The association between Down syndrome and advanced maternal age has been long documented (Hook, 1981
). Maternal age of 35 years and older is associated with an increased risk of fetal death (Huang, Sauve, Birkett, Fergusson, & van Walraven, 2008
; Silver, 2007
) and obstetrical complications, perinatal morbidity, and mortality. Children born to mothers younger than 19 or older than 35 years of age have an increased risk of prematurity, congenital anomalies, and risks from other complications of pregnancy (March of Dimes, 2011a
). However, researchers report that pregnancy outcomes previously linked to maternal age are mitigated by poverty (Cunningham et al., 2010
; Markovitz, Cook, Flick, & Leet, 2005
). With poor socioeconomic status, the risk of perinatal morbidity increases after the age of 35, but with adequate income and healthcare, women in that age group experienced only a slight increase in gestational diabetes (GDM), pregnancy-induced hypertension, placenta previa or placental abruption, and cesarean birth (Markovitz et al., 2005
Complications common in pregnant adolescents include low birth weight, preeclampsia and pregnancyinduced hypertension, IUGR, and preterm labor. In younger mothers, socioeconomic factors largely explain increased neonatal mortality risk (Markovitz et al., 2005
). Although much of the literature links advanced maternal age to adverse perinatal outcomes, there is a paucity of data linking advanced maternal age with outcomes of preterm newborns. Recently, Kanungo and colleagues (2011)
reported that among preterm newborns, the odds of survival without major morbidity improved by 5% and mortality (8%), necrotizing enterocolitis (11%), and sepsis (9%) reduced as maternal age group increased by 5 years. Knowledge of these risks and outcomes serves as a guide for counseling women for whom age is a risk factor.
Medical and Obstetric History
Assessment of health factors that may influence pregnancy outcome includes careful evaluation of the woman’s individual medical, gynecologic, obstetric, psychosocial, and environmental history. Pertinent family history of the woman and her partner is necessary for complete evaluation. Maternal-family reproductive health history (e.g., preeclampsia, hypertension, diabetes, preterm birth) may be particularly significant. The additional physiologic stress of pregnancy affects chronic conditions (e.g., diabetes, hypertension, cardiac disease). Likewise, factors such as a recent history of STDs or chemical dependency may be indicative of lifestyle behaviors that threaten maternal-fetal well-being.
Obstetric history, such as length of previous labors, cesarean birth, birth weight, gestational age, history of preterm labor or preterm birth, grand multiparity, elective or spontaneous abortion, instrument-assisted birth, previous stillbirth, or uterine or cervical anomaly may indicate potential risks for the current pregnancy. Apply these risk factors within the context of the gestational age. For example, a history of preterm birth would be a pertinent risk to a woman who is presently at 20 weeks’ gestation but is not relevant when the woman is at 37 weeks’ gestation. Note familial history, including cardiac disease, diabetes, and bleeding disorders. The woman may also be affected by her mother’s
obstetric history. There is a familial predisposition to develop preeclampsia. The medical and genetic history of the birth parents serves to guide counseling and testing for predisposed genetic complications. The family history is the most important source of genetic information. The ideal time for genetic screening is before attempting pregnancy. Although general population screening is not considered appropriate, Williams and Lea (2003)
recommend that persons with the following conditions be offered genetic screening:
Developmental disability of unknown etiology, including women with developmental disabilities who present for preconception or prenatal care
Unexplained mental retardation or developmental delay, particularly if the member of the family is related to the patient through females
Family history of fragile X syndrome
Family history that suggests increased risk for specific autosomal recessive disease
Probably the most common indications for genetic counseling and prenatal diagnosis are maternal age and abnormal maternal serum screening. If the initial prenatal risk assessment reveals factors that carry risk for the baby (e.g., Tay-Sachs, sickle cell disease/trait, thalassemia, cystic fibrosis), the woman (and her partner) should be offered genetic counseling and additional testing if the woman so desires.
