auditory dysfunction, dental- Anemia of Prematurity
enamel dysplasia, upward gaze, as well as intellectual and
other handicaps (AAP, 2004). Premature newborns are often anemic for several reasons.
One reason is that the newborn undergoes many lab evalua-
tions. Even though small amounts of blood are taken for
Retinopathy of Prematurity
each study, multiple studies are done and it reduces circula-
The retinal vessels of the preterm newborn are frail and tory volume. A second reason for anemia is the rapid growth
immature. Retinopathy of prematurity (ROP) is a result of a preterm newborn undergoes in a short period of time. A
immature retinal vasculature followed by hypoxia. The third reason has to do with erythropoietin release. Erythro-
concentration and duration of supplemental oxygen are poietin is not released until 34 to 36 weeks of gestation and
thought to play a role in the development of ROP. then responds when hematocrit levels are low. There is an
ROP is inversely related to gestational age. Therefore, the approximately 1-week delay between erythropoietin release
younger the infant the greater the likelihood he has of devel- and the production of reticulocytes.
oping this condition. Risk factors include gestational age of
less than 32 weeks, birth weight of less than 1500 g, hypo- SIGNS AND SYMPTOMS. Typical sign and symptoms
thermia, sepsis, and high-intensity lighting. The extent of include fatigue, shortness of breath, headache, dizziness,
retinal damage in the preterm newborn is dependent on and pale skin.
three criteria: (1) the gestational age of the newborn, (2) the DIAGNOSIS. A drop in hemoglobin below the average
length of exposure to oxygen, and (3) arterial pressure. hematocrit value (between 35% and 45%) is the definitive
SIGNS AND SYMPTOMS. In the first stage of ROP, the reti- sign of anemia.
nal vessels react to oxygen administration with vasocon- NURSING CARE. Nursing care consists of transfusions of
striction. If the vasoconstriction of the vessels is prolonged, blood, although many times necessary, actually delay the
abnormal vessel growth ensues. In the second stage vessel erythropoietin mechanism. Anemia of prematurity is treated
hemorrhages and edema into the vitreous occurs. In the with recombinant human erythropoietin (r-HuEPO) subcu-
third stage the vessels fibrose. The fourth stage is severe taneous to stimulate erythropoiesis. It is given it until 34 to
and is classified by retinal detachment. 35 weeks of gestation (Fike, 2004; Klaus & Fanaroff, 2005).
DIAGNOSIS. Retinopathy of prematurity is diagnosed The nurse assesses hematocrit levels per hospital policy.
based on five stages, ranging from mild to severe.
Sudden Infant Death Syndrome
Stage I — abnormal blood vessel growth is mild.
“Back to sleep” is the American Academy of Pediatric
Stage II — abnormal blood vessel growth is moderate.
(AAP) campaign to educate parents and families who are
Stage III — abnormal blood vessel growth is severe.
involved in newborn care to prevent sudden infant death
Stage IV — the retina is partially detached.
syndrome (SIDS). Since US public education started in
Stage V — completely detached retina. This is the
the early 1990s there has been a 50% reduction rate in
end stage of the disease.
SIDS deaths. The current incidence of SIDS is 1:2000
newborns.
NURSING CARE. During oxygen administration, fluctua-
tions in arterial concentrations of oxygen must be pre- NURSING CARE. Priority nursing care includes education
vented. The nurse understands that the PaO2 should not about sudden infant death.
be set greater than 80 mm Hg and that the preterm new- The following recommendations are incorporated into
born should be weaned off oxygen as soon as possible. In the care of the preterm newborn in the NICU. Newborns
addition, the nurse can decrease the constant bright lights who have been in the NICU and are preparing for discharge
in the infant’s environment. A blanket can be placed over in the near future must be taught to sleep on their backs
the incubator during the day. Nap time can be designated even though the prone position may have been used as a
where the lights are lowered and other environmental care intervention to increase gastric motility. Home moni-
stimuli are decreased. tors are not recommended for SIDS prevention although
The preterm newborn should be checked routinely for preterm newborns may be sent home on monitoring for
signs of ROP by a specialist. Examinations should be other reasons. Most preterm newborns are well acquainted
started at 4 to 6 weeks of age and continue until vascular- with a pacifier long before their discharge date to assist with
ization of the retina to reduce the risk of visual impair- their sucking and swallowing coordination, so this practice
ment (usually myopia) and blindness. Most babies who should be continued.
chapter 19 Caring for the Newborn at Risk 621
The chest x-ray film usually shows: patchy infiltrates, overexpansion, atelec-
tasis, flattened diaphragm, and bulging intercostal spaces (Noerr, 2000).
The Postterm Newborn NURSING CARE. Nursing care of meconium aspiration
Postterm newborns are also considered high-risk. Although pneumonia consists of chest physiotherapy (PT) and oxy-
fewer pregnancies are carried to post-term today due to gen administration. Chest physiotherapy can be done by
elective inductions there are still incidences where a new- percussion with a small cup, base of a feeding nipple, or
born is born after 42 weeks of gestation. Postterm new- specifically made neonatal chest PT device or vibration
borns may or may not be LGA. The newborn may have by a battery-operated vibrator. Chest PT should be done
actually lost weight in utero because of declining placental every 3 to 4 hours to help maintain a clear airway. Pos-
ability to transport nutrients and oxygen. tural drainage with percussion or vibration is followed by
Because these newborns are in utero after the optimal suction.
growth time they undergo developmental changes includ- CPAP is frequently used to provide oxygen. Oxygen by
ing skin desquamation or peeling. The skin of a post-term noninvasive means such as hood or cannula is often
infant is often parchment-like and is often cracked on the not sufficient. If the newborn cannot maintain a PaO2 of
abdomen and extremities. The fingers appear long and are 50 mm Hg or higher in 100% oxygen then mechanical
often peeling and sometimes general muscle wasting is ventilation is used.
evident. Because the newborn is postterm and neurologically
Postterm newborns are at risk for passing meconium more mature than ventilated preterm newborn, neuromus-
stool in utero, which increases their chances of meconium cular medications such as Pavulon (Pancuronium) or
aspiration pneumonia and persistent pulmonary hyperten- vecuronium (Norcuron) may be used to increase the effec-
sion (PPHN). Often the cord is meconium stained on assess- tiveness of ventilation efforts. Analgesic and sedative medi-
ment indicating that meconium was passed in utero at some cations may also be used such as fentanyl (Sublimaze),
time well before delivery (Klaus & Fanaroff, 2005). lorazepam (Ativan), morphine sulfate (Astramorph), or
demerol (Meperidine) so the newborn does not “fight “the
ventilator (Taeusch et al., 2005).
CONDITIONS AFFECTING THE POSTTERM
NEWBORN Persistent Pulmonary Hypertension of the Newborn
Meconium Aspiration Pneumonia Persistent pulmonary hypertension of the newborn
Meconium aspiration pneumonia occurs in 10% to 26% of (PPHN) was once termed persistent fetal circulation
all deliveries and the incidence increases directly with because there is right-to-left shunting of blood across the
gestational age (before 37 weeks of gestation there is a 2% foramen ovale and through the ductus arteriosus. The
incidence and at 42 weeks of gestation a 44% incidence). meconium in the newborn’s lung induces platelet aggrega-
The passage of meconium in utero is believed to be either tion in the microcirculation of the pulmonary system,
622 unit five Care of the New Family
Nursing Interventions:
1. Monitor respiratory rate, lung sounds, effort of respirations, color, and oxygen saturation frequently (specify
how often) for 24–48 hours after meconium-stained delivery.
RATIONALE: PPHN sometimes develops after the first 12–24 hours of life.
2. Notify the caregiver of signs of respiratory distress: tachypnea, grunting, nasal flaring, retracting, cyanosis, or
decreased oxygen saturation.
RATIONALE: Respiratory distress related to PPHN can occur rapidly.
3. Record a preductal (right radial) pulse oximeter reading and postductal (left radial or either foot) pulse
oximeter reading simultaneously.
RATIONALE: A difference of 5% may be helpful in diagnosing the right-to-left shunt produced by PPHN.
4. Take four extremity blood pressures.
RATIONALE: A difference of 10–15 mmHg preductal and postductal may suggest a right-to-left shunt.
5. Provide and monitor oxygen and respiratory support as ordered (specify) to maintain a pulse oximetry
reading of 92%.
RATIONALE: Oxygen therapy may be needed to maintain adequate saturation levels.
6. Maintain infant in a neutral thermal environment without excessive noise or stimulation.
RATIONALE: A thermoneutral environment decreases metabolic needs and decreased environmental stimuli
may avoid excess neurological stimulation.
7. Administer sedation as ordered (specify drug, dose, route, and time)
RATIONALE: (Specify action of the drug) Sedation may reduce metabolic needs.
8. Closely monitor intake and output. Restrict fluids as ordered (specify).
RATIONALE: Excessive fluids can increase pulmonary workload and increase respiratory distress.
9. Provide information and support to the family.
RATIONALE: These newborns can become critically ill and are often transferred out to the most technologically
advanced Level III NICU for Extracorporeal Membrane Oxygenation (ECMO) support.
Phenylketonuria Homocystinuria
As early as 1961, Dr. Robert Guthrie developed a blood test Homocystinuria is screened for in 22 U.S. states/territories.
to diagnose newborns with phenylketonuria (PKU). It was The incidence is 1:50,000. It is an autosomal recessive
the first metabolic disease that prompted universal screen- genetic transmission. There is a deficiency in cystathionine
ing for metabolic diseases and it is currently screened for in beta-synthase which causes high levels of serum methio-
all U.S. states/territories. It is a disease transmitted by an nine. Children with homocystinuria have ocular abnormal-
autosomal recessive gene. The incidence varies greatly by ities and thromboembolisms that affect both legs.
race from 1:6000 in Caucasian to 1:60,000 in newborns of
SIGNS AND SYMPTOMS. Signs of homocystinuria can
Japanese descent. There is a deficiency of phenylalanine
include skeletal abnormalities, displacement of the eye
hydroxylation and phenylalanine cannot be broken down.
lens, an increase risk for blood clots, and as the child
SIGNS AND SYMPTOMS. There are no signs or symptoms grows problems with learning and development.
at birth. Accumulations of phenylalanine eventually cause
DIAGNOSIS. Homocystinuria is diagnosed through a
developmental delays, mental retardation, and seizures.
blood test.
DIAGNOSIS. Phenylketonuria is diagnosed through a
NURSING CARE. Diet therapy includes high doses of vitamin
blood test.
B6 and methionine and cystine restriction (AAP, 2008).
NURSING CARE. The nurse communicates to the parents
that phenylketonuria is controlled by a phenylalanine-free Biotinidase Deficiency
diet with the elimination of proteins (including breast Biotinidase deficiency is screened for in 21 U.S. states/
milk and formula). The diet is continued for child’s entire territories. It is an autosomal recessive metabolic disorder
life. Parents can find information about this condition and in which leads to carboxylase deficiency due to faulty biotin
diet at Centers for Disease Control and Prevention (PKU) recycling.
(http://www.cdc.gov/; AAP, 2008).
SIGNS AND SYMPTOMS. Without treatment, symptoms
Galactosemia show at 7 weeks to 3 years and include developmental
Galactosemia is screened in 46 U.S. states/territories. The delay, hypotonia, uncoordinated movement, alopecia,
incidence is 1:60,000-80,000. It is an inherited metabolic rash, hearing loss, optic nerve atrophy, seizures, and men-
deficiency. Children with galactosemia cannot metabolize tal retardation. Untreated cases progress to metabolic aci-
galactose and it results in failure to thrive, vomiting, liver dosis that can lead to death.
disease cataracts, mental retardation, and even death. DIAGNOSIS. Biotinidase deficiency is diagnosed through
SIGNS AND SYMPTOMS. The signs and symptoms of galac-
a blood test.
tosemia cause the inability to use galactose to produce NURSING CARE. The nurse communicates to the family
energy. the infant must receive Pantothenic acid or biotin (types of
DIAGNOSIS. Galactosemia is diagnosed through a B vitamins). These vitamins must be replaced every day
blood test. because they are essential to growth and help the body
break down and use food. Pantothenic acid and biotin are
NURSING CARE. Children diagnosed with galactosemia also found in foods such as eggs, fish, milk and milk prod-
are placed on a galactose-free diet that needs to be main- ucts, whole grain cereals, lean beef, legumes, and broccoli
tained for life (AAP, 2008). (AAP, 2008).
enlarging head circumference needs immediate attention has a smaller than normal head circumference. It is defined
and is indicative of a worsening IVH or periventricular as a head circumference 2 standard deviations below the
hemorrhage (PVH). mean for gestational age and is identified by progressive
NURSING CARE. The priority nursing care centers on recog- head circumference measurements. Microcephalic new-
nition of infant seizures so treatment can begin immediately. borns may have other congenital malformations but in
Phenobarbital (Luminal Sodium) is the drug of choice as many cases do not show a recognizable syndrome (Vargas,
well as phenytoin (Dilantin), lorazepam (Ativan), and diaze- Allred, Leviton, & Holmes, 2001). There is no treatment
pam (Valium). It is also essential to prevent cerebral damage for microcephaly and nursing care is supportive. The nurse
as well as maintain adequate oxygenation. Parents will need teaches parents how to rear the child according to the most
information about their infant’s status and subsequent care. realistic developmental level.
Neurological sequelae related to IVH and PHV are asso-
ciated with the severity of the bleed. Severe bleeds can
lead to seizures, mental deficiencies, and cerebral palsy. clinical alert
Head ultrasounds are done routinely in the nursery, usu- Microcephaly
ally every week in order to evaluate the presents of IVH It is critical to maintain accurate and consistent head circumference
and PVH in the preterm population. If the bleed causes measurements by plotting on the growth chart and monitoring the
obstruction of cerebral spinal fluid (CSF), a shunt is newborn for neurological symptoms.
needed to prevent hydrocephalous.
GASTROINTESTINAL CONDITIONS
Anencephaly Cleft Lip and Cleft Palate
Anencephaly is a condition in which the skull and cere- Cleft lip (CL), cleft palate (CP), or both is a multifacto-
brum is malformed but the anterior lobe of the pituitary is rial congenital defect that has genetic and environmen-
intact. These newborns can be born alive but the condition tal predispositions. It is the fourth most common con-
is lethal so they die in a short period of time. Anencephaly genital birth defect. During intrauterine fetal life the
has a higher incidence in girls than boys. The defect is primary palate does not fully fuse and any one of several
visually disturbing because most of the skull is not present variations of clefts can occur depending on the timing of
(Taeusch et al., 2005). Nurses provide palliative and spiri- the insult. Cleft lip is sometimes detected prenatally on
tual care with no effort at resuscitation. The family requires ultrasound.
emotional support to cope with the infant’s devastating
condition. SIGNS AND SYMPTOMS. A cleft lip can occur unilaterally
or bilaterally. Either type can occur with or without a cleft
Encephalocele of the hard and/or soft palate. Also, both or either of the
Encephalocele is a neural tube defect that is noticeable at palates can be cleft without the lip. The uvula can also
birth because there is protrusion of the brain through a contain a cleft.
skull defect. Sixty to 80% of the time it occurs in the occipi- DIAGNOSIS. Cleft lip is obvious but cleft palates call for
tal area but it can also occur in the parietal, frontal or nasal a thorough examination of the newborn’s mouth with a
regions. This defect often accompanies other congenital good light source.
anomalies and surgical repair is attempted to close the
defect and prevent infection. The mortality rate is higher NURSING CARE. The focus of nursing care is on main-
than 30% and the many of the survivors have neurological taining adequate nutrition because cleft lip and palate
deficits. Like anencephaly, encephalocele requires care that present feeding difficulties. The nurse understands that
is directed at the defect, including the neurological and newborns with cleft lip and palate can be successfully
developmental effects (Taeusch et al., 2005). breastfed. Breastfeeding may be interrupted for a period of
time based on the need for surgical repair. Bottle feeding
Microcephaly is usually initiated with a special nipple that is longer than
Microcephaly may be caused by an autosomal recessive a regular newborn nipple to help prevent aspiration. One
disorder, toxic stimulus during prenatal development, or a type of nipple is the Haberman nipple, which is longer
chromosomal abnormality. Microcephaly means the infant and has a reservoir to regulate the flow of formula.
626 unit five Care of the New Family
Newborns with clefts are fed in an upright position to circulation for future functioning. If a large section of the
decrease the incidence of regurgitation. Surgical repair of bowel is affected, a surgical bowel resection may be war-
cleft lip is typically done at 3 months of age and cleft pal- ranted and sometimes it can lead to a colostomy that may
ates are usually repaired before 18 months. Some clefts or may not be permanent.
require more than one surgical procedure to reconstruct.
Parents must be supported by having all the treatments,
feeding methods, and course of care explained. Emotional critical nursing action Necrotizing Enterocolitis
support is needed to assist in the grieving process of deal- (NEC)
ing with the reality of the nonperfect child with surgical
needs (Merritt, 2005). When caring for a child with necrotizing enterocolitis the nurse must
measure and record frequent abdominal circumferences, auscultate
bowel sounds before every feeding, and observe abdomen for disten-
— Communicating to parents tion (observable loops or shiny skin indicating distention).
about cleft lip and palate repair
Before a feeding, the nurse must check for aspirates at each feed for
The nurse can provide parents emotional support related undigested formula or breast milk. If excessive (20%) undigested
to their newborn’s cleft lip and palate repair. The nurse breast milk or formula is found, the nurse must follow the hospital’s
can also refer parents to Web sites that contain valuable protocol, which may suggest that the next feeding be held and the
primary care practitioner notified. All bowel movements must be
information. Some Web sites provide the parents with
recorded: amount, consistency, and frequency. Hematesting stools may
suggestions on wording for the birth announcement so be needed to detect occult (nonvisible) fecal blood.
that family and friends are informed about this issue
prior to seeing the baby.
March of Dimes: http://www.marchofdimes.com/
pnhec/4439.asp
Wide Smiles: http://www.widesmiles.org/ ABDOMINAL WALL DEFECTS
CLAPA (Cleft Lip and Palate Association): http://
Gastroschisis and Omphalocele
www.clapa.com/
American Society of Plastic Surgeons: http://www. Gastroschisis is a congenital anomaly that is usually diag-
plasticsurgery.org/public_education/procedures/ nosed during a prenatal ultrasound. In gastroschisis, the
CleftLipPalate.cfm stomach and intestine herniate through the abdominal
wall (Fig. 19-13).
Omphalocele (exomphalos) is a congenital condition
in which the intestines protrude into the umbilical cord
Necrotizing Enterocolitis
region of the abdominal wall. It is often associated with
Necrotizing enterocolitis (NEC) is another complication trisomy 13 and 18, and urinary tract anomalies.
that affects mostly preterm newborns. It is due to an isch-
emic episode of the bowel. When a lack of oxygen occurs SIGNS AND SYMPTOMS. In gastroschisis the abdominal
in any human, blood is shunted from the nonessential wall fails to close, usually on the right side of the umbili-
organs (bowel) to the essential organs: lungs and brain. If cus, and the intestines are exposed (DiTanna, Rosano, &
the ischemic attack is severe it can decrease the circulation Mastroiacovo, 2002)
to the bowel to the point of ischemia. The extent that any In omphalocele, if the abdominal wall defect is less
portion of the bowel is affected depends on the severity of then 4 cm it is usually considered an umbilical hernia and
the ischemic attack. Once the bowel is necrotic or the tissue does not usually require repair.
dies from lack of O2 there is no peristalsis to move food or DIAGNOSIS. Diagnosis can be made by visualization and
gas and it builds up in that section of the bowel. NEC is assessment of the defect.
dangerous because it can easily produce septicemia in the
preterm newborn (full-term newborns who experience a
severe asphyxia can also experience NEC).
SIGNS AND SYMPTOMS. NEC is suspected if there is lack
of bowel movements, abdominal distention, or an increase
of 1 to 2 cm in abdominal circumference from the last
feed, or newborn irritability or lethargy.
DIAGNOSIS. NEC is diagnosed via x-ray exam where a
sausage-shaped dilation of the intestine is present. Labo-
ratory findings show leukopenia, metabolic acidosis,
anemia, electrolyte imbalance, and leukocytosis. A dan-
gerous sign is free air in the abdomen that may indicate
perforation.
NURSING CARE. When providing care to an infant sus-
pected with NEC oral feedings are immediately stopped
and the primary care provider is notified.
The nurse understands that if only a small portion of
the bowel is affected, a rest period may reinstate enough Figure 19-13 The newborn with gastroschisis.
chapter 19 Caring for the Newborn at Risk 627
NURSING CARE. Surgery is performed immediately on other associated needs of the infant and family. The nurse
the infant with gastroschisis to prevent intestinal atresia can ensure that the infant receives proper developmental
resulting in obstruction. Surgical repair should be done stimulation.
within 2 to 4 hours of birth if the repair can be accom-
plished in one stage. The amount of displaced intestines Neonatal Sepsis
determines the course of treatment of an omphalocele The incidence of sepsis is 1 to 10:1000 for newborns
(Taeusch et al., 2005). but is increased in the high-risk newborn population to
In gastroschisis, the nurse keeps the abdominal con- 13 to 27:1000. Mortality rate can be anywhere from
tents sterile by covering them with moist gauze and 13% to 50%.
wrapped in plastic. Extreme care should be taken to Newborn sepsis is a systemic infection and can be due
position the newborn supine and prevent the mesenteric from any number of causes. The most common causes
vessels from kinking so adequate blood supply continues include preterm delivery, prolonged labor, rupture of
to flow to the bowel. membranes greater than 18 hours, maternal fever, amnio-
Both conditions may require either a nasogastric or nitis, or maternal group B streptococcal infection. Sepsis is
orogastric tube to eliminate air in the bowel. The nurse classified according to the time of onset. Early onset occurs
replaces fluids intravenously at 1.5 times the normal within the first 5 to 7 days of life and can progress rapidly.
maintenance volume due to insensible water loss from the Late-onset sepsis is most common after a week of life and
exposed bowel. Antibiotics are started preoperatively to it often results in meningitis. Nosocomial sepsis occurs in
prevent against infection. high-risk newborns who have extended periods of stay in
the NICU. The most common causes of neonatal sepsis
according to onset of symptoms are listed in Table 19-5.
Nursing Insight— Gastroschisis SIGNS AND SYMPTOMS. Sepsis in the newborn may be
For larger bowel exposure a silo device is used to cover the asymptomatic, so risk factors and maternal history need
abdominal contents and they are pushed back into the abdomi- to be evaluated carefully. When symptoms do appear the
nal cavity gradually over 7–10 days, then repair is accom- first indications of sepsis may be behavioral changes
plished (Taeusch et al., 2005). which is a good reason to have consistent nursing care in
the nursery and NICU because a nurse who “knows the
newborn” may pick up subtle changes earlier then some-
Postoperative care for either condition should be one who has not previously cared for the newborn.
focused on fluid and electrolyte balance, nutritional sup- Newborns respond differently to systemic infections
port with total parental nutrition (TPN) through a central than adults. Some newborns may get hypothermia while
line, infection protection, and pain management. Support- others become hyperthermic. Lethargy, hypoglycemia,
ive care is given to all other related problems as well as the and poor feeding are other signs of sepsis.
infant who requires mechanical ventilation. Parents must
be kept informed about the infant’s condition and treat- DIAGNOSIS. If a newborn displays signs of sepsis or is
ment regimes. from an environmental condition that is predisposing him
to sepsis, the appropriate laboratory tests should be done
and interpreted for a definitive diagnosis.
INFECTIONS IN THE NEWBORN
NURSING CARE. The diagnostic workup includes a com-
Herpes Simplex plete blood count with differential, C-reactive protein level
Genital herpes simplex virus (HSV-2) is one of the fastest (CRP), platelet count, and blood culture. Some septic work-
growing sexually transmitted infections in the United ups may include a spinal tap and urinalysis. No one test is
States. Mothers who contract a primary infection in the sensitive so an evaluation of all the data is important. Neu-
third trimester are more likely to transmit the infection to tropenia (low neutrophils in the blood) may be a significant
the newborn. A small percentage of newborns can acquire sign because neutrophils battle bacterial infections and may
an HSV-2 infection transplacentally in utero or through a be depleted if the newborn has an infection. Many nurseries
reoccurring genital infection. Newborns can acquire HSV use a formula that analyzes the ratio of immature to total
type 1 infections from people in the environment with neutrophils (I/T ratio) in the white blood cell (WBC) count.
herpes lesions of the mouth
SIGNS AND SYMPTOMS. Genital HSV-2 may be asymptom-
atic but can be activated anytime because the virus persists Table 19-5 Most Common Causes of Neonatal Sepsis
in the dorsal root ganglia for the lifetime of an infected Broken Down into Onset of Symptoms
individual. This neonatal infection can be disseminated or Early Onset and Late Onset Nosocomial Onset
involve multiple organs, or localized involving the brain or
skin, eyes and mouth. Disseminated infections carry a high Group B streptococci (GBS) Staphylococci epidermidis
mortality rate and chance for neurological sequelae.
Listeria monocytogenes Pseudomonas
DIAGNOSIS. HSV is cultured from the stool, urine, cere-
brospinal fluid (CSF) conjunctivae, nasopharynx, and skin. Staphylococcus Klebsiella
Labs: Differential White Blood Cell Count Table 19-6 Drugs that Can Cause Withdrawal Symptoms
The formula for an I/T ratio is bands divided by segs bands or Opiates Barbiturates Others
bands
segs bands Codeine Butalbital Alcohol
7 bands 0.11 shift Heroin Phenobarbital Amphetamine
54 7
Example: Meperidine Secobarbital Chlordiazepoxide
This is 0.3 shift and is not indicative of an infection.
Methadone Clomipramine
Morphine Cocaine
Most neutrophils should be segmented (SEGS) or mature Pentazocine Desmethylimipramine
cells. When 20% to 25% of the neutrophils are immature or Propoxyphene Diazepam
bands (sometimes called juveniles or stabs) or unsegmented
neutrophils it is suspicious of an infection. If a shift of 0.3 or Diphenhydramine
greater is detected, the newborn is treated for sepsis. Ethchlorvynol
Antibiotic treatment is started for a minimum of 48
hours at which time the reports on the cultured specimens Fluphenazine
should be known. A broad spectrum antibiotic or a combi- Glutethimide
nation of antibiotics is started as soon as possible. The
Hydroxyzine
usually antibiotics of choice are ampicillin (Marcillin) and
gentamicin (Garamycin) (Klaus & Fanaroff, 2005). Imipramine
Meprobamate
Nursing Insight— Group B Streptococcus (GBS) Phencyclidine
infection in the newborn
Group B Streptococcus (GBS) is the leading cause of neona-
tal sepsis in the United States. One in three women has colo-
nized GBS in her vagina and it can be spread to the newborn
Box 19-8 Signs of Neonatal Abstinence Syndrome
during the labor process, which is vertical transmission. Before
the recognition of GBS as a cause of newborn sepsis in the Irritability Hypertonia
1970s the mortality rate was 55%. Today mortality rate is less Tremors Seizures
than 5% of those newborns contracting GBS because of proto-
Wakefulness Exaggerated rooting reflex
cols in place to treat women in labor or to treat the newborn if
Uncoordinated feeding pattern Regurgitation and vomiting
the woman was not adequately treated in labor. All women
should be screened for GBS at 35 to 37 weeks of gestation. For Loose stools Tachypnea or apnea
newborns delivered in which the maternal GBS status is Yawning or hiccups Sneezing and stuffy nose
unknown due to premature delivery or inadequate prenatal care Poor weight gain Lacrimation
the newborn should be carefully observed for signs of sepsis
including poor feeding, inability to maintain body temperature,
inability to maintain blood glucose level over 60 mg/dL, leth-
argy, and seizure activity (Dremer, Lee, & Few, 2004). (Gomella, 1999). The maternal history may be a clue if
there is a history of inconsistent prenatal care.
NUTRITIONAL CARE
Nursing Insight— Using Naloxone (Narcan) in a Adequate nutritional intake is a major concern for the pre-
newborn with neonatal abstinence syndrome term newborn. Feeding readiness in preterm newborns is
Naloxone (Narcan) use may increase the severity of drug determined by each individual newborn’s behavioral states.
withdrawal in IDAMs. If the mother is a suspected drug Alert states around feeding time are assessed to determine
abuser it should not be used. newborn feeding readiness. Preterm newborns spend less
time in wake states than full-term newborns (White-Traut,
Berlbaum, Lessen, McFarlin, & Cardenaas, 2005).
The nutritional needs of the preterm newborn are com-
plicated for three reasons:
Care of the High-Risk Newborn
1. They have not had the time in utero to build up
Care of the high-risk newborn is multifaceted and complex. nutritional stores.
The nurse provides general care measures, interventions 2. They have extrauterine complications such as RDS
tailored to specific conditions, holistic and developmental which increases their metabolic expenditure.
care, as well as ensuring a safe nurturing environment. A 3. They should be gaining weight daily at rates
thorough physical assessment is completed and vital signs double those of a full-term newborn. In addition
are monitored frequently. Vital signs include temperature, the preterm newborn may not be able to feed
pulse, respiration, and blood pressure. Pain is considered due to regurgitating the feeding, losing weight
the fifth vital sign. or cold. If an infant is not ready to feed
by mouth, the nurse uses alternative ways to
ensure proper nutrition such as intravenous or
BLOOD PRESSURE enteral feeding.
Blood pressure measuring in newborns is an indicator of
cardiovascular function. In high-risk newborns hypoten- Intravenous Feedings
sion is encountered more often than hypertension. Hyper- Initially fluids are given parenterally. Peripheral lines are
tension although rare is usually related to neonatal renal used for shorter periods of time and most preterm new-
dysfunction. borns are placed on parenteral fluids for the first few days
Systolic, diastolic, and mean arterial pressure (MAP) of life The goal for the infant in the first few days of life is
should be assessed on the high-risk newborn. MAP is the to provide sufficient fluid to result in an urine output of
average pressure during the entire cardiac cycle and it is 1 to 3 mL/kg per hour, and a urine specific gravity of no
reported on cardiac monitors and may differ by birth greater than 1.012.
weight. Arterial pressure can be calculated by internal A central line placed in the umbilical artery (UA) or
blood pressure monitoring done through an umbilical vein (UV) is used for longer periods of time and provide
vessel. Pulse pressure is the difference between the sys- the high-risk newborn with fluids, nutrients, blood com-
tolic and diastolic pressures and is another, less signifi- ponents and medications. Another type of line called a
cant, cardiac indicator. A wide pulse pressure is some- peripherally inserted central catheter (PICC) line is also
times indicative of a patent ductus (the average values used for long term parenteral therapy.
are 25 to 30 mm Hg in term newborns and 15 to 25 mm
Hg in preterm newborns). Total Parenteral Nutrition
Most NICUs use oscillometry methods to take nonin- Total parenteral nutrition (TPN) is the initial essential
vasive blood pressure readings in the neonate. Studies nutritional support for high-risk newborns and is used to
have shown that non invasive blood pressure readings by establish positive nitrogen and energy balance to promote
oscillation are consistent with invasive blood pressure growth (Premji, 2005). TPN also increases protein syn-
readings. thesis and reversal of any negative nitrogen effects that
To take a blood pressure reading accurately on a neo- may take place in the first days of life.
nate several things need to be considered. The equip- The TPN solution is a calculated combination of glu-
ment needs to be reliably and calculated correctly for cose, amino acids, and electrolytes. TPN is usually started
neonates. The appropriate cuff size needs to be chosen. by the third or fourth day. After the first days of TPN
Blood pressures can be greatly affected by the newborn’s intravenous lipid emulsions are added to the parenteral
temperature, activity, or posture (newborns that are therapy as a piggybacked or secondary solution in concen-
awake and sucking average 10 to 20 mm Hg higher). trations of 10% to 20% over a slow continuous infusion.
Single and four extremity blood pressures can be done This is done to reverse fatty acid deficiency and provide
(Stebor, 2005). energy for tissue healing and growth.
630 unit five Care of the New Family
5. Inspect the cuff for intactness and decompress it 2/17/10 1300 Murmur auscultated, HR 160 BPM, pulse
to ensure it is not leaking. O2 97%, 4 extremity B/Ps done.
RATIONALE: Proper function equipment is essential for —R. Wittmann-Price, RN
accurate blood pressure measurement.
