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Maternal Child Nursing Care

SIXTH EDITION

MATERNITY

Shannon E. Perry, RN, PhD, FAAN Professor Emerita, School of Nursing San Francisco State University San Francisco, California

Deitra Leonard Lowdermilk, RNC, PhD, FAAN Clinical Professor Emerita, School of Nursing University of North Carolina at Chapel Hill Chapel Hill, North Carolina

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Kitty Cashion, RN-BC, MSN Clinical Nurse Specialist, College of Medicine, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine University of Tennessee Health Science Center Memphis, Tennessee

Kathryn Rhodes Alden, EdD, MSN, RN, IBCLC Associate Professor, School of Nursing University of North Carolina at Chapel Hill Chapel Hill, North Carolina Associate Editor

Ellen F. Olshansky, PhD, RN, WHNP-BC, NC-BC, FAAN Professor and Chair, Department of Nursing Suzanne Dworak-Peck School of Social Work University of Southern California Los Angeles, California PEDIATRIC

Marilyn J. Hockenberry, PhD, RN, PPCNP-BC, FAAN Bessie Baker Professor of Nursing and Professor of Pediatrics Associate Dean of Research Affairs, School of Nursing Chair, Duke Institutional Review Board Duke University

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Durham, North Carolina

David Wilson, MS, RNC-NIC (deceased) Staff Children's Hospital at Saint Francis Tulsa, Oklahoma

Cheryl C. Rodgers, PhD, RN, CPNP, CPON Assistant Professor Duke University School of Nursing Durham, North Carolina

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Table of Contents

Cover image

Title Page

Copyright

Contributors

Reviewers

About the Authors

Maternity

Pediatric

Preface

Approach

Special Features

Teaching And Learning Package

Acknowledgments

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Part 1 Maternity Nursing

Unit 1 Introduction to Maternity Nursing

1 21st Century Maternity Nursing

Advances in the Care of Mothers and Infants

Efforts to Reduce Health Disparities

Contemporary Issues and Trends

The Future of Nursing

Standards of Practice and Legal Issues in Delivery of Care

References

2 The Family, Culture, Spirituality, and Home Care

The Family in Cultural and Spiritual Context

Theoretic Approaches to Understanding Families

The Family in a Cultural Context

Developing Cultural Competence

Home Care in the Community

Care Management

Assessment and Nursing Diagnoses

Nursing Considerations

References

Unit 2 Reproductive Years

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3 Assessment and Health Promotion

Female Reproductive System

Menstruation

Sexual Response

Barriers to Entering the Health Care System

Caring for the Well Woman Across the Life Span: The Need for Health Promotion and Disease Prevention

Approaches to Care at Specific Stages of a Woman's Life

Spiritual Approaches to Women's Health Promotion

Assessment of the Woman: History and Physical Examination

References

4 Reproductive System Concerns

Menstrual Disorders

Infections

Problems of the Breast

References

5 Infertility, Contraception, and Abortion

Infertility

Contraception

Abortion

References

Unit 3 Pregnancy

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6 Genetics, Conception, and Fetal Development

Genetics

Genetic Counseling

Cell Division and Conception

The Embryo and Fetus

Multifetal Pregnancy

Nongenetic Factors Influencing Development

References

7 Anatomy and Physiology of Pregnancy

Gravidity and Parity

Pregnancy Tests

Adaptations to Pregnancy

References

8 Nursing Care of the Family During Pregnancy

Diagnosis of Pregnancy

Adaptation to Pregnancy

Care Management

Variations in Prenatal Care

Perinatal Education

Perinatal Care Choices

References

References

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9 Maternal and Fetal Nutrition

Nutrient Needs Before Conception

Nutrient Needs During Pregnancy

References

Care Management

References

10 Assessment of High-Risk Pregnancy

Assessment of Risk Factors

Antepartum Testing

Biophysical Assessment

Biochemical Assessment

Fetal Care Centers

Antepartum Assessment Using Electronic Fetal Monitoring

Psychologic Considerations Related to High-Risk Pregnancy

The Nurse's Role in Assessment and Management of the High-Risk Pregnancy

References

11 High-Risk Perinatal Care

Diabetes Mellitus

Pregestational Diabetes Mellitus

Care Management

Gestational Diabetes Mellitus

Care Management

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References

Thyroid Disorders

Maternal Phenylketonuria

Cardiovascular Disorders

Care Management

Other Medical Disorders in Pregnancy

Substance Abuse

Care Management

References

12 High-Risk Perinatal Care

Hypertension in Pregnancy

Preeclampsia

Care Management

References

Hyperemesis Gravidarum

Care Management

Hemorrhagic Disorders

Care Management

Infections Acquired During Pregnancy

Surgery During Pregnancy

Care Management

Trauma During Pregnancy

References

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Unit 4 Childbirth

13 Labor and Birth Processes

Factors Affecting Labor

Process of Labor

Physiologic Adaptation to Labor

References

14 Maximizing Comfort for the Laboring Woman

Pain During Labor and Birth

Factors Influencing Pain Response

References

Nonpharmacologic Pain Management

Pharmacologic Pain Management

Care Management

References

15 Fetal Assessment During Labor

Basis for Monitoring

Monitoring Techniques

References

Fetal Heart Rate Patterns

Care Management

Documentation

References

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16 Nursing Care of the Family During Labor and Birth

First Stage of Labor

Care Management

Second Stage of Labor

Care Management

Third Stage of Labor

References

Fourth Stage of Labor

Care Management

References

17 Labor and Birth Complications

Preterm Labor and Birth

Care Management

References

Premature Rupture of Membranes

Chorioamnionitis

Postterm Pregnancy, Labor, and Birth

Dysfunctional Labor (Dystocia)

Obesity

Obstetric Procedures

Obstetric Emergencies

References

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Unit 5 Postpartum Period

18 Postpartum Physiologic Changes

Reproductive System and Associated Structures

Endocrine System

Urinary System

Gastrointestinal System

Breasts

Cardiovascular System

Respiratory System

Neurologic System

Musculoskeletal System

Integumentary System

Immune System

References

19 Nursing Care of the Family During the Postpartum Period

Transfer From the Recovery Area

Planning for Discharge

References

References

20 Transition to Parenthood

Parental Attachment, Bonding, and Acquaintance

References

13

Parent-Infant Contact

Communication Between Parent and Infant

Parental Role After Birth

Diversity in Transitions to Parenthood

Parental Sensory Impairment

Sibling Adaptation

Grandparent Adaptation

Care Management

References

21 Postpartum Complications

Postpartum Hemorrhage

Care Management

Hemorrhagic (Hypovolemic) Shock

Care Management

Coagulopathies

Venous Thromboembolic Disorders

Postpartum Infection

Care Management

Postpartum Mood Disorders

References

Care Management

Bipolar Disorder

Postpartum Anxiety Disorders

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Maternal Death

References

Unit 6 Newborn

22 Physiologic and Behavioral Adaptations of the Newborn

Transition to Extrauterine Life

Physiologic Adjustments

Behavioral Adaptations

References

23 Nursing Care of the Newborn and Family

Care Management: Birth Through the First 2 Hours

Care Management: From 2 Hours After Birth Until Discharge

References

References

24 Newborn Nutrition and Feeding

Recommended Infant Nutrition

Infant Feeding Decision-Making

Cultural Influences on Infant Feeding

Nutrient Needs

Anatomy and Physiology of Lactation

Care Management

References

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Formula-Feeding

References

25 The High-Risk Newborn

Birth Injuries

Neonatal Infections

Congenital Infections

Drug-Exposed Infants*

References

Hemolytic Disorders

Infants of Diabetic Mothers

Congenital Anomalies

Preterm and Postterm Infants

References

Care of the High Risk Newborn and Family

Newborn Screening for Disease

Neonatal Loss

References

Part 2 Pediatric Nursing

Unit 7 Children, Their Families, and the Nurse

26 21st Century Pediatric Nursing

Health Care for Children

16

Infant Mortality

The Art of Pediatric Nursing

The Process of Providing Nursing Care to Children and Families

Quality Outcome Measures

References

27 Family, Social, Cultural, and Religious Influences on Child Health Promotion

General Concepts

Family Structure and Function

Family Roles and Relationships

Parental Roles

Parenting

Special Parenting Situations

Sociocultural Influences Upon the Child and Family

Influences in the Surrounding Environment

Broader Sociocultural Influences Upon the Child and Family

Understanding Cultures in the Health Care Encounter

Health Beliefs and Practices

References

28 Developmental and Genetic Influences on Child Health Promotion

Growth and Development

Role of Play in Development

Developmental Assessment

17

Genetic Factors That Influence Development

References

Unit 8 Assessment of the Child and Family

29 Communication and Physical Assessment of the Child and Family

Guidelines for Communication and Interviewing

Resources for Telephone Triage Protocols

Communicating With Families

History Taking

General Approaches Toward Examining the Child

References

References

References

30 Pain Assessment and Management in Children

Pain Assessment

Behavioral Pain Measures

Self-Report Pain Rating Scales

Multidimensional Measures

Chronic and Recurrent Pain Assessment

Assessment of Pain in Specific Populations

Pain Management

Consequences of Untreated Pain in Infants

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Common Pain States in Children

References

Unit 9 Health Promotion and Special Health Problems

31 The Infant and Family

Promoting Optimal Growth and Development

Promoting Optimal Health During Infancy

References

Special Health Problems

References

32 The Toddler and Family

Promoting Optimal Growth and Development

Promoting Optimal Health During Toddlerhood

Skin Disorders Related to Animal Contacts

Ingestion of Injurious Agents

Safety Promotion and Injury Prevention

Anticipatory Guidance—Care of Families

References

33 The Preschooler and Family

Promoting Optimal Growth and Development

Promoting Optimal Health During the Preschool Years

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Infectious Conditions: Communicable Diseases

Intestinal Parasitic Diseases

Child Maltreatment

References

34 The School-Age Child and Family

Promoting Optimal Growth and Development

Promoting Optimal Health During the School Years

Infections of the Skin

School-Age Disorders With Behavioral Components

References

35 The Adolescent and Family

Promoting Optimal Growth and Development

Promoting Optimal Health During Adolescence

Special Health Problems

Nutritional and Eating Disorders

Health Problems With a Behavioral Component

References

Unit 10 Special Needs, Illness, and Hospitalization

36 Impact of Chronic Illness, Disability, or End-of-Life Care for the Child and Family

Care of Children and Families Living With or Dying From Chronic or Complex Diseases

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The Family of the Child With a Chronic or Complex Condition

The Child With a Chronic or Complex Condition

Nursing Care of the Family and Child With a Chronic or Complex Condition

Perspectives on the Care of Children at the End of Life

References

Nursing Care of the Child and Family at the End of Life

References

37 Impact of Cognitive or Sensory Impairment on the Child and Family

Cognitive Impairment

Sensory Impairment

Communication Impairment

References

References

38 Family-Centered Care of the Child During Illness and Hospitalization

Stressors of Hospitalization and Children's Reactions

Stressors and Reactions of the Family of the Child Who Is Hospitalized

Nursing Care of the Child Who Is Hospitalized

Nursing Care of the Family

Care of the Child and Family in Special Hospital Situations

References

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39 Pediatric Variations of Nursing Interventions

General Concepts Related to Pediatric Procedures

Skin Care and General Hygiene

Safety

Positioning for Procedures

Collection of Specimens

References

Administration of Medication

References

Maintaining Fluid Balance

Alternative Feeding Techniques

References

Procedures Related to Elimination

Procedures for Maintaining Respiratory Function

References

References

Unit 11 Health Problems of Children

40 The Child With Respiratory Dysfunction

Respiratory Infection

Upper Respiratory Tract Infections

Croup Syndromes

Infections of the Lower Airways

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References

Other Respiratory Tract Infections

Pulmonary Dysfunction Caused by Noninfectious Irritants

Long-Term Respiratory Dysfunction

Respiratory Emergency

References

41 The Child With Gastrointestinal Dysfunction

Distribution of Body Fluids

Gastrointestinal Dysfunction

Disorders of Motility

Nutritional Disorders

Recurrent and Functional Abdominal Pain

Hepatic Disorders

Structural Defects

Obstructive Disorders

Malabsorption Syndromes

References

42 The Child With Cardiovascular Dysfunction

Cardiovascular Dysfunction

Congenital Heart Disease

Clinical Consequences of Congenital Heart Disease

Nursing Care of the Family and Child With Congenital Heart Disease

Acquired Cardiovascular Disorders

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References

Heart Transplantation

Vascular Dysfunction

References

43 The Child With Hematologic or Immunologic Dysfunction

Hematologic and Immunologic Dysfunction

Red Blood Cell Disorders

References

Defects in Hemostasis

Immunologic Deficiency Disorders

Technologic Management of Hematologic and Immunologic Disorders

References

44 The Child With Cancer

Cancer in Children

Care Management

Cancers of Blood and Lymph Systems

Nervous System Tumors

Bone Tumors

Other Solid Tumors

The Childhood Cancer Survivor

References

45 The Child With Genitourinary Dysfunction

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Genitourinary Dysfunction

Problems Related to Elimination

External Defects of the Genitourinary Tract

Glomerular Disease

Miscellaneous Renal Disorders

Renal Failure

Technologic Management of Renal Failure

References

46 The Child With Cerebral Dysfunction

Cerebral Dysfunction

Neurologic Examination

Nursing Care of the Unconscious Child

Cerebral Trauma

Intracranial Infections

References

Seizure Disorders

Cerebral Malformations

References

47 The Child With Endocrine Dysfunction

The Endocrine System

Disorders of Pituitary Function

Disorders of Thyroid Function

Disorders of Parathyroid Function

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Hypoparathyroidism

Disorders of Adrenal Function

Disorders of Pancreatic Hormone Secretion

References

48 The Child With Musculoskeletal or Articular Dysfunction

The Immobilized Child

Traumatic Injury

Sports Participation and Injury

Birth and Developmental Defects

Acquired Defects

Infections of Bones and Joints

Disorders of Joints

References

49 The Child With Neuromuscular or Muscular Dysfunction

Congenital Neuromuscular or Muscular Disorders

Acquired Neuromuscular Disorders

References

Index

Special Features

Atraumatic Care

Clinical Reasoning Case Study

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Community Focus

Cultural Considerations

Emergency Treatment

Evidence-Based Practice

Family-Centered Care

Guidelines

Medication Guide

Nursing Care Plan

Patient Teaching

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Copyright

3251 Riverport Lane St. Louis, Missouri 63043

MATERNAL CHILD NURSING CARE, SIXTH EDITION ISBN: 978-0-323-54938-7

Copyright © 2018 by Elsevier Inc. All rights reserved.

NANDA International Nursing Diagnoses: Definitions and Classifications 2012-2014; Herdman T.H. (ED); copyright © 2012, 1994-2012 NANDA International; used by arrangement with John Wiley & Sons, Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in the work.

NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks and service marks of the National Council of State Boards of Nursing, Inc.

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Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2010, 2006, 2002, and 1998.

Library of Congress Cataloging-in-Publication Data

Names: Perry, Shannon E., author. | Olshansky, Ellen Frances, 1949- editor. Title: Maternal child nursing care : maternity pediatrics / Shannon E. Perry, Marilyn J. Hockenberry, Deitra Leonard Lowdermilk, David Wilson, Kitty Cashion, Cheryl C. Rodgers, Kathryn Rhodes Alden ; associate editor, Ellen Olshansky. Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017036656 | ISBN 9780323549387 (hardcover : alk. paper) Subjects: | MESH: Maternal-Child Nursing–methods | Pediatric Nursing–methods | Maternal Health | Infant Health | Child Health Classification: LCC RG951 | NLM WY 157.3 | DDC 618.92/00231–

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dc23 LC record available at https://lccn.loc.gov/2017036656

Senior Content Strategist: Sandra Clark Senior Content Development Specialist: Heather Bays Publishing Services Manager: Julie Eddy Book Production Specialist: Clay S. Broeker Design Direction: Brian Salisbury

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

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Contributors

Debbie Fraser MN, RNC-NIC Associate Professor Director Nurse Practitioner Program Faculty of Health Disciplines Athabasca University Advanced Practice Nurse NICU St. Boniface Hospital Winnipeg, Canada

Pat Mahaffee Gingrich MSN, RN, WHNP-BC Assistant Professor School of Nursing University of North Carolina at Chapel Hill Chapel Hill, North Carolina Evolve Contributors

Key Points

Joanna Cain BSN, BA, RN President and Founder, Auctorial Pursuits, Inc. Austin, Texas Review Questions

Daryle Wane PhD, ARNP, FNP-BC Baccalaureate Degree Nursing Program Director Professor of Nursing BSN Faculty

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Pasco-Hernando State College New Port Richey, Florida Test Bank

Linda Turchin RNH, MSN, CNE Assistant Professor, Nursing Fairmont State University Fairmont, West Virginia

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Reviewers

Michael D. Aldridge PhD, RN, CNE Assistant Professor of Nursing Pediatric Nursing Concordia University Texas Austin, Texas

Sandy Barker RN, MSN Master Nursing Instructor Nursing Tennessee College of Applied Technology Elizabethton, Tennessee

Judy Carlyle MSN, RN Faculty Arkansas Rural Nursing Education Consortium Nashville, Arkansas

Brigit Carter PhD, RN, CCRN Assistant Professor School of Nursing Duke University Durham, North Carolina

Janie Corbitt RN, MLS Instructor of Nursing (retired) Milledgeville, Georgia

Stephanie Evans PhD, APRN, PNP-PC

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Assistant Professor Harris College of Nursing and Health Sciences Texas Christian University Fort Worth, Texas

Vanessa Lynn Flannery MSN, PHCNS-BC, CNE Associate Professor Morehead State University Morehead, Kentucky

Kari Gali DNP, RN, CPNP Post-Doctoral Fellow Case Western Reserve University Cleveland, Ohio

Terry Hadler MSN, RN Assistant Professor Dakota Wesleyan University Mitchell, South Dakota

Teresa Howell DNP, RN, CNE Department of Nursing Morehead State University Morehead, Kentucky

Kathleen S. Jordon DNP, MS, FNP-BC, ENP-BC, SANE-P Clinical Assistant Professor School of Nursing University of North Carolina at Charlotte Nurse Practitioner Emergency Department Mid-Atlantic Emergency Medicine Associates Charlotte, North Carolina

Christina D. Keller MSN, RN, CHS Instructor Nursing Radford University Clinical Simulation Center Radford, Virginia

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Rebecca M. Padgett MSN, RN Nursing Faculty Jefferson Davis Community College Brewton, Alabama

Latoya Rawlins DNP, RN-BC, CNE Assistant Professor School of Nursing Rutgers, The State University of New Jersey New Brunswick, New Jersey

Debra Lee Stayer RN, PhD, CCRN-K Assistant Professor Nursing Bloomsburg University Bloomsburg, Pennsylvania

Michelle Van Wyhe DNP, ARNP-BC Professor of Nursing Northwestern College Nurse Practitioner Orange City Area Health System Orange City, Iowa

Donna Wilsker RN, BSN, MSN Assistant Professor Nursing Lamar University Beaumont, Texas

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About the Authors

Maternity

Shannon E. Perry is Professor Emerita, School of Nursing, San Francisco State University, San Francisco, California. She received her diploma in nursing from St. Joseph Hospital School of Nursing, Bloomington, Illinois; a BSN from Marquette University; an MSN from the University of Colorado Medical Center; and a PhD in Educational Psychology from Arizona State University. She completed a 2-year postdoctoral fellowship in perinatal nursing at the University of California, San Francisco, as a Robert Wood Johnson Clinical Nurse Scholar.

Dr. Perry has had clinical experience in obstetrics, pediatrics, gynecology, and neonatal nursing. She has taught in schools of nursing in several states for over 30 years and was director of the School of Nursing at San Francisco State University. She is a Fellow in the American Academy of Nursing. Dr. Perry's experience in international nursing includes teaching in the United Kingdom, Ireland, Italy, Thailand, Ghana, and China, as well as participating

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in health missions in Ghana, Kenya, and Honduras.

Deitra Leonard Lowdermilk is Clinical Professor Emerita, School of Nursing, University of North Carolina at Chapel Hill. She received her BSN from East Carolina University and her MEd and PhD in Education from the University of North Carolina at Chapel Hill. She is certified in in-patient obstetrics by the National Certification Corporation. She is a Fellow in the American Academy of Nursing. In addition to being a nurse educator for more than 34 years, Dr. Lowdermilk has clinical experience in maternity and women's health care.

Dr. Lowdermilk has been recognized for her expertise in nursing education and women's health by state and national nursing organizations and by her alma mater, East Carolina University. A few examples include Educator of the Year by the Association of Women's Health, Obstetric and Neonatal Nurses and by the North Carolina Nurses Association. Dr. Lowdermilk also is co-author of Maternity and Women's Health Care (eleventh edition), Maternity Nursing (eighth edition), and Maternal and Child Health (fifth edition). In Fall 2010, the East Carolina University College of Nursing named the Neonatal Intensive Care and Midwifery Laboratory in honor of Dr. Lowdermilk. In 2011, she was named as one of the first 40 nurses inducted into the College of Nursing Hall of Fame.

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Kitty Cashion is a Clinical Nurse Specialist in the Maternal-Fetal Medicine Division, College of Medicine, Department of Obstetrics and Gynecology at The University of Tennessee Health Science Center in Memphis. She received her BSN from the University of Tennessee College of Nursing in Memphis and her MSN in parent- child nursing from the Vanderbilt University School of Nursing in Nashville, Tennessee. Ms. Cashion is certified as a high risk perinatal nurse through the American Nurses Credentialing Center.

Ms. Cashion's job responsibilities at the University of Tennessee include providing education regarding low- and high-risk obstetrics to staff nurses in West Tennessee community hospitals. For over 20 years, Ms. Cashion has been an adjunct clinical instructor in maternal-child nursing at Northwest Mississippi Community College in Senatobia, Mississippi, and Union University in Germantown, Tennessee. Ms. Cashion has contributed many chapters to maternity nursing textbooks over the years and also co-authored several major maternity nursing textbooks.

Kathryn Rhodes Alden is Associate Professor at the University of North Carolina at Chapel Hill School of Nursing, where she has taught clinical and didactic in maternal/newborn nursing for 29

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years. She has received numerous awards for excellence in nursing education at the University of North Carolina, being recognized for clinical and classroom teaching expertise as well as for academic counseling. Dr. Alden was instrumental in the adoption of simulation-based learning for nursing education as well as for interprofessional education.

Dr. Alden earned a BSN from University of North Carolina at Charlotte, an MSN from the University of North Carolina at Chapel Hill, and a doctorate in adult education from North Carolina State University. She has clinical experience as a staff nurse in pediatrics, pediatric intensive care, and neonatal intensive care, as well as in postpartum home care of mothers, newborns, and families. She has served as a nursing administrator and coordinator of quality improvement. Dr. Alden has been an international board certified lactation consultant for more than 20 years and has extensive experience working as an inpatient lactation consultant and a lactation educator.

Ellen F. Olshansky is Professor and Founding Chair of the Department of Nursing in the Suzanne Dworak-Peck School of Social Work at the University of Southern California. She earned a BA in Social Work from the University of California, Berkeley, and a BS, MS, and PhD from the University of California, San Francisco School of Nursing. She is a Fellow in the American Academy of Nursing and the Western Academy of Nursing through the Western Institute of Nursing.

Dr. Olshansky is a women's health nurse practitioner, certified through the National Certification Corporation, and her research focuses on women's health across the lifespan, with an emphasis on

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reproductive health. She is one of the founders of the Orange County Women's Health Project, which promotes women's health and wellness in Orange County, California. She recently completed a 10-year term as editor of the Journal of Professional Nursing, the official journal of the American Association of Colleges of Nursing. She has published extensively in numerous nursing and other health-related journals as well as authoring many book chapters and editorials.

Pediatric Marilyn J. Hockenberry is the Bessie Baker Distinguished Professor of Nursing and Professor of Pediatrics at Duke University. She is the Associate Dean of Research Affairs in the Duke School of Nursing. Her research focuses on symptom management and treatment-related side effects experienced by children who have cancer. Dr. Hockenberry's current National Institutes of Health– funded research studies are evaluating the treatment-related symptoms and neurocognitive deficits of leukemia treatment.

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Cheryl C. Rodgers is an Assistant Professor at Duke University School of Nursing in Durham. Her research focuses on symptom assessment and symptom management among children undergoing cancer treatment or stem cell transplant. Dr. Rodgers is certified as a primary care pediatric nurse practitioner and a pediatric oncology nurse. She has over 25 years of clinical experience caring for children with hematologic and oncologic diseases.

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Preface

This sixth edition of Maternal Child Nursing Care combines essential maternity and pediatric nursing information into one text. The text focuses on the care of women during their reproductive years and the care of children from birth through adolescence. The issues and concerns of childbearing women and the health care of children are the primary concentrations. The promotion of wellness and the management of common women's health problems and child development in the context of the family are also addressed. As we move further into the twenty-first century, this edition of Maternal Child Nursing Care is designed to address the changing needs of women during their childbearing years and children during their developing years.

Maternal Child Nursing Care was developed to provide students with the knowledge and skills they need to become competent critical thinkers and to attain the sensitivity needed to become caring nurses. This sixth edition has been revised and refined in response to comments and suggestions from educators, clinicians, and students. It includes the most accurate, current, and clinically relevant information available.

Approach Professional nursing practice continues to evolve and adapt to society's changing health priorities. The rapidly changing health care delivery system offers new opportunities for nurses to alter the practice of maternity and pediatric nursing and to improve the way care is given. Increasingly, nursing practice must be evidence

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based. It is incumbent on nurses to use the most up-to-date and scientifically supported information on which to base their care. To assist nurses in providing this type of care, Evidence-Based Practice boxes with implications for practice are included throughout the text.

Consumers of maternity and pediatric care vary in age, ethnicity, culture, language, social status, marital status, and sexual orientation. They seek care from a variety of health care providers in numerous health care settings, including the home. To meet the needs of these consumers, clinical education must offer students a variety of health care experiences in settings that include hospitals and birth centers, homes, clinics, private physicians' offices, shelters for the homeless or for women and children in need of protection, and other community-based settings.

Care management has been used as an organizing framework for discussion in the nursing care chapters. Interprofessional care is emphasized because this approach demonstrates how nursing must collaborate with other health care disciplines to provide the most comprehensive care possible to women and children. Nursing Care Plans reinforce the problem-solving approach to patient care. In chapters that focus on complications of childbearing, reproductive conditions, and childhood illnesses, medical interventions are included along with nursing care management. Throughout the discussion of assessment and care, we alert the nurse to signs of potential problems and provide informational boxes that highlight warning signs and emergency situations.

Patient education is an essential component of the nursing care of women and children. The chapter on women's health promotion and screening emphasizes teaching for self-care to promote wellness and to encourage preventive care. The chapter on transition to parenthood focuses on teaching for new parents and infants at home. Special boxes highlight community care throughout the text. Family-Centered Care boxes incorporate family considerations important to the care of women and children. Issues concerning grandparents, siblings, and different family constellations are addressed. In the pediatric chapters, these boxes focus on the special learning needs of families. Legal Tips are integrated into the maternity section to emphasize issues related to

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the care of women and infants. Alerts are located throughout the text to draw attention to important information on medications, nursing care, and safety.

This sixth edition features a contemporary design with logical, easy-to-follow headings and an attractive four-color design that highlights important content and increases visual appeal. Hundreds of color photographs and drawings throughout the text, many of them new, illustrate important concepts and techniques to further enhance comprehension. To help students learn essential information quickly and efficiently, we have included numerous features that prioritize, condense, simplify, and emphasize important aspects of nursing care. In addition, the text encourages students to think critically.

Special Features • Atraumatic Care boxes emphasize the importance of providing

competent care without creating undue physical and psychologic distress. Although many of the boxes provide suggestions for managing pain, atraumatic care also considers approaches to promoting self-esteem and preventing embarrassment.

• Clinical Reasoning Case Studies present students with real-life situations and encourage them to make appropriate clinical judgments. A focus on interprofessional care encourages students to think beyond the nursing role to include collaboration with other health care professionals. Answer guidelines are provided in TEACH for Nurses.

• Community Focus boxes emphasize community issues, provide resources and guidance, and illustrate nursing care in a variety of settings.

• Cultural Considerations boxes describe beliefs and practices about pregnancy, labor and birth, parenting, and women's health concerns.

• Emergency Treatment boxes alert students to the signs and symptoms of various emergency situations and provide interventions for immediate implementation.

• Evidence-Based Practice is incorporated in new boxes that

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integrate findings from recent studies on selected clinical practices topics; relevant Quality and Safety Education for Nurses (QSEN) competencies are identified in these boxes.

• Family-Centered Care boxes highlight the needs and concerns of families that should be addressed when family-centered care is provided.

• Guidelines boxes provide students with examples of various approaches to implementing care.

• Legal Tips are integrated throughout Part 1 to provide students with relevant information to deal with important legal matters in the context of maternity nursing.

• Medication Guide boxes and Medication Alerts include key information about medications used in maternity and newborn care, including their indications, adverse effects, and nursing considerations.

• Nursing Alerts call the reader's attention to critical information that could lead to deteriorating or emergency situations.

• Nursing Care Plans are provided for many commonly encountered situations and disorders. Rationales are included for nursing interventions that might not be immediately evident to students. The care plans present a brief case study to help students conceptualize how to individualize patient care.

• Patient Teaching boxes assist students to help patients and families become involved in their own care with optimal outcomes.

• Resources, including websites and contact information for organizations and educational resources available for the topics discussed, are listed throughout.

• Safety Alerts call the reader's attention to potentially dangerous situations that should be addressed by the nurse.

• During assessment, the nurse must be alert for Signs of Potential Complications; these are included in chapters that cover uncomplicated pregnancy and childbirth.

• A highly detailed, cross-referenced Index allows readers to quickly access needed information.

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Teaching And Learning Package Several ancillaries for this text have been developed for instructors and students to use in classroom and clinical settings.

For Students Evolve: Evolve is an innovative website that provides a wealth of content, resources, and state-of-the-art information on maternity and pediatric nursing. Learning resources for students include Animations, Case Studies, Content Updates, Glossary, Printable Key Points, Nursing Skills, and NCLEX-Style Review Questions.

Simulation Learning System (SLS): The Simulation Learning System (SLS) is an online toolkit that helps instructors and facilitators effectively incorporate medium- to high-fidelity simulation into their nursing curriculum. Detailed patient scenarios promote and enhance the clinical decision-making skills of students at all levels. The SLS provides detailed instructions for preparation and implementation of the simulation experience, debriefing questions that encourage critical thinking, and learning resources to reinforce student comprehension. Each scenario in the SLS complements the textbook content and helps bridge the gap between lectures and clinical practice. The SLS provides the perfect environment for students to practice what they are learning in the text for a true-to-life, hands-on learning experience.

Study Guide: This comprehensive and challenging study aid presents a variety of questions to enhance learning of key concepts and content from the text. Multiple-choice and matching questions and Critical Thinking Case Studies are included. Answers for all questions are included at the back of the study guide.

Virtual Clinical Excursions: Virtual Hospital and Workbook Companion: A virtual hospital and workbook package has been developed as a virtual clinical experience to expand student opportunities for critical thinking. This package guides students through a virtual clinical environment and helps users apply textbook content to virtual patients in that environment. Case studies are presented that allow students to use this textbook as a reference to assess, diagnose, plan, implement, and evaluate “real”

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patients using clinical scenarios. The state-of-the-art technologies reflected in this virtual hospital demonstrate cutting-edge learning opportunities for students and facilitate knowledge retention of the information found in the textbook. The clinical simulations and workbook represent the next generation of research-based learning tools that promote critical thinking and meaningful learning.

For Instructors Evolve includes these teaching resources for instructors:

Image Collection, containing more than 700 full-color illustrations and photographs from the text, helps instructors develop presentations and explain key concepts.

PowerPoint Slides, with lecture notes for each chapter of the text, assist in presenting materials in the classroom. Case Studies and Audience Response Questions for i-clicker are included.

TEACH for Nurses includes teaching strategies; in-class case studies; and links to animations, nursing skills, and nursing curriculum standards such as QSEN, concepts, and BSN Essentials.

Test Bank in ExamView format contains more than 1850 NCLEX- style test items, including alternate-format questions. An answer key with page references to the text, rationales, and NCLEX-style coding is included.

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Acknowledgments

Thanks to Pat Gingrich for preparing the Evidence-Based Practice boxes in Part 1 and to those parents who permitted us to use photos of their infants and families. Very special thanks to Heather Bays, Clay Broeker, and Laurie Gower, whose support was crucial for the completion of this project. Thanks also to those faculty and students who provided reports and offered suggestions to ensure accuracy.

Shannon E. Perry

Deitra Leonard Lowdermilk

Kitty Cashion

Kathryn Rhodes Alden

Ellen F. Olshansky

We are fortunate to have worked for many years with David Wilson, who served as a co-editor on numerous editions. We miss him greatly with this edition. We are grateful to the many nursing faculty members, practitioners, and students who have offered their comments, recommendations, and suggestions. This edition could not have been completed without the dedication of these special people. We are also grateful to the editorial staff at Elsevier, especially Sandra Clark, Heather Bays, and Clay Broeker, for their support and commitment to excellence.

Marilyn J. Hockenberry

Cheryl C. Rodgers

The authors would like to acknowledge the following individuals for contributions to the ninth edition of Wong's Essentials of Pediatric Nursing: Rose A.U. Baker, PhD, PMHCNS-BC; Annette L. Baker,

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RN, BSN, MSN, CPNP; Raymond Barfield, MD, PhD; Amy Barry, RN, MSN, PNP-BC; Heather Bastardi, MSN, BSN, PNP; Debra Brandon, PhD, RN, CNS, FAAN; Terri L. Brown, MSN, RN, CPN; Meg Bruening, PhD,MPH, RD; Rosalind Bryant, PhD, RN, PPCNP- BC; Cynthia J. Camille, MSN, RN, CPNP, FNP-BC; Patricia M. Conlon, MS, APRN, CNS, CNP; Erin Connelly, APRN, CPNP; Martha R. Curry, MS, RN, CPNP; Amy Delaney, RN, MSN, CPNP- AC/P; Sharron L. Docherty, PhD, PNP-BC, FAAN; Angela Drummond, MS, APRN, CPNP; Jan M. Foote, DNP, ARNP, CPNP, FAANP; Quinn Franklin, MS; Debbie Fraser, MN, RNC-NIC; Teri A. Huddleston Lavenbarg, MSN, APRN, PPCNP-BC, FNP-BC, CDE; Patricia Barry McElfresh, MN, RN, PNP-BC; Tara Taneski Merck, CPNP; Mary A. Mondozzi, MSN, BSN, RN; Rebecca A. Monroe, MSN, RN, CPNP; Kim Mooney-Doyle, PhD, RN, CPNP- AC; Patricia O'Brien, MSN, RN, CPNP-AC; Cynthia A. Prows, MSN, CNS, FAAN; Patricia Ring, MSN, RN, CPNP; Maureen Sheehan, MS, CPNP; Anne Feierabend Stanton, MSN, APRN, PCNS-BC; Barbara J. Wheeler, RN, BN, MN, IBCLC; and Kristina Wilson, PhD, CCC-SLP.

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PART 1

Maternity Nursing OUTLINE

Unit 1 Introduction to Maternity Nursing Unit 2 Reproductive Years Unit 3 Pregnancy Unit 4 Childbirth Unit 5 Postpartum Period Unit 6 Newborn

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UNIT 1

Introduction to Maternity Nursing OUTLINE

1 21st Century Maternity Nursing 2 The Family, Culture, Spirituality, and Home Care

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1

21st Century Maternity Nursing Ellen F. Olshansky

Maternity nursing encompasses care of childbearing women and their families through all stages of pregnancy and childbirth and the first 6 weeks after birth. Some practitioners also include preconception as part of maternity nursing because of the importance of counseling related to planning for pregnancy. Throughout the prenatal period, nurses, nurse practitioners, and nurse-midwives provide care for women in clinics and physicians' offices and teach classes to help families prepare for childbirth. Nurses and nurse-midwives care for childbearing families during labor and birth in hospitals, and nurse-midwives also care for childbearing families in birthing centers (e.g., www.birthcenters.org), and in the home. Nurses with special training may provide intensive care for high-risk neonates in special care units and high-risk mothers in antepartum units, in critical care obstetric units, or in the home. Maternity nurses teach about pregnancy; the process of labor, birth, and recovery; newborn care, and parenting skills. They provide continuity of care throughout the childbearing cycle. This chapter presents a general overview of issues and trends related to the health and health care of women and infants.

