|Hello, I am Debra Neiman, RN BSN.
I have worked in Neonatal Care, at Beauregard Memorial Hospital, DeRidder for over four years. My college experience at Louisiana State University at Alexandria, resulted in a great deal of research papers, which are gathering dust in my office. My curriculum at Northwestern State University also added to this wealth of information.
I hereby begin this series to provide a way to get this information to those in the nursing field and any other person with a passing interest in these subjects.
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Nursing's Role In Promoting Preconceptual Care
Debra Neiman, RN, BSN, Fall 1994
Prepared for Introduction to Professional Nursing
Northwestern State University
Changing Dynamics of Responsibility
Demographics over the last 40 years indicate the American family is becoming smaller. The average family in 1950 was composed of 3.5 people and reduced to 2.6 in 1991. The future forcasts a continued downward trend (Aburdene & Naisbitt, 1992). However, significant changes in economic conditions, subsidized day care and other structural supports for working women may increase the number of children in families of young adults. First time parents are getting older, mostly because of priorities to complete education or become established financially ( Edmonson, 1993).
The number of single parent households has increased more than 40% since 1980. Single mothers comprised 87% of the 10 million single parents in the United States in 1991. One child in four, including 60% of black children, is now raised by a single parent. Since more than one third of female headed households are poor, this results in one child in five living in poverty (Aburdene & Naisbitt, 1992).
Statistics cited during a 1993 conference on neonatal nursing, indicate the United States in nineteenth place for decreased morbidity/mortality risk in neonates, well behind Japan, Finland, Australia and fifteen other countries (Zdanuk, 1993). This is occurring at a time when fewer children per family should be allowing for increased time and resources for positive outcomes. Realistically, although parents want a perfect baby, the physician and nurse cannot fulfill this goal every time (Bushy, 1992). Preconceptual care shifts this responsibility back to the parents. Better reproductive outcomes may be achieved with increased education and nursing intervention on many levels.
The average first prenatal visit occurs 10 weeks after conception when most of fetal organogenesis has already been accomplished, greatly reducing chance for outcome intervention. A need for preconception nursing intervention is also evident due to the difficulty of effectively changing poor health habits during pregnancy (Bushy, 1992).
Early Trends of Preconceptual Care
Until 1941, the placental barrier was believed to protect the developing fetus from adverse exposure to environmental hazards. Studies of birth defects caused by rubella infection during pregnancy disproved this theory (Bernhardt, 1990). Prenatal care currently includes screening for immunity to rubella, which identifies those at risk while offering no protection. Primary care nursing intervention is providing a complementary approach with the routine vaccination of infants and reinforced with screening for missed vaccination during entry level into school. Immunization of infants and children has resulted in reducing rubella exposure risk in currently unprotected pregnancies. Additionally, the preconceptual targeting of prepubescent girls has resulted in reduction of future prenatal rubella infection in the population.
Further progress toward protecting neonatal outcomes has included education and close management of insulin dependent diabetic women before and during pregnancy. Testing of glycosylated hemoglobin (Ghb) levels give a reliable indicator of glycemic control during the past 4 to 12 weeks (Eskes, 1992). Primary nursing interventions as client educator has a critical affect for the diabetic woman considering pregnancy, since the association between diabetes and birth defects is not always known or understood by the woman (Cousins, 1983).
Studies of the Dutch famine during WWII revealed the vital need for good preconceptual nutrition to ensure healthy newborns. During the famine a 42/1000 neonatal mortality rate was observed. However, eight months after food supplies were restored to this population a 65/1000 neonatal mortality rate occurred. An increase of 160% in neural tube defects and 130% in congenital malformations also occurred in the newborns of the group starved the longest amount of time. This demonstrates a critical preconceptual window of time. Maternal nurtition 90-120 days prior to conception is believed to be as critical, if not more, the the first trimester ( Zdanuk, 1993).
Young females in the United States and Britain are depriving themselves of sound nutritional habits to meet social images of feminine beauty. Primary care nursing intervention attempts to address this problem through education and counseling. However, poor nutrition due to poverty may be the single greatest risk factor for many future mothers. Nurses must become involved politically to help reduce the affects of poverty, poor housing, and inadequate diets. The role of client advocacy clearly comes into focus when the connection between poverty and at-risk pregnancy and neonatal outcomes is made (Potrykus, 1992).
A standard analysis in 1973 divided the risks of birth defects into three groups. Known environmental factors cause 10%, genetic and chromosomal changes account for 25% and the remaining 65% are from unknown causes ( Bernhardt, 1990). Studies of occupational hazards and their effects currently support a much larger environmental risk, mostly due to problems with previous standards of safety.
Hazard protection for the worker often fails to include the fetus. An example of this is the noise protection devices for workers exposed to high levels of low frequency noise, less than 85 decibels. Testing of children exposed in utero revealed a three fold increase in development of a high frequency hearing loss, greater than 4000 decibels ( Bernhardt, 1990). The protective device the pregnant woman wears over her ears does not provide any barrier for her developing fetus.
Another deficit is the safe levels of chemicals. With over 50,000 chemicals on the marker, there are less than 100 animal studies to determine the affect on human development (Zdanuk, 1993). The MSDS sheets, nurses are familiar with, can be misleading when advising pregnant workers and clients. Studies did not consider pregnant workers, sensitive workers, or those who could become pregnant. An adult's safe level of chemical exposure is believed to be five to ten times higher than fetal tolerances (Bernhardt, 1990). Fetal vulnerability is due to a high rate of cell division and differentiation, a small relative size, a lack of enzymes to metabolize drugs, and a less efficient excretory system. These are factors usually not known or considered by the public and many health care workers.
