215CHAPTER 8

Maternal–Child Nursing: Obstetrics

Tonya A. Schneidereith

Arguably, nurses working in the field of obstetrics must have a greater depth and breadth of genetic knowledge over any other subspecialty. Application of genetics can begin before pregnancy with assessment of risk and principles of prevention. During gestation, nurses should include education on the effects of teratogens, prenatal screening options, and prenatal diagnoses. After delivery, early recognition of genetic disorders (chromosomal, single gene errors of metabolism, congenital malformations) is important for immediate initiation of potentially life-saving therapies. Many of the diseases manifested in the pediatric period are discussed in Chapter 9.

PRECONCEPTION OR PREPREGNANCY COUNSELING

Preconception education is a critical component of health care for women of reproductive age. Today all women considering pregnancy should have the following areas addressed, including appropriate education and genetic referral (if needed):

Family history

Risk factors

Diet

Immunization status

Medications

The Centers for Disease Control and Prevention (CDC) recommend that all women of childbearing age consume 0.4 mg of folic acid daily to prevent neural tube defects (NTDs). If there is a history of a pregnancy with an NTD, the recommended dose increases to 4 mg daily beginning at least 1 month before becoming pregnant. Additionally, the male partner should be counseled to avoid environmental chemicals, cigarette smoking, certain drugs, radiation, and so on.

For those who seek prenatal counseling, identification of risk and appropriate treatments can result in a more favorable pregnancy outcome. For example, women with altered maternal metabolism such as diabetes mellitus or PKU can benefit from strict control and diet therapy before pregnancy. Understanding potential risk in someone who had a corrected congenital anomaly may help to reduce anxiety. For women with genetic disorders, such as Ehlers–Danlos disease (a group of connective tissue disorders), the effect of the disorder on the pregnancy should be considered. It is important for nurses to educate parents who may not be aware that relatively minor problems in themselves may mean that they are at increased risk for a more severe outcome in their children. An example of this is the case of a mother with spina bifida occulta who is at increased risk for a larger NTD in a child. In cases of disabilities arising from unknown or nongenetic causes, counseling can still be useful in terms of optimum pregnancy management in a setting best able to cope with any anticipated problems. Additionally, identification of likely hazards and prevention may decrease risk to the fetus. An example is the case of the potential for urinary tract infection. With avoidance of contributory factors and increased proactive measures (e.g., adequate fluid intake), the possibility of necessary treatment with medication is minimized.

217Persons at risk of problems during pregnancy should consider:

Then reproductive options, therapeutic options, and the possibility of prenatal diagnosis can be considered before embarking on the pregnancy. Prevention of genetic disorders is also discussed in Chapter 5.

PREGNANCY

Issues identified above in preconception counseling should be addressed as early as possible in pregnancy, especially if the mother has not participated in preconception counseling. This section discusses in more detail effects of teratogens on the fetus, prenatal screening, detection and diagnosis, and assisted reproductive technology (ART).

During the first prenatal visit, it is important to establish ABO blood type and RhD antigen status. RhD^– women with an RhD⁺ pregnancy are at 1.5% risk of developing alloimmunization. However, treatment with RhoGAM (Rh_ºD immune globulin) decreases that risk to 0.2%. It is recommended to nonsensitized women at 28 weeks gestation and again within 72 hours after delivery if the infant is RhD⁺. This should also be done after amniocentesis, abortion, and other procedures such as chorionic villus sampling (CVS) unless the biologic father is RhD^–. (More information on this is in Chapter 3.)

Through personal and family history, women will be identified who should have carrier screening early in pregnancy for genetic disorders that occur more frequently in certain ethnic groups. This is important so that a full range of options, such as prenatal diagnosis, are available. In addition, the Committee on Genetics and the American College of Obstetricians and Gynecologists recommend that carrier screening for cystic fibrosis is offered to all pregnant women. Recent carrier frequencies from over 20,000 individuals were published, which corroborated and differed from published data. These results, as shown in Table 8.1, identify the 10 most commonly detected diseases alongside the number tested and previously published frequencies. With the blurring lines of self-reported ethnicity in the population, using ethnicity-based screening may be antiquated practice.