Nurses caring for women have helped make the health care system more responsive to women's needs. They have been

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critically important in developing strategies to improve the well- being of women, their families, and their infants and have led the efforts to implement clinical practice guidelines and to practice using an evidence-based approach. Through professional associations, nurses have a voice in setting standards and influencing health policy by actively participating in the education of the public and state and federal legislators (e.g., www.nursingworld.org; www.can-nurses.ca; www.awhonn.org; www.capwhn.ca). Some nurses hold elective office and influence policy directly. For example, Mary Wakefield, a nurse, served for a time as Acting Deputy Secretary of the Health Resources and Services Administration (HRSA), the agency that oversees approximately 7000 community clinics that serve low-income and uninsured people.

Advances in the Care of Mothers and Infants Although tremendous advances have taken place in the care of mothers and their infants during the past 150 years (Box 1.1), serious problems exist in the United States related to the health and health care of mothers and infants. Lack of access to prepregnancy and pregnancy-related care for all women and the lack of reproductive health services for adolescents are major concerns. Sexually transmitted infections, including acquired immunodeficiency syndrome (AIDS), continue to adversely affect reproduction.

Box 1.1 Historic Overview of Milestones in the Care of Mothers and Infants

1847—James Young Simpson in Edinburgh, Scotland, used ether for an internal podalic version and birth; the first reported use of obstetric anesthesia

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1861—Ignaz Semmelweis wrote The Cause, Concept and Prophylaxis of Childbed Fever

1906—First US program for prenatal nursing care established

1908—Childbirth classes started by the American Red Cross

1909—First White House Conference on Children convened

1911—First milk bank in the United States established in Boston

1912—US Children's Bureau established

1915—Radical mastectomy determined to be effective treatment for breast cancer

1916—Margaret Sanger established first American birth control clinic in Brooklyn, New York

1918—Condoms became legal in the United States

1923—First US hospital center for premature infant care established at Sarah Morris Hospital in Chicago, Illinois

1929—The modern tampon (with an applicator) invented and patented

1933—Sodium pentothal used as anesthesia for childbirth; Natural Childbirth published by Grantly Dick-Read

1934—Dionne quintuplets born in Ontario, Canada, and survive partly due to donated breast milk

1935—Sulfonamides introduced as cure for puerperal fever

1941—Penicillin used as a treatment for infection

1941—Papanicolaou (Pap) test introduced

1942—Premarin approved by the Food and Drug Administration (FDA) as treatment for menopausal symptoms

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1953—Virginia Apgar, an anesthesiologist, published Apgar scoring system of neonatal assessment

1956—Oxygen determined to cause retrolental fibroplasia (now known as retinopathy of prematurity)

1958—Edward Hon reported on the recording of the fetal electrocardiogram (ECG) from the maternal abdomen (first commercial electronic fetal monitor produced in the late 1960s)

1958—Ian Donald, a Glasgow physician, was first to report clinical use of ultrasound to examine the fetus

1959—Thank You, Dr. Lamaze published by Marjorie Karmel

1959—Cytologic studies demonstrated that Down syndrome is associated with a particular form of nondisjunction now known as trisomy 21

1960—American Society for Psychoprophylaxis in Obstetrics (ASPO/Lamaze) formed

1960—International Childbirth Education Association founded

1960—Birth control pill introduced in the United States

1962—Thalidomide found to cause birth defects

1963—Title V of the Social Security Act amended to include comprehensive maternity and infant care for women who were low income and high risk

1963—Testing for PKU begun

1965—Supreme Court ruled that married people have the right to use birth control

1967—Rho(D) immune globulin produced for treatment of Rh incompatibility

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1967—Reva Rubin published article on maternal role attainment

1968—Rubella vaccine became available

1969—Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) founded; renamed Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and incorporated as a 501(c)(3) organization in 1993

1969—Mammogram became available

1972—Special Supplemental Food Program for Women, Infants, and Children (WIC) started

1973—Abortion legalized in United States

1974—First standards for obstetric, gynecologic, and neonatal nursing published by NAACOG

1975—The Pregnant Patient's Bill of Rights published by the International Childbirth Education Association

1976—First home pregnancy kits approved by FDA

1978—Louise Brown, first test-tube baby, born

1987—Safe Motherhood initiative launched by World Health Organization and other international agencies

1991—Society for Advancement of Women's Health Research founded

1992—Office of Research on Women's Health authorized by US Congress

1993—Female condom approved by FDA

1993—Human embryos cloned at George Washington University

1993—Family and Medical Leave Act enacted

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1994—DNA sequences of BRCA1 and BRCA2 identified

1994—Zidovudine guidelines to reduce mother-to-fetus transmission of HIV published

1996—FDA mandated folic acid fortification in all breads and grains sold in United States

1998—Newborns' and Mothers' Health Act went into effect

1998—Canadian Obstetric, Gynecologic, and Neonatal Nurses (COGNN) becomes AWHONN Canada

1999—First emergency contraceptive pill for pregnancy prevention (Plan B) approved by FDA

2000—Working draft of sequence and analysis of human genome completed

2006—Human papilloma virus (HPV) vaccine available

2010—Centenary of the death of Florence Nightingale

2010—Patient Protection and Affordable Care Act signed into law by President Obama

2011—AWHONN Canada becomes the Canadian Association of Perinatal and Women's Health Nurses (CAPWHN)

2012—US Supreme Court upheld individual mandate but not the Medicaid expansion provisions of the Patient Protection and Affordable Care Act

2012—Scientists reported findings of the ENCODE (Encyclopedia of DNA Elements) project showing that 80% of the human genome is active

2016—Zika virus discovered, spread by mosquitos, and sexually transmitted by sperm if a male is infected, affects the fetus/neonate (microcephaly)

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Efforts to Reduce Health Disparities Racial and ethnic diversity is increasing within the United States. It is estimated that by 2060, 43% of the population will be composed of non-Hispanic Whites, resulting in this previous “majority” group no longer being in the majority. Predicted distribution of other ethnic groups is: 14% African-American, 28% Hispanic, 11% Asian- American, 2% American Indians and Alaska Natives, and 0.7% Native Hawaiian and other Pacific Islanders (Colby & Ortman, 2015). These percentages are estimates and therefore do not add up to 100% exactly; the intent here is to show trends.

These trends reflect a slight decrease in non-Hispanic whites and a slight increase in the other ethnic groups: African-Americans, Hispanics, Asian-Americans, Alaskan Natives, Native Hawaiians, and other Pacific Islanders.

African-Americans, Native Americans, Hispanics, Alaska Natives, and Asian/Pacific Islanders experience significant disparities in morbidity and mortality rates compared to Caucasians. Shorter life expectancy, higher infant and maternal mortality rates, more birth defects, and more sexually transmitted infections are found among these ethnic and racial minority groups. The disparities are thought to result from a complex interaction among biologic factors, environment, socioeconomic factors, and health behaviors. Social determinants of health are those nonbiologic factors that have profound influences on health. Disparities in education and income are associated with differences in morbidity and mortality.

The HRSA Health Disparities Collaboratives are part of a national effort to eliminate disparities and improve delivery systems of health care for all people in the United States who are cared for in HRSA-supported health centers. The National Partnership for Action to End Health Disparities (NPA), sponsored by the Office of Minority Health, has developed priorities to address and end health disparities (NPA, 2016). The Institute for Healthcare Improvement (IHI, 2016) has implemented virtual training sessions on Advancing Safer Maternal and Newborn Care (www.ihi.org/education/WebTraining/Expeditions/AdvancingSaferMaternalandNewbornCare/Pages/default.aspx The National Institutes of Health (NIH) have a commitment to

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improve the health of minorities and provide funding for research and training of minority researchers (www.nih.gov). The National Institute of Nursing Research includes in its strategic plan support of research that promotes health equity and eliminates health disparities.

The Centers for Disease Control and Prevention (CDC) publishes reports of recent trends and variation in health disparities and inequalities in some social and health indicators and provides data against which to measure progress in eliminating disparities. Topics specific to perinatal nursing that are addressed are infant deaths, preterm births, and adolescent pregnancy and childbirth. In 2015, the US Department of Health and Human Services (USDHHS) released a progress report on its HHS Disparities Action Plan that provides a vision of “a nation free of disparities in health and health care” (USDHHS, 2015). Through this plan, HHS will promote evidence-based programs, integrated approaches, and best practices to reduce disparities. The Action Plan complements the 2011 National Stakeholder Strategy for Achieving Health Equity prepared by the NPA. Since this strategy was developed, much progress has been made in addressing disparities and health equity through a comprehensive, community-driven approach to achieve health equity through collaboration and synergy (NPA, 2016). Through these initiatives, the United States is making a concerted effort to eliminate health disparities.

Contemporary Issues and Trends Healthy People 2020 Goals Healthy People provides science-based 10-year national objectives for improving the health of all Americans. It has four overarching goals: (1) attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieving health equity, eliminating disparities, and improving the health of all groups; (3) creating social and physical environments that promote good health for all; and (4) promoting quality of life, healthy development, and healthy behaviors across all life stages (www.healthypeople.gov/2020/about/default.aspx). The goals of

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Healthy People 2020 are based on assessments of major risks to health and wellness, changes in public health priorities, and issues related to the health preparedness and prevention of our nation. Of the objectives of Healthy People 2020, 33 are related to maternal, infant, and child health (Box 1.2).

Box 1.2 Healthy People 2020 Maternal, Infant, and Child Health Objectives

• Reduce the rate of fetal and infant deaths.

• Reduce the 1-year mortality rate for infants with Down syndrome.

• Reduce the rate of child deaths.

• Reduce the rate of adolescent and young adult deaths.

• Reduce the rate of maternal mortality.

• Reduce maternal illness and complications caused by pregnancy (complications during hospitalized labor and delivery).

• Reduce the incidence of cesarean births among low-risk (full- term, singleton, vertex presentation) women.

• Reduce the incidence of low birth weight (LBW) and very low birth weight (VLBW). births.

• Reduce the incidence of preterm births.

• Increase the proportion of pregnant women who receive early and adequate prenatal care.

• Increase abstinence from alcohol, cigarettes, and illicit drugs in pregnant women.

• Increase the proportion of pregnant women who attend a series of

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prepared childbirth classes.

• Increase the proportion of mothers who achieve a recommended weight gain during their pregnancies.

• Increase the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements.

• Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations.

• Increase the proportion of women delivering a live birth; increase the number of those who receive preconception care services and practice key recommended preconception health behaviors.

• Reduce the proportion of people 18 to 44 years of age who have impaired fecundity (i.e., a physical barrier preventing pregnancy or carrying a pregnancy to term).

• Decrease postpartum relapse of smoking in women who quit smoking during pregnancy.

• Increase the proportion of women giving birth who attend a postpartum care visit with a health worker.

• Increase the proportion of infants who are placed on their backs to sleep.

• Increase the proportion of infants who are breastfed.

• Increase the proportion of employers who have worksite lactation programs.

• Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.

• Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

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• Reduce the occurrence of fetal alcohol syndrome (FAS).

• Reduce the proportion of children diagnosed with a disorder through newborn blood spot screening who experience developmental delay requiring special education services.

• Reduce the proportion of children with cerebral palsy born as LBW infants (less than 2500 g).

• Reduce the occurrence of neural tube defects.

• Increase the proportion of young children with an autism spectrum disorder (ASD) and other developmental delays who are screened, evaluated, and enrolled in early intervention services in a timely manner.

• Increase the proportion of children, including those with special health care needs, who have access to a medical home.

• Increase the proportion of children with special health care needs who receive their care in family-centered, comprehensive, coordinated systems.

• Increase appropriate newborn blood-spot screening and follow- up testing.

• Increase the number of states, including the District of Columbia, that verify through linkage with vital records that all newborns are screened shortly after birth for conditions mandated by their state-sponsored screening program.

• Increase the proportion of screen-positive children who receive follow-up testing within the recommended time period.

• Increase the proportion of children with a diagnosed condition identified through newborn screening who have an annual assessment of services needed and received.

• Increase the proportion of VLBW infants born at level III hospitals or subspecialty perinatal centers.

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Adapted from HealthyPeople.gov. (2012). Maternal, infant, and child health. Retrieved from www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26.

Millennium Development Goals The United Nations Millennium Development Goals (MDGs) are eight goals that were to be achieved by 2015, responding to the main development challenges in the world (www.un.org/millenniumgoals). Goals three through five of the MDGs relate specifically to women and children.

In September 2015, the United Nations site in New York City hosted a conference of world leaders, where they adopted the 2030 Agenda for Sustainable Development. This 2030 agenda consists of 17 Sustainable Development Goals (SDGs), also referred to as Global Goals, which are now replacing the MDGs (United Nations Development Programme, 2016). The majority of these SDGs are related to the environment and eliminating poverty, in many ways collectively encompassing social determinants of health, all of which are relevant to childbearing and childrearing. They are listed in Box 1.3.

Box 1.3 United Nations Sustainable Development Goals

1. No poverty

2. Zero hunger

3. Good health and well-being

4. Quality education

5. Gender equality

6. Clean water and sanitation

7. Affordable and clean energy

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8. Decent work and economic growth

9. Industry, innovation, and infrastructure

10. Reduced inequalities

11. Sustainable cities and communities

12. Responsible consumption and production

13. Climate action

14. Life below water

15. Life on land

16. Peace, justice and strong institutions

17. Partnerships for the goals

From United Nations Development Programme. (2016). Sustainable Development Goals. Retrieved from http://www.un.org/sustainabledevelopment/sustainable-development- goals/.

Integrative Health Care Integrative health care encompasses complementary and alternative therapies in combination with conventional Western modalities of treatment. Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the patient's input and honor the individual's beliefs, values, and desires. The focus of these modalities is on the whole person, not just on a disease complex. Patients often find that alternative modalities are more consistent with their own belief systems and also allow for more patient autonomy in health care decisions (Fig. 1.1). Examples of alternative modalities include acupuncture, macrobiotics, herbal medicines, massage therapy,

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biofeedback, meditation, yoga, chelation therapy, and guided imagery (See Fig 1.1). Chelation therapy is an alternative therapy that consists of infusing intravenous substances to remove calcium and heavy metals from hardened arteries.

FIG 1.1 Nurse and patient during guided imagery session. (Courtesy of Nurses Certificate Program in Interactive Imagery,

Foster City, CA.)

The National Center for Complementary and Integrative Health (NCCIH) (https://nccih.nih.gov) is a US government agency that supports research and evaluation of various alternative and complementary modalities and provides information to health care consumers about such modalities. It is one of the 27 institutes and centers included in the NIH.

Interprofessional Education Interprofessional education (IPE) consists of faculty and students from two or more health professions who create and foster a collaborative learning environment. The underlying premise of interprofessional collaboration is that patient care will improve when health professionals work together. Numerous organizations, including the World Health Organization (WHO), the National Academy of Medicine, the National Academies of Practice, and the American Public Health Association, have expressed support of interprofessional education. See Box 1.4 for a description of the practice competencies related to IPE.

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Box 1.4 Interprofessional Education and Collaboration The Interprofessional Education Collaborative builds on earlier work, in which practice competencies were identified to include the following:

1. Values/ethics for interprofessional practice

2. Roles/responsibilities

3. Interprofessional communication

4. Teams and teamwork

In 2013, The Interprofessional Education Collaborative developed a new collaborative that expands the number of health professionals involved (https://ipecollaborative.org/uploads/IPEC- 2016-Updated-Core-Competencies-Report__final_release_.PDF).

Teamwork and communication are key aspects of IPE. Failure to communicate is a major cause of errors in health care. The Situation-Background-Assessment-Recommendation (SBAR) technique provides a specific framework for communication among health care providers about a patient's condition, reducing the potential for errors. SBAR is an easy to remember, useful, concrete mechanism for communicating important information that requires a clinician's immediate attention (Kaiser Permanente of Colorado, 2014) (Table 1.1). A specific program to enhance teamwork and collaboration is TeamSTEPPS, which was developed by the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ) as a teamwork system for health professionals to provide higher- quality, safer patient care (www.teamstepps.ahrq.gov/about- 2cl_3.htm). It provides an evidence base to improve communication and teamwork skills. Through this system, health care teams use information, people, and resources to achieve the best possible clinical outcomes, increase team awareness and clarify roles and

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responsibilities of team members, resolve conflicts and improve sharing of information, and eliminate barriers to quality and safety.

TABLE 1.1 Sample SBAR Report to Physician or Nurse-Midwife*

S Situation Hello, I am Ellen Olshansky on the mother/baby unit, and I'm calling about Mary Smith, who just gave birth 12 hours ago. I have just assessed her, and she saturated a peripad in the last hour. Her blood pressure is 112/62, pulse 86, and respirations 18. I think she is bleeding excessively.

B Background Mrs. Smith is 12 hours' postpartum after giving birth vaginally to a 9-lb, 12-oz term infant after an uncomplicated pregnancy. She had a rapid labor, just over 4 hours, and had no analgesia. She plans to bottle-feed this baby. She had an IV with 10 units of oxytocin (Pitocin), but it was completed and discontinued about 2 hours ago. This is her sixth birth. All were uncomplicated, and she had an uneventful recovery from them.

A Assessment Her fundus becomes firm after massage but relaxes again. She has a slightly malodorous vaginal discharge. She has voided, and her bladder feels empty. I think she might have retained placenta and she needs to be examined.

R Recommendation I would like you to come and examine her immediately. Do you want her IV restarted? Do you want her to have a hemoglobin and hematocrit?

*The SBAR tool was developed by Kaiser Permanente, and the example was prepared by Shannon E. Perry. IV, Intravenous infusion; SBAR, Situation-Background-Assessment- Recommendation.

Problems With the US Health Care System Structure of the Health Care Delivery System The US health care delivery system is often fragmented and expensive and is inaccessible to many. Opportunities exist for nurses to alter nursing practice and improve the way care is delivered through managed care, integrated delivery systems, and redefined roles. Information about health and health care is readily available on the Internet (e-health). Consumers use this information to participate in their own care and consult health care providers with a knowledge base that was previously difficult to access.

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Reducing Medical Errors Medical errors are the third leading cause of death in the United States (Leapfrog Group, 2015; Makary & Daniel, 2016). Since the Institute of Medicine (IOM) released its report, To Err Is Human: Building a Safer Health System (IOM, 2000), a concerted effort has been under way to analyze causes of errors and develop strategies to prevent them. Hayes, Jackson, Davidson, and Power and colleagues (2015) explored how nurses can decrease interruptions and distractions that contribute to medical errors. Recognizing the multifaceted causes of medical errors, the Agency for Healthcare Research and Quality (AHRQ) prepared a fact sheet in 2000, 20 Tips to Help Prevent Medical Errors, which was updated in 2014, for patients and the public. Patients are encouraged to be knowledgeable consumers of health care and ask questions of providers, including physicians, midwives, nurses, and pharmacists.

In 2002, the National Quality Forum (NQF) published a list of Serious Reportable Events in Healthcare. The list was most recently updated in 2011 (NQF, 2011), resulting in a total of 29 events. Of these 29 events, three pertain directly to maternity and newborn care (Box 1.5).

Box 1.5 National Quality Forum Serious Reportable Events Pertaining to Maternal and Child Health

• Maternal death or serious injury associated with labor or birth in a low-risk pregnancy while being cared for in a health care facility

• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

• Artificial insemination with the wrong donor sperm or wrong egg

From National Quality Forum. (2011). Serious reportable events in healthcare—2011 update: A consensus report. Washington, DC: NQF.

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The NQF published Safe Practices for Better Healthcare in 2003 and updated it most recently in 2013 (http://www.hfap.org/pdf/patient_safety.pdf). The 34 safe practices included should be used in all applicable health care settings to reduce the risk for harm that results from processes, systems, and environments of care. Table 1.2 contains a selection of practices from that document.

TABLE 1.2 Selected Safe Practices for Better Health Care

Safe Practice Practice Statement Safe Practice 2: Culture Measurement, Feedback, and Intervention

Health care organizations must measure their culture, provide feedback to leadership and staff, and undertake interventions that reduce patient safety risk.

Safe Practice 5: Informed Consent

Ask each patient or legal surrogate to “teach back” in his or her own words key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent.

Safe Practice 12: Patient Care Information

Ensure that care information is transmitted and appropriately documented in a timely manner and a clearly understandable form to patients and all of the patients' health care providers/professionals, within and between care settings, who need that information to provide continued care.

Safe Practice 19: Hand Hygiene

Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

CT, Computed tomography. From National Quality Forum. (2013). Safe practices for better healthcare—2013 update: A consensus report. Washington, DC: NQF. In Health Care Facilities Accreditation Program. Retrieved from http://www.hfap.org/pdf/patient_safety.pdf.

High Cost of Health Care Health care is one of the fastest-growing sectors of the US economy. Currently 17.5% of the gross domestic product is spent on health care (Centers for Medicare & Medicaid, 2015). These high costs are related to higher prices, readily accessible technology, and greater obesity. Most researchers agree that caring for the increased number of low–birth weight (LBW) infants in neonatal intensive care units contributes significantly to overall health care costs.

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Nurse-midwifery and advanced practice nursing care have helped contain some health care costs. However, not all insurance carriers reimburse nurse practitioners and clinical nurse specialists as direct care providers, nor do they reimburse for all services provided by nurse-midwives, a situation that continues to be a problem. Nurses must become involved in the politics of cost containment because they, as knowledgeable experts, can provide solutions to many health care problems at a relatively low cost. Nurse practitioners are among the health care providers included in the Affordable Care Act (ACA). Despite this, only 21 states and the District of Columbia allow nurse practitioners to practice to their fullest potential without physician involvement (American Academy of Nurse Practitioners, 2015).

Limited Access to Care Barriers to access must be removed so pregnancy outcomes and care of children can be improved. The most significant barrier to access is the inability to pay. Some improvement in ability to pay has been seen due to the ACA. The uninsured rate in 2014 was 10.4%, or 33 million people, which was lower than the rate of 13.3%, or 41.8 million people, in 2013 (Smith & Medalia, 2015). Lack of transportation and dependent child care are other barriers. In addition to a lack of insurance and high costs, a lack of providers for low-income women exists because many physicians either refuse to take Medicaid patients or take only a few such patients. This presents a serious problem because a significant proportion of births are to mothers who receive Medicaid.

Health Care Reform In early 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, commonly referred to as Obamacare. The Act aims to make insurance affordable, contain costs, strengthen and improve Medicare and Medicaid, and reform the insurance market. There are provisions to promote prevention and improve public health; improve the quality of care for all Americans; reduce waste, fraud, and abuse; and reform the health delivery system. There are some immediate benefits, but the fate of the ACA is uncertain in the current political climate.

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In 2012, 26 states, several individuals, and the National Federation of Independent Business brought suit challenging the constitutionality of the individual mandate (requirement for most Americans to have minimum essential health insurance) and the Medicaid expansion (expand the scope of coverage and increase the number of individuals the states must cover). The Supreme Court upheld the individual mandate but not the Medicaid expansion. The debate continues on how the plan will be implemented and there is much uncertainty regarding health care reform.

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) advocated successfully for the inclusion in the ACA of contraceptive methods, services, and counseling, without any out-of-pocket costs to women; preventive services such as mammograms, well-woman visits, and screening for gestational diabetes; and providing breastfeeding equipment and counseling for pregnant and nursing women in new insurance plans. Work continues on implementation.

Accountable Care Organizations In 2011, the Center for Medicaid and Medicare Services (CMS) finalized new rules under the ACA to help health care providers and hospitals better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). An ACO is a group of health care providers and health care agencies that are accountable for improving the health of populations while containing costs. These groups of health care providers and hospitals voluntarily come together to coordinate high-quality care, eliminate duplication of services, and prevent medical errors, which results in savings of health care dollars.

Health Literacy Health literacy involves a spectrum of abilities, ranging from reading an appointment slip to interpreting medication instructions. These skills must be assessed routinely to recognize a problem and accommodate patients with limited literacy skills. Most education materials are written at too high a level for the average adult; e-health literacy has emerged as a concept.

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Individuals use the Internet for diagnosis, but more than half of these individuals seek the opinion of a medical professional rather than trying to care for themselves based on the information accessed (Dickens & Piano, 2013).

The CDC (2016a) has a health literacy website (www.cdc.gov/healthliteracy) that highlights implementation of goals and strategies of the National Action Plan to Improve Health Literacy. Health literacy is part of the Patient Protection and Affordable Care Act.

As a result of the increasingly multicultural US population, there is a more urgent need to address health literacy as a component of culturally and linguistically competent care. Older adults, racial or ethnic minorities, and those whose income is at or below the poverty level are most vulnerable. Lower health literacy is associated with adverse health outcomes (Dickens & Piano, 2013).

Health care providers contribute to health literacy by using simple, common words; avoiding jargon; and assessing whether the patient understands the discussion. Speaking slowly and clearly and focusing on what is important increase understanding.

Trends in Fertility and Birth Rate Fertility trends and birth rates reflect women's needs for health care. Box 1.6 defines biostatistical terminology useful in analyzing maternal health care. In 2015, the fertility rate in the United States declined by 1% as compared with 2014 (down from 62.9 to 62.5 births per 1000 women ages 15-44). There was a decline in births among Hispanic and non-Hispanic white women, and the rate was unchanged for non-Hispanic black women. Among women in their early 20s, there was a record low birth rate in 2015. There was a lesser decline for women in their late 20s, with an increase for women in their 30s and early 40s. The birth rate also fell among unmarried women, which is notable as this was the seventh year in a row in which this group experienced a decline in birth rate. The teenage birth rate (ages 15-19) decreased by 8% (down to 22.3 births per 1000 young women ages 15 to 19. Fertility rates declined among teenagers in all racial groups (Martin, Hamilton, Osterman, et al., 2017).

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Box 1.6 Maternal-Infant Biostatistical Terminology

Abortus: An embryo or fetus that is removed or expelled from the uterus at 20 weeks of gestation or less, weighs 500 g or less, or measures 25 cm or less

Birth rate: Number of live births in 1 year per 1000 population

Fertility rate: Number of births per 1000 women between 15 and 44 years of age (inclusive), calculated on an annual basis

Infant mortality rate: Number of deaths of infants younger than 1 year of age per 1000 live births

Maternal mortality rate: Number of maternal deaths from births and complications of pregnancy, childbirth, and puerperium (the first 42 days after termination of the pregnancy) per 100,000 live births

Pregnancy-associated deaths: All deaths during pregnancy and within the 1 year following the end of pregnancy

Pregnancy-related deaths (subset of pregnancy-associated): Deaths that are a complication of pregnancy, an aggravation of an unrelated condition by the physiology of pregnancy, or a chain of events initiated by the pregnancy

Neonatal mortality rate: Number of deaths of infants younger than 28 days of age per 1000 live births

Perinatal mortality rate: Number of stillbirths and number of neonatal deaths per 1000 live births

Stillbirth: An infant who at birth demonstrates no signs of life such as breathing, heartbeat, or voluntary muscle movements

Low–Birth Weight and Preterm Birth

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The risks of morbidity and mortality increase for newborns weighing less than 2500 g (5 lb, 8 oz)—low–birth weight (LBW) infants. Multiple births contribute to the incidence of LBW. There has been a 9% decline in triplet and higher order multiple births from 2014 to 2015 and a decline in the twin birth rate during this same year. This is particularly significant because the rate of twin births in 2014 had been at an all-time high (Martin et al., 2017).

Non-Hispanic black infants are almost twice as likely as non- Hispanic white infants to be of LBW and to die in the first year of life. Cigarette smoking is associated with LBW, prematurity, and intrauterine growth restriction, with a higher rate among non- Hispanic white women and non-Hispanic black women (Tong, Dietz, Morrow, et al., 2013).

The percentage of infants born preterm (i.e., born before 37 weeks of gestation) was 9.63% in 2015, which is slightly higher than the 2014 rate of 9.57%. Non-Hispanic black and Hispanic black women experienced increased rates of preterm births (Martin et al., 2017).

International Infant Mortality Trends In 2010, the infant mortality rate in the United States (6.1/1000) ranked twenty-sixth, when compared with those of other industrialized countries (MacDorman, Mathew, Mohangoo, et al., 2014). Decreases in the infant mortality rate in the United States do not keep pace with the rates of other industrialized countries. One reason for this is the high rate of LBW infants in the United States in contrast with the rates in other countries.

Maternal Mortality Worldwide approximately 800 women die each day of problems related to pregnancy or childbirth. In the United States in 2011, the annual maternal mortality rate (number of deaths per 100,000 live births) was 17.8; the rate decreased to 15.9 in 2012, and then increased again to 17.3 in 2013 (CDC, 2016b). Although the overall number of maternal deaths is small, maternal mortality remains a significant problem because a high proportion of deaths are preventable, primarily through improving the access to and use of prenatal care services. In the United States, there is significant racial

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disparity in the rates of maternal death, which are highest in non- Hispanic black women, followed by non-Hispanic white women (CDC, 2016b).

The leading causes of maternal death attributable to pregnancy differ over the world. In the United States, the three major causes are cardiovascular diseases, non-cardisovascular diseases, and infection (CDC, 2016b). Unsafe abortion is an additional cause. Factors that are strongly related to maternal death include age (younger than 20 years and 35 years or older), lack of prenatal care, low educational attainment, unmarried status, and non-Caucasian race. Worldwide strategies to reduce maternal mortality rates include improving access to skilled attendants at birth, providing postabortion care, improving family planning services, and providing adolescents with better reproductive health services.

Maternal Morbidity Although mortality is the traditional measure of maternal health and maternal health is often measured by neonatal outcomes, pregnancy complications are important. Currently no surveillance method is available to measure the incidence of maternal morbidity (Firoz, Chou, von Dadelszen, et al., 2013).

Maternal morbidity includes such conditions as acute renal failure, amniotic fluid embolism, cerebrovascular accident, eclampsia, pulmonary embolism, liver failure, obstetric shock, respiratory failure, septicemia, and complications of anesthesia (pulmonary, cardiac, central nervous system). Maternal morbidity results in high-risk pregnancy. The diagnosis of high risk imposes a situational crisis on the family. The combined efforts of interprofessional health care teams that includes nurses, physicians, and others are required to care for these patients, who often need the expertise of health care providers trained in both critical care obstetrics and intensive care medicine or nursing.

Obesity Approximately 25% of women who were pregnant in 2014 in the United States were obese (Branum, Kirmeyer, Gregory, 2016). The two most frequently reported maternal medical risk factors are

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hypertension associated with pregnancy and diabetes, both of which are associated with obesity. Decreased fertility, congenital anomalies, miscarriage, and fetal death are also associated with obesity. Obesity in pregnancy is associated with higher risks, and there are significant disparities in obesity associated with race and ethnicity (Marshall, Guild, Cheng, et al., 2014).

Regionalization of Perinatal Health Care Services Not all facilities can develop and maintain the full spectrum of services required for high-risk perinatal patients. A regionalized system focusing on integrated delivery of graded levels of hospital- based perinatal health care services is effective and results in improved outcomes for mothers and their newborns. This system of coordinated care can be extended to preconception and ambulatory prenatal care services. In 2015, ACOG and the Society for Maternal- Fetal Medicine (SMFM) published a consensus statement on levels of maternal care (ACOG & SMFM, 2015).

Ambulatory Prenatal Care Guidelines have been established regarding the level of care that can be expected at any given facility. In ambulatory settings, providers must distinguish themselves by the level of care they provide. Basic care is provided by obstetricians, family physicians, certified nurse-midwives, and other advanced practice clinicians approved by local governance. Routine risk-oriented prenatal care, education, and support are provided. Providers offering specialty care are obstetricians who must provide fetal diagnostic testing and management of obstetric and medical complications in addition to basic care. Subspecialty care is provided by maternal-fetal medicine specialists and reproductive geneticists and includes the aforementioned in addition to genetic testing, advanced fetal therapies, and management of severe maternal and fetal complications. Collaboration among providers to meet the woman's needs is the key to reducing perinatal morbidity and mortality.

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High-Technology Care Advances in scientific knowledge and the large number of high-risk pregnancies have contributed to a health care system that emphasizes high-technology care. Maternity care has extended to preconception counseling, more and better scientific techniques to monitor the mother and fetus, more definitive tests for hypoxia and acidosis, and neonatal intensive care units. The labors of virtually all women who give birth in hospitals in the United States are monitored electronically despite the lack of evidence of efficacy of such monitoring. The numbers of assisted labors and births are increasing. Internet-based information is available to the public that enhances interactions among health care providers, families, and community providers. Point-of-care testing is available. Personal data assistants are used to enhance comprehensive care; the medical record is increasingly in electronic form.

Strides are being made in identifying genetic codes, and genetic engineering is taking place. Women's health has expanded to emphasize care of older women, new cancer-screening techniques, advances in the diagnosis and treatment of breast cancer, and work on an AIDS vaccine. In general, high-technology care has flourished, whereas “health” care has become relatively neglected. Nurses must use caution and prospective planning and assess the effect of the emerging technology.

Telehealth is an umbrella term for the use of communication technologies and electronic information to provide or support health care when the participants are separated by distance. It permits specialists, including nurses, to provide health care and consultation when distance separates them from those needing care. This technology has the potential to save billions of dollars annually for health care, but these technologic advances have also contributed to higher health care costs..

Social Media Social media uses Internet-based technologies to allow users to create their own content and participate in dialog. The most common social media platforms are Facebook, Twitter, and LinkedIn, with others also gaining in popularity. Social media can

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be integrated into nursing practice, facilitating communication among nurses and between nurses and other health care providers and patients (Casella, Mills, Usher, et al., 2014). However, there are pitfalls for nurses using this technology. Patient privacy and confidentiality can be violated, and institutions and colleagues can be cast in unfavorable lights with negative consequences for those posting the information. Nursing students have been expelled from school, and nurses have been fired or reprimanded by a Board of Nursing for injudicious posts. To help make nurses aware of their responsibilities when using social media, the American Nurses Association (ANA) published six principles for social networking and the nurse (Box 1.7). Brous (2013) referred to the White Paper: A Nurse's Guide to the Use of Social Media that was published by the National Council of State Boards of Nursing (NCSBN, 2011; https://www.ncsbn.org/Social_Media.pdf), detailing issues of confidentiality and privacy, possible consequences of inappropriate use of social media, common myths and misunderstandings of social media, and tips on how to avoid problems.

Box 1.7 American Nurses Association's Principles for Social Networking and the Nurse

• Nurses must not transmit or place online individually identifiable patient information.

• Nurses must observe ethically prescribed professional patient- nurse boundaries.

• Nurses should understand that patients, colleagues, institutions, and employers may view postings.

• Nurses should take advantage of privacy settings and seek to separate personal and professional information online.

• Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of appropriate authorities.

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• Nurses should participate in developing institutional policies governing online contact.

From American Nurses Association. (2011). Fact sheet: Navigating the world of social media. Washington, DC: Author.

Community-Based Care A shift in settings from acute care institutions to ambulatory settings, including the home, has occurred. Even childbearing women at high risk are cared for on an outpatient basis or in the home. Technology previously available only in the hospital is now found in the home. This has affected the organizational structure of care, the skills required in providing such care, and the costs to consumers.

Home health care also has a community focus. Nurses are involved in providing care for women and infants in homeless shelters and adolescents in school-based clinics and in promoting health at community sites, churches, and shopping malls. Nursing education curricula are increasingly community based.

