Prenatal Risk Factors and Helping a Healthy Pregnancy | Case Study

Women’s Clinic Scholarly Paper

Introduction

Pregnancy is a time of highs and lows, ups and down. But overall it is a period of great growth and development for the mother and the child. Throughout a pregnancy, a mother’s prenatal visits are very important. These are the visits that she looks forward to. She looks forward to coming in, to hear the baby’s heartbeat for the first time, to get ultrasound pictures to show to the family, and to find out the baby’s gender if desired. Prenatal visit are also essential to ensure the health of the mother and the baby. During these visits, the nurses, physicians, and other members of the healthcare team all work together to make sure the mother and the baby are in the best health possible.

For a healthy pregnancy, focus on health should begin even before conception. The mother should work to be an optimal weight, as well as preparing her body by taking prenatal vitamins which supplement a lot of the important substances needed to maintain a healthy pregnancy. An example is folic acid, which prevents neural tube defects. The mother should also focus on her lifestyle choices. For example, a mother should quit smoking, stop drinking alcohol, and stop using illicit drugs. All of these changes to the mother’s life will help to make her pregnancy decreases her risk of multiple complications.

Prenatal visits are the most important part of a pregnancy. While the mother is excited for her coming baby, the health care team is working hard performing multiple tests, and screenings to rule out any risks or complications that may arise. Throughout these visits, there is a lot of education provided. Education regarding the test and screenings being performed, vaccinations that will be administer, expectations during the pregnancy and labor, and education regarding methods of feeding. Overall, prenatal visits are the forefront of a healthy pregnancy and can make a difference in the outcome of a mothers pregnancy. That is why the purpose of this paper is to explore information collected during prenatal visits, pinpoint risk factors related to the mother and baby, and to analyze the teaching done during these visits to ensure that the mother has a healthy, happy, and successful pregnancy.

Health History

AE, is a 20 year old who is 13 weeks and 3 days gestation, due on Aug. 10^th, 2019. She is Caucasian, and of non-Hispanic or Latino ethnicity. She is a high school graduate, graduating in 2017. The pateint resides in Bloomsburg, where her and her boyfriend have their own apartment together. AE is currently unemployed. She was let go from her job at a call center in Bloomsburg about 2 weeks ago, due to her pregnancy. She claims she was not being treated fairly, since she disclosed to her boss that she was pregnant, and then was let go soon after. This is her first pregnancy GTPAL: 1,0,0,0,0, so she has no past obstetric history. Her last menstrual period fell on Nov. 3, 2018. Since then, she has experienced symptoms such as nausea, vomiting, headaches, fatigue, breast tenderness, mild cramps, light spotting for a day, and right sided pain due to a cyst, that is being monitored on her right ovary.

A.E. has a past medical history that includes Lyme disease, gallbladder disease, frequent dehydration, and fibromyalgia. In 2014, she had two surgeries, one which was a cholecystectomy or removal of her gall bladder due to her gallbladder disease. The other was an EGD, she then had a follow up EGD in 2015. The patient has a mental health history of anxiety and depression, but is currently in good health and has not had any problems associated with her diagnosis in over a year; she is not currently on medication for them. The patient is currently just taking her prenatal vitamins in the gummy form, which the doctor has approved. A.E. was previously taking naproxen for her fibromyalgia but has stopped taking it since she has been pregnant. In regards to her family medical history, there is nothing evident of much concern. Her mother suffers from peptic ulcer disease, while her father has a history of viral hepatitis. Her maternal grandmother has a history of thyroid disorder, and her fraternal grandmother had a cholecystectomy is her md 30’s. She also discussed her mother’s sister has an extensive history dealing with a heart disorder. The father’s family medical history was not obtained during the appointment.

The patient A.E., is 20 years old, she is 5 foot 8 inches tall and before pregnancy she weighted 121 pounds. Her starting BMI was calculated to be 18.44. Upon arrival of her most recent monthly visit A.E. weighs 115 pounds, that is a 6 pound weight loss from her initial prenatal visit. This loss of weight has altered her BMI which is now 17.48, she is now considered underweight and has not effectively gained weight during the first trimester of her pregnancy. This is a slight concern, the patient was referred to maternal fetal medicine and will be closely monitored for the duration of her term. The patient’s dietary intake is very little. She claims that she often does not have an appetite, and even when an appetite is present, she eats very little. On a regular day depending on what time she wakes up ,she might have a small or a half of sandwich and fruit during that day and not eat again until dinner. A consultation with a dietitian was recommended, but the patient refused.