Enteral Feedings There are many different types of formulas used for
Enteral feedings of prescribed formula or breast milk given newborns. Each type of formula has a different nutritional
through either a nasogastric or orogastric tube are started goal. When preparing a formula feeding for high-risk
as soon as the preterm newborn is stable. A continuous newborns the procedure should be done on a clean sur-
infusion pump method ensures safe administration of the face with only one formula preparation being done at a
feeding. As the infant grows and becomes more stable, time with proper labeling.
bolus feedings ever 3 hours are eventually started because Breastfeeding should be encouraged for families who
the newborn can now tolerate this kind of feeding. As the choose it as soon as the newborn is able to spend limited
feedings are increasingly tolerated by the preterm newborn amounts of time out of the incubator and is more than
the parenteral therapy can be decreased. 32 to 34 weeks postconceptual age. Preterm newborns can
be successfully taught to breastfeed if there is a planned
Bottle- and Breastfeeding approach that supports the family’s decision (Callen &
Once the newborn reaches 32 weeks of gestational age Pinelli, 2005).
and is stable, bottle and or breastfeeding is attempted usu- Breast milk has benefits for the preterm newborn.
ally once a day and increased as tolerated. The feedings Breast milk can supply IgA and other proteins that
should start slowly and advance over several days. decrease the incidence of infection in the preterm new-
born. Neurological benefits have also been suggested with
the use of breast milk (AAP, 2005).
clinical alert
Aspiration Non-nutritive Sucking
Newborns with greater than 60 respirations/minute should never Non-nutritive sucking (NNS) is promoted for the preterm
be PO feed because they have an increased risk of aspiration and high-risk newborn for physiological and psychologi-
pneumonia cal reasons. Using a pacifier promotes comfort (Klaus &
Fanaroff, 2005) and NNS may promote breastfeeding in
chapter 19 Caring for the Newborn at Risk 631
and take ownership of their infant. This is sometimes diffi- • Phone inquiries can only be done by the parents after
cult because the nurses are providing the care. Third, the they identify themselves by the infant’s medical record
parents eventually take an active role in the newborns care or bracelet number and they have signed a consent per-
and become the voice of the newborn. This stage lends mitting nursing and medical personnel to discuss infor-
itself to parents as partners in providing the best individual mation on the phone with them.
developmental care for the newborn (Heermann, Wilson, • Nurses and physicians will not answer questions regarding
& Wilhelm, 2005). the condition of other newborns in the unit.
Most NICUs practice primary care nursing in order for • Pictures of their own newborn are allowed but they can-
the parents to have a consistent contact person to ask not photograph other newborns in the unit.
questions and to call when they are home. Some NICU For more information on Protecting the Privacy of Health
staffs make routine phone calls to the family to give Information go to: http://www.hhs.gov/news/facts/privacy.
updates. html
From the very first visit onward, the parents are
encouraged to touch the newborn. Touch is a very
important act for bonding with the newborn. Kangaroo
care is also encouraged as soon as the newborn is stable CLASSIFICATION OF THE NEONATAL
enough to be taken out of the incubator. Many parents INTENSIVE CARE UNIT
have the need to stay at the bedside for extended periods NICUs are classified according to level of care. Regional-
of time. The NICU nurse must assist the parents in find- ization is a concept in care that arose in the 1980s to con-
ing a realistic routine that enhances the newborn’s health serve health care dollars, consolidate services, and improve
care needs. Fathers should be included in the educa- outcomes. Today hospitals often compete within the same
tional and care process of the newborn. Studies show geographic area to have the largest and most recognized
that parents of NICU newborns report stress and anxiety services in specialty care areas. Level I nursery care is for
about the future of the newborn years after discharge. well newborns and can stabilize high-risk newborns for
Education about developmental care and continuity of transport. Level II nurseries can provide the same care as
care that includes home care are most important to the Level I nurseries plus provide premature care, give oxygen
high-risk newborn (Bakewell-Sachs & Gennara, 2004). by hood and start intravenous therapy. Level III NICUs
Parents also have anxiety about the newborn’s discharge, are the most sophisticated of the nurseries because they
so the nurse must prepare them to care for their child ventilate newborns (Klaus & Fanaroff, 2005).
at home.
TRANSPORTING THE PRETERM NEWBORN
critical nursing action The Neonatal Intensive Newborn transport is done if more technologically
Care Unit advanced care is needed then can be safely provided at the
institution (Fig. 19-15). Most Level III NICUs have a spe-
• Orient the parents to the NICU environment and policies and cially trained transport team who go to the referring insti-
procedures and HIPAA regulations. tution, stabilize the newborn, and bring the high-risk
• Assign one primary care nurse as the main contact for the parents. newborn back to the regional Level III center by ambu-
• Explain the rationale for policies and procedures. lance or helicopter. The terrain, location, and weather of
• Listen to the parent’s expectation of their role in the NICU. each referring NICU determine the safest transport mode.
• Explain the integration of caretaking roles between parents and
staff.
• Use a white board at the newborn’s bed to relay messages back
and forth.
• Encourage parents to call the NICU and inquire about their
newborn 24/7.
• Encourage parents to bring in the newborn’s personal clothes when
the newborn can be dressed.
• Encourage parents to verbalize dissatisfaction with newborn’s
care.
Try to incorporate parent’s suggestions into care when possible.
Transport of newborns is traumatic for the newborn and follow-up (Wittmann-Price & Pope, 2002). They often
family and should be avoided when at all possible (Klaus need intervention from developmental and educational
& Fanaroff, 2005). specialists, physical therapists, and occupational thera-
pists. Case management is an invaluable resource in the
The Transport Team NICU when coordinating follow-up efforts with insur-
Neonatal transport teams are comprised of a physician or ance reimbursements plans. Many NICU units host social
nurse practitioner from the Level III nursery along with events that increase parent-to-parent support after
nursing and respiratory staff that are educated in stabiliz- discharge.
ing the newborn. Specific protocols are followed and the
team should be able to contact the referring neonatologist
during transport for any unanswered questions.
The S.T.A.B.L.E. Program is a program designed to summar y poi nt s
assist health care professionals in the post resuscitation/
pre transport phase of neonatal care. It is an acronym for ◆ Newborns can be put at risk any time during their
aspects critical to stabilization of the high-risk newborn intrauterine or extrauterine development, by genetic
(Box 19-10). It is a program promoted by the March of disorders, congenital anomalies, maternal factors,
Dimes and American Academy of Pediatrics as an adjunct asphyxia or birth injuries resulting from conditions
to neonatal resuscitation to improve neonatal outcomes such as hypothermia, poor oxygenation, prematurity
(STABLE program, 2006). or congenital anomalies.
◆ Small-for-gestational-age (SGA) infants are newborns
— Communicating to parents born at any gestational age and have a birth weight that
about transporting the newborn falls below the 10th percentile on the growth chart and
have suffered a nutritional or oxygenation deficit in
Parents often ask if it is necessary for the newborn to be utero due to maternal causes, fetal causes or a placenta
transported. The nurse can explain the advantages of or cord malfunction.
treatment offered at the referring hospital and make sure ◆ Newborns who are large for gestational age (LGA) are
the parents have a direct number to the unit and the over the 90th percentile on the growth chart because of
name and number of the admitting neonatologist. genetics or, more commonly, have been exposed to an
imbalance of nutrients in utero.
◆ Infants of diabetic mothers are often LGA. LGA new-
borns are also at risk for transient tachypnea, hypogly-
Discharge Planning cemia, hypocalcemia, hypomagnesemia, birth injuries,
Discharge planning must be started as soon as the newborn brachial plexus injuries, and fractures.
is admitted. Most NICUs use standards for discharge such as ◆ Premature newborns are at risk for respiratory distress
respiratory stability, consistent weight gain, and successful syndrome, apnea of prematurity, jaundice, retinopathy
oral feedings as discharge criteria (McGrath & Braescu, of prematurity, anemia of prematurity, and sudden
2004). Studies show that nursing follow up and phone calls infant death syndrome.
decrease parental anxiety and hospital readmission (Monsen, ◆ Postterm newborns are at high-risk for complications
2005). Parent information on discharge topics can be such as meconium aspiration pneumonia and persis-
obtained at www.advanceinneonatalcare.org. tent pulmonary hypertension.
The newborn at risk may have immediate and long-
term disabilities. Newborns are extremely resilient but ◆ Appropriate developmental care in the NICU may be a
the lack of neurological development associated with key to decreasing long-term developmental disabilities
interrupted intrauterine growth affects them not only for the preterm newborn.
physically but socially and developmentally. NICU “grad- ◆ Discharge planning includes respiratory stability,
uates” often need intensive follow-up care. They are consistent weight gain, and successful oral feedings as
sometimes referred to specialists for sight and hearing discharge criteria. Discharge planning must be started
as soon as the newborn is admitted to the NICU.
Box 19-10 Steps Emphasized in the Stable Program r evi ew quest i ons
S Sugar
T Temperature Multiple Choice
A Airway 1. Immediate conditions that pose nursing concerns for
B Blood pressure the small for gestational age (SGA) newborn include
L Lab work which of the following?
E Emotional support
A. Long-term chronic or end of life care
B. Bronchopulmonary dysplasia and ischemia
Source: STABLE Program. (2006). http://www.stableprogram.org/addinfo.html. C. Muscle contractures and hyperthermia
D. Hypothermia and pain management
chapter 19 Caring for the Newborn at Risk 635
Doctor, B., O’Riordan, M., & Kirchner, H. (2001). Perinatal correlates National Eye Institute. (2008). Retinopathy of Prematurity (ROP). Retrieved
and neonatal outcomes for small for gestational age infants born at from http://www.nei.nih.gov/health/rop/ (Accessed March 10, 2008).
term gestation. American Journal of Obstetrics and Gynecology, 185, NIDCAP Federation International. (2006). Retrieved from http://www.
652–659. nidcap.com/ (Accessed October 24, 2008).
Doenges, M., Moorhouse, M., & Geissler-Murr, A. (2005). Nursing Diag- Noerr, B. (2000). Neonatal respiratory disease and management strate-
nosis manual: Planning Individualizing and Documenting Client Care. gies, May 18. Hershey, PA. A continuing education service of Penn
Philadelphia: F.A. Davis. State’s College of Medicine at the Milton S. Hershey Medical
Dremer, P., Lee, E., & Few, B. (2004). A history of neonatal group B Center.
streptococcus with its related morbidity and mortality rates in the Pasero, C. (2002). Pain control. Pain assessment in infants and young
United States. Journal of Pediatric Nursing, 19(5), 357–363. children: Premature Infant Pain Profile. American Journal of Nursing,
Duhn, L., & Medves, J.(2004). A systematic integrative review of infant 102(9), 105–106.
pain assessment tools. Advances in Neonatal Care, 4(3), 126–140. Pinelli, J., & Symington, A. (2005). Non-nutritive sucking for promoting
Fike, D. (2004). Recombinant erythropoietin for the treatment of anemia physiologic stability and nutrition in preterm infants. The Cochrane
of prematurity: Is it beneficial? Newborn and Infant Nursing Reviews, Library. (Oxford) (ID no. CD001071.
(3), 156–161. Premji, S. (2005). Enteral feeding for high-risk neonates. Journal of Perinatal
Fok, T., Wong, H., Chang, A., Lau, C., & Lee, W. (2003). Updated and Neonatal Nurses, 19(1), 59–71.
gestational age specific birth weight, crown-heel length, and head Rivkees, S., & Hao, H. (2000). Developing circadian rhythmicity. Seminars
circumference of Chinese newborns. Archives of Diseases in Child- in Perinatology, 24(4), 232–242.
hood, 88, F229–F236. Sahni, R., Ammari, A., Suri, M., Milisavljevic, V., Ohira-Kist, K., Wung,
Gomella, T. (1999). Neonatology. Stamford, CT: Appleton & Lange. J., et al. (2005). Is the new definition of bronchopulmonary dysplasia
Graven, S. (2000). The full-term and premature newborn. Journal of Per- more useful? Journal of Perinatology, 25, 41–46.
inatology, 20, S88–S93. Shapiro, S. (2005). Definition of the clinical spectrum of kernicterus
Heermann, J.A., Wilson, M.E., & Wilhelm, P.A. (2005). Mothers in the and bilirubin-induced neurological dysfunction (BIND). Journal of
NICU: Outsider to partner. Pediatric Nursing, 31(3), 176–181. Perinatology, 25, 54–59.
Hummel, P., & Conin, J. (2004). Home care of the high-risk infant. Sharts-Hopko, N, (2005). Why every nurse should be concerned about
Advances in Neonatal Care, 4(6), 354–364. prematurity. AJN, 105(7), 60–61.
Johnson, A. (2005). Kangaroo holding beyond the NICU. Pediatric Nursing Spatz, D. (2005). Report of a staff program to promote and support
31(1), 53–56. breastfeeding in the care of vulnerable infants at a children’s hospital
Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Journal of Perinatal Education, 14(1), 30–38.
Maas, M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and Spence, K., Gillies, D., Harrison, D., Johnston, L., & Nagy, S. (2005). A
NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.). reliable pain assessment tool for clinical assessment in the neonatal
St. Louis, MO: Mosby Elsevier. intensive care unit JOGNN: Journal of Obstetric, Gynecologic, and
Kenner, C., & Moran, M. (2005). Newborn screening and genetic testing. Neonatal Nursing, 34(1), 80–86.
Journal of Midwifery and Women’s Health, 50(3), 219-226. STABLE Program. (2006). http://www.stableprogram.org/addinfo.html
Klaus, M., & Fanaroff, A. (2005). Care of the high-risk neonate (5th ed.). (Accessed August 15, 2006).
Philadelphia: W.B. Saunders. Stebor, A.D. (2005). Basic principles of noninvasive blood pressure mea-
March of Dimes. (2006). Perinatal Overview. Retrieved from http:// surement in infants. Advances in Neonatal Care, 5(5), 252-261.
www.marchofdimes.com/peristats/tlanding.aspx?reg99&top1&l Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. (1996). Premature
ev0&slev1 (Accessed October 24, 2008). Infant Pain Profile: development and initial validation. Clinical Journal
Merritt, L. (2005). Part 2: Physical assessment of the infant with cleft lip of Pain, 12(1):13–22.
an/or palate. Advances in Neonatal Care, 5(3), 125–134. Stokowski, L. (2005). A primer on apnea of prematurity. Advances in
McCall, E., Alderdice, F., Halliday, H., Jenkins, J., & Vohra S. (2005). Neonatal Care, 5(3), 155–170.
Interventions to prevent hypothermia at birth in preterm and/or low Taeusch, H., Ballard, R., & Gleason, C. (2005). Avery’s diseases of the
birth weight babies. The Cochrane Library, No. 2. Chichester, UK: newborn. (8th ed.). Philadelphia: Elsevier Saunders.
John Wiley & Sons. Thear, G., & Wittmann-Price, R.A. (2006). Project Noise Buster in the
McGrath, J., & Braesu, A. (2004). State of the science: Feeding readiness NICU. AJN, 106(5), 64AA-EE.
in preterm infants. Journal of Perinatal and Neonatal Nursing, 18(4), Understanding Decibels. Retrieved from http://www.jimprice.com/
353–370. prosound/db.htm (Accessed October 24, 2008).
Molloy, C. (2006). Preemie massage. Premature Magazine, (winter), 64–68. Vargas, J., Allred, E., Leviton, A., & Holmes, L. (2001). Congenital micro-
Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing cephaly: phenotypic features in a consecutive sample of newborn
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby. infants. Journal of Pediatrics, 139(2), 210–214.
NANDA International (2007). NANDA-I nursing diagnoses: Definitions White-Traut, R., Berbaum, M., Lessen, B., McFarlin, B., & Cardenaas, L.
and classifications 2007–2008. Philadelphia: NANDA-I. (2005). Feeding readiness in preterm infants. MCN 30 (1), 52–59.
National Center for Health Statistics (NCHS). (2004). NCHS FASTATS. Wittmann-Price, R.A., & Pope, K.A. (2002), Universal newborn hearing
Retrieved from http://www.cdc.gov/hchs/fastats/birthwt.htm (Accessed screening. AJN, 102(11), 71–77.
October 24, 2008). Young, K.D. (2005). Pediatric procedural pain. Annals of Emergency
Medicine, 45(2), 160–71.
CONCEPT MAP
Clinical Alert:
• Fractured clavicles–T-shirt is pinned so arm is in flexed position
• Microcephaly–Accurate head circumference measurement
• Aspiration–Newborns with respirations over 60 breaths/minute should never be fed PO
Genetic
Disorders
Infants of Diabetic Mom/ Preterm Infant Postterm Infant
Insulin-Dependent Mom
• Trisomies:
21,18 13,
metabolic
• Hypoglycemia • Cold stress • Meconium aspiration
• Hypocalcemia • Respiratory distress syndrome pneumonia
• Hypomagnesemia • Apnea of prematurity – Pneumothorax
• Polycythemia • Bronchopulmonary dysplasia – Pneumomediastinum
• Hyperbilirubinemia; • Patent ductus arteriosus • Persistent pulmonary
possible jaundice, • Anemia of prematurity hypertension
encephalopathy, • GERD
kernicterus • Necrotizing enterocolitis
• Transient tachypnea • Intra/periventricular Nursing Considerations
hemorrhage • Chest physiotherapy
• Retinopathy of prematurity • CPAP
Nursing Considerations
• SIDS • Mechanical ventilation
• Phototherapy
• Extracorporeal membrane
• Glucose/bilirubin monitoring oxygenation
• Magnesium sulfate, calcium Nursing Considerations
gluconate • Thorough, ongoing physical
• Monitor for seizures/dehydration assessment Critical Nursing Action:
• CPAP; ABGs • Oxygenation issues: • Assess for signs of cold
mechanical ventilation: stress
cannulas; CPAP • Correct positioning; suction
• C-R monitor; BP monitoring equipment; ongoing
Critical Nursing Action:
• Nutritional support; parenteral; respiratory assessment
• R/T phototherapy:
naso/orogastric, fortified • Breastfeeding teaching
- Temperature check breast or bottle
- Cover eyes/genitalia • Monitor growth rate; weight
• Hydration status; I&O gain; head circumference
- Adequate hydration • “Back to sleep” • Abdominal circumference;
- Bilirubin monitoring • Transportation issues to and bowel sounds; stools
from the NICU • Lowest oxygen level
Collaboration In Caring:
• Radiology: RDS, ET tube placement Now Can You:
• Teach home monitor/CPR • Identify a clavicle fracture by palpating for crepitus
• “Eye rounds” • Correctly interpret ABG results: to identify acid–base imbalances
one
two
three
four
five
six
seven
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Describe the principles inherent in the developmental process.
◆ Identify and explain physical, emotional, cognitive, moral, and spiritual theories of growth and
development.
◆ Discuss the important Touchpoints in the development of infants, toddlers, and preschoolers.
◆ Address the discipline needs for each developmental stage.
◆ Develop a plan care for the child and family across care settings.
The purpose of this study was to describe the physical and emo- Frequency distribution and Pearson’s Product-Moment
tional health of grandparents who were raising grandchildren and Correlation were used to determine the relationship among the
the extent to which their health was impacted by this role. The variables including age, income, physical and mental health,
study consisted of both qualitative and quantitative data obtained socioeconomic resources, and stress level. Qualitative analysis
from a sample of 17 grandparents 46 to 83 years of age. All of was used to identify codes and categories, which were further
the actual participants were women, although grandfathers were collapsed into themes.
present in five of the homes. The sample included 15 black grand- Demographic data indicated that 47% of the participants
mothers and 2 white grandmothers. The participants resided in a reported being married. Their incomes ranged from $3,600 to
three-state metropolitan area of the United States. $94,900 per year, with an average of $31,605. The mean for
The following were criteria for inclusion in the study: (1) the educational achievement was completion of 12th grade; 35%
children lived with the grandparent on a daily basis; (2) the grand- of participants were employed; 65% were retired or unem-
parent had responsibility for raising the children; (3) the children ployed. In 66% of the families, incarceration of the birth parent
were younger than 18 years of age; and (4) the birth parent who as a result of drug addiction led to the grandparent’s role
also may have resided in the home was considered a minor. change. For the remainder (24%) of the participant families,
Strategies for data collection included: (1) a self-report ques- the birth mother died as a result of addiction or terminal
tionnaire to obtain demographic characteristics; (2) an in-depth illness.
interview that was audiotaped; and (3) an observation about The researchers reported that although there was wide varia-
the home environment. In addition, the grandparents completed tion in the participants’ physical and mental health status, most
a Parenting Stress Index (PSI) Likert scale tool (Abidin, 1995) as scored high in the area designated as “parental stress.” Analysis
well as a personal home assessment. Home visits, which lasted of the PSI scores revealed that 47% of the participants had
1–2 hours, were made over a 10-month period by the primary exceptionally high stress scores. Areas of significant concern
investigator. included to the participants were financial problems, disrupted
(continued)
641
642 unit six Caring for the Child and Family
Erik Erikson
Box 20-3 Freud’s Stages of Psychosexual Development Erik Erikson (1902–1994) was a contemporary of Freud’s.
ORAL STAGE (BIRTH–1 YEAR)
Unlike Freud, who attributed personality formation only
The infant is fixated on oral curiosity (whatever he can put in the mouth). to the interplay within a person’s family of origin, Erikson
The infant derives pleasure from and relieves anxiety through oral sensa- focused on the influence of social interaction. Erikson
tions; for example, the infant sucks on his mother’s breast or his bottle and identified seven stages of development. Mastery of each
is fed and pleasured. The infant puts his fist in his mouth, or uses a teeth- stage requires that the individual achieve a balance
ing ring. Children at this stage often use pacifiers or thumbs to decrease between two tasks (conflicting variables). Each stage rep-
anxiety and increase comfort. resents a crisis that must be resolved in order to move on
ANAL STAGE (1–3 YEARS) healthily to the next stage. Erikson’s stages are well
By the time the child reaches this stage; the child is ready to control elimi- known, and used often in tracking the development of
nation. Some children readily use the “big kid” potty; others resist. This is children.
a time of increasing control in other areas of the life of the child. The child
recognizes that this newfound control can run a collision course with the Trust versus Mistrust
world, hence the term “the terrible twos.” For example, the child explores, Trust versus mistrust occurs between birth and 1 year. The
asserts, and learns boundaries about where to play safely. The child may task of this stage is for the baby to recognize that there are
struggle against these boundaries by escaping the backyard and running people in his life, generally parents that can be trusted to
down the block.
take care of basic needs. The baby’s struggle becomes
PHALLIC STAGE (3–6 YEARS) evidenced in the recognition that not everyone or every
By early childhood, sexual difference is discovered. The child begins to situation is “safe.” Through trust the baby learns to have
compare both the male and female bodies simply out of curiosity. For confidence in personal worth and well-being along with
example, the child notices that girls are physically different from boys. connectedness to others. Failure to master this stage leaves
During this time, a girl child wants to push mommy aside and marry daddy
a sense of hopelessness and disconnectedness. Examples of
or vice versa.
this disconnect can be seen in infants with failure to thrive
LATENCY STAGE (6–12 YEARS) or with attachment disorders. Difficulty in trusting can be
Freud believed that the child “takes a break” psychosexually during this seen even in adults who have problems maintaining signif-
period of development. This allows the child to focus more intently on icant relationships.
other aspects of growth and learning. For example, the child spends time
with his same-gender friends, excelling in sports or video games. At this Autonomy versus Shame and Doubt
age, the child presumably has little interest in issues of sexuality.
Autonomy versus Shame and Doubt occurs between 1 and
GENITAL STAGE (12–18 YEARS) 3 years. The task of this stage is for the child to balance
By the time the child reaches puberty, sexuality and relationships are the independence and self-sufficiency against the predictable
focus. For example, this is a time for exploring relationships and of devel-
sense of uncertainty and misgiving when placed in life’s
oping a sense of romanticism.
situations. It is the time for the child to establish will-
power, determination, and a can-do attitude about self. An
example of this stage happens when the toddler wants to
choose clothing and dress independently. The struggle
the infant responds to all stimuli emotionally. The infant happens when the parents allow the child to make per-
cries, laughs, or coos automatically and without thought. sonal choices yet expect the choices to be socially accept-
The id is the part of the personality that relies solely on able. At this age, the child is able to do many new things
instinct. During the baby’s first year, the ego begins to and wants to explore everything. This newfound indepen-
develop to provide balance between the competing id and dence is accompanied by new rules that may cause inter-
reality. The ego provides a sense of identity separate from nal conflict. The child must develop personal abilities
others and promotes the ability of the child to function while struggling with both fears and wishes.
individually. During infancy, the ego helps the baby begin
to learn that the mother is not simply an extension of his Initiative versus Guilt
body. They are separate. Between the ages of 3 and 6 a Initiative versus guilt occurs between 3 and 6 years. The
superego, which serves to help regulate behavior, is devel- child’s task during this stage is to develop the resourceful-
oped. In this stage, the child develops cognitively and ness to achieve and learn new things without receiving
learns about rules and the needs of others. The superego self-reproach. It is difficult for a young child to resolve the
functions as not only a center for conscience, but as a sense conflict between wanting to be independent and needing
of what and how the child perceives self. An example of to stay attached to parents. The child’s writing plays or
the superego is the young child obeying the parents’ rules new songs, games, or jokes are good examples of initia-
by picking up toys even though the child would rather tive. The child feels confident to try new ideas. It is impor-
continue playing. The child is learning that there is a dif- tant that parents and teachers encourage this initiative to
ference between right and wrong and that they are not the help the child develop a sense of purpose. If initiative is
“center of the universe” as previously believed. The child discouraged or ignored, the child may feel guilt and lack
knows that a “good” boy obeys his parents. of resourcefulness.
During adolescence, the ego again provides a balance,
this time between the id and the superego. When the ado- Industry versus Inferiority
lescent refuses to drink alcohol with friends because it is Industry versus inferiority occurs between the ages of 6 and
against the child’s conscience and the law, it shows that 12. In this stage, the child develops a sense of confidence
the ego has prevailed. through mastery of tasks. This sense of accomplishment
chapter 20 Caring for the Developing Child 645
can be counterbalanced by a sense of inadequacy or inferi- ment as biological and evolutionary adaptation. The infant
ority that comes from not succeeding. The realization that develops an attachment to his mother as a means of surviv-
the child is competent is one of the important building ing the vulnerability of infancy, rather than as a simple
blocks in the development of self-esteem. Industry is evi- response to having, his biological needs met. As the infant
dent when the child is able to do homework independently begins to explore the world and the other people in it the
and regulate social behavior. Performing the prescribed mother is perceived as “home base.” When the infant
tasks at school or home also show industry. If the child becomes frightened or threatened, home base is found. If
cannot accomplish realistic expected tasks, the feeling of the infant feels secure in the knowledge that the home base
inferiority may result. is reliable, the infant can move on to develop additional
relationships and attachments.
Identity versus Role Confusion
Identity versus role confusion occurs between the ages of Mary Ainsworth
12 and 18. This is a time of forging ahead and acquiring a Mary Ainsworth (1913–1999) was a colleague of Bowlby’s
clear sense of self as an individual in the face of new and and added to the work with studies about infants in unfa-
at times conflicting demands or desires. During this stage miliar situations. Through the use of the “strange situation”
the adolescent wants to define “what to be when I grow room, the researcher introduced infants (10 to 24 months
up.” She begins to concentrate on goals and life plans sep- old) to a series of situations that tested the strength of their
arate from those of peers and family. At this point, the attachment to their mothers. The situations demonstrated
child has the ability to think about self as well as others three patterns:
and proceeds accordingly.
• Secure attachment: Baby cries when the mother leaves
and is happy when the mother returns.
— When a parent inquires about • Avoidant attachment: Baby rarely cries when the
the development of their child mother leaves and avoids the mother upon return.
• Ambivalent attachment: Baby becomes anxious prior
When parents ask the nurse about a delay in their child’s to the mother leaving, is very upset when the mother
development the nurse can respond by saying “It is leaves, and seeks contact with her while pushing her
important to note that your child may not have reached the away on return.
‘appropriate’ developmental stage based on chronological
age alone. There may be events or variables that stunt your Ainsworth’s research in Uganda, and later in Baltimore
child’s attempts to move forward such as an illness.” was important because it was the first truly empirical
studies related to Bowlby’s original attachment theory.
Phase I Orientation and signals The initial The infant responds to everyone
(birth–2 months) without discrimination of figure preattachment phase in his environment without
discrimination.
Phase II Orientation and signals Attachment-in-the The infant responds most to
(8–12 weeks) directed toward one or making phase those significant caretakers in
more discriminated figures his life.
Phase III Maintenance of proximity Clear-cut attachment The baby attaches to his
(6–7 months) to a discriminated figure caretaker crawling toward the
by locomotion and signals. caregiver, reaching for or cooing
at the caregiver.
Phase IV Implications of the partnership Goal-corrected The preschool child begins to
(around age 3) for the organization of partnership develop an understanding of the
attachment behavior during caregiver’s goals. The child
the preschool years knows that a tantrum might get
the mother to fulfill demands.
Source: Ainsworth, M. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ:
Lawrence Erlbaum Associates.
social learning scientists. Behavioral scientists saw the success-inducing experiences, may suffer negative conse-
learner as passive, while social learning scientists empha- quences and lack good self-efficacy.
size the interplay of the individual within his environ-
ment. J.B. Watson, a behavioral scientist, sought to under- Lev Vygotsky
stand observable behavior. B.F. Skinner, also a behavioral Vygotsky (1896–1934) was a Russian psychologist who stud-
scientist, described growth and development as a process ied the influence of culture on development. Vygotsky was a
of responding to stimuli within the environment (positive contemporary of Albert Bandura. He emphasized that culture
and negative reinforcement) that created new learning and certain factors within the child’s environment have a
along with adaptive behaviors. While both types of scien- dramatic impact on language development. He believed
tific investigation are important, this chapter discusses the that development occurs on two levels: personal (intrapsy-
theories of the social learning theorists, Albert Bandura, chological) and social (interpsychological). Vygotsky coined
Lev Vygotsky, and Urie Bronfenbrenner. the term “zone of proximal development,” which means
that one learns much more successfully when assisted by
Albert Bandura another person. In other words, a child left alone to their own
Albert Bandura’s (1925–present) theory of development does devices would accomplish fewer developmental tasks, not
not rely on predetermined stages. Bandura proposed that nearly to the degree if the child had assistance of another
learning occurs within a social context through observation person.
and modeling. The child pays attention to a new concept/
task, retains that image, and then reproduces the action Urie Bronfenbrenner
physically. Each successful approximation (reproduction) of Urie Bronfenbrenner (1917–2005) studied the effects that
the action increases the child’s perception of personal effec- social environment has on a child’s development (1979).
tiveness, which then contributes to the development of new Within this ecological approach, Bronfenbrenner defined
social skills. For example, a newborn has no sense of self as four systems in each child’s life. The microsystem refers to
separate from others. As the infant develops new skills, inad- the systems where the child is actively involved. Typically,
vertently at first, he becomes motivated to continue learning. in a child’s life, the microsystem would be family, school,
Bandura also describes self-efficacy (sense of self) and refers and peer group. Mesosystem refers to the interaction
to several foundations for developing self-efficacy. They are between two microsystems, such as the interplay between
mastery (being successful), modeling by others (imitation), a child’s home and school. The exosystem refers to those
“social persuasion” (pairing situations in which success is systems that may have an impact on the child, but with
likely to occur after positive feedback), and being able to which the child is not intimately involved, for instance,
decrease the perception of stress and threat (a conscience the parent’s work. The parent’s work affects the child’s
willingness to continue using the senses for learning rather life, yet he is not directly involved in it.
than simply for surviving).
As the infant acquires this sense of self and begins to
differentiate himself from others, the infant develops new COGNITIVE THEORIES
skills, and, hopefully resilience in the face of life’s difficul- Cognitive theory focus on how an individual thinks and how
ties along with adaptations to surviving developmental thinking influences worldview. The capacity to think devel-
transitions. Conversely, children who have not had ade- ops overtime and with experience. Jean Piaget discussed
quate positive modeling, or who have not had access to cognition (thought) and how it influences development.
chapter 20 Caring for the Developing Child 647
Lawrence Kohlberg
Table 20-4 Lawrence Kohlberg’s Stages of Moral
Lawrence Kohlberg (1927–1987) based the theory of moral Development
development (1984) on the thinking processes involved
when making moral decisions. Kohlberg identified three Level I. Stage 1: Obedience and Punishment—
levels of moral development: preconventional, conven- Preconventional Morality The child will obey in order to avoid
tional, and postconventional. Each level of moral develop- being punished.