It is important to understand that screening tests are for the most frequent gene mutations in particular diseases; therefore, a negative screening test for either partner does not guarantee that the child will not be affected. For detailed information or complicated situations, the couple should be referred for genetic counseling. More information about genetic variation in population groups can be found in Chapter 3.

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THE VULNERABLE FETUS AND TERATOGENESIS

The term teratogen is often used to describe agents that interrupt the development of the fetus. The term fetus as used in this chapter also includes the embryo. In a given exposure during pregnancy, a teratogen can have any of the consequences shown in Box 8.1.

Complex and multifaceted maternal and fetal factors influence the consequences of drugs, radiation, and chemical and infectious agents to the developing fetus. As described in Table 8.2, drugs and chemicals can cause fetotoxic effects through direct fetal interaction and interference with maternal systems (e.g., circulatory, endocrine, excretory, appetite regulating). Table 8.3 identifies some of the problems involved in determining whether a specific substance is injurious to the fetus.

Drugs and Chemical Agents in Pregnancy

Several questions must be asked before recommending a drug for a pregnant woman, as shown in Box 8.2. To begin, the statement that a drug “has not been shown to be a human teratogen” does not mean that it is safe; it may never have been tested in the pregnant human female. As discussed previously, establishing drug safety is difficult due to the problems and factors influencing effects on the fetus (Table 8.3). In addition, when doing animal and laboratory studies, drug testing for safety may not use a species that is sensitive to the effects of the drug. Thalidomide appeared harmless in the species in which it was tested; however, it was extremely teratogenic in humans. Drugs tested in humans may be in specific population groups, from which generalizations should not be made, or have few or no pregnant women in the sample because of ethical concerns for safety. If the effect is one in which the increased incidence of defects is small and nonspecific, then the number of subjects in preliminary tests may not be sufficient to demonstrate the effect. Cost and time may limit the extent of testing due to the extreme pressure to get new drugs on the market quickly.

The association of detrimental fetal effects with a specific drug is made by case reports, surveillance, and epidemiologic studies. The teratogenicity of thalidomide was discovered because of the sudden, increased incidence of a rare limb defect (phocomelia), coinciding with the widespread use of thalidomide in pregnant women. The numerous published case reports established a teratogenic association and subsequent withdrawal from the market. Thalidomide is available again, this time as an investigational drug particularly for erythema nodosum and aphthous ulcers.

After the birth of a child with a congenital defect, a retrospective analysis can help establish connections between the mother’s illnesses and medications used during her pregnancy. Epidemiologic surveillance and reporting of congenital anomalies, especially the frequency of certain sentinel defects, is conducted by the CDC at several sites across the United States (www.cdc.gov/ncbddd/birthdefects/research.html). By using multiple sites, patterns or incidence that might reflect an environmental influence can be established.

Traditionally, prescription drugs were placed into five categories by the Food and Drug Administration (FDA) based on their pregnancy category (A, B, C, D, X). However, in 2014, the FDA released a new Pregnancy and Lactation Labeling Rule (PLLR) removing the pregnancy letter categories and instead using a new format to help health care providers counsel women to make informed decisions for themselves and their children. These categories are Pregnancy (including Labor and Delivery), Lactation (including Nursing Mothers), and Females and Males of Reproductive Potential. Effective June 2015, new prescription drugs will use the recent format while drugs approved after 2001 will be gradually phased in.

The Pregnancy category contains a risk summary, clinical considerations, and data for each prescribed drug used by women during pregnancy, labor, and delivery. Additionally, a pregnancy exposure registry will be required for all prescription drugs used in this category. The Lactation category includes information pertinent to the breastfeeding mother. This includes drug amounts in breast milk and drug effects on the nursing infant. Finally, the category for Females and Males of Reproductive 227Potential provides information on the effects of the prescription drug on contraception, pregnancy testing, and infertility.