Genetic counseling has grown into a well-recognized specialty. Our understanding of genetics and genomics in healthcare has changed in recent years, however. Genetic conditions inherited in families are caused by gene mutations present on one or both chromosomes of a pair. The three main patterns of Mendelian inheritance are autosomal dominant, autosomal recessive, and X-linked (Fig. 4-1
). The term “genomics” refers to the study of all the genes in the human genome together, including their interactions with each other and the environment (Feetham, Thomson, & Hinshaw, 2005
). Genes can cause diseases, and they also may affect disease susceptibility and resistance, prognosis and progression, and responses to illnesses and their treatments. This range of responsiveness results in variable testing sensitivity, specificity, and predictive value of the genetic test (Feetham et al., 2005
FIGURE 4-1. The inheritance pattern of offspring when both parents are carriers of an autosomal recessive gene.
As knowledge of the behavioral, environmental, and genetic mechanisms of disease increases, individuals and families will need to reframe their concepts and experiences with diagnosis, treatment, and prevention (Feetham et al., 2005
). Therefore, individualized education, planning, and support are vital to the process of genetic counseling. Genetic counseling and fetal surveillance techniques force a woman (and her partner) to consider the amount and kind of information desired, subsequent decisions related to that information, and what those decisions may reflect about their self-image and personal values. Nurses are knowledgeable, nonthreatening confidants as the woman and her partner sort through the information and decision making. Nurses, therefore, need to be cognizant of the benefits, limitations, and social implications of the counseling and testing process.
Lifestyle or behavioral factors significantly affect women’s health in general and perinatal health specifically. Living conditions, marital status, occupation, nutrition, and use of tobacco, alcohol, and illicit substances can all affect pregnancy outcome. Socioeconomic factors may influence gestational age at entry to prenatal care, nutritional status, and availability of support systems. Number of years of
completed maternal education has been correlated with birth weight, perinatal mortality and morbidity, and neonatal neurologic sequelae. In general, as years of maternal education increase, incidence of perinatal mortality and morbidity decreases. Not surprisingly, adolescents are more likely to begin prenatal care later than adults (March of Dimes, 2011b
). Pregnant women who have more education are more likely to start prenatal care early and have more visits. Between 1989 and 1997 (the last data analysis that was performed), the percentage of women with delayed prenatal care or no prenatal care decreased from 25% to 18%, with improvement in both delayed prenatal care (from 22% to 16%) and in no prenatal care (from 2% to 1%). Groups more likely to have delayed or no prenatal care between 1989 and 1997 included non-Hispanic blacks, Hispanics, women aged <20 years, women with <12 years of education, and multiparous women (CDC, 2000
). This association may be a reflection of education as an indicator of socioeconomic status. Women in lower socioeconomic groups tend to initiate prenatal care later than their middle socioeconomic group counterparts. The three most common reasons for late entry into care are (1) no knowledge that she was pregnant, (2) financial barriers, and (3) inability to get an appointment (CDC, 2000
The marital status of the mother and the presence of the father as related to perinatal outcome are complex social phenomena. Marital status may be a marker for the presence or absence of social, emotional, and financial resources. Infants of mothers who are not married have been shown to be at higher risk for poor outcomes. In 2006, infants of unmarried mothers had an infant mortality rate of 9.19 per 1,000, 80% higher than the rate for infants of married mothers (Mathews & MacDorman, 2010
Findings of older studies demonstrated an increase in perinatal morbidity and mortality associated with single motherhood (Bennett, Braveman, Egerter, & Kiely, 1994
; Cooperstock, Bakewell, Herman, & Schramm, 1998
; Hein, Burmeister, & Papke, 1990
; Luo, Wilkins, & Kramer, 2004
; Mathews, MacDorman, & Menacker, 2002
). That unmarried mothers often are younger, are less well educated, and have a lower socioeconomic status than married mothers was controlled for in the older studies. More recently, births to women who live in an intimate relationship with a partner but without legal marriage have become increasingly common and widely accepted in many Western societies. However, pregnancy outcomes are worse among mothers in common-law unions versus traditional marriage relationships. One study found an overall 20% increase of adverse outcomes in unmarried, cohabiting mothers, and that free maternity care did not overcome the difference (Raatikainen, Heiskanen, & Heinonen, 2005
. The highest incidence of perinatal morbidity and loss occurs in families where the father is not present (Luo et al., 2004
When employment status of the Finnish parents in 24,939 pregnancies was examined, unemployment was associated with adolescent maternal age, unmarried status, overweight, anemia, smoking, alcohol consumption, and prior pregnancy terminations. Although antenatal care is free in Finland, this was unable to fully overcome the adverse pregnancy outcomes associated with unemployment, and small-forgestational-age risk is highest when both parents are unemployed (Raatikainen, Heiskanen, Verkasalo, & Heinonen, 2006
The cause of congenital malformations can be divided into three categories: unknown, genetic, and environmental. The cause of a majority of human malformations is unknown. Both maternal and paternal environmental exposures can produce human developmental disease including preterm birth, growth restriction, functional or structural abnormalities, or death.