Morality is determined by
ment represents a major modification in the child’s think- external sources—rules, Stage 2: Individualism and Exchange—
ing and is further separated into stages (Table 20-4). Within laws, possibility The child thinks that it may be okay to
Level I, Preconventional Level, the child’s thinking is con- of punishment. do something wrong if a good comes
crete and egocentric. Obedience and punishment are from it (in other words, the end
unquestioned and understood as either good or bad. The justifies the means).
child behavior is based on which actions are rewarded or
Level II. Stage 3: Good Interpersonal
punished. Individualism and exchange occurs when the Conventional Morality Relationships—The child’s moral
child begins to define right and wrong and develops an decisions are based on the “goodness”
individual sense of fairness and personal justification. As Morality is determined by of motivation and on what others
the child matures and is confronted with opposing views, being a “good person.” expect.
he begins to recognize that not everything is black and The intent is to please
white. The child’s sense of morality is still concrete but the others and to do the Stage 4: Maintaining the Social
“right thing.” Order—The child’s good moral
child begins to take into account personal reasoning. If the decisions are those that preserve the
child can justify an action, then, in his mind, it is acceptable needs of society.
to bend or break rules.
Transition to the Level II, Conventional Level for the Level III. Stage 5: Social Contract and Individual
child, is marked by the child’s incorporation of social and Postconventional Morality Rights—The individual’s thinking is
interpersonal relationships. The good interpersonal and characterized by a deeper questioning
of social order versus an individual’s
relationships stage is where the child’s actions are justified personal rights. A person in this stage
by personal motivation to “do good” for family members would work tirelessly to change unjust
or other individuals. The child understands that maintain- laws.
ing the social order means that society as a whole may
benefit by her actions. Stage 6: Universal Principles—An
Level III, Postconventional Morality, is divided into individual incorporates a deep
awareness of justice. An example
social contract and individual rights and universal prin- would be breaking an unjust law to
ciples both of which require significant degrees of per- save lives of innocent people.
sonal deliberation and maturity. These stages are sequen-
tial and require a level of cognitive development, they
are not necessarily age-related. In fact, an adult may have
reached only the preconventional level of moral develop- SPIRITUAL DEVELOPMENT THEORIES
ment and has not reached the postconventional level of
James Fowler (1981) identified seven stages related to
moral development because progression through the
faith and spiritual development. Fowler defined faith out-
levels is influenced by a variety of factors such as experi-
side the usual “religious” definition. Fowler believed that
ence, health, socioeconomic status, family structure, and
faith is commonly experienced and that it is the individual
culture.
striving for something “more than the self.” The develop-
Carol Gilligan ment of faith depends on a certain level of cognitive
Carol Gilligan (1936–present) initially worked with achievement. Deepening levels of belief rely on the ability
Kohlberg as a research assistant. Gilligan became con- to think abstractly. Understanding Fowler’s stages are
cerned that Kohlberg’s studies of moral development were important in providing complementary care to children
based only on norms for males. When girls were com- and their families (see Complemenatry Care: Understand-
pared to boys using Kohlberg’s framework, girls appeared ing Spirituality).
morally weaker or slower to develop than their male
counterparts. In Gilligan’s book, In a Different Voice
(1982), previously held beliefs about female moral devel- Box 20-4 Gilligan’s Three Levels of Moral Development
opment were questioned by interviewing both women and
men about their life experiences. Gilligan identified two Level 1: Orientation of individual survival. As the girl transitions
tracts of moral development. One was based on autonomy through this level, they move from selfishness to responsibility where
and justice (Gilligan, 1982), as seen in Kohlberg’s inter- they consider other people.
views with men. The other was based on caring and rela- Level 2: Goodness as self-sacrifice. This level involves looking at the
world through the needs of others. The girl sacrifices her own needs and
tionship (Gilligan, 1982), which Gilligan attributed to considers herself responsible for others.
women. Gilligan’s work helped to define moral develop- Level 3 (the transition level) requires movement from goodness to
ment for women in a different way than men. Even though truth. In other words, the woman recognizes that choice is importance
Gilligan later withdrew the charge of gender bias, Gilligan when doing for herself or others, rather than focusing on being good for
continued to champion the study of female moral devel- the sake of being good.
opment (Box 20-4).
chapter 20 Caring for the Developing Child 651
life were identified. These traits exist on a continuum Newborn and Infant
depending on the infant’s reaction to the environment. To
help ensure effective parenting the nurse can teach parents The entire infant period of development encompasses the
about their infant’s temperament traits. development from 1 to 12 months of life. This period of
development continues to be a time of rapid change in all
aspects of development. The baby develops on all levels,
Across Care Settings: Infant temperament at a varying pace. It is important for the nurse to remem-
During a normal daily routine the child may be exposed to a ber that each infant moves at his pace and with his own
variety of settings and exposed to several people; a day care style.
center, visiting extended family, physician’s office or in The neonate’s movements are random and erratic. The
public places in the community. Understanding an infant’s neonate can move the head from side to side, but has little
temperament is essential in the care of the child to help both control of her neck and back muscles.
the parent and child adapt to these experiences. Based on the
work by Thomas, Chess, and Brich (1968) the following REFLEXES AND NEUROLOGICAL
descriptors are used to help recognize the infant’s unique DEVELOPMENT
personality. Primitive reflexes are those adaptive and innate mecha-
Regularity: The child needs regularity in sleeping, nisms that protect the developing infant while the brain is
eating, and bowel habits. A child who is “easy” is one who maturing (see Chapter 18 for more information). The
can adapt to relatively flexible schedules. A child who is reflexes are controlled by the lower brain centers. There
“difficult” has difficulty when the schedule has been are several reflexes present at birth or shortly after. They
disrupted. naturally disappear by 9 months.
Reaction to new people and situations: The “easy” child
responds easily to new people in their environment. Another
child may stand back or withdraw when something or clinical alert
someone new is present.
Reflexes
Adaptability to change: This trait refers to a child’s
willingness to change routine. An “easy” child makes As the nurse performs an assessment it is imperative to note
transitions with little or no discomfort. A slow-to-adapt child important infant reflexes:
will become distressed with even the smallest changes, for • Rooting baby’s head turns and begins to suck when her cheek
instance, taking a different route home from school. or lower lip is stroked.
Sensory sensitivity: An “easy” child with lower sensitivity • Sucking motion of lips, mouth, and tongue allowing infant to
will appear much less meticulous or disturbed by her senses. take in sustenance.
A “difficult” child with high sensitivity may react strongly • Moro: Startle response with sudden jarring causes extension
when exposed to sensory stimuli. The child may chafe of the head. The arms abduct and move upward. The hands
against certain textures, tastes, smells, or sounds. form a “C”
Emotional intensity: An “easy” child shows little • Grasping: When palm of hands or soles of feet are stroked
or no response to a situation. An intense child reacts • Babinski: Turning in of foot and out of toes when sole of foot
dramatically and profoundly, whether that reaction is is stroked
loud or withdrawn.
Level of persistence: This trait refers to the child’s
willingness to stay engaged regardless of setbacks. A At birth, the lower portions of the nervous system
persistent child has difficulty giving up until the goal is (spinal cord and the brainstem) are already developed.
reached. A less persistent child is more flexible and may They are necessary for the infant to sustain life (basic
give up easier. body functions and primitive reflexes). As the infant
Activity level: An “easy” child will generally be less matures, the higher sections of the nervous system become
frenetic with activity. A “difficult” child has difficulty with more developed. For instance, the limbic system and the
inactivity, preferring to always be on the move. cerebral cortex are responsible for ongoing learning that
Distractibility: The distractible child has difficulty occurs during the lifespan.
concentrating on tasks in which they are not immersed; not
the same as Attention Deficit Disorder (ADD). A less SENSORY DEVELOPMENT
distractible child stays with a task longer.
Touch is an extremely important sense and is the first
Mood: An “easy” child tends to see the world in a more
sense to develop. The ability to feel objects, textures, and
positive way. A “difficult” child will react more negatively.
other people opens up the newborn’s world of learning.
It is important for the infant to experience soft comfort-
The ability to recognize these traits is helpful for deter- ing textures. The ability to experience pain is also an
mining the goodness of fit between the caregiver(s), fam- extremely important element, particularly as a protective
ily members, and the child along with helping families device. If the infant has a pain experience, he reacts to
strategize to improve the fit. This way of understanding pain with the whole body by quickly extending and then
the child takes into account that each person in the retracting the extremities. Along with this reaction, the
child’s life has also a unique temperamental style, which infant cries.
complements, becomes enmeshed with, or antagonizes Smell and taste begin developing in utero and intrinsi-
that of the child. cally connected. Infants respond to smells within the first
chapter 20 Caring for the Developing Child 653
PHYSICAL DEVELOPMENT
Growth is rapid. Infants gain 1.5 pounds (680 g)/month, Figure 20-2 One of the first fine motor skills to
double their weight by 6 months and triple it by 1 year. develop is the ability to pinch to pick up small objects
Height increases by 1 inch (2.5 cm) for the first 6 months like food.
654 unit six Caring for the Child and Family
mother than to anyone else, but the infant continues to experiences as children. It is essential that parents be
respond indiscriminately to others. It is not until the third taught what to expect at each of the developmental stages
stage (6 or 7 months) that the infant demonstrates a and how to recognize appropriate strategies for teaching
strong connection to the mother and possibly develop a and limit-setting.
fear of strangers. Not all babies develop stranger anxiety
as was historically thought. Throughout the first year, the
infant is developing attachments to all of the important critical nursing actions Anticipatory Guidance
people in the family. Achieving the necessary milestones
is essential for the infant to move on to the next stage of Anticipatory guidance is a way of providing caregivers with informa-
psychosocial development. An example of psychosocial tion and examples about what to expect in the future regarding their
development is the infant becoming more aware of others child’s next developmental phase. A few examples of important topics
may include discipline, nutrition, safety, schooling, elimination, immu-
and responding to people (or animals) that are physically nizations, or play.
on the same level (Fig. 20-3).
It is important that the nurse teach parents that infants do not misbe-
have on purpose. Exploration and crying are normal behaviors for
DISCIPLINE infants. The purpose of discipline at this age is to keep the child safe.
Discipline plays an important role in the psychosocial Using a firm tone of voice or facial expression while telling the child
development of the infant. Merriam-Webster’s Online “no” or “stop” as he or she reaches for the stove helps the infant
Dictionary (n.d.) defines discipline as “training that cor- know that there are limits to his actions. The infant can then be redi-
rects, molds, or perfects mental capacities or moral char- rected to a similar experience such as reaching instead for a toy off
a countertop.
acter.” The definition additionally identifies teach as a
synonym. In the best of all worlds, discipline and teaching
would be the same. In reality, much of what is designated
as discipline is in fact punishment. Punishment, as defined
in Merriam-Webster’s online dictionary, is “suffering,
pain, or loss that serves as retribution.” It is important for Toddler (1 to 3 years)
the nurse to be aware of these definitions when helping
parents and caretakers determine how they plan to pro-
PHYSICAL DEVELOPMENT
vide for the correction, molding, and refining of their By the time, the infant reaches 1 year of age, physical
children’s mental capacities and moral characters. growth has slowed. Between ages 1 and 3, each year the
It is important for the nurse to include information typical toddler gains 4 to 6 pounds (1.8 to 2.7 kg) and
about discipline when teaching the parents about the grows 3 inches (7.5 cm) taller. Much of the toddler’s
infant. Teaching parents about disciple helps the infant energies during this period are directed to other realms
learn about maintaining safety measures, develop satisfy- of development. As the physical growth rate slows, the
ing relationships, and become a good global citizen. The toddler develops skills (physical, cognitive, and emo-
American Academy of Pediatrics (1998, 2004) indicates tional), that help him to become more independent. As
that early forms of discipline take place when the care- the toddler develops mobility, he explores how things
giver molds and structures the infant’s daily routines and work and his senses become more refined. The toddler
by responding to the infant’s needs. Limit setting func- uses newly acquired gross motor skills to run, jump, and
tions to acclimate the infant to the world and to keep move up and down stairs with increasing ease. Around
the infant out of harms way. It is important to note age 3, he may learn to ride a tricycle or slide down the
that parents often learn how to discipline from their own slide in the park without help. All this newfound free-
dom and movement create many opportunities for dan-
ger as the toddler moves quickly from one new experi-
ence to another.
Fine motor skills continue to develop rapidly also. The
toddler can hold a spoon or a large crayon appropriately
and continues to make artwork that is more representative
of the object she is trying to depict. He is increasingly able
to manipulate smaller toys.
COGNITIVE DEVELOPMENT
Early toddlerhood corresponds with Piaget’s fifth substage
of cognitive development, Tertiary circular reactions, dur-
ing which the toddler experiments and learns new behav-
iors. The toddler then moves into Piaget’s sixth substage,
Mental combinations, during which she begins to under-
stand cause and effect and is able to imitate others.
The toddler loves to imitate (Fig. 20-4). Much of the
Figure 20-3 An example of psychosocial development toddler’s behavior is through replicating what she sees
is when an infant becomes more aware of others by and hears. The toddler also learns through repetition. This
responding to people or animals that are physically is why a toddler may want the same book to be read over
on the same level. and over, staying engrossed in the story every time.
656 unit six Caring for the Child and Family
MORAL DEVELOPMENT
Cognitively, the toddler is still a very concrete thinker and
knows that something is “good” or “bad,” but does not
know why. At this stage, the toddler identifies good and
bad, right and wrong by virtue of whether or not it is
Figure 20-4 Toddlers love to imitate.
rewarded or punished. This corresponds to Kohlberg’s
preconventional level of moral development.
A toddler also likes order and often responds with dif- DISCIPLINE
ficulty to any disruption in routine. The level of response The purpose of discipline is to teach the child socializa-
is related to the temperament of the child. Some toddlers tion and safety. It is the responsibility of the parent to
may revolt with pure temper tantrum while others provide a firm structure so the toddler can explore the
can calmly transition. Regardless of temperament, most world while offering safe limits. Most children will
children at this stage respond favorably to predictable repeatedly test rules, while also unconsciously learning
routines. to rely on the security those limits provide. Having a
structured environment for the child does not necessarily
LANGUAGE DEVELOPMENT mean rigid or inflexible. Parents must learn to structure
Because toddlers are increasing in cognitive develop- the toddler’s surroundings that allow enough flexibility
ment, they are able to listen to and understand short to test limits.
explanations. This is a time when the child develops a A child at this stage needs much guidance in deter-
more understandable language system. Language is about mining how to act appropriately. The toddler thinks
fulfilling needs; “I do” or “want drink.” The toddler concretely and must rely on others to help give realistic
moves from using single words to short phrases. Some parameters. Some parameters may create a great deal of
parents worry when their child does not fall exactly conflict when what the toddler can do does not match
within what are considered normal language parameters. what the toddler wants to do, which may result in a
The nurse can reassure parents that it is important to temper tantrum. Praise becomes an excellent compo-
assess what the child understands and what the child is nent of discipline as most children want to please the
able to communicate, with or without words, rather than parent.
exact correctness in pronunciation.
TEMPER TANTRUMS
PSYCHOSOCIAL DEVELOPMENT Because this is a time of intense exploration and discov-
Toddlers typically exemplify characteristics of Freud’s ery and a time when the toddler is establishing a sense of
anal stage. The child begins to develop a sense of self as herself as a competent doer, there will be “bumps in the
separate from his mother. The toddler’s task is to move road.” A tantrum is a normal way for a toddler of working
away from the primary caregiver while in some way main- things out internally. Parents and caregivers need to
taining enough connection to feel secure. This process, know that tantrums are normal for the toddler. It may be
called rapprochement, is healthy and expected. possible for parents to anticipate when tantrums are most
chapter 20 Caring for the Developing Child 657
apt to occur (e.g., when the toddler is tired, hungry, or Early Childhood (Preschooler)
overwhelmed by new situations, reserves are low and
therefore, he may be more likely to explode or “melt- (3 to 6 years)
down”). Tantrums may be avoided or minimized if antici-
pated. Get a tired child to rest or feed a hungry child to PHYSICAL DEVELOPMENT
decrease his frustration level. If a tantrum does develop, Children at this age come in various sizes, shapes, and body
there are coping strategies that a nurse can teach a parent. types. As a rule, preschoolers begin to grow taller and thin-
When the child is wailing and thrashing, but not doing ner. Their bellies flatten as they grow and their abdominal
any harm, ignore her. Often this is not possible, and it muscles strengthen, and their pelves straighten. The physical
may be necessary for the parent to intervene quickly and growth rate for this stage of development is slow but steady.
decisively to remove the child to a quieter or safer place. The preschooler average weight gain is about 4.5 to 6.5
Touching and distractions may help soothe a tantrum; pounds (2 to 3 kg) and growth is 2.5 to 3.5 inches (6.2 to
while another child may need to continue the tantrum 8.7 cm) per year. The 4-year-old’s posture straightens and the
under the watchful eye of the parent. The latter requires young child is able to move around in a more balanced fash-
that the parent be present, but not engaged in direct com- ion. Preschoolers become stronger as their muscles become
munication with the child. The goal is for the child to feel more developed. Their faces become more like they will be
(and be) safe without being reinforced (positively or neg- when they grow up with narrowing of the face, enlargement
atively) for having a tantrum. of the nose, and a more adult-like appearance to the skin.
When faced with the sometimes daunting task of car- The preschooler is much more agile. The preschooler
ing for a “willful” toddler (one who is regularly assert- can climb stairs using alternating feet and is able to ride
ing her power), parents are often confused. It is indeed his tricycle. At 4, the preschooler can climb up and down
difficult to know how and when to avoid the power the stairs comfortably using alternating feet. The pre-
struggles inherent in a clash of wills. It is essential to be schooler can skip and hop and is much more coordinated
able to create boundaries that limit the toddler’s scope on the balance beam.
of power. Inevitably, there are times when the toddler Fine motor skills rely on the use of the forefinger and
must be disciplined, so seeking help from a professional the thumb. As the brain becomes more developed, she is
child counselor is essential (Box 20-5). better able to pick things up with the fingers. Hand domi-
nance (whether or not the child is right- or left-handed)
begins to develop around the age of 3. At this time, the
— Tips for effective discipline
preschooler may show a preference in using one hand over
During effective discipline, allow for negotiation and the other. By the age of 4, that preference is established.
flexibility, which can help build the child’s social skills.
Also, allow the child to experience the consequences of COGNITIVE DEVELOPMENT
behavior. This period of development corresponds with the first sub-
• Speak to the child as you would want to be spoken to stage of Piaget’s preoperational stage (2 to 4 years). During
if someone were reprimanding you. this time, the preschooler increases the ability to verbalize.
• Never resort to name-calling, yelling, or disrespect. The preschooler can symbolically use language to repre-
sent concepts that need to be conveyed. The young child is
• Be clear about what you mean. still egocentric (focused only on his own sense of things)
• Be firm and specific. and therefore is limited socially. This is in large part due to
Note: Whenever possible, the consequences must be concrete thinking processes and the inability to abstractly
delivered immediately, relate to the rule broken, be short shift focus from self to others. The preschooler is also not
enough in duration and emphasize the positives. In able to transfer attention from one aspect of an object to
addition, the consequences must be fair and appropriate another (e.g., a child at this stage can identify a dog’s col-
to the situation and the child’s age. lar, but is not able to describe its texture).
LANGUAGE
The preschooler has increased ability to verbalize; vocab-
ulary increases from 1500 to 2000 words between the ages
Box 20-5 Discipline Strategies 3 and 5. The preschooler uses sentences and is much more
able to convey an intended message. When the young
Distraction: Provide a toy to divert the child’s attention. child is more able to use words, tantrums generally begin
Time-out: Move the child to a “cooling-off” place where the child can to subside. The preschooler loves silly words, rhymes, and
calm down. asks many questions, generally those that begin with
Removal of privileges: Withhold a favorite toy until the child’s behavior “why?” To meet the needs of the preschooler, keep
is appropriate. answers simple and avoid giving too much information.
Verbal reprimands: Give spoken warnings or disapprovals without Bombarding the preschooler with overwhelming answers
berating the child or judging the child as “bad.” can be quite disconcerting for the child. The nurse can tell
Corporal punishment (e.g., spanking, swatting, grabbing): Not the parent that a preschooler may stutter as he tries to get
recommended. out all of the words faster than he is able to speak them.
Stuttering generally resolves fairly quickly.
658 unit six Caring for the Child and Family
MORAL DEVELOPMENT
case study Early Childhood Development
Early childhood typically corresponds with Kohlberg’s
Mrs. James brings Steven, her three-year-old son, into the clinic preconventional morality stage (4 to 10) when the major
for a well-child visit. She states she is concerned because Steven impetus for moral judgment is to avoid punishment. It is
does not talk as well as his peers. She describes how at play not uncommon for the child in this age group to tell lies
group, the other 3-year olds talk more than Steven, and states to avoid consequences. A child at this age may judge an
that Steven barely says a word. When asked how Steven com- action to be wrong only if caught. The young child is only
municates what he wants, Mrs. James states that he points to guilty if the parent has seen the actions.
things and sometimes say one word such as “more” or “juice.”
Mrs. James added that Steven often gets frustrated when his DISCIPLINE
parents do not understand what he wants. A review of his medi-
cal history reveals that Steven was born 39 weeks, weighed Since the preschooler is beginning to understand that
8 lbs, 1 oz (3.7 kg) and had an unremarkable delivery. He has actions have consequences, caregivers can take advantage
had no difficulties with feeding or sleep. He began babbling at of this understanding. The preschooler is able to under-
6 months but did not speak his first word until 14 months. By stand that there are rules and that not obeying those rules
19 months he could say “mama,” “dada, and “juice.” Pres- leads to consequences. It is best if rules are explained before
ently, Mrs. James states he uses approximately 10 words but infractions occur. At the very least, the rules should be
does not combine them. addressed before disciplining the child. This helps the pre-
critical thinking questions school child to learn more clearly how to behave. Conse-
quences can, as much as possible, follow naturally and fit
1. What further assessments would you complete for Steven? the behavior being punished (e.g., having the child clean
2. What would you say to Mrs. James about Steven? up his own messes, or miss a favorite show if he dawdles).
3. What nursing interventions would be appropriate at this time? A typical discipline strategy instituted at this stage of
development is having the child take time-out. Whether
◆ See Suggested Answers to Case Studies in text on the that time-out is in a specified chair, or section of the room,
Electronic Study Guide or DavisPlus. it is important to help the child know that the purpose of
the time-out is to calm himself and to shift gears and act
appropriately.
Many parents begin using behavioral charts (charts con-
PSYCHOSOCIAL DEVELOPMENT structed to praise positive behavior) at this age to help their
Early childhood is a wonderful time of exploration of new toddler visually see what is expected and to be rewarded
skills and about finally being able to figure out how to get when “good” behavior is shown. For many preschoolers,
and do things for oneself. As the preschooler develops, he simply getting a star or sticker on the chart is reward
is presented with many situations where he can truly enough to encourage behavior. For others, a more sophisti-
excel. The preschooler has learned many new skills and is cated measure of rewards is needed. Again, the goal of
becoming a “big kid.” The preschooler enjoys positive discipline and limit-setting at this stage of development is
feedback for accomplishments. The fact that the pre- to begin teaching the preschooler to begin regulating own
schooler is able to do many new things creates a dilemma behavior.
and the preschooler must decide which things are most
important. Parents may not approve of the decisions made
by the preschooler and he may become conflicted when School-Age Child (6 to 12 years)
limits are set. Often times the preschooler ponders doing
“the right thing” or do “the wrong thing” and risk the PHYSICAL DEVELOPMENT
mother’s dismay? Conscience develops and begins to Early in this stage (ages 6 to 9), boys and girls follow simi-
guide the child through the maze of wants versus cans. lar growth trajectories. Both begin to grow taller, reducing
The preschool child has a good deal of magical think- their “baby fat” even more. Children at this age gain about
ing. In a preschooler’s desire to do what she wants to do, 4 to 6 pounds (1.8 to 2.7 kg) and grow 2 inches (5 cm)
she may angrily wish something bad would happen to per year. As their abdominal muscles strengthen, their
another person, often a parent. If something bad actually posture straightens. Facial features become more refined.
does happen, the preschooler will believe that her think- Still, there are many variations in size and shape of chil-
ing caused the outcome. dren in this period. These variations are influenced not
Freud described this period as the phallic or oedipal only by familial and cultural genetics, but also by environ-
period. The child is becoming more aware of gender differ- mental factors (e.g., diet and exercise).
ences. The preschooler may want to marry mom or the girl Most school-age children (boys and girls) begin to
in preschool, rather than relate to his best male friend. develop axillary sweating. In girls, hips begin to broaden
Family is very important to the preschooler. However, and the pelvis widens in preparation for childbearing.
the preschooler is now discovering the joys of having Breasts begin to enlarge and become tender. The vaginal
friendships. The young child looks to his peers for new ph changes from alkaline to acidic and the vagina devel-
ideas and information and begins to develop an under- ops a thick mucoid lining. Usually, pubic hair begins to
standing of what it means to be kind. The preschooler is develop between the ages of 8 and 14. While menarche
more social and is often more willing to share toys with can begin as early as 8 to 10 years of age, the average age
others than when he was a toddler. in the United States is 12 years of age.
chapter 20 Caring for the Developing Child 659
LANGUAGE DEVELOPMENT
Language improves considerably. The child uses words
more accurately, particularly verbs, metaphors, and simi-
les. The child is able to elaborate on concepts that she Figure 20-5 Establishing strong friendships is very
wants to get across. important to school-age children.
660 unit six Caring for the Child and Family
DISCIPLINE
Be sure to— Include the adolescent in the
Since the child in this stage of development is beginning informed consent process
to internalize rules, it is important to allow the child more
independence, and thus more awareness of the natural An informed consent is a way to elicit permission that is
consequences of behavior. An effective parent technique given freely that protects a person’s right to autonomy and
is to refrain from “rescuing” their child from the conse- self-determination. Informed consent is given when the
quences of their behavior (e.g., do not rush home to person understands the usual procedures, their rationales,
retrieve a forgotten piece of homework whenever the and associated risks. A legal parent or guardian customar-
child calls rather allow her to learn a valuable lesson). ily gives informed consent on behalf of the child. As chil-
While many school-age children respond appropri- dren gain critical thinking skills they can become more
ately to natural consequences, some do not yet under- active in the consent process. Depending on state law,
stand responsibility. In addition, most children opt at children 18–21 years of age can give legal informed con-
some time to ignore the natural consequences. Parents sent under these circumstances: when they are minor
may need to impose the previously discussed time-out parents of the child patient, when they are between 16 and
strategy (e.g., grounded for a period of time or pleasures 18 years old seeking birth control, counseling or help for
restricted). substance abuse or when the are self-supporting (emanci-
pated). In many states, a pregnant teen is considered
emancipated and can provide informed consent. The phy-
sician is ultimately responsible for explaining the proce-
Adolescence (12 to 19 years) dure and related risks while the nurse’s role is to serve as a
witness to the parent’s signature for the child or an eman-
PHYSICAL DEVELOPMENT cipated adolescent’s signature. The nurse is responsible to
Adolescence technically begins with the onset of puberty notify the physician if the parent (or legal guardian) does
when the pituitary gland relays messages to sex glands to not understand the procedure or related risks.
manufacture hormones necessary for reproduction. It is a
period of great growth, second only to infancy. While the
growth rate is not as dramatic as that of the earlier stage,
it is still significant. It is not unusual for girls to gain MORAL DEVELOPMENT
15 to 55 pounds (6.8 to 25 kg) and grow 2 to 8 inches At this stage, conflicts emerge between what the adoles-
(5 to 20 cm) and boys to gain 15 to 66 pounds (6.8 to cent has believed to be right or wrong, and what others
30 kg) and grow 4 to 12 inches (10 to 30 cm) before they may believe. This is a time of great questioning and con-
reach maturity. While girls develop earlier than boys, sternation as the adolescent learns that it is possible for
they tend to have a smaller overall physical structure. several views of morality to exist. Kohlberg defines this
Both boys and girls develop primary and secondary sex stage as postconventional morality.
characteristics at this stage. The timing of development
is variable.
— Helping the teen make good
decisions
COGNITIVE DEVELOPMENT
Adolescence corresponds with Piaget’s formal operations The nurse can be influential in helping the teenager
stage. The teenager is able to think abstractly and uses logic make healthy decisions. This can be accomplished by the
to solve problems and to test out hypotheses. In addition, employing the following techniques:
the teen uses deductive reasoning and can think about • Listen: Pay close attention not only to what the
thinking. Teenagers are often beginning to be concerned adolescent is saying, but also to his nonverbal cues.
with such things as philosophy, morality, and social issues. Try to understand his view of the world and stay
They are able to project their thoughts over the long term, open minded.
thus making plans and setting life goals. They often com- • Discuss without judging: The nurse can share her
pare their beliefs with those of peers. understanding of the issues and her perspectives while
respecting those of the teenager.
LANGUAGE • Encourage critical thought: Allow the teenager to
By adolescence, children have highly developed language explore and further develop his options.
skills. They have the ability to speak and write correctly as
well as communicate alternative points of view. They have
sophisticated communication skills. DISCIPLINE
The adolescent is at the stage where she begins to internal-
PSYCHOSOCIAL DEVELOPMENT ize responsibility for behavior. The adolescent still needs
According to Erikson, the adolescent crisis is concerned parental input and guidance in terms of rules (curfew,
with identity versus role confusion. The adolescent must homework, chores, etc.) and possible consequences for
begin to identify who they are and who they will be in life. infractions, but the adolescent is much more able than in
The three major issues that must be confronted; establish any previous stage to monitor and regulate her own
and subscribe to a set of values, and to have developed a actions based on her own critical thinking. It is important
satisfactory sexual identity. in this stage, as in all others, that the parent focus on the
chapter 20 Caring for the Developing Child 661
positives of the teen’s behavior. Natural consequences are with her!” What is the best therapeutic response the
powerful motivators, but by this time, the adolescent may nurse can make?
have learned that he can avoid consequences by being A. “The terrible two’s are a difficult time. You have
crafty. Removing privileges may be an effective conse- to show her that you are the boss!”
quence for the teen’s poor decisionmaking. B. “When she does something wrong, tell her she is
a bad girl and has to be punished for her
actions.”
s umma ry p o in t s C. “Grab her by the arm and give her a time out on
a chair in the corner.”
◆ Information about growth and development, newborn D. “Take away her favorite doll and tell her that she
through adolescence, is important information for the cannot have it back until she changes her
nurse and family. behavior.”
◆ Principles of growth and development can assist the 5. The parents of a toddler ask the nurse how to best
nurse when teaching the family about their child. prepare the toddler for a planned medical procedure.
◆ While all children grow and develop in their own man- The pediatric nurse recognizes that:
ner, each child typically follows a designated pattern or A. The toddler is too young to understand what will
trajectory. happen and does not need an explanation.
B. The use of short explanations can best help the
◆ Characteristics of children can help the nurse and fam- toddler understand the planned procedure.
ily understand about the uniqueness of the child. C. Allowing the toddler to explore the procedure
◆ Prominent theories of development allow the nurse room may be helpful.
and family to have a deeper understanding of the D. It is beneficial for the nurse to demonstrate the
“why’” behind developmental tasks and stages. upcoming procedure to the toddler.
◆ Understanding growth and development provides the 6. The father of a 4-year-old is concerned about his
nurse with tools to develop a plan care for the family son’s reaction to an injury of his friend. He told
across care settings. the nurse that the child stayed in his room over the
weekend and cried himself to sleep. When the
pediatric nurse questioned the child, he described an
r e v i e w q u est io n s argument that he and his friend had about a week
prior to his friend’s injury. The nurse recognizes that
Multiple Choice the preschooler is suffering from.
1. The pediatric nurse assesses the toddler’s fine motor A. Magical thinking
skills by observing which one of the following? B. Inferiority
A. Buttoning a shirt C. Guilt complex
B. Writing with a pencil D. A morality issue
C. Holding a spoon to eat 7. Key aspects in a teens’ environment that help him
D. Using the pincer grasp make good decisions include all of the following
2. According to Piaget, an infant uses his senses to learn except:
and explore the environment. The pediatric nurse A. Ability to think abstractly
understands the concept of object permanence by: B. Ability to use deductive reasoning
A. Playing the game of peek-a-boo C. Ability to make long-term plans
B. Encouraging the infant to shake a rattle D. Ability to use logical thinking
C. Pushing a button on an overhead mobile
D. Placing the child in a stroller and going for a True or False
walk 8. The pediatric nurse is aware that although
3. The pediatric nurse is promoting anticipatory developmental advances occur in an orderly fashion,
guidance about safety to the mother of a 10-month- each child progresses through the predicted stages
old infant. Included in the teaching, the pediatric within her own time frame.
nurse includes all of the following except: 9. The nurse is teaching parents of a school-age child
A. “Do not leave small objects on the floor as your about discipline. The nurse stresses to the parents
baby will be crawling soon.” that if the child does not follow family rules they
B. “Keep the side rails up to prevent your baby from should use corporal punishment.
falling out of the crib.”
C. “Put safety locks on all cabinets to prevent 10. The use of a pacifier or thumb/sucking is a concern
accidents.” during toddler years.