Certain fetotoxic drugs are discussed below, and others are presented in Table 8.4. Absence from the table does not imply safety, and some adverse fetal effects are not teratogenic. It is not possible to present an inclusive list here, and reports on the safety (or nonsafety) of drugs in pregnancy often conflict. Nevertheless, these drugs are best avoided when a less harmful, more efficacious one can be substituted. Selected drugs are discussed in more detail below.

Note: Not all exposed fetuses will show these effects. Absence from this table does not imply safety. See the text for discussion.

Diethylstilbestrol (DES)

DES, a proven teratogen, is a synthetic estrogen that was introduced in the 1940s. It was used extensively in pregnant women in the 1950s and 1960s to treat habitual abortion, bleeding, premature delivery, and toxemia. Many women (as many as 7% of all pregnant) took DES before the hazards to the fetus were identified. In 1971, the association was made between an epidemic in young women of clear cell adenocarcinoma (CCA) of the vagina and cervix and the maternal use of DES during pregnancy. Despite wide publicity in the lay press, the magnitude of the DES exposure problem is not completely known because many women did not know the precise medication they took or knew only the trade name and did not recognize that they had been exposed. It is estimated that there may have been about 4 million male (DES sons) and female (DES daughters) exposed offspring. The association between maternal DES use and delayed onset of CCA in the daughters has been well documented. Less widely recognized consequences in women include non-neoplastic alterations of the reproductive system, especially in the vagina, uterus (often T-shaped), or cervix, which may be seen in 25% to 35% of exposed women, and an increased incidence of spontaneous abortion, ectopic pregnancies, and prematurity. In exposed males (DES sons), sperm and semen abnormalities; testicular abnormalities, including benign cysts in the epididymis; and small and undescended testes have been reported as more prevalent than in controls, but no excess risk of cancer has been reported after long-term study. Some investigators report altered social behavior, but others disagree. DES daughters should not be given estrogen and should be advised to have continuing care. DES sons should see a urologist and be taught the technique and importance of self-examination of the testes.

231More recently, animal studies have suggested that the effects of DES may transcend into the third generation. Mouse models have shown an increased susceptibility to tumor formation, suggesting that grandchildren of those who took DES may be at increased risk for cancer. These grandchildren, both males and females, should be closely monitored for reproductive tumors.

Anticonvulsants

The use of anticonvulsants for maternal seizures such as epilepsy during pregnancy needs to be carefully considered, balancing the risk of malformations with the risk of uncontrolled seizures to the fetus. Phenobarbital and phenytoin (Dilantin) are given together about three quarters of the time, so the individual effects of each drug have been hard to separate. Phenytoin and other hydantoins are associated with a risk of orofacial clefts, especially cleft lip and palate, and congenital heart disease of 5 to 10 times and 2 to 3 times that of the general population, respectively. In addition, a fetal hydantoin syndrome has been reported, which has many characteristic features of the head and neck (see Table 8.5). More recently, features were added to the phenotype of this “anticonvulsant face,” including a widened philtrum and small mouth.

Other antiepileptic medications, including carbamazepine, valproic acid, lamotrigine, and topiramate, have been associated with congenital malformations and delays. These include craniofacial defects, developmental delay, and lower IQ scores.

The consequences of these congenital defects must be weighed against the problems associated with prolonged, uncontrolled seizures. Risks have been estimated and appear to be about 10% for the full syndrome, and up to an additional 30% for part of the syndrome. If possible, monotherapy at the lowest possible effective dose is preferred, particularly in the first trimester, taking into consideration the stage of pregnancy most affected by the particular agent. Infants who were exposed to phenytoin during pregnancy may show vitamin K deficiency about 48 to 72 hours after birth. In these cases, vitamin K can be given to the mother during labor to prevent complications associated with hemorrhage.

Anticancer Drugs

Cancer during pregnancy is becoming more pervasive, with breast and hematological tumors among the most common forms. Chemotherapies administered during the first trimester often lead to congenital malformations; when given after the first trimester, surprisingly, many cytotoxic agents are not detrimental to the developing fetus. Anthracyclines (e.g., doxorubicin, daunorubicin, Epirubicin), potentially toxic to the heart, were shown in a European study to have no adverse effects on children exposed in utero. Additionally, these children were found to have no impairments to overall health.