Childbirth Practices Prenatal care can promote better pregnancy outcomes by providing early risk assessment and promoting healthy behaviors such as improved nutrition and smoking cessation. Preconception care ideally begins before pregnancy because early decisions lay the foundation for the entire perinatal year. If at all possible, education continues in each trimester of pregnancy and extends through the early postpartum weeks. Some health care providers today promote preconception care as an important component of perinatal services. Preconception or early-pregnancy classes also emphasize health-promoting behavior and choices of care.

In the United States, most women received care in the first trimester. There is disparity, however, in receiving prenatal care by race and ethnicity, with non-Hispanic black women and Hispanic women receiving significantly later prenatal care as compared to non-Hispanic whites. In spite of these statistics, substantial gains have been made in the use of prenatal care since the early 1990s,

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which are attributed to the expansion in the 1980s of Medicaid coverage for pregnant women.

Women can choose physicians or nurse-midwives as primary care providers. In 2015, doctors of medicine attended 84% of births in hospitals, certified nurse-midwives attended 8.1%, and doctors of osteopathy attended 7.1% (Martin et al., 2017). Women who choose nurse-midwives as their primary care providers participate more actively in childbirth decisions, receive fewer interventions during labor, and are less likely to give birth prematurely (Sandall, Soltani, Gates, et al., 2013). From 2014 to 2015, there was a decline in the rate of cesarean births from 32.2% to 32.0% (Martin et al.), although Thielking (2015) reported that the approximately 1/3 rate for cesarean births is too high for resulting benefits, as benefits usually plateau at about a 19% cesarean birth rate.

Involving Consumers and Promoting Self- Management Self-management of health care is appealing to both patients and the health care system because of its potential to reduce health care costs. Maternity care is especially suited to self-management because childbearing is primarily health focused, women are usually well when they enter the system, and visits to health care providers can present the opportunity for health and illness interventions. Measures to improve health and reduce risks associated with poor pregnancy outcomes and illness can be addressed. Topics such as nutrition education, stress management, smoking cessation, alcohol and drug treatment, prevention of violence, improvement of social supports, and parenting education are appropriate for such encounters.

International Concerns Access to prenatal care and family planning education, care for women experiencing postpartum hemorrhage, obstructed labors with no access to hospital care or operative birth, fistulas due to obstructed labors, and HIV-positive parents are major international concerns. The high maternal and infant mortality in developing

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countries is a serious problem with limited resources to address the contributing factors. Two concerns that nurses in the United States and Canada might encounter are female genital mutilation and human trafficking.

Female genital mutilation, infibulation, and circumcision are terms used to describe procedures in which part or all of the female external genitalia is removed for cultural or nontherapeutic reasons (WHO, 2016). Worldwide, many women undergo such procedures. The International Council of Nurses and other health professionals have spoken out against procedures that result in mutilation as harmful to women's health. Although it is illegal in the United States to perform female genital mutilation on a person younger than 18 years of age, it is estimated that 513,000 women and girls in the United States have experienced or are at risk for female genital mutilation (Office of Women's Health, 2015).

Human trafficking is a serious crime, an illegal business that exists in the United States and internationally, in which mostly women and children are “trafficked,” or forced into hard labor, sex work, and even organ donation (Budiani-Saberi, Raja, Findley, et al., 2014; United Nations Office on Drugs & Crime, 2016). Health care professionals may interact with victims who are in captivity. This provides an opportunity to identify victims, intervene to help them obtain necessary health services, and provide information about ways to escape from their situation (Fig. 1.2) (see Chapter 3). The National Human Trafficking Resource Center (1-888-373-7888) can provide assistance.

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FIG 1.2 Father “catching” newborn daughter who cried before her lower body had emerged. (Courtesy of Darren and

Julie Nelson, Loveland, CO.)

The Future of Nursing In 2008, the Robert Wood Johnson Foundation and the IOM initiated a 2-year process to meet the need to assess and transform the nursing profession. The IOM appointed a committee that developed four key messages: (1) nurses should practice to the full extent of their education and training; (2) nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; (3) nurses should be full partners with physicians and other health care professionals in redesigning health care in the United States; and (4) effective workforce planning and policy-making require better data collection and an improved information infrastructure (IOM, 2010). Throughout the United States individual states and nursing organizations are making concerted efforts to implement the recommendations of the report. In 2015, a meeting was convened to assess the progress toward the goals outlined in the original report (National Academy of Sciences, 2015). Efforts continue toward meeting the recommendations of the original IOM report.

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Trends in Nursing Practice The increasing complexity of care for maternity and women's health patients has contributed to specialization of nurses working with these patients. This specialized knowledge is gained through experience, advanced degrees, and certification programs. Nurses in advanced practice (e.g., nurse practitioners and nurse-midwives) may provide primary care throughout a woman's life, including during the pregnancy cycle. In some settings, the clinical nurse specialist and nurse practitioner roles are blended, and nurses deliver high-quality, comprehensive, and cost-effective care in a variety of settings. In other settings, nurses educated in both critical care and high-risk obstetrics provide care in obstetric critical care units. Lactation consultants provide services in the hospital setting, in clinics and physician offices, and during home visits.

Nursing Interventions Classification When the National IOM proposed that all patient records be computerized by 2000, a need for a common language to describe the contributions of nurses to patient care became evident. Nurses from the University of Iowa developed a comprehensive standardized language that describes interventions that are performed by generalist or specialist nurses. This language is included in the Nursing Interventions Classification (NIC) (Bulechek, Buthcer, Dochterman, et al., 2013). Interventions commonly used by maternal-child nurses include those in Box 1.8.

Box 1.8 Childbearing Care Interventions Level 1 Domain: Family

• Care that supports the family

Level 2 Class: Childbearing Care

• Interventions to assist in the preparation for childbirth and management of the psychologic and physiologic changes before,

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during, and immediately after childbirth

Level 3: Interventions

• Amnioinfusion

• Birthing

• Bleeding reduction: antepartum uterus

• Bleeding reduction: postpartum uterus

• Cesarean birth care

• Childbirth preparation

• Circumcision care

• Electronic fetal monitoring: antepartum

• Electronic fetal monitoring: intrapartum

• Environmental management: attachment process

• Family integrity promotion: childbearing family

• Family planning: contraception

• Family planning: infertility

• Family planning: unplanned pregnancy

• Fertility preservation

• Genetic counseling

• Grief work facilitation: perinatal death

• High-risk pregnancy care

• Infant care: newborn

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• Infant care: preterm

• Intrapartal care

• Intrapartal care: high-risk delivery

• Kangaroo care

• Labor induction

• Labor suppression

• Lactation support

• Lactation suppression

• Newborn care

• Nonnutritive sucking

• Phototherapy: neonate

• Postpartal care

• Preconception counseling

• Pregnancy termination care

• Prenatal care

• Reproductive technology management

• Resuscitation: fetus

• Resuscitation: neonate

• Risk identification: childbearing family

• Surveillance: late pregnancy

• Tube care: umbilical line

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• Ultrasonography: limited obstetric

From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby.

Evidence-Based Practice Evidence-based practice—providing care based on evidence gained through research and clinical trials—is increasingly emphasized. Although not all practice can be evidence-based, practitioners must use the best available information on which to base their interventions. In 2013, AWHONN developed a draft document of quality measures for women's health and perinatal nursing, comparing NQF measures with AWHONN Nursing Care Quality measures (AWHONN, 2013). Discussion of nursing care and evidence-based practice boxes throughout this text provide examples of evidence-based practice in perinatal and women's health nursing (see Evidence-Based Practice box).

Evidence-Based Practice Seeking and Evaluating Evidence: A Necessary Competency for Quality and Safety

Throughout this text you will see Evidence-Based Practice boxes. These boxes provide examples of how a nurse might conduct an inquiry into an identified practice question. Curiosity and access to a virtual or real library are all the nurse needs to be confident that his or her practice has a sound foundation of evidence.

A literature search may reveal up to three levels of evidence. The first layer consists of primary studies. The strongest of these are randomized controlled trials. Well-designed studies, even small ones, add another piece to the puzzle.

These primary studies may be combined into the second level of evidence. In systematic analyses such as those in the Cochrane Database, the researcher uses a methodology to identify all studies relevant to a particular question. If the data are similar

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enough, they can be pooled into a meta-analysis. If the evidence is strong, some analyses will form the basis for recommendations for practice and guide further inquiry.

At the tertiary level, professional organizations such as the Agency for Healthcare Research and Quality (AHRQ) (www.ahrq.gov) or the National Guidelines Clearinghouse (NGC) (guideline.gov) may decide to address a broad practice question by sorting through all the available primary and secondary evidence and consulting experienced clinicians. After thoughtful review, the committee of experts in the organization crafts its consensus statement. These recommendations for best practice stand on the shoulders of the systematic analysts, who stand on the many shoulders of the primary researchers.

Provided that the professional organization is well-respected and the process is rigorous, these guidelines in the consensus statement carry enormous authority. Individuals and institutions may choose to adopt them with confidence. An example of this is the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) (www.awhonn.org) Late Preterm Infant Initiative. This initiative began in 2005 in response to the confusion that surrounded the care of infants who do not qualify for NICU admission yet require extra vigilance. Nurseries can adapt these recommendations to their specific institutions, enabling nurses to become more effective at caring for the unique problems of this population of neonates. Like AWHONN, most of the professional organizations make their guidelines available free of charge on their websites.

To develop common language and goals for nursing education, the Quality and Safety Education for Nurses (QSEN) (www.qsen.org) Project expert panel identified six competencies necessary to enable the new nurse to continuously improve the health care system: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Most nursing challenges require a combination of these competencies. Each competency is further defined as having targets for knowledge, skills, and attitude. The Evidence-

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Based Practice boxes in this textbook include examples that illustrate each of these targets specific to that competency. A mastery of QSEN competencies greatly enriches the nurse's ability to identify and improve patient and health care–system problems and communicate within the interdisciplinary team.

Pat Mahaffee Gingrich NICU, Neonatal intensive care unit.

Cochrane Pregnancy and Childbirth Database The Cochrane Pregnancy and Childbirth Database was first planned in 1976 with a small grant from the World Health Organization to Dr. Iain Chalmers and colleagues at Oxford. In 1993, the Cochrane Collaboration was formed, and the Oxford Database of Perinatal Trials became known as the Cochrane Pregnancy and Childbirth Database. The Cochrane Collaboration oversees up-to-date, systematic reviews of randomized controlled trials of health care and disseminates these reviews. The premise of the project is that these types of studies provide the most reliable evidence about the effects of care.

The evidence from these studies should encourage practitioners to implement useful measures and abandon those that are useless or harmful. Studies are ranked in the following six categories:

1. Beneficial forms of care

2. Forms of care that are likely to be beneficial

3. Forms of care with a trade-off between beneficial and adverse effects

4. Forms of care with unknown effectiveness

5. Forms of care that are unlikely to be beneficial

6. Forms of care that are likely to be ineffective or harmful

Joanna Briggs Institute Established in 1996 as an initiative of the Royal Adelaide Hospital

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and the University of Adelaide in Australia, the Joanna Briggs Institute (JBI) uses a collaborative approach for evaluating evidence from a range of sources (www.joannabriggs.edu.au). The JBI has formed collaborations with a variety of universities and hospitals around the world including in the United States and Canada. The JBI uses the following grades of recommendation for evidence of feasibility, appropriateness, meaningfulness, and effectiveness: A, strong support that merits application; B, moderate support that warrants consideration of application; and C, not supported (JBI, 2013). The JBI provides another source for perinatal nurses to access information to support evidence-based practice.

Outcomes-Oriented Practice Outcomes of care (i.e., the effectiveness of interventions and quality of care) are receiving increased emphasis. Outcomes-oriented care measures effectiveness of care against benchmarks or standards. It is a measure of the value of nursing using quality indicators and assesses whether or not the patient benefitted from the care provided (Moorhead, Johnson, Maas, et al., 2013). The Outcome and Assessment Information Set (OASIS) is an example of an outcome system important for nursing. Its use is required by the CMS in all home health organizations that are Medicare accredited. The Nursing Outcomes Classification (NOC) is an effort to identify outcomes and related measures that can be used for evaluation of care of individuals, families, and communities across the care continuum (Moorhead et al.).

A Global Perspective Advances in medicine and nursing have resulted in increased knowledge and understanding in the care of mothers and infants and reduced perinatal morbidity and mortality rates. However, these advances have affected predominantly the industrialized nations. With more knowledge and implementation of interventions in other countries (e.g., antiretroviral treatment for mother during pregnancy and for baby as well, more education about prevention of transmission), the rates of HIV have the potential to decrease worldwide. Without intervention, rates of HIV

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transmission to infants range from 15% to 45%, but with interventions it is possible to decrease the rate to 5% (WHO, 2017).

The Zika virus is a recently discovered concern (CDC, 2016c). This is a virus that is spread via bites from infected mosquitos and may be spread through sexual intercourse with an infected partner. The virus can also be spread to a fetus, leading to microcephaly. Currently there is no vaccine for this virus, and much more research is needed to better understand and treat this infectious disease. More discussion about the Zika virus is included in Chapter 4.

As the world becomes smaller because of travel and communication technologies, nurses and other health care providers are gaining a global perspective and participating in activities to improve the health and health care of people worldwide. Nurses participate in medical outreach, providing obstetric, surgical, ophthalmologic, orthopedic, or other services (Fig. 1.3); attend international meetings; conduct research; and provide international consultation. International student and faculty exchanges occur. More articles about health and health care in various countries are appearing in nursing journals. Several schools of nursing in the United States are World Health Organization Collaborating Centers.

FIG 1.3 Nurse interviewing a young girl accompanied by her mother in a clinic in rural Kenya. (Courtesy of Shannon

Perry, Phoenix, AZ.)

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Standards of Practice and Legal Issues in Delivery of Care Several organizations have described standards of practice in perinatal and women's health nursing. These organizations include the ANA, which publishes standards for maternal-child health nursing; the AWHONN, which publishes standards of practice and education for perinatal nurses (Box 1.9); the American College of Nurse-Midwives (ACNM), which publishes standards of practice for midwives; and the National Association of Neonatal Nurses (NANN), which publishes standards of practice for neonatal nurses. These standards reflect current knowledge, represent levels of practice agreed on by leaders in the specialty, and can be used for clinical benchmarking.

Box 1.9 Standards of Care for Women and Newborns Standards That Define the Nurse's Responsibility to the Patient

Assessment

• Collection of health data of the woman or newborn

Diagnosis

• Analysis of data to determine nursing diagnosis

Outcome Identification

• Identification of expected outcomes that are individualized

Planning

• Development of a plan of care

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Implementation

• Performance of interventions for the plan of care

Evaluation

• Evaluation of the effectiveness of interventions in relation to expected outcomes

Standards of Professional Performance That Delineate Roles and Behaviors for Which the Professional Nurse Is Accountable Quality of Care

• Systematic evaluation of nursing practice

Performance Appraisal

• Self-evaluation in relation to professional practice standards and other regulations

Education

• Participation in ongoing educational activities to maintain knowledge for practice

Collegiality

• Contribution to the development of peers, students, and others

Ethics

• Use of American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) to guide practice collaboration

• Involvement of patient, significant others, and other health care providers in the provision of patient care

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Research

• Use of research findings in practice

Resource Utilization

• Consideration of factors related to safety, effectiveness, and costs in planning and delivering patient care

Practice Environment

• Contribution to the environment of care delivery

Accountability

• Legal and professional responsibility for practice

From Association of Women's Health, Obstetric and Neonatal Nurses. (2009). Standards and guidelines for professional practice in the care of women and newborns (7th ed.). Washington, DC: Author.

In addition to these more formalized standards, agencies have their own policies, procedures, and protocols that outline standards to be followed in that setting. In legal terms, the standard of care is that level of practice that a reasonably prudent nurse would provide in the same or similar circumstances. In determining legal negligence, the care given is compared with the standard of care. If the standard was not met and harm resulted, negligence occurred. The number of legal suits in the perinatal area typically has been high. As a consequence, malpractice insurance costs are high for physicians, nurse-midwives, and nurses who work in labor and birth settings.

Legal Tip Standard of Care

When a nurse is uncertain about how to perform a procedure, he or she should consult the agency’s policies and procedures documents. These guidelines are the standard of care for that

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agency.

Prevention of Errors in Nursing Care Medical errors are now the third leading cause of death (Makary & Daniel, 2016). To decrease the risk for errors in the administration of medications, in 2009 The Joint Commission (TJC) developed an official list of abbreviations, acronyms, and symbols not to use, which was updated in 2013 (Glassman, 2013) (Table 1.3). In addition, each agency must develop its own list.

TABLE 1.3 The Joint Commission “Do Not Use” List

Do Not Use Potential Problem Use Instead IU (International Unit)

Mistaken for IV (intravenous) or the number 10 (ten)

Write “International Unit”

Lack of leading zero (.X mg)

Decimal point is missed Write “0.X mg”

MS Can mean morphine sulfate or magnesium sulfate

Write “morphine sulfate”

MSO4 and MgSO4 Confused for one another Write “magnesium sulfate” Q.D., QD, q.d., qd (daily)

Mistaken for each other Write “daily”

Q.O.D., QOD, q.o.d, qod (every other day)

Period after the Q mistaken for “I” and the “O” mistaken for “I”

Write “every other day”

Trailing zero (X.0 mg)*

Decimal point is missed Write “X mg”

U, u (unit) Mistaken for “0” (zero), the number “4” (four), or “cc”

Write “unit”

Additional Abbreviations, Acronyms, and Symbols* > (greater than) < (less than)

Misinterpreted as the number “7” (seven) or the letter “L”; confused for one another

Write “greater than” Write “less than”

Abbreviations for drug names

Misinterpreted because of similar abbreviations for multiple drugs

Write drug names in full

Apothecary units Unfamiliar to many practitioners Use metric units Confused with metric units

@ Mistaken for the number “2” (two) Write “at” cc Mistaken for U (units) when poorly written Write “mL” or “ml” or

“milliliters” (“mL” is preferred)

µg Mistaken for mg (milligrams) resulting in one-thousandfold overdose

Write “mcg” or “micrograms”

*For possible future inclusion in the Official “Do Not Use” List. From The Joint Commission. The Joint Commission “Do Not Use” list, updated 2012. Retrieved from www.jointcommission.org/PatientSafety/DoNotUseList.

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See “dnu_list.pdf” and “Facts about the Official Do Not Use List of Abbreviations.” Cited in Pharmacy Technician. (2015). Retrieved from http://pharmacytechniciantoday.com/joint-commission-do-not-use-list/.

Sentinel Events TJC (2015) revised its definition of a sentinel event as any event that is not due to underlying conditions or natural courses of a patient’s condition that affects a patient, resulting in death, permanent harm, or severe temporary harm. This refers to perinatal events, specifically the need for receiving 4 or more units of blood products and/or admission to the ICU.

Failure to Rescue Failure to rescue is the failure to recognize or act on early signs of distress. Key components of failure to rescue are (1) careful surveillance and identification of complications, and (2) quick action to initiate appropriate interventions and activate a team response. For the perinatal nurse, this involves careful surveillance, timely identification of complications, appropriate interventions, and activation of a team response to minimize patient harm. Maternal complications that are appropriate for process measurement are placental abruption, postpartum hemorrhage, uterine rupture, eclampsia, and amniotic fluid embolism (Simpson, Knox, Martin, et al., 2011). Fetal complications include nonreassuring fetal heart rate and pattern, prolapsed umbilical cord, shoulder dystocia, and uterine hyperstimulation (Simpson et al.).

Ethical Issues in Perinatal Nursing and Women's Health Care Ethical concerns and debates have multiplied with the increased use of technology and scientific advances. For example, with reproductive technology pregnancy is now possible in women who thought they would never bear children, including some who are menopausal or postmenopausal. Should scarce resources be devoted to achieving pregnancies in older women? Is giving birth

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to a child at an older age worth the risks involved? Should older parents be encouraged to conceive a baby when they may not live to see the child reach adulthood? Should a woman who is HIV positive have access to assisted reproduction services? Should third-party payers assume the costs of reproductive technology such as the use of induced ovulation and in vitro fertilization? With induced ovulation and in vitro fertilization, multiple pregnancies occur, and multifetal pregnancy reduction (selectively terminating one or more fetuses) may be considered. Questions about informed consent and allocation of resources must be addressed with innovations such as intrauterine fetal surgery, fetoscopy, therapeutic insemination, genetic engineering, stem cell research, surrogate childbearing, surgery for infertility, “test tube” babies, fetal research, and treatment of very low–birth weight (VLBW) babies. The introduction of long-acting contraceptives has created moral choices and policy dilemmas for health care providers and legislators (i.e., should some women [substance abusers, women with low incomes, or women who are HIV positive] be required to take the contraceptives?). With the potential benefits from fetal tissue transplantation, what research is ethical? What are the rights of the embryo? Should cloning of humans be permitted? Discussion and debate about these issues will continue for many years. Nurses and patients, together with scientists, physicians, attorneys, lawmakers, ethicists, and clergy, must be involved in the discussions.

References Agency for Healthcare Research and Quality. 20 Tips to Help

Prevent Medical Errors: Patient Fact Sheet. [December 2014, Rockville, MD; Retrieved from] http://archive.ahrq.gov/patients-consumers/care- planning/errors/20tips/index.html; 2014.

American Academy of Nurse Practitioners. AANP Voices Support for Senate Bill Empowering Nurse Practitioners in the Veterans Health Administration. [Retrieved from] https://www.aanp.org/press-room/press-releases/166- press-room/2015-press-releases/1730-aanp-voices-support-

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for-senate-bill-empowering-nurse-practitioners-in-the- veterans-health-administration; 2015.

American College of Obstetricians and Gynecologists. Levels of maternal care. Obstetric Care Consensus No. 2. Obstetrics and Gynecology. 2015;1225:502–515 [Retrieved from] http://www.acog.org/Resources-And- Publications/Obstetric-Care-Consensus-Series/Levels-of- Maternal-Care.

American Nurses Association. Code of ethics for nurses with interpretive statements. Author: Silver Spring, MD; 2015.

Association of Women's Health, Obstetric and Neonatal Nurses. Women's health and perinatal nursing quality draft measures specifications. [Retrieved from] https://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalqualitymeasures.pdf 2013.

Branum AM, Kirmeyer SE, Gregory ECS. Prepregnancy body mass index by maternal characteristics and state: Data from the birth certificate, 2014. National Vital Statistics Reports. 2016;65(6):1–11.

Brous E. How to avoid pitfalls in social media. American Nurse Today. 2013;8(5) [Retrieved from] https://americannursetoday.com/how-to-avoid-the-pitfalls- of-social-media/.

Budiani-Saberi DA, Raja KR, Findley KC, et al. Human trafficking for organ removal in India: A victim-centered, evidence-based report. Transplantation. 2014;97(4):380–384.

Bulechek GM, Butcher HK, Dochterman JM, et al. Nursing interventions classification (NIC). 6th ed. Mosby: St. Louis, MO; 2013.

Casella E, Mills J, Usher K. Social media and nursing practice: Changing the balance between the social and technical aspects of work. Collegian. 2014;21:121–126.

Centers for Disease Control and Prevention. CDC Health disparities & inequalities report—United States, 2013. Morbidity and Mortality Weekly Report. 2013;62(3 suppl):1– 187.

Centers for Disease Control and Prevention. Health literacy. [Retrieved from] www.cdc.gov/healthliteracy; 2016.

97

Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. [2016; Retrieved from] https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 2016.

Centers for Disease Control and Prevention. Zika and pregnancy. [Retrieved from] http://www.cdc.gov/zika/pregnancy/question- answers.html; 2016.

Centers for Medicare and Medicaid. NHE fact sheet. [Retrieved from] https://www.cms.gov/research-statistics-data-and- systems/statistics-trends-and- reports/nationalhealthexpenddata/nhe-fact-sheet.html; 2015.

Colby SL, Ortman J. Projections of the size and composition of the US population: 2014-2016. [US Census Bureau] 2015 [Retrieved from] https://www.census.gov/library/publications/2015/demo/p25- 1143.html.

Dickens C, Piano MR. Health literacy and nursing: An update. American Journal of Nursing. 2013;113(6):52–57.

Firoz T, Chou D, von Dadelszen P, et al. Measuring maternal health: Focus on maternal morbidity. [for; the Maternal Morbidity Working Group] Bulletin of the World Health Organization. 2013;91:794–796 [Retrieved from] http://www.who.int/bulletin/volumes/91/10/13-117564/en/.

Glassman P. The Joint Commission's “Do Not Use” list: Brief review (NEW). [In Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Reports/Technology Assessments, No. 211. Rockville, MD: Agency for Healthcare Research and Quality] 2013.

Hayes C, Jackson D, Davidson PM, Power T. Medication errors in hospitals: A literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing. 2015;24(21–22):3063–3076 [(epub Aug 9, 2015)].

Institute for Healthcare Improvement. [Retrieved from] http://www.ihi.org/education/WebTraining/Expeditions/AdvancingSaferMaternalandNewbornCare/Pages/default.aspx

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2016. Institute of Medicine. To err is human: Building a safer health

system. Kohn LT, Corrigan JM, Donaldson MS. National Academy Press: Washington, DC; 2000.

Institute of Medicine. The future of nursing: Leading change, advancing health. National Academy of Sciences: Washington, DC; 2010.

Interprofessional Education Collaborative. [Retrieved from] https:/ipecollaborative.org/About_IPEC.html; 2016.

The Joanna Briggs Institute. JBI grading recommendations. [Retrieved from] http://joannabriggs.org/jbi- approach.html#tabbed-nav-Grades-of-Recommendation; 2013.

The Joint Commission. Official “do not use” list. [Retrieved from] http://www.jointcommission.org/assets/1/18/dnu_list.pdf; 2009 [2009].

The Joint Commission. Comprehensive accreditation manual for hospitals. [Update 2. Sentinel events; Retrieved from] http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf 2015.

Kaiser Permanente of Colorado. SBAR technique for communication: A situational briefing model. [Retrieved from] http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx 2014.

Leapfrog Group. Hospital errors are the third leading cause of death in the U.S., and new hospital safety scores show improvements are slow. Author: Washington, DC; 2015 [Retrieved from] http://www.hospitalsafetygrade.org/newsroom/display/hospitalerrors- thirdleading-causeofdeathinus-improvementstooslow.

MacDorman MF, Mathews TJ, Mohangoo AD, et al. International comparisons of infant mortality and related factors: United States and Europe, 2010. National Vital Statistics Reports. 2014;63(5) [Retrieved from] http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf.

Makary MA, Daniel M. Medical error—The third leading cause of death in the United States. British Medical Journal.

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2016;353(i2139). Marshall NE, Guild C, Cheng YW, et al. Racial disparities in

pregnancy outcomes in obese women. Journal of Maternal Fetal Neonatal Medicine. 2014;27(2):122–126.

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2015. National Vital Statistics Report. 2017;66(1) [Retrieved from] https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf.

Moorhead S, Johnson M, Maas M, et al. Nursing outcomes classification (NOC). 5th ed. Elsevier: St. Louis, MO; 2013.

National Academy of Sciences. Assessing progress on the Institute of Medicine report on the Future of Nursing. [Retrieved from] http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2015/AssessingFON_releaseslides/Nursing- Report-in-brief.pdf; 2015.

National Partnership for Action to End Health Disparities. NPA background. [Rockville, MD: US Department of Health & Human Services, Office of Minority Health; Retrieved from] http://minorityhealth.hhs.gov/npa/templates/browse.aspx? 1v1=1&1v1id=45; 2016.

National Quality Forum. Serious reportable events in healthcare —2011 update: a consensus report. [Washington, DC: NQF] 2011.

National Quality Forum. Safe Practices for Better Healthcare— 2013 update: a consensus report. [Washington, DC: NQF. In Health Care Facilities Accreditation Program; Retrieved from] http://www.hfap.org/pdf/patient_safety.pdf; 2013.

Office of Women's Health. Female genital cutting. [Retrieved from] http://womenshealth.gov/publications/our- publications/fact-sheet/female-genital-cutting.html; 2015.

Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models of care for childbearing women. [The Cochrane Library, issue 8. John Wiley & Sons] 2013.

Simpson KR, Knox E, Martin M, et al. Michigan Health & Hospital Association Keystone Obstetrics: A statewide collaborative for perinatal patient safety in Michigan. Joint Commission Journal on Quality and Patient Safety.

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2011;37(12):544–552. Smith JC, Medalia C. Health insurance coverage in the United

States: 2014. [Current Population Report. US Census Bureau. P60-253. Washington, DC: US Government Printing Office; Retrieved from] https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60- 253.pdf; 2015.

Thielking M. Sky-high C-section rates in the US don't translate to better birth outcomes. [Stat; Retrieved from] https://www.statnews.com/2015/12/01/cesarean-section- childbirth/; 2015.

Tong VT, Dietz PM, Morrow B, et al. Trends in smoking before, during, and after pregnancy—Pregnancy risk assessment monitoring system, United States, 40 sites, 2000- 2010. Morbidity and Mortality Weekly Report. 2013;62(6):1–19.

United Nations Development Programme. Sustainable Development Goals. [Retrieved from] http://www.un.org/sustainabledevelopment/sustainable- development-goals/; 2016.

United Nations Office on Drugs and Crime. Human trafficking. [Retrieved from] https://www.unodc.org/unodc/en/human- trafficking/what-is-human-trafficking.html; 2016.

US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National action plan to improve health literacy. Author: Washington, DC; 2015 [Retrieved from] http://minorityhealth.hhs.gov/omh/browse.aspx? lvl=2&lvlid=10.

World Health Organization. WHO guidelines on the management of health complications from female genital mutilation. [Geneva, Switzerland: World Health Organization; Retrieved from] http://www.who.int/mediacentre/news/releases/2016/female- genital-mutilation-guidelines/en/; 2016.

World Health Organization. Mother-to-child transmission of HIV. World Health Organization.: Geneva, Switzerland; 2017 [Retrieved from] http://www.who.int/hiv/topics/mtct/about/en/.

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2

The Family, Culture, Spirituality, and Home Care Shannon E. Perry

The composition, structure, and function of the American family have changed dramatically in recent years, largely in response to economic, demographic, sociocultural, and technologic trends that influence family life and health. Despite current efforts to improve the overall health of the nation, there is widespread concern about family health and well-being as a reflection of individual, community, and national health status. Recent economic changes have further reduced the ability to access health care. In addition to facing significant barriers in accessing needed services, women and families are faced with the challenge of overcoming discrimination in health care practices. It is critical to consider racial and ethnic differences and sexual orientation when addressing the health status of women. American women with a minority racial or ethnic affiliation share poorer outcomes in a wide variety of conditions. Lesbian women may conceal sexual orientation for fear of discrimination. As cultural diversity increases and demographics change, nurses must become culturally competent in order to recognize and reduce or eliminate health disparities (Freund, 2012).

As perinatal health trends emerge, nurses are assuming greater

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roles in assessing family health status and providing care across the perinatal continuum. This continuum begins with family planning and continues with the following categories of care: preconception, prenatal, intrapartum, postpartum, newborn, and interconception (between pregnancies). Depending on the needs of the individual family unit, independent self-management, outpatient care, home care, low-risk hospitalization, or specialized intensive care may be appropriate at different points along this continuum.

The Family in Cultural and Spiritual Context The family and its cultural and spiritual context play an important role in defining the work of maternity nurses. Despite modern stresses and strains, the family forms a social network that acts as a potent support system for its members. Family health-seeking behavior and relationships with health care professionals are influenced by culturally related health beliefs and spiritual values. Ultimately, all of these factors have the power to affect maternal and child health outcomes. The current emphasis in working with families is on wellness and empowerment for families to achieve control over their lives. It is essential that nurses become culturally competent and cognizant of spirituality in its various meanings and interpretations in order to provide appropriate care.

Defining Family The family has traditionally been viewed as the primary unit of socialization. The family plays a pivotal role in health care, representing the primary target of health care delivery for maternal and newborn nurses. As one of society's most important institutions, the family represents a primary social group that influences and is influenced by other people and institutions. A variety of family configurations exist. Each of these is characterized by certain structural features.

Family Organization and Structure

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The nuclear family has long represented the traditional American family in which husband, wife, and their children (either biologic or adopted) live as an independent unit, sharing roles, responsibilities, and economic resources (Fig. 2.1). Today the number of families living in a nuclear family structure is steadily decreasing in response to societal changes. By race and Hispanic origin, this family structure is represented as follows (Lofquist, Lugaila, O'Connell, et al., 2012):

FIG 2.1 Nuclear family. (Courtesy of Makeba Felton, Wake Forest, NC.)

• Caucasian: 51.1% • Hispanic: 50.1% • African-American: 28.5% • Asian: 59.7% • American Indian and Alaska Native: 40.1% • Native Hawaiian and Pacific Islander: 51.3%

Many nuclear families have other relatives living in the same household. These extended family members include grandparents, aunts, uncles, or other people related by blood. Members of

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extended families can also live in close proximity to the nuclear family. Due to societal changes, Internet access, and increased mobility, these families may also be a long-distance unit (Fig. 2.2). The extended family is becoming more common as American society ages. The extended family provides social, emotional, and financial support to one another. It is therefore important for nurses to recognize the desire for people of many cultures to include their family in making important decisions even if extended family members are not physically close. This has implications for privacy and sharing individual health information under the Health Insurance Portability and Accountability Act (HIPAA) rules.

FIG 2.2 Extended family. (Courtesy of Makeba Felton, Wake Forest, NC.)

Multigenerational families, consisting of three or more generations of relatives (grandparents, children, grandchildren) are becoming increasingly common. In 2015, they made up 5.9% of all households (US Census Bureau, 2015). This type of arrangement can create stress for some as children must care for their parents as well as their own children. Other types of multigenerational families consist of grandparents supporting children and grandchildren or as sole caregivers for the grandchildren.

No-biologic-parent families are those in which children live independently in foster or kinship care such as living with a grandparent. In 2012, an estimated 7 million children in the United

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States live with grandparents (Ellis & Simmons, 2014). Of these grandparents, 2.7 million are responsible for most of the basic needs (i.e., food, shelter, and clothing) of one or more grandchildren (US Census Bureau, 2011).

Married-blended families, those formed as a result of divorce and remarriage, consist of unrelated family members (stepparents, stepchildren, stepsiblings) who join to create a new household. These family groups frequently involve a biologic or adoptive parent whose spouse may or may not have adopted the child.

Cohabiting-parent families are those in which children live with two unmarried biologic parents or two adoptive parents. Hispanic children are almost twice as likely as African-American children to live in cohabiting-parent families and about four times as likely as Caucasian children to live in this kind of family arrangement (Lofquist et al., 2012).

Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. The single- parent family may result from the loss of a spouse by death, divorce, separation, or desertion; from either an unplanned or planned pregnancy, including those achieved through reproductive technology; or from the adoption of a child by an unmarried woman or man. This family structure is continually on the rise. In 2012, 24% of children lived with only their mothers, 4% lived with only their fathers, and 4% lived with neither of their biologic parents (America's Children, 2013). The single-parent family tends to be vulnerable economically and socially, creating an unstable and deprived environment for the growth of children. This in turn affects health status, school achievement, and high-risk behaviors for these children (Scharte & Bolte, 2012). Some families become more stable with the absence of drugs, alcohol, and/or physical/emotional abuse.

Homosexual families (lesbian, gay, bisexual, transgender [LGBT]) may live together with or without children. Usually formed by same-sex couples, they can also consist of single LGBT parents or multiple parenting figures. Children in LGBT families may be the offspring of previous heterosexual unions, conceived by one member of a lesbian couple through natural or therapeutic insemination, conceived by a gay couple using a surrogate, or

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adopted. Approximately 594,000 same-sex couple households lived in the United States in 2010, raising about 115,000 children younger than 18 years of age. When these children are combined with LGBT parents who are raising children, almost 2 million children are being raised by LGBT parents in the United States (Siegel & Perrin, 2013).

The Family in Society The social context for the family can be viewed in relation to social and demographic trends that define the population as a whole. Racial and ethnic diversity of the population has grown dramatically, necessitating consideration of such diversity in provision of health care. According to the 2010 census, approximately 36% of the population belongs to a racial or ethnic minority group (Centers for Disease Control and Prevention [CDC], 2016).