D. “Allow your baby to stay alone for short periods
of time to promote independence.” Fill-in-the-Blank
4. The mother of a 26-month-old toddler tells the 11. According to Erikson’s psychosocial stage of
pediatric nurse that she is having trouble disciplining ____________ vs. _____________, the infant will
her daughter. The mother states; “She really knows learn to trust his environment if his needs are
how to push me to my limit. I don’t know what to do consistently met.
662 unit six Caring for the Child and Family
12. When caring for the developing child, _________ Davidson, J. (2005). Multiple intelligences. Retrieved from http://
refers to the continuous adjustment in the size of the childdevelopmentinfo.com/learning/multiple_intelligences.htm
(Accessed September 29, 2008).
child and ________________ refers to the ongoing Duvall, E.R. (1977). Marriage and family development. Philadelphia:
process of adaptation. Lippincott.
Fowler, J.W. (1981). Stages of faith: The psychology of human development
See Answers to End of Chapter Review Questions on the and the quest for meaning. San Francisco: Harper & Row.
Electronic Study Guide or DavisPlus. Gardner, H. (2004). Audiences for the theory of multiple intelligences.
Teachers College Record, 106, 212–220.
Gilligan, C. (1982). In a different voice: Psychological theory and women’s
REFERENCES development. Cambridge, MA: Harvard University Press.
Abidin, R. (1995). Parenting stress index manual (3rd ed.). Odessa, FL: Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
Psychological Assessment Resources. Maas, M., Moorhead, S., & Swanson, E. (2006). NANDA, NOC, and
Ainsworth, M. (1978). Patterns of attachment: A psychological study of the NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.).
strange situation. Hillsdale, NJ: Lawrence Erlbaum Associates. St. Louis, MO: Mosby Elsevier.
American Academy of Pediatrics (AAP). (2008). Children’s health Kohlberg, L. (1984). Essays on moral development. San Francisco: Harper
topics. Retrieved from http://www.aap.org (Accessed October 1, & Row.
2008). Merriam-Webster Online Dictionary (n.d.) Retrieved from http://www.
American Academy of Pediatrics (AAP). (2005). Policy statement: m–w.com (Accessed Ocotber 1, 2005).
The changing concept of sudden infant death syndrome: Diagnostic Moorehead, S., Johnson, M., Mass, M., & Swanson, E. (2008) Nursing
coding shifts, controversies regarding the sleeping environment, outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
and new variables to consider in reducing risk. 116 (5):1245–1255. NANDA-International (2007). NANDA-I nursing diagnoses: Definitions
Retrieved from http://www.aap.org/ (Accessed September 9, and classifications 2007–2008. Philadelphia: NANDA-I.
2007). Pfeiffer, E., Johnson, T., & Chiofolo, R. (1981). Functional assessment
American Academy of Pediatrics (AAP) Policy Statement. (1998, 2004). of elderly subjects in four service settings. Journal of American Geri-
Guidance for effective discipline. Pediatrics, 101 (4), 723–728. atrics Society, 29, 433–347.
Retrieved from http://www.aap.org/ (Accessed May 16, 2008). Piaget, J. (1969). The moral judgment of the child. New York: Free Press.
Bowlby, J. (1978). Attachment and loss. Harmondsworth: Penguin Piaget, J., & Inhelder, B. (1969). The psychology of the child. New York:
Education. Basic Books.
Brazelton, T.B. (1992). Touchpoints: Emotional and behavioral develop- Thomas, A., & Chess, S. (1977). Temperament and development. New
ment. Reading, MA: Addison–Wesley. York: Brunner/Mazel.
Brazelton, T.B., & Sparrow, J. (2002). Touchpoints: 3–6: Your child’s Thomas, A., Chess, S., & Birch, H. G. (1968). Temperament and behavior
emotional and behavioral development. Cambridge, MA: Perseus. disorders in children. New York: New York University Press.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, Zero To Three Brainwonders (n.d.). Brain development: Frequently asked
MA: Harvard University Press. questions Retrieved from http://www.zerotothree.org/brainwonders/
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven- FAQ–body.html (Accessed May 16, 2008).
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
CONCEPT MAP
Nursing Insight:
• Duvall’s theory: only Be Sure To:
speaks to traditional • include the adolescent
family group Optimizing Outcomes: in the informed concert
• Anticipate developmental process
transition points
Clinical Alert:
• Reflexes
• Remember privacy for school age
child due to physical changes
Complementary Care:
• Care delivery
enhanced by
Now Can You: understanding
Family Teaching Guidelines: • Identify the importance of using growth Fowler’s 7 stages
• Introducing solid foods and development theories as the basis of faith and spiritual
for care of children and families development
chapter
Caring for the Child
21 in the Hospital and
in the Community
It is when we include caring and love in our science,
we discover our caring-healing professions and disciplines
are much more than a detached scientific endeavor,
but a life-giving and life-receiving endeavor for humanity.”
—Jean Watson (from Caring Science as Sacred Science, p. 3)
L EA R NIN G T AR G E T S At the completion of this chapter, the student will be able to:
◆ Discuss how to gather the history of the child and family.
◆ Discuss the physical assessment of an infant, toddler, pre-schooler, school-aged child and
adolescent, as well as resources available for families.
◆ Identify general care measures for the child in the hospital or clinic setting.
◆ Examine ways to prevent injuries in children.
◆ Identify common procedures for the child in the hospital or clinic setting.
◆ Explore the common practices when medicating the child.
◆ Discuss the child in pain.
◆ Identify the needs of the child in the family who is living with disabilities.
moving toward evidence-based practice Parent Satisfaction with Care of Developmentally Disabled Children
Liptak, G.S., Orlando, M., Yingling, J.T., Theurer-Kaufman, K.L., Malay, D.P., Tompkins, L.A., & Flynn, J.R. (2006). Satisfaction with primary
health care received by families of children with developmental disabilities. Journal of Pediatric Health Care, 20(4), 245–252.
The purpose of this study was to examine the perceptions of The MAPS was described as a valid tool for measuring satis-
families who had children with developmental disabilities in faction with provider care in five areas: coordination of care,
relation to care and differences based on a specific condition. family-centered care, developmentally appropriate care, and
The sample included patients and their families who received interpersonal and technical competence of the provider. The
services through a developmental center at a children’s hospital MAPS has been shown to have a standardized alpha coefficient
in New York. This center provided care to children with both (a measure of internal consistency) of 0.87. The Pearson correla-
physical and developmental disabilities, such as spina bifida, tion coefficient ranged from 0.85 to 0.91 in terms of validity
cerebral palsy, autism, and mental retardation. between the satisfaction scale and the mean score of the three
Three hundred potential participants with the aforemen- items used in the study. Seven general questions regarding
tioned four conditions were identified through the hospital health care, including baseline attitudes toward providers in
database and received mailed surveys; responses were returned general, were added. The questions measured the attitudes
from 121 families. The survey consisted of three parts: demo- toward physicians in primary care as described by Hulka, Zyzan-
graphic information, the Multidimensional Assessment of Paren- ski, Cassel, and Thompson (1970). Data from the MAPS were
tal Satisfaction for Children with Special Needs (MAPS) devel- scored using the method established by Ireys and Perry (1999),
oped by Ireys and Perry (1999), and general questions regarding i.e., those answering fair or poor were combined into one group
health care. (continued)
664
chapter 21 Caring for the Child in the Hospital and in the Community 665
Young children need to feel secure before engaging in After the chief complaint is determined, the child’s past
conversation with the nurse. In this instance, the nurse medical history is reviewed. This includes past acute ill-
should establish a rapport with the parent first. Once the nesses and history of chronic illnesses, immunization his-
child feels comfortable with the nurse present, the child tory, hospitalizations, emergency room visits, serious
may be more apt to contribute to the interview process. injuries, operations, and current medication usage. Inqui-
The child may be able to add an important piece of infor- ries are made as to the use of any over-the-counter medi-
mation needed for optimum care. cations, herbal preparations, or folk remedies, as well as
The older child may elect to be interviewed without the any history of allergic reactions to food, medications, and
parent in the room. In this case, the nurse should speak environmental allergens. Information regarding reactions
with the parent separately to determine if the child has experienced by the child to a reported allergen is noted on
specific concerns or issues that may need to be addressed the patient’s chart.
during the visit. The impact of the current illness is evaluated by inquir-
With the preadolescent and adolescent, the nurse may ing about the child’s daily activities, using the mnemonic
ask the parent to leave the room during the discussion of SODA to ask the appropriate questions:
issues related to social and sexual content. The older child
Sleep: “How has your child been sleeping?”
needs to know that a discussion can take place without
Output: “How many times per day do you _________?”
the parent’s knowledge. In this way, appropriate medical
(Use the expression the family has adopted to convey
and nursing care can be given to ensure the safety of the
urine/stool output). Or, for the younger child ask, “How
child. Exceptions to maintaining confidentiality involve
many wet diapers has he had today?”
situations concerning abuse or life-threatening situation.
Diet: “How much fluid has your child taken in today?”
“Has the illness affected the child’s appetite or diet?”
Ethnocultural Considerations— Avoiding Activity: “Has the child’s activity level changed since he
stereotyping has been ill?”
Stereotyping an individual or family based on a specific racial or Interviews are commonly concluded by asking if the
cultural background, or assuming that all members of a particu- parents have any other concerns or problems they would
lar culture subscribe to the traditions, beliefs, and customs like to discuss.
associated with that culture, must be avoided. Length of time in
the country, level of education, level of acculturation, and eco- COMPREHENSIVE HEALTH HISTORY
nomic status all affect the degree to which the culture shapes
the parent’s approach to health care (Salimbene, 2005). When a child is seen for a well-child visit, a comprehen-
sive health history is necessary. Components of a child’s
health history include family medical and social history,
immunizations, past medical history, developmental mile-
ASKING QUESTIONS stones achieved, patterns of daily activities, and a review
of systems.
The interview is conducted in a comfortable room with
available seating for the parent, and with eye-level interac- Family Medical and Social History
tion with both the parent and the child. An unhurried
The family medical and social history includes document-
environment encourages the parent to ask questions appro-
ing the current household make-up as well as the age and
priate to the health of the child. The nurse projects a genu-
health of each family member. Document the following:
ine interest in and a desire to help the child and family. This
lays the foundation for a positive therapeutic relationship. • Ages and cause of death of any deceased parents,
Beginning with open-ended questions allows for con- grandparents, and siblings
cerns to be explored, as the nurse invites the child or par- • Chronic illnesses experienced by family members
ent to tell his story by asking, “How can I help you today?” • Inherited diseases
or, for a problem-oriented visit, “What made you come in • Parents’ professions, religious affiliations or spiritual
today?” (Bickley & Szilagyi, 2007). This type of question beliefs, and family activities
allows the parent to recount the history of the present • For the older child, interviewed without the presence
condition, also known as the chief complaint. A focused or of the parent, the social history must also include
problem-oriented health history is then obtained. information regarding grade level, friendships, drug or
When clarifying the child’s history, the nurse may use alcohol use, smoking, sexual activity, and safe sex
the mnemonic OLD CAT (Bickley & Szilagyi, 2007, p. 31) practices
to ask the appropriate questions:
Onset: “When did the child become ill?” Past Medical History
Location: “Where is the pain?” A thorough birth history can provide valuable informa-
Duration: “How long does the pain last?” tion about the health status of a younger child. The his-
Character: “Can you tell me on a scale of 1 to 10 how bad tory of the pregnancy, labor and delivery, and the health
it is?” Or, for a younger child, parent, “How much pain do of the baby at birth are documented, including the birth
you think the child is experiencing?” weight and APGAR scores, if available. In addition, any
Aggravating/Alleviating: “What has made the pain better difficulties with feeding, breathing, jaundice, or other
or worse?” medical problems in the early neonatal period must be
Timing: “When does the pain start/stop?” documented.
chapter 21 Caring for the Child in the Hospital and in the Community 667
Balances on alternate feet with eyes closed Uses fork, spoon and knife with
supervision
Colors, prints letters
Mostly independent toileting
School-age: Gradual increase in dexterity and becomes Good eye–hand coordination 20/20 Visual acuity
6–12 Years limber
Balance improves Color discrimination fully
Improves coordination and balance, rhythm developed
Can sew, draw, make arts and
Climbs, bikes, skips, jumps rope and swings crafts, build models, play video Mature sense of smell
games
Learns to swim, dance, do somersaults and Hearing deficits may be discovered
skate Prints and writes as language develops
Likes activities that promote Language: Accelerated, vocabulary
dexterity such as playing a musical expands to 8000–15,000 words
instrument
Play: Cooperative play (play with
peers), solitary activities and active
play (e.g., dance or karate)
Continued
670 unit six Caring for the Child and Family
Patterns of Daily Activities the amount and type of milk, juices, and all other liquids.
SLEEP In addition, the nurse must document food allergies for
The nurse must determine both the number of hours and all children. Analysis of the food intake is compared
the quality of sleep the child receives each night. Sleep to the foods suggested in the Food Guide Pyramid for
requirements change as the child grows and each child’s Young Children. (Go to http://www.mypyramid.gov/kids/
sleep requirements are different. Newborns sleep about index.html.)
16 or 17 hours a day, typically in stretches of 2 to 3 hours PLAY, ACTIVITIES, AND SCHOOLWORK
at a time. Babies are typically able to sleep through the Patterns of play and children’s activities reflect the inter-
night by age 6 months (http://www.mayoclinic.com/). ests of the child, the family financial circumstances, and
Children also differ in their ability to sleep. Some can work schedules of the parents, environmental safety, and
sleep anywhere under any conditions while others suffer the availability of after-school activities. Throughout
sleepless nights if there is even the slightest change in infancy, learning takes place in the context of sensory
their normal routine. Naps may be a part of a child’s life stimulation. The parent can provide insight into whether
up to the preschool years. Children may experience night- there is sufficient stimulation in the immediate environ-
mares or night terrors that can disrupt sleep. Nightmares ment to help the child learn. For example, talking and
may reflect the struggles children experience during the singing adds auditory stimulation. Holding, cuddling, and
day, or the fears a child has regarding separation, impulses, consoling the infant provides the tactile sensory stimula-
or conflicts. Night terrors occur during the first few hours tion for developing a sense of trust and facilitates the bond-
of sleep. Nightmares and night terrors can be frightening ing process.
experiences for a child; a child can recount her night- As the child matures, continued supervision of the
mares. However, with night terrors the child has no child’s activities is needed to encourage social competence
recollection. and healthy habits. Information is gathered about the daily
NUTRITION routine of the child, the contact the child has with play-
The questions a nurse asks regarding nutrition are based mates, older siblings, and adults, and whether the child
on the child’s age. If the infant is breastfed, information is has an opportunity to develop gross and fine motor skills
gathered as to how often and for how long the child is fed or has attended community programs such as Head
at each feeding, and how many wet diapers are changed in Start. For school age children, additional information is
the course of one day. With sufficient breast milk intake, gathered regarding achievement with schoolwork, special
the infant will have six or more wet diapers and gain education needs, extracurricular activities, and interaction
weight. Newborns often lose 10% of their birth weight. with peers.
This weight loss is usually by the 12th day of life (Wright A good understanding of the patterns of daily activities
& Parkinson, 2004). allows the nurse to make suggestions for a healthy life-
For the infant who is receiving formula, information is style to the parent or child, alert the primary care provider
gathered as to the type of formula, the amount taken at of potential problems, and provide anticipatory guidance
each feeding, and the number of feedings per day. It is also as appropriate to the situation.
important to note if and when juices or solid foods have
been started, and whether supplements or vitamins have REVIEW OF SYSTEMS
been prescribed. Much like the physical examination, the review of systems
When assessing children and adolescents, a 24-hour is best conducted with a “head-to-toe” approach, starting
recall elicits the food items eaten in a typical day and with a general question regarding each body system. It can
reflects sociocultural trends. The nurse can document also be conducted by asking questions during the physical
chapter 21 Caring for the Child in the Hospital and in the Community 671
N u r s i n g C a r e P l a n Imbalanced Nutrition
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake
Measurable Short-term Goal: Child will ingest adequate nutrients
Measurable Long-term Goal: Child will demonstrate appropriate growth for age on normal curve
NOC Outcomes: NIC Interventions:
Appetite (1014) Desire to eat when ill or receiving Nutrition Therapy (1120)
treatment Nutritional Monitoring (1160)
Nutritional Status (1004) Extent to which nutrients Nutrition Management (1100)
are available to meet metabolic needs
Nursing Interventions:
1. Monitor weight daily on same scale and at same time during hospitalization and at every encounter in
community-based care.
RATIONALE: Monitoring assists in early identification and correction of nutritional deficiencies to prevent
complications from malnutrition.
2. Provide favorite high-protein, high-calorie, nutritious foods and drinks in small frequent meals (specify for child).
RATIONALE: Child is more likely to eat familiar foods and small frequent meals may be better tolerated during
illness.
3. Ensure that mealtime is pleasant and uninterrupted. Be sure to schedule treatment and procedures at times
other than feeding time. Do not mix medications in food offered during mealtimes.
RATIONALE: Child may refuse to eat essential foods if they have been associated with unpleasant activities,
smells, or tastes.
4. Encourage additional nutritious, high-calorie snacks as tolerated by child (e.g., milkshakes, string cheese)
RATIONALE: Supplemental nutrition may provide the additional calories and nutrients via the preferred oral route.
5. Initiate oro- or nasogastric supplementation as appropriate
RATIONALE: The ill child may be unable to ingest adequate calories and nutrients orally.
examination. The review of systems includes the follow- menarche, date of last menstrual period, dysmenor-
ing areas: rhea, and date of last Pap smear (if appropriate)
• Musculoskeletal: injuries, fractures, weakness, clumsi-
• General: usual weight, change in weight, weakness,
ness, gait, muscle pains
fatigue, fever or allergies
• Neurological: seizures, tics, psychiatric diseases,
• Skin: rashes, pruritus, turgor, changes in color, indica-
anxiety, depression
tions of injury, acne, changes in nails or hair
• Endocrine: history or symptoms of thyroid disease or
• Head, Eyes, Ears, Nose, Throat (HEENT): injury to
diabetes or diseases that affect normal growth.
head, headaches, dizziness; eye infections, itching or
watering eyes, behaviors indicating change in visual
acuity, use of glasses, date of last eye exam; ear infec- Nursing Insight— Family dynamics
tions, behaviors indicating change in hearing; nose
bleeds, colds, hay fever, sinus infections; sore throats, Family dynamics are assessed by observing the behaviors
tonsils, dentition, caries between the child and his parent.
• Neck: neck pain, enlarged lymph glands, neck range Questions to consider:
of motion • During a health care visit, does the parent or caregiver seem
• Chest: respiratory infections, asthma, chronic cough, sufficiently concerned about the problem? Or, does the parent
wheezing, shortness of breath, breast changes or caregiver seem overly concerned about the problem?
• Cardiovascular: heart murmur, palpitations, date of • Does the parent or caregiver have the information that a
last blood work responsible parent would know regarding the child’s
• Gastrointestinal: regurgitation, vomiting, changes in illness, past medical history and immunizations? Is the
bowel habits, constipation, diarrhea, food intolerance, parent or caregiver a reliable historian?
abdominal pain, changes in appetite or eating pattern • Is the parent or caregiver providing comfort to the child if
• Genitourinary: General—dysuria, urgency, odor to the child is frightened?
urine, date of last urinalysis, signs of puberty, urethral • Does the parent or caregiver appear angry about being in
or vaginal discharge, presence of lesions, sexual habits, the office?
contraceptive use, and symptoms or history of sexu- • Is the parent or caregiver aware of the needs of the child?
ally transmitted infections; males—changes in groin/ • Does the child look well cared for?
scrotum/glans, presence of circumcision; females—
672 unit six Caring for the Child and Family
Now Can You— Discuss the health history for the child? diagnostic tools Body Mass Index (BMI)
1. State the major components of a thorough health history
A BMI-for-age plotted below the 5th percentile indicates a child who is
for the child? underweight; a BMI-for-age between the 5th and 85th percentile is consid-
2. Ask salient questions about the child’s health? ered a healthy weight; children with a BMI-for-age between the 85th and
95th percentile are considered at risk for obesity; and those with a BMI-for-
age 95% are considered obese.
Health Assessment
assessment tools Body Mass Index (BMI)
When examining children, the approach to the physical
The BMI-for-age is calculated by dividing the weight in kilograms by the
assessment is based on the child’s age, cognitive level, and meter height squared. However, since most health care providers obtain
degree of illness. Infants can be examined from head to height in centimeters, an alternative calculation is to divide the weight in
toe without difficulty. Some children are fearful of any kilograms by the centimeter height squared multiplied by 10,000. For exam-
examiner and are uncooperative. Others seem to enjoy the ple, the BMI for an 8-year-old boy who weighs 26 kg with a height of
experience as something new. As a guideline, an exam 135 cm is calculated as follows: 26 divided by 1352 (18,225) 10,000
starts with the least invasive actions and concludes with 14.26. A BMI of 14.26 plots on the growth chart between the 10th and
the most distressful actions. For example, it is easier to 25th percentile, which is a healthy weight. The nurse can help the family cal-
examine the posterior lung fields with the caregiver hold- culate their child’s BMI by accessing the CDC Web site. This Web site has a
ing the child on her lap early in the exam while leaving BMI Percentile Calculator for the Child and the Teen: http://apps.nccd.cdc.
gov/dnpabmi/Calculator.aspx.
the examination of the ears and mouth for the end of the
exam (see Chapter 18 for assessment of the newborn).
Head Circumference
ANTHROPOMETRIC MEASUREMENTS For children 2 years of age and younger, head circum-
Before the physical assessment, vital signs and growth ference measurements are done at routine well-child
measurements of length, weight, head circumference. and visits. The head’s largest circumference is measured by
skinfold thickness are taken and recorded. Growth charts placing the tape over the lower forehead, above the
from the National Center for Health Statistics (NCHS) pinna of the ears, and over the occipital prominence
were revised in 2000 to include body mass index-for-age (Fig. 21-1). This measurement is recorded in centime-
(BMI-for-age) (see Chapter 18). These growth charts can ters and displayed as a percentile. As with weight and
be found at http://www.cdc.gov/nchs/about/major/nhanes/ height, evidence of growth within the percentiles
growthcharts/charts.htm. remains consistent over time, with normal values accord-
ing to age and gender reflecting normal development.
Length When there is a deviation, either below or above the
Length is measured in the infant while he is lying supine percentile from the previous visit, it may signify a
on a measuring tray or board. If a measuring board is not potential problem. The nurse informs the primary care
available, the nurse holds the head in midline while an provider of these findings
assistant holds the hips and knees extended flat on a
Skinfold Thickness Measurements
paper-covered table. Points are marked at the top of the
head and the heels of the feet, the child is moved, and the Skinfold thickness measurements indicate the degree of
distance between markings is measured. For the older adipose tissue or body fat. In addition to calculating and
child a stadiometer is used to obtain a standing height. plotting the BMI once yearly, as recommended by the
The child removes his shoes and stands with his back to American Academy of Pediatrics (AAP, 2003), skinfold
the stadiometer, with the back of the heels and shoulders thickness measurements can add to the objective assess-
touching the wall. ment of obesity in children and adolescents who are at
risk. The nurse might measure the degree of skinfold
Weight thickness in the tricep or abdominal areas. The average of
The weight of an infant is measured using an infant scale two consecutive readings is used as the skinfold thickness
lined with a thin paper cover. After the scale setting is measurement. The reliability of the skin fold measure-
balanced, the infant’s clothing is removed and the child ment is entirely dependent on correct measurement
is weighed in either a supine or sitting position. The technique.
nurse protects the child from an accidental fall by plac-
ing a hand over the infant without direct contact. Older
children are weighed on a standing scale. The same
scales should be used to measure height and weight at
each visit.
up. Once released, the skin should quickly return to its develop due to the malleability of the skull bones. The supine
normal position. Skin that remains in the “tenting” posi- sleep position has greatly reduced the incidence of sudden
tion for several seconds indicates absence or presence of infant death syndrome (SIDS). However, infants who are
skin turgor and inadequate hydration. placed in the recommended supine position for sleep are at
If a rash is present or if jaundice is suspected, the nurse increased risk for deformational posterior plagiocephaly, or
determines if the skin blanches or turns pale. The nurse flattening, of the occiput (Nield & Kamat, 2006). Head repo-
applies pressure to the skin with the thumbs about 1 to sitioning techniques, especially during play times, may be
2 inches apart. This presses the normal pink and darker useful when the first signs of plagiocephaly occur (Persing,
colors out. In the presence of jaundice, there is a yellowish James, Swanson, & Kattwinkel, 2003).
underlying color. Petechial lesions do not blanch, which The skull is palpated to evaluate fontanels, sutures,
may indicate a serious bacterial infection in an ill child. contusions, or other swellings. Fontanels are fibrous-
The primary health care provider should be notified membrane-covered areas where two or more skull bones
immediately. converge. Although there are six fontanels, the two most
The skin examination concludes with the inspection commonly evaluated are the posterior and anterior fonta-
and documentation of the texture of the hair and the con- nels. The posterior fontanel closes within 1 to 3 months
dition of the scalp, palms, and nails. Cradle cap is most after birth, while the diamond-shaped anterior fontanel
common in newborns and is identified by thick, crusty remains open until 12 to 18 months of age.
scales over the scalp. The older child is monitored for lice The anterior fontanel is the most significant fontanel
or ticks. for evaluation (Fig. 21-3). The average width is 2.1 cm
Normal nails are pink and convex, with white edges (Kreisler & Ricter, 2003). A larger fontanel or one with
extending over the end of the fingers. In children with a delayed closure may signify an infant with hypothyroid-
cardiac disease, nails are examined for evidence of club- ism, Down syndrome, achondroplasia (congenital dwarf-
bing. Nail biting is a nervous habit that is evidenced by ism) or increased intracranial pressure. Assess the fonta-
very short nails without the normal white edges. nels when the infant is held in a sitting position. Depression
The palms are examined for the normal flexion creases. of the fontanel may be indicative of dehydration, fullness
Normally there are three creases. In a small section of the of the fontanel a potential sign of increased intracranial
population, the two horizontal creases fuse to form a sin- pressure.
gle horizontal palmar crease. This is a common finding in The face is examined for general appearance and the
many genetic disorders, particularly Down syndrome. If comparison of features to those of the parents. Unusual
this palmar crease is evident on only one hand, the child features are noted, such as a micrognathia (shortened
may have no genetic disorders. chin), low-set ears, flattened nasal bridge, enlarged or
protruding tongue, allergic shiners (dark, under-eye rings)
Ethnocultural Considerations— Skin or a wide and flattened philtrum (the vertical groove from
assessment the bottom of the nose to the upper lip).
Postauricular
Preauricular
Anterior Occipital
fontanel Posterior Parotid
fontanel
Posterior
Sublingual cervical
Submaxillary
Anterior cervical
Supraclavicular
Figure 21-3 Anterior and posterior fontanels. Figure 21-4 Lymph nodes of the head and neck.
chapter 21 Caring for the Child in the Hospital and in the Community 675
common for young children to have palpable, painless, TESTING FOR OCULAR ALIGNMENT. A common method for
movable nodes up to 1 cm in diameter. Pain upon palpa- assessing ocular alignment is the Hirschberg corneal light
tion may be indicative of an upper airway infection. The reflex test, in which a light is shone directly into the
trachea is palpated for midline placement and masses. A child’s eyes and note is taken of the position of the corneal
lateral deviation of the trachea may be due to a mass or a light reflection in both eyes. The reflection should fall in
collapsed lung. The thyroid gland is examined for enlarge- the same location on the cornea of each eye. Displacement
ment, nodules, and goiters. of the corneal light reflection in one eye is indicative of
strabismus.
Eye Assessment The second screening test is the cover–uncover test, in
Observation of the eyes includes assessment of symme- which the child is asked to focus on a distant object
try, shape, and placement in relation to the nose. In across the room. The nurse covers the first eye while
addition, the nurse can assess for symmetry and size of watching the second eye for any movement. The cover is
the pupils and their response to light. The conjunctiva then removed from the first eye, which is observed for
and lids are observed for conjunctivitis, styes, or chalazi- any movement. If no movement is detected, ocular align-
ons (small discrete swellings of the upper lid that ment is intact. The examination is repeated on the oppo-
develop when a meibomian oil gland becomes blocked). site eye.
The sclerae are inspected for color. The nurse notes The red reflex is tested by viewing the pupil through an
erythema, swelling, or discharge from the eye. Docu- ophthalmoscope from a distance of ten inches. If the pupil
mentation of the presence of discharge includes type appears red, the finding is normal. A white retinal reflex
(watery, purulent), color, amount, and associated symp- may indicate cataracts, retinoblastoma, or chorioretinitis.
toms. Treatment depends on the cause, which may be
TESTING FOR COLOR BLINDNESS. Children should be
bacterial, viral, or an allergen.
screened at least once during the school-age years for the
ability to discriminate between red, yellow, and green. A
assessment tools Visual Acuity common method for detecting color blindness is the use
of the Ishihara pseudochromatic charts. Each chart con-
Visual screening for children can begin at the age of 2 ½ years. There are sists of a field of colored dots, each with a number in the
a variety of charts that will assist in the assessment of visual acuity. center of the colored field: the inability to identify these
Visual acuity for each eye is assessed by occluding the contralateral eye numbers indicates color blindness.
with a plastic paddle. With all charts the objects, letters and numbers
decrease in size. The Allen chart requires the child to identify common
Ear Assessment
objects; the “tumbling E” requires the child to identify in which direction
each E is facing; and the Snellen charts require the child to identify letters The external ears are examined for size, shape, placement,
or numbers. pain, and presence of drainage from the ear canal. The
pinna of the ear should be above the imaginary horizontal
line drawn from the medial and lateral canthi toward the
occiput. Low-set ears may indicate a congenital anomaly
such as Down syndrome. To assess for pain, the nurse
moves the pinna of the ear up and down. If the child com-
plains of pain when pressure is applied to the tragus, the
canal is examined for evidence of otitis externa. Cerumen
(ear wax) may be seen on the external ear or in the exter-
nal canal with an otoscope. Purulent drainage may indi-
cate a foreign body in the external ear canal or a ruptured
tympanic membrane. Any clear drainage noted from the
ear, particularly after head trauma or with cranial infec-
tions, should be reported to the health care provider
immediately as this fluid may indicate a cerebrospinal
fluid leak.
To ensure optimal eye health in children, testing for — Use of a small cotton swab to
ocular alignment and visual acuity is essential (Bickley clean the ear
& Szilagyi, 2007). Assessment of visual acuity depends The nurse can instruct parents on the use of a small
on the age of the child. Infants begin to use a steady cotton swab to clean the ear. A small cotton swab should
gaze to regard faces or objects with interesting be used to clean only the external ear, and not the ear
patterns. The nurse observes for and documents this canal. When a small cotton swab is used in the ear canal,
finding during the physical exam. Any difference in the cerumen is pushed back into the canal where it
visual acuity between one eye and the other is abnor- cannot be moved out by the mechanical action of the
mal and should be referred. In addition, children tiny ear hairs. Cerumen tends to dry, harden, and
are referred for further evaluation if they have a visual become difficult to remove over time. Impacted cerumen
acuity reading of less than 20/50 or after failing a in the ear canal may lead to hearing deficits.
second screening.
676 unit six Caring for the Child and Family
When an otoscope is used, the canal should be posi- Tympanometry assesses the status of the middle ear.
tioned for the optimal viewing of the tympanic membrane The nurse places a probe into the ear canal. The amount
and canal. As a general rule, the pinna is pulled down and of sound that is reflected by the tympanic membrane is
back for children younger than 3 years, and up and back measured along with the pressure in the canal. The tym-
for older children. The child is positioned to prevent panogram delineates the movement of the eardrum as
injury or discomfort. With the parent’s help to gently stiffness, floppiness, or normal eardrum movement.
restrain the child from moving, the otoscopic examination Early detection of hearing loss is important to prevent
can take place either with the child either sitting on the delayed hearing, speech, and language development
parent’s lap or in the supine position. The nurse under- (Box 21-1). Hearing loss may affect both the academic
stands that holding the otoscope upside down allows the success and psychosocial development of the child.
nurse the use of one hand to help hold the child’s head Since hearing loss in childhood is associated with middle
and the other to position the stem of the otoscope against ear disease, it is recommended that children with posi-
the child’s head for more stability. The tympanic mem- tive results from office screening exams be referred to an
brane is examined for the presence of normal anatomical audiologist for further evaluation and treatment.
landmarks (Fig. 21-5).