More than 50 teratogenic environmental drugs, chemicals, and physical agents have been described using modern epidemiologic tools and clinical dysmorphology. Severe congenital malformations occur in 3% of births. According to the CDC (Martin et al., 2006
), severe congenital malformations include birth defects that cause death, hospitalization, or mental retardation; necessitate significant or repeated surgical procedures; are disfiguring; or interfere with physical performance. Each year in the United States, 120,000 newborns are born with severe birth defects (CDC, 2008
). Our understanding of this process is evolving:
Whereas single genes and individual chemical exposures are responsible for some instances of adverse pregnancy outcome or developmental disease, gene-environment interactions are responsible for the majority. These gene-environment interactions may occur in the father, mother, placenta or fetus, suggesting that critical attention be given to maternal and paternal exposures and gene expression as they relate to the mode of action of the putative developmental toxicant both prior to and during pregnancy (Mattison, 2010, p. 208
Counseling regarding possible teratogenic influences should be performed in a factual yet sympathetic and supportive way so the woman is not unduly alarmed or burdened with guilt (ACOG, 1997
). Nurses should also be cognizant of the common potential teratogens in the population for which they provide care. For example, if the majority of the women come from an urban setting in which it is known that lead exposure is problematic, the history should include
special attention to the risk. Maternal blood lead levels of approximately 10 mcg/dL have been linked to increased risks of pregnancy hypertension, spontaneous abortion, and reduced neurobehavioral development in the child (Bellinger, 2005
Teratogen exposure may be associated with an occupation (e.g., X-rays, chemicals, viruses) or a lifestyle. The most common substances used by pregnant women include tobacco, alcohol, and marijuana. Alcohol is a potent teratogen in humans, and prenatal alcohol exposure is a leading preventable cause of birth defects and developmental disabilities. The harm from substance use and abuse is well known and may have disastrous effects in pregnancy, affecting all body systems and causing cardiac, pulmonary, gastrointestinal, and psychiatric complications. “Although the prevalence of substance abuse is significantly lower in pregnant women compared to nonpregnant women, some groups remain vulnerable to continued use, including those who did not intend to get pregnant and those who are less educated, unemployed, unmarried, and exposed to violence” (Massey et al., 2011, p. 143
). The effects of tobacco use in pregnancy are well documented. No amount of alcohol is safe in pregnancy. Marijuana is the most commonly used illicit substance taken during pregnancy. The impact on the child is not clear. While prenatal marijuana use does not increase the risk of preterm birth, birth defects, or mortality in the first 2 years of life in exposed infants, emerging evidence indicates effects on later functioning. These effects include cognitive deficits, especially in visuospatial function, impulsivity, inattention and hyperactivity, depressive symptoms and substance use disorders, and cancer (Gray, Day, Leech, & Richardson, 2005
; Huizink & Mulder, 2006
). Methamphetamine abuse is becoming more common among women of reproductive age. “Meth,” also known as speed or chalk, or as ice, crystal, and glass when smoked, is a powerfully addictive stimulant and a known neurotoxic agent that damages the endings of brain cells containing dopamine. Definitive information on the impact of exposure to methamphetamine in utero is lacking. There is fair to good evidence that amphetamines do not cause congenital anomalies. Studies consistently show amphetamine exposure during pregnancy is associated with an increased risk of preterm birth, low birth weight, and birth of small-for-gestational-age infants, but most of these studies have not adjusted for confounding factors, such as tobacco use, polydrug exposure, nutrition, and access to prenatal care (UpToDate, 2012
). Screening for alcohol and substance use and abuse is discussed in more detail later in this chapter.