Since being unemployed, A.E. has not been very active. She has no current occupational demands and does not exercise on a regular basis. Most of her days are spent in her apartment. At this moment, she has no physical stressors or limitations. The patient disclosed that her and her partner are still sexually active and have not experienced any problems or discomfort with intercourse. She has no risk of STIs at this moment, all of her screenings came back negative. Overall, the patient lives a pretty healthy lifestyle. She is a former smoker, who went through about a half a pack a day. She has not smoked in over a year and does not plan on starting again. She does not drink and has no history of substance abuse. She has even stopped taking prescription medication that could potentially cause any harm to the baby. She does drink caffeine in sodas occasionally, but not enough for it to be of concern. In conclusion, A.E. is in overall good health for her pregnancy.

For A.E. and her boyfriend, this was not a planned pregnancy. Originally, the couple were very nervous and scared. They were not sure if they were fit to be parents just yet. They are both young and had recently just moved into an apartment together. Their main concern was being financially stable to properly care for the baby. It took a while for them to emotionally adjust, but since their pregnancy journey has begun their attitudes have shifted. A.E. is now extremely excited about not only her experience of being pregnant but excited for the baby to arrive. She is aware that she is still in the beginning stages her pregnancy, but she is anxious to see what the rest of her journey entails. During the appointment, when discussing the baby and movement, A.E. could not stop smiling. She described the baby as a jumping bean especially since the last ultrasound that she had during her appointment with maternal fetal medicine. Together, they are very excited and are trying to mentally prepare for what is to come. The couple, as a whole, has a very strong and supportive family structure. Both the father and mother’s parents are very involved. A.E. claims that she has a family full of nurses and has multiple people to go to, if the couple needed something. She plans on delivering at Danville, where her cousin is a labor and delivery nurse. No culturally or religious needs were specified by the couple. Generally, the couple and the baby seem to have a very strong support system and are in very good hands.

Prenatal Risk Factors

In general, this primigravida mother is healthy. The only risk factor of concern for her pregnancy is her poor diet. However, this is a modifiable risk factor. As discussed previously, the patient had a 6 pound weight loss in the first trimester of the pregnancy. This is sometimes normally seen during this stage of pregnancy due to intolerances to certain food and decreases in appetite as a result of nausea and vomiting (Davidson, 2016). For a women whose pre-pregnancy BMI falls within the healthy range of 18-24.9, the recommended weight gain during pregnancy is somewhere between 25-35 pounds. In general, the mother to gain 2-3 pounds in her first trimester and ¾ – 1 pound per week there after throughout the rest of the pregnancy (Davidson, 2016). However, this is an important time of growth and development for the fetus so inadequate nutrition or poor weight gain puts the mother and the fetus at risk. For the mother, it increases her risk of having a preterm birth. This also puts her at greater risk for anemia, due to decreased iron intake through food. As well as an increased risk of preeclampsia, which can be describes as the toxemia of pregnancy that lead to hypertension, albuminuria, and edema, that can be life threating to both the mother and the fetus (Davidson, 2016). As a result of the mother malnutrition and poor weight gain, the fetus could suffer complications from prematurity, fetal malnutrition, intrauterine growth restriction, or be small for gestation age, which are all concerns for the mother and the Healthcare Provider. Due to the high risk and poor outcomes associated with the mothers poor diet, she was referred to maternal fetal medicine for a consultation and to be closely monitored during her pregnancy. The mother should also be referred to a dietitian to discuss plans for increasing caloric intake and focusing on proper elements of nutrition to incorporate into her diet to ensure proper management of weight for the remainder of the pregnancy. Even though the risk are evident, overall she is not a high risk pregnancy, due to the fact that this risk factor is modifiable. With proper education and lifestyle changes any further complications can be prevented.