Visual loss of these landmarks may be due to ery-
thema, fullness behind the tympanic membrane, inflam- Nursing Insight— Screening techniques for
mation, purulent exudate, or fluid. Due to the anatomic children
structure of their ears, infants and young children are
Screening tests require cooperation of the child. Hearing
prone to developing otitis media. The eustachian tubes screening should be performed before any injections, vaccines,
are shorter and more horizontally positioned, enabling or laboratory work. With testing, the nurse assesses for fre-
viruses and bacteria to travel to the middle ear. Infants quency (pitch) and the decibel level (loudness). Frequency is
who are breastfed, do not attend daycare, and are fed in defined as the number of vibrations a sound creates per second.
an upright position have decreased rates of otitis media. As the frequency increases, the pitch of the sound also increases.
HEARING SCREENING. The frequency range is 250–6000. For a normal finding, the
In the older cooperative child, a tuning fork is utilized to child should hear at all frequencies at the 20-dB range.
assess bone and air conduction of sound. The Weber test Conditioned play audiometry (CPA) is a common test for
involves striking the tines of the tuning fork and immediately children older than 3 years. In this test, the child is asked to
placing the handle of the tuning fork midline on top of the engage in a play-oriented activity, like placing a colorful block
child’s head. The nurse asks the child in which ear he hears in a box each time a sound is heard. The child is subjected to
the sound best. If hearing is normal, sound is heard equally sounds of different frequencies that a child with normal hear-
in both ears. Sound heard in one ear better than the other ing could hear.
indicates a conductive hearing loss. A conventional audiogram assesses hearing acuity by ask-
The Rinne test assesses both air and bone conduction ing the child to raise her hand or press a button each time a
of sound. Bone conduction is tested by placing the handle sound is heard. The child must be able to understand the lan-
of the vibrating tuning fork on the mastoid process behind guage spoken, be able to follow directions, pay attention, and
the ear. The child informs the nurse when he no longer wait to listen to the sounds.
can hear the sound of the vibrating tuning fork and the
nurse immediately moves the tines forward to within 1 to
2 inches of the auditory meatus. The child should hear the
air-conducted sound of the vibrating tines twice as long as Optimizing Outcomes— Hearing screening
he heard the bone-conducted sound. Children should be screened for hearing loss as needed. A
hearing impairment may interfere with normal psychoso-
cial development, communication among friends, and
educational pursuits. The best outcome to detect hearing
loss includes periodic screenings because of the increased
potential for hearing loss due to overexposure to high lev-
els of noise associated with yard work, listening to music
at concerts and via earphones, and through chronic ear
infections, ototoxic drugs, head injuries, including abuse,
Malleus or diseases.
Tympanic Umbo
membrane
Box 21-1 Risk Factors for Hearing Loss in Preschoolers
Cone of
light • Family history of childhood hearing loss.
• Parental concerns regarding hearing, speech, or language development.
• Prior infections with meningitis, mumps or otitis media.
• Head trauma.
Figure 21-5 Tympanic membrane landmarks.
chapter 21 Caring for the Child in the Hospital and in the Community 677
Inspection Skin color, shape and Pink, symmetrical chest Pallor, cyanosis, asymmetry Poor cardiac output.
symmetry of chest, clubbing of chest shape and Deoxygenated circulating blood,
movement, hyperdynamic Ventricular failure or
precordium hypertrophy, tachycardia
Palpation Skin and body temperature, Warm, dry, symmetrical Cold extremities, dry flaky Poor circulation, heart failure,
moisture, chest movement, movement, PMI at 4th or skin, diaphoresis. Thrills or ventricular hypertrophy
point of maximal impulse (PMI) 5th ICS at midclavicular line heaves.
Percussion Heart shape and size Normal size and shape for Enlarged heart, axis Heart failure and hypertrophy
age and weight deviation
Auscultation Murmurs, other sounds No murmurs, innocent Murmurs, clicks, rubs, Structural defects, increased
murmurs. Quiet precordium snaps. workload of heart and volume
overload
right after the S2. It is called a ventricular gallop and, due and its contour, which may be flat, round, protuberant, or
to the cadence of the rhythm, sounds like the word “Ken- scaphoid (shaped like a boat). Visible peristalsis may be
tucky.” Although an S3 is most likely a finding not associ- noted in a thin child, and should be documented and
ated with heart disease, the finding should be documented reported. The umbilicus and inguinal areas are inspected
and reported. S4, heard in late diastole, is heard only in for bulging, and note is made of any scars, rashes, and
children who have congenital heart disease such as pulmo- lesions or piercings.
nary hypertension and pulmonic stenosis. It is never a The abdomen is divided into four quadrants: right
normal finding and must be reported to the primary health upper quadrant (RUQ), left upper quadrant (LUQ), right
care provider. The sound is sometimes compared to the lower quadrant (RLQ), and left lower quadrant (LLQ)
word “Tennessee.” (Fig. 21-7). The terms epigastric, umbilical, periumbilical,
Murmurs are attributed to turbulent blood flow within and suprapubic can also be used to describe symptoms
the vessels. The nurse assesses for intensity, location, and physical findings that are specific to these areas. The
radiation, timing, and quality. Innocent murmurs are sys- nurse must listen for up to 1 minute before determining
tolic, musical, or vibratory and of low intensity. The Still’s the absence of bowel sounds in any one quadrant.
murmur is the most common murmur and is located over After inspection, the abdomen is auscultated in all four
the mid or lower left sternal border. This murmur may be quadrants to assess for bowel motility. These high-pitched
heard in well children, those with fever, after exercise, or sounds occur every 5 to 10 seconds, so it is important for the
in children with anemia when cardiac output is increased. nurse to allow enough time to adequately assess frequency
A venous hum is a continuous soft, hollow sound that and character of the bowel sounds. The absence of bowel
disappears when the child is supine. Diastolic murmurs sounds or high-pitched tinkles in the presence of abdominal
usually indicate pathology. distention and/or peritoneal signs suggest an acute abdomi-
nal condition. A child who is experiencing signs of a bowel
Abdominal Assessment obstruction has absent bowel sounds below the obstruction.
The child should lie quietly in the supine position. The
assessment begins with an inspection of the abdomen
Diaphragm
RUQ LUQ
Transverse colon Transverse colon
Clavicle Ascending colon Descending colon
Liver Pancreas
Gallbladder Spleen
Pancreas Left kidney
Aortic Right kidney
Pulmonary valve
valve
1 2
Tricuspid
valve RLQ LLQ
3 4 Colon Descending colon
Sternum Mitral valve Appendix Sigmoid colon
Uterus
Rectum Left ovary and
Right ovary and Bladder fallopian tube
fallopian tube
Palpation of the abdomen occurs last so as not to reported to the primary health care provider for further
disrupt bowel sounds. Palpation is divided into light evaluation and separation of the labia minora. A malodorous
palpation and deep palpation. Light palpation assists in vaginal discharge may indicate the presence of a foreign
identifying abdominal tenderness. Deep palpation is use- body, especially in young children, or an infection. In the
ful when assessing for the liver, kidneys, spleen, inguinal neonate, the labia majora is often under developed and does
lymph nodes, and abnormal masses. If a mass is encoun- not cover the labia minora. This is even more pronounced
tered, it is reported, noting its location, size, shape, con- in the premature. Vaginal exams in young children need to
sistency, and tenderness. Throughout the abdominal be completed by trained examiners. The American Academy
assessment, the nurse observes for changes in facial of Pediatrics recommends the first annual pelvic exam
expression, guarding, and tensing of the abdominal between the ages of 18 and 21 or when the girl becomes
muscles. sexually active, regardless of age (AAP, 2007).
MALE GENITALIA. The penis is inspected for size, presence
Nursing Insight— Palpation of the abdomen of foreskin, placement of the urinary meatus, and signs of
inflammation and infections. The penis should be straight,
To minimize the sensation of tickling during palpation of the glans clean and smooth, and the slit-shaped urinary
the abdomen the nurse may palpate through a layer of light meatus near the end of the glans.
clothing or place the child’s hand on top of the nurse’s hand
while palpating. To relax the abdominal muscles, bend the
child’s knees until feet are flat on the exam table. Palpate any Nursing Insight— Uncircumcised Males
tender or painful areas last. The suprapubic area may feel ten-
The foreskin of uncircumcised males should not be forci-
der if the child’s bladder if full. Consider having the child
bly retracted until after 1 year of age. After 1 year of age, geni-
empty their bladder before the abdominal assessment.
tal retraction and subsequently replacing the foreskin to its
neutral position is possible.
Breast Slight to no Breast buds appear; Entire breast enlarged with Enlargement of the entire Mature breast with
Development in elevation of areolar widening with no protrusion of the papilla breast with formation of protrusion of nipple
Females papilla slight elevation or nipple secondary mound of only. No protrusion of
areola and papilla the papilla
Pubic Hair None Sparse, lightly Darker and increasing Coarse, thicker, curly. Adult female triangle
Development in pigmented, straight amount on labia and pubis. Increasing amount, less with extension of hair
Females along border of labia Distribution in typical than adult. onto medial thighs
female inverted triangle
Pubic Hair and No pubic Scant, long, slightly Pubic hair darker, starting Pubic hair is coarse, Adult distribution of
Genital hair. pigmented pubic hair. to curl and extends across curly, less quantity than pubic hair with
Development in Preadolescent Slight enlargement of pubis. Scrotum and testes adult. Scrotum is darker; extension to medial
Males genitalia scrotum and testes; continue to enlarge. Penis penis increases in length thighs; genitalia adult
scrotum reddens and becomes longer and and breadth. Glans is in size and shape
becomes more slightly wider broader.
textured
Adapted from Tanner, J.M. (1962). Growth at adolescence (2nd ed.). Oxford: Blackwell Scientific.
chapter 21 Caring for the Child in the Hospital and in the Community 681
decreased with the removal of sources of lead in gasoline, intravenous drug users. Other risk factors include living
lead paint, and water supplies. However, lead can be with a household member who has an active case of TB, a
found in tap water and in some folk medicines. Visit chronic condition such as diabetes or renal failure, or who
http://www.cdc.gov/nceh/lead/publications/books/plpyc/ is immunocompromised. Tuberculin skin testing (TST)
chapter3.htm#top for more information on the prevention for latent TB infection is administered to children who
of lead poisoning in children. have one or more risk factors (Reznik & Ozuah, 2006).
REST
critical nursing action Key Actions in Caring for
Hospitalization disrupts a child’s normal daily routine as
the Child Confined to Bed well as their sleep pattern. The pediatric nurse can assess
normal sleep patterns, including information on both night-
The child confined to bed is at risk for skin breakdown. The nurse
should do the following:
time hours of sleep and daytime naps. Most pediatric units
allow parents to “sleep-in.” This provides both the parent
• Keep the skin clean and dry. and child with comfort and creates an environment with
• Assess nutritional status for adequate protein. decreased levels of unfamiliarity and anxiety. The nurse
• Use the draw sheet for position changes.
• Assess skin for irritated areas.
understands that children up to the age of 5 may take an
• Assess for pressure ulcers by looking for the “red flush” (the first afternoon nap. If the child’s condition allows, uninter-
sign of tissue compromise and ischemia). rupted naptimes should be included in the plan of care.
SAFETY MEASURES
FEEDING Safety measures instituted on a pediatric unit are based on
the developmental level of each child to protect him from
Basic knowledge of nutritional requirements is essential harm. Safety measures include keeping toxic materials out
when working with children. Formula-fed infants require of reach, identifying children with name bands, and
no more than 24 to 32 ounces of iron-fortified formula knowing the whereabouts of children on the unit. The
daily. For infants who have a gastrointestinal disturbance, nurse must also provide a safe environment in the hospital
pulmonary failure, or are in congestive heart failure, it room and in the transport of children from their room to
may be difficult to ingest the required amount of calories other departments in the hospital.
without tiring and gavage feedings may be necessary.
For the older child, assess preferences by taking a diet
history and asking about routines at mealtimes. Children clinical alert
are often prescribed an “as tolerated” diet and they are able
to select foods that appeal to them. It is best to gently Keeping children safe in the home or hospital
encourage the intake of wholesome and nutritious foods In the home, parents must think like a child thinks. Suggest that
and snacks. Foods ingested are also important for their parents get down on the floor in their home to see what their child
fluid content (e.g., gelatin and ice pops). Parents can be sees (e.g., electrical plugs and outlets, tablecloths ready to be
encouraged to bring in favorite foods from home. Cultural pulled, hot coffee mugs on the edge of the table).
preferences may make a difference in whether or not a child In the hospital, toxic and nontoxic materials should be stored in a
eats while hospitalized. Foods and caloric intake should be locked utility room, on the top shelf of a cabinet, or in another
appropriate for age and developmental level (Table 21-6). location where children do not have ready access. Utility rooms,
kitchens, medication carts, treatment rooms, and supply rooms are
locked, denying access to children. Play areas should be locked
Nursing Insight— Encouraging adequate food unless the child is accompanied by an adult.
and fluid intake
• Offer small portions at frequent intervals. The nurse verifies the child’s identity by checking the
• Host a “tea party” using medicine cups filled with the name band before any treatment or medication is admin-
child’s favorite drink. istered. Name bands can be removed by the child easily or
• Make food into fun shapes (trace a smile face with a spread they may inadvertently fall off leaving the nurse with no
on a sandwich; use a cookie cutter to make different shapes means to verify a child’s identity. If a child is found with-
for sandwiches). out a name band, the child’s name must be verified and a
• Offer incentives of more time doing a favored activity. new name band applied to an extremity. The nurse cannot
• Offer two choices (“Would you like to use a straw or a depend on all children to correctly identify themselves.
colored cup for your drink?”). This allows autonomy. Younger children may answer to any name or may not
answer at all. When a name band is not on a child’s
extremity, medications or treatments are administered
only after a parent or nurse has identified the child and
the name band has been replaced.
The nurse is responsible for keeping children safe on
the pediatric unit. Many pediatric units have alarms and
restricted access at stairways, elevators, and the entrance
Text rights not available. to the unit. The nurse can review with the older child the
places she is allowed to go and the activities she can
engage in while a patient on the unit. Limits must be set
and enforced. To prevent child abduction, pediatric per-
sonnel need to be vigilant about visitors.
In the child’s room, safety features are used on high
chairs and strollers, and beds are kept in the locked posi-
tion with the height of the bed in the lowest position. Crib
684 unit six Caring for the Child and Family
side rails are elevated when the child is in the bed. Bubble Once the precautions are in place, and the child and
tops may be needed to prevent a child from climbing over family are coping with the restrictions, children may
the rails. Check the room for any small articles that may be need diversional activities. Child life specialists can assist
left behind in a bed, such as syringe covers and alcohol in the selection of age-appropriate games and toys. Once
wipes. All items must be removed from the bed. a toy is brought into a precaution room, it must be
Safety concerns regarding the transport of children are cleaned before other children can play with the toy. Visi-
based on their developmental level. Infants can be carried tors need not be restricted from the room but they do
short distances in the room or on the unit. For longer need specific instructions on how to protect themselves
transports to other areas of the hospital, bassinets, cribs, and the patient. Guidelines are placed on the door with
strollers, wheelchairs, or special vehicles are used (e.g., step-by-step instructions on what is required prior to
wagon with raised sides). The wagon can be painted in entering the room. Hand washing before and after leaving
bright colors, and some have plastic bubble tops in the the room is essential.
shape of small automobiles. Children enjoy this type of
transport. It is important to check that restraint devices FEVER-REDUCING MEASURES
like a seat belt in a stroller are securely fastened and that
Fever (a temperature greater than 100.4ºF [38.0ºC]) accom-
the child is not left unattended during transport.
panies many childhood illnesses. A fever is a natural and
beneficial response to the invasion of an offending organism
INFECTION CONTROL MEASURES and can help “kill” the virus or bacteria. If a child with a
Transmission of infection requires three essential ele- fever is very uncomfortable and irritable his fever may be
ments: an offending microorganism, a susceptible host, treated with antipyretics or by using environmental mea-
and a method of transmission to infect the host. The sures. Antipyretics work to lower the set point at the ther-
offending microorganism can be brought into the hospital moregulatory center in the hypothalamus. Antipyretic drugs
setting with the ill child or can be part of the new environ- commonly administered to children include acetaminophen
ment. Main routes of transmission include contact, drop- and nonsteroidal anti-inflammatory drugs (NSAIDs).
let, airborne, common vehicle, and vector borne. Funda-
mental isolation precautions include handwashing and
gloving, the appropriate placement of a patient, and the clinical alert
use of barrier gear to protect the caregiver and prevent Aspirin (Salicylates)
further transmission of infection.
The Healthcare Infection Control Practices Advisory Aspirin (Salicylates) is not given due to the correlation between the
use of aspirin and the development of Reye’s syndrome in children
Committee (HICPAC, 2008) lists two tiers of isolation with viral infections.
precautions. The first tier is “standard precautions” that
integrate the features of universal precautions designed to
reduce the risk of transmission of blood borne pathogens.
The second tier is “transmission-based precautions” that Acetaminophen (Children’s Tylenol) is available in
are intended to prevent the transmission of pathogens suppository, liquid, and capsule form. It can be given every
from those with infectious diseases. Transmission-based 4 hours with no more than five doses in a 24-hour period;
precautions include airborne, droplet, and contact precau- there is little risk of hepatic toxicity. Ibuprofen (Children’s
tions (Schulster et al., 2004). When caring for children in Advil), a common NSAID, is given to children as a fever-
a hospitalized setting, the specific guidelines from the reducing measure. This drug is given every 6 hours and
CDC should be followed for procedures related to precau- may be an advantage when rest is crucial or when admin-
tions (Schulster et al., 2004). istering medications to the child is a challenging task.
Dyspepsia and nausea are common side effects of ibupro-
fen. The medication, taken as a chewable tablet, caplet, or
clinical alert liquid, can be given with food or after meals if gastrointes-
tinal (GI) upset occurs. The child should be monitored for
Hand washing GI bleeding. Dosing for ibuprofen is dependent on the
The nurse knows that hand washing is essential prior to patient care.
Hand washing removes microorganisms and can minimize infection
to the patient. Meticulous hand washing also allows antimicrobial medication: Dosage Recommendations for
products to be effective against the transmission of infection. Acetaminophen (Children’s Tylenol)
Acetaminophen (a-seet-a-min-oh-fen)
The experience of isolation for a child can be perceived Age: Dosage (mg):
in negative ways. In the preschool years, when magical 0–3 months 40
4–11 months 80
thinking is the predominant manner of processing infor-
12–23 months 120
mation, the child may perceive the situation as a punish- 2–3 years 160
ment for some previous thought or action. Koller, David, 4–5 years 240
Goldie, Gearing, and Selkirk (2006) found that children 6–8 years 320
placed in isolation because of the SARS (severe acute 9–10 years 400
respiratory syndrome) outbreak in Canada experienced 11 years 480
emotional upheaval. The authors recommended that
Data from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for
nurses be aware of the difficult situation that existed and
nurses (11th ed.). Philadelphia: F.A. Davis.
continue to provide family-centered care.
chapter 21 Caring for the Child in the Hospital and in the Community 685
temperature of the child. A fever below 102.6ºF (39.2ºC) experience that is stressful not only to the child but to the
warrants a dose of 5 mg/kg of body weight. If a child’s parent as well. Developmental characteristics dictate how
temperature is over 102.6ºF (39.2ºC), the dose is increased to approach the child and what to say to the child. What
to 10 mg/kg of body weight. The efficacy of antipyretic the nurse conveys to the patient and the parents can
medication is assessed by retaking the child’s temperature diminish the anxiety and fearfulness associated with com-
one hour after administration. mon procedures.
Environmental measures can be effective in reducing
fevers in children. Measures that do not cause shivering
are essential. Shivering produces heat, which is counter- critical nursing action Preparing an Infant for a
productive in reducing fever. Cooling measures, such as
Procedure
reducing room temperature, applying cool compresses to
the skin, and wearing a light layer of clothing, are effective • Describe the procedure to the parents, explaining what will happen
alone or when administered 1 hour after an antipyretic and how long it will take. Encourage the parent to stop you at any
is given. point if there is a question.
A cooling blanket, which has coils through which a • Remind parents that infants often cry for reasons other than
refrigerated solution circulates, may be necessary to con- discomfort, but be honest about any discomfort the infant may
trol hyperthermia. The cooling blanket is placed on the experience with the procedure.
bed, covered with a sheet, connected, and set to a tem- • Identify what restraints may be used and give an explanation as to
perature of 98.6ºF (37ºC). The temperature is decreased why they are needed.
according to the child’s response to cooling. Rectal • Allow parents to decide whether they would like to be present
for the procedure. Parents may prefer to leave the room and
temperature must be monitored every 15 minutes while return immediately following the procedure to comfort their
the child is on the machine, and the child must be child.
assessed for shivering. Cooling blankets are only used in
circumstances warranting an immediate drop of a very
high fever.
Nursing Insight— Distraction a sense of control. Provide a peer video of the procedure if possible.
Allow the adolescent to make decisions such as when the procedure
A distraction kit is a set of materials that help divert the should take place, if possible. Allow the adolescent the option of
child’s attention to a more pleasant experience than the pain- having a parent present. Offer tips for distraction such as deep breath-
ful experience. ing, relaxation, counting, or squeezing an object or parent’s hand.
• Appropriate for any age
• Use before, during and after procedure
• Can also suggest holding someone’s hand really tight, say
‘ouch’ really loud, count to 10 or count backwards, sing a
critical nursing action Before, During, and After
song, pretend to be somewhere else.
a Procedure
Environment:
• Use designated treatment rooms when possible. Before:
• Child’s inpatient room should be kept as a ‘safe area’ 1. Think through the procedure in advance and anticipate problems.
whenever possible. 2. Gather all equipment and check to make sure it functions properly.
• Optimal lighting for a procedure should be sufficiently 3. Establish trust. Get to know the child first.
bright and focused on safety, but otherwise without glare. 4. Through the use of play, allow the child to “perform” the
procedure on her doll, teddy bear, or other appropriate surrogate.
Preparations: 5. Offer a coping strategy such as guided imagery or relaxation
• Parent: Relieve parental anxiety so they can help prepare breathing.
and reassure the child/youth. Provide an explanation of 6. Give the child realistic choices.
what they will see and hear. 7. Be sure informed consent is signed.
• Patient: Relieve patient anxiety. Use simple explanations 8. Wash hands.
that are developmentally appropriate to explain how, why, 9. Let the child know that it is “OK” to cry.
where and when. During:
1. Whenever possible, all treatments need to be scheduled away from
Source: Stollery Children’s Hospital, Edmonton, Alberta, Canada. the child’s bed or “safe area.”
2. Expect the child to do well.
3. Talk to the child and ask how he is doing.
4. Keep the child informed as to the progress of the procedure.
critical nursing action Preparing a School-Age 5. Use distraction techniques such as pop-up picture books, bubbles,
Child for a Procedure “shutting off the pain switch,” or other techniques that have been
practiced before the procedure.
Explain the procedure in terminology that the child can understand. 6. When appropriate, give the child some control by allowing him to
Children in this stage of development have a good concept of time, so make some of the decisions.
preparation can begin in advance of the procedure. 7. Involve the parent to provide comfort to the child, if the parent is
For the younger school-age child, use play to demonstrate the able. Sometimes a parent’s presence at the procedure may not be
procedure and if possible have the child demonstrate on and practice beneficial for the child.
positioning with a doll or teddy bear. Allow the child to touch and After:
explore equipment to be used in the procedure, and involve the child 1. Praise the child for completing the procedure.
in simple tasks during the procedure when possible. Set limits for the 2. Provide an opportunity for the child to verbalize feelings.
child so she is aware of expectations. For example, tell her she can yell 3. If the parents were not involved in the procedure, comment on a
and scream as much as she wants, but must hold very still. Give legiti- positive aspect involving the child during the procedure. “Jill was
mate choices to the child whenever possible. Allow parents and the able to help out and keep still when she was asked to do so! She
child to decide together whether parents will be present for the proce- did a great job!”
dure. Some school-age children may be modest about exposing body 4. Give a reward (stickers, small toy, previously agreed-upon reward
parts in front of family members. Allow the parents to stroke their negotiated with parents).
child or speak soothingly to their child if they remain in the room. 5. Document the child’s response to procedure and outcomes.
Teach the child techniques such as deep breathing, counting, reciting
a silly rhyme, or anything else that might help distract and relax the
child during the procedure.
— Using developmentally
appropriate words
critical nursing action Preparing an Adolescent for For children with beginning language skills, use simple
a Procedure terms that are familiar to the child, such as “go potty,”
“owie,” and “boo boo.” For the concrete thinker who
Describe the procedure, explaining exactly what will happen and takes what is said literally, do not use words that may
how long it will take. frighten the child (e.g., “dye in your vein,” “shot in the
Encourage the adolescent to stop you at any point if she has a ques- arm,” “cut out the tonsils,” and “take your temperature”).
tion. Be honest. Describe potential risks and pain associated with the Instead, use “special medicine in your vein,” “special
procedure, but don’t dwell on it. Allow the adolescent to take as active medicine in your arm,” “make your tonsils better,” “check
a role as possible in the procedure. Practicing positioning or demonstrat- to see if your temperature is working.” For all children,
ing the equipment prior to the procedure will help give the adolescent be honest and they will learn to trust you.
chapter 21 Caring for the Child in the Hospital and in the Community 687
or children to gain weight, a continuous feeding may be Non-nutritive sucking has been shown to increase weight gain
given during hours of sleep to boost calorie intake with- and decrease crying, and to allow for the normal muscular
out interfering with a normal daily feeding/eating development of the mouth and tongue.
schedule.
OROGASTRIC AND NASOGASTRIC FEEDING TUBES. For new- Once placement of the tube is confirmed and the
born infants requiring gavage feedings (a feeding done child is in position, the nurse administers a bolus feed-
using a tube that is passed through the nares and into the ing of room-temperature formula via gravity through an
stomach; the food is in liquid form, usually at room tem- appropriately sized syringe attached to the feeding tube.
perature), the orogastric route is preferred because new- The formula-filled syringe is held less than 12 inches
borns are obligate nose breathers. The tube is inserted and above the infant. When the feeding is complete, the tub-
then removed at the end of the bolus feed. If the tube is to ing is flushed with tap water to prevent clogging of the
be left in place, the nasogastric route should be consid- lumen, the syringe is removed, and the feeding port
ered. Nasogastric tube feedings are preferred over total capped. To decrease the chance of regurgitation, the
parenteral nutrition since they preserve the stomach’s infant is burped after the bolus is infused. Follow hos-
mucosa, allow the digestive process to continue, and are pital guidelines for nasogastric gavage feedings. The
cost-effective (Procedure 21-1). nurse must remember that the amount of water should
be only the amount required to successfully flush the
length of tubing, excess water may result in over
Nursing Insight— Psychosocial needs of the feeding.
infant receiving gavage feedings
GASTROSTOMY FEEDING TUBES. When a child requires
The time taken to administer a gavage feeding can be used enteral tube feedings over a longer period of time, such as
in the same way as in a regular feeding. Place the infant com- those with oral feeding aversions or neurological dysfunc-
fortably in the mother’s arms with the head elevated. Provide tion, a gastrostomy tube (GT) is an alternative to the
the infant with a pacifier to help simulate an actual feeding. nasogastric tube. A GT is inserted through the abdominal
chapter 21 Caring for the Child in the Hospital and in the Community 691
Adapter
Tubing clamp
External bumper
Skin
Fat
Muscle
Internal bumper
Mushroom
catheter tip
A Stomach
Ostomies
RESTRAINING THE CHILD
An ostomy is a surgical opening from either the small or
large bowel to the surface of the abdomen to allow for fecal Physical Restraint
elimination (Fig. 21-13). An ostomy may be needed for a Restraining a child may be a necessary intervention to
variety of reasons, including trauma, obstruction, disease, ensure a child’s safety during a procedure or to prevent
and infection. It may be needed on a temporary basis to allow injury to an operative site. Parents as well as the child
the bowel sufficient time to heal, or permanently when the need to be informed as to why a restraint is necessary.
child’s condition does not allow for ostomy reversal. Once the restraint is applied, the child must be checked
For infants and toddlers, the parent assumes all respon- and documentation made as to the condition of the skin
sibility for the care of the ostomy. The nurse assists the and circulation of the affected extremity. The extremity is
parents by clarifying misconceptions, addressing concerns checked every 15 minutes for 1 hour after initial applica-
about caring for the child with an ostomy, and providing tion and then every 1 to 2 hours to ensure the child’s
teaching guidelines regarding ostomy care. It is necessary safety.
692 unit six Caring for the Child and Family
Face No particular expression or smile; Occasional grimace or frown; Frequent to constant frown, clenched
disinterested withdrawn jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal position, Squirming, shifting back and forth, Arched, rigid, or jerking
moves easily tense
Cry No cry (awake or asleep) Moans or whimpers, occasional Crying steadily, screams or sobs,
complaint frequent complaints
Consolability Content, relaxed Reassured by occasional touching, Difficult to console or comfort.
hugging, or talking to. Distractible.
Each of the 5 categories—(F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability—is scored from 0 to 2, which results in a total score
between 0 and 10.
the severity of pain; any aggravating and alleviating factors; subsides over time. With orthopedic trauma, a short period
and, if appropriate, previous interventions that alleviated of auto-anesthesia can occur that belies the extent of
the pain. It is useful to know what experiences the child has the injury. As narcotics do not relieve all of the pain follow-
had with pain, including previous surgeries, illnesses, or ing surgery, they can be accompanied with some success
congenital conditions. A child’s ability to manage pain is by comfort measures, such as holding a hand or encourag-
sometimes related to the child’s position in the family or his ing the child “to send his pain to you by squeezing your
experience of illnesses in other close family members. Pain hand tightly.”
has many descriptors: mild, moderate, severe, chronic, Chronic pain in children is any pain lasting more
stabbing, burning, pricking, aching, throbbing, or dull. than 3 months. It can result in fear of re-injury,
Pain is also expressed nonverbally with facial expressions, anorexia, weight loss, changes in sleep patterns, guarded
guarding, and muscle tension. movements, a rigid facial expression, and an overall
Mild pain is a slight discomfort. Its management may diminishment of the child’s joy of living. Management
include minor analgesics along with comfort measures or of chronic pain involves careful observation of which
distraction. However, engaging in a distraction does not pain relief measures work best for a particular child.
mean that the child has no pain. It is simply a coping Decreasing pain to acceptable levels allows the child
mechanism that diverts a child’s attention from the pain to carry on with as many age-appropriate activities as
for a finite period of time. Pharmacological intervention possible given the circumstances of his illness or condi-
for mild pain starts with analgesics such as acetamino- tion. Table 21-9 shows a comparison of acute and
phen (Tylenol) or ibuprofen (Advil, Motrin), and is chronic pain.
administered on a scheduled or as-needed basis.
Although moderate pain may also be relieved by using
distraction, the child experiences much stronger unpleas- Clinical Alert
ant sensations. Using a child’s vivid imagination is very
Naloxone (Narcan)
effective in pain management, as long as it is used in con-
junction with regularly timed analgesic administration, When giving morphine sulfate (Astramorph), be sure to have the
opioid antagonist Naloxone (Narcan) available. Narcan completely
including milder opioids such as codeine in varying com- blocks the effects of opioids including CNS effects and respiratory
binations of acetaminophen (Children’s Tylenol). depression. The dose for children is 5–10 mcg/kg (0.01 mg/kg).
Severe pain causes pallor, sweating, piloerection (ele-
vation of the hair above the skin), dilated pupils, increased Data from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for
respiration and blood pressure, and muscle tension. How- nurses (11th ed.). Philadelphia: F.A. Davis.
ever, if pain has been prolonged then the child’s body may
have become accustomed to it, in which case marked
increases in vital signs may not be noted. Again, that does
medication: Morphine Sulfate (Astramorph)
not mean that the child is not experiencing pain. When
brief, intense pain subsides, the child’s body may respond Morphine mor-feen
with a lower BP or pulse rate. Morphine sulfate (Astramorph) is an opioid analgesic. It is frequently used
Management of severe pain, often associated with sur- for children with chronic pain. It can be given PO, IV, IM, epidurally, or via
gical interventions, usually calls for strong analgesics like a patient-controlled analgesia pump (PCA). For children 50 kg (22.7 lbs.)
morphine (Astramorph). The maximum allowable dosage the dose is:
may be started in the recovery room and followed by regu- 0.3 mg/kg PO every 3–4 hours, or
lar dosing, within the allowable limit for the specific child, 0.1 mg/kg IV or IM every 3–4 hours.
to ensure adequate pain coverage. Data from Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses
Acute pain occurs 24 to 48 hours after trauma or sur- (11th ed.). Philadelphia: F.A. Davis.
gery. It is initially experienced as severe pain, and gradually
694 unit six Caring for the Child and Family
Nursing Insight— Myths about pain management The Child with Disabilities
• Children do not feel pain with the same intensity as Disabilities may be congenital or develop from illness,
adults. injury, or disease progression. Regardless of the cause,
• Neonates do not feel pain because their nervous systems families of children with disabilities are beset with emo-
are not mature. tional upset and confusion about the reality of not having
• Children cannot tell where they hurt. the child they expected (i.e., one without a disability). In
• Children will tell you if they are really having pain. addition, the family is often distressed about the child’s
• Children become accustomed to pain. pain and her experiences with surgery, treatments, proce-
• Narcotic analgesics are dangerous for children because they dures, and repeated clinic appointments. The child is apt
become addicted or go into respiratory distress. to have ongoing physical, occupational, or speech therapy,
• If children can be distracted, they are not in pain. and parents often need to perform physically painful pro-
• If children say they are in pain, but do not look in pain, cedures at home in order to promote their child’s develop-
they do not need to be medicated. ment. Other ongoing treatments and procedures include
• Being in pain for only a little while is not that bad. respiratory therapy, gavage feedings, medication adminis-
• After children have undergone surgery they should not be tration, using assistive devices, planning special diets,
given analgesia until they can vocalize pain, because they taking care of elimination needs, and implementing spe-
received enough anesthetic to “cover” their pain. cial techniques to maintain the musculoskeletal system.