Assessing the use of prescription or over-the-counter medications and use of complementary and alternative therapies such as herbs, homeopathy, and folk remedies is crucial. This provides nurses with a more complete picture of the woman’s approach to healthcare and allows them to identify potentially harmful practices. Commonly, pregnant women are counseled that using acetaminophen is safe whereas using a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen is not. If there is a potential substance or practice about which there is a question of teratogenicity, nurses can contact the Organization of Teratology Information Services at its toll-free number ( 626-OTIS or  626-6847) or visit www.otispregnancy.org
for more information. This organization is a national service that can answers questions or refer pregnant women or nurses to local resources.
Over the last three decades, first trimester use of prescription medications increased by more than 60% and the use of four or more medications more than tripled; approximately half of childbearing-aged women use at least one medication (Mitchell et al., 2011
). As more women delay childbearing and as the population has grown more obese, there are more likely to be women of childbearing age using medications for chronic diseases such as diabetes, hypertension, and hyperlipidemia. Medications to treat the later disorders include angiotensin-converting enzyme inhibitor (ACE inhibitor), angiotensin receptor blocker (ARB), or HMG-coenzyme A reductase inhibitor (statin). Use of ACE inhibitors and ARBs are associated with wellestablished risks: oligohydramnios, fetal renal dysplasia, IUGR, and fetal death (Morrical-Kline, Walton, & Guildenbacher, 2011
). Statin use during pregnancy is contraindicated with case reports demonstrating vertebral, anal, cardiac, tracheal, esophageal, renal, and limb anomalies (Patel, Edgerton, & Flake, 2006
). Consequently, it is important for the primary care provider as well in women’s health to be cognizant of this growing shift in the population of childbearing women with regard to medication use and to counsel women appropriately.
The impact of nutrition on maternal and fetal wellbeing cannot be underestimated. The special physiology of a woman creates variable nutrient requirements during different stages of the life cycle. Nutritional practices influence every pregnancy, as well as a woman’s risk for anemia, diabetes mellitus, cardiovascular disease, osteoporosis, and several types of cancer. Specific complications of pregnancy, such as preeclampsia, preterm birth, IUGR, and low-birth-weight infants with associated detrimental outcomes, can be correlated to nutritional status. A healthy, well-nourished woman has a surplus of all nutrients. The key components of a health-promoting lifestyle during pregnancy include appropriate weight gain; appropriate physical
activity; consumption of a variety of foods in accordance with the Dietary Guidelines for Americans 2005; appropriate and timely vitamin and mineral supplementation; avoidance of alcohol, tobacco, and other harmful substances; and safe food handling.
Approximately 60% of American women do not gain the appropriate amount of weight during pregnancy, with more gaining too much, especially those with a high prepregnancy BMI (Olson, 2008
). Current weight gain guidelines are described in Table 4-1
. In 2005, the U.S. Department of Agriculture created an interactive Web-based MyPyramid, now ChooseMyPlate. The Web site provides food intake and physical activity recommendations for persons aged 2 and older, replacing healthy foods for unhealthful and offering diet tracking, menu planning, nutrition information, and personalized advice. The strategies are easy to understand for the lay public. The information should be used to complement and not substitute for prenatal education (Shieh & Carter, 2011
). The nurse is encouraged to explore the Web site for use with preconception, prenatal, and lactating women: www.choosemyplate.gov
The nutrition assessment includes diet intake information (3-day recall), monitoring weight gain, and hematologic assessment. Assessment of usual dietary patterns provides a basis for understanding nutritional health. Variations from the normal dietary routine, such as eating disorders, food avoidance, or special diets; food resources; and metabolic disorders such as diabetes, warrant additional interventions. Women who have eating disorders may be reticent to reveal this information. This assessment may require a number of prenatal visits and a building of a trusting relationship between the nurse and the woman. After an eating disorder is revealed, the nurse should ask the woman how she manages eating food and meals, as well as what her attitude is toward eating (e.g., preoccupation with food, feeling guilty after eating, engaging in dieting, enjoyment of food).