Critique of Teaching and Additional Teaching

During the follow up appointment, the mother expressed her concerns about her recent weight loss and lack of appetite during the pregnancy. The patient had already been referred to and seen by maternal fetal medicine. A consultation with the dietitian was also offered, which the patient denied. No further teaching was done in regard to nutrition at this visit. Other education that was discussed was related to second trimester screenings and health as the mother would be approaching her second trimester at the end of the week. Screenings including AFP testing for neural tube defects. The one hour glucose tolerance test done between 24 and 28 weeks, and preparation education for the t-dap vaccine which is administered in the third trimester, between weeks 27 and 36 (Davidson, London, & Ladewig, 2016). The nurse provided the mother and father with brochures and pamphlets that had all the information regarding the topics discussed during the appointment, which was very appropriate for her education level. Overall, the teaching was very family centered. She provided the information to both the mother and the father and assessed both of their understanding of the information presented to them. From observation, the teaching that was provided was effective, relevant, and understood by the young parents.

While the teaching during this follow up appointment was effective, there was a lot more education that could have been done. More recommendations in regard to nutrition and education on adequate weight gain could have been provided. For example, the mother should have been educated on increasing her caloric intake by 300 calories per day (Davidson, London, & Ladewig, 2016). Along with increasing her intake of protein, calcium, iron, and vitamins (Davidson, London, & Ladewig, 2016). Protein is important for muscle growth of the fetus, as well as allows cells to increase in number and size to allow maternal tissue, like the uterus and the breast to grow (Davidson, London, & Ladewig, 2016). Iron is essential to avoid anemia and for the formation and maintenance of blood cells for both the mother and the fetus (Davidson, London, & Ladewig, 2016). In addition, the mother should ensure her intake of folic acid, at least 0.4mg/day, to prevent neural tube defects (Davidson, London, & Ladewig, 2016). This is usually achieved through prenatal vitamins. Tips such as adding a meal a day of nutrient-dense food should have been discussed. This additional meal has been shown to assist in meeting the increased caloric intake needed for the pregnant women and growing fetus, as well as improves the nutritional quality of the mother’s diet to help with consuming adequate amount of necessary micronutrients (Wessells et al., 2018). Proper intake of all these components is important for adequate health of the mother and proper growth of the fetus.

Pregnant women view nurses in the maternity field as a trusted source of knowledge and guidance. Nurses are in the perfect position to provide education that can promote health in these women during such a critical time. It is essential for nurses in this field to have the proper education and training in order to provide the women with the appropriate education needed to have a healthy pregnancy for both the mother and the baby. Nankumbi, Ngbirano, & Nalwadda (2018), conducted a study, where they performed six in-depth interviews with midwives, who are frequently involved in the care of pregnant women, at an antenatal clinic. The study explained how every pregnant women should be provided education concerning the importance of adequate nutrition, relevancy of weight gain, increased nutrient requirements, nutrient-rich dietary sources, importance of micronutrient supplementation, and appropriate food preparation during routine antenatal visits (Nankumbi, Ngbirano, & Nalwadda, 2018). Not only is all of this crucial to a healthy pregnant women as a source of health promotion but also for women who have specific nutritional needs. As discussed in the article, it was found that education about nutrition provided to pregnant women, has a significantly positive impact on the general outcomes of the pregnancy. Overall, it improved the mother’s awareness of her increased nutritional needs. Hence, contributing to the improved nutritional intake by the mothers who received this education (Nankumbi, Ngbirano, & Nalwadda, 2018). In spite of the increased knowledge, the bulk of education is usually done at the initial or first prenatal visit. Lack of follow-up education and reinforcement or summary of information previously covered can contribute to the parents’ lack of knowledge regarding important topics, such as nutrition. Nutrition, along with other educational material provided during pregnancy, plays an important part in the postpartum period, especially if the mother is planning on breastfeeding.

Another topic not discussed enough during this follow-up prenatal appointment was vaccinations. During the appointment, the nurse explained routine vaccinations that are given during pregnancy. She briefly discussed each vaccination that is recommended and when they are routinely administered. There was no discussion of the reasons for these vaccinations or how these vaccinations work. With the recent controversy surrounding vaccinations, immunizations are a very important topic that should be discussed in detail at every prenatal visit to ensure the health of both the mother and the fetus. One of these immunizations is the T-dap vaccine. As reviewed previously, the t-dap is administered to the mother in her third trimester around 27 to 36 weeks of gestation (Davidson, London, & Ladewig, 2016). The nurse explained that it is used to protect against pertussis and that the mother and father should be vaccinated. A pamphlet with more information was given to the couple but no further information was provided at this time. This could be contributed to the nurse’s lack of information or confidence regarding the topic.