• The best way to give analgesics is intramuscularly.
• Children with neurological impairments do not feel pain as EMOTIONAL CONCERNS
much as other children. Raising a child with a disability is distressing due to the
• Children, especially boys, should learn to tolerate pain; disruption of the normal routine, the conveyance of con-
they will make better, stronger adults. tinuous “bad news” or prognostics, the reconfirmation of
future emotional and physical concerns, and the aware-
ness of financial implications the diagnosis and treatment
Children react to pain and its management in provoke. These financial concerns include medical care
individual ways that also correspond to their develop- that is not covered by insurance or government-sponsored
mental level (Table 21-10). Responses to analgesia, health care programs, as well as expenses incurred for
time, route, and dose are documented to enable nurses child care or respite care. Often, a parent is required to
across all shifts to provide a continuum of care for the stop working and become a full-time caregiver resulting in
child. further economic distress.
Now Can You— Discuss important aspects for the care Across Care Settings: Insurance for children
of the child in the hospital or clinic
setting? The nurse can teach the family about how to obtain health
1. Discuss general care measures for the child in the hospital or insurance for their child. Health insurance provided to
clinic setting. children through state and national programs is free or low-
2. Discuss the important aspects of preparing the infant and cost. The costs are different depending on the state and the
child for a procedure. family’s income. When there are charges for health care the
3. Describe developmentally appropriate assessments of pain in charges are minimal. Children who have health insurance
children? generally have better health throughout their childhood.
Benefits of insurance for children include: (1) receiving
Table 21-10 Pain Management Strategies
Age Concerns/ Parental Post Procedure
(Guidline Only) Reactions Distraction Environment Involvement Preparation Positions Comforting
Infant /Toddler Separation anxiety Pacifier Controlled lighting Encourage parental Prepare parent: offer Swaddle Soothe
(0–3 Years) and noise. presence, provide explanations of what they
Protest Swaddling guidance and if will see and hear. Cuddle Swaddle
Use treatment possible, comfort/
Despair Rocking room. Develop a plan “who will Hold and rock
cuddle baby during
Denial Eye contact procedure. do what” Soft music
Music Soothing voice
Picture books
Preschool Separation anxiety Distraction kit Use treatment Encourage parental Medical play with relevant Lap Praise and reward (stickers)
(3–6 Years) room presence and provide medical equipment and
Concerns with body Deep breathing guidance in participation Parent or staff may Medical play
image Music encouraging support patient or have
Bubble blowing Pre-procedural teaching other close physical Play
Develops fantasies with Controlled lighting participation during
Counting strategies contact Stories
illness and treatment and noise Reassurance of what child
Singing is to expect—focus on Present patient with
Battle for control
chapter 21
senses. choices
School Age Has questions regarding Deep breathing Use treatment Encourage parental Simple medical terms to Lap Praise, reward (stickers)
(6–11 Years) body and illness room presence and provide describe what will happen
Hand guidance Parent may support Play, medical play
Concerns of squeezing Music Allow appropriate play with patient or have other
helplessness, passivity, Encourage parents to medical equipment close physical contact Stories
and dependency Riddles/trivia Controlled lighting be part of the team
and noise Explain reasons for various Present patient with Evaluate procedures and
Tend to be phobic and Pretend games components of tests and choices discuss suggestions for next
develop fears allow appropriate time
Talking
participation by patient
Anger Distraction kit
Teens Illness interferes with Imagery Use treatment Ask permission of Clarify misconceptions and Present patient with Praise, reward (stickers)
(12 and older) struggle for room patient for parental initiate discussions about the choices
independence Walkman involvement past experiences with Play, medical play
Music procedures Plan positioning with
Illness is a major threat Deep breathing Encourage parents to teen Stories, evaluate
to developing self-image Controlled lighting be part of the team Allow appropriate procedures and discuss
Hand and noise suggestions for next time
squeezing participation by patient
Very threatened by
helplessness and loss Talking Pre-procedural teaching
Caring for the Child in the Hospital and in the Community
needed immunizations that prevent disease, (2) receiving severely disabled child needs to perform a simple task, such
treatment for acute as well as recurring illnesses and as getting into “puppy position” or standing independently
(3) receiving preventative care to keep the child healthy. for 15 seconds, 10,000 more times than a physically healthy
The nurse can encourage the family to call 1-877 KIDS child in order to accomplish it. These children have extra
NOW (1-877-543-7669) or go to your state’s program: requirements for stamina, calories, vitamins, minerals, and
http://www.insurekidsnow.gov/states.asp protein in order to accomplish normal daily activities, let
It is important to note that children who are eligible for alone learning developmentally appropriate mental skills.
Medicaid cannot enroll in the state program because These children also need additional sleep, but may have
Medicaid provides comprehensive health benefits. more trouble getting enough sleep if the demands of their
care interfere with a normal sleep pattern. All of these fac-
tors contribute to caregiver fatigue.
DEVELOPMENTAL CONCERNS
RESILIENCY
Many congenital problems are repaired surgically either
shortly after birth or once the child is physically developed Coping mechanisms give rise to resiliency in children and
and strong enough to withstand the rigors of surgery. Par- their families. Resiliency theory defines the protective fac-
ents and the child need constant support from health care tors in families, schools, and communities that exist in the
personnel to sustain a loving environment for the child lives of children. Four common attributes of resilient chil-
with a disability who may be undergoing the same growth dren include social competence, problem-solving skill,
and development changes as any other child of the same autonomy, and a sense of purpose and future. Nurses can
age. However, due to constant medical and surgical inter- help parents and children develop resiliency and positive
ventions, the child may demonstrate either signs of regres- self-esteem by fostering a mix of love and nurturing in the
sion to more immature behaviors, or surprising evidence face of overwhelming stressors (DuHoux, 2004). Emo-
of what some call a “maturity beyond their years.” The lat- tional security and maturity provide the foundation for
ter has been observed in children with cancer who are resiliency (Box 21-2).
faced with pain and/or body image disturbances, such as
alopecia or extreme weight loss, and with their own mor- nursing diagnoses The Developing Child
tality as they might understand it at their age.
Family Processes, altered—related to health condition (specify), injury, violence
Growth and Development, altered—related to trauma, hospitalization,
PHYSICAL CONCERNS congenital defects, prolonged pain, separation from family
The child with a disability undergoing surgery, especially Injury, high risk for—related to lack of awareness of environmental hazards
at a younger age, may experience rapid fluid and electro- Pain, Chronic—related to effects of condition (specify)
lyte changes (see Chapter 32). These conditions may Poisoning, high risk for—related to age-specific environmental hazards
require intensive care procedures that are worrisome to Self-esteem, chronic low—related to disfigurement, separation, ineffective
relationship with parents or peers
parents and often painful for the children. Children with Sleep Pattern Disturbance—related to pain, fear, desire to sleep with
severe congenital heart problems (see Chapter 27) face a parents at night
lifetime of corrective procedures to augment initial surger- Social Isolation—related to physical handicap, hospitalization, terminal
ies or pharmacological therapy that consume time, energy, illness
and finances. In addition, both parents and child need to Violence, high risk for—related to verbal threats of physical assault,
learn physical self-care techniques, such as diabetes or perceived threat to self-esteem
anticoagulation monitoring. Often, abnormalities affect
several body systems so that visits must be made to several
different medical specialists who may require multiple
pharmacotherapeutic regimens. Throughout all this, fami- Family Teaching Guidelines...
lies must learn to care for the physical needs of the child. Caring for the Child with a Disability
How to: Care for the child with a disability
CAREGIVER FATIGUE
Topic: The nurse will improve the care of the family and
Caring for a child with a significant disability takes its toll a child with a disability
on the entire family. Respite care agencies were developed Essential information:
in response to the needs of parents of extremely disabled
◆ Maintain a respectful attitude toward the parent and
children to give short-term relief from the 24-hour sur-
the child
veillance and care often required in cases of severe dis-
ability. As medical advancements have increased the life ◆ Listen carefully to the parent’s concerns, realizing that
expectancy of disabled children, so too have the number parents often “know their child best”
of disabled children or premature births resulted in larger ◆ Evaluate how social and healthcare agencies can assist
numbers of children and families requiring long-term parents and the child to manage the disability—financial,
medical care and social systems to support their needs. medical, community services
Most disabilities in childhood result in multiple visits to
clinics, hospitals, or rehabilitation centers, thus disrupting ◆ Assess the child’s skills for coping with pain or fatigue
normal activity and sleep patterns. It requires much more ◆ Evaluate the need for respite care and reliable commu-
energy for a disabled child to perform even the simplest task nity resource providers
than it does for a healthy child. It has been estimated that a
chapter 21 Caring for the Child in the Hospital and in the Community 697
8. The pediatric nurse is aware that the posterior Hay W.W. Jr. (2005). Current pediatric diagnosis & treatment (17th ed.).
fontanel closes at approximately ___ to ___ months New York: Lange Medical Books/McGraw-Hill.
Healthcare Infection Control Practices Advisory Committee (HICPAC).
of age and that the anterior fontanel remains open (2008). Department of Human Service, Center for Disease Control
until approximately ___ to ___ months of age. and Prevention. Retrieved from http://www.cdc.gov/ncidod/dhqp/
hicpac.html (Accessed May 22, 2008).
True or False Hulka, B.S., Zyzanski, S.J., Cassei, J.C., & Thompson, S.J. (1970). Scale
for the measurement of attitudes toward physicians and primary
9. It is not necessary for the pediatric nurse to ask the medical care. Medical Care, 8, 429–436.
parent questions related to the use of herbal products Ireys, H.T., & Perry, J.J. (1999). Development and evaluation of a satis-
because this is not a common finding in pediatrics. faction scale for parents of children with special health care needs.
Pediatrics, 104, 118–1191.
10. An accurate and effective way to assess the pediatric Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Maas,
patient’s respiratory rate is by counting the M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and
respirations while the child is sleeping and by NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.).
observing the abdominal area. St. Louis, MO: Mosby Elsevier.
Koller, D., David, N., Goldie, R.S., Gearing, R., & Selkirk, E.K. (2006).
11. According to the Centers for Disease Control and When family-centered care is challenged by infectious disease: Pedi-
Prevention, handwashing is not necessary if the pediatric atric health care delivery during the SARS outbreak. Qualitative
nurse is wearing gloves when providing care. Health Research, 16(1), 47–60.
Kreisler, J., & Ricter, R. (2003). The abnormal fontanel. American Acad-
12. It is important for the pediatric nurse to incorporate emy of Family Physicians, 67(12), 2547–2552.
developmental theory when working with children. Lanski, S.L., Greenwald, M., Perkins, A., & Simon, H.K. (2003). Herbal
The preschool-age child who is on isolation therapy use in a pediatric emergency department population: Expect
precautions will perceive isolation as a punishment the unexpected. Pediatrics, 111(5), 981–986.
Lee, K.J., Haven, P.L., Sato, T.T., Hoffman, G.M., & Leuthner, S.R.
for a previous thought or action because of the (2006). Assent for treatment: Clinical knowledge, attitudes, and
developmental stage of magical thinking. practice, Pediatrics, 118(2), 723–731.
Mayo Clinic Tools for healthier lives. Retrieved from http://www.
See Answers to End of Chapter Review Questions on the mayoclinic.com (Accessed May 22, 2008).
Electronic Study Guide or DavisPlus. Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing
outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
NANDA International (2007). NANDA-I nursing diagnoses: Definitions
REFERENCES and classifications 2007–2008. Philadelphia: NANDA-I.
American Academy of Pediatrics (AAP). (2005). Recommendations for Nemours Foundation. (2007). How to perform a testicular self-examination.
Preventive Pediatric Health Care (RE9353). Retrieved from http:// Retrieved from http://kidshealth.org (Accessed May 21, 2007).
www.aappolicy.aappublications.org/sub-journals/pediatrics/html Newman, T.B., & Garber, A.M. (2003). Cholesterol screening in children
(Accessed May 28, 2007). and adolescents, Pediatrics, 105(3), 637–639.
American Academy of Pediatrics (AAP). (2003). Health supervision rec- Nield, L.S., & Kamat, D.M. (2006). Odd skull shapes: Heads up on diag-
ommendations: Prevention of pediatric overweight and obesity, nosis and therapy, Consultant for Pediatricians, 5(11), 701–709.
Pediatrics, 112, 424–430. Persing, J., James, H., Swanson, J., & Kattwinkel, J. (2003). Prevention
American Nurses Association (ANA). (2004). Nursing: Scope and stan- and management of positional skull deformities in infants. American
dards of practice. Washington, DC: Nursesbooks.org Academy of Pediatrics Committee on Practice and Ambulatory Medi-
Bascom, A. (2002). Incorporating herbal medicine into clinical practice. cine. Pediatrics, 111, 199–202.
Philadelphia: F.A. Davis. Reznik, M., & Ozuah, P.O. (2006). Tuberculin skin testing in children.
Berger, K.S. (2005). The developing person through the life span (6th ed). Emergency Infectious Disease. Retrieved from http://www.cdc.gov/
New York: Worth. ncidod/EIF/vol12no05/05-0980.htm (Accessed February 24, 2007).
Bickley, L.S., & Szilagyi, P.G. (2007). Bates’ guide to physical examination Salimbene, S. (2005). What language does your patient hurt in? St. Paul,
and history taking (9th ed). Philadelphia: Lippincott Williams & MN: EMCParadigm.
Wilkins. Schulster, L.M., Chinn, R.Y.W., Arduino, M.J., Carpenter, J., Donland, R.,
Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven- Ashford, D., Besser, R., Fields, B., McNeil, M.M., Witney, C., Wong,
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby. S., Juranek, D., & Cleveland, J. (2004). Guidelines for environmental
Centers for Disease Control and Prevention (CDC). (2007). Recom- infection control in health-care facilities: Recommendations from CDC
mended immunization schedule for persons aged 0–6 years. Retrieved and the healthcare infection control practices advisory committee
from http://www.cdc.gov/nip/recs/child-schedule-color-print.pdf (HICPAC). Chicago: American Society for Healthcare Engineering/
(Accessed April 15, 2007). American Hospital Association.
Clark, J., Lieh-Lai, M., Sarnaik, A., Mattoo, T. (2002). Discrepancies Stollery Children’s Hospital, 8440-112 Street, Edmonton, Alberta, Canada.
between direct and indirect blood pressure measurements using Tanner, J.M. (1962). Growth at adolescence (2nd ed.). Oxford: Blackwell
various recommendations for arm cuff selection. Pediatrics, 110 (5), Scientific.
920–923. U.S. Department of Agriculture. (2007). Steps to a healthier you.
Deglin, J.H., & Vallerand, A.H. (2009). Davis’s drug guide for nurses Retrieved from http://www.mypyradmid.gov/kids/index.html
(11th ed.). Philadelphia: F.A. Davis. (Accessed May 1, 2007).
Denver Developmental Materials. (1990). Denver II developmental test. U.S. Department of Health and Human Services. (2002). Bright futures:
Denver, CO: Denver Developmental Materials. Guidelines for health supervision of infants, children, and adoles-
Dossey, B.M., Keegan, L., Guzzetta, C.E., & Kolkmeier, L.G. (2005). cents. Retrieved from http://www.brightfutures.org (Accessed
Holistic nursing: A handbook for practice (4th ed.). Sudbury, MA: December 13, 2006).
Jones & Bartlett. U.S. Department of Health and Human Services. (2007). CDC growth
DuHoux, M. (2004). Building resiliency: Helping children to weather tough charts: United States. Retrieved from http://www.cdc.gov/nchs/about/
times. Retrieved from http://www.nasponline.org/communications/ major/nhanes/growthcharts/charts.htm (Accessed April 3, 2007).
topicalresources.aspx U.S. Department of Health and Human Services. Insure kids now!
Feldman-Winter, L., & McAbee, G.N. (2002). Legal issues in caring for Retrieved from http://www.insurekidsnow.gov/questions.asp#why1
adolescent patients: Physicians can optimize healthcare. Postgraduate (Accessed June 7, 2007).
Medicine, 111(3), 15–21. U.S. Preventive Services Task Force (2006). Screening for iron deficiency
Frankenburg, W.K., Dobbs, J.B., Archer, P., Shapiro, H., & Bresnick, B. anemia—including iron supplementation for children and pregnant
(1992).The Denver II: A major revision and restandardization of the women. The American Journal for Nurse Practitioners, 10(10),
Denver developmental screening test. Pediatrics, 89(1), 91–97. 79–84.
chapter 21 Caring for the Child in the Hospital and in the Community 699
Van Leeuwen, A.M., Kranpitz, T.R., & Smith, L.S. (2006). Davis’s com- Woolf, A.D., Gardiner, P., Whelan, J., Alpert, H.R., & Dvorkin, L.
prehensive handbook of laboratory and diagnostic tests with nursing (2005). Views of pediatric health care providers in the use of herbs
implications. Philadelphia: F.A. Davis. and dietary supplements in children. Clinical Pediatrics, 44(7),
Venes, D. (Ed.). (2009). Taber’s cyclopedic medical dictionary (21st ed.). 579–584.
Philadelphia: F.A. Davis. Wright, C.M., & Parkinson, K.N. (2004). Postnatal weight loss in
Watson, J. (2005). Caring science as sacred science. Philadelphia: F.A. term infants: What is normal and do growth charts allow for it?
Davis. Archives of Disease in Childhood. Fetal and Neonatal Edition, 89(3),
Wong, D.L., Hockenberry-Eaton, M., Wilson, D., Winkelstein, M.L., & 254–257.
Schwartz, P., (2001). Wong’s essentials of pediatric nursing (6th ed.).
St. Louis: C.V. Mosby.
CONCEPT MAP
General Care Measures Caring for the Child in the Routine Screenings: Comprehensive Health History
• Bathing: shampooing Hospital and in the Community • Lead poisoning • “OLDCAT” ; “SODA”
• Feeding: nutritional • Iron-deficiency anemia • Family/social/past medical
needs; diet hx/routines; • Cholesterol history
home food • Tuberculosis • Immunizations
• Rest: parents • Developmental milestones
sleeping-in; naps – Fine/gross motor; language
• Safety: store toxics; Where Research And Practice Meet: • Patterns of daily activity
name bands; alarm • Issues r/t providers asking – Sleep; nutrition
exits; transportation about/using herbs in treatment – Play/activity/schoolwork
issues
• Review of body systems
• Infection control:
isolated child
• Fever reduction: Across Care Settings:
antipyretics; manage • Teach family how to
environment
obtain insurance
Health Assessment:
for child
• Anthropometric measurements: length; weight/BMI; head
circumference; skin fold
• Physical assessment: Vital signs.
– Skin color; turgor; lesions; includes hair/nails
Restraining a Child Ethnocultural Considerations:
– Head & neck symmetry; shape; fontanels; facial
• Instruct parents • To establish therapeutic relationship:
features; thyroid, lymph
• Follow assessment and avoid stereotyping
– Chest shape; symmetry; respiratory effort; breast
documentation policies • Color of sclera can vary
development
• Types: elbow; mummy; • Lead found in some folk medicine
– Lungs adventitious breath sounds; stridor
pharmacological
– Cardiac pulses; PMI; heart sounds; edema; murmurs
– Abdomen contour; umbilicus; inguinal area; bowel
sounds; organ palpation
Common Procedures Specimen Collection: – GU/perineal male/female genitalia; anus; Tanner
• IV access: peripheral; central • Stool/urine: depends on potty training staging/hair; sexual abuse
venous access; PICC; ports • Blood: address fears and discomfort – Musculoskeletal symmetry of movement; ROM;
• I&O: includes breastfeeding/ • Throat cultures: NOT in epiglottitis alignment; strength
gavage feeding; weighing diapers • Lumbar puncture: positioning for and – Neurological mental status; motor functioning;
• X-ray exam help with positioning assessments after procedure sensory functioning
• Consents: give parent information
to decide
LEAR NING T AR GETS At the completion of this chapter, the student will be able to:
◆ Identify the effects of hospitalization on the child and his or her family.
◆ Discuss ways in which nurses can decrease the stress of hospitalization for the child and family.
◆ Discuss the concept of across care settings.
◆ Identify various community settings.
◆ Determine the nurse’s role in assisting children and families in the various care settings.
The purpose of this study was to examine variations in the level United States. Each survey respondent is allowed to provide
of dental care and unmet dental needs among low-income chil- data on up to two children regardless of the number of children
dren. Data for the study were drawn from the 2002 National residing in the household. The data must be from two catego-
Survey of American’s Families (NSAF). The NSAF is a national ries: children 5 years of age or younger and/or children ages
household survey that provides information on more than 6 through 17 years.
100,000 children and adults younger than the age of 65 in the (continued)
701
702 unit six Caring for the Child and Family
continuation of naughty behavior. Another reaction to child to bring something from home to familiarize the
this stress may be that regression occurs in their bowel room and make it personal. They might also encourage the
and bladder control and the toddler who was once potty child to draw a picture or design that can be hung up in
trained may revert to diapers for a short period. Older the hospital room or give him or her a choice to watch a
children also may exhibit negative responses to hospital- movie or select a game that he or she would like to play.
ization through the display of negative behavior and ver-
THERAPEUTIC PLAY. Therapeutic play otherwise known as
bal expressions of anger or sadness. They begin to associ-
play therapy or medical play has been shown to help to
ate certain health care providers with specific treatments
ease the stress of hospitalization and provide children with
or procedures that cause stress, such as a laboratory tech-
a means for dealing with their concerns and feelings.
nician drawing their blood or a nurse giving an intramus-
cular injection.
Regardless of age or separation from family, a child Nursing Insight— Therapeutic play
who is hospitalized will exhibit three stages: protest,
despair, and detachment. The protest phase begins when Therapeutic play is the use of play as therapy to help
the child realizes his or her parent is leaving or that he or children who have had or will have a stressful experience.
she is separated from them, even if for a brief period. Therapeutic play may decrease the child’s fear and anxiety. It
Depending on the child’s age, the child could cry, cling, also may help to correct misconceptions the child may have
and act aggressively. This is then followed by the despair about being in the hospital. There are two types of play tech-
phase in which the child seems to withdraw from the envi- niques: directed and nondirected. Directed therapeutic play is
ronment and becomes very apathetic. If the parent does guided by an adult who facilitates the play, including determi-
not return, the child begins to show renewed interest in nation of the goals. In nondirected therapeutic play, the child
his or her surroundings and begins to form new relation- is in control of the activity, although an adult may select the
ships with others. During this formation of new relation- materials. Both types of play allow the child to demonstrate
ships, the child begins detaching his or her feeling from his or her emotions regarding the hospitalized experience.
their parents. Sometimes, in this detachment phase, health
care providers see this as a good sign of the child’s adjust- Often, a child life therapist may be available to assist
ment; however, it is really an important clue for interven- with therapeutic play and offer age appropriate toys or
tion. These children have simply repressed their pain at distraction such as music or games. Therapeutic play also
the sense loss of their about their parents’ absence. This may help the child to cope with, and master, stressful
may help explain why children sometimes show disinter- experiences (Fig. 22-3). Pediatric nurses are encouraged
est on the return of their parents, as a way of acting out to incorporate the use of therapeutic play in their every-
their anger. It is encouraging to note that this process is day care of the child. By using play techniques and activi-
reversible but potentially may leave permanent emotional ties in all settings, including the emergency and outpatient
scars if the parents are away for an extended length of departments, children benefit even if it means only that
time. Detachment is the final phase, when the child has they are able to watch other children at play.
begun to internalize the stressor and seems outwardly Therapeutic play happens when a child is preparing to
happy, although the stressors are still present. receive an injection. The nurse or child life therapist encour-
ages the child to play with equipment such as a needle-less
Now Can You— Describe the effects of hospitalization syringe filled with water, a doll, and alcohol prep pad. After
on a child? the injection, the nurse can then provide a bandage and
1. Describe how family-centered care impacts hospitalization? a sticker for a reward. Another example is an older child
2. Discuss developmental differences related to reactions to simulating the medical procedure (administering IV antibi-
hospitalization? otics), a therapeutic play technique that the nurse uses is
3. Describe protest, despair, and detachment in relation to
hospitalization?
Table 22-1 Erikson’s Developmental Tasks and What May Happen During Hospitalization
Developmental What May Happen
Age Task During Hospitalization The Nurse Can
Infant Trust vs. mistrust Separation anxiety Encourage consistency among caregivers.
Stranger anxiety Encourage the parents to stay with the infant.
Disruption in normal Encourage bonding.
routine Allow the infant’s home routine whenever possible.
Comfort the infant; rock, hold cuddle, swaddle.
Encourage parents to bring familiar toys/blanket from home.
Communicate with parents.
Preschool Initiative vs. guilt Play restrictions Encourage consistency among caregivers.
Fearfulness Encourage the parents to stay with the preschool child.
Thinks that hospitalization Allow the child’s home routine whenever possible.
is a punishment
Encourage parents to bring familiar toys from home.
Communicate with parents.
Allow the child to participate in care whenever possible.
Use therapeutic play.
Offer praise.
Ensure a safe environment.
Encourage use of the playroom and interaction with other children.
Explain a procedure, treatment and/or surgery in simple terms. Allow the
child to ask questions.
Encourage realistic choices whenever possible.
School Industry vs. inferiority Play restrictions Encourage the parents to stay with the school age child.
Age
Questions identity Allow the child’s home routine whenever possible.
Increased need or attention Encourage parents to bring familiar toys from home.
Regression Communicate with parents.
Fear of bodily mutilation Allow the child to participate in care whenever possible.
Use therapeutic play.
Offer praise.
Ensure a safe environment.
Encourage use of the playroom and interaction with other children.
Explain a procedure, treatment and/or surgery in simple terms. Allow the
child to ask questions.
Encourage realistic choices whenever possible.
Encourage the child to verbalize feelings.
Alleviate fears about changes in body image.
Respect the child’s privacy.
chapter 22 Caring for the Family Across Care Settings 707
Table 22-1 Erikson’s Developmental Tasks and What May Happen During Hospitalization—cont’d
Developmental What May Happen
Age Task During Hospitalization The Nurse Can
Adolescent Identity vs. role Concerns about body image Encourage visits or contact from peers.
confusion
Separation from peers Explain a procedure, treatment and/or surgery in understandable terms.
Loss of independence Be honest.
Decrease in socialization Allow the teen to ask questions.
Encourage realistic choices whenever possible.
Encourage the teen to verbalize feelings.
Alleviate fears about changes in body image.
Respect the teen’s privacy.
Encourage parent’s involvement in care.
Recognize the teen’s tendency to reject authority.
knowledge, concerns, expectations, and coping abilities is • Perform ongoing assessment to ensure that the nurse fully
imperative to direct nursing actions that ease parental role understands any changes in the plan of care for the child.
stress. Parental stressors include sights and sounds of the • Observe for the need for crisis intervention, should the
hospital, chansges in the child’s behavior or appearance, child’s condition deteriorate or change.
changes in the parental role, unknown outcome, financial • Encourage the parents to participate in the child’s care,
concerns, guilt or anger over the situation, and frustration while being supportive of the child and family.
about the function of the entire family (Fig. 22-4). Seeking
parental advice about the best way to approach their child,
acknowledging parental need for involvement, and antici-
pating stressful events are integral to appropriately caring
for the child in a family-centered manner. The communica-
tion between the pediatric nurse and family members must
be genuine and the plan of care must include resources
available in the hospital as well as the community.
— Developing a plan of care surgery. This type of experience minimizes the separation
between child and family and can be emotionally less
Admission to the hospital is a critical period for both the stressful. Although the surgery is usually minor, it is
child and parents. The nurse can ease the experience by essential to teach the family about the surgery entails and
including the parents in the plan of care. The nurse can ways to care for the child at home. Some of the recovery
request information from the parents about the child’s takes place in the surgery center, but the longer recovery
personal routine as well as the child’s perception of process continues at home. At home, parents need to be
hospitalization. informed about the exact recovery process along with
how care for the child and when the child can resume
• What are your child’s daily routines related to eating, normal daily activity. The nurse assesses the family’s
elimination, sleeping, bathing, and play?
knowledge in order to determine their ability to care for
• Who are the important people in your child’s life? the child independently at home or if additional support
• Does your child have a favorite toy or attachment is needed.
object?
• Has your child had previous hospitalizations?
• What has your child been told about hospitalization? critical nursing action Caring for the Child at
• Does your child have any fears that the staff should Home After Minor Surgery
know about?
Nurses can teach parents how to care for their child at home after
• Have there been any recent changes or problems in minor surgery:
your child’s life?
• Taking the child’s axillary temperature
• How does your child usually react to pain or when • Assessing the child’s level of consciousness
frightened? • When to begin giving the child liquids
• When to offer liquids based on type of surgery, prescribed diet,
and age
The nurse must recognize the parent’s concerns, includ- • When to offer solid food based on type of surgery, prescribed diet,
ing possible guilt, fear, or other anxieties about the child’s and age
hospitalization. The pediatric nurse plans care ensuring • What type of activity is expected or should be encouraged
the promotion of trust by the child and parents through • What are the actions and side effects of medications
prompt attention to the child’s needs. The nurse provides • What are the signs and symptoms of infection
opportunities for the child and family to participate in • What are signs of poor airway exchange
care and by including parental preferences and home • How to use assistive devices and medical equipment and perform
home treatments
schedules so that care is provided in a familiar and consis- • How to contact a nurse, pharmacist, health care professonial, or
tent manner. The nurse can also provide positive rein- community agency
forcement for the parents that may help alleviate some • When to call the doctor
stress. Finally, the nurse ensures an ongoing evaluation of
the plan of care is necessary in order to make needed
adaptations and modifications.
CRITICAL CARE UNIT
TWENTY-FOUR-HOUR OBSERVATION UNIT When critical care of the child is required, the child is
A short-stay hospitalization experience is also known as admitted to the critical care unit, usually through the
24-hour observation. A 24-hour observation occurs when emergency department or the operating room. A child
a child becomes suddenly ill and will most likely recover who becomes very ill on a medical–surgical floor is
quickly. The child may need a shortened hospital stay for transferred into a pediatric critical care unit (Hohen-
observation and specifically for treatments such as rehy- haus, 2005). After delivery, a newborn who requires
dration, aerosol treatment for acute asthma, or medication intensive care is transferred to a neonatal intensive
for an allergic reaction. At the conclusion of the 24-hour care unit. Other types of critical care units where chil-
period the child is reassessed and it is then determined dren might receive care include cardiac, surgical, or
whether continued hospitalization is needed or whether psychiatric critical care units. In any of these units, the
the child can be discharged home. The pediatric nurse child is extremely ill and receives specialized care, medi-
provides acute nursing care and then quickly begins to cation, intravenous fluid, respiratory, or ventilator
prepare the child and family for discharge. As a part of support (Fig. 22-5).
discharge process, the nurse explains specific medical
orders as well as when to notify the primary health care
provider with any questions, concerns, or change in clinical alert
condition.
