Perinatal Questions-Answers

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risk factors which impact perinatal outcomes
11.03.2019
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Question 1

Though there are no national guidelines on the intervals for screening for depression during postpartum, a number of professional organizations have provided important guidelines for healthcare professionals. Most of these professional organizations recommend periodic depression screening during the postpartum period (American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, 2010). A tool that is regularly utilized for screening is the Edinburgh Postpartum Depression Scale; and various studies have pointed out that it is dependable in recognizing mothers at high risk for postpartum depression (Earls & The Committee on Psychosocial Aspects of Child and Family Health, 2010).

The guidelines provided by Bright Futures encourage healthcare providers to support mothers and their families as a component of their role offering health care to children. These guidelines include anticipatory guidance and questions that healthcare providers may utilize to assess parental well-being (Earls & The Committee on Psychosocial Aspects of Child and Family Health, 2010). Unique questions, which are provided to examine depressive symptoms, are customized to be used at different periods. Guidelines provided by the Kaiser Permanente Care Management Institute indicate that it is necessary to examine for the existence of psychotic symptoms, homicidal ideas, and suicidal ideas for mothers who are depressed during the postpartum period (American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, 2010). This assessment should also consider the parenting skills for the newborn as well as other children in the mother’s care. AAP/ACOG guidelines recommend all patients to be monitored for severe postpartum depression symptoms and offered suitable treatment that adheres to their culture or referral to community resources (American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, 2010). The first postpartum visit that occurs at around 4-6 weeks after delivery should involve a thorough review of depression symptoms in order to determine whether intervention is required.

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As there are no treatment guidelines that are directed to the treatment for postpartum depression, it is advisable to customize treatment for each mother depending on her individual conditions. Clinical indicators of postpartum depression may include thoughts of hurting oneself or the child, withdrawal from loved ones, trouble bonding with the baby, extreme emotional swings, sentiments of deficiency, guilt or shame, lack of satisfaction in life, absence of enthusiasm in sex, overpowering fatigue, intense anger and irritability, sleep deprivation, and loss of appetite (American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, 2010). Two findings which would indicate the need for further assessment or referral are suicidal thoughts and poor parenting skills of the baby and other children.

This discussion is very important to the nursing field as the number of women who suffer from postpartum depression is still very high. This information has also made me realize that the Edinburgh Postpartum Depression Scale is very important in assessing postpartum depression. There are other assessment tools that can be applied in practice. What surprised me most is that there are no specific national guidelines on the intervals for screening for depression during postpartum.

Question 2

An obstetric panel (OB Panel) refers to a number of blood tests that are carried out to determine the state of health of a woman before and during the first trimester of pregnancy. The results of the OB Panel test may assist in identifying some problems during pregnancy. They may also assist in determining the treatment required for a pregnant woman or treatment required for the infant after birth. The tests that are conducted in OB Panel include complete blood count (CBC), antibody screening, maternal blood type and Rh factor, human immunodeficiency virus (HIV) antibody, baseline urine culture, hepatitis B surface antigen, syphilis screening, and rubella (German measles) status (Walley, Simkin, & Keppler, 2010). Rh factor is normally checked to determine whether there will be Rh incompatibility between a mother and a baby. If tests indicate there is a possibility of Rh incompatibility, steps may be taken to avoid complications associated with it.

A number of interventions can be taken depending on the results of each test. For instance, if a mother is found to have Rh-negative blood, there is a high possibility of Rh incompatibility as the baby is likely to have Rh-positive blood. To avoid Rh incompatibility and its associated complications, a woman with Rh-negative blood is injected with an Rh immune globulin medicine to prevent the body from producing Rh antibodies (Simkin, Durham, & Whalley, 2012). Another example of an intervention that can be taken during the OB Panel is when a woman is found to be HIV positive. The mother is normally put on ARTs medications to minimize the risk of transmission to the unborn baby as well as her partner (if negative) (Simkin, Durham, & Whalley, 2012).