Table 4-1. RECOMMENDATIONS FOR WEIGHT GAIN DURING PREGNANCY
Weight Gain (Pounds/Kilograms)
28-40 lb (12.7-18.2kg)
25-35 lb (11.4-15.9 kg)
15-25 lb (7.0-11.5 kg)
11-20 lb (5.0-9.0 kg)
No recommendation due to insufficient data
37-54 lb (16.8-24.5 kg)
31-50 lb (14.1-22.7 kg)
11-20 lb (11.4-19.1 kg)
From Institute of Medicine (2009) . Weight Gain During Pregnancy: Reexamining the Guidelines. www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
Most nutritional advice for pregnant women is based on the 1990 Institute of Medicine (IOM) Pregnancy Report, the 2005 Dietary Guidelines for Americans by the USDHHS and U.S. Department of Agriculture, and the 2006 IOM publication, Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. The current dietary recommendations developed by the IOM include (1) increased intake of protein from 60 to 80 g/day (1.1 g/kg/day); (2) 340 additional calories per day in the second trimester and 452 calories per day in the third trimester; (3) increased iron intake from 15 to 30 g/day; and (4) increased folate consumption from 400 to 800 mcg/day. The recommended amount of calcium for women aged 19 to 50, pregnant or not, is 1,000 mg/day; for adolescents up to age 18, it is 1,300 mg daily. There are certain special circumstances that may affect these recommendations. For example, if there is a history of a child with a neural tube defect (NTD), the folic acid recommendation is increased to 4 mg rather than 0.4 to 0.8 mg/day. Nurses should encourage women to consume a variety of foods, eat at regular intervals (three meals a day and healthy snacks), drink milk two to three times per day, reduce caffeine, and avoid alcohol. Common discomforts (e.g., nausea and vomiting of pregnancy, heartburn, and varied reactions to taste or smell of food) can prove challenging to the woman who is trying to follow pregnancy dietary recommendations. Knowledge of safe remedies is the basis for advice when helping women with these discomforts. For example, acupressure wristbands and small, frequent feedings can be of help to some women to decrease nausea.
Another aspect of the nutritional assessment is the use of vitamins and herbs. Because herbs and vitamins are considered dietary supplements, these products are not regulated in the same manner that prescription and over-the-counter medications are. Often the products are labeled as “natural,” and the woman may conclude that the product is therefore not harmful. Excesses of one nutrient can alter the need for, absorption of, or use of other nutrients. Supernutrient regimens or megadoses of vitamins (especially those that are fat soluble) may be harmful and cannot ensure a healthy pregnancy.
Vitamin D deficiency is the most common nutritional deficiency worldwide in both children and adults. It has also been observed that vitamin D deficiency is linked to preeclampsia during pregnancy and an increased risk of having a cesarean section (Bodnar et al., 2007
; Merewood, Mehta, Chen, Bauchner, & Holick, 2009
However, it is not necessary to screen vitamin D levels in the general population of pregnant women. Instead, a dietary supplement of 400 IU (10 mcg) daily is recommended and can be found in most prenatal vitamins. There is insufficient evidence to recommend more than what is contained in prenatal vitamins. Women at risk of vitamin D deficiency (low dietary intake as in vegetarians, inadequate sunlight exposure, and ethnic minorities, especially those with darker skin) can be screened and treated (1,000 to 2,000 IU/day) if low levels are found (ACOG, 2011
Fish are an excellent source of protein, are low in saturated fats, and contain omega-3 fatty acids. Nearly all fish and shellfish contain trace amounts of mercury; therefore, pregnant and lactating women are advised to avoid fish with potentially high methylmercury levels: shark, swordfish, king mackerel, and tile fish. Pregnant women ingest no more than 12 oz or two servings of canned tuna per week and no more than 6 oz of albacore or “white” tuna (U.S. Environmental Protection Agency, 2011). If the mercury content of locally caught fish is unknown, then overall fish consumption should be limited to 6 oz per week.