Furthermore, pharmacokinetics are altered in the pregnant woman (beginning at about 4 weeks gestation) leading to a reduced plasma volume of chemotherapeutics. This, combined with the protective filtering of the placenta, may have clinical implications for providers prescribing chemotherapies.

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If possible, therapy should be delayed until the second trimester, and combination therapy should be avoided, with the least toxic agent used. Males may wish to take advantage of sperm banking before beginning therapy, and women may wish to consider harvesting and saving ova.

233Other Drugs

As new drugs come on the market, occasionally there is concern about their teratogenic potential. The vitamin A derivatives, including isotretinoin (Accutane) used in acne treatment, are known teratogens. These drugs are associated with an increase in spontaneous abortion, craniofacial malformations, heart defects, and central nervous system abnormalities. Frequently used in adolescent females, education regarding its teratogenicity is essential. Pregnancy should be avoided within 6 months of use.

Serotonin-reuptake inhibitors (SSRIs) have an associated increased risk of congenital malformations if taken during the first trimester of pregnancy. Additionally, if taken in the third trimester, there is an increased risk of infant withdrawal, prematurity, and persistent pulmonary hypertension of the newborn.

Nursing Pointers

       Educate all women of reproductive age about the potential teratogenic effects of medications.

       Encourage the client to tell her pharmacist, physician, nurse, and other health practitioners involved in her care that she is pregnant.

       Identify those most likely to be users of medications and drugs (including alcohol, caffeine, and cigarettes), and inform those who are considering pregnancy or who are already pregnant of the hazards.

       Teach women that over-the-counter products, including extra vitamins, herbals, and iron, are considered drugs.

       Integrate the above information into school health programs.

       Educate men about their role in conception and fetal health; advise waiting 90 days after certain medications before conceiving.

       Educate women regarding the dangers of self-medication in pregnancy.

       Provide education on nonpharmacologic measures to manage common conditions (e.g., relaxation techniques for tension).

       Involve the client in decision making regarding medications

       Instruct the client to keep an accurate list of all medications ingested during pregnancy, with the date, dose, length of time taken, and the reason.

       Maintain a record of all prescription or recommended drugs with the same information. This should be readily accessible for easy reference in the patient profile.

       If drug therapy is necessary, the lowest effective therapeutic dose of the least toxic agent should be used.

       The risks and benefits should always be considered, and doses should be individualized.

       Question any drug that appears contraindicated in pregnancy, as the practitioner prescribing it may not know that the patient is pregnant.

234Alcohol in Pregnancy

The issues associated with alcohol in pregnancy and abnormal children were reported as far back as Ancient Greece, with scientific description of fetal alcohol spectrum disorders as early as the late 1800s. In 1980, the Surgeon General advised pregnant women not to drink alcoholic beverages and to be aware of alcohol content in other foods. A warning addressed to pregnant women is on alcohol containers and in stores selling alcohol that contains language such as, “According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects.”

Influences on Effects of Alcohol in Pregnancy. Factors such as genetic susceptibility, genetically determined differences in the metabolism of alcohol, the extent of fetal exposure, maternal nutritional status, and the dose of alcohol all play a role in fetal consequences. These include decreased birth rate, increases in spontaneous abortion rates, and stillbirths, as well as growth retardation, congenital anomalies, and functional deficits. Fetal alcohol syndrome (FAS) is the most severe form of the spectrum of effects that occur as a result of maternal consumption of alcohol in pregnancy. Additional contributors to fetal effects that can be found in conjunction with alcohol use may include the use of other drugs, cigarette smoking, and malnutrition.