Common problems of critical illness
AMBULATORY SURGERY CENTER Common problems of critical illness are shock, acute respiratory
failure, chronic respiratory failure, infection, sepsis, renal failure,
An ambulatory surgery center is a place where children neurological conditions, bleeding and clotting disorders, or
receive minimal surgical treatment, recover from the multiorgan dysfunction.
procedure, and then are discharged home soon after the
710 unit six Caring for the Child and Family
Community Settings
In the care of children and families, the focus for health
Children have special health care needs where families, care is early identification, assessment, and referral. Com-
nurses, and other health care providers collaborate to cre- munity settings often provide primary care along with
ate a family-centered plan of care. Today children are apt health screening and surveillance. Health screening
to receive the majority of their health care in a community means to test or examine children for the presence a dis-
setting. Community settings are on the front line of pre- ease, illness, chronic condition, developmental delays, or
vention and early detection and these settings may be mental health issue. Health screening plays an important
located in neighborhood clinics, schools, shopping malls, role in the early diagnosis and management of selected ill-
or health care centers. nesses or conditions and the initiation treatment which
chapter 22 Caring for the Family Across Care Settings 711
can then prolong and improve lives (The National Acad- that is specifically designed for children with eating
emy Press, 2008). Health surveillance is the continuous disorders, such as anorexia nervosa or bulimia
observation related to tracking health conditions and risk Endocrinology Clinic: A clinic for children that provides
behaviors. Nurses, physicians, and other health care pro- comprehensive services for diagnosis and treatment of
fessionals gather ongoing information about disease inci- endocrine and metabolic conditions
dence, demographics of an illness, and implementation of Gastroenterology—Nutrition Clinic: A clinic for children
policies that may prevent further spread of diseases. that provides comprehensive services for diagnosis and
treatment of gastrointestinal, nutritional, and liver conditions
Genetic Clinic: A clinic for children that provides
Collaboration in Caring— The nurse’s role comprehensive services for diagnosis and treatment of inborn
in health screening and surveillance
errors of metabolism and biochemical genetic conditions
The nurse has a key role in health screening and surveillance: along with genetic counseling of patients and prenatal testing
Immunology Clinic: A clinic for children that provides
• Pay attention to voiced parental concerns.
comprehensive services for diagnosis and treatment of
• Ask questions about the child’s growth and development.
children with unusual infections, primary immune
• Observe the child’s mental, physical, and spiritual state
deficiencies, or complement deficiencies
(not just a diagnosed condition).
Infectious Disease Clinic: A clinic for children that
• Note any risk factors that may be present.
provides comprehensive services for diagnosis and treatment
• Document specific observations and findings.
of acute infections or chronic infections
• Provide community resources and make appropriate
Neurology Clinic: A clinic for children with neurological
referrals.
conditions such as spina bifida, cerebral palsy, or autism
• Track disease incidence and demographics of illnesses.
who require comprehensive care and treatment
• Implement policies that may prevent further spread of
Oncology Clinic: A clinic for children that provides
diseases.
comprehensive services for diagnosis and treatment of cancer
• Initiate follow-up care for any concerns and conditions.
Ophthalmology Clinic: A clinic for children that provides
comprehensive services for diagnosis and treatment of
ophthalmologic conditions
CLINICS Orthopedics: A clinic for children that provides
comprehensive services for diagnosis and treatment of acute
When a child comes to a community setting such as a
and chronic musculoskeletal and bone conditions
clinic to receive health care services, her symptoms are
Pulmonary/Cystic Fibrosis Clinic: A clinic for children
noted and she may undergo a physical assessment by a
that provides comprehensive services for diagnosis and
primary health care provider or nurse practitioner to diag-
treatment for acute and chronic respiratory conditions
nose the condition. In the community setting, children
Rheumatology Clinic: A clinic for children that provides
can receive treatment for the condition and may experi-
comprehensive services for diagnosis and treatment of
ence diagnostic testing such as x-ray exam or blood sam-
arthritis, lupus, and inflammatory conditions
pling. In a small town or rural area only one community
Urology Clinic: A clinic for children that provides
clinic might be available. In a large urban area there can
comprehensive services for diagnosis and treatment of acute,
be many specialty sites. Clinics can also be housed in an
chronic, and congenital genitourinary conditions
acute care setting such as a hospital.
◆ Hospitalization can occur when the child becomes ill 7. Effective parenting children can help meet children’s
and his or her care requires more in-depth treatment physical, emotional, and spiritual needs.
than can be provided by a primary health care provider
in the office or clinic. See Answers to End of Chapter Review Questions on the
Electronic Study Guide or DavisPlus.
◆ The pediatric nurse must possess a broad base of
knowledge about growth and development, family func- REFERENCES
tioning, and environmental influences in order to care Alberg, J., & Kerr, I. (2004). Meeting challenges of the 21st century:
for children and their families across care settings. Multicultural populations.Volta Voices: Early Intervention Issue,
November, 16–17.
American Academy of Pediatrics (2008). The National Center of Medical
r e v i e w q u est io n s Home Initiatives for Children with Special Needs. Retrieved from
http://www.medicalhomeinfo.org/ (Accessed June 10, 2008).
Multiple Choice Bulechek, G., Butcher, H.M., & Dochterman, J. (2008). Nursing interven-
tions classification (NIC) (5th ed.). St. Louis, MO: C.V. Mosby.
1. During a well baby visit, the pediatric nurse initiates Gurwitch, R.H., Kees, M., Becker, S.M., Schreiber, M., Pfefferbaum, B.,
teaching related to health promotion and prevention & Diamond, D. (2004). When disaster strikes: Responding to the
of illness. Which of the following suggestions should needs of children. Prehospital and Disaster Medicine, 19(1), 21–28.
the nurse include in the teaching session? Healthy People 2010. Retrieved from http://www.healthypeople.gov/
(Accessed March 1, 2008).
A. “Call the pediatrician if the baby has a temperature Hohenhaus, S.M. (2005). Practical considerations for providing pediatric
of 99ºF (37.2ºC).” care in a mass casualty incident. Nursing Clinics of North America, 40,
B. “If you smoke be sure to blow the smoke away 523–533.
from the baby’s face.” Hopia, H., Tomlinson, P.S., Paavilainen, E., & Astedt-Kurki, P. (2005).
Child in hospital: Family experiences and expectations of how nurses
C. “Call the pediatrician if you notice a change in the can promote family health. Journal of Clinical Nursing, 14, 212–222.
baby’s activity level or feedings.” Johnson, M., Bulechek, G., Butcher, H., McCloskey Dochterman, J.,
D. “We want to watch the baby’s weight gain, so feed Maas, M., Moorehead, S., & Swanson, E. (2006). NANDA, NOC, and
the baby when she cries.” NIC linkages: Nursing diagnoses, outcomes, & interventions (2nd ed.).
St. Louis, MO: Mosby Elsevier.
2. The pediatric nurse utilizes Erikson’s developmental Leininger, M. (1988). Leininger’s theory of nursing: Cultural care diver-
model to help the 2-year-old master the stage of sity and universality. Nursing Science Quarterly, 1(4), 152–160.
autonomy. Which of the following will help the Meadows-Oliver, M. (2003). Mothering in public: A meta-synthesis of
homeless women with children living in shelters. Journal of the Society
toddler to accomplish this task? of Pediatric Nursing, 8(4), 130–136.
A. Allow the child to dress herself as much as Moorehead, S., Johnson, M., Maas, M., & Swanson, E. (2008). Nursing
possible. outcomes classification (NOC) (4th ed.). St. Louis, MO: C.V. Mosby.
B. Tell the parents to keep the child in view at all NANDA International (2007). NANDA-I nursing diagnoses: Definitions
times. and classifications 2007–2008. Philadelphia: NANDA-I.
National Academy Press: Children’s health, the nation’s wealth (2008).
C. Suggest colored mobiles be placed above the bed. Retrieved from http://www.nap.edu/openbook/0309091187/html/
D. Instruct the parents to rock the child once a day. 1.html (Accessed November 12, 2008).
National Association of School Nurses. Retrieved from http://www.nasn.
Select all that apply org/ (Accessed March 1, 2008).
3. Nurses have a responsibility to educate families about National Center for Injury Prevention and Control. Retrieved from http://
www.cdc.gov/ncipc/cmprfact.htm (Accessed March 1, 2008).
the information found in Healthy People 2010. Which of National Center for Medical Home Initiatives for Children with Special
the following are included as leading health indicators? Needs. Retrieved from http://www.medicalhomeinfo.org/ (Accessed
A. Reducing or eliminating various indigenous cases November 12, 2008)
of vaccine-preventable diseases. Tusek, D. (2008). What is guided imagery? Retrieved from http://www.
guidedimageryinc.com/guided.html (Accessed June 10, 2008).
B. Reducing the proportion of adolescents who are U.S. Department of Health and Human Services. Retrieved from http://
overweight. www.hhs.gov/about/whatwedo.html/ (Accessed March 1, 2008).
C. Decreasing the proportion of adolescents who U.S. Department of Health and Human Services Health Resources and
participate in daily school physical education. Services Administration, Maternal and Child Health Bureau (2008).
D. Reducing the proportion of adolescents with Retrieved from http://www.mchb.hrsa.gov/programs/ (Accessed
June 10, 2008).
Chlamydia infections. Walker-Brown, T. (2005). Parish nursing/health ministry: An emerging
health delivery system. Alabama Nurse, 32(2), 7.
Fill-in-the-Blank Ward, S. (2006). What healing means to nursing students: A phenome-
4. In order to provide effective pediatric nursing care nological study. Health Ministry Journal, 2(1), 15–27.
to a child, the nurse must incorporate the child’s Watson, J. (1996). Watson’s theory of transpersonal caring. In P. H. Walker
& B. Neuman (Eds.). Blueprint for use of nursing models: Education,
______________ ___________ into the plan of care. research, practice, and administration (pp. 141-184). New York: National
5. Pediatric nurses utilize ________________ _________ League for Nursing Press.
WebMD.Retrieved from http://www.webmd.com. (Accessed June 10,
to help decrease the stress and fear of hospitalization. 2008).
6. Providing culturally competent care means that a Wheeler, H.J. (2005). The importance of parental support when caring
pediatric nurse can integrate the family’s cultural for the acutely ill child. Nursing in Critical Care, 10(2), 56–62.
elements to enhance communication and work effectively
with one another.
CONCEPT MAP
What To Say:
• When a family asks about follow-up
care related to rehabilitation services
Clinical Alert:
• Admission to the hospital is a critical
• Common problems of the time for both the child and parents
child with a critical illness
– Shock
– Respiratory failure
– Infection
– Sepsis Issues Affecting Children/Families
– Renal failure • Hospitalization
– Neurological conditions – Effects of hospitalization on child
– Bleeding/clotting When Caring for the Family and parents
– Multiorgan dysfunction Across Care Settings • Ways to decrease effects of
hospitalization
– Family-centered care
Who
– Therapeutic play
Concerns of Care Across Settings – Help child gain control
• Pair advanced technology with – Compensatory care
Nursing Goals Children:
humanized care – Role modeling
– Provide family-centered care • Have distinct – Assist parent to adapt
– Ensure continuity of care health care needs
– Facilitate optimal health
– Provide anticipatory guidance What Illness Prevention
Health Promotion
• Teaching tips for families
Health Restoration
• Early disease detection
• Primary care provider Nurse: collaborative approach
Where • Hospital/ICU/ER • Evaluate financial concerns
• Ambulatory surgery/ and baseline knowledge
24-hour observation • Family education
• Community/ • Support medical/rehab services
school-based care/
specialty camps
How
Collaboration In Caring:
• Create a family-centered plan
of care Optimizing Outcomes:
• Places in community where Why • Emphasize optimization
care is delivered of preventative health
• Nurse’s role in and safety measures
screening/surveillance
LEA R NING T AR G ET S At the completion of this chapter, the student will be able to:
◆ Explain the importance of integrating aspects of developmental psychopathology, and
intergenerational transmission of vulnerability and resilience to form a framework to understand
how to promote children’s cognitive and psychosocial health.
◆ Explore intervention options for children with cognitive and psychosocial problems/disorders.
◆ Describe the influence of ethnicity and culture on the promotion of children’s cognitive and
psychosocial health.
◆ Examine the incidence of the various cognitive and psychosocial problems/disorders.
◆ Relate how developmentally sensitive approaches are used in identification of disorders and
strengths used to devise a care plan.
◆ Describe criteria for referring children for mental health evaluation or psychological testing.
The purpose of this study was to examine the relationship For study purposes, alcohol use was defined as “drinking a
between depressive symptoms and the early onset of alcohol full can or bottle of beer, a glass of wine or wine cooler, a shot
use in children and adolescents. of liquor, or a mixed drink with liquor in it.”
The investigation was based on data from a longitudinal study Depressive symptoms were considered positive if reported by
of psychopathology in 2491 children and early adolescents, ages either the parent or child. The numbers of depressive symptoms
5–13 years. A subsample of 1119 children ages 10–13 years who were measured in categories: ⬍2 (low level depressive symptoms);
reported never having used alcohol at the initiation of the study 2–9 (medium-level depressive symptoms); and ⬎10 (high-level
also completed the baseline and follow-up interviews. All of the depressive symptoms). Parents were asked about the presence of
children in the study had a Puerto Rican background. emotional, alcohol, or drug problems in either parent.
Data collection included several types of measurements: Parents completed a “parental monitoring” Likert-type scale
A structured interview was conducted with both parents and that consisted of nine questions. The purpose of the tool was to
children. The interview included assessing the children for affec- determine how often the parent monitored the child’s television
tive disorders, anxiety disorders, disruptive behavior disorders, watching, video game playing, and other activities in or outside
and substance abuse and dependence disorders using the Diag- of the home. A high score indicated a high level of parental
nostic Interview Schedule for Children (DISC-IV) and based on monitoring.
the criteria identified in the Diagnostic and Statistical The parents’ use of discipline was measured through an
Manual of Mental Disorders, 4th ed. (DSM-IV). interview that consisted of six items regarding the use of physical
(continued)
717
718 unit seven Ongoing Care of the Child in the Hospital and in the Community
Vulnerability and Resilience beliefs about health). Race is used to describe categories of
people, mostly based on physical characteristics (e.g., skin
Vulnerability and resilience are important topics in the care color, shape of nose).
of children. The intergenerational transmission model is Another issue that deserves a great deal of attention
based on the premise that vulnerability toward maladjust- from the nursing community involves health disparities.
ment or resilience in the face of adversity may be passed on There is vast information research indicating that health
from one generation to the next. It is important that the care disparities in racial and ethnic minorities are wide-
nurse working with children and their families have a good spread compared to those in non-minorities, and barriers
understanding of the key concepts of intergenerational such as mistrust, fear, and discrimination stand in the way
transmission of vulnerability and resilience. Vulnerability is of optimal mental health outcomes in ethnically diverse
defined as “a predispositional factor, or set of factors, that families (Heffernan, 2004). For instance, the nurse must
makes a disorder state possible” (Ingram & Luxton, 2005, recognize that new immigrants may be concerned with
p. 34). Children with resilience show positive adaptation learning the language and getting and keeping a job, and
despite significant life adversity (Cicchetti, 2003). may focus only on their children’s basic health care needs
(e.g., vaccines, treatment for ear infection) and may not at
all attend to children’s cognitive and psychosocial health
Optimizing Outcomes— Understanding resilience needs. It is important that the nurse do a thorough assess-
in the face of vulnerability ment of health care needs, including cognitive and psy-
It is important to keep in mind that not all offspring of chosocial wellbeing.
parents with mental health issues go on to develop mental Given the magnitude of mental health disparities in
health-related problems themselves. In fact, the children of children and adolescents, nurses at all levels of practice
parents or caregivers with mental health issues who do not along with other health care providers must become bet-
exhibit any maladjustment or symptoms of mental health ter prepared to implement strategies designed to reduce
problems during childhood are known to be resilient chil- health care disparities. In particular, nurses are well
dren (Hammen, 2003). Researchers in this area of study positioned to take a leadership role in the movement
found that much can be learned about mental health well- toward abating and eliminating health care disparities
being from these children. The best outcome gained from (Heffernan, 2004).
this knowledge can be used to prevent and promote good
mental health for all children.
Nursing Insight— Understanding mental health
disparities in children
Culture, Diversity, and Health In contrast to younger children, adolescents have the nec-
Disparities essary cognitive and social structures to be able to perceive
discrimination. In a study with Latino children and adoles-
The anthropological model of culture, ethnicity, and race cents, researchers found that adolescents who perceived severe
disputes beliefs that culture and race are innate (Smedley discrimination had poorer mental health outcomes compared
& Smedley, 2005). Within an anthropological framework, with their peers (Szalacha et al., 2003). This indicates that
culture and race are learned behaviors. This dynamic view children’s perceptions about how they are treated make an
can be used to illustrate the value of how culture and important difference in their own mental health outcomes. It
diversity influence children’s and families’ cognitive and is therefore important for the nurse to assess children’s per-
psychosocial health. Culture is considered to be an exter- ceptions of how they are viewed by others, including health
nal and acquired phenomenon. It is the complex set of care professionals.
beliefs and attributes passed on within a group. Ethnicity
refers to groups of people who share similar cultural char-
acteristics (i.e., common language, religion, food, and
Ethnocultural Considerations— Promoting
understanding of culture in diverse families
where research and practice meet: It is important that nurses gain an in-depth understanding
Is Mental Illness Passed Along to Children? regarding the culture of various people; acquire sensitivity and
In a study of 166 low-income and racially diverse adolescent chil- empathy in working with diverse families (e.g., give up pre-
dren of mentally ill mothers, Mowbray et al. (2004) discovered that conceived notions or generalizations about particular ethnic
the majority of children (30.1%) were actually socially and academi- or racial groups); and attain skills in relationship building
cally proficient, whereas, 15.1% of the children showed anxiety and with children, adolescents, and parents/caregivers of various
depression with poor social and academic competence. In addition, ethnic and racial backgrounds. It is recommended that nurses
27.1% of the children were delinquent and peer-oriented, and 4.8% working with children and families of diverse socioeconomic
were classified as isolated noncomformists. Of the total children,
backgrounds take an approach of listening, providing as much
22.3% were in the middle of these groups (Mowbray et al., 2004).
The intergenerational transmission of vulnerability and resilience positive feedback as possible for what families are doing well
model is important to consider while the nurse conducts assessment, and keep resilience-promoting strategies in mind. Using antic-
formulates a nursing diagnosis, devises preventive interventions or ipatory guidance, nurses working with children and their
plan of care for the child or family, and finally executes evaluation. families may be most effective suggesting alternative ways of
handling a specific cognitive or psychosocial-related concern.
720 unit seven Ongoing Care of the Child in the Hospital and in the Community
In this way, nurses can provide health and psychoeducation in Psychopathology in Children
a nonthreatening way to help families decide what works best
for them. Children and adolescents are not immune to mental and
emotional illnesses. Mental illness in children and adoles-
There is also a flawed belief that poverty predisposes cents may be confusing and frightening for children and
children and families to mental illness. Although it needs families. The disorders can be quite devastating, particu-
to be studied more thoroughly, there is evidence suggest- larly if they are not detected and treated.
ing that poverty by itself does not cause mental health
problems in children and families (Rutter, 2003). Strate- ANXIETY
gies outlined above for nurses to decrease health care dis- Anxiety disorders are among the most common psychiat-
parities also apply in working with families who may be ric complaints in children. While children commonly
poor, disenfranchised, affected by substance abuse, family experience transient anxieties at various developmental
violence, and child maltreatment. points, clinically significant anxiety must be recognized as
a problem. It is important to distinguish between develop-
mentally expected anxiety, anxious temperament, and
Barriers to Child and Adolescent symptoms of a disorder. The following diagnostic catego-
Mental Health ries related to anxiety disorders have been identified in the
Diagnostic and Statistical Manual (DSM-IV-TR): separa-
There are a number of barriers to the diagnosis and treat- tion anxiety disorder (SAD), generalized anxiety disorder
ment of children’s cognitive and psychosocial health. A (GAD), specific phobia, panic disorder, social phobia,
brief overview is provided here to help the nurse gain an selective mutism, posttraumatic stress disorder, and
understanding of the issues in order to intervene to mini- obsessive–compulsive disorder (OCD) (American Psychi-
mize these barriers. Though there are increasing efforts to atric Association [APA], 2000). In separation anxiety dis-
educate the public, the stigma of mental illness continues order, children experience overwhelming fear of becoming
to be a major barrier to accessing mental health services separated from or losing a caregiver (Fig. 23-1). The nurse
for children and their families (Hinshaw, 2006). The understands that some degree of separation anxiety is
health care community and the lay public have long been normal at various stages of development and during tran-
skeptical about whether young children, in particular, sitions, but if the anxiety is severe and excessively disrup-
experience clinically significant mental health disorders, tive, and if it persists for longer than 4 weeks, the child
such as depression. There is a prominent belief that child- should be evaluated by a mental health professional. In
hood is a “sacred” happy time free of problems. Health GAD, children experience excessive worry about every-
care providers have also had a role in perpetuating barri- thing, including peer relationships, social acceptance, and
ers by minimizing or dismissing parents’ or caregivers’ pleasing others. Specific phobia refers to unrelenting fear
concerns. Parents may be told that the child is simply of certain objects or situations (i.e., spiders, storms,
going through a stage that will pass, when there are snakes, water). These may be difficult to evaluate because
indeed grounds for concern (e.g., early signs of autism
spectrum disorder). It is important for the nurse to under-
stand that this type of thinking may lead to several issues
for children, adolescents, and their families such as:
(1) not getting screened on a timely basis for disordered
behaviors and emotional difficulties that often can be
attenuated or resolved if early intervention is sought in a
timely fashion; (2) having a sense of shame for the family
if a child or adolescent is eventually diagnosed with a
mental health problem that might have been prevented or
attenuated earlier; and (3) inability to receive adequate
mental health or psychosocial treatment when indicated
because of lack of resources (Hinshaw, 2005).
at each developmental stage children and adolescents lessen their impact on children. Simply paying attention
have various expected fears. Panic disorder usually begins to any signs of anxiety (SAMSHA, n.d.) is the first step in
in adolescence but may start earlier. Symptoms of a panic recognizing clinically significant symptoms. The nurse
attack might include palpitations, sweating, shaking, nau- should refer a child to a mental health professional if the
sea, dizziness, fear of dying, tingling sensations, chills, or child’s anxiety interferes with normal functioning or if it
hot flushes. Selective mutism refers to a child’s enduring persists regardless of attempts to reassure the child. The
refusal to speak in certain situations. This refusal inter- nurse can provide health teaching related to what makes
feres with the child’s functioning and development and is the child anxious or worried and how to cope with such
not due to physiological or deficit of knowledge. Posttrau- worries. Teaching may involve teaching relaxation and
matic stress disorder occurs in response to a perceived deep breathing as well as problem-solving techniques
or actual threat to one’s life or safety. There is a clear (Tomb & Hunter, 2004). Young people are more likely
precipitant and a reaction is generally understandable. to respond to someone who takes the time to listen
The response may persist for weeks, months, or years and care.
and is accompanied by panic symptoms. In obsessive– Current Western culture is filled with scary images,
compulsive disorder (OCD), the child experiences whether in the form of games, movies, television, or actual
sometimes debilitating recurrent worries or thoughts events in the news. It is important for the nurse to under-
(obsessions) and repetitive actions or thoughts that to stand and to help parents think about how and when to
bind the anxious thoughts (compulsions). protect children from the influx of information that might
It is estimated that 13% of children between the ages be overwhelming.
of 9 and 17 suffer with some type of anxiety disorder There are several evidence-based therapies provided by
(Substance Abuse and Mental Health Services Administra- qualified advanced practice clinicians. The pediatric nurse
tion [SAMHSA], n.d.). Nearly 50% of children with anxi- can be aware of some of these therapies in order to assist
ety disorders have at least one other psychiatric disorder parents in finding a referral. The Coping Cat program is
(SAMSHA, n.d.). designed for children ages 7 to 13 with anxiety disorders
and the CAT program is for adolescents (Kendall, Aschen-
Signs and Symptoms brand, & Hudson, 2003). Both of these cognitive–behav-
It is important for the nurse to understand normal devel- ioral programs are designed to help the child develop
opmental anxiety. This understanding provides a baseline skills to cope with anxiety, as well as techniques to
from which to judge the occurrence of clinically signifi- decrease fears through systematic exposure to the feared
cant distress. Anxiety is an important factor in motivation object. These programs are intended to be used with chil-
and alertness. Worries and fears are a part of every devel- dren and adolescents who have SAD, GAD, and social
opmental stage, even throughout adulthood. An occa- phobia.
sional bout of feeling nervous accompanied by sweating, The FRIENDS program was designed for the parents as
nausea, diarrhea, worry, and/or tearfulness is well within well as their children with anxiety disorders (Barrett &
normal limits. But when the anxiety does not abate or it Shortt, 2003). It is similar to the Coping Cat in that it uses
gets worse with time, it may be indicative of an anxiety cognitive–behavioral techniques to help children and their
disorder. The nurse should question a child’s or adoles- families cope with anxiety. FRIENDS is an acronym for
cent’s level of anxiety if it does not respond to reassurance Feeling worried? Relax and feel good. Inner thoughts.
or closeness with a safe person or if it interferes with Explore plans. Nice work so reward yourself. Don’t forget to
functioning. practice. Stay calm, you know how to cope. This program
Anxiety often presents in the form of somatic com- has proved to be useful in reducing the risk of development
plaints like stomachaches and restlessness (Ginzburg, of anxiety disorders in children (Barrett, Farrell, Ollendick,
Riddle, & Davies, 2006). The school nurse can recognize & Dadds, 2006), but has proven less useful when used to
anxiety problems when a child persistently presents with prevent depression (Spence & Shortt, 2007).
symptoms that do not have a recognizable physical
cause. Complementary Care: Mindful breathing
Children or adolescents with clinically diagnosable
anxiety disorders may suffer from persistent worry, Mindfulness means paying attention in the present moment.
unfounded fears, separation difficulties, sleep problems, Paying attention to one’s breathing may be a way of coping
or obsessions or compulsions (Cleveland Clinic, 2007). with anxiety. The teaching works best before an anxiety
Anxious children may also resist going to school or stay- episode.
ing there after arriving. They may avoid play time, even The nurse teaches slow breathing by telling the child to
with good friends, and not be able to explain why. (Fig. 23-2):
• Consciously direct your attention to your breathing.
Diagnosis
• Breathe in slowly, paying attention as the air enters nose
As with any emotional or psychiatric difficulty, a complete and mouth and filling your lungs.
physical, psychosocial and family history helps reveal • Breathe out slowly, paying attention as the air leaves
genetic, biological, and familial contributors to anxiety. your body.
• Allow your mind to follow the breath in and out.
Nursing Care
• Imagine yourself in a rubber raft riding the gentle waves
There are specific interventions that a nurse may do to of your breath.
help prevent anxiety disorders from occurring or to
722 unit seven Ongoing Care of the Child in the Hospital and in the Community
Diagnosis
A complete history reveals a traumatic event(s) that may
POSTTRAUMATIC STRESS DISORDER help diagnosis PTSD. Diagnosis is based on the symptoms
Posttraumatic stress disorder (PTSD) is an anxiety disor- and reaction(s) to the event.
der that occurs in response to a real or perceived trauma
or threat to one’s life or safety. PTSD in young children Nursing Care
has been the subject of great debate at professional meet- Many children who endure posttraumatic distress may
ings because not all children who have endured trauma not be brought into a health care facility for clinical inter-
present with a neat and simple set of symptoms (Scheer- vention. A significant number of seriously traumatized
inga, 2006). children enter treatment through the court system after
It is known that the types of events that are experi- having experienced abuse or serious loss within the family
enced by young children as traumatic are similar to those of origin (Osofsky, 2004). The nurse may come in contact
of older children, adolescents, adults, and elderly (e.g., with these children in primary care or in school or other
automobile crashes, natural disasters, war, witnessing settings.
brutal deaths) (Scheeringa, 2006). Other types of trauma, In the community, the nurse can be instrumental in
like physical or sexual abuse, or witnessing of domestic educating parents about the symptoms and helping the
violence can be devastating for the child and can cause family and child by making referrals for appropriate
PTSD that persists even into adulthood if not treated. services. The nurse can reinforce that it is important to
Children who endure trauma often exhibit additional provide a secure base for the child, one that includes fam-
symptomatology to that of PTSD and frequently may suffer ily or caregiver’s willingness to be available to and comfort
from comorbid disorders such as depression, conduct the child without judgment.
disorders, and other anxiety disorders as well as physical Be aware of resources available that might provide play
disorders. While the current DSM-IV-TR (APA, 2000) crite- therapy for young children and their parents (Van Horn &
ria are not developmentally sensitive for young children, Lieberman, 2006) or cognitive behavioral therapies (CBTs)
they are used by most clinicians to help develop a diagnosis. for older children. The nurse can also teach the family that
Many children do not experience all of the criteria required pharmacotherapy with selective serotonin reuptake inhibitors
to meet the DSM diagnosis, but children can still suffer (SSRIs) has also been known to be effective in adolescents
greatly with the anxiety resulting from the original trauma. (Commission on Adolescent Anxiety Disorders, 2005).
Implementing nursing care similar to that given with
Nursing Insight— Posttraumatic stress disorder any anxious child may help to allay fears. During an acute
in adolescence panic episode when the child is re-experiencing the trig-
gering event or feels completely out of control, the nurse
Adolescence is a time of experimentation and of a sense of must remain with him, talk soothingly, and reassure the
invincibility. For those reasons, adolescents may be more child that the nurse is providing personal safety.
likely to be in a position to experience traumatic events, thus
being exposed to the possibility of PTSD. In a survey of
American adolescents, researchers found that 23% had been Mood Disorders
both a victim and witness a traumatic event (i.e., assault) and
more than 20% had symptoms that met criteria for PTSD Similar to adult psychiatric disorders, pediatric mood disor-
(Commission on Adolescent Anxiety Disorders, 2005). ders may take the form of major depression (serious, time-
limited depression), dysthymic disorder (longer-term, less
chapter 23 Caring for the Child with a Psychosocial or Cognitive Condition 723
intense depression), or bipolar disorder (consisting of mood in solving problems, responding to caregivers or
swings between depression and mania). These disorders are sustaining attention. An example is a drop in grades
sometimes more difficult to diagnose in children and adoles- and/or school performance.
cents than in adults because of developmental phases and • Recurrent thoughts of death or suicide with or without
the lack of language and cognitive skills to describe symp- a suicide plan, and in younger children consistent
toms and experiences. Health care providers may also not engagement in activities or play that involve themes of
have adequate knowledge about prior symptoms. death and suicide.
Depression in infants may include:
DEPRESSION
• Listlessness without physical cause
Infants born of mothers who have been significantly
• Failure to respond to caregiver
depressed or stressed during pregnancy can exhibit depres-
sive symptoms (listlessness, failure to attach, irritability) The nurse understands that symptoms in the infant
(Commission on Adolescent Depression & Bipolar Disor- and very young child mirror the symptoms of attachment
der, 2005). Likewise, infants who are unable to attach disorders and failure to thrive.
securely or who are listless or irritable may be difficult for
the mother to care for and show attachment. This behavior Diagnosis
can perpetuate disengaged attachment and depression in Diagnosis is based on the exhibited depressive symptoms.
the infant. Some studies have indicated that children as
young as 3 years old are capable of experiencing depressive Nursing Care
disorders (Luby et al., 2003, 2006). These depressions may The most important aspect of helping a depressed
be related to environmental factors combined with genetic child is to ensure safety. It is recommended that any
and biological factors. nurse working with a child who is depressed under-
Depressive symptoms are estimated to occur in 10% to stand how to deal with the potential suicide ideation or
15% of children and adolescents. Untreated depression in intent.
a young person often increases the likelihood of recurrent Since depression often goes unrecognized in children
depression or bipolar illness later in life. For this reason it or adolescents, the nurse can be instrumental in determin-
is important to recognize and treat depression early on ing its presence. Pediatric and school nurses are in a posi-
(SAMHSA, n.d.). tion to observe changes in a child’s behavior and demeanor
as well as grades. Developing a trusting relationship with
Signs and Symptoms a child and asking about feelings or thoughts may provide
Five key features must be present and persistent for evidence of underlying depression and provide the child
most days during a period of 2 weeks for the diagnosis with a first step in feeling better. Nurses should talk with
of a major depressive disorder in children and adoles- the parent(s) or caregiver(s) of a child about suspected
cents. The nurse must remember that children can have depression and suggest referral to a counselor for evalua-
just a few of these depressive symptoms that will inter- tion and treatment.
fere with optimal functioning. This list of symptoms
was compiled based on several diagnostic classification BIPOLAR DISORDER
publications to reflect a developmentally sensitive
Bipolar disorder (BPD), also known as manic–depres-
criterion (APA, 2000; Greenspan, 2005; Zero to Three,
sion, is a mood disorder that is evidenced by significant
2005b):
mood swings (from depression to mania). It is thought
• Persistent sad or irritable mood—by subjective that childhood or adolescent onset bipolar disorder may
report (e.g., sad or empty) or observed by others have an extended early course and may respond less
(e.g., appears tearful). This mood is different from
the child’s baseline emotional and behavioral state,
and is unrelated to events that may cause temporary
distress or sadness (e.g., getting a time-out).
• Loss of interest in activities once enjoyed (anhedonia)— medication: Somatic Therapies for Depression
reported by child or observed by others.