Theoretic Approaches to Understanding Families Family Nursing Family plays a pivotal role in health care, representing the primary target of health care delivery for maternal and newborn nurses. It is crucial that nurses assist families as they incorporate new additions into their family (see Nursing Care Plan). When treating the woman and family with respect and dignity, health care professionals listen to and honor perspectives and choices of the woman and family. They share information with families in ways that are positive, useful, timely, complete, and accurate. The family is supported in participating in the care and decision making at the level of their choice.

Nursing Care Plan Incorporating the Infant Into the Family

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Case Study Corita, who is Mexican-American and 23 years of age, gave birth to her first baby at term, a healthy male infant weighing 3600 grams. Her husband, Juan, also Mexican-American, was present at the birth and is very excited to have a son whom he named Jesus. Soon after birth, the infant latched readily and sucked strongly for 5 minutes before falling asleep. The nurse assisted Juan to hold Jesus in an appropriate position. Juan asked several questions of the nurse: how often should Jesus be fed, what are the red spots on the back of his neck, why is he bundled so tightly in his blanket.

Assessment

What are signs that Corita and Juan have prepared for incorporating the baby into the family?

Defining Characteristics

Corita demonstrates appropriate baby feeding techniques and Juan demonstrates basic baby care techniques

The couple provide safe a environment for the baby

Corita and Juan use support systems appropriately

Nursing Diagnosis

Readiness for Enhanced Childbearing Process

Expected Outcomes

Corita and Juan will convey confidence in their knowledge of newborn care.

Corita and Juan will demonstrate attachment behaviors toward Jesus.

Jesus' physical, nutritional, and social needs will be met.

Nursing Interventions Rationales

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Assess baseline knowledge of newborn care.

To identify knowledge deficits

Provide written literature on newborn care.

To allow time to understand new information

Teach Corita and Juan newborn care.

Demonstrating proper care improves confidence and reduces anxiety

Case Study (Continued) Corita and Jesus were discharged 2 days after his birth. Corita's lochia was diminishing, her perineum was healing, she was breastfeeding successfully, and both Corita and Juan were comfortable holding Jesus and changing diapers. Corita's mother is planning to stay with them to cook and help as needed for 1 week. Corita and Juan welcome her input about caring for Jesus and interpreting his behavioral cues.

Assessment

What are the signs of enhanced parenting?

Defining Characteristics

Willingness of Juan and Corita to enhance parenting

Bonding and attachment

Fulfillment of emotional and physical needs of Jesus

Realistic expectations of Jesus

Nursing Diagnosis

Readiness for Enhanced Parenting

Expected Outcomes

Corita and Juan express satisfaction in role of parent

Corita and Juan will express confidence in their ability to parent

Baby care routines are adequate

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Family will enjoy spending time together

Nursing Interventions Rationales Discuss with Corita and Juan their perceptions and philosophy of parenting.

To provide an opportunity to clarify the parent's perceptions

Support Corita and Juan as they adapt to the changing family needs.

Recogning and appreciating the efforts of Corita and Juan enhances their motivation to continue to improve

Explore Juan's and Corita's value system and their spiritual beliefs and practices

Values and spirituality provide a basis for moral and ethical reasoning and enhance the meaning of life

Case Study (Continued) Corita and Juan have increasing confidence in their infant caregiving skills, and breastfeeding is going well. Jesus is gaining weight and sleeping several hours at a time. Juan is ready to resume their sexual relationship, while Corita is somewhat hesitant, fearing that penile penetration will be painful.

Assessment What was their usual pattern of sexual relations prior and during pregnancy? Does Corita still have lochia? How comfortable are Corita and Juan discussing their sexual relations?

Defining Characteristics

Demonstrate mutual respect between partners

Demonstrate understanding of partner's hesitance in resuming sexual relations

Understand physiologic changes due to pregnancy and childbirth

Express desire to enhance communication between partners

Nursing Diagnosis

Readiness for Enhanced Relationship

Expected Outcomes

Corita and Juan will communicate effectively.

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Corita will articulate ways to mutually meet physical and emotional needs of herself and Juan.

Corita and Juan will understand the changes in sexuality related to pregnancy and childbirth.

Corita and Juan will express satisfaction with sharing of information and ideas between partners.

Corita and Juan's sexual relationship will resume when both partners are ready.

Nursing Interventions Rationales Assess communication techniques and effectiveness of couple and family.

To be able to counsel and/or refer appropriately as needed

Encourage Corita and Juan to share information and ideas.

To enhance communication

Teach Corita and Juan normal changes in sexuality due to pregnancy and postpartum status.

So they can better understand what is normal and resume sexual relations when they are both comfortable

Refer as needed to colleagues in other disciplines.

To facilitate enhanced communication

Families are viewed as part of the interprofessional health care team and as the unit of care. Because so many variables affect ways of relating, the nurse must be aware that family members may interact and communicate with each other in ways that are distinct from those of the nurse's own family of origin. Most families will hold some beliefs about health that are different from those of the nurse. Their beliefs can conflict with principles of health care management predominant in the Western health care system.

Family nursing interventions occur within nurse-family relationships through therapeutic conversation (Bell, 2013; Wright & Bell, 2009). This necessitates interacting with family members present during caregiving, asking about those who may be absent, and actively listening to words and noting expressions to facilitate understanding. To do this within time constraints, Wright and Leahey (1999, 2013) developed a format for a brief therapeutic interview (Table 2.1).

TABLE 2.1

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Key Ingredients of a 15-Minute (or Shorter) Family Interview

Ingredient Exemplars Manners Introduce yourself to patients and families, preferably by your full name (i.e.,

Ms., Mrs., Mr. Jones). Make eye contact with all members of the family. Inquire about relationship of persons with the patient. Always call your patients by name.

Therapeutic Conversations

Interview is purposeful and time-limited Provide opportunity for patient and family to be acknowledged. Involve patients in information giving and decision making. Routinely invite families to accompany the patient to the unit/clinic. Invite families to ask questions during patient orientation. Routinely consult families and patients about their ideas for treatment and discharge.

Family Genograms and Ecomaps

Draw a quick genogram (and if indicated, an ecomap) for all families (see Figs. 2.4 and 2.5). Acknowledge that illness is a family affair. Include essential information such as ages, occupation, school grade, religion, ethnic background, and current health status of all family members.

Therapeutic Questions

Think of at least three questions to routinely ask all families. Basic themes include sharing of information, expectations of hospitalization, clinic, or home care visit, challenges, sufferings, and most pressing concerns/problems.

Commending Family and Individual Strengths

Offer at least two commendations to family on strengths, resources, or competencies that were observed or reported to the nurse. These are observations of behavior patterns rather than one-time occurrences. Evaluate usefulness of the interview and conclude.

From Wright, L. M., & Leahey, M. (1999). Maximizing time, minimizing suffering: The 15-minute (or less) family interview. Journal of Family Nursing, 5(3), 259-273.

Family Theories A family theory can be used to describe families and how the family unit responds to events both within and outside the family. Each family theory makes certain assumptions about the family and has inherent strengths and limitations. Most nurses use a combination of theories in their work with families. For more in depth information about family theories, a textbook describing various family theories can be consulted. Use of a family theory can guide assessment and interventions for the family.

Family Assessment When selecting a family assessment framework, an appropriate model for a perinatal nurse is one that is a health-promotion rather

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than an illness-care model. The low-risk family can be assisted in promoting a healthy pregnancy, childbirth, and integration of the newborn into the family. The high-risk perinatal family has illness- care needs, and the nurse can help meet those needs while also promoting the health of the childbearing family.

A family assessment tool such as the Calgary Family Assessment Model (CFAM) (Box 2.1) can be used as a guide for assessing aspects of the family. Such an assessment is based on “the nurse's personal and professional life experiences, beliefs, and relationships with those being interviewed” (Wright & Leahy, 2013) and is not “the truth” about the family but, rather, one perspective at one point in time.

Box 2.1 Calgary Family Assessment Model There are three major categories of the Calgary Family Assessment Model (CFAM)—structural, developmental, and functional. Each category has several subcategories. In this box, only the major categories are included. A few sample questions are included.

Structural Assessment

• Determine the members of the family, relationship among family members, and context of family.

• Genograms and ecomaps (see Figs. 2.4; 2.5) are useful in outlining the internal and external structures of a family.

Sample Questions

• Who are the members of your family?

• Has anyone moved in or out lately?

• Are there any family members who do not live with you?

Developmental Assessment

• Describe the life cycle—that is, the typical trajectory most families

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experience.

Sample Questions

• When you think back, what do you most enjoy about your life?

• What do you regret about your life?

• Have you made plans for your care as your health declines?

Functional Assessment

• Evaluate the way in which individuals behave in relation to each other in instrumental and expressive aspects. (Instrumental aspects are activities of daily living; expressive aspects include communication, problem solving, roles, etc.)

Sample Questions

• Who in the family is responsible for making sure Grandma takes her medicine?

• Whose turn is it to make dinner for Grandma?

• How can we get Martin to help with Grandma's care?

Data from Wright, L. M., & Leahy, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). Philadelphia, PA: FA Davis.

The CFAM comprises three major categories: structural, developmental, and functional. Several subcategories are within each category. The three assessment categories and the many subcategories can be conceptualized as a branching diagram (Fig. 2.3). These categories and subcategories can be used to guide the assessment that will provide data to help the nurse better understand the family and formulate a nursing care plan. The nurse asks questions of family members about themselves to gain understanding of the structure, development, and function of the family at this point in time. Not all questions within the subcategories should be asked at the first interview, and some

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questions may not be appropriate for all families. Although individuals are the ones interviewed, the focus of the assessment is on interaction of individuals within the family.

FIG 2.3 Branching diagram of Calgary Family Assessment Model (CFAM). (From Wright, L. M., & Leahy, M.

[2013]. Nurses and families: A guide to family assessment and intervention (6th

ed.) Philadelphia, PA: FA Davis.)

Graphic Representations of Families A family genogram (family tree format depicting relationships of family members over at least three generations) (Fig. 2.4) provides valuable information about a family and can be placed in the nursing care plan for easy access by care providers. An ecomap, a graphic portrayal of social relationships of the woman and family, may also help the nurse understand the social environment of the family and identify support systems available to them (Fig. 2.5). Software is available to generate genograms and ecomaps

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(www.interpersonaluniverse.net).

FIG 2.4 Example of a family genogram.

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FIG 2.5 Example of an ecomap. An ecomap describes social relationships and depicts available supports.

The Family in a Cultural Context Cultural Factors Related to Family Health The culture of an individual and a group is influenced by religion, environment, and historic events and plays a powerful role in the individual's and group's behaviors and patterns of human interaction. Culture is not static; it is an ongoing process that influences a woman throughout her entire life, from birth to death. Culture is an essential element of what defines us as people.

Cultural knowledge includes beliefs and values about each facet of life and is passed from one generation to the next. Cultural beliefs and traditions relate to food, language, religion, spirituality, art, health and healing practices, kinship relationships, and all other aspects of community, family, and individual life. Culture has also been shown to have a direct effect on health behaviors. Values, attitudes, and beliefs that are culturally acquired may influence perceptions of illness, as well as health care–seeking behavior and

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response to treatment. The political, social, and economic context of people's lives is also part of the cultural experience.

Culture, shared beliefs, and values of a group play a powerful role in an individual's behavior, particularly when the individual is faced with health care issues. Understanding a culture can provide insight into how a person reacts to illness, pain, and invasive medical procedures, as well as patterns of human interaction and expressions of emotion. The effect of these influences must be assessed by health care professionals in providing health care and developing effective intervention strategies.

Many subcultures are found within each culture. Subculture refers to a group existing within a larger cultural system that retains its own characteristics. A subculture may be an ethnic group or a group organized in other ways. For example, in the United States and Canada, many ethnic subcultures such as African-Americans, Asian-Americans, Hispanic-Americans, and Native Americans exist. It is important to note that subcultures also exist within these groups. In addition, the Caucasian population in America has multiple subcultures of its own. Because every identified cultural group has subcultures and because it is impossible to study every subculture in depth, greater differences may exist among and between groups than is generally acknowledged. It is important to be familiar with common cultural practices within these subgroups. However, it is also important to avoid the generalization that every person practices every cultural belief within a group because this could lead to stereotyping and misunderstanding of the nuances of various cultural groups.

In a multicultural society, many groups can influence traditions and practices. As cultural groups come into contact with each other, acculturation and assimilation may occur.

Acculturation refers to the changes that occur within one group or among several groups when people from different cultures come into contact with one another. People may retain some of their own culture while adopting some cultural practices of the dominant society. This familiarization among cultural groups results in overt behavioral similarity, especially in mannerisms, styles, and practices. Dress, language patterns, food choices, and health practices are often much slower to adapt to the influence of

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acculturation. In the United States, second-generation Americans consider themselves to be fully American (Pew Research Center, 2013).

During times of family transitions such as childbearing or during crisis or illness, a woman may rely on old cultural patterns even after she has become acculturated in many ways. This is consistent with the family developmental theory that states that during times of stress, people revert to practices and behaviors that are most comfortable and familiar (Carter & McGoldrick, 1999).

Assimilation occurs when a cultural group loses its cultural identity and becomes part of the dominant culture. Assimilation is the process by which groups “melt” into the mainstream, thus accounting for the notion of a “melting pot,” a phenomenon that has been said to occur in the United States. This is illustrated by individuals who identify themselves as being of Irish or German descent without having any remaining cultural practices or values linked specifically to that culture such as food preparation techniques, style of dress, or proficiency in the language associated with their reported cultural heritage. Spector (2013) asserts that in the United States, the melting pot, with its dream of a common culture, is a myth. Instead, a mosaic phenomenon exists in which we must accept and appreciate the differences among people.

Implications for Nursing As our society becomes more culturally diverse, it is essential that nurses become culturally competent. Nurses must examine their own beliefs so that they have a better appreciation and understanding of the beliefs of their patients. To promote culturally congruent practice, a new standard has been added to Nursing: Scope and Standards of Practice, 3rd edition (American Nurses Association, 2015b). Standard 8 directs nurses to practice “in a manner that is congruent with cultural diversity and inclusion principles” (Cipriano, 2016, p. 15). Understanding the concepts of ethnocentrism and cultural relativism may help nurses care for families in a multicultural society.

Ethnocentrism is the view that one's own way of doing things is best (Giger, 2013). Although the United States is a culturally diverse

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nation, the prevailing practice of health care is based on the beliefs and practices held by members of the dominant culture, primarily Caucasians of European descent. This practice is based on the biomedical model that focuses on curing disease states.

Pregnancy and childbirth in this biomedical perspective are viewed as processes with inherent risks that are most appropriately managed by using scientific knowledge and advanced technology. The medical perspective stands in direct contrast to the belief systems of many cultures. Among many women, birth is viewed as a completely normal process that can be managed with a minimum of involvement from health care practitioners. When encountering behavior in women unfamiliar with the biomedical model or those who reject it, the nurse may become frustrated and impatient and may label the women's behavior as inappropriate and believe that it conflicts with “good” health practices. If the Western health care system provides the nurse's only standard for judgment, the behavior of the nurse is ethnocentric.

Cultural relativism is the opposite of ethnocentrism. It refers to learning about and applying the standards of another's culture to activities within that culture. The nurse recognizes that people from different cultural backgrounds comprehend the same objects and situations differently. In other words, culture determines viewpoint. Cultural relativism does not require nurses to accept the beliefs and values of another culture. Instead, nurses recognize that the behavior of others can be based on a system of logic different from their own. Cultural relativism affirms the uniqueness and value of every culture.

Childbearing Beliefs and Practices Nurses working with childbearing families care for families from many different cultures and ethnic groups. To provide culturally competent care, the nurse must assess the beliefs and practices of patients. When working with childbearing families, a nurse considers all aspects of culture including communication, space, time orientation, and family roles.

Communication often creates the most challenging obstacle for nurses working with patients from diverse cultural groups.

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Communication is not merely the exchange of words. Instead, it involves (1) understanding the individual's language, including subtle variations in meaning and distinctive dialects; (2) appreciating individual differences in interpersonal style; and (3) accurately interpreting the volume of speech as well as the meanings of touch and gestures. For example, members of some cultural groups tend to speak loudly when they are excited, with great emotion and with vigorous and animated gestures; this is true whether their excitement is related to positive or negative events or emotions. It is important, therefore, for the nurse to avoid rushing to judgment regarding a person's intent when he or she is speaking, especially in a language not understood by the nurse. Instead, the nurse should withhold an interpretation of what has been expressed until it is possible to clarify the patient's intent. The nurse needs to enlist the assistance of a person who can help verify with the patient the true intent and meaning of the communication (see Clinical Reasoning Case Study).

Clinical Reasoning Case Study Providing Culturally Appropriate Care

Elisabeth, a 22-year-old first-generation Mexican-American, comes into your office for her initial prenatal visit. You are concerned because Elisabeth's fundal height is consistent with 32 weeks of gestation and this is her first prenatal visit. Elisabeth, who lives with her husband, four children (ages 6, 4, 3 years, and 15 months), her mother, her aunt, and her uncle, states that she has been doing well this pregnancy and did not start prenatal care in her previous pregnancies until she was almost ready to give birth. She also comments that all the babies were full term with uneventful labors and births. In obtaining the history, you note the presence of a safety pin in Elisabeth's shirt and wonder what this is for. You want to provide culturally appropriate care to this woman and her family.

1. Evidence—Is there sufficient evidence to support the components of culturally appropriate care for Elisabeth?

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2. Assumptions—Describe an underlying assumption about culturally appropriate care for Elisabeth in relation to these topics:

a. The view of pregnancy in Elisabeth's culture

b. The role of family in Elisabeth's culture

c. The acceptability for women of Elisabeth's age to begin having children at such young ages

d. The religious or spiritual beliefs that Elisabeth may have that affect contraception

3. What implications and priorities for nursing care can be made at this time?

4. Does the evidence objectively support your conclusion?

Inconsistencies between the language of patients and the language of providers present a significant barrier to effective health care. For example, there are many dialects of Spanish that vary by geographic location. Because of the diversity of cultures and languages within the US and Canadian populations, health care agencies are increasingly seeking the services of interpreters (of oral communication from one language to another) or translators (of written words from one language to another) to bridge these gaps and fulfill their obligation for culturally and linguistically appropriate health care (Box 2.2). Finding the best possible interpreter in the circumstance is critically important as well. Ideally, interpreters should have the same native language and be of the same religion or have the same country of origin as the patient. Interpreters should have specific health-related language skills and experience and help bridge the language and cultural barriers between the patient and the health care provider. The person interpreting also should be mature enough to be trusted with private information. However, because the nature of nursing

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care is not always predictable and because nursing care that is provided in a home or community setting does not always allow expert, experienced, or mature adult interpreters, ideal interpretive services sometimes are impossible to find when they are needed. In crisis or emergency situations or when family members are having extreme stress or emotional upset, it may be necessary to use relatives, neighbors, or children as interpreters. If this situation occurs, the nurse must ensure that the patient is in agreement and comfortable with using the available interpreter to assist. Having a man or a child interpret for a woman can create embarrassment and interfere with obtaining an accurate history or detail of symptoms.

Box 2.2 Working With an Interpreter Step 1: Before the Interview

• Outline your statements and questions. List the key pieces of information you want/need to know.

• Learn something about the culture so that you can converse informally with the interpreter.

Step 2: Meeting with the Interpreter

• Introduce yourself to the interpreter and converse informally. This is the time to find out how well he or she speaks English. No matter how proficient or what age the interpreter is, be respectful. Some ways to show respect are to ask a cultural question to acknowledge that you can learn from the interpreter, or you could learn one word or phrase from the interpreter.

• Emphasize that you do want the patient to ask questions, because some cultures consider this inappropriate behavior.

• Make sure the interpreter is comfortable with the technical terms you need to use. If not, take some time to explain them.

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Step 3: During the Interview

• Ask your questions and explain your statements (see Step 1).

• Make sure that the interpreter understands which parts of the interview are most important. You usually have limited time with the interpreter, and you want to have adequate time at the end for patient questions.

• Try to get a “feel” for how much is “getting through.” No matter what the language is, if in relating information to the patient, the interpreter uses far fewer or far more words than you do, something else is going on.

• Stop now and then and ask the interpreter, “How is it going?” You may not get a totally accurate answer, but you will have emphasized to the interpreter your strong desire to focus on the task at hand. If there are language problems, (1) speak slowly; (2) use gestures (e.g., fingers to count or point to body parts); and (3) use pictures.

• Ask the interpreter to elicit questions. This may be difficult, but it is worth the effort.

• Identify cultural issues that may conflict with your requests or instructions.

• Use the interpreter to help problem solve or at least give insight into possibilities for solutions.

Step 4: After the Interview

• Speak to the interpreter and try to get an idea of what went well and what could be improved. This will help you be more effective in the future with this or another interpreter.

• Make notes on what you learned for your future reference or to help a colleague.

Remember

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• Your interview is a collaboration between you and the interpreter. Listen as well as speak.

Notes

• The interpreter may be a child, grandchild, or sibling of the patient. Be sensitive to the fact that the child is playing an adult role.

• Be sensitive to cultural and situational differences (e.g., an interview with someone from urban Germany will likely be different from an interview with someone from a transitional refugee camp).

• Younger females telling older males what to do may be a problem for both a female nurse and a female interpreter. This is not the time to pioneer new gender relations. Be aware that in some cultures it is difficult for a woman to talk about some topics with a husband or a father present.

Courtesy of Elizabeth Whalley, PhD, San Francisco State University.

When using an interpreter, the nurse respects the family by creating an atmosphere of respect and privacy. Questions should be addressed to the woman and not to the interpreter. Even though an interpreter will of necessity be exposed to sensitive and privileged information about the family, the nurse should take care to ensure that confidentiality is maintained. A quiet location free from interruptions is ideal for interpretive services to take place. Culturally and linguistically appropriate educational materials that are easy to read, with appropriate text and graphics, should be available to assist the woman and her family in understanding health care information. To ensure understanding and avoid liability issues, it is important to make certain that the material has been translated by someone who is trained appropriately.

Personal Space Cultural traditions define the appropriate personal space for

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various social interactions. Although the need for personal space varies from person to person and with the situation, the actual physical dimensions of comfort zones differ from culture to culture. Actions such as touching, placing the woman in proximity to others, taking away personal possessions, and making decisions for the woman can decrease personal security and heighten anxiety. Conversely, respecting the need for distance allows the woman to maintain control over personal space and supports personal autonomy, thereby increasing her sense of security. Nurses must touch patients. However, they frequently do so without any awareness of the emotional distress they may be causing.

Time Orientation Time orientation is a fundamental way in which culture affects health behaviors. People in cultural groups may be relatively more oriented to past, present, or future. Those who focus on the past strive to maintain tradition or the status quo and have little motivation for formulating goals. In contrast, individuals who focus primarily on the present neither plan for the future nor consider the experiences of the past. These individuals do not necessarily adhere to strict schedules and are often described as “living for the moment” or “marching to their own drummer.” Individuals oriented to the future maintain a focus on achieving long-term goals.

The time orientation of the childbearing family may affect nursing care. For example, talking to a family about bringing the infant to the clinic for follow-up examinations (events in the future) may be difficult for the family who is focused on the present concerns of day-to-day survival. Because a family with a future- oriented sense of time plans far in advance, thinking about the long-term consequences of present actions, they may be more likely to return as scheduled for follow-up visits. Despite the differences in time orientation, each family can be equally concerned for the well-being of its newborn.

Family Roles Family roles involve the expectations and behaviors associated

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with a member's position in the larger family system (e.g., mother, father, grandparent). Social class and cultural norms also affect these roles, with distinct expectations for men and women clearly determined by social norms. For example, culture may influence whether a man actively participates in pregnancy and childbirth, yet maternity care providers working in the Western health care system expect fathers to be involved. This can create a significant conflict between the nurse and the role expectations of very traditional Mexican or Arabic families, who usually view the birthing experience as a female affair (see Cultural Considerations box). The way that health care practitioners manage such a family's care molds its experience and perception of the Western health care system.

Cultural Considerations Questions to Ask to Elicit Cultural Expectations About Childbearing

1. What do you and your family think you should do to remain healthy during pregnancy?

2. What can you do to improve your health and the health of your baby?

3. What foods will help make a healthy baby?

4. Who do you want with you during your labor?

5. What can your labor support person do to help you be most comfortable during labor?

6. What actions are important for you and your family after the baby's birth?

7. What do you and your family expect from the nurse(s) caring for you?

8. How will family members participate in your pregnancy,

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childbirth, and parenting?

In maternity nursing, the nurse supports and nurtures the beliefs that promote physical or emotional adaptation to childbearing. However, if certain beliefs might be harmful, the nurse should carefully explore them with the woman and use them in the reeducation and modification process. Table 2.2 provides examples of some cultural beliefs and practices surrounding childbearing. The cultural beliefs and customs in the table are categorized on the basis of distinct cultural traditions and are not practiced by all members of the cultural group in every part of the country. Women from these cultural and ethnic groups may adhere to a few, all, or none of the practices listed. In using this table as a guide, the nurse should take care to avoid making stereotypic assumptions about any person based on sociocultural-spiritual affiliations. Nurses should exercise sensitivity in working with every family, being careful to assess the ways in which they apply their own mixture of cultural traditions.

TABLE 2.2 Traditional* Cultural Beliefs and Practices: Childbearing and Parenting

Pregnancy Childbirth Parenting Hispanic-American (Based primarily on knowledge of Mexican-Americans; members of the Hispanic community have their origins in Spain, Cuba, Central and South America, Mexico, Puerto Rico, and other Spanish-speaking countries.) Pregnancy

• Pregnancy desired soon after marriage

• Late prenatal care • Expectant mother influenced

strongly by mother or mother- in-law

• Cool air in motion considered dangerous during pregnancy

• Unsatisfied food cravings thought to cause a birthmark

• Some pica observed in the eating of ashes or dirt (not common)

• Milk avoided because it causes large babies and difficult births

• Many predictions about sex of

Labor

• Use of partera or lay midwife preferred in some places; expectant mother may prefer presence of mother rather than husband

• After birth of baby, mother's legs brought together to prevent air from entering uterus

• Loud behavior in labor Postpartum

• Diet may be restricted after birth; for first 2 days only boiled milk and toasted tortillas permitted (special foods to restore warmth to

Newborn

• Breastfeeding begun after third day; colostrum may be considered “filthy” or “spoiled” or just not enough nourishment

• Need a balance of heat and cold to promote milk flow

• Olive oil or castor oil given to stimulate passage of meconium

• Male infant not circumcised

• Female infant's ears pierced

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baby • May be unacceptable and

frightening to have pelvic examination by male health care provider

• Use of herbs to treat common complaints of pregnancy

• Drinking chamomile tea thought to ensure effective labor

• May wear ribbon or band around pregnant belly in belief that baby will be born healthy

• Need a balance of hot and cold

body) • Avoid cold foods • Bed rest for 3 days after

birth • Mother's head and feet

protected from cold air; bathing permitted after 14 days

• Mother often cared for by her own mother

• Forty-day restriction on sexual intercourse

• Mother may want baby's first wet diaper to wipe her face in belief that it aids in making “mask of pregnancy” go away

• Belly band used to prevent umbilical hernia

• Religious medal worn by mother during pregnancy; placed around infant's neck

• Infant protected from mal de ojo (“evil eye”)

• Various remedies used to treat mal de ojo and fallen fontanel (depressed fontanel)

African-American (Members of the African-American community, many of whom are descendants of slaves, have different origins. Today a number of black Americans have emigrated from Africa, the West Indies, the Dominican Republic, Haiti, and Jamaica.) Pregnancy

• Acceptance of pregnancy depends on economic status

• Pregnancy thought to be state of “wellness,” which is often the reason for delay in seeking prenatal care, especially by lower-income African- Americans

• Old wives' tales include beliefs that having a picture taken during pregnancy will cause stillbirth and reaching up will cause cord to strangle baby

• Craving for certain foods, including chicken and greens, and nonfood substances such as clay, starch, and dirt (pica)

• Pregnancy may be viewed by African-American men as a sign of their virility

• Self-treatment for various discomforts of pregnancy, including constipation, nausea, vomiting, headache, and heartburn

Labor

• Use of “Granny midwife” in certain parts of United States

• Varied emotional responses: some cry out, some display stoic behavior to avoid calling attention to selves

• Woman may arrive at hospital in far-advanced labor

• Emotional support often provided by other women, especially the woman's own mother

Postpartum

• Vaginal bleeding seen as sign of sickness; tub baths and shampooing of hair prohibited

• Sassafras tea thought to have healing power

• Eating liver thought to cause heavier vaginal bleeding because of its high “blood” content

Newborn

• Feeding very important: • “Good” baby thought to

eat well • Early introduction of

solid foods • May breastfeed or

bottle-feed; breastfeeding may be considered embarrassing

• Parents fearful of spoiling baby

• Commonly call baby by nicknames

• May use excessive clothing to keep baby warm

• Belly band used to prevent umbilical hernia

• Abundant use of oil on baby's scalp and skin

• Strong feeling of family, community, and religion

• African-American minister and church important in recovery

Asian-American (Typically refers to groups from China, Korea, the Philippines, Japan, Southeast Asia [particularly Thailand], Indochina, and Vietnam.) Pregnancy

• Pregnancy considered time when mother “has happiness in her body”

• Pregnancy seen as natural process

Labor

• Mother attended by other women, especially her own mother

• Father does not actively participate

Newborn

• Concept of family important and valued

• Father is head of household; wife plays a subordinate role

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• Strong preference for female health care provider

• Belief in theory of hot and cold • May omit soy sauce in diet to

prevent dark-skinned baby • Prefer soup made with ginseng

root as general strength tonic • Milk usually excluded from

diet because it causes stomach distress

• Inactivity or sleeping late may cause difficult birth

• Korean women practice Tae- kyo (think about good things and maintain a calm attitude)

• Many diagnostic tests such as amniocentesis, ultrasonography, or drawing blood considered unnecessary and dangerous

• Sexual intercourse in last 2 months of pregnancy may be restricted

• May moan or grunt • Cesarean birth not desired

Postpartum

• Must protect self from yin (cold forces) for 30 days

• Ambulation limited • Shower and bathing

prohibited for about 10 days • Warm room • Diet: • Warm fluids • Some women are

vegetarians • Korean mother served

seaweed soup with rice • Chinese diet high in hot

foods • Chinese mother avoids

fruits and vegetables

• Birth of boy preferred • May delay naming child • Some groups (e.g.,

Vietnamese) believe colostrum is dirty; therefore they may delay breastfeeding until milk comes in

• Traditionally Filipino babies are not circumcised at birth

European-American (Members of the European-American [Caucasian] community have their origins in countries such as Ireland, Great Britain, Germany, Italy, and France.) Pregnancy

• Pregnancy viewed as a condition that requires medical attention to ensure health

• Emphasis on early prenatal care

• Variety of childbirth education programs available, and participation encouraged

• Technology driven • Emphasis on nutritional science • Involvement of the father

valued • Written sources of information

valued

Labor

• Birth is a public concern • Technology dominated • Birthing process in

institutional setting valued • Involvement of father

expected • Physician seen as head of

team Postpartum

• Emphasis or focus on early bonding

• Medical interventions for dealing with discomfort

• Early ambulation and activity emphasized

• Self-management valued

Newborn

• More women breastfeeding

• Breastfeeding begins as soon as possible after childbirth

Parenting

• Motherhood and transition to parenting seen as stressful time

• Nuclear family valued, although single parenting and other forms of parenting more acceptable than in the past

• Women often deal with multiple roles

• Early return to prenatal activities

Native American (Many different tribes exist within the Native-American culture; viewpoints vary according to tribal customs and beliefs.) Pregnancy

• Pregnancy considered a normal, natural process

• Late prenatal care • Avoid heavy lifting • Herb teas encouraged

Labor

• Prefers female attendant, although husband, mother, or father may assist with birth

• Birth may be attended by whole family

Newborn

• Infant not fed colostrum • Use of herbs to increase

flow of milk • Use of cradle boards for

infant • Babies not handled

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• Herbs may be used to promote uterine activity

• Birth may occur in squatting position

Postpartum

• Herbal teas to stop bleeding

often

*Variations in some beliefs and practices exist within subcultures of each group. Note: Most of these cultural beliefs and customs reflect the traditional culture and are not universally practiced. These lists are not intended to stereotype patients but, rather, to serve as guidelines while discussing meaningful cultural beliefs with a woman and her family. Examples of other cultural beliefs and practices are found throughout this text. Data from Amaro, H. (1994). Women in the Mexican-American community: religion, culture, and reproductive attitudes and experiences, Journal of Comparative Psychology 16(1):6–19; D'Avanzo, C. (2008). Mosby's pocket guide to cultural health assessment (4th ed.). St. Louis, MO: Mosby; Giger, J. N. (2013). Transcultural nursing: Assessment and intervention (6th ed.). St. Louis, MO: Mosby; Mattson, S. (1995). Culturally sensitive prenatal care for Southeastern Asians, Journal of Obstetric, Gynecologic, and Neonatal Nursing 24(4):335–341; Spector, R. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice- Hall

Developing Cultural Competence Cultural competence has many names and definitions, all of which have subtle shades of difference but which are essentially the same: multiculturalism, cultural sensitivity, and intercultural effectiveness. Cultural competence involves acknowledging, respecting, and appreciating ethnic, cultural, and linguistic diversity. Culturally competent professionals act in ways that meet the needs of the patient and are respectful of ways and traditions that may be very different from their own. In today's society, it is critically important that nurses develop more than technical skills. At every level of preparation and throughout their professional lives, nurses must engage in a continual process of developing and refining attitudes and behaviors that will promote culturally competent care (Giger, 2013).

Key components of culturally competent care include the following: • Recognizing that differences exist between one's own culture and

that of the patient

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• Educating and promoting healthy behaviors in a cultural context that has meaning for patients

• Taking abstract knowledge about other cultures and applying it in a practical way so that the quality of service improves and policies are enacted that meet the needs of all patients

• Communicating respect for a wide range of differences, including patient use of nontraditional healing practices and alternative therapies

• Recognizing the importance of culturally different communication styles, problem-solving techniques, concepts of space and time, and desires to be involved with care decisions

• Anticipating the need to address varying degrees of language ability and literacy, as well as barriers to care and compliance with treatment

In addition to issues of preserving and promoting human dignity, the development of cultural competence is of equal importance in terms of health outcomes. Nurses who relate effectively with patients are able to motivate them in the direction of health-promoting behaviors. Provider competence to address language barriers facilitates appropriate tailoring of health messages and preventive health teaching. Cross-cultural experiences also present an opportunity for the health care professional to expand cultural sensitivity, awareness, and skills (Fig. 2.6).

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FIG 2.6 Nurse volunteering in a day care center in Ecuador. (Courtesy of CoraLee Thompson, RN, BA, CNP [ret].)

Spirituality and the Family Spirituality is an aspect of humans that is above and beyond the mind and body. It “speaks to what gives ultimate meaning and purpose to one's life. It is that part of people that seeks healing and reconciliation with self or others” (Puchalski, 2006). Spirituality is important in all phases of life; it relates to deep and important things and will affect how patients face health issues (Giske & Cone, 2015). While religion is a more organized or rule-driven form of spirituality, one can be spiritual without being a member of an organized religion.

Many studies of religion and health suggest that religious people are healthier and generally live longer than nonreligious people. Those who attend church once a week are less likely to become ill than those who do not. The studies did not control for rates of smoking and alcohol use, so no inference can be made as to whether the improved health status was from better habits or religion. In general, it is known that religious people do tend to have healthier lifestyles overall than people who are not religious (Condon, 2004). Spiritual wellness can be estimated by answering questions such as those suggested in Box 2.3

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Box 2.3 Spiritual Wellness Self-Assessment

1. How do you describe your purpose in life?

2. What activities do you do regularly that bring you joy?

3. What goals do you have for 6 months from now?

4. What goals do you have for 2 years from now?

5. What activities make you feel nourished?

6. What kinds of things do you do for yourself every day?

7. What do you hope for in the future?

8. Are there people to whom you can reach out?

9. On whom can you count for encouragement and/or support?

10. Are there others to whom you give encouragement and/or support?

11. Who loves you?

12. Whom do you love or care about?

13. In what areas are you growing?

14. How do you go about forgiving yourself?

15. How do you go about forgiving others?

16. To whom do you confide your hopes, dreams, and pain?

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17. Do you believe in some kind of higher power?