Avoidance of foodborne illnesses (e.g., norovirus causing acute gastroenteritis, Salmonella, listeriosis, Escherichia coli, or hepatitis A), which cause maternal disease, congenital defects, preterm labor, miscarriage, and fetal death, is also important for the nurse to assess and to teach the woman. To reduce the risk of foodborne illness, it is important for the woman to:
Practice good personal hygiene (hand washing and care of kitchen utensils, cookware, and surfaces).
Consume meats, fish, poultry, and eggs that are fully cooked.
Avoid unpasteurized dairy and fruit/vegetable products.
Wash fresh fruits and vegetables prior to eating.
Avoid raw sprouts (alfalfa, clover, radish, and mung bean).
Avoid listeriosis by refraining from processed/deli meats, hot dogs, soft cheeses, smoked seafood, meat spreads, and pate.
Many pregnant women experience pica (eating non-food substances) during pregnancy. Some women are embarrassed to tell the nurse about these cravings, yet they may significantly interfere with dietary intake of proper nutrients during pregnancy. Pica cravings are not limited to any one group, educational level, race, ethnic group, income level, or religious belief but rather are universal; however, the type of substance ingested does seem to be culturally influenced (Young, 2010
). In the United States, the practice of pica during pregnancy is linked to lower income women, African American heritage, family or personal history of pica during childhood or before pregnancy, strong cravings during pregnancy, and cultural groups that endorse pica during pregnancy as important for fertility and femininity (Corbett, Ryan, & Weinrich, 2003
). As a part of nutrition assessment, nurses should question (in a nonjudgmental style) patients at each prenatal visit regarding pica practice. Pica may be practiced for cultural or other reasons unknown to nurses. Working with patients to discover what they are eating and helping them to substitute foods with nutritional value can be a part of a nursing care plan that results in a positive pregnancy outcome (Corbett et al., 2003
Psychosocial screening of every woman presenting for prenatal care is an important step toward improving the woman’s health and the birth outcome. In this way, the nurse can identify areas of concern, validate major issues, and make suggestions for possible changes. Depending on the nature of the identified problem, a referral may be made to an appropriate member of the healthcare team. A woman may be reluctant to share information until a trusting
relationship has been formed. Questions asked at the first prenatal visit bear repeating with ongoing prenatal care. The woman may need reassurance as to the confidentiality of the information. For example, if she reveals she uses cocaine, would she be turned over to the judicial system and possibly jailed? Nurses are obligated to know how to answer the woman when these issues arise.
Pregnancy affects the entire family, and, therefore, assessment and intervention must be considered in a family-centered perspective. Stress has been suggested as a potential contributor to preterm birth and physical complications during pregnancy and birth, including prolonged labor, increased use of intrapartum analgesics and barbiturates, and other complications. Unusual stressful events, such as the death of a significant family member or friend, job loss, or a problematic relationship with the baby’s father may increase risk of poor pregnancy outcome. Home conditions (e.g., private or government housing), quality of comfort (e.g., heat, water), housekeeping burden, and number and age of previous children influence stress levels. Nurses should be aware that many women continue to work under hazardous or stressful conditions out of economic necessity, but that they will attempt to minimize any known risk factors as much as possible. Additionally, nurses should assess how the woman appraises her situation (e.g., what one woman finds stressful, another may not). Nurses should identify resources available to the pregnant woman (e.g., support groups, social worker, counselor, etc.).
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