Education regarding the importance of this vaccine and how it works should have been given during the visit. An example is pertussis, which is a common disease that can be easily transmitted to a vulnerable child who is under a year. While adults have the proper immune system to fight this disease, it is life-threatening to infants and young children. Information regarding how this vaccination should be administered to both parents and any immediate family, who may be in contact with the child is extremely important; this information should have also been included in the education session. It has been proven that vaccination of the mother and act of “concooning” or vaccination of immediate family, decreases the incidence of transmission of pertussis to the infant (Unisa, 2017).

Unisa (2017), conducted a study on improving the education of pertussis in postpartum women and their families. The researcher studied staff nurses at a hospital in California. The nurses in the study participated in two educational sessions about importance of vaccination of close family, as well as provide these nurses with a toolkit to help them better educate mothers and families on this topic. The goal of this study was to increase the nurses’ knowledge of the subject, in return making them more confident in educating women and families about the vaccine. In the end, this increased the amount of vaccinations given, due to the education and awareness of the disease. Most pregnant women are not aware of the risk related to not being vaccinated. There is also a lack of knowledge regarding disease, and its mode of transmission (Unisa, 2017). This study supports the claim, that further education is needed on the importance and risk of this vaccine. The author suggests that a toolkit for education should be provided to nurses in order to guide their education and follow up and to ensure that all information is being successfully provided to the mothers and family (Unisa, 2017). It has been proven that patients’ decisions are based on the effectiveness of education and information provided to them by their nurse, especially in a maternity setting (Unisa, 2017). By providing our nurses with further education, it allows them to be better equipped and knowledgeable on topics that allows them to provide proper education to patients. As a result of better educating our nurses, parents and families will be thoroughly educated, not only on topics such as pertussis and its vaccination, but on all health promotion topics. This allows parents to make educated decisions which ensures the health of themselves during pregnancy, as well as their child during a period of growth and development.

Conclusion

Generally speaking, there is a lot that goes in to a healthy pregnancy. Prenatal visits are essential for positive outcomes for the mother and the baby. These appointments, are crucial to identify risk factors, and to prevent complications. The effectiveness of the information gathered from these meetings will make all the difference. In terms of the patient observed, she was mostly healthy and had very few risk factors. Her only risk factor of concern was her recent weight loss during the first trimester of pregnancy, which lead to her being underweight. Aside from her concerns about her weight, she was very excited to be having a baby. Throughout the appointment, she was provided with education on a glucose tolerance test and Tdap vaccination. The education provided could have been in more detail in order for the mother to fully understand the implications on mother and baby.

Through the research presented, it was found that that more in depth education regarding individualized topics specific to the client results in better overall outcomes for the parent and the child. Topics such as nutrition and immunization were discussed during the follow up prenatal visit. Further education could have been provided on both of these topics. Parents rely on healthcare providers for information and recommendations to guide them to make the best decision possible regarding the health of mother and the baby. It was proven that education is a crucial part of health promotion, as well as addressing risk factors present. As nurses and health care providers, it is important to be well educated on topics, in order to provide adequate, updated, evidenced-based information to our patients. The better we educate our patients, the better their overall outcomes will be.

References

• Davidson, M. R., London, M. L., & Ladewig, P. W. (2016). Olds maternal-newborn nursing & womens health across the lifespan. Boston: Pearson.
• Nankumbi, J., Ngabirano, T. D., & Nalwadda, G. (2018). Maternal Nutrition Education Providedby Midwives: A Qualitative Study in an Antenatal Clinic, Uganda. Journal of Nutritio nand Metabolism, 2018, 1-7. doi:10.1155/2018/3987396
• Wessells, K., Young, R., Ferguson, E., Ouédraogo, C., Faye, M., & Hess, S. (2019). Assessment of Dietary Intake and Nutrient Gaps, and Development of Food-Based Recommendations, among Pregnant and Lactating Women in Zinder, Niger: An Optifood Linear Programming Analysis. Nutrients, 11(1), 72. doi:10.3390/nu11010072
• Unisa, M. (2017). Improving Pertussis Education for Postpartum Women and their Family Members. Doctor of Nursing Practice (DNP) Projects. Retrieved February 11, 2019.