18. What do you hope for in the future?

19. When do you reach out to people?

20. Do you look forward to getting up in the morning?

21. Would you like to live to be 100?

The more questions you answer in the positive, the higher the level of spiritual wellness.

Adapted from Condon, M. (2004). Women's health: Body, mind, spirit: An integrated approach to wellness and illness. Upper Saddle River, NJ: Prentice-Hall.

Spirituality is a component of holistic nursing and thus a professional responsibility. The International Council of Nurses Code of Ethics for Nurses (2012) states that: “In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family, and community are respected” (p. 2). The American Nurses Association Code of Ethics for Nurses With Interpretive Statements states that: “Factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression and primary language are to be considered when planning individual, family and population-centered care” (American Nurses Association, 2015, p. 1). NANDA-I includes two nursing diagnoses related to spirituality: Readiness for Enhanced Spiritual Well-Being and Spiritual Distress (Ackley, Ladwig, & Makic, 2017).

Spirituality is a component of basic professional nursing education; graduates are to include spirituality in assessments and provide spiritually and culturally appropriate health promotion (American Association of Colleges of Nursing, 2008). The Joint Commission (2016) includes among patient rights the right to religious and other spiritual services; religion, spiritual beliefs, values, and preferences are to be taken into account in the provision

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of care. Thus, many health care and nursing organizations and associations recognize the importance of spiritual care and incorporate the provision of such care into their standards.

Spiritual care encompasses those “interventions, individual or communal, that facilitate the ability to experience the integration of the body, mind, and spirit to achieve wholeness, health, and a sense of connection to self, others, and a higher power” (American Nurses Association and Health Ministries Association, 2005, p. 38). Spirituality is of relevance for all of nursing, not just for those in palliative care or for dying patients (Giske & Cone, 2015).

Religious preference is usually included with demographic information on initial contact with health care organizations. Hospital chaplains and other clergy use the information to arrange visits with parishioners or others who desire their services. Nurses can use the information to pose questions about preferences or requests for prayers, blessings, counseling, or visits from clergy. Taylor (2012) provided a guide for nurses by describing a number of religions and the rituals and relation to health important to those denominations.

Baptisms, b'nai mitzvah, salat, anointings, blessings, communion services, sacrament of the sick, and other religious observances and practices may occur. Memorial services may be held in the hospital chapel or prayer room. Occasionally weddings are performed within a hospital. Nurses may be requested to provide the space and opportunity for such events to occur. At times they may be invited or requested to participate. Depending on preferences, the nurse may choose to remain for the service or decline respectfully. The nurse need not be of the same religion, or any religion, to provide support by his or her presence.

The Pause, which originated in an emergency room after the death of a patient, is a minute or two of taking time to acknowledge a lost human life, and is an example of the recognition of the individual in this sad time as well as giving support to those health care providers who worked to save the life (Bartels, 2014). After a death, the staff are asked to remain and bear witness, to be together and present in this time of grief and loss. The staff is able to be together and achieve some type of closure or resolution surrounding the unsuccessful efforts to resuscitate the individual.

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Use of the Pause is growing and winning advocates.

Spiritual Assessment As part of patient assessments, questions related to spirituality and religion should be included. Questions can be directed to patients as well as the family. Examples of such questions are in Box 2.4.

Box 2.4 Spiritual Assessment Questions

• Who or what provides the patient with strength and hope?

• Does the patient use prayer in his or her life?

• How does the patient express his or her spirituality?

• How would the patient describe his or her philosophy of life?

• What type of spiritual/religious support does the patient desire?

• What is the name of the patient's clergy, ministers, chaplains, pastor, rabbi?

• What does suffering mean to the patient?

• What does dying mean to the patient?

• What are the patient's spiritual goals?

• Is there a role of church/synagogue in the patient's life?

• How does faith help the patient cope with illness?

• How does the patient keep going day after day?

• What helps the patient get through this health care experience?

• How has illness affected the patient and his or her family?

Adapted from The Joint Commission, Standards FAQ details, medical record—Spiritual

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assessment. Retrieved from https://www.jointcommission.org/standards_information/jcfaqdetails.aspx? StandardsFAQId=765&StandardsFAQChapterId=29&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=spiritual

The FICA Spiritual Assessment Tool (Box 2.5) is a short and simple guide for spiritual assessment. Small cards are available to assist health care professionals to guide assessments.

Box 2.5 FICA Spiritual Assessment Tool* F - Faith and Belief “Do you consider yourself spiritual or religious?” or “Is spirituality something important to you” or “Do you have spiritual beliefs that help you cope with stress/difficult times?” (Contextualize to reason for visit if it is not the routine history).

If the patient responds “No,” the health care provider might ask, “What gives your life meaning?” Sometimes patients respond with answers such as family, career, or nature.

(The question of meaning should also be asked even if people answer yes to spirituality.)

I - Importance “What importance does your spirituality have in your life? Has your spirituality influenced how you take care of yourself, your health? Does your spirituality influence you in your healthcare decision making? (e.g., advance directives, treatment, etc.)

C - Community “Are you part of a spiritual community? Communities such as churches, temples, and mosques, or a group of like-minded friends, family, or yoga, can serve as strong support systems for some patients. Can explore further: Is this of support to you and how? Is there a group of people you really love or who are important to you?”

A - Address in Care “How would you like me, your healthcare provider, to address these issues in your healthcare?” (With the newer models including

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diagnosis of spiritual distress A also refers to the Assessment and Plan of patient spiritual distress or issues within a treatment or care plan.)

*Copyright 1996 by C. Pulchalski.

From Puchalski, C. (2006). Spiritual assessment in clinical practice. Psychiatric Annals, 36(3), 150-155. Used with permission from George Washington Institute for Spirituality and Health (GWish), Washington, DC.

Brussat and Brussat (1996) described characteristics of the spiritually literate person as being present, having compassion, being connected, having hope, being kind and listening, having meaning and openness, and using silence. All of these are characteristics of a nurse who is interested in providing spiritual care.

To provide spiritual care, the nurse must understand the meaning of spirituality to the person for whom care is provided (Gordon, Kelly, & Mitchell, 2011). The nurse must listen attentively to learn what is important to the patient, what gives meaning to her life, what gives hope and strength, and what are her fears and concerns (Burkhardt & Nagai-Jacobson, 2015). Only then can the nurse respond appropriately and provide spiritual care that is healing.

Parish nursing or faith community nursing is another opportunity to provide spiritual care. Parish nurses work through their church, synagogue, mosque, or faith community to promote health, manage disease, coordinate care, and assist with access to health care through classes, home visits, and other types of outreach (Wordsworth, Moore, & Woodhouse, 2016). These visits do not replace community health visits but supplement them.

Home Care in the Community Modern home care nursing has its foundation in public health nursing, which provided comprehensive care to sick and well patients in their own homes. Specialized maternity home care nursing services began in the 1980s when public health maternity

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nursing services were limited and services had not kept pace with the changing practices of high-risk obstetrics and emerging technology. Lengthy antepartum hospitalizations for such conditions as preterm labor and gestational hypertension created nursing care challenges for staff members of inpatient units.

Many women expressed their concerns about the negative effect of antepartum hospitalizations on the family as well as the costs and burdens of lengthy hospitalization. Although clinical indications showed that a new nursing care approach was needed, home health care did not become a viable alternative until third- party payers (i.e., public or private organizations or employer groups that pay for health care) pushed for cost containment in maternity services.

In the current health care system, home care is an important component of health care delivery along the perinatal continuum of care (Fig. 2.7). The growing demand for home care is based on several factors:

FIG 2.7 Perinatal continuum of care.

• Interest in family birthing alternatives • Shortened hospital stays • New technologies that facilitate home-based assessments and

treatments • Reimbursement by third-party payers

As health care costs continue to rise and because millions of

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American families lack health insurance, there is greater demand for innovative, cost-effective methods of health care delivery in the community. Large health care systems are developing clinically integrated health care delivery networks whose goals are: (1) improved coordination of care and care outcomes; (2) better communication among health care providers; (3) increased patient, payer, and provider satisfaction; and (4) reduced cost. The integration of clinical services changes the focus of care to a continuum of services that are increasingly community based.

Communication and Technology Applications As maternity care continues to consist of frequent and brief contacts with health care providers throughout the prenatal and postpartum periods, services that link maternity patients throughout the perinatal continuum of care have assumed increasing importance. These services include critical pathways, telephonic nursing assessments, discharge planning, specialized education programs, parent support groups, home visiting programs, nurse advice lines, and perinatal home care (Fig. 2.8). Hospitals may provide cross- training for hospital-based nurses to make postpartum home visits or to staff outpatient centers for postpartum follow-up.

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FIG 2.8 Home care nurse visits with a woman in preterm labor at home on bedrest. (Courtesy of Shannon Perry,

Phoenix, AZ.)

Telephonic nursing through services such as warm lines, nurse advice lines, and telephonic nursing assessments is a valuable means of managing health care problems and bridging the gaps among acute, outpatient, and home care services. Health care professionals use the Internet and Skype to communicate with patients. Newborns in distress in rural hospitals can be assessed by neonatologists using high-definition telemedicine robots. Nursing care that occurs by telephone is interactive and responsive to immediate health care questions about particular health care needs. Warm lines are telephone lines that are offered as a community service to provide new parents with support, encouragement, and basic parenting education. Nurse advice lines, or toll-free nurse consultation services, often are supported by third-party payers or health maintenance organizations/managed care organizations (HMOs/MCOs) and are designed to provide answers to medical questions. Nurse care managers are prepared to guide callers through urgent health care situations, suggest treatment options, and provide health education. Telephonic nursing assessments or nurse consultation, assessment, and health education that take place during a telephone conversation can be added to the nursing care plan in conjunction with skilled nursing visits, or they may comprise a separate nursing contact for the woman. Telephonic nursing assessments are commonly used after a postpartum home care visit to reassess a woman's knowledge about the signs and symptoms of adequate hydration in breastfeeding or, after initiating home phototherapy, to assess the caregiver's knowledge regarding problems with equipment.

Guidelines for Nursing Practice The Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN, 2009) defines home care as the provision of technical, psychologic, and other therapeutic support in the woman's home rather than in an institution. The scope of nursing care delivered in the home is necessarily limited to practices

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deemed safe and appropriate to be carried out in an environment that is physically separated from a health care institution and its resources. Nursing practice at home is consistent with federal and state regulations that direct home care practice. The nurse demonstrates practice competence through formalized orientation and ongoing clinical education and performance evaluation in the respective home care agency. Standards for practice from key specialty organizations such as AWHONN, the National Association of Neonatal Nurses (NANN), ACOG, the American Academy of Pediatrics (AAP), and the Intravenous Nursing Society (INS) provide the basis for clinical protocols and pathways and organizational programs in home care practice. The Joint Commission (www.jointcommission.org) provides criteria for home care procedures based on Centers for Medicare & Medicaid Services (CMS) regulations (www.cms.gov).

A wide range of professional health care services and products can be delivered or used in the home by means of technology and telecommunication. For example, telehealth and telemedicine make it possible for patients in the home to be interviewed and assessed by a specialist located hundreds of miles away. Home health care can be viewed as an extension of in-hospital care.

Essentially, the primary difference between health care in a hospital and home care is the absence of the continuous presence of professional health care providers in a patient's home. Generally, but not always, home health care entails intermittent care by a professional who visits the patient's home for a particular reason and/or provides care onsite for fewer than 4 hours at a time. The home health care agency maintains on-call professional staff to assist home care patients who have questions about their care and for emergencies, such as equipment failure.

Perinatal Services Home care is best delivered by an interprofessional care team. Nurses, obstetricians, maternal-fetal medicine, pharmacy, mental health practitioners, social workers, the public health department, and case managers working together can provide comprehensive and patient-centered care. Home care perinatal services may be

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provided by hospital-based programs, independent proprietary (for-profit) agencies, or nonprofit home care agencies and by official or tax-supported agencies. Innovative programs may be supported by research grants for a period of years, but ultimately they must be sponsored by an agency with long-term funding. Home visits have advantages and disadvantages. The pregnant woman can maintain bed rest if indicated, and vulnerable neonates are not exposed to the weather or external sources of infection. The nurse can observe and interact with family members in their most natural and secure environment. Adequacy of resources and safety factors can be assessed. Teaching can be tailored to the actual home conditions, and other family members can be included. A home visit is less expensive than a day's hospitalization, but a 60- to 90-minute visit requires 2.5 to 3 hours of nursing time, including travel and documentation. Areas of challenge include limited availability of nurses with expertise in maternity care and concerns about the nurse's physical safety in the community. One alternative that is less expensive is contacting women via telephone or the Internet.

Visits for outreach and health promotion are an integral part of community (or public) health nursing. In countries with national health systems, a nurse or midwife may see all women during pregnancy and after birth. In the United States, visits of this sort have been provided mainly to low-income families without health insurance and Medicaid recipients who use the clinics provided by local health departments. Until recently, private insurers did not reimburse for health promotion visits. MCOs now recognize that anticipatory guidance can be cost-effective, but home visitation programs for the most part still target specific, high-risk populations, such as adolescents and women at risk for preterm labor.

Home care agencies are subject to regulation by governmental and professional organizations and provide interdisciplinary services including social work, nutrition, and occupational and physical therapy. Increasingly, their caseloads are made up of women who require high-technology care, such as infusions or home monitoring. Although the home health nurse develops the care plan, all care must be ordered by a physician. In addition, interventions must meet the insurer's criteria for reimbursement,

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and services are limited to registered patients. Preconception care and low-risk antepartum care can usually be provided more efficiently in offices and clinics. High-risk antepartum care can be provided by home care agencies; for example, women with hyperemesis gravidarum who require parenteral nutrition may be treated at home. Conditions requiring bed rest, such as preterm labor and hypertension, are other common indications for home care. Other conditions often managed with home care include cardiac disease, substance abuse, and diabetes in pregnancy.

Insurers may reimburse for at least one postpartum visit to families after early discharge or in the presence of high-risk factors. Many neonates who require long-term high-technology care are also managed with home care.

Patient Selection and Referral The office- or hospital-based nurse is often the key person in making effective referrals to home care. When considering a referral to home care, the following factors are evaluated: • Health status of mother and fetus or infant: Is the condition

serious enough to warrant home care, and is it stable enough for intermittent observation to be sufficient?

• Availability of professionals to provide the needed services within the woman's community.

• Family resources, including psychosocial, social, and economic resources: Will the family be able to provide care between nursing visits? Are relationships supportive? Is third-party reimbursement available, or can it be negotiated with the insurer? Could a voluntary or tax-supported community agency provide needed care without payment?

• Cost-effectiveness: Is it more reasonable for the woman to receive these services at home or to go to a local outpatient facility to receive them?

Community referrals should not be limited to women with physiologic complications of pregnancy that require medical treatment. Women at risk (e.g., young adolescents, families with a history of abuse, members of vulnerable population groups,

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developmentally disabled individuals) may need follow-up care at home. As we move more and more into an interdisciplinary health care society, it is crucial that nurses communicate with social workers to tap into valuable community resources that women can use in their own communities after being discharged.

Standardized forms simplify the referral process and ensure that all needed information will be forwarded to the home health agency. The nursing assessment should include the woman's physical and psychologic status, her level of knowledge about self- management activities, her willingness to learn, the availability of caregivers and social support in the home, and her level of comfort with home care. If the referral is for a mother-and-infant home care visit, the nursing assessment should include newborn data.

High-technology home care requires additional information to be collected from the chart and consultation with the referring physician and other members of the health care team before a home care referral is made. These additional data include the medical diagnosis, medical prognosis, prescribed therapies, medication history, drug-dosing information, potential ancillary supplies, type of infusion and access device, and the available systems of social support for the woman and family. The nursing assessment and therapy data provide baseline information for the home care nurse and other health care providers involved in the care plan.

Whenever a referral is called in to a home health care agency, a member of the nursing or admissions staff determines the agency's ability to accept the woman for service. The use of telecommunication modalities such as fax machines, cellular phones, electronic files, and the Internet to transmit information has eliminated delays in initiating home care services, even in more remote rural areas.

Care Management Preparing for the Home Visit Home care is an excellent example of the benefits of interprofessional care. The home care nurse reviews the available clinical data, demographic information, and completed care plan

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form and consults with the home care pharmacist or other health care team members who have previously contacted the woman to determine the goals of the visit. At this point, the nurse uses the medical diagnosis and the location of the case on the perinatal continuum as a starting point to organize the woman's care. The nurse reviews agency policies and procedures, professional literature about diagnosis, and community resources as part of the previsit preparation work (Box 2.6).

Box 2.6 Protocol for Perinatal Home Visits Previsit Interventions

• Contact the family to arrange details for home visit.

• Identify self, credentials, and agency role.

• Review purpose of home visit follow-up.

• Schedule convenient time for visit.

• Confirm address and route to family home.

• Review and clarify appropriate data.

• Review all available assessment data for mother and fetus or infant (i.e., referral forms, hospital discharge summaries, identified learning needs of the family).

• Review records of any previous nursing contacts.

• Contact other professional caregivers as necessary to clarify data (e.g., obstetrician, nurse-midwife,

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pediatrician, referring nurse).

• Identify community resources and teaching materials appropriate to meet those needs already identified.

• Plan the visit, and prepare a bag with equipment, supplies, and materials necessary for assessments of mother and fetus or infant, actual care anticipated, and teaching.

In-Home Interventions: Establishing a Relationship

• Reintroduce yourself, and establish the purpose of the visit for mother, infant, and family; offer the family the opportunity to clarify their expectations of the contact.

• Spend a brief time socially interacting with the family to become acquainted and establish a trusting relationship.

In-Home Interventions: Working With the Family

• Conduct a systematic assessment of the mother and the fetus or newborn to determine their physiologic adjustment and any existing complications (see Fig. 2.8).

• Throughout the visit, collect data to assess the emotional adjustment of individual family members to the pregnancy or birth and lifestyle changes. Note any evidence of family-newborn bonding and sibling rivalry; note relationships among mother, father, children, and grandparents.

• Determine the adequacy of the support system.

• To what extent does someone help with cooking, cleaning, and other home-management tasks?

• To what extent is help being provided in caring for the newborn and any other children?

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• Are support persons encouraging the new mother to care for herself and get adequate rest?

• Who is providing helpful information? Emotional support?

• Throughout the visit, observe the home environment for adequacy of resources.

• Space: privacy, safe play of children, sleeping

• Overall cleanliness and state of repair

• Number of steps pregnant woman/new mother must climb

• Adequacy of cooking arrangements

• Adequacy of refrigeration and other food storage areas

• Adequacy of bathing, toilet, and laundry facilities

• Arrangements in home for newborn: sleeping, bathing, formula preparation (if needed), layette items, and diapers

• Throughout the visit, observe the home environment for overall state of repair and existence of safety hazards.

• Storage of medications, household cleaners, and other substances hazardous to children

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• Presence of peeling paint on furniture, walls, or pipes

• Factors that contribute to falls, such as dim lighting, broken steps, scatter rugs

• Presence of vermin

• Use of crib or playpen that fails to meet safety guidelines

• Existence of emergency plan in case of fire; fire alarm or extinguisher

• Provide care to the mother, the newborn, or both as prescribed by their respective primary care provider or in accord with agency protocol.

• Provide teaching on the basis of previously identified needs.

• Refer the family to appropriate community agencies or resources, such as warm lines and support groups.

• Ensure that the woman knows potential problems to watch for and who to call if they occur.

• Ensure that used disposable items have been handled appropriately and that reusable items are cleaned and repacked appropriately in the nurse's bag.

In-Home Interventions: Ending the Visit

• Summarize the activities and main points of the visit.

• Clarify future expectations, including the schedule of the next visit.

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• Review the teaching plan, and provide major points in writing.

• Provide information about reaching the nurse or agency if needed before the next scheduled visit.

Postvisit Interventions

• Document the visit thoroughly, using the necessary agency forms to serve as a legal record of the visit and to allow third-party reimbursement, as possible.

• Initiate the plan of care on which the next encounter with the woman and/or family will be based.

• Communicate appropriately (e.g., by telephone, letter, progress notes, or referral form) with the primary care provider, other health care professionals, or referral agencies on behalf of the woman and family.

First Home Care Visit Making the first home care visit can be stressful for the nurse and the woman. The home care nurse is faced with an unknown environment controlled by the woman and her family. The woman and her family also experience feelings about the unknown, such as anxiety about the way the nurse will treat them or what the nurse will do during the visit. The challenge for the home care nurse is to establish a positive nurse-patient relationship that includes the family and provide the prescribed home care services within the time provided for the initial home visit. One of the most important roles of the home care nurse is modeling health-related behaviors for the woman and others who are in the home during the visit.

Assessment and Nursing Diagnoses The major areas of the assessment are demographics, medical history, general health history, medication history, physical assessment, psychosocial assessment (Box 2.7), and the home and community environment. Information can be obtained from patient

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records sent to the home care agency at the time of referral or from the previsit interview. These data will be used to develop and complete the nursing care plan, which is required for many licensed home health care agencies.

Box 2.7 Psychosocial Assessment Language

• Identify the primary language spoken in the home.

• Assess whether there are any language barriers to receiving support.

Community Resources/Access to Care

• Identify primary and secondary means of transportation.

• Identify community agencies family uses for health care and support.

• Assess cultural and psychosocial barriers to receiving care.

Social Support

• Determine the people living with the pregnant woman.

• Identify who assists with household chores.

• Identify who assists with child care and parenting activities.

• Identify who the pregnant woman turns to for problems or during a crisis.

Interpersonal Relationships

• Identify the way decisions are made in the family.

• Identify the family's perception of the need for home care.

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• Identify roles of adults in caring for family members.

Caregiver

• Identify the primary caregiver for home care treatments.

• Identify other caregivers and their roles.

• Assess the caregiver's knowledge of treatments and the care process.

• Identify potential strain from the caregiver role.

• Identify the level of satisfaction with the caregiver role.

Stress and Coping

• Identify what the woman perceives as lifestyle changes and their effect on her and her family.

• Identify the changes she and her family have made to adjust to her health condition and home health care treatments.

The nursing care plan is developed in collaboration with the woman, based on her health care needs. Home care nurses working in home health care agencies regulated by the CMS use a nursing care plan that includes patient demographics, the health care provider's orders, home care goals, and the woman's level of functioning. This document is initiated at the time of referral to the home care agency and must be updated every 60 days or as specified by state regulations. The frequency of the skilled nursing visit may vary with the individual plan of care and reimbursement criteria established by the third-party payers.

Nursing Considerations There are several areas of concern when caring for a woman in the home. In home care, the woman or family members are responsible for administration of medications in the absence of the nurse. A

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careful medication history should be obtained to see if the woman is taking her medications correctly and understands their desired action and potential side effects. It is important that women and caretakers have a clear understanding of medication regimens and are notified when medications change in any way.

Nurses have to be skilled at performing various procedures such as venipuncture and administration of intravenous medications or fluids. Nurses must be sure that women know how to respond in emergency situations. Women need to be able to have 24-hour access to resources in the community in emergency situations. Women and family members are also encouraged to learn how to perform cardiopulmonary resuscitation (CPR), especially for infants.

Safety Alert The homes of women using electronic home health care equipment, such as phototherapy equipment or infusion pumps, require physical inspection of any electrical outlets, electrical cords, and extension cords that will be used. Homes with faulty electrical wiring may place the woman at risk for being involved in an electrical fire; faulty wiring may require inspection and repair by a professional electrician before electronic devices are used. Findings from the assessment are incorporated into the nursing care plan.

Oral explanations should be supplemented with clearly written instructions. General information to promote well-being includes nutrition and common discomforts of pregnancy. The need for childbirth education and preparation can be addressed by using books or videos and supplemented by individual teaching at home. Coping with bed rest or other limitation of activity is a problem for many women with high-risk pregnancies. The nurse can share strategies that others have used, such as support groups for women on bed rest using Facebook or Skype, help with time management, and provide information about support services. Teaching about infant care or the special needs of the preterm infant may be appropriate during the prenatal period.

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Safety Alert In caring for the home care patient, Occupational Safety and Health Administration (OSHA) guidelines should be followed. The use of strict handwashing techniques, sharps containers, gloves, personal protective equipment (PPE), and proper equipment is essential in preventing the spread of disease to the care provider, the woman, and her family.

The home care nurses should adhere to personal safety measures such as parking the car for access to a quick departure and should never enter a home where guns are visible.

Clear documentation of assessments, problems identified, treatments and interventions performed, and the woman's response is essential. Third-party payers base reimbursement on the nurse's written record of providing skilled nursing care and assessments that support the woman's continuing need for those services. The nurse must promptly inform the health care provider by telephone, fax, or electronic file of any significant changes. When new orders are transmitted by telephone, a written copy must be sent for the physician's signature.

References Ackley BJ, Ladwig GB, Makic MBF. Nursing diagnosis

handbook. An evidence-based guide to planning care. Elsevier: St. Louis , MO; 2017.

American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. Author: Washington, DC; 2008.

American Nurses Association. Code of ethics for nurses with interpretive statements. Author: Silver Spring, MD; 2015.

American Nurses Association. Nursing: Scope and standards of practice. Author: Silver Spring, MD; 2015.

American Nurses Association and Health Ministries Association. Faith community nursing: Scope & standards of practice. American Nurses Association: Silver Spring, MD; 2005.

155

America's Children. Key national indicators of well-being. [Retrieved from] www.childstats.gov/pdf/ac2013/ac_13.pdf; 2013.

Association of Women's Health, Obstetric, and Neonatal Nurses. Standards for professional nursing practice in the care of women and newborns. 7th ed. Author: Washington, DC; 2009.

Bartels JB. The pause. Critical Care Nurse. 2014;34(1):74–75. Bell JM. Family nursing is more than family centered care.

Journal of Family Nursing. 2013;19(4):411–417. Brussat F, Brussat M. Spiritual literacy: Reading the sacred in

everyday life. Scribner: New York, NY; 1996. Burkhardt P, Nagai-Jacobson MG. Tips for spiritual care-

giving. Beginnings (American Holistic Nurses' Association). 2015;35(5):6–7.

Carter B, McGoldrick M. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. Allyn & Bacon: Boston; 1999.

Centers for Disease Control and Prevention. Minority Health. [Retrieved from] www.cdc.gov/MinorityHealth/index.html; 2016.

Cipriano PF. Attaining a culturally congruent practice. American Nurse Today. 2016;11(5):15.

Condon M. Women's health: Body, mind, spirit. An integrated approach to wellness and illness. Prentice-Hall: Upper Saddle River, NJ; 2004.

Ellis RR, Simmons T. Coresident grandparents and their grandchildren: 2012. Population characteristics. [US Census Bureau, 2012 American Community Survey; Retrieved from] census.gov/content/dam/Census/library/publications/2014/demo/p.20- 576.pdf; 2014.

Freund K. Health disparities among women. Goldman L, Schafer A. Goldman's Cecil medicine. 24th ed. Elsevier: Philadelphia, PA; 2012.

Giger JN. Transcultural nursing: Assessment and intervention. 6th ed. Mosby: St. Louis, MO; 2013.

Giske T, Cone PH. Discerning the healing path—how nurses assist patient spirituality in diverse health care settings.

156

Journal of Clinical Nursing. 2015;24:2926–2935. Gordon T, Kelly E, Mitchell D. Spiritual care for healthcare

professionals: Reflecting on clinical practice. Radcliffe Publishing: London, UK; 2011.

International Council of Nurses. ICN code of ethics for nurses. Author: Geneva, Switzerland; 2012.

Joint Commission. Comprehensive accreditation manual for hospitals (CAMH). Joint Commission Resources: Oak Brook, IL; 2016.

Lofquist D, Lugaila T, O'Connell M, Feliz S. Households and families: 2010. [Retrieved from] www.census.gov/prod/cen2010/briefs/c2010br-14.pdf; 2012.

Pew Research Center. Second-generation Americans. A portrait of the adult children of immigrants. Pew Research Center: Washington, DC; 2013 [Retrieved from] www.pewsocialtrends.org/files/2013/02/FINAL_immigrant_generations_report_2- 7-13.pdf.

Puchalski C. Spiritual assessment in clinical practice. Psychiatric Annals. 2006;36(3):150–155.

Scharte M, Bolte G. Increased health risks of children with single mothers: The impact of socio-economic and environmental factors. Journal of Public Health. 2012;23(3):469–475.

Siegel BS, Perrin EC. Policy statement: Promoting the well- being of children whose parents are gay or lesbian. Pediatrics. 2013;13(4):827–830.

Spector R. Cultural diversity in health and illness. 8th ed. Prentice-Hall: Upper Saddle River, NJ; 2013.

Taylor EJ. Religion: A clinical guide for nurses. Springer: New York; 2012.

US Census Bureau. Children characteristics: American community survey 1-year estimates. [Retrieved from] https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml? src=bkmk; 2015.

US Census Bureau. Population estimates. [Retrieved from] www.census.gov/popest/data/national/asrh/2011/index.html 2011.

Wordsworth H, Moore R, Woodhouse D. Parish nursing: A

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unique resource for community and district nurses. British Journal of Community Nursing. 2016;21(2):66–74.

Wright LM, Bell JM. Beliefs and illness: A model for healing. 4th Floor Press: Calgary, Canada; 2009.

Wright LM, Leahey M. Maximizing time, minimizing suffering: The 15-minute (or less) family interview. Journal of Family Nursing. 1999;5(3):259–273.

Wright LM, Leahy M. Nurses and families: A guide to family assessment and intervention. 6th ed. FA Davis: Philadelphia, PA; 2013.

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UNIT 2

Reproductive Years OUTLINE

3 Assessment and Health Promotion 4 Reproductive System Concerns 5 Infertility, Contraception, and Abortion

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3

Assessment and Health Promotion Ellen F. Olshansky

Care of the well woman is focused on health promotion and illness prevention, recognizing that a woman is a bio-psycho-social- spiritual being, requiring a holistic approach to nursing care. To encourage appropriate health-promotion activities, it is important to conduct systematic health assessments and screenings. This chapter presents an overview of the nurse's role in encouraging health promotion and illness prevention in women. It provides guidelines for how to conduct a complete history and physical examination. This chapter also includes a schedule of screening tests recommended for women at different stages of their lives. As a background to understanding assessment, a review of female anatomy and physiology as well as the menstrual cycle is presented. Facilitators and barriers to women entering the health care system and risk factors for women's health across the life cycle are described. Anticipatory guidance suggestions, including nutrition and stress management, are included. Violence against women, particularly intimate partner violence (IPV) and battering of women, is discussed because it is often in the health care setting that the woman is able to acknowledge being in an abusive relationship. Examples of health-promotion efforts in the community are presented in an effort to emphasize community health approaches to care, especially since much of well woman

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care occurs in the community.

Female Reproductive System The female reproductive system consists of external structures visible from the pubis to the perineum and internal structures located in the pelvic cavity. The external and internal female reproductive structures develop and mature in response to estrogen and progesterone. This process starts in fetal life and continues through puberty and the childbearing years. Reproductive structures atrophy with age or in response to a decrease in ovarian hormone production. A complex nerve and blood supply supports the functions of these structures. The appearance of the external genitalia varies greatly among women. Heredity, age, race, and the number of children a woman has borne influence the size, shape, and color of her external organs.

External Structures The external genital organs, or vulva, include all structures visible externally from the pubis to the perineum. These include the mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethral opening. The external genital organs are illustrated in Fig. 3.1.

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FIG 3.1 External female genitalia.

The mons pubis is a fatty pad that lies over the anterior surface of the symphysis pubis. In the postpubertal female, the mons is covered with coarse, curly hair. The labia majora are two rounded folds of fatty tissue covered with skin that extend downward and backward from the mons pubis. The labia are highly vascular structures that develop hair on the outer surfaces after puberty. They protect the inner vulvar structures. The labia minora are two flat, reddish folds of tissue visible when the labia majora are separated. There are no hair follicles on the labia minora, but many sebaceous follicles and a few sweat glands are present. The interior of the labia minora is comprised of connective tissue and smooth muscle and is supplied with extremely sensitive nerve endings. Anteriorly, the labia minora fuse to form the prepuce (the hoodlike covering of the clitoris) and the frenulum (the fold of tissue under the clitoris). The labia minora join to form a thin, flat tissue called the fourchette underneath the vaginal opening at midline. The clitoris is located underneath the prepuce. It is a small structure composed of erectile tissue with numerous sensory nerve endings. During sexual arousal, the clitoris increases in size.

The vaginal vestibule is an almond-shaped area enclosed by the labia minora that contains openings to the urethra, Skene glands, vagina, and Bartholin glands. The urethra is not a reproductive organ but is discussed here because of its location. It usually is

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found about 2.5 cm below the clitoris. Skene glands are located on each side of the urethra and produce mucus, which aids in lubrication of the vagina. The vaginal opening is in the lower portion of the vestibule and varies in shape and size. The hymen, a connective tissue membrane that surrounds the vaginal opening, can be perforated during strenuous exercise, insertion of tampons, masturbation, and vaginal intercourse. Bartholin glands lie under the constrictor muscles of the vagina and are located posteriorly on the sides of the vaginal opening, although the ductal opening usually is not visible. During sexual arousal, the glands secrete clear mucus to lubricate the vaginal introitus.

The area between the fourchette and the anus is the perineum, a skin-covered muscular area that covers the pelvic structures. The perineum forms the base of the perineal body, a wedge-shaped mass that serves as an anchor for the muscles, fascia, and ligaments of the pelvis. The muscles and ligaments form a sling that supports the pelvic organs.

Internal Structures The internal structures include the vagina, uterus, uterine tubes (fallopian tubes), and ovaries. The description of these structures follows.

The vagina is a fibromuscular, collapsible, tubular structure that lies between the bladder and rectum and extends from the vulva to the uterus. During the reproductive years, the mucosal lining is arranged in transverse folds called rugae. These rugae allow the vagina to expand during childbirth. Estrogen deprivation that occurs after childbirth, during lactation, and at menopause causes dryness and thinning of the vaginal walls and smoothing of the rugae. The vagina, particularly the lower segment, has few sensory nerve endings. Vaginal secretions are slightly acidic (pH 4 to 5) so that vaginal susceptibility to infections is limited. The vagina serves as a passageway for menstrual flow, as a female organ of copulation, and as a part of the birth canal for vaginal childbirth. The uterine cervix projects into a blind vault at the upper end of the vagina. Anterior, posterior, and lateral pockets called fornices (singular: fornix) surround the cervix. The internal pelvic organs can

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be palpated through the thin walls of these fornices. The uterus is a muscular organ shaped like an upside-down pear

that sits midline in the pelvic cavity between the bladder and rectum and above the vagina. Four pairs of ligaments support the uterus: cardinal, uterosacral, round, and broad. Single anterior and posterior ligaments also support the uterus. The cul-de-sac of Douglas is a deep pouch, or recess, posterior to the cervix formed by the posterior ligament.

The uterus is divided into two major parts: an upper triangular portion called the corpus and a lower cylindric portion called the cervix (Fig. 3.2). The fundus is the dome-shaped top of the uterus and is the site at which the uterine tubes (fallopian tubes) enter the uterus. The isthmus, or lower uterine segment, is a short, constricted portion that separates the corpus from the cervix.

FIG 3.2 Midsagittal view of female pelvic organs with woman lying supine.

The uterus serves for reception, implantation, retention, and nutrition of the fertilized ovum and later of the fetus during pregnancy and for expulsion of the fetus during childbirth. It is also responsible for cyclic menstruation.