The information gathered here has improved my understanding of the OB Panel and all the blood tests done during the first trimester. One thing I have learned, which is also carried out in our clinical practice, is that additional tests may be required for specific indication if some abnormalities have been identified. This information also encouraged me to go through most of the tests that are done during the first trimester such as genetic defects screening, chlamydia/gonorrhea testing, and Pap smear among others, though I did not include this information here as it was not needed.

Question 3

There are varying cultural beliefs and practices related to pregnancy among different ethnic groups. Some ethnic groups still cling to their cultural beliefs, while others have accepted change by doing away with some of their practices. In the Indian ethnic group, there are many cultural beliefs that are related to pregnancy. They believe that pregnancy is a normal physiologic occurrence that should not involve health care professionals. The only time they believe a woman should seek medical advice is when a problem occurs. Another belief in the Indian community is that it is considered unlucky to have twins or multiple pregnancies. Sex preference is another belief where males are preferred than females and some women may even terminate their pregnancies if they believe the fetus is a female (Choudhry, 2012).

It is crucial to be aware of cultural influences regarding pregnancy and prenatal care so that one can guide women who might not be aware of how these practices are influencing their reproductive health and childbearing. There many resources available that can help an APN to provide culturally appropriate health care services in pregnancy, especially from the U.S. Department of Health and Human Services (HHS) (Galanti, 2012). The other organizations that provide cultural related health information include Resources for Cross-Cultural health care (RCCHC), Center for the Advancement of Health, Office of Minority Health (OMH), and Administration for Community Living (ACL) among others. Information provided by these organizations may be in the form of technical information, program summaries, and case studies (Galanti, 2012).

This information made remember a situation where I was interviewing a Hispanic pregnant woman last year. It was during the cold season, but the woman told me that she could not wear anything around her neck no matter how cold it was. The reason for it was that wearing anything around her neck would cause problems to the umbilical cord. It was a stupid reason, I must say, but that is how her cultural beliefs dictate. Such a situation indicates how health care professionals should be aware of cultural practices so that they can advise patients accordingly. In my practice, I always try to understand the cultural beliefs of my patients to be able to help them.

Question 3

Offering support services to mothers and their families after experiencing a perinatal loss has become an acceptable component of maternal services in a number of countries. Interventions such as counseling and psychological support have been recommended in such situations as they improve the outcomes for mothers and their families after perinatal loss (Koopmans, Wilson, Cacciatore, & Flenady, 2013). Support services that are available after perinatal loss include family, couple, and individual support and counseling; parental guidance to assist siblings of different ages cope with the loss; education and guidance in regard to the grieving process and skills building to create coping strategies that are healthy; support groups in different languages for mothers and couples dealing with neonatal loss, miscarriage, and stillbirth; support groups for mothers and couples who have been forced by prenatal diagnosis to terminate a wanted pregnancy; mental health community-based referrals and other supports; facilitating important rituals sensible to families’ religious, cultural, and spiritual beliefs; an annual service for mothers and their families to remember and honor children who died during childhood and pregnancy; and finally, mother’s day service to honor women who have experienced perinatal loss (Kersting & Wagner, 2012).

There are a number of resources that can assist a woman who is not sure how to support her children while she is actively grieving. Perinatal grief resources for such a woman include individualized parent information brochures, children’s storybooks, staff brochures, and web-based mental health services (Koopmans, Wilson, Cacciatore, & Flenady, 2013). Some of the web-based mental health services include automated therapy programs for certain mental health issues, such as complicated grief and post-traumatic stress, virtual counseling services, online self-help groups, and informative websites (Koopmans, Wilson, Cacciatore, & Flenady, 2013). Some of the informative grief websites include A Place to Remember, Alive Alone, Bereaved Parents of the USA, Centre for Loss in Multiple Births among others. Most hospitals also have perinatal bereavement programs, and they are a number of international and national organizations that help families experiencing perinatal loss.

The information presented in this discussion is very important because it is dealing with an issue that APN has to face in practice. I was surprised to know there are so many informative grief websites that mothers who have experienced perinatal loss may get some helpful information. In my practice, I will be directing women and their families to these websites as information presented here may help them overcome their condition.