Serotonin Selective Reuptake Inhibitors (SSRIs):
• Significant change in appetite or body weight—weight Open-label studies suggest that fluoxetine (Prozac) is an effective
loss or gain reflected by more than a 5% change in medication in the treatment of pediatric major depression and dysthy-
body weight. mia in patients with and without co-occurring mental health disorders
• Difficulty sleeping or oversleeping—insomnia or (Findling, Feeny, Stansbrey, Delorto-Bedoya, & Demeter, 2001). This
hypersomnia (excessive sleep). type of medication has been used in children as young as 8 years old
• Physical agitation or slowing—observed by others and (National Institute of Mental Health [NIMH], 2001). Other SSRIs are
the child’s subjective report of being restless or “slowed used off-label (meaning use other than specifically approved for by
down.” the Food & Drug Administration [FDA]) such as sertraline (Zoloft),
• Fatigue or loss of energy. paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexipro), or
fluvoxamine (Luvox) have also been prescribed by some clinicians
• Feelings of worthlessness or excessive/inappropriate
(NIMH, 2001).
guilt. NOTE: Recent evidence that SSRIs can contribute to suicide ideation in
• Decreased ability to think or concentrate or to make adolescents and children have left many parents and physicians leery
decisions as self-reported or observed by others, and of using this medication to treat depression in young people.
in younger children this sign may appear as difficulty
724 unit seven Ongoing Care of the Child in the Hospital and in the Community
N u r s i n g C a r e P l a n Depressed Child
Nursing Diagnosis: Self-Esteem: Situational Low related to cognitive and perceptual distortions
Measurable Short-term Goal: Child will use positive talk to interrupt negative thinking about self.
Measurable Long-term Goal: Child will demonstrate increased self-esteem by accepting positive feedback
from others
NOC Outcome: NIC Interventions:
Self-Esteem (1205) Personal judgment of self-worth Self-Esteem Enhancement (5400)
Active Listening (4920)
Nursing Interventions:
1. Listen actively to child, displaying interest without judgment or responding too quickly.
RATIONALE: Active listening shows attention to the message and respect for the child’s thinking and
perceptions.
2. Monitor and help the child to identify statements reflecting perceived self-worth.
RATIONALE: Provides information about distorted or negative perceptions.
3. Assist the child to examine perceptions of self reflected in negative “self-talk” and turn these into positive
statements of self-worth.
RATIONALE: Allows replacement of negative self-evaluations with positive statements that enhance
self-esteem.
4. Encourage the child to identify personal strengths and accept valid positive responses from others.
RATIONALE: Helps the child develop positive self-esteem.
5. Assist child to set realistic goals to enhance self-esteem, providing appropriate praise or rewards for
progress.
RATIONALE: Positive reinforcement supports progress in meeting realistic personal goals.
Although young children do not have distinct episodes nurse can have the family visit the following Web site for
of mania, children may have severe mood dysregulation more information about bipolar disorder: http://www.
with multiple, intense, prolonged mood swings each day bpkids.org, a parent-led organization that provides
(Kowatch et al., 2005). Also, children are more likely to supportive information for children, caregivers, and
display irritability or destructiveness than adults who dis- families.
play euphoria.
Now Can You— Differentiate between depression and
Diagnosis bipolar disorder?
Diagnosis is based on a thorough history and physical as 1. Describe the signs and symptoms of depression and bipolar
well as the identification of the significant mood swings disorder?
(from depression to mania). Often family members or sig- 2. Describe nursing care for the child with depression or
nificant others can describe the behavior that may help bipolar disorder?
lead to a diagnosis.
Nursing Care
It is important for the nurse to recognize that if a child SUICIDE
is in an acutely manic state, the child is struggling Suicide represents a devastating consequence resulting
against an internal force and is not being a “bad child.” from any number of psychiatric difficulties. What was
The nurse can teach the family and the child, as well as relatively rare before the mid-1950s has now become an
model the following therapeutic parenting techniques alarmingly frequent occurrence. Barrio (2007) summa-
presented by the Child and Adolescent Bipolar Founda- rized potential factors that might influence a child or
tion (CABF, 2008): adolescent to consider or attempt suicide: (1) certain
psychiatric disorders that may be related to a sense of
• Practice and teach relaxation techniques
helplessness (depression, substance abuse, anxiety disor-
• Use firm restraint holds to control rages
ders, or aggressive disorders); (2) a history of family or
• Prioritize battles and let go of less important matters
friend having attempted or actually committed suicide;
• Reduce stress in the home
(3) personal or familial biological factors (related to
• Use good listening and communication skills
depression and/or impulsivity); (4) environmental fac-
• Use music and sound, lighting, water, and massage tors , such as accessibility of a means (guns, poison, etc.),
to assist the child with waking, falling asleep, and or lack of connection or supervision; previous suicide
relaxation attempts; and/or (5) disenfranchised status (sexual orien-
• Become an advocate for stress reduction and other tation, minority status).
accommodations at school According to the National Center for Health Statistics,
• Help the child anticipate and avoid, or prepare for suicide is the third leading cause of death in young peo-
stressful situations by developing coping strategies ple 10 to 24 years of age, which in 2004 translated in
beforehand into the following statistics: 1.3 children (ages 10 to 14)
• Engage the child’s creativity through activities that per 100,000, 8.2 adolescents (ages 15 to 19) per 100,000,
express and channel gifts and strengths and 12.5 young adults (ages 20 to 24) per 100,000.
• Provide routines, structure and freedom within Younger children more often resorted to suffocation as a
limits method to kill themselves while older children tended to
• Remove objects from the home (or lock them in a safe use firearms or poison. There were gender differences
place) that could be used to harm self or others during that identified males as four times more likely in their
a rage, especially guns adolescents and six times more likely in early adulthood
• Keep medications in a locked cabinet or box to succeed at suicide than females (Centers for Disease
It is also important to note that a person should be Control and Prevention [CDC], n.d.). This difference
present to care for a child experiencing a depressed may be due to the choice of method (males tend to chose
phase of bipolar disorder. Just in case the diagnosis of more lethal means).
bipolar disorder is missed, and an antidepressant is pre-
scribed, the nurse understands that an antidepressant Signs and Symptoms
could trigger mania. It is important to fully assess history The nurse should suspect suicide potential when faced
of symptoms and to teach the family what to watch for with any of the following in the child or adolescent:
in terms of the child’s reaction to the medication(s). The
• Symptoms of depression or other mental illness
• Alienation or withdrawal from friendships or
relationships
• Personality changes
medication: Valproate (Depakote) • Decline in schoolwork
• Giving away personal possessions that were once
The nurse needs to be aware that most medications used for
the treatment of bipolar disorder have not been studied specifically with
prized
children. Lithium carbonate (Eskalith, Lithobid) has been the most • Preoccupation with death in writing or drawings
common treatment. It is a mood stabilizer that calms the manic • References to dying or no longer being around
symptoms. • Access to a method of suicide (e.g., medications,
weapons)
726 unit seven Ongoing Care of the Child in the Hospital and in the Community
Diagnosis
clinical alert
Nursing Insight— Assessing the child for Suicidal behavior related to antidepressant therapy
suicide risk In 2006, the Food and Drug Administration (FDA) requested that
pharmaceutical companies manufacturing SSRIs add a “black box”
If the nurse is concerned that a child or adolescent might warning to the packaging. This warning is related to an apparent
be suicidal, the nurse must ask the child about suicidal rise in suicide in children and adolescents recently prescribed an
thoughts or behaviors. This information may help to save the SSRI for depression. Subsequent studies discussed by Goodman,
child’s life. Murphy, & Storch (2007) related that the increased incidence of
suicide ideation and attempt was not universal, nor was it related
• “Have you thought about doing something to hurt yourself only to those diagnosed with depression, but also in children taking
or take your life?” SSRIs for other disorders. The evidence is controversial because
• “Do you ever wish you were not alive?” other studies have shown antidepressants to be very effective in
• “What would you do if you were to hurt yourself?” decreasing the suicide risk by effectively dealing with the underlying
causes. Several factors have been proposed to explain the occur-
rence of suicidal ideation in children treated with these medications.
When a child or adolescent gives information that indi- (1) The prescription may be an inadequate dose and therefore the
cates risk for suicidal behavior, the nurse must take steps depression is not treated. (2) An energizing phenomenon, which
to keep the child or adolescent safe and make a referral for describes a situation in which the depressive symptoms related to
immediate mental health evaluation. energy decrease before the mood symptoms, may occur, thus
making it more possible for the depressed individual to have the
Nursing Care energy to attempt suicide. (3) The emergence of an activation
The school nurse is in a position to recognize children or syndrome may be related to a toxic reaction to the medication.
adolescents who might be suicidal. This care involves (4) Motor restlessness related to akathisia (motor restlessness that
may appear as a side effect of antipsychotic medication) may occur.
awareness of the signs of suicide ideation and the risk fac-
(5) A shift from depression to mania in a not-yet-diagnosed bipolar
tors that may precede suicide ideation. The nurse must child may occur. (6) Idiosyncratic reactions (perhaps related to
ask about suicide ideation. The nurse can discern: Does gene-drug reactions) may occur (Goodman et al., 2007).
the child have a plan? Is that plan possible (i.e., is the
means to self-harm accessible)? Has the child attempted
suicide before? Foremost, if any of these factors are pres-
ent, the nurse must refer the child (and family) to a men-
tal health professional that can assess the level of risk. The SCHIZOPHRENIA
child or adolescent may need immediate hospitalization to Schizophrenia is a serious chronic mental health disorder
remain safe. that is thought to be the result of abnormalities in neuro-
If danger is not imminent, the nurse can assist the child developmental processes that occur early (prenatal,
or adolescent and the family in identifying and further infancy, early childhood) as well as later (late childhood
developing the protective factors available to them. The and adolescence) in life (Bearden, Meyer, Loewy, Nien-
nurse can identify family strengths and resources available dam, & Cannon, 2006). The disorder typically begins in
in the community (crisis or suicide hot lines, counseling, late adolescence or early adulthood, but it is possible for
inpatient treatment facilities) to help protect the child. children as young as 5 or 6 to exhibit signs. Researchers
The nurse can also talk with the family about other mea- have found that the age at onset of schizophrenia plays an
sures that can be implemented to keep their child safe important role in the course and outcome of illness. The
(e.g., remove all guns or other weapons from the home, earlier the onset of symptoms occur, the greater the
ridding cupboards of poisons, locking medicines away, impairment (Bearden et al., 2006). Although schizophre-
monitor the child closely). nia is a chronic mental illness, early recognition and
Specific psychotherapeutic approaches like cognitive treatment can vastly improve the outcome for the child.
behavior therapy (CBT) or dialectical behavior therapy Untreated, schizophrenia can be devastating for the indi-
(DBT) focuses on helping the child and adolescent develop vidual and the family.
skills for coping with emotional intensity and impulsivity Schizophrenia is rarer in children younger than pre-
(Katz, Cox, Gunasekara, & Miller, 2004). Both types of adolescence. About 1% of the world’s population (adult,
therapy are performed by specifically educated clinicians, adolescent, and child) is identified with a diagnosis of
but the nurse, particularly in the hospital, can be support- schizophrenia (Nicholson & Rapoport, 1999, cited in
ive. Pharmacological treatments include medications to NIMH, 2001). Further complicating the diagnosis is that
treat the underlying psychiatric difficulty (Table 23-1). early symptoms are similar to those of pervasive develop-
In the community, the nurse can raise awareness about mental disorders such as autism. In some cases, it is
the programs that seek to prevent suicidal behavior in thought that a pervasive developmental disorder is a pre-
adolescents. There are some school-based programs that cursor of schizophrenia.
target students who are at-risk for dropping out of school
and assist the child or adolescent to remain involved in Signs and Symptoms
school. Once a child or adolescent has dropped out of The nurse knows that discerning the signs and symp-
school, economic and social changes also might play a toms of schizophrenia begins with a mental health inter-
role in suicidal thoughts. In addition, the child or adoles- view that includes a comprehensive developmental and
cent may be more susceptible to feelings of hopelessness family history. Schizophrenia typically has a gradual
and isolation. onset, is difficult to identify in young children, and may
chapter 23 Caring for the Child with a Psychosocial or Cognitive Condition 727
be indistinguishable from other disorders. The nurse organization is the National Alliance for the Mentally Ill
understands that it is important to recognize early signs (NAMI; www.nami.org) that provides parents and fami-
and symptoms and begin treatment as early as possible lies with important information. The nurse is in an ideal
(Commission on Adolescent Schizophrenia, 2005). position to help identify children and adolescents with
There are two types of symptoms in the presentation of early prodromal signs and refer for further evaluation,
schizophrenia. Positive symptoms are those that are gen- family psychoeducation, and other interventions such as
erally seen after observing and listening to the parent or understanding the importance of medication.
the child. These symptoms include hallucinations (hear-
ing voices, seeing things, experiencing strange sensa- AUTISM SPECTRUM DISORDERS
tions), delusions (false beliefs, i.e., beliefs that the radio is
sending special messages), and disorganized speech and Autism spectrum disorder (ASD) can be first diagnosed in
behavior (APA, 2000). Negative symptoms are less obvi- infancy or childhood. The DSM-IV-TR defines autism
ous. These symptoms include a decrease or “flattening” of spectrum disorder as a continuum of disorders that involve
affect (visible expression of mood), speech, and motiva- limitations in social relatedness, verbal and nonverbal
tion (APA, 2000). communication, and the range of interests and behaviors
(APA, 2000). There are five specific autism spectrum diag-
Diagnosis noses. Pervasive developmental disorder (PDD) is the term
A diagnosis of schizophrenia is based on a mental health used by DSM-IV-TR and is synonymous with autism
interview that includes a comprehensive developmental spectrum disorders. The five pervasive developmental dis-
and family history. If the child has had has a gradual onset orders include autistic disorder (serious deficits in the
of the signs and symptoms this condition may be suspected. development of social and communication skills accom-
Before the actual evidence of diagnostic symptoms there panied by significant repetitive behaviors), Asperger’s
is often a prodromal (period marked by a shifting in per- disorder (a milder form of autistic disorder), Rett’s disorder
sonality) and the emergence of “odd” behaviors (i.e., with- (a rare disorder that predominantly affects girls; develop-
drawal, obsessions, aloofness), thoughts (distractibility), or ment is normal until around 6 to 18 months when autistic
emotions (lability, anxiety). symptoms appear), childhood disintegrative disorder (a rare
Diagnosis may be confirmed by the presence of initial disorder in which the child usually develops normally until
and subsequent psychoses such as hallucinations, delu- age 2 before developing symptoms of autism; predominantly
sions, disorganized thinking and speech, lack of motiva- affects boys), and pervasive developmental disorder not oth-
tion and interest in life, and aberrant emotional expres- erwise specified (a disorder in which either autism or
sions (Bearden et al., 2006). Asperger’s is suspected but the diagnostic criteria are not
fully met) (APA, 2000; Ozonoff, Rogers, & Hendren, 2003).
Nursing Care
Early treatment for schizophrenia usually involves pharma- Signs and Symptoms
cological agents (e.g., atypical antipsychotics), adolescent Three clusters of symptoms characterize autism spectrum
and family psychoeducation, and brief psychotherapy aimed disorder (ASD). The first symptom cluster involves quali-
at increasing level of functioning. Treatment is usually tative impairment in social reciprocity which means the
divided into the acute and maintenance phase. To obtain the child is unable to engage in socially appropriate commu-
best outcome, the adolescent and family should always stay nication. This impairment is marked by poor eye
in treatment (Commission on Adolescent Schizophrenia, contact, lack of interest in other people, and failure to
2005). Acute treatment for active psychosis (hallucinations, interact appropriately with others.
delusions, fearfulness, acting out) consists of maintaining The second symptom cluster is characterized by
the safety of the child and others. It is frightening to lose communication impairment. The child either uses no
sight of reality. The child may act out against misperceived language at all, or exhibits deviant speech with errors in
threats and injure self or others. The majority of treatment tone, prosody, pitch, grammar, or pragmatics. Errors in
at this point is pharmacological adjustment. The nurse uses pragmatics, such as difficulty taking turns in conver-
therapeutic communication to convey a sense of security to sation, are particularly common in higher functioning
the child and family. It is also important to approach the individuals.
child in a calm and reassuring manner. If the symptoms are Restrictive and repetitive behaviors, interests, or activ-
severe the child may be hospitalized. ities characterize the third symptom cluster. Specifically,
The schizophrenic child will always need to take med- restrictive interests are narrow in focus, overly intense,
ications to control symptoms. Pharmacological treatment and/or unusual. An example might include experiencing
involves the use of antipsychotic medications such as sensory qualities of objects in unusual ways (e.g., sniffing
Risperidone (Risperdal), Olanzapine (Zyprexa), and qui- objects or playing with toys in unusual ways). Another
etapine fumarate (Seroquel). Other forms of care for the example of unusual interests would be a preoccupation
child include group training in social skill acquisition (as with the parts of a toy rather than enjoying the toy.
most schizophrenic children have inadequate social Restrictive behavior is characterized by unreasonable
skills) and cognitive behavioral therapy (CBT). Nursing insistence on sameness or following familiar routines in a
care also includes educating the child and family about very rigid or extreme way.
the importance of taking the medications and related side Repetitive behavior is a common symptom that is dis-
effects. Families of children with schizophrenia, like played by children with autism spectrum disorder through
those with any chronic difficult illness, may need ongo- repetitive motor mannerisms such as hand flapping or spin-
ing support. There are organizations that offer support ning or rocking, these movements are called stereotypies or
and advocacy for families of the mentally ill. One such tics (sudden uncontrollable movement or vocalization).
chapter 23 Caring for the Child with a Psychosocial or Cognitive Condition 729
Diagnosis
Nursing Insight— Autism spectrum disorders
In 2003, a partnership between the American Pediatric
The reported number of children with autism spectrum Association and the Center for Disease Control created a
disorders has increased since the early 1990s. Whether there is program called First Signs. This widely disseminated pub-
a true increase in prevalence or whether past rates were under- lic awareness campaign was designed to increase pediatric
reported is a matter of debate. The factors involved in under- primary care provider and parental awareness about the
standing the potential increase in prevalence include that the signs and symptoms of autism. Based on this awareness, a
true prevalence rates 10 or 20 years ago are difficult to ascer- thorough developmental history can be conducted that
tain retrospectively; changes in diagnostic criteria, e.g., the can lead to an early diagnosis.
concept of autism is now viewed as a spectrum of disorders; a
heightened public awareness of autism; and increased media Nursing Care
coverage of affected children and families. Also relevant is that Nurses who work in primary care settings can provide
in 1991, the US Department of Education added autism as a care for children with autism. Awareness of the need for
category for special education services. It is speculated that this early intervention is important because of the substantial
change led to increases in the number of children classified as cortical plasticity (the ability of tissues to grow during
autistic, because a diagnosis would allow children to take part early brain development). There are many successful non-
in available educational services (Yeargin-Allsopp et al., 2003). medical treatments for children with autism. One of the
The CDC estimates that 1 in 166 children are diagnosed with most important interventions involves early language
an autism spectrum disorder (CDC, 2004). development. Ozonoff et al. noted that “language func-
tioning is the strongest predictor of outcome in autism
and very limited language at age five is a powerful indica-
tor of severe handicap in adulthood” (2003, p. 134). Poor
critical nursing action Understanding Autism functional communication skills also contribute signifi-
cantly to the problematic behaviors that some autistic
Spectrum Disorder
children display (e.g., poor frustration tolerance and
The “First Signs” program uses the acronym Autism A.L.A.R.M. to aggression toward self or others). Equally important are
highlight important clinical guidelines: interventions that address social competence. The nurse
can teach parents that social skills training and acquisition
Autism is prevalent (Wiseman, 2006):
groups provide the child with an opportunity to learn and
• 1 out of 6 children are diagnosed with a developmental disorder practice appropriate social relatedness.
and/or behavioral problem. Using the actions suggested in the mnemonic
• 1 in 166 children are diagnosed with an autism spectrum disorder.
A.L.A.R.M., the nurse can assist the child and family in
• Developmental disorders have subtle signs and may be easily missed.
coping with this disorder. Children with autistic spec-
Listen to patients: trum disorders respond best to structure and predictabil-
• Early signs of autism are often present before 18 months. ity. Learning and social interactions should be approached
• Parents usually do have concerns that something is wrong. systematically and gradually, allowing the child to develop
• Parents generally do give accurate and quality information. comfort with the concepts (Wiseman, 2006). As with the
• When parents do not spontaneously raise concern, ask if they have schizophrenic child, it is important to stay aware of the
any concerns. child’s physical boundaries and reluctance to be touched
Act early: by others.
• Make screening and surveillance an important part of your practice
(as endorsed by the AAP).
• Know the subtle differences between typical and atypical Psychosocial and Cognitive Disorders
development.
• Learn to recognize red flags.
• Improve the quality of life for children and their families through
REACTIVE ATTACHMENT DISORDER
early and appropriate intervention. Reactive attachment disorder (RAD) mirrors the infor-
Refer: mation on attachment theory. It is important to note that
developmental research in attachment is vast and grow-
• To Early Intervention or a local school program (do not wait for a
diagnosis).
ing but that clinical research regarding attachment disor-
• To an autism specialist, or team of specialists, immediately for a ders is just beginning to emerge and there is much yet to
definitive diagnosis. be learned about assessment, prevention, and treatment
• To audiology and rule out a hearing impairment. (Stafford & Zeanah, 2006). There are few if any statistics
• To local community resources for help and family support. citing the incidence of RAD. It is reportedly a rare disor-
Monitor: der (APA, 2000). Adoptive and foster parents are most
frequently faced with attachment difficulties in children
• Schedule a follow-up appointment to discuss concerns more placed after the first 11 months of life.
thoroughly.
• Look for other features known to be associated with autism.
There are two types of RAD: emotionally withdrawn/
• Educate parents and provide them with up-to-date information. inhibited and indiscriminately social/disinhibited. The
• Advocate for families with local early intervention programs, inhibited RAD children usually lack the ability to seek and
schools, respite care agencies, and insurance companies. accept comfort, and to respond to or show affection.
• Continue surveillance and watch for additional or late signs of These children may have problems with emotion regula-
autism and/or other developmental disorders. tion evidenced by withdrawal, avoidance, and “frozen
watchfulness” (APA, 2000).
730 unit seven Ongoing Care of the Child in the Hospital and in the Community
The disinhibited RAD children usually show more abil- in treatment. Developing trust through meeting the child’s
ity to interact with caregivers but seek comfort and affec- basic needs or responding to cries or tantrums or listless-
tion from strangers indiscriminately (APA, 2000). This ness with patience and consistency is exceptionally impor-
describes the child who arbitrarily wanders off with any tant. A child with RAD has no true concept about which
stranger, not even thinking to turn back to ensure that the basic needs will be met.
caregiver is near. When a caring person is available to the infant or child
that person should receive support and education from pro-
fessionals. Nurses can work with all types of families such as
Nursing Insight— Understanding reactive foster care families, families with children adopted from
attachment disorder
institutions, and children in other situations to help the fam-
The nurse must first understand how the attachment system ily with RAD. It is important to let the families know that
works. Basically, the goal of the attachment system is designed while the children need loving and nurturing, they may
“to ensure survival of offspring by promoting mutual proximity rebuff the care that is offered. Nurses can also identify barri-
of infants and caregivers, thereby providing protection from ers to intervention that might include parental mental
danger” (Stafford & Zeanah, 2006, p. 231). Another role of the health needs, substance abuse, family violence, and trauma.
attachment system is to help with regulation of developing They can then mobilize the appropriate resources to involve
emotion in the infant and child (Stafford & Zeanah, 2006). The children and families into recovery. Child–parent psycho-
attachment system works in conjunction with other systems therapy is a respected intervention that should be consid-
that include affiliate, exploratory, and wariness (temperament) ered and nurses can connect families with these services
systems. (Van Horn & Lieberman, 2006).
clinical alert
Signs and Symptoms
Infants and children diagnosed with attachment disor- Dangerous “attachment therapies”
ders have usually endured neglect or maltreatment or Nurses should know that there is a group of therapies to avoid for
have experienced severe trauma. Many of these children children with attachment disorders because of coercive techniques
have been institutionalized during the first year of life employed, and in fact these therapies have been dangerous as
when the ability to connect with another is forming. The there have been child deaths related to treatment. These therapies
main sign/symptom is children who experience difficul- are usually known as “attachment therapy,” “holding therapy,”
“rage reduction,” and “rebirth” (Barth, Crea, John, Thoburn, &
ties attaching or bonding (even to a parent). Quinton, 2005; Stafford & Zeanah, 2006).
Diagnosis
There are currently no established tools to use to make a
diagnosis of RAD, but a thorough clinical interview and FAILURE TO THRIVE
observation is essential in identifying behaviors that suggest Failure to thrive (FTT) is not a diagnosis but a description
a diagnosis of attachment disorder (Stafford & Zeanah, of a condition that usually happens early in life when the
2006). Infants typically exhibit attachment patterns around infant does not meet age-appropriate weight gain (Locklin,
9 to 12 months of age. The pediatric nurse can aid in the 2005). It is known that FTT infants do not obtain or are
diagnostic process by observing how the child interacts unable to take in enough nutrition to adequately meet
around parents and strangers. standard growth and weight expectations.
The medical diagnosis of RAD as per DSM-IV-TR Certain situations from a mental health perspective are
(APA, 2000) requires that marked disturbances and related to the development of FTT. Families in vulnerable
developmentally inappropriate social relatedness symp- situations (e.g., poverty, young and/or single parent, men-
toms start before the age of 5 and must be evident in most tally ill or substance-abusing parents), or those in which
situations. child abuse or neglect exist, are at risk for FTT.
Bassali and Benjamin (2007) reported that in the
Nursing Care
1980s, 1% to 5% of the admissions to tertiary care for
Since attachment disorders in infants and children result children younger than 1 year were related to FTT and 10%
from the lack of opportunity to experience a caring rela- of outpatient visits were related to FTT. This condition is
tionship, this opportunity should be offered as a first step more common in underdeveloped countries where pov-
erty and hunger are more rampant. Poverty is by far the
greatest determinant in FTT (Block & Krebs, 2006).
where research and practice meet:
Signs and Symptoms
Patterns of Attachment
Assessment of the signs and symptoms of failure to thrive
Through the Strange Situation procedure (Ainsworth, Blehar, is accomplished by tracking the growth rate of the infant
Waters, & Wall, 1978) researchers are able to assess the infant’s or child to determine if an actual lack of adequate progres-
or children organizational patterns of attachment during low- and
high-stress episodes involving a caregiver. The patterns are divided
sion exists. Physical examination and evaluation of the
into three categories of strategies: secure organized, insecure child’s developmental status is also important, since lack
organized (avoidant, resistant, dependent), and insecure not orga- of sufficient nutrition on an ongoing basis will affect the
nized (disorganized, controlling, defended/coercive, unclassified) child’s cognitive and emotional development. Beyond
(Stafford & Zeanah, 2006). that, it is important to develop an understanding of the
underlying cause(s).
chapter 23 Caring for the Child with a Psychosocial or Cognitive Condition 731
Historically, health care providers distinguished FTT of the child, it must also encompass the emotional needs.
according to organic (medical conditions or illnesses that If the nurse suspects neglect or abuse, steps must be taken
would affect the child’s ability to take in or use nutrition) to the appropriate child protection agency.
versus nonorganic (related to abuse, neglect, or attachment
difficulties) classifications. In recent years, however, these nursing diagnoses Failure to Thrive
distinctions have been less useful as many children with
FTT exhibit symptoms of both causes (Block & Krebs, • Imbalanced Nutrition: less than body requirements related to inability to
2006). As a result, there is much less emphasis on attribut- ingest or digest food or absorb nutrients because of biological or
ing FTT to a problematic infant–caregiver relationship or psychological factors
maternal deprivation (Locklin, 2005). Still, psychosocial • Delayed Growth and Development related to inadequate caretaking,
factors cannot be ruled out without assessing the family environmental and stimulation deficiencies, or physical/psychosocial
situation as well as potential physiological causes. conditions
• Risk for Impaired Parenting related to unmet social and emotional needs
Diagnosis of parental caregivers, ineffective role modeling, insufficient knowledge
or crisis
Infants that have weights below the 3rd percentile or are
two standard deviations below the mean for their gesta-
tional age on standardized growth charts are commonly ATTENTION-DEFICIT/HYPERACTIVITY
diagnosed with FTT (Locklin, 2005) (Fig. 23-3). DISORDER
Attention-deficit/hyperactivity disorder (ADHD) is famil-
iar to parents, school teachers, and others who know the
Nursing Insight— Failure to thrive child. Images of the overactive, talkative child “bouncing
During a nursing assessment the nurse can discern: off the walls,” and always in trouble are likely portrayed.
ADHD is one of the most publicized and perhaps overdi-
• How does the caretaker interact with the child?
agnosed psychiatric conditions of childhood. A child can
• Are there signs of abuse or neglect?
have attention-deficit disorder with or without hyperac-
• Does the caretaker understand appropriate feeding amounts
and routines?
tivity. The category of ADHD without hyperactivity typi-
• Does the caretaker mistakenly believe that a healthy adult
cally has symptoms of distractibility. While ADHD with-
diet (i.e., lower fat) is also healthy for an infant?
out hyperactivity garners much less attention than ADHD
with hyperactivity, it can cause just as much difficulty in
the life of the child and the family.
The CDC indicated that a total of 4 million children
Nursing Care between the ages of 3 and 17 have been diagnosed with
A comprehensive history and physical examination are ADHD. This comprises 6.5% of the children of the num-
vital in identifying the source of the problem and develop- ber of U.S. children born since the diagnosis of ADHD has
ing a plan of care. There are sometimes challenging cases been used.
of FTT that require specialized intervention by develop-
mental pediatric or mental health care providers. Nurses Signs and Symptoms
can help identify these cases and provide education Symptoms of ADHD may include hyperactivity, impulsiv-
regarding feeding practices and the importance of support ity, distractibility, and inattention. Although ADHD is
for caregivers and families. The nurse can also provide most often diagnosed in early school-age children, symp-
support and reassurance to new mothers and caregivers toms can be seen in much younger children. Children
who are struggling with FTT infants and young children. with these symptoms often have difficulty with school
While nursing care must address the physiological needs performance as well as social and peer interaction. While
poor school performance is usually the driving factor in
seeking help for children with these symptoms, difficulty
with peer groups and family relationships are just as evi-
dent. Many children with ADHD also have comorbid con-
ditions such as depression, anxiety, oppositional defiant
disorder, and learning disabilities.
Diagnosis
Evaluations for ADHD are conducted by advanced prac-
tice nurses, physicians, and other heath care providers.
For appropriate assessment of ADHD, the child must first
meet the diagnostic criteria outlined in the DSM-IV-TR
(APA, 2000) (Table 23-2).
When the criterion is met, the final diagnosis requires
evidence of the child’s behavior in a variety of settings,
such as classroom, during homework, or playtime. Evi-
dence is obtained by asking parents, teachers, and other
caregivers to complete rating scales about behavior. Addi-
tional information needed includes the age at onset of
symptoms, duration of symptoms, and degree of impaired
Figure 23-3 Failure to thrive. functioning.
732 unit seven Ongoing Care of the Child in the Hospital and in the Community
medications from a number of categories such as stimu- premonitory urge (warning signal) (Spessot & Peterson,
lants for ADHD symptoms; antipsychotics for behavior 2006). Tics occur more frequently in children than in
regulation; mood stabilizers for regulation of high and low adults. The incidence is estimated to be 5 to 30 per
mood presentations; as well as antianxiety agents. 10,000. The tic can begin as early as 2 years of age and
Nurses who work with families that have children with can last throughout the lifetime with asymptomatic peri-
ODD or CD must be mindful of the stress that these dis- ods (APA, 2000).
orders have on the whole family. It may be exhausting for
parents to cope with the defiant behaviors. Siblings may Signs and Symptoms
be put at risk simply spending time with the misbehaved Children with Tourette’s syndrome often exhibit symptoms
child. Respite care (short-term care) can give the family a of other disorders, similar to obsessive–compulsive disor-
“rest” from the child who has the disorder. Encouraging der (APA, 2000; Leckman et al., 2006; Snider & Swedo,
family members to take care of personal needs as well as 2003), autism spectrum disorders (Canitano & Vivanti,
the child’s may be useful in helping them to find balance 2007), and ADHD (Leckman et al., 2006). Many of the
in daily living. symptoms are similar. Children with co-existing disorders
are more likely to suffer depression, low self-esteem, nega-
nursing diagnoses Oppositional Defiant Disorder and tive peer acceptance, and poor school performance than
Conduct Disorder those with tics alone (Leckman et al., 2006).