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The uterine wall is made up of three layers: the endometrium, the myometrium, and part of the peritoneum. The endometrium is a highly vascular lining made up of three layers, the outer two of which are shed during menstruation. The myometrium is made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) (Fig. 3.3). Longitudinal fibers of the outer myometrial layer are found mostly in the fundus, and this arrangement assists in expelling the fetus during the birth process. The middle layer contains fibers from all three directions, which form a figure-eight pattern encircling large blood vessels. These fibers assist in ligating blood vessels after childbirth and control blood loss. Most of the circular fibers of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibers help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation.

FIG 3.3 Schematic arrangement of directions of muscle fibers. Note that uterine muscle fibers are

continuous with supportive ligaments of the uterus.

The cervix is made up of mostly fibrous connective tissue and elastic tissue, making it possible for the cervix to stretch during

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vaginal childbirth. The opening between the uterine cavity and the canal that connects the uterine cavity to the vagina (endocervical canal) is the internal os. The narrowed opening between the endocervix and the vagina is the external os, a small circular opening in women who have never been pregnant. The cervix feels firm (like the end of a nose) with a dimple in the center that marks the external os.

The outer portion of the cervix is covered with a layer of squamous epithelium. The mucosa of the cervical canal is covered with columnar epithelium and contains numerous glands that secrete mucus in response to ovarian hormones. The squamo- columnar junction, where the two types of cells meet, is usually located just inside the external cervical os. This junction is also called the transformation zone and is the most common site for neoplastic changes. Cells from this site are scraped for the Papanicolaou (Pap) test (see discussion later in this chapter).

The uterine tubes (fallopian tubes) attach to the uterine fundus. The tubes are supported by the broad ligaments and range from 8 to 14 cm in length. The tubes are divided into four sections: the interstitial portion is closest to the uterus; the isthmus and the ampulla are the middle portions; and the infundibulum is closest to the ovary. The uterine tubes provide a passage between the ovaries and the uterus for the movement of the ovum. The infundibulum has fimbriated (fringed) ends, which pull the ovum into the tube. The ovum is pushed along the tubes to the uterus by rhythmic contractions of muscles of the tubes and by the current produced by the movement of the cilia that line the tubes. The ovum is usually fertilized by the sperm in the ampulla portion of one of the tubes.

The ovaries are almond-shaped organs located on each side of the uterus below and behind the uterine tubes. During the reproductive years, they are approximately 3 cm long, 2 cm wide, and 1 cm thick; they diminish in size after menopause. Before menarche, each ovary has a smooth surface; after menarche, they are nodular because of repeated ruptures of follicles at ovulation. The two functions of the ovaries are ovulation and hormone production. Ovulation is the release of a mature ovum from the ovary at intervals (usually monthly). Estrogen, progesterone, and androgen are the steroid hormones produced by the ovaries.

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The Bony Pelvis The bony pelvis serves three primary purposes: protection of the pelvic structures, accommodation of the growing fetus during pregnancy, and anchorage of the pelvic support structures. The two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Fig. 3.4). Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones.

FIG 3.4 Adult female bony pelvis. A, Anterior view. B, External view of innominate bone (fused).

The pelvis is divided into two parts: the false pelvis and the true pelvis (Fig. 3.5). The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower, curved, bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. The upper portion of the outlet is at the level of the ischial spines, and the lower portion is at the level of the ischial tuberosities and the pubic arch. Variations that occur in the size and shape of the pelvis are usually related to age, race, and sex. Pelvic ossification is complete at about 20 years of age.

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FIG 3.5 Female pelvis. A, Cavity of false pelvis is shallow. B, Cavity of true pelvis is irregularly curved

canal (arrows).

Breasts The breasts are paired mammary glands located between the second and sixth ribs (Fig. 3.6). About two thirds of the breast overlies the pectoralis muscle, between the sternum and midaxillary line, with an extension to the tail of Spence. The lower one third of the breast overlies the serratus anterior muscle. The breasts are attached to the muscles by connective tissue or fascia. Besides their function of lactation, breasts function as organs for sexual arousal in the mature adult female.

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FIG 3.6 Anatomy of the breast showing position and major structures. (Adapted from Ball, J. W., Dains, J. E., Flynn, J. A., et al. [2016]. Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier.)

The breasts of the healthy, mature woman are approximately equal in size and shape but often are not absolutely symmetric. The size and shape vary with the woman's age, heredity, and nutrition. However, the contour should be smooth with no retractions, dimpling, or masses. Estrogen stimulates growth of the breasts by inducing fat deposition in the breasts, development of stromal tissue (i.e., increase in its amount and elasticity), and growth of the extensive ductile system. Estrogen also increases the vascularity of breast tissue.

Once ovulation begins in puberty, progesterone levels increase. The increase in progesterone causes maturation of mammary gland tissue, specifically the lobules and acinar structures. During adolescence, fat deposition and growth of fibrous tissue contribute to the increase in the size of the glands. Full development of the breasts is not achieved until after the end of the first pregnancy or in the early period of lactation.

Each mammary gland is composed of a number of lobes that are

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divided into lobules. Lobules are clusters of acini. An acinus is a saclike terminal part of a compound gland emptying through a narrow lumen or duct. The acini are lined with epithelial cells that secrete colostrum and milk. Just below the epithelium is the myoepithelium (myo, or muscle), which contracts to expel milk from the acini. Mammary glands are modified sweat glands.

The ducts from the clusters of acini that form the lobules merge to form larger ducts draining the lobes. Ducts from the lobes converge in a single nipple (mammary papilla) surrounded by an areola. The anatomy of the ducts is similar for each breast but varies among women. Protective fatty tissue surrounds the glandular structures and ducts. Cooper's ligaments, or fibrous suspensory ligaments, separate and support the glandular structures and ducts. Cooper's ligaments provide support to the mammary glands while permitting their mobility on the chest wall (see Fig. 3.6). The round nipple is usually slightly elevated above the breast. On each breast the nipple projects slightly upward and laterally. It contains multiple openings from the milk ducts. The nipple is surrounded by fibromuscular tissue and covered by wrinkled skin (the areola). Except during pregnancy and lactation, there is usually no discharge from the nipple.

The nipple and surrounding areola are usually more deeply pigmented than the skin of the breast. The rough appearance of the areola is caused by sebaceous glands, known as Montgomery tubercles, directly beneath the skin. These glands secrete a fatty substance thought to lubricate the nipple. Smooth muscle fibers in the areola contract to cause the nipple to become erect, making it easier for the breastfeeding infant to grasp.

The vascular supply to the mammary gland is abundant. In the nonpregnant state, there is no obvious vascular pattern in the skin. The normal skin is smooth without tightness or shininess. The skin covering the breasts contains an extensive superficial lymphatic network that serves the entire chest wall and is continuous with the superficial lymphatics of the neck and abdomen. The lymphatics form a rich network in the deeper portions of the breasts. The primary deep lymphatic pathway drains laterally toward the axillae.

The breasts change in size and nodularity in response to cyclic

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ovarian changes throughout reproductive life. Increasing levels of both estrogen and progesterone in the 3 to 4 days before menstruation increase the vascularity of the breasts, induce growth of the ducts and acini, and promote water retention. The epithelial cells lining the ducts proliferate in number, the ducts dilate, and the lobules distend. The acini become enlarged and secretory, and lipid (fat) is deposited within their epithelial cell lining. As a result, breast swelling, tenderness, and discomfort are common symptoms just before the onset of menstruation. After menstruation, cellular proliferation begins to regress, acini begin to decrease in size, and retained water is lost. After breasts have undergone changes numerous times in response to the ovarian cycle, the proliferation and involution (regression) are not uniform throughout the breast. In time, after repeated hormonal stimulation, small, persistent areas of nodulations may develop. This normal physiologic change must be remembered when breast tissue is examined. Nodules may develop just before and during menstruation, when the breast is most active. The physiologic alternations in breast size and activity reach their minimum level about 5 to 7 days after menstruation stops. Therefore breast self-examination (BSE) (systematic palpation of breasts to detect signs of breast cancer or other changes) is best carried out during this phase of the menstrual cycle. Although monthly BSE used to be recommended to all women, there is very little evidence that BSE or a clinical breast exam by a health care provider helps to detect breast cancer early when a woman also gets a screening mammogram (United States Preventive Task Force [USPTF], 2016). However, all women should be familiar with how their breats normally appear and feel, and report any changes to a health care provider immediately.

Menstruation Menarche and Puberty Although young girls secrete small, rather constant amounts of estrogen, a marked increase occurs between 8 and 11 years of age. The term menarche denotes first menstruation. Puberty is a broader term that denotes the entire transitional stage between

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childhood and sexual maturity. Increasing amounts and variations in gonadotropin and estrogen secretion develop into a cyclic pattern at least 1 year before menarche. In North America, menarche occurs in most girls at about 13 years of age. There is a possible correlation between obesity and decreased age of menarche (Mohamad, Jamshidi, & Nouri-Jelyani, 2013).

Initially, menstrual periods are irregular, unpredictable, painless, and anovulatory (no ovum is released from the ovary). After 1 or more years, a hypothalamic-pituitary rhythm develops and the ovary produces adequate cyclic estrogen to make a mature ovum. Ovulatory (ovum released from the ovary) periods tend to be regular, with estrogen dominating the first half of the cycle and progesterone dominating the second half of the cycle.

Although pregnancy can occur in exceptional cases of true precocious puberty, most pregnancies in young girls occur after the normally timed menarche. All young adolescents of both sexes would benefit from knowing that pregnancy can occur at any time after the onset of menses.

Menstrual Cycle Menstruation is the periodic uterine bleeding that begins approximately 14 days after ovulation. It is controlled by a feedback system of three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but variations are normal. The first day of bleeding is designated as day 1 of the menstrual cycle, or menses (Fig. 3.7). The average duration of menstrual flow is 5 days (with a range of 3 to 6 days) and the average blood loss is 50 mL (with a range of 20 to 80 mL), but these vary greatly.

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FIG 3.7 Menstrual cycle: hypothalamic-pituitary, ovarian, and endometrial. GnRH, Gonadotropin-

releasing hormone.

For about 50% of women, menstrual blood does not appear to clot. The menstrual blood clots within the uterus, but the clot usually liquefies before being discharged from the uterus. Uterine discharge includes mucus and epithelial cells in addition to blood.

The menstrual cycle is a complex interplay of events that occur simultaneously in the endometrium, the hypothalamus, the

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pituitary glands, and the ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. A woman's age, physical and emotional status, and environment influence the regularity of her menstrual cycles.

Endometrial Cycle The four phases of the endometrial cycle are (1) the menstrual phase, (2) the proliferative phase, (3) the secretory phase, and (4) the ischemic phase (see Fig. 3.7). During the menstrual phase, shedding of the functional two thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in this layer.

The proliferative phase is a period of rapid growth lasting from about the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on, an eightfold to tenfold thickening occurs, with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles.

The secretory phase extends from the day of ovulation to about 3 days before the next menstrual period. After ovulation, large amounts of progesterone are produced. An edematous, vascular, functional endometrium is now apparent. At the end of the secretory phase, the fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions—a suitable protective and nutritive bed for a fertilized ovum.

Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid decrease in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal

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layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 3.7).

Hypothalamic-Pituitary Cycle Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone decrease. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH). FSH stimulates development of ovarian graafian follicles and their production of estrogen. Estrogen levels begin to decrease, and hypothalamic GnRH triggers the anterior pituitary gland to release luteinizing hormone (LH). A marked surge of LH and a smaller peak of estrogen (day 12) (see Fig. 3.7) precede the expulsion of the ovum from the graafian follicle by about 24 to 36 hours. LH peaks at about day 13 or 14 of a 28-day cycle. If fertilization and implantation of the ovum have not occurred by this time, regression of the corpus luteum follows. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is called the hypothalamic-pituitary cycle.

Ovarian Cycle The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, a monthly process in which an ovum is normally released from the ovary, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The pre-ovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (pre-ovulatory phase) (see Fig. 3.7) of the ovarian cycle varies in length from woman to woman. Almost all variations in ovarian cycle length are the result of variations in the length of the follicular phase. On rare occasions (i.e., 1 in 100 menstrual cycles), more than one follicle is selected and more than one oocyte matures and undergoes ovulation.

After ovulation, estrogen levels drop. For 90% of women, only a small amount of withdrawal bleeding occurs, and it goes unnoticed.

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In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is termed midcycle bleeding.

The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting the steroids estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses and steroid levels drop. Two weeks after ovulation, if fertilization and implantation do not occur, the functional layer of the uterine endometrium is shed through menstruation.

Other Cyclic Changes When the hypothalamic-pituitary-ovarian axis functions properly, other tissues undergo predictable responses. Before ovulation, the woman's basal body temperature is often less than 37° C (98.6° F); after ovulation, with increasing progesterone levels, her basal body temperature rises. Changes in the cervix and cervical mucus follow a generally predictable pattern. Preovulatory and postovulatory mucus is viscous (thick) so that sperm penetration is discouraged. At the time of ovulation, cervical mucus is thin and clear. It looks, feels, and stretches like egg white. This stretchable quality is termed spinnbarkeit. Some women have localized lower abdominal pain called mittelschmerz that coincides with ovulation. Some spotting may occur.

Prostaglandins Prostaglandins (PGs) are oxygenated fatty acids classified as hormones. The different kinds of PGs are distinguished by letters (PGE and PGF), numbers (PGE2), and letters of the Greek alphabet (PGF2α).

PGs are produced in most organs of the body, including the uterus. Menstrual blood is a potent PG source. PGs are metabolized quickly by most tissues. They are biologically active in minute amounts in the cardiovascular, gastrointestinal, respiratory,

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urogenital, and nervous systems. They also exert a marked effect on metabolism, particularly on glycolysis. PGs play an important role in many physiologic, pathologic, and pharmacologic reactions. PGF2α, PGE4, and PGE2 are most commonly used in reproductive medicine.

PGs affect smooth muscle contractility and modulation of hormonal activity. Indirect evidence indicates that PGs have an effect on ovulation, fertility, changes in the cervix and cervical mucus that affect receptivity to sperm, tubal and uterine motility, sloughing of endometrium (menstruation), onset of miscarriage and induced abortion, and onset of labor (term and preterm). After exerting biologic actions, newly synthesized PGs are rapidly metabolized by tissues in such organs as the lungs, kidneys, and liver.

PGs may play a key role in ovulation. If PG levels do not rise along with the surge of LH, the ovum remains trapped within the graafian follicle. After ovulation, PGs may influence production of estrogen and progesterone by the corpus luteum.

The introduction of PGs into the vagina or the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which may assist the transport of sperm through the uterus and into the oviduct.

PGs produced by the woman cause regression of the corpus luteum and regression and sloughing of the endometrium, resulting in menstruation. PGs increase myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation. They may be a factor in the initiation of labor, the maintenance of labor, or both (see Chapters 13 and 17). They may also be involved in dysmenorrhea (see Chapter 4).

Climacteric and Menopause The climacteric is a transitional phase during which ovarian function and hormone production decline. This phase spans the years from the onset of premenopausal ovarian decline to the postmenopausal time when symptoms stop. Menopause (from Latin mensis, month, and Greek pauses, to cease) refers only to the last menstrual period. However, unlike menarche, menopause can

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be dated with certainty only 1 year after menstruation ceases. The average age at natural menopause is 51.4 years, with an age range of 35 to 60 years. Perimenopause is a period preceding menopause that lasts about 4 years. During this time, ovarian function declines. Ova slowly diminish, and menstrual cycles may be anovulatory, resulting in irregular bleeding. The ovary stops producing estrogen, and eventually menses no longer occur.

Sexual Response The hypothalamus and anterior pituitary glands in females regulate the production of FSH and LH. The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism between hormone secretion from the ovaries, the hypothalamus, and the anterior pituitary gland aids in the control of the production of sex cells and sex steroid hormone secretion.

Although the first outward appearance of maturing sexual development occurs at an earlier age in females, both females and males achieve physical maturity at approximately 17 years of age; however, individual development varies greatly. Anatomic and reproductive differences notwithstanding, women and men are more alike than different in their physiologic response to sexual excitement and orgasm. For example, the glans clitoris and the glans penis are embryonic homologs. Little difference exists between female and male sexual response; the physical response is essentially the same whether stimulated by coitus, fantasy, or masturbation. Physiologic sexual response can be analyzed in terms of two processes: vasocongestion and myotonia (increased muscular tension).

Sexual stimulation results in increased circulation to circum- vaginal blood vessels (lubrication in the female), causing engorgement and distention of the genitals. Venous congestion is localized primarily in the genitalia, but it also occurs to a lesser degree in the breasts and other parts of the body. Arousal is characterized by myotonia, resulting in voluntary and involuntary rhythmic contractions. Examples of sexually stimulated myotonia are pelvic thrusting, facial grimacing, and spasms of the hands and

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feet (carpopedal spasms). Although other sex researchers have noted various sexual

response cycles, the sexual response cycle is classically divided into four phases: excitement, plateau, orgasm, and resolution, according to the seminal work of Masters and Johnson (1966). The four phases occur progressively, with no sharp dividing line between any two phases. The time, intensity, and duration for cyclic completion also vary for individuals and situations, and there are other models to explain sexual response, though less prevalent than the Masters and Johnson model. Sexuality and sexual response may change during pregnancy and postpartum, emphasizing the need to discuss with women possible sexual changes during this time. Specific issues related to this period (and prior procedures such as episiotomy) must be considered in counseling to promote healthy sexuality during the postpartum period. Despite these alternate models of sexual response, it is still common to describe the classic four stages in which specific body changes take place in sequence, and this description is useful in educating and talking with women who may have concerns about possible sexual dysfunction.

Barriers to Entering the Health Care System Financial Issues Access to care varies greatly, depending on type and size of the system, source of payment for services, private versus public programs, availability of and accessibility to providers, individual preferences, and insurance coverage or ability to pay. The existing system continues to be oriented to treatment of acute or episodic conditions rather than to the promotion of health and comprehensive care, despite the fact that people are discharged earlier from hospitals, requiring more care in homes and community settings.

In the United States, disparity among races and socioeconomic classes affects many facets of life including health. Limited finances is associated with lack of access to care, delay in seeking care, few prevention activities, and little accurate information about health

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and the health care system. Women use health care services more often than men but are more likely than men to have difficulty in financing the services. Many poor women have traditionally been underinsured or uninsured, but rules about health insurance and who and what are covered are undergoing a transition with the Affordable Care Act (ACA) (USDHHS, 2015). With the new presidential administration, the future of the ACA is uncertain; insurance coverage of preexisting conditions and various preventive health services is not assured. With a greater focus on preventive health care services, nurses, advanced practice nurses, including nurse practitioners, nurse-midwives, and clinical nurse specialists, are critical to the provision of high quality, safe, effective, and accessible health care.

Cultural Issues We live in a multicultural society with constantly changing demographics, and for nursing care of women to be optimal, cultural differences must be addressed with great sensitivity and competency. Nurses are in excellent positions to be responsible for providing culturally sensitive and competent health care (Douglas, Rosenkoetter, Pacquiao, et al., 2016). A variety of reasons are given to explain some of the differences in accessing care when financial barriers are adjusted. Some women experience racial discrimination or disrespectful, disillusioning, or discouraging encounters with community service providers such as social services and health care providers. Many women do not seek care from the health care system because of lack of trust. A lack of cross-cultural communication also presents problems. Desired health outcomes are best achieved when the health care provider has knowledge of and understanding about the culture, language, values, priorities, and health beliefs of those in various ethnic groups. Conversely, members of these various groups should understand the health goals to be achieved and the methods proposed to do so. Language differences can produce profound barriers between patients and providers. Even with an interpreter, misinformation can occur on both sides of the communication.

Providers must consider culturally based differences that could

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affect the treatment of diverse groups of women, and the women themselves must share practices and beliefs that could influence their responses to treatment or willingness to adhere to treatment. For example, women in some cultures value privacy to such an extent that they are reluctant to disrobe and, as a result, avoid physical examination unless absolutely necessary. Other women rely on their husbands to make major decisions, including those affecting the woman's health. Religious beliefs may dictate a plan of care, as with birth control measures or blood transfusions. Some cultural groups prefer folk medicine, homeopathy, or prayer to traditional Western medicine; others attempt combinations of some or all practices. Nurses can integrate into their own practice various holistic approaches to care, in accordance with Dossey's (2013) Theory of Integral Nursing. It is critically important to be sensitive to cultural differences and at the same time not stereotype and assume that a woman has certain beliefs because of her ethnic background. Although the amount of health information on the Internet is increasing, information in languages other than English is limited and not all information on the Internet is accurate, making health literacy an important issue in culturally competent care.

Gender Issues Gender influences communications between health care professionals and patients and may influence access to health care in general. Researchers have reported significant male-female differences in receipt of major diagnostic and therapeutic interventions, especially with cardiac and kidney problems. Women tend to use primary care services more often than do men and, some believe, more effectively. The gender of the provider plays a role. The concept of “gender concordance,” in which the patient's gender matches the health care provider's gender, was found to be important for women seeking Pap tests (Lin & Chen, 2014).

Sexual orientation may produce another barrier. Nurses and other health care professionals need to understand the specific health care needs and issues related to sexual orientation,

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particularly since many lesbian, gay, bisexual, and transgender (LGBT) individuals feel stigmatized and are reluctant to seek health care (Olshansky & Zender, 2015). Some lesbians may not disclose their sexual orientation to health care professionals because they feel they may be at risk for hostility, inadequate health care, or breach of confidentiality. In many health care settings, heterosexuality is assumed, and the setting may be one in which the woman does not feel welcome (magazines, brochures, and environment reflect heterosexual couples, or the health care provider shows discomfort interacting with the woman). Lesbians themselves may hold beliefs that are incorrect (e.g., that they have immunity to human immunodeficiency virus [HIV], sexually transmitted infections [STIs], and certain cancers [e.g., cervical]). The perceived lack of risk can result in lesbians avoiding health care, as well as in health care providers giving incorrect advice or not providing appropriate screening for these women. Not all gynecologic cancers are related to sexual activity; lesbians who have never had children may be more at risk for breast, ovarian, and endometrial cancers. Their risk for heart disease, cancer of the lung, and colon cancer is not different from that of the heterosexual woman. To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all patients are heterosexual. More content related to this issue needs to be included in nursing curricula.

Caring for the Well Woman Across the Life Span: The Need for Health Promotion and Disease Prevention Maintaining optimal health is a goal for all women. Essential components of health maintenance are the identification of unrecognized problems and potential risks and the education and health promotion needed to reduce them. Current trends in the health care of women have expanded beyond a reproductive focus. A holistic approach to women's health care goes beyond only reproductive needs and includes a woman's health needs throughout her lifetime, with attention to physical, mental,

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emotional, social, and spiritual health. Women's health is considered to be part of the primary health care delivery system with assessment and screening focusing on a multisystem evaluation that emphasizes the maintenance and enhancement of wellness. Prevention of cardiovascular disease, promotion of mental health, and prevention of cancers beyond just reproductive- related cancers are all components of well-woman care. It is important to consider all aspects of women's health, particularly in light of the fact that the leading causes of death in women in the United States include more than just reproductive health conditions (Box 3.1).

Box 3.1 Top 10 Leading Causes of Death in Women in the United States

1. Heart disease

2. Malignant neoplasm (cancer)

3. Chronic lower respiratory disease

4. Stroke

5. Alzheimer's disease

6. Unintentional injury

7. Diabetes mellitus

8. Influenza and pneumonia

9. Nephritis

10. Septicemia

Data from Centers for Disease Control and Prevention (2015). Leading causes of death in females United States, 2013. Retrieved from http://www.cdc.gov/women/lcod/2013/index.htm.

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Even when focusing on reproductive health, it is critical to take a holistic approach to the health of women. This is especially important for women in their childbearing years because conditions that increase a woman's health risks are related not only to her well- being but also to the well-being of both mother and baby in the event of a pregnancy. Prenatal care is an example of prevention that is practiced after conception. However, prevention and health maintenance are needed before conception because many of the mother's risks can be identified and eliminated, or at least modified.

As a female progresses through developmental ages and stages, she is faced with conditions that are age related. An overview of conditions and circumstances that increase health risks in women across the life span is presented in the next section.

Adolescents All teenagers undergo progressive development of sex characteristics. They experience the developmental tasks of adolescence such as establishing identity and sexual orientation, emancipating from family, and establishing career goals. Some of these processes can produce great stress for the adolescent, and the health care provider should treat her very carefully. Female teenagers who enter the health care system usually do so for screening or because of a problem such as episodic illness or accidents. Previous guidelines recommended that young women should be screened with Pap tests at 18 years of age or when they become sexually active. Current guidelines suggest that Pap tests begin at 21 years of age (Sammarco, 2016), but controversy exists about the evidence to support these new guidelines, with some health care providers advising earlier testing, especially if a woman is sexually active at a younger age. Gynecologic problems are often associated with menses (either bleeding irregularities or dysmenorrhea), vaginitis or leukorrhea, STIs, contraception, or pregnancy. The adolescent is also at risk for use of street drugs, for eating disorders, and for stress, depression, and anxiety.

Many women first enter the health care delivery system for a Pap test or for contraception. Visits to the nurse may be their only contact with the system unless they become ill. Some women

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postpone examination until a specific need arises such as pregnancy, infertility, pain, abnormal bleeding, or vaginal discharge. Recently the availability of the human papillomavirus (HPV) vaccine has created another reason for young women to enter the health care system (Berg, Taylor, & Woods, 2015).

Teenage Pregnancy Most young women begin having sex in the mid- to late teens. The average age at first intercourse is 18 (Guttmacher Institute, 2016), meaning that many begin sexual activity at an earlier age. A sexually active teenager who does not use contraception has a 90% chance of pregnancy within 1 year. The unintended pregnancy rate increased from 48% to 51% between 2001 and 2008, but it has since decreased to 45% based on 2011 data (Guttmacher Institute). The teen pregnancy rate has also decreased, but 77% of teen pregnancies are unplanned (USDHHS, 2016a).

Effective educational programs about sex and family life are imperative to control the rate of teen pregnancy and STIs. The nurse can provide information regarding the need for child spacing, methods of family planning that are consistent with religious and personal preferences, non-contraceptive benefits of certain methods, the appropriate use of methods selected, and the protection of future fertility when so desired.

Pregnancy in the teenager who is 16 years of age or younger often introduces additional stress into an already stressful developmental period. The emotional level of such teenagers is commonly characterized by impulsiveness and self-centered behavior, and they often place primary importance on the beliefs and actions of their peers. In attempts to establish a personal and independent identity, many teenagers do not realize the consequence of their behavior; their thinking processes do not include planning for the future.

Teenagers usually lack the financial resources to support a pregnancy and may not have the maturity to avoid teratogens or seek prenatal care and instruction or follow-up care. Children of teen mothers may be at risk for abuse or neglect because of the teenager's inadequate knowledge of growth, development, and parenting. Implementation of specialized adolescent programs in

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schools, communities, and health care systems is demonstrating continued success in reducing the birth rate in teenagers.

Young and Middle Adulthood Because women 20 to 40 years of age have a need for contraception, pelvic and breast screening, and pregnancy care, they may prefer to use their gynecologic or obstetric provider as their primary care provider. During these years the woman may be “juggling” family, home, and career responsibilities, with resulting increases in stress- related conditions. Health maintenance includes not only pelvic and breast screening but also promotion of a healthy lifestyle (i.e., good nutrition, regular exercise, no smoking, moderate or no alcohol consumption, sufficient rest, stress reduction, and referral for medical conditions and other specific problems). Common conditions requiring well-woman care include vaginitis, urinary tract infections, menstrual variations, obesity, sexual and relationship issues, and pregnancy.

Parenthood After 35 Years of Age The woman older than 35 years of age does not have a different physical response to a pregnancy per se but, rather, has had health status changes as a result of time and the aging process. These changes may be responsible for age-related pregnancy conditions. For example, a woman with type 2 diabetes may not have had expression of her diabetes at 22 years of age but may have full- blown disease at 38 years of age. Other chronic or debilitating diseases or conditions increase in severity with time, and these in turn may predispose to increased risks during pregnancy. Of significance to women in this age group is the risk for certain genetic anomalies (e.g., Down syndrome). The opportunity for genetic counseling should be available to all women (see Chapter 6).

Late Reproductive Age Women of later reproductive age are often experiencing change and reordering personal priorities. In general, the goals of education,

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career, marriage, and family have been achieved and now the woman has increased time and opportunity for new interests and activities. Divorce rates are high at this age, and children leaving home may produce an “empty nest syndrome,” resulting in increased levels of depression. Chronic diseases also become more apparent. Most problems for the well woman are associated with perimenopause (e.g., bleeding irregularities and vasomotor symptoms). Health maintenance screening continues to be of importance because some conditions such as breast disease or ovarian cancer occur more often during this stage.

Approaches to Care at Specific Stages of a Woman's Life There are certain specific approaches to care of women at different stages of their lives. Several of these approaches are described in the next section.

Preconception Counseling and Care Preconception health promotion provides women and their partners with information that is needed to make decisions about their reproductive future. Preconception care guides couples on how to avoid unintended pregnancies, identify and manage risk factors in their lives and their environment, and identify healthy behaviors that promote the well-being of the woman and her potential fetus. It has been estimated that 32% of pregnant women experience some complications of pregnancy, including mental health issues (mostly depression) and factors that lead to the need for cesarean birth (CDC, 2016a). In addition, 9.63% of births result in preterm infants, and 8.07% result in low–birth weight (LBW) infants (Martin, Hamilton, Osterman, et al., 2017).

Activities that promote healthy mothers and babies must be initiated before the period of critical fetal organ development, which is between 17 and 56 days after fertilization. By the end of the eighth week after conception and certainly by the end of the first trimester, any major structural anomalies in the fetus are

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already present. Because many women do not realize that they are pregnant and do not seek prenatal care until well into the first trimester, the rapidly growing fetus may be exposed to many types of intrauterine environmental hazards during this most vulnerable developmental phase. These hazards include drugs, viruses, and chemicals. In many instances, counseling can promote behavior modification before damage is done, or the woman can make an informed decision about her willingness to accept potential hazards.

Preconception care is important for women who have had a problem with a previous pregnancy (e.g., miscarriage or preterm birth). Although causes are not always identifiable, in many cases problems can be discovered and treated and do not recur in subsequent pregnancies. Preconception care is also important to minimize fetal malformations. For example, the offspring of women who have pre-existing diabetes mellitus have significantly more congenital anomalies than do children of mothers without diabetes. The rate of malformation is greatly reduced when the woman with pre-existing diabetes has excellent blood glucose control at the time she becomes pregnant and maintains euglycemia (normal blood glucose level) throughout the period of organ development in the fetus. The incidence of neural tube defects such as spina bifida and anencephaly is decreased significantly with the daily intake of 400 mcg of supplemental folic acid.

The components of preconception care such as health promotion, risk assessment, and interventions are outlined in Box 3.2.

Box 3.2 Components of Preconception Care Health Promotion: General Teaching

• Nutrition

• Healthy diet, including folic acid

• Optimal weight

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• Exercise and rest

• Avoidance of substance abuse (tobacco, alcohol, “recreational” drugs)

• Use of risk-reducing sex practices

• Attending to family and social needs

Risk Factor Assessment

• Chronic diseases

• Diabetes, heart disease, hypertension, asthma, thyroid disease, kidney disease, anemia, mental illness

• Infectious diseases

• HIV/AIDS, other sexually transmitted infections, vaccine-preventable diseases (e.g., rubella, hepatitis B, HPV)

• Reproductive history

• Contraception

• Pregnancies—unplanned pregnancy, pregnancy outcomes

• Infertility

• Genetic or inherited conditions (e.g., sickle cell anemia, Down syndrome, cystic fibrosis)

• Medications and medical treatment

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• Prescription medication use (especially those contraindicated in pregnancy), over-the-counter medication use, radiation exposure

• Personal behaviors and exposures

• Smoking, alcohol consumption, illicit drug use

• Overweight or underweight; eating disorders

• Folic acid supplement use

• Spouse or partner and family situation, including intimate partner violence

• Availability of family or other support systems

• Readiness for pregnancy (e.g., age, life goals, stress)

• Environmental (home, workplace) conditions

• Safety hazards

• Toxic chemicals

• Radiation

Interventions

• Anticipatory guidance or teaching

• Treatment of medical conditions and results

• Medications

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• Cessation or reduction in substance use and abuse

• Immunizations (e.g., rubella, hepatitis)

• Nutrition, diet, weight management

• Exercise

• Referral for genetic counseling

• Referral to and use of:

• Family planning services

• Family and social needs management

Pregnancy A woman's entry into health care is often associated with pregnancy, for either diagnosis or actual prenatal care. Early entry into prenatal care (i.e., within the first 12 weeks of pregnancy) allows for identification of the woman at risk for complications and initiation of measures to prevent problems or treat them if they arise. The US Department of Health and Human Services and the National Institute of Child Health and Human Development (2013) emphasized the importance of early and consistent prenatal care to improve outcomes for both mother and infant. Major goals of prenatal care are listed in Box 3.3 and should be addressed in the first visit. Extensive discussion of pregnancy is found in Unit 3.

Box 3.3 Major Goals of Prenatal Care

• Define health status of mother and fetus.

• Determine the gestational age of the fetus, and monitor fetal development.

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• Identify the woman at risk for complications, and minimize the risk whenever possible.

• Provide appropriate education and counseling.

Fertility Control and Infertility Although the unintended pregnancy rate is slowly decreasing, the problem of unintended pregnancies remains significant (Guttmacher Institute, 2016). The majority of these occur in women who either do not use contraception or who experienced a contraceptive failure. Education is the key to encouraging women to make family planning choices based on preference and actual benefit-to-risk ratios. Providers can influence the user's motivation and ability to use the method correctly (see Chapter 5).

Women also enter the health care system because of their desire to become pregnant. Approximately 12.3% of women in the United States have some degree of infertility (CDC, 2016b). Many couples have delayed starting their families until they are in their 30s or 40s, which allows more time to be exposed to factors that affect fertility negatively (including age-related infertility for the woman). In addition, STIs, which can predispose to decreased fertility, are becoming more common, and many women and men are in workplaces and home settings where they may be exposed to reproductive environmental hazards.

Infertility can cause emotional pain for many couples, and the inability to produce offspring sometimes results in feelings of failure and places inordinate stress on the couple's relationship. Much time, money, and emotional investment can be used for testing and treatment in efforts to build a family.

Steps toward prevention of infertility should be undertaken as part of ongoing routine health care, and information about how women may prevent some causes of infertility is especially appropriate in preconception counseling. Primary care providers can undertake initial evaluation and counseling before couples are referred to specialists. For additional information about infertility, see Chapter 5.

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Menstrual Problems Irregularities or problems with the menstrual period are among the most common concerns of women and often cause them to seek help from the health care system. Common menstrual disorders include amenorrhea, dysmenorrhea, premenstrual syndrome, endometriosis, and menorrhagia or metrorrhagia. Simple explanation and counseling may handle the concern; however, history and examination must be completed, as well as laboratory or diagnostic tests, if indicated. Questions should never be considered inconsequential, and age-specific reading materials are recommended, especially for teenagers. See Chapter 4 for an in- depth discussion of menstrual problems.

Perimenopause The body responds to this natural transition in a number of ways, most of which are caused by the decrease in estrogen. Most women seeking health care during the perimenopausal period do so because of irregular bleeding. Others are concerned about vasomotor symptoms (hot flashes and flushes). Although fertility is greatly reduced during this period, women are urged to maintain some method of birth control because pregnancies still can occur. All women need to have factual information, the dispelling of myths, a thorough examination, and periodic health screenings thereafter.

Identification of Risk Factors to Women's Health In caring for women at all stages of life, it is important to understand the various and complex risk factors that can affect a woman's health. This section describes these risk factors. A thorough and systematic health history can elicit information about risk factors that exist for each woman.

Social, Cultural, and Genetic Factors Differences exist among people from different socioeconomic levels

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and ethnic groups with respect to risk for illness and distribution of disease and death. Some diseases are more common among people of selected ethnicity (e.g., sickle cell anemia in African-Americans, Tay-Sachs disease in Ashkenazi Jews, adult lactase deficiency in Chinese individuals, β-thalassemia in Mediterranean individuals, and cystic fibrosis in northern Europeans). Cultural and religious influences also increase health risks because the woman and her family may have life and societal values and a view of health and illness that dictate practices different from those expected in the Judeo-Christian Western model. These may include food taboos or frequencies, methods of hygiene, effects of climate, care-seeking behaviors, willingness to undergo screening and diagnostic procedures, and conflicts in values.