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Question 4

There a number of risk factors that may have an adverse effect on perinatal outcomes. Smoking and alcohol abuse are some of them. There is well-documented scientific evidence that tobacco smoking during pregnancy has severe effects on long-term and short-term perinatal outcomes (Ashford, 2012). Prenatal smoking is responsible for fetal mortality and morbidity. Most studies agree that maternal smoking may cause placental abruption (Ashford, 2012). Maternal smoking also significantly affects fetal growth and the growth of parts such as femur length, abdominal circumference, and head circumference. Prenatal smoking is associated with a double increase in the occurrence of sudden infant death syndrome (SIDS), elevating the risk of infant mortality by 40% and greater possibility (20-30%) of stillbirth (Ashford, 2012). Prenatal alcohol abuse may pose a number of risks to the developing fetus. Effects of alcohol on pregnancy include miscarriage, premature birth (preterm birth and very preterm birth), low birth weight, fetal alcohol syndrome (FAS), alcohol-related birth defects (ARBD), alcohol-related neurodevelopmental disorder (ARND), and birth complications (Murphy, Mullally, Cleary, Fahey, & Barry, 2013).

There a number of evidence-based interventions that can be recommended for a woman whose risk assessment indicated a potential or actual risk, but these interventions depend on the type of risk. Some of the interventions I would recommend include preconception counseling; encouraging a healthy lifestyle by offering health promotion; detecting, preventing, and managing tobacco and alcohol consumption; regular prenatal check-ups; and adequate access to obstetric care.

This discussion has helped me understand a number of things concerning risk factors which impact perinatal outcomes. One of the things that surprised me is that there is still a great number of pregnant women engaged in risky behaviors despite the fact that they are aware they might harm the baby and themselves. Most of the studies I went through indicated that most the women were aware of some of the dangers of the behaviors they were engaged in. I think preconception counseling may greatly help as most of the factors are present before conception. This is something I will definitely apply in my practice.

Question 5

A gynecological examination is very important as it can assist in the screening for colon, ovarian, uterine, cervical, and breast cancers as well as the other infections. Essential components of a gynecological and obstetrical history include chief complaint, presenting problem, past medical and surgical history, medications and allergies, menstrual history, contraception, sexual history, obstetric history, cervical and vaginal cytology (history of abnormal Pap smears/last Pap smear), infection, fertility/infertility, intimate partner violence screening, family history, social history, review of systems, vaccine history, urinary and rectal symptoms, and health maintenance (Szymoniak, 2014). The obstetric history should include live births as well as elective or spontaneous abortions.

There are a number of health promotion/disease prevention recommendations and anticipatory guidance for women which can either be classified as counseling, medications, immunizations, screenings (laboratory and diagnostic tests) and physical examination. Some guidelines and recommendations are carried out at certain ages while others can be done at any age. Two health promotion recommendations and guidelines for adolescent women include counseling to reduce risky sexual behavior and HPV vaccine. Two health promotion recommendations and guidelines for childbearing women include the annual pelvic examination and clinical breast exam for every 3 years. Two health promotion recommendations and guidelines for perimenopausal women include annual mammography and fasting blood sugars. Two health promotion recommendations and guidelines for menopausal women include colorectal screening, which involves sigmoidoscopy (every 5 years), colonoscopy (every 10 years), fecal occult blood (annually), and endometrial biopsy. Two health promotion recommendations and guidelines for geriatric women include osteoporosis screening, which is most common in postmenopausal women, and annual mental status exam (Alden, Lowdermilk, Cashion, & Perry, 2014).

This discussion is very important to my practice because it has helped me understand some issues that I was not aware of before. For instance, I never thought screening for violence was important in the gynecological examination. I usually assume violence screening as not very important in the gynecological examination, but now I know it is an important component in this assessment and I would definitely start taking it seriously during an interview for gynecological and obstetrical history taking. Another important thing I learned in this discussion is that some health promotion recommendations and guidelines are more important to some age groups than others. Though this section focused on women, I also understood that some recommendations and guidelines only apply to either men or women.

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