Knowledge of the dangers of physical stresses and strains to pregnancy needs to continue to evolve along with the activities of the modern pregnant woman. Modern amusement park rides can generate high negative G-forces, which cause shearing affects known to cause placental abruptions. However, many nurses do not know that the environment of a hot tub is also a hazard. The early pregnancy is largely protein embryonic cells. Proteins, as in a chicken egg, undergo great changes in hot water. Assessment of client undrestanding of hazards and risks is a nursing challenge.
Financial Influences for Change
The pressures to limit health care costs have forced physicians and hospitals to form networks of managed care in areas like Dallas and Fort Worth. Many physicians are including more preconceptual planning and usa a risk screening profile at the initiation of care. This helps the physician define the client base by risk level and ability to pay for medical care (Zdanuk, 1993). Possible target goals for the patient with a vaginal delivery will be an 18 hour length of stay, with one follow-up visit by the home health nurse 24-48 hours after discharge. Due to projected capitated costs, the physician must stay within these targets or forfeit the additional cost. Physicians not agreeing to capitated limits on fees will not be included as approved providers ( Bushy, 1992).
Individual responsibility for preventing health risks and the possible inability to obtain care where preferred due to screening of client bases are two issues which can be addressed by client education. Primary care nursing will also be faced with issues of client advocacy and ethical dilemmas stemming from this type of financial fallout. To be effective in these roles, nurses must examine their own values and be vocal in the public arena where these changes are occurring.
Nurses must stay abreast of the continuing evolution of the knowledge base of health and developing interventions. Genetic counseling has been vital in the prevention of many birth defects. Education and screening for common problems, such as sickle cell trait, tay-sachs, and hemophilia have provided couples opportunity to make informed decisions about their reproduction risks. Studies indicate a three fold increase in the demand for prepregnancy counseling over a five year period and often results in the reduction in the number of negative outcomes in various studies (Cox, Whittle, Byrne,Kingdom & Ryan, 1992).
Significant progress has been demonstrated in a small study aimed at correcting the genetic defect in a few children with ADA deficiency. Temporary results are achieved by extracting white blood cells from the client, inserting normal ADA genes into the cells and reinjecting them. The result is that the child with the "bubble boy disease" begins to produce adenosine deaminase, the missing enzyme, which is vital to the immunie system. The altered cells die after a few months, requiring repeated procedures. Stem cells from the bone marrow of one child were removed, healthy ADA genes inserted into the cells, and then replaced into her bloodstream. It is hoped that the altered stem cells will find their way back to the bone marrow for a more total cure of the disorder ( Elmer-Dewitt, 1994). Health care providers need to stay current of the ongoing research and options for clients with questions about their genetic risks.
Methods for Consideration
Preconceptual care can be defined as preventive care for women of reproductive age and their partners, including assessment by history and physical exam, counseling, educaitons, and intervention. A useful tool is the Preconceptual Health Appraisal Questionaire which is available in the public domain. By using a separate surbey of the each in the couple the nurse can obtain reliable information ( Zdanuk, 1993).
Nursing roles of health education and counseling provides primary prevention future mothers, including the adolescent, teenager, and adult female during her childbearing years. Education of males is also important since they often influence health risks and behaviors in the female. Potential hazards for reproductive outcomes, including genetics, workplace hazards, nutrition, smoking and drug use includes areas of knowledge that the public expects when seeking counseling and conception and pregnancy. The informed nurse also enhances secondary nursing care by aiding early diagnosis and prompt treatment for reproduction problems (Bernhardt, 1990).
Nurses acting individually and collectively as change agents can ensure that an overall improvement that an overall improvement of a women's health care needs includes preconceptual care. Social factors, school lunches, health education and promotion, along with improved genetic services need to be addressed in the restruture of health care in the United States. There should be access to the client through the primary health care setting, in schools, in community based family planning clinics and in maternity services (Potrykus, 1992).
Nurses are viewed by the public as experts and thus should integrate new information into their nursing practice from current research base. Pragmatic and opportunistic approaches are needed to disseminate that information to the public. By providing women and prospective couples with current information, nurses can encourage them to actively plan for their pregnancy. Couples can be educated and motivated to enter pregnancy in good health and with as few risk factors as possible. The best protection available against low birth and other poor pregnancy outcomes may be a public fully informed about their reproductive and general health and supported by the social influences to act on reducing their risk factors.
Aburdene, P. & Naisbitt, J. (1992). Megatrends for Women. New York: Fawcett.
Bernhardt, J. (1990). Potential workplace hazards to reproductive health:
Information for primary prevention. JOGNN, 19(1), 53-62.
Bushy, A. (1992). Preconceptual health promotion: Another approach to improve
pregnancy outcomes. Public Health Nursing, 9(1), 10-14.
Cousins, L. (1983). Congenital anomalies among infants of diabetic mothers.
American Journal of Obstetrics and Gynecology, 147(3), 333-338.
Prepregnancy counseling: experience from 1,075 cases. British Journal
of Obstetrics and Gynaecology, 99, 873-876.
Edmonson, E., et al. (Eds.). (1993, December). The future of households.
American Demographics, 15(12), 27-40.
Elmer-Dewitt, P. (1994, January 17). The genetic revolution. Time, 143(3), 46-53.
(1992). Prepregnancy care and prevention of birth defects. Journal of
Perinatal Medicine, 20, 253-265.
Potrykus, C. (1992, January). Stop the cycle of deprivation. Health Visitor,
Zdanuk, J. (1993, October). Promoting positive reporductive outcomes.
Neonatal Nursing Cnference '93. Symposium presented by Schumpert
Medical Center and Willis-Knight Medical Center, Shreveport, Louisiana.
Copyright, ©1997 Debra Kay Neiman,
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