Socioeconomic status affects birth outcomes. The rates of perinatal and maternal deaths, preterm births, and LBW infants are considerably higher in disadvantaged populations. Social consequences for poor women as single parents are great because many mothers with few skills are caught in the bind of insufficient income to afford child care. These families generate fewer and fewer resources and increase their risks for health problems. Multiple roles for women in general produce overload, conflict, and stress, resulting in higher risks for mental health problems.

Substance Use and Abuse Use of illicit drugs and inappropriate use of prescription drugs continue to increase and are found in all ages, races, ethnic groups, and socioeconomic levels. Addiction to substances is seen as a biopsychosocial disease, with several factors leading to risk. These include biogenetic predisposition, lack of resilience to stressful life experiences, and poor social support. Women are less likely than men to abuse drugs, but the rate in women is increasing significantly. See Chapter 11 for more details about substance use and abuse during pregnancy.

Prescription Drug Use Psychotherapeutic medications such as stimulants, sleeping pills, tranquilizers, and pain relievers are used by an estimated 2.3% of

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American women (Substance Abuse and Mental Health Services Administration, 2015). Such medications can bring relief from undesirable conditions such as insomnia, anxiety, and pain. Because the medications have mind-altering capacity, misuse can produce psychologic and physical dependency in the same manner as illicit drugs. Risk-to-benefit ratios should be considered when such medications are used for more than a very short period. Depression and anxiety are the most common mental health problems in women (depression used to be considered the most common, but recently it is noted that depression occurs comorbidly with anxiety). Many kinds of medications are used to treat depression and anxiety. All of these psychotherapeutic drugs can have some effect on the fetus and must be monitored very carefully.

Illicit Drug Use

Marijuana Marijuana is a substance derived from the cannabis plant. It is usually rolled into a cigarette and smoked, but it also may be mixed into food and eaten. Marijuana produces distorted perceptions, difficulty with problem solving as well as with thinking and memory, altered state of awareness, relaxation, mild euphoria, reduced inhibition, and mood changes (National Institute on Drug Abuse, 2016a). Marijuana is the most frequently used illicit drug, although a number of states have legalized it for recreational use.

Cocaine Cocaine is a powerful central nervous system stimulant that is addictive because of the tremendous sense of euphoria that it creates. It can be snorted, smoked, or injected (National Institute on Drug Abuse, 2016b). Crack or rock cocaine is a form of the drug that is exceedingly potent and even more highly addictive. (Some say that an individual is “hooked” after the first use or at least after two or three “hits.”) After ingestion of cocaine, an intensely pleasurable high results that is followed by an uncomfortable low; this increases the urge to continue taking the drug.

Predisposing factors and problems associated with cocaine use are polydrug use; poor nutrition; poverty; STIs; hepatitis B

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infection; dysfunctional family systems; employment difficulties; stress; anger; poor self-esteem; and previous or present physical, emotional, and sexual abuse. Cocaine use is especially concentrated among poor women of color.

Cocaine affects all major body systems. Among other complications, it produces cardiovascular stress (including tachycardia and hypertension) that can lead to heart attack or stroke, liver disease, central nervous system simulation that can cause seizures, and even perforation of the nasal septum. Needle- borne diseases such as hepatitis B and acquired immunodeficiency syndrome (AIDS) are common among cocaine users.

Opiates The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. Heroin is one of the most commonly abused drugs of this class. It is usually taken by intravenous injection but can be smoked or “snorted.” The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, “nodding out” (apathy, detachment from reality, impaired judgment, and drowsiness), constricted pupils, nausea, constipation, slurred speech, and respiratory depression.

Opiate use has become a priority problem area for the US Department of Health and Human Services with the recognition that prescription drugs, of which some opiates are a part, contribute to this serious abuse of opiates. Drug overdose, much of which occurs due to opiate abuse, is the leading cause of death due to injury (USDHHS, 2016b).

Methamphetamine Methamphetamine is a relatively cheap and highly addictive stimulant. Over the past few years, use of this dangerous drug has decreased. Methamphetamine makes many users feel hypersexual and uninhibited, leading to more sex and less protection from pregnancy and STIs.

The active metabolite of methamphetamine is amphetamine, a central nervous system stimulant known as both “speed” and “meth.” The crystalline form, which is smoked, is known as “ice.” Methamphetamine causes a person to experience an elevated mood

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state as well as increased energy and creates addiction within a short period (Medline Plus, 2016). It can lead to cardiac problems, including irregular heartbeat and hypertension and, over time, can create cognitive and mental as well as dental problems (National Institute on Drug Abuse, 2014). Most of the effects of amphetamines are similar to those of cocaine.

Phencyclidine Phencyclidine (PCP) is a synthetic drug known by various names (“peace pill,” “elephant,” “angel dust,” “hog”). PCP causes a person to experience dissociative symptoms that include distorted perceptions and detached feelings, memory loss, depression, delusions, hallucinations, anxiety, panic, and disordered thinking, and high doses can cause seizures, coma, and possibly death (National Institute on Drug Abuse, 2016c). Because some effects mimic the signs and symptoms of schizophrenia, a user may be admitted to a psychiatric unit.

Other Illicit Drugs A number of street drugs pose risks to users. A few are derived from organic materials, but more and more are produced synthetically in laboratories. Sedatives such as “downers,” “yellow jackets,” or “red devils” are used to come off of “highs.” Hallucinogens alter perceptions and body function. Lysergic acid diethylamide (LSD) produces vivid changes in sensation, often with agitation, euphoria, paranoia, and a tendency toward antisocial behavior. Its use may lead to flashbacks, chronic psychosis, and violent behavior.

Alcohol Consumption Current data estimates that 5.3 million women drink to such an extent that it endangers their health (National Institute on Alcohol Abuse and Alcoholism, 2016). About one-third of alcoholics are women, and many relate the onset of their drinking problem to stressful events. Women who are problem drinkers are often depressed, have more motor vehicle injuries, and have a higher incidence of attempted suicide than do women in the general population. They are also at risk for alcohol-related liver damage.

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Early case finding and treatment are important in alcoholism for both the ill individual and family members.

Cigarette Smoking Tobacco use is the leading cause of preventable death and illness. Smoking is linked to cardiovascular disease, various types of cancers (especially lung and cervical), chronic lung disease, and negative pregnancy outcomes. Premature death is estimated to occur in 480,000 people annually because of either smoking or being exposed to secondhand smoke, with cigarette smoking being the leading cause of preventable deaths. However, it is also estimated that 46.6 million adults in the United States smoke; 14.8% of women are smokers (CDC, 2016c). Women who smoke decrease their life span by 14.5 years compared with nonsmokers, but recent data indicate that the sooner a person quits smoking, the sooner he or she can decrease the risk for early death (American Cancer Society [ACS], 2015). Box 3.4 includes guidelines for smoking cessation.

Box 3.4 Interventions for Smoking Cessation: The Five A's Ask

• What was her age when she started smoking?

• How many cigarettes does she smoke a day? When was her last cigarette?

• Has she tried to quit?

• Does she want to quit?

Advise

• Give her information about the effects of smoking on pregnancy and her fetus, on her own future health, and on the members of her household.

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Assess

• What were her reasons for not being able to quit before, or what made her start again?

• Does she have anyone who can help her?

• Does anyone else smoke at home?

• Does she have friends or family who have quit successfully?

Assist

• Provide support; give self-help materials.

• Encourage her to set a quit date.

• Refer to a smoking-cessation program, or provide information about nicotine replacement products (not recommended during pregnancy) if she is interested.

• Teach and encourage the use of stress-reduction activities.

• Provide for follow-up with a phone call, letter, or clinic visit.

Arrange Follow-up

• Arrange to follow the woman to find out about smoking-cessation status.

• Make a phone call around the time of her quit date. Assess her status at every prenatal visit.

• Congratulate her on her success, or provide support for her if she relapses.

• Referral to intensive treatment may be necessary.

Adapted from Fiore, C. (2012). Tobacco use and dependence: A 2011 update of treatments. Retrieved from http://www.medscape.org/viewarticle/757167 (reviewed May 15, 2016).

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Tobacco contains nicotine, which is an addictive substance that creates physical and psychologic dependence. Recently, alternatives to cigarettes have been used, including electronic cigarettes (e- cigarettes), smokeless tobacco, and water pipes. These alternative methods, however, may cause serious side effects due to the chemicals used in them and may have deleterious effects on the developing fetus (England, Bunnell, Pechacek, et al., 2015).

Cigarette smoking impairs fertility in both women and men, may reduce the age for menopause, and increases the risk for osteoporosis after menopause. Passive, or secondhand, smoke (environmental tobacco smoke) contains similar hazards and presents additional problems for the smoker and harm for the nonsmoker. Smoking during pregnancy may have adverse consequences for the infant, such as low-birth weight.

Caffeine Caffeine is found in society's most popular drinks: coffee, tea, and soft drinks. It is a stimulant that can affect mood and interrupt body functions by producing anxiety and sleep interruptions. Heart dysrhythmias may be made worse by caffeine, and there can be interactions with certain medications such as lithium. Birth defects have not been related to caffeine consumption; however, high intake has been related to a slight decrease in birth weight and may also increase the risk for miscarriage. The March of Dimes (2013) recommends that pregnant women, or women who are trying to conceive, limit their caffeine intake to no more than 200 mg/day, which is the equivalent of one 12-ounce cup of coffee.

Nutrition Problems and Eating Disorders Good nutrition is essential for optimal health. A well-balanced diet helps prevent illness and also is used to treat certain health problems. Conversely, poor eating habits, eating disorders, and obesity are linked to disease and debility. Dietary Guidelines for Americans (Office of Disease Prevention and Health Promotion [ODPHP], 2015) provides evidence-based recommendations to promote health and reduce risks for chronic diseases through diet and physical activity. This guide contains resources for health

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professionals and consumers on dietary guidelines. Previously, the US government advocated the Food Pyramid, followed by MyPlate. The 2015 recommendations include five guidelines: (1) follow a healthy eating pattern across the life span, (2) focus on variety, nutrient density, and amount, (3) limit calories from added sugars and saturated fats, and reduce sodium intake, (4) shift to healthier food and beverage choices, and (5) support healthy eating patterns for all.

In addition to specific guidelines for healthy eating, environmental factors play an important role in nutrition. Environmental factors are part of what is referred to as social determinants of health, in which the availability of resources is a critical factor in nutrition and health.

Nutritional Deficiencies Overt disease caused by a lack of certain nutrients is rarely seen in the United States. However, insufficient amounts or imbalances of nutrients do pose problems for individuals and families. Overweight or underweight status, malabsorption, listlessness, fatigue, frequent colds and other minor infections, constipation, dull hair and nails, and dental caries are examples of problems that can be related to nutrition and indicate the need for further nutritional assessment. Poor nutrition, especially related to obesity and high fat and cholesterol intake, may lead to more serious conditions such as heart diseases, malignant neoplasms, cerebrovascular diseases, and diabetes.

Other dietary extremes also produce risk. For example, insufficient amounts of calcium can lead to osteoporosis, too much sodium can aggravate hypertension, and megadoses of vitamins can cause adverse effects in several body systems. Fad weight-loss programs and yo-yo dieting (repeated and cyclic weight gain and weight loss) result in nutritional imbalances and, in some instances, medical problems. Such diets and programs are not appropriate for weight maintenance. Adolescent pregnancy produces special nutritional requirements because the metabolic needs of pregnancy are superimposed on the teenager's own needs for growth and maturation at a time when eating habits are not ideal. Neural tube defects are more common in infants born to women with a diet

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poor in folate. In their childbearing years, women should ingest at least 0.4 mg (400 mcg) of folic acid daily in addition to consuming a diet rich in folate-containing foods (CDC, 2016d).

Obesity During the past 20 years, obesity has increased dramatically in the United States. More than one third of women in the United States are obese (body mass index [BMI] of 30 or greater), with adults 40 to 59 years of age having the highest prevalence. The BMI is defined as a measure of an adult's weight in relation to his or her height, specifically the adult's weight in kilograms divided by the square of his or her height in meters (Box 3.5). It is estimated that one-third of adults (CDC, 2015a) and one-sixth of children and adolescents are in the obese range (CDC, 2015b). Overweight and obesity are known risk factors for premature death, diabetes, heart disease, stroke, hypertension, type 2 diabetes, gallbladder disease, diverticular disease, some anemias, oral disease, constipation, osteoarthritis, gout, osteoporosis, respiratory dysfunction, sleep apnea, and some types of cancer (uterine, breast, esophageal, colorectal, kidney, and pancreatic) (ACS, 2016a). In addition, obesity is associated with high cholesterol, menstrual irregularities, hirsutism (excess body/facial hair), stress incontinence, depression, complications of pregnancy, increased surgical risk, and shortened life span. Pregnant women who are morbidly obese are at increased risk for hypertension, diabetes, gallbladder disease, postterm pregnancy, and musculoskeletal problems.

Box 3.5 Ideal Body Weight With Body Mass Index

BMI 18.5 or less—Underweight

BMI 18.5 to 24.9—Normal weight

BMI 25.0 to 29.9—Overweight

BMI 30.0 to 34.5—Obese

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BMI 35.0 to 40—Very obese

Source: Centers for Disease Control and Prevention (2015). About adult BMI. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/.

Eating Disorders Eating disorders are estimated to have a prevalence of 20 million women and 10 million men in the United States. Eating disorders are considered a mental illness, and the mortality rate is the highest of all mental illnesses (Sammarco, 2016).

Anorexia nervosa and bulimia are two forms of eating disorders, although there are additional forms, such as binge eating disorders or other specified feeding or eating disorders. Some women, especially adolescents, do not have symptoms that lend themselves to a diagnosis of anorexia nervosa or bulimia, but they do fall under an unspecified category and require accurate diagnosis and prompt treatment (Sammarco, 2016). Eating disorders can affect not only the woman, but her family as well. Treatment must be personalized, including nutritional and behavioral/psychotherapeutic approaches.

It is important to assess for and treat women with eating disorders early because they are at increased risk for serious physical problems as well as diminished quality of life (Sammarco, 2016). Eating disorders during pregnancy are also associated with increased risk to the pregnant woman and her fetus.

Anorexia Nervosa Some women have a distorted view of their bodies and, no matter what their weight, perceive themselves to be much too heavy. As a result, they undertake strict and severe diets and rigorous extreme exercise. This chronic eating disorder is known as anorexia nervosa. Women can carry this condition to the point of starvation, with resulting endocrine and metabolic abnormalities. If not corrected, significant complications of dysrhythmias, amenorrhea, cardiomyopathy, and heart failure occur and, in the extreme, can lead to death. The condition commonly begins during adolescence in young women who have some degree of personality disorder. They gradually lose weight over several months, have amenorrhea,

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and are abnormally concerned with body image. A coexisting depression usually accompanies anorexia.

There are no specific tests to diagnose anorexia nervosa. A medical history, physical examination, and screening tests help identify women at risk for eating disorders. Several tools are available to use in primary care settings. The SCOFF questionnaire, developed by Morgan, Reid, & Lacey (1999) is still in use and is easy to administer and can help the nurse decide whether an eating disorder is likely and whether the woman needs further assessment and possibly psychiatric and medical intervention (Hautala, Junnila, Alin, et al., 2009). See Box 3.6 for a description of the SCOFF.

Box 3.6 Screening for Eating Disorders: SCOFF Questions Each question scores 1 point. A score of 2 or more indicates the person may have anorexia nervosa or bulimia.

1. Do you make yourself Sick (i.e., induce vomiting) because you feel too full?

2. Do you worry about loss of Control over the amount you eat?

3. Have you recently lost more than One stone (6.4 kg [14 lbs]) in a 3-month period?

4. Do you think you are too Fat even if others think you are too thin?

5. Does Food dominate your life?

From Morgan, J., Reid, F., & Lacey, J. (1999). The SCOFF questionnaire: Assessment of a new screening tool for eating disorders, British Medical Journal, 319(7223), 1467–1468.

Bulimia Nervosa Bulimia refers to secret, uncontrolled binge eating alternating with methods to prevent weight gain: self-induced vomiting, laxatives or

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diuretics, strict diets, fasting, and rigorous exercise. During a binge episode, a large number of calories are consumed, usually consisting of sweets and “junk foods.” Binges occur at least twice per week. Bulimia usually begins in early adulthood (18 to 25 years of age) and is found primarily in females. Complications can include dehydration and electrolyte imbalance, gastrointestinal abnormalities, and cardiac dysrhythmias. Unlike those with anorexia, individuals with bulimia may feel shame or disgust about their disorder and tend to seek help earlier. The SCOFF screening assessment also can be used to assess patients with bulimia (see Box 3.6).

Lack of Exercise Exercise contributes to good health by lowering risks for a variety of conditions that are influenced by obesity and a sedentary lifestyle. It is effective in the prevention of cardiovascular disease and in the management of chronic conditions such as hypertension, arthritis, diabetes, respiratory disorders, and osteoporosis (Fig. 3.8). Exercise also contributes to stress reduction and weight maintenance. Women report that engaging in regular exercise improves their body image and self-esteem and acts as a mood enhancer. Aerobic exercise produces cardiovascular involvement because an increased amount of oxygen is delivered to working muscles. Anaerobic exercise such as weight training improves individual muscle mass without stress on the cardiovascular system. Because women are concerned about both cardiovascular and bone health, weight-bearing aerobic exercises such as walking, running, racket sport, and dancing are preferred. However, excessive or strenuous exercise can lead to hormone imbalances, resulting in amenorrhea and its consequences. Physical injury is also a potential risk.

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FIG 3.8 Exercise should be part of one's regular health routine. A cycle class is fun and provides moderate to vigorous exercise. (Courtesy of Shari Rivera Sharpe, Chapel Hill, NC.)

One particular exercise that is important for women is Kegel exercise, or pelvic muscle exercise. This exercise is used to strengthen the muscles that support the pelvic floor and should be practiced regularly. Instructions for this exercise are in presented in the Guidelines box.

Guidelines Kegel Exercise

Description and Rationale Kegel exercise, or pelvic muscle exercise, is a technique used to strengthen the muscles that support the pelvic floor. This exercise involves regularly tightening (contracting) and relaxing the muscles that support the bladder and urethra. By strengthening these pelvic muscles, a woman can prevent or reduce accidental urine loss.

Specific Instructions

1. Each contraction should be as intense as possible without contracting the abdomen, thighs, or buttocks.

2. Contractions should be held for at least 10 seconds. The woman

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may have to start with as little as 2 seconds per contraction until her muscles get stronger.

3. The woman should rest for 10 seconds or more between contractions so that the muscles have time to recover and each contraction can be as strong as the woman can make it.

4. The woman should feel the pulling up over the three muscle layers so that the contraction reaches the highest level of her pelvis.

Data from Sampselle, C. (2003). Behavior interventions in young and middle-aged women: Simple interventions to combat a complex problem, American Journal of Nursing, 103(suppl), 9–19; Sampselle, C. (2000). Behavioral interventions for urinary incontinence in women: Evidence for practice, Journal of Midwifery Women's Health, 45(2), 94–103; Sampselle, C., Wyman, J., Thomas, K., et al. (2000). Continence for women: A test of AWHONN's evidence-based protocol, Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(1), 312–317.

Physical activity and exercise counseling for persons of all ages should be undertaken at schools, work sites, and primary care settings. Specific recommendations include 20 to 30 minutes of moderate activity at least 3 times per week. Few Americans exercise this often, and physical inactivity increases with age, especially during adolescence and early adulthood. Even small increases in activity can be beneficial. During pregnancy, an ongoing exercise regimen can be continued but intensity and duration should be decreased. Sedentary women should obtain medical clearance to initiate exercise during pregnancy and should begin with low- intensity and low-impact workouts.

Stress The modern woman faces increasing levels of stress and, as a result, is prone to a variety of stress-induced complaints and illnesses. Stress often occurs because of multiple roles in which coping with job and financial responsibilities conflicts with parenting and duties at home. To add to this burden, women are socialized to be caregivers, which is emotionally draining, creating additional stress. They also may find themselves in positions of minimal power that do not allow them control over their everyday

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environments. Some stress is normal and contributes to positive outcomes. Many women thrive in busy surroundings. However, excessive or high levels of ongoing stress trigger physical reactions such as rapid heart rate, elevated blood pressure, slowed digestion, release of additional neurotransmitters and hormones, muscle tenseness, and a weakened immune system. Consequently, constant stress can contribute to clinical illnesses such as flare-ups of arthritis or asthma, frequent colds or infections, gastrointestinal upsets, cardiovascular problems, and infertility. Box 3.7 lists symptoms that may be related to chronic or extreme stress. Psychologic symptoms such as anxiety, irritability, eating disorders, depression, insomnia, and substance abuse have also been associated with stress.

Box 3.7 Stress Symptoms Physical

• Perspiration/sweaty hands

• Increased heart rate

• Trembling

• Nervous tics

• Dryness of throat and mouth

• Tiring easily

• Urinating frequently

• Sleeping problems

• Diarrhea, indigestion, vomiting

• Butterflies in stomach

• Headaches

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• Premenstrual tension

• Pain in neck and lower back

• Loss of appetite or overeating

• Susceptibility to illness

Behavioral

• Stuttering and other speech difficulties

• Crying for no apparent reason

• Acting impulsively

• Startling easily

• Laughing in a high-pitched and nervous tone of voice

• Grinding teeth

• Increasing smoking

• Increasing use of drugs and alcohol

• Being accident prone

Psychologic

• Feeling anxious

• Feeling scared

• Feeling irritable

• Feeling moody

• Having low self-esteem

• Being afraid of failure

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• Being unable to concentrate

• Embarrassing easily

• Worrying about the future

• Being preoccupied with thoughts or tasks

• Forgetful

Adapted from State University of New York Counseling Center (2002). Stress management. Buffalo, NY: University of Buffalo, State University of New York.

Because it is neither possible nor desirable to avoid all stress, women must learn how to manage it. The nurse should assess each woman for signs of stress, using therapeutic communication skills to determine risk factors and the woman's ability to function. Some women must be referred for counseling or other mental health therapy. Women experiencing major life changes such as separation and divorce, bereavement, serious illness, and unemployment also need special attention.

Many centers offer support groups to help women prevent or manage stress. Social support and good coping skills can improve a woman's self-esteem and give her a sense of mastery. Anticipatory guidance for developmental or expected situational crises can help her plan strategies for dealing with potentially stressful events. Role playing, relaxation techniques, biofeedback, meditation, desensitization, imagery, assertiveness training, yoga, diet, exercise, and weight control are all techniques nurses can include in their repertoire of helping skills.

Depression, Anxiety, and Other Mental Health Conditions Women experience depression and/or anxiety frequently. Women are twice as likely as men to suffer from anxiety panic attacks and suffer more major depression than men (Anxiety and Depression Association of America, 2016). Nurses must be alert to the symptoms of serious mental disorders such as depression and

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anxiety and make referrals to mental health practitioners when necessary. In addition, depression is sometimes described as a cotraveler because it is exists comorbidly with other physical conditions. Depression and/or anxiety create difficulties for quality of life and, at the extreme, a risk for suicide. Recent research (Cohen, Edmundson, & Kronish, 2014) indicates that persons with comorbid anxiety and depression are at greater risk for developing cardiac disease. In addition to depression and anxiety, women experience other mental health disorders, such as bipolar disease.

Sleep Disorders Many women suffer from sleep disorders, including difficulty initiating sleep or staying asleep and experiencing nonrestorative sleep. During pregnancy and postpartum, many factors can negatively affect sleep, and restless leg syndrome may result. Sleep disorders are correlated with physical and mental health problems, including depression, pain, and fibromyalgia. Women experience sleep and sleep problems at various stages across the life span (Shaver, 2015). It is important that the nurse talk with the woman about her sleep patterns and discuss ways to improve sleep, such as avoiding alcohol before going to sleep and sleeping in a regular pattern.

Environmental and Workplace Hazards Environmental hazards in the home, the workplace, and the community can contribute to poor health at all ages. Categories and examples of health-damaging hazards include the following: (1) pathogenic agents, including viruses, bacteria, fungi, parasites; (2) natural and synthetic chemicals, including natural toxins from animals, insects, and plants, consumer and industrial products such as pesticides and hydrocarbon gases, medical and diagnostic devices, tobacco, fuels, and drug and alcohol abuse; (3) radiation, including radon, heat waves, sound waves; (4) food substances, including added components that are not necessary for nutrition; and (5) physical objects, including moving vehicles, machinery, weapons, water, and building materials.

Environmental hazards can affect fertility, fetal development, live

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birth, and the child's future mental and physical development. Children are at special risk for poisoning from lead found in paint and soil. Everyone is at risk from air pollutants such as tobacco smoke, carbon monoxide, smog, suspended particles (dust, ash, and asbestos), and cleaning solvents; noise pollution; pesticides; chemical additives; and poor preparation of food. Workers also face safety and health risks caused by ergonomically poor work stations and stress. It is important that risk assessments continue to be in effect to identify and understand environmental problems in public health. The March of Dimes (http://www.marchofdimes.org) provides information about various risks posed in the environment to pregnant women and their fetuses.

Risky Sexual Practices Potential risks related to sexual activity include undesired pregnancy and STIs. The risks are particularly high for adolescents and young adults who engage in sexual intercourse at earlier and earlier ages. Adolescents report many reasons for wanting to be sexually active: peer pressure, desire to love and be loved, experimentation, to enhance self-esteem, and to have fun. However, many teenagers do not have the decision-making or values- clarification skills needed to take this important step. They may also lack knowledge about contraception and STIs. Many do not believe that becoming pregnant or getting an STI will happen to them.

Although some STIs can be cured with antibiotics, many cause significant problems. Possible sequelae include infertility, ectopic pregnancy, neonatal morbidity and mortality, genital cancers, AIDS, and even death. Choice of contraceptive method has an impact on the risk for contracting an STI. No method of contraception offers complete protection, unless it is abstinence that is consistently used. (See Chapter 4 for a discussion of STIs and Chapter 5 for a discussion of contraception.)

Prevention of STIs is predicated on the reduction of high-risk behaviors by educating toward a behavioral change. Behaviors of concern include multiple and casual sexual partners and unsafe sexual practices. Specific self-management measures to prevent STIs are listed in Box 3.8. The abuse of alcohol and drugs is a high-

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risk behavior, resulting in impaired judgment and thoughtless acts. Behavioral changes must come from within; therefore the nurse must provide sufficient information for the individual or group to “buy into” the need for change. Education is a powerful tool in health promotion and prevention of STIs and pregnancy. However, it works best when delivered in a way that considers the language, culture, and lifestyle of the intended listener.

Box 3.8 STI and HIV Prevention

• Prevention of STIs and HIV is possible only if there is no oral, genital, or rectal exchange of body fluids or if a person is in a long-term, mutually monogamous relationship with an uninfected partner.

• Correct use of latex condoms, although greatly reducing risk, is not exclusively protective.

• Sexual partners should be selected with great care.

• Partners should be asked about history of STIs.

• Preexposure vaccination is one of the most effective methods for preventing transmission of some STIs (hepatitis A, hepatitis B, human papillomavirus).

• A new condom should be used for each act of sexual intercourse.

• Abstinence from sexual intercourse is encouraged for persons who are being treated for an STI or whose partners are being treated.

STI, Sexually transmitted infection; HIV, human immunodeficiency virus.

Adapted from Workowski,, K.A., & Bolan, G.A. (2015). Sexually transmitted diseases treatment guidelines.Morbidity and Mortality Weekly Report, 64(RR3), 1–127.

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Risk for Certain Medical Conditions Most women of reproductive age are relatively healthy. Heart disease; lung, breast, colon, and other nongynecologic cancers; chronic lung disease; and diabetes are all concerns for adult women because they are among the leading causes of death in women. Certain medical conditions present during pregnancy can have deleterious effects on both the woman and the fetus. Of particular concern are risks from all forms of diabetes, urinary tract disorders, thyroid disease, hypertensive disorders of pregnancy, cardiac disease, and seizure disorders. Effects on the fetus vary and include intrauterine growth restriction, macrosomia, anemia, prematurity, immaturity, and stillbirth. Effects on the woman also can be severe. These conditions are discussed in later chapters.

Risk for Certain Gynecologic Conditions Women are at risk throughout their reproductive years for pelvic inflammatory disease, endometriosis, STIs and other vaginal infections (see Chapter 4), uterine fibroids, uterine deformities such as bicornuate uterus, ovarian cysts, interstitial cystitis, and urinary incontinence related to pelvic relaxation. Uterine deformities, in fact, are conditions that are congenital and are therefore present in some women at times other than the reproductive years. These gynecologic conditions may contribute negatively to pregnancy by causing infertility, miscarriage, preterm labor, and fetal and neonatal problems. Gynecologic cancers also affect women's health, although the risk for most cancers is low in pregnancy. Risk factors depend on the type of cancer. The impact of developing a gynecologic problem or cancer on women and their families is shaped by a number of factors, including the specific type of problem or cancer, the implications of the diagnosis for the woman and her family, and the timing of the occurrence in the woman's and the family's lives.

Female Genital Mutilation Female genital mutilation (FGM), infibulation (surgical closure of the labia majora), and circumcision are terms used to describe procedures

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in which part or all of the female external genitalia is removed for cultural or nontherapeutic reasons (WHO, 2016). These procedures are attempts to control women through controlling their sexuality. FGM is supposed to remove sexual desire so that the girl will not become sexually active until married. FGM is practiced in more than 45 countries, with the majority of these countries being in Africa. As emigrants from these countries arrive in North America, nurses in the United States and Canada will see patients who have had such procedures performed. Although it is illegal in the United States to perform FGM on a person younger than 18 years of age, it is estimated that 513,000 women and girls in the United States have experienced or are at risk for FGM (Office of Women's Health, 2015).

Female circumcision occurs in women of many different ethnic, cultural, and religious backgrounds. Although circumcision is usually performed during childhood, some communities circumcise infants or older females. The procedure involves the removal of a portion of the clitoris but may extend to the removal of the entire clitoris and labia minora. In addition, the labia majora, which are often stitched together over the urethral and vaginal openings, may be affected.

The extent of the circumcision site affects the seriousness of complications. Common complications include bleeding, pain, local scarring, keloid or cyst formation, and infection. Impaired drainage of urine and menstrual blood may lead to chronic pelvic infections, pelvic and back pain, and chronic urinary tract infections. Some women may require surgery before vaginal examination, intercourse, or childbirth if the vaginal opening is obstructed.

FGM in the United States is punishable by fines, imprisonment, and deportation. An obstetric care provider may incise the closed labia to deliver a baby or remove cysts but may not sew the labia back to its previous state, reinfibulation. If performed on a minor, FGM is considered child abuse in the United States. FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. FGM is nearly always carried out on minors and it is a violation of the rights of children. The practice also violates a person's rights to

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health, security, and physical integrity; the right to be free from torture and cruel, inhuman, or degrading treatment; and the right to life when the procedure results in death (WHO, 2016).

Nurses are providing care to a growing number of women who have emigrated from the Middle East, Asia, and Africa, where female circumcision is more common. Nurses must be sensitive to the unique needs of these patients, especially if these women have concerns about maintaining or restoring the intactness of the circumcision after childbirth.

Human Trafficking Human trafficking is actually a form of slavery in which people are forced into the United States in order to become part of the unpaid labor force, usually in sweatshops or in domestic work, or in order to serve as sex slaves (Green, 2016). The majority of these trafficking slaves are women and children, and many women have some interaction with health care providers. Thus, the implications for nursing are that it is imperative that signs of trafficking are recognized so that appropriate care can be delivered. In fact, it is mandatory that nurses report any suspected minor (younger than 18 years of age) human trafficking victims. Green (2016) recommended asking simple “yes” or “no” questions in order to screen for suspected trafficking (Box 3.9). Certain findings on history are also indicative of possible trafficking (see “History” section later in this chapter).

Box 3.9 Screening for Victims of Human Trafficking If human trafficking is suspected, the nurse should ask simple questions that are not threatening and that mostly require a “yes” or “no” response, as follows:

• Is the place where you sleep clean?

• Do you have enough food?

• Have you been threatened or harmed physically? Has your

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family been threatened?

• Are you free to talk to people outside of your home or job?

• Are you free to come and go as you please?

• Are you ever forced to have sex?

• Are you ever forced to work?

• Where are you from?

• How did you get here?

• Do you know where you are now?

• Do you have money? If you earn money, do you keep it? Or are you forced to give it to someone?

• Do you have identification papers?

Adapted from Green, C. (2016). Human trafficking: Preparing for a unique patient population. American Nurse Today, 11(1), 9–12.

Intimate Partner Violence Intimate partner violence (IPV) is the most common form of violence experienced by women worldwide, with a reported incidence of one of every six women having been a victim of domestic violence. In the United States, IPV is a significant social problem and a major health care problem that affects millions of women and men each year and costs millions of dollars. The US Department of Justice, Office on Violence Against Women (2015) describes violence and abuse as including one or more of the following: physical, sexual, emotional, economic, and psychologic factors. One in four women in the United States has experienced severe physical violence by a current or former intimate partner. In addition, 5.2 million women were victimized by stalkers. It is estimated that 18.3% of women in the United States are raped at some point in their lives. It is also important to note that sometimes

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IPV is committed by women against men. Statistics are not clear, as there is much inconsistency in reporting of IPV (Sammarco, 2016).

Although IPV is the preferred term, wife battering, spousal abuse, and domestic or family violence are also terms that may be applied to a pattern of assaultive and coercive behaviors inflicted by a male partner in a marriage or other heterosexual, significant, intimate relationship. Because IPV is common, with women being abused frequently, routine assessment of violence against women should be included in primary care histories. Common elements of IPV are physical abuse; psychologic or emotional abuse; sexual assault; isolation; and controlling all aspects of the victim's life, including money, shelter, time, and food.

Battering is neither random nor constant; rather, it occurs in repeated cycles. Health care providers often refer to the “cycle of violence” (Fig. 3.9). A three-phase cycle includes a period of increasing tension leading to the battery. The battery consists of slaps, punches to the face and head, kicking, stomping, choking, pushing, breaking of bones, burns from irons, and mutilations from knives and guns. The honeymoon phase is characterized by a period of calm and remorse in which the male partner displays kind, loving behavior and pleas for forgiveness. This honeymoon phase lasts until stress or other factors cause conflict and tension to mount again toward another episode of battering. Over time, the tension and battering phases last longer and the calm phase becomes shorter until there is no honeymoon phase.

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FIG 3.9 Cycle of violence.

Because violence against women crosses all ethnic, educational, religious, and socioeconomic backgrounds and there are often misconceptions regarding who is at risk for being abused, it is important to differentiate myths from facts about this serious and often devastating condition.

Battering During Pregnancy Estimates of prevalence of battering in pregnancy vary, but it is estimated that 300,000 pregnant women annually are affected by intimate partner violence (Domestic Shelters, 2017). Most women abused before pregnancy will be abused during pregnancy, and the incidence may escalate. Abuse also may happen for the first time during pregnancy. Pregnant adolescents are abused at higher rates than are adult women; thus they should be considered at high risk. Battering during pregnancy in teenagers constitutes a particularly difficult situation. Adolescents may be more trapped in the abusive relationship than adult women because of their inexperience. They may ignore the violence because the jealous and controlling behavior is interpreted as love and devotion. Because pregnancy in young adolescent girls is frequently the result of sexual abuse, feelings about the pregnancy should be assessed.

During pregnancy, the nurse should assess for abuse at each prenatal visit and for labor and birth. Battering episodes initiate or

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increase in pregnancy for a variety of reasons: (1) the biopsychosocial stresses of pregnancy may strain the relationship beyond the couple's ability to cope, and frustration is followed by violence; (2) the man may be jealous of the fetus, resenting the intrusion into the couple's relationship and the woman's displacement of attention; (3) the man may be angry at the unborn child or the woman; and (4) the beating may be the man's conscious or subconscious attempt to end the pregnancy. After birth, the mother may be so physically and emotionally drained that she may have difficulty bonding with her infant. She may be at risk for becoming an abusive mother whether or not she remains in the abusive relationship.