Fetal Alcohol Spectrum Disorders (FASD). Fetal alcohol spectrum disorders (FASD) encompass alcohol-related effects, alcohol-related neurodevelopmental disorder (ARND), alcohol-related birth defects (ARBD), and the most clinically evident category, FAS, which is considered with and without confirmed maternal alcohol exposure. FASD is not considered a diagnostic term but is defined as an umbrella term for the other alcohol-related conditions. Alcohol consumption can affect reproduction and offspring:

A variety of dysmorphic features and congenital anomalies have been associated with FAS. A dysmorphology scoring system is available along with cognitive and behavioral patterns to assist with diagnosis. Among the most frequent features found are microcephaly, growth deficiency, short palpebral fissures, smooth philtrum, and thin upper lip border. Cognitive and behavioral findings include emotional lability, motor dysfunction, poor attention span, deficient social interactions, 235communication and speech problems, disorganization, and hyperactivity. Long-term studies of adolescents and adults with FAS found deficits in socialization, communication skills, attention deficits, and hyperactivity, and about half were mentally retarded. The facies were not as distinct, but microcephaly and shortness persisted.

The incidence of FAS is estimated at 0.5 per 1,000 live births overall but may be as high as 10 to 15 per 1,000 in some high-risk populations. Alcohol-related effects may be more frequently seen. These may be low estimates because diagnosis may not be made until later in life when functional deficits are more noticeable. FAS is many times higher among those of low socioeconomic status (SES) and is higher in some ethnic populations, but these data may be confounded because of SES. Various researchers have examined the outcomes from women who used alcohol in pregnancy. The results of studies vary because of different definitions of mild, moderate, and severe alcohol use; different alcohol content in different alcoholic beverages; and varying patterns of alcohol consumption, ranging from a regular daily amount, to periodic binges, to a combination of both. Nevertheless, it is estimated that the risk for any major or minor congenital anomaly in an alcohol-abusing pregnancy ranges from 38% to 71%, with an overall adverse pregnancy outcome average of 50%.

The toxicity of ethanol on the neurons through the agonistic effects on gamma aminobutyric acid (GABA) receptors is established. There are also known effects on specific receptors (glycine, NMDA, serotonin) and L-type calcium channels. However, the effects on the pregnant woman who ingests a minimal amount of alcohol either consistently or sporadically are less clear. Some researchers suggest that alcohol does not need to be totally avoided during pregnancy and that it may be more realistic for women to restrict their intake to one standard measure (1 oz equivalent of absolute alcohol) per day. They fear that unnecessary guilt may arise in mothers of children with birth defects who drank mildly during pregnancy. However, others disagree; presently, no minimum safe level for alcohol consumption in pregnancy has been established. Pregnant women should avoid drinking alcohol and be aware of the alcohol content in food and drugs.

Although there is a relationship between the dose of alcohol consumed, the time of pregnancy, and the severity of defects in the fetus, studies in animals and humans have determined that benefits are accrued if maternal consumption of alcohol ceases, even if this occurs after the first trimester. Thus, it is important to identify individuals who are still using alcohol at the first prenatal visit, or before conception at a contraceptive or annual gynecologic visit. In general, women want to have healthy babies, and this provides motivation even in the severe alcoholic. There is a decreased desire for alcohol during pregnancy, which may help to support nursing efforts to eliminate gestational intake of alcohol.

Nursing Pointers

       Be aware of referral information for women seeking help with alcohol consumption.

       Nurses working with women of reproductive age should familiarize themselves with common signs and symptoms of alcoholism including neglect, 236family disruption, agitation, tremors, and laboratory signs (e.g., macrocytic anemia, liver function abnormalities).

       Encourage women identified as alcohol abusers to discontinue or decrease their intake before conception.

       Anticipate problems associated with chronic alcohol consumption, including abruptio placentae, precipitous delivery, tetanic contractions, or infection.

       At delivery, the infant exposed to alcohol perinatally may be at risk for altered glucose metabolism, withdrawal symptoms, respiratory problems, seizures, and tremors. The need for resuscitation is not uncommon.

       Consider the morphology associated with FASD when assessing newborns and infants.

       If FAS or alcohol-related effects are suspected in newborns, be alert for other defects.

       Infants with intrauterine growth retardation (IUGR) and an apparent cause (e.g., placental insufficiency) may also have undetected FAS. Therefore, all small-for-date infants should be closely followed for several years.

       Infants born with FASD typically have a poor suck. Therefore, those with failure to thrive are at increased risk for poor feeding and slowed development.

       Support and help for the mother should begin in the immediate postpartum period and reinforced on follow-up visits.

       Observe for problems associated with mother–infant bonding. Home follow-up should be arranged before the mother leaves the hospital.

       Consider enrolling the parents in parenting classes.

       Affected children and families should be referred to early intervention programs, counseling, family therapy, and appropriate language, speech, and learning services.

       Ongoing contact with a family who has had alcohol problems during pregnancy is necessary. Children who later manifest fretful behavior, hyperactivity, and abnormal sleep may be more prone to child abuse in an already unstable situation.

       School nurses may need to continue follow-up of the children, some of whom have learning deficits that manifest in the school years. These children often superficially appear to have a large vocabulary and may not be detected early.

       Include the rest of the family when making assessments and referrals.

Cocaine and Use of Other Social and Street Substances

The use of cocaine and crack cocaine has become epidemic; estimates are that 1% of the U.S. population has tried cocaine. Many women who use cocaine also use other street drugs such as marijuana or methamphetamines or alcohol and may also suffer from poor nutrition, stress, infections, and other confounding conditions, making 237effects on the fetus difficult to isolate to one agent and difficult to evaluate. Multiple drug use may also be synergistic.

Street drug use is probably more dangerous to the homeless woman without prenatal care than to the middle-class woman. In general, cocaine use can result in IUGR, low birth weight, increased fetal loss, prematurity, obstetrical complications, microcephaly, urogenital and other congenital malformations, and neurologic and behavioral effects such as irritability, excitability, poor state regulation, and poor sleep. Later, poor feeding and poor visual and auditory tracking may occur. Prenatal exposure may also delay development of the prefrontal cortex. Cognitive and attentional process deficits as well as language delay and behavioral problems seem to persist.

Cigarette Smoking

Between 19% and 30% of pregnant women continue to smoke. Maternal cigarette smoking in pregnancy is related to detrimental effects. These include an increased spontaneous abortion rate, an increased perinatal mortality rate, an increased incidence of maternal complications such as placenta abruptio and placenta previa, decreased birth weight and size in later childhood, an increased incidence of preterm delivery, and lower Apgar scores at 1 and 5 minutes after birth. The last is a source of particular concern because low Apgar scores have been associated in other studies with developmental and neurologic disabilities in later life.

Ionizing Radiation

Radiation occurs naturally in the background such as cosmic radiation, and people on flights have some exposure depending on altitude and length of time. This is usually significant only for pregnant frequent flyers such as pilots and flight attendants. A frequent reason for seeking genetic counseling is radiation exposure during pregnancy. The consequences of the effects of low-dose radiation to the fetus are still undetermined. There is probably no threshold level that can be considered absolutely safe for radiation exposure. The type of radiation emitted, its affinity for certain tissues, and the actual dose absorbed by the fetus are factors to consider. The most sensitive stage for spontaneous abortion due to radiation is just before or after the time of the first menstrual period after becoming pregnant when neither pregnancy nor the loss may be realized. However, radiation may be detrimental to the fetus in any stage of pregnancy, including fetal death, malformation, tissue effects, or cancer, especially leukemia.

The major hazard associated with in utero radiation exposure is an increased risk of childhood cancer for the fetus, no matter which trimester in which it occurred. Doses less than 0.05 Gy (5 rads) typically have no cancerous effect on the embryo or fetus, while larger doses of radiation greater than 0.50 Gy (50 rads) may result in microcephaly, intellectual disability, microphthalmia, genital and skeletal malformations, retinal changes, and cataracts. The largest radiation accident occurred at the Chernobyl nuclear power plant in Ukraine on April 26, 1986. Some children exposed in utero were said to exhibit intellectual disability and behavioral effects. The Three Mile Island nuclear accident in Pennsylvania in 1979 has not led to a 238significant increase in cancer deaths for area residents. The population exposed to the more recent Fukushima Daiichi nuclear accident in Japan in 2011 continues to be monitored for radiation effects.

It is obviously preferable to prevent inadvertent or unnecessary radiation exposure of pregnant women. Pregnant nurses and other female employees should not work with patients receiving radioisotopes.

Nursing Pointers

Nurses should educate women to:

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