A pregnant woman is often accompanied by a male partner to the prenatal appointment, especially if the woman does not speak English and the partner does. Unless an interpreter is available, it is difficult to interview the woman alone; in addition, asking questions about abuse through an interpreter is more difficult unless the interpreter is a woman and can communicate the nurse's sensitivity and concern accurately.

It is imperative that the woman has knowledge of resources available to her and a plan of action if she stays with the battering partner. First, the nurse should provide services and telephone numbers of a hotline and the battered women's shelter or other safe haven. The woman can be offered use of a telephone to call the shelter if this is an option she chooses. If she chooses to go back to the abuser, a safety plan includes necessities for a quick escape: a bag packed with personal items for an overnight stay (can be hidden or left with a neighbor), money or a checkbook, an extra set of car keys, and any legal documents for identification. Legal options such as those for restraining orders or arrest of the perpetrator also are important aspects of the safety plan. A restraining order can be obtained from the county court or police department 24 hours a day. Shelters also can be helpful with assistance in obtaining orders of protection. If the woman chooses not to act in the middle of a violent episode, she may use the hotline or shelter for some counseling when the threat of harm is no longer present.

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Legal Tip Reporting Requirements for Domestic Violence

Domestic violence is considered a crime in all states, but it varies by state between being a misdemeanor or a felony offense; in the majority of states, domestic violence is a misdemeanor. Forty states and the District of Columbia have laws that mandate reporting by health care providers in situations in which the woman has an injury that may be caused by a deadly weapon. Some states also require reports when there is a reason to believe that the woman's injury may have resulted from an illegal act or act of violence. Because of the wide variation from state to state in mandatory reporting, nurses must be knowledgeable about the reporting requirements of the state in which they practice.

Spiritual Approaches to Women's Health Promotion Many women find that spirituality is helpful in maintaining wellness as well as coping with illness. Spirituality refers to the essence of our being and humanity, reflected in a connection to a Sacred Source (Burkhardt & Nagai-Jacobson, 2013). The concept of Sacred Source is experienced in different ways, with some experiencing it as a person, some as a presence, and some as a nondescribable mystery (Burkhardt & Nagai-Jacobson). The idea of connection is important, and experiencing this connection in a sacred space is central to spirituality. Spirituality may be experienced within a context of organized religion. Nurses, taking a holistic approach to women's wellness, must be sensitive and nonjudgmental to the spiritual aspect of their patients. In an optimal healing approach to care, nurses can facilitate and encourage the patient to express her spirituality in a way that is comfortable for the patient.

Assessment of the Woman: History

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and Physical Examination Trends in women's health have expanded beyond a reproductive focus to include a holistic approach to health care across the life span and place women's health within the scope of primary care. Women's health assessment and screening focus on a systems evaluation that begins with a careful history and physical examination. During assessment and evaluation, the responsibility for self-management, health promotion, and enhancement of wellness is emphasized.

In a market-driven system such as managed care, specific guidelines may be provided for health screening by the insurer or the managed care organization. A nurse often takes the history, orders diagnostic tests, interprets test results, makes referrals, coordinates care, and directs attention to problems requiring medical intervention. Advanced practice nurses who have specialized in women's health such as nurse practitioners, clinical nurse specialists, and nurse-midwives perform complete physical examinations, including gynecologic examinations.

History Contact with the woman usually begins with an interview, which is an integral part of the history. This interview should be conducted in a private, relaxed setting (Fig. 3.10). The nurse is seated and makes sure that the woman is comfortable. The woman is addressed by her title and name (e.g., Mrs. Martinez), and the nurse introduces herself or himself using name and title. It is important to phrase questions in a sensitive and nonjudgmental manner. Body language should match oral communication. The nurse is aware of a woman's vulnerability and assures her of strict confidentiality. For many women, fear, anxiety, and modesty make the physical examination a dreaded and stressful experience. Many women are uninformed, misguided by myths, or afraid they will appear ignorant by asking questions about sexual or reproductive functioning. The woman is assured that no question is irrelevant.

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FIG 3.10 Nurse interviews a woman as part of routine history and physical examination. (Courtesy of Ed Lowdermilk,

Chapel Hill, NC.)

The history begins with an open-ended question such as “What brings you to the office/clinic/hospital today?” and is furthered by other questions such as “Is there anything else?” and “Tell me about it.” Additional ways to encourage women to share information include the following:

Facilitation: Using a word or posture that communicates interest such as leaning forward, making eye contact, or saying “Mm- hmmm” or “Go on”

Reflection: Repeating a word or phrase that a woman has used

Clarification: Asking the woman what is meant by a stated word or phrase

Empathic responses: Acknowledging the feelings of a woman by statements such as “That must have been frightening”

Confrontation: Identifying something about the woman's behavior or feelings not expressed verbally or apparently inconsistent with her history

Interpretation: Putting into words what you infer about the

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woman's feelings or about the meaning of her symptoms, events, or other matters

Nurses need to develop rapport and trust with their patients as they take a history. Because communication within a caring context is core to nursing practice, nurses are well suited to taking a comprehensive patient history. Nurses should ask questions incrementally to build a comprehensive understanding. They should also share insights with the woman by eliciting her concerns or thoughts as well as offering clarification to her. Trust is a key aspect of the nurse-patient relationship, and it is critical that nursing approaches to establishing trust are developed and respected by the entire team (Rortveit, Hansen, Leiknes, et al., 2015).

At a woman's first visit, she is often expected to fill out a form with biographic and historical data before meeting with the examiner. This form aids the health care provider in completing the history during the interview. Most forms include information about the following categories: • Biographic data • Reason for seeking care • Present health or history of present illness • Past health • Family history • Screening for abuse (Fig. 3.11)

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FIG 3.11 Screening for intimate partner violence. (Adapted from American College of Obstetricians and Gynecologists [ACOG]

[2012]. Are you being abused? Screening tool for domestic violence. Retrieved

from

www.acog.org/About_ACOG/ACOG_Departments/Violence_Against_Women/Are_you_being_abused

Nursing Research Consortium on Violence and Abuse [1991].)

• Review of systems • Functional assessment (activities of daily living)

Box 3.10 describes a complete health history based on the categories just mentioned.

Box 3.10 Health History and Review of Systems

Identifying data: Name, age, race, sex, marital status, occupation, religion, and ethnicity

Reason for seeking care: A response to the question, “What problem or symptom brought you here today?” More than one reason? Focus on the one she thinks is most important.

Present health: Current health status is described with attention to

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the following:

• Use of safety measures: seat belts, bicycle helmets, designated driver

• Exercise and leisure activities: regularity

• Sleep patterns: length and quality

• Sexuality: Is she sexually active? With men, women, or both? Risk-reducing sex practices?

• Diet, including beverages: 24-hour dietary recall

• Nicotine, alcohol, illicit or recreational drug use: type, amount, frequency, duration, and reactions

• Environmental and chemical hazards: home, school, work, and leisure setting; exposure to extreme heat or cold, noise, industrial toxins such as asbestos or lead, pesticides, radiation, cat feces, or cigarette smoke

History of present illness: A chronologic narrative of the problem that includes a description of the following: location, quality or character, quantity or severity, timing (onset, duration, frequency), setting, factors that aggravate or relieve, associated factors, and woman's perception of the meaning of the symptom

Past health:

• Infectious diseases: e.g., measles, mumps, rubella, tuberculosis (TB), hepatitis, sexually transmitted infections (STIs)

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• Chronic disease and system disorders: e.g., arthritis, cancer, diabetes, heart, lung, kidney

• Adult injuries, accidents

• Hospitalizations, operations, blood transfusions

• Obstetric history

• Allergies: medications, previous transfusion reactions, environmental allergies

• Immunizations: e.g., diphtheria, pertussis, tetanus, mumps, rubella, influenza hepatitis A, hepatitis B, HPV

• Last date of screening tests: e.g., Pap test, mammogram, cholesterol test

• Current medications: name, dose, frequency, duration, reason for taking, and compliance with prescription medications; home remedies, over-the- counter drugs, vitamin and mineral or herbal supplements used

Family history: Information about the ages and health of family members. Check for history of diabetes, heart disease, or other chronic disorders.

Screen for abuse: Has she ever been hit, kicked, slapped, or forced to have sex against her wishes? Verbally or emotionally abused? History of childhood sexual abuse? If yes, has she received counseling or does she need referral?

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Review of systems: It is probable that all questions in each system will not be included every time a history is taken. The essential areas to be explored are listed in the following head-to-toe sequence. If a woman gives a positive response to a question about an essential area, more detailed questions should be asked.

• General: weight change, fatigue, weakness, fever, chills, or night sweats

• Skin: skin, hair, and nail changes; itching, bruising, bleeding, rashes, sores, lumps, or moles

• Lymph nodes: enlargement, inflammation, pain, or drainage

• Head: trauma, vertigo (dizziness), convulsive disorder, syncope (fainting); headache: location, frequency, pain type, nausea and vomiting, or visual symptoms present

• Eyes: glasses, contact lenses, blurriness, tearing, itching, photophobia, diplopia, inflammation, trauma, cataracts, glaucoma, or acute visual loss

• Ears: hearing loss, tinnitus (ringing), vertigo, discharge, pain, fullness, recurrent infections, or mastoiditis

• Nose and sinuses: trauma, rhinitis, nasal discharge, epistaxis, obstruction, sneezing, itching, allergy, or smelling impairment

• Mouth, throat, and neck: hoarseness, voice changes,

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soreness, ulcers, bleeding gums, goiter, swelling, or enlarged nodes

• Breasts: masses, pain, lumps, dimpling, nipple discharge, fibrocystic changes, or implants; breast self-examination practice

• Respiratory: shortness of breath, wheezing, cough, sputum, hemoptysis

• Cardiovascular: hypertension, rheumatic fever, murmurs, angina, palpitations, dyspnea, tachycardia, orthopnea, edema, chest pain, cough, cyanosis, cold extremities, ascites, phlebitis, or skin color changes

• Gastrointestinal: appetite, nausea, vomiting, indigestion, dysphagia, abdominal pain, ulcers, bleeding with stools or black, tarry stools, diarrhea, constipation, bowel movement frequency, food intolerance, hemorrhoids, jaundice, or hepatitis

• Genitourinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection, or urethral discharge; menstrual history, dyspareunia, discharge, sores, itching

• Sexual health and sexual activity: with men, women, or both; contraceptive use; sexually transmitted infections

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• Peripheral vascular: coldness, numbness and tingling, leg edema, varicose veins, thromboses, or emboli

• Endocrine: heat and cold intolerance, dry skin, excessive sweating, polyuria, polydipsia, polyphagia, thyroid problems, diabetes, or secondary sex characteristic changes

• Hematologic: anemia, easy bruising, bleeding, petechiae, purpura, or transfusions

• Musculoskeletal: muscle weakness, pain, joint stiffness, scoliosis, lordosis, kyphosis, range-of- motion, instability, redness, swelling, arthritis, or gout

• Neurologic: loss of sensation, numbness, tingling, tremors, weakness, vertigo, paralysis, fainting, twitching, blackouts, seizures, convulsions, loss of consciousness or memory

• Mental status: moodiness, depression, anxiety, obsessions, delusions, illusions, or hallucinations

• Functional assessment: ability to care for self

Nurses should screen all women entering the health care system for abuse. Abuse is a life-threatening public health problem that affects millions of women and their children. The risk for intimate partner violence increases during pregnancy and after separation or divorce. Help for the woman may depend on the sensitivity with which the nurse screens for abuse, the discovery of abuse, and subsequent intervention. The nurse must be familiar with the laws

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governing abuse in the state in which she or he practices. It also is important that the nurse is alert to any indication from

the woman that she is being abused, despite the fact that she may not have specifically stated that she is in an abusive relationship. Box 3.11 provides a list of signs of IPV. If a male partner is present, he should be asked to leave the room because the woman may not disclose experiences of abuse in his presence, or he may try to answer questions for her to protect himself. The same procedure applies to partners of lesbians or the adult children of older women.

Box 3.11 Signs of Intimate Partner Violence

• Overuse of health services

• Vague, nonspecific complaints

• Chronic pain

• Depression, anxiety

• Missed appointments

• Unexplainable injuries or bruising

• Nonadherence to treatment

• Untreated serious injuries

• Injuries not matching the description

• Intimate partner never leaving the patient's side

• Intimate partner insisting on telling the story of the injury

From American College of Physicians (2016). Asking right questions key to detecting abuse. From Berthold, J. (2009). Posted on ACP website in 2016. Retrieved from http://www.acpinternist.org/archives/2009/03/abuse.htm

There is no universally accepted screening tool for all populations

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regarding IPV. The Guidelines Box presents a suggested list of questions to screen for IPV.

A therapeutic relationship and skillful interviewing help women disclose and describe their abuse. Language is important when talking with women. For example, using the term victim connotes powerlessness and hopelessness; a more empowering term is survivor. Women who have identified their abuse may appear passive, hostile, anxious, depressed, or hysterical because they may think they are at the mercy of the man's temper or that he is “out of control.” In addition, they may be embarrassed, afraid, angry, sad, and shocked.

Guidelines Communicating With Abused Women

What Not to Say

1. Do not ask “why.” This question “revictimizes” and blames the victim.

2. Do not talk negatively about the abuser to the victim. She may become defensive and stop talking.

3. Do not talk directly to the abuser about your suspicions of abuse. The abuser will assume the victim told you, and the victim risks retaliation.

What to Say

1. “I'm afraid for your safety (and the safety of your children).”

2. “I believe you.”

3. “It is progressive and will only get worse.”

4. “You deserve better than this. You deserve to be treated with respect.”

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5. “You are not alone.”

6. “It is a crime.”

7. “I'm here for you.”

What to Do

1. Empower the victim.

2. Sit down with her.

3. Assure her of total privacy and confidentiality (but only if you can).

4. Use your best listening skills.

5. Call 911 and report any incident of imminent danger.

6. Give the woman the telephone number of the nearest battered women's shelter.

Questions adapted from American College of Obstetricians and Gynecologists (2012). Committee option No. 518. Intimate partner violence. Obstetrics and Gynecology, 119, 412– 417.

Pocket cards listing emergency numbers (abuse counseling, legal protection, and emergency shelter) can be obtained from local police departments, women's shelters, or emergency departments. It is helpful to have these on hand in the setting where screening is done.

Human trafficking is another important situation to which the nurse should be alert in the history. Signs that a woman may be a victim of human trafficking include demonstrating an exaggerated startle response, appearing to be very anxious and/or panicked, having a flat affect and social withdrawal/difficulty or refusing to engage in conversation, or showing signs of alcohol or dug abuse. These signs require further investigation (Green, 2016).

Physical Examination

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In preparation for the physical examination, the woman is instructed to undress and she is given a gown to wear during the examination. She is usually given the opportunity to undress privately. Objective data are recorded by system or location. A general statement of overall health status is a good way to start. Findings are described in detail. • General appearance: age, race, sex, state of health, posture,

height, weight, development, dress, hygiene, affect, alertness, orientation, cooperativeness, and communication skills

• Vital signs: temperature, pulse, respirations, blood pressure • Skin: color; integrity; texture; hydration; temperature; edema;

excessive perspiration; unusual odor; presence and description of lesions; hair texture and distribution; nail configuration, color, texture, and condition; presence of nail clubbing

• Head: size, shape, trauma, masses, scars, rashes, or scaling; facial symmetry; presence of edema or puffiness

• Eyes: pupil size, shape, reactivity, conjunctival injection, scleral icterus, fundal papilledema, hemorrhage, lids, extraocular movements, visual fields and acuity

• Ears: shape and symmetry, tenderness, discharge, external canal, and tympanic membranes; hearing—Weber should be midline (loudness of sound equal in both ears) and Rinne negative (no conductive or sensorineural hearing loss); should be able to hear whisper at 3 feet

• Nose: symmetry, tenderness, discharge, mucosa, turbinate inflammation, frontal or maxillary sinus tenderness; discrimination of odors

• Mouth and throat: hygiene; condition of teeth; dentures; appearance of lips, tongue, buccal and oral mucosa; erythema; edema; exudate; tonsillar enlargement; palate; uvula; gag reflex; ulcers

• Neck: mobility, masses, range of motion, tracheal deviation, thyroid size, carotid bruits

• Lymphatic: cervical, intraclavicular, axillary, trochlear, or inguinal adenopathy; size, shape, tenderness, and consistency

• Breasts: skin changes, dimpling, symmetry, scars, tenderness,

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discharge, masses; characteristics of nipples and areolae • Heart: rate, rhythm, murmurs, rubs, gallops, clicks, heaves, or

precordial movements • Peripheral vascular: jugular vein distention, bruits, edema,

swelling, vein distention, Homans' sign, or tenderness of extremities

• Lungs: chest symmetry with respirations, wheezes, crackles, rhonchi, vocal fremitus, whispered pectoriloquy, percussion, and diaphragmatic excursion; breath sounds equal and clear bilaterally

• Abdomen: shape, scars, bowel sounds, consistency, tenderness, rebound, masses, guarding, organomegaly, liver span, percussion (tympany, shifting, dullness), or costovertebral angle tenderness

• Extremities: edema, ulceration, tenderness, varicosities, erythema, tremor, or deformity

• Genitourinary: external genitalia, perineum, vaginal mucosa, cervix; inflammation, tenderness, discharge, bleeding, ulcers, nodules, or masses; internal vaginal support, bimanual and rectovaginal palpation of cervix, uterus, and adnexa

• Rectal: sphincter tone, masses, hemorrhoids, rectal wall contour, tenderness, and stool for occult blood

• Musculoskeletal: posture, symmetry of muscle mass, muscle atrophy, weakness, appearance of joints, tenderness or crepitus, joint range of motion, instability, redness, swelling, or spinal deviation

• Neurologic: mental status, orientation, memory, mood, speech clarity and comprehension, cranial nerves II to XII, sensation, strength, deep tendon and superficial reflexes, gait, balance, and coordination with rapid alternating motions

Cultural Considerations and Communication Variations in the History and Physical Recognizing signs and symptoms of disease and deciding to seek treatment are influenced by cultural perceptions. Culture evolves over time and is a system of symbols that are learned, shared, and passed on through generations of a social group. In recognizing the

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value of these differences, the nurse can modify the plan of care to meet the needs of each woman. Modifications may be necessary for the physical examination. In many cultures, a woman examiner is preferred. In some cultures, it may be considered inappropriate for the woman to disrobe completely for the physical examination. Communication may be hindered by cultural beliefs, even when the nurse and woman speak the same language.

History and Physical Examination in Women With Disabilities Women with emotional or physical disorders have special needs. Women who have vision, hearing, emotional, or physical disabilities should be respected and involved in the assessment and physical examination to the full extent of their capabilities. The nurse should communicate openly, directly, and with sensitivity. It is often helpful to learn about the disability directly from the woman while maintaining eye contact. Family and significant others should be relied on only when necessary. The assessment and physical examination can be adapted to each woman's individual needs.

Communication with a woman who is hearing-impaired can be accomplished without difficulty. Many of these women can read lips, write, or both. The interviewer who speaks and enunciates each word slowly and in full view may be easily understood. If a woman is not comfortable with lip reading, she may use an interpreter. In this case, it is important to continue to address the woman directly, avoiding the temptation to speak directly with the interpreter.

The visually impaired woman needs to be oriented to the examination room and may have her guide dog with her. As with all patients, the visually impaired woman needs a full explanation of what the examination entails before proceeding. Before touching her, the nurse explains, “Now I am going to take your blood pressure. I am going to place the cuff on your right arm.” The woman can be asked if she would like to touch each of the items that will be used in the examination to reduce her anxiety.

Many women with physical disabilities cannot comfortably lie in

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the lithotomy position for the pelvic examination. Several alternative positions may be used, including a lateral (side-lying) position, a V-shaped position, a diamond-shaped position, and an M-shaped position (Fig. 3.12). The woman can be asked what has worked best for her previously. If she has never had a pelvic examination or has never had a comfortable pelvic examination, the nurse proceeds slowly by showing her a picture of various positions and asking her which one she prefers. The nurse's support and reassurance can help the woman relax, which will make the examination go more smoothly.

FIG 3.12 Lithotomy and variable positions for women who have a disability. A, Lithotomy position. B, M-

shaped position. C, Side-lying position. D, Diamond- shaped position. E, V-shaped position.

History and Physical Examination in Adolescent Girls (13 to 19 Years of Age)

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As a young woman matures, she should be asked the same questions that are included in any history. Particular attention should be paid to hints about risky behaviors, eating disorders, and depression. Sexual activity is addressed after rapport has been established. It is best to talk to a teenager with the parent (or partner or friend) out of the room. The nurse should engage with the patient in a sensitive manner, using active listening and conveying a nonjudgmental stance.

Injury prevention should be a part of the counseling at routine health examinations, with special attention to seat belts, helmets, firearms, recreational hazards, and sports involvement. The use of drugs and alcohol and the nonuse of seat belts contribute to motor vehicle injuries, accounting for a significant proportion of accidental deaths in women. Contraceptives/STI prevention information may be needed for teenagers who are sexually active.

To provide developmentally appropriate care, it is important to review the major tasks for women in this stage of life. Major tasks for teenagers include values assessment; education and work goal setting; formation of peer relationships that focus on love, commitment, and becoming comfortable with sexuality; and separation from parents. The teenager is egocentric as she progresses rapidly through emotional and physical change. Her feelings of invulnerability may lead to misconceptions such as the belief that unprotected sexual intercourse will not lead to pregnancy.

Pelvic Examination Many women fear the gynecologic portion of the physical examination. The nurse can be instrumental in allaying these fears by providing information and assisting the woman to express her feelings to the examiner.

The woman is assisted into the lithotomy position (see Fig. 3.12, A) for the pelvic examination. When she is in the lithotomy position, the woman's hips and knees are flexed, with buttocks at the edge of the table, and her feet are supported by heel or knee stirrups.

Some women prefer to keep their shoes or socks on, especially if

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the stirrups are not padded. Many women express feelings of vulnerability and strangeness when in the lithotomy position. During the procedure, the nurse assists the woman with relaxation techniques (Box 3.12).

Box 3.12 Nurse's Role in Assisting With Pelvic Examinations

1. Wash hands. Assemble equipment (see illustration below).

2. Ask woman to empty her bladder before the examination (obtain clean-catch urine specimen as needed).

3. Assist with relaxation techniques. Have the woman place her hands on her chest at about the level of the diaphragm and breathe deeply and slowly.

4. Encourage the woman to become involved with the examination if she shows interest. For example, a mirror can be placed so that she can see the area being examined.

5. Assess for and treat signs of problems such as supine hypotension.

6. Warm the speculum in warm water if a prewarmed one is not available.

7. Instruct the woman to bear down when the speculum is being inserted.

8. Apply gloves and assist the examiner with collection of specimens for cytologic examination, such as a Pap test. After handling specimens, remove gloves and wash hands.

9. Lubricate the examiner's fingers with water or water-soluble lubricant before bimanual examination.

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10. Assist the woman at completion of the examination to a sitting position and then a standing position.

11. Provide tissues to wipe lubricant from perineum.

12. Provide privacy for the woman while she is dressing.

Many women find it distressing to attempt to converse in the lithotomy position. Most women appreciate an explanation of the procedure as it unfolds, as well as coaching for the type of sensations they may expect. Generally, however, women prefer not to have to respond to questions until they are again upright and at eye level with the examiner. Being asked questions during the procedure, especially if they cannot see their questioner's eyes, may make women tense.

A teenager's first speculum examination is the most important because she will develop perceptions that will remain with her for future examinations. What the examination entails should be discussed with the teenager while she is dressed. Models or illustrations can be used to show exactly what will happen. All of the necessary equipment should be assembled so there are no interruptions. Pediatric specula that are 1 to 1.5 cm wide can be inserted with minimal discomfort. If the teenager is sexually active, a small adult speculum may be used.

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External Inspection The examiner wears gloves and sits at the foot of the table for the inspection of the external genitalia and the speculum examination. In good lighting, external genitalia are inspected for sexual maturity, clitoris, labia, perineum, and lesions indicative of STIs. After childbirth or other trauma, healed scars may be present.

External Palpation Before touching the woman, the examiner explains what is going to be done and what the woman should expect to feel (e.g., pressure). The examiner may touch the woman in a less sensitive area such as the inner thigh to alert her that the genitalia examination is beginning. This gesture may put the woman more at ease. The labia are spread apart to expose the structures in the vestibule: urinary meatus, Skene glands, vaginal orifice, and Bartholin glands (Fig. 3.13). To assess Skene glands, the examiner inserts one finger into the vagina and “milks” the area of the urethra. Any exudate from the urethra or the Skene glands is cultured. Masses and erythema of either structure are assessed further. Ordinarily the openings to the Skene glands are not visible; prominent openings may be seen if the glands are infected (e.g., with gonorrhea). During the examination, the examiner keeps in mind the data from the review of systems such as history of burning on urination.

FIG 3.13 External examination: separation of the labia.

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(From Wilson, S. F., & Giddens, J. F. [2013]. Health assessment for nursing

practice (5th ed.). St. Louis, MO: Mosby.)

The vaginal orifice is examined. Hymenal tags are normal findings. With one finger still in the vagina, the examiner repositions the index finger near the posterior part of the orifice. With the thumb outside the posterior part of the labia majora, the examiner compresses the area of Bartholin glands located at the 8 o'clock and 4 o'clock positions and looks for swelling, discharge, and pain.

The support of the anterior and posterior vaginal wall is assessed. The examiner spreads the labia with the index and middle finger and asks the woman to strain down. Any bulge from the anterior wall (urethrocele or cystocele) or posterior wall (rectocele) is noted and compared with the history, such as difficulty starting the stream of urine or constipation.

The perineum (area between the vagina and anus) is assessed for scars from old lacerations or episiotomies, thinning, fistulas, masses, lesions, and inflammation. The anus is assessed for hemorrhoids, hemorrhoidal tags, and integrity of the anal sphincter. The anal area is also assessed for lesions, masses, abscesses, and tumors. If there is a history of STI, the examiner may want to obtain a culture specimen from the anal canal at this time. Throughout the genital examination, the examiner notes any odor, which may indicate infection or poor hygiene.

Vulvar Self-Examination The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self- examination (VSE) and to teach this procedure. Because there has been a dramatic increase in cancerous and precancerous conditions of the vulva in recent years, VSE should be an integral part of preventive health care for all women (ACS, 2016b). VSE should be performed monthly between menses or more often if there are symptoms or a history of serious vulvar disease. Most lesions, including malignancy, condyloma acuminatum (wart-like growth), and Bartholin cysts, can be seen or palpated and are easily treated if diagnosed early.

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The VSE can be performed by the practitioner and woman together by using a mirror. A simple diagram of the anatomy of the vulva can be given to the woman, with instructions to perform the examination herself that evening to reinforce what she has learned. She does the examination in a sitting position with adequate lighting, holding a mirror in one hand and using the other hand to expose the tissues surrounding the vaginal introitus. She then systematically examines the mons pubis, clitoris, urethra, labia majora, perineum, and perianal area and palpates the vulva, noting any changes in appearance or abnormalities such as ulcers, lumps, warts, and changes in pigmentation.

Internal Examination A vaginal speculum consists of two blades and a handle. Specula come in a variety of types and styles. A vaginal speculum is used to view the vaginal vault and cervix. The speculum is gently placed into the vagina and inserted to the back of the vaginal vault. The blades are opened to reveal the cervix and are locked into the open position. The cervix is inspected for position and appearance of the os: color, lesions, bleeding, and discharge (Fig. 3.14, A–D). Cervical findings that are not within normal limits include ulcerations, masses, inflammation, and excessive protrusion into the vaginal vault. Anomalies such as a cockscomb (a protrusion over the cervix that looks like a rooster's comb), a hooded or collared cervix (seen in diethylstilbestrol [DES] daughters), or polyps are noted.

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FIG 3.14 Insertion of speculum for vaginal examination. A, Opening of the introitus. B, Oblique insertion of the speculum. C, Final insertion of the

speculum. D, Opening of the speculum blades. (From Wilson, S. F., & Giddens, J. F. [2013]. Health assessment for nursing practice (5th

ed.). St. Louis, MO: Mosby.)

Collection of Specimens The collection of specimens for cytologic examination is an important part of the gynecologic examination. Infection can be diagnosed by examination of specimens collected during the pelvic examination. These infections include candidiasis, trichomoniasis, bacterial vaginosis, group B streptococcus, gonorrhea, chlamydia,

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and herpes simplex virus. Once the diagnoses have been made, treatment can be instituted.

Papanicolaou Test Carcinogenic conditions, whether potential or actual, can be determined by examination of cells from the cervix collected during the pelvic examination (i.e., a Pap test) (Box 3.13).

Box 3.13 Papanicolaou Test

• In preparation, make sure the woman has not douched, used vaginal medications, or had sexual intercourse for 24 to 48 hours before the procedure. Reschedule the test if the woman is menstruating. Midcycle is the best time for the test.

• Explain to the woman the purpose of the test and the sensations she will feel as the specimen is obtained (e.g., pressure but not pain).

• The woman is assisted into a lithotomy position. A speculum is inserted into the vagina.

• The cytologic specimen is obtained before any digital examination of the vagina is made or endocervical bacteriologic specimens are taken. A cotton swab may be used to remove excess cervical discharge before the specimen is collected.

• The specimen is obtained by using an endocervical sampling device (Cytobrush, Cervex-brush, spatula, or broom) (see Figs. A and B). If the two-sample method of obtaining cells is used, the Cytobrush is inserted into the canal and rotated 90 to 180 degrees, followed by a gentle smear of the entire transformation zone by using a spatula. Broom devices are inserted and rotated 360 degrees 5 times. They obtain endocervical and ectocervical samples at the same time. If the patient has had a hysterectomy, the vaginal cuff is sampled. Areas that appear abnormal on visualization will require colposcopy and biopsy. If using a one-

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slide technique, the spatula sample is smeared first. This is followed by applying the Cytobrush sample (rolling the brush in the opposite direction from which it was obtained), which is less subject to drying artifact; then the slide is sprayed with preservative within 5 seconds. The ThinPrep or SurePath Pap Test is a liquid-based method of preserving cells that reduces blood, mucus, and inflammation. The Pap specimen is obtained in the manner described above except that the cervix is not swabbed before collection of the sample. The collection device (brush, spatula, or broom) is rinsed in a vial of preserving solution that is provided by the laboratory. The sealed vial with solution is sent off to the appropriate laboratory. A special processing device filters the contents, and a thin layer of cervical cells is deposited on a slide, which is then examined microscopically. The AutoPap and Papnet tests are similar to the ThinPrep test. If cytology is abnormal, liquid-based methods allow follow-up testing for human papillomavirus (HPV) DNA with the same sample.

• Label the slides or vial with the woman's name and site. Include on the form to accompany the specimens the woman's name, age, parity, and chief complaint or reason for taking the cytologic specimens.

• Send specimens to the pathology laboratory promptly for staining, evaluation, and a written report, with special reference to abnormal elements, including cancer cells.

• Advise the woman that repeated tests may be necessary if the specimen is not adequate.

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• Instruct the woman concerning routine checkups for cervical and vaginal cancer. Women vaccinated against HPV should follow the same screening guidelines as unvaccinated women. Current recommendations of the US Preventive Services Task Force (USPSTF, 2014) and the American Cancer Society (ACS) (2015) for Pap tests are that women 21 to 65 years of age be screened every 3 years, or for women 30 to 65 years of age every 5 years (if they had a Pap test plus HPV test that were both negative). These guidelines recommend no screening in women younger than 21 years of age, although if a girl becomes sexually active, the guidelines recommend that she get a Pap test within 3 years of initiating sexual activity or at 21 years of age, whichever comes first. Women with high-risk factors such as exposure to diethylstilbestrol (DES) in utero, those treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, cervical cancer, or human immunodeficiency virus (HIV) may need more frequent screening.

• Young women who have been treated with excisional procedures for dysplasia have had an increase in premature births. A large majority of the cervical dysplasias in adolescents caused by HPV resolve on their own without treatment. It is important to avoid unnecessary instrumentation and procedures that negatively affect the cervix. Women who have had a complete hysterectomy for noncancerous reasons who have no history of high-grade CIN may have routine cervical cytology testing discontinued. Women who are older than 65 years of age who have not had serious cervical precancer or cancer in the past 20 years may discontinue cervical cancer screening (ACS, 2015).

• Record the examination date on the woman's record.

• Communicate findings to the woman per agency protocol.

Adapted from American Cancer Society. (2015). Cancer prevention and early detection facts and figures, 2015-2016. Atlanta, GA: Author. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and- statistics/cancer-prevention-and-early-detection-facts-and-figures/cancer-prevention-and- early-detection-facts-and-figures-2015-2016.pdf; US Preventive Services Task Force. (2014). US preventive services task force issues new cervical cancer screening recommendations. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-

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task-force-issues-new-cervical-cancer-screening-recommendations.

Vaginal Wall Examination After the specimens are obtained, the vagina is viewed when the speculum is rotated. The speculum blades are unlocked and partially closed. As the speculum is withdrawn, it is rotated; the vaginal walls are inspected for color, lesions, rugae, fistulas, and bulging.

Bimanual Palpation The examiner stands for this part of the examination. A small amount of lubricant is placed on the first and second fingers of the gloved hand for the internal examination. To avoid tissue trauma and contamination, the thumb is abducted, and the ring and little fingers are flexed into the palm (Fig. 3.15).

FIG 3.15 Bimanual palpation of the uterus. (From Ball, J., Dains, J., Flynn, J., et al. [2015]. Seidel's guide to physical examination [8th ed.].

St. Louis: Elsevier.)

The vagina is palpated for distensibility, lesions, and tenderness. The cervix is examined for position, shape, consistency, motility,

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and lesions. The fornix around the cervix is palpated. The other hand is placed on the abdomen halfway between the

umbilicus and symphysis pubis and exerts pressure downward toward the pelvic hand. Upward pressure from the pelvic hand traps reproductive structures for assessment by palpation. The uterus is assessed for position, size, shape, consistency, regularity, motility, masses, and tenderness.

With the abdominal hand moving to the right lower quadrant and the fingers of the pelvic hand in the right lateral fornix, the adnexa is assessed for position, size, tenderness, and masses. The examination is repeated on the woman's left side.

Just before the intravaginal fingers are withdrawn, the woman is asked to tighten her vagina around the fingers as much as she can. If the muscle response is weak, the woman is assessed for her knowledge about Kegel exercise.

Rectovaginal Palpation To prevent contamination of the rectum from organisms in the vagina (e.g., Neisseria gonorrhoeae), it is necessary to change gloves, add fresh lubricant, and then reinsert the index finger into the vagina and the middle finger into the rectum (Fig. 3.16). Insertion is facilitated if the woman strains down. The maneuvers of the abdominovaginal examination are repeated. The rectovaginal examination permits assessment of the rectovaginal septum, the posterior surface of the uterus, and the region behind the cervix and the adnexa. The vaginal finger is removed and folded into the palm, leaving the middle finger free to rotate 360 degrees. The rectum is palpated for rectal tenderness and masses.

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FIG 3.16 Rectovaginal examination. (From Ball, J., Dains, J., Flynn, J., et al. [2015]. Seidel's guide to physical examination [8th ed.]. St. Louis:

Elsevier.)

After the rectal examination, the woman is assisted into a sitting position, given tissues or wipes to cleanse herself, and afforded privacy to dress. The examiner returns after the woman is dressed to discuss findings and the plan of care.

Pelvic Examination During Pregnancy The pelvic examination during pregnancy is done in the same way as it is during a routine examination on a nonpregnant woman. Pelvic measurements are completed, and uterine size is estimated. A Pap test may be done initially and cytologic specimens collected to test for gonorrhea, chlamydia, human papillomavirus, herpes simplex virus, and group B streptococcus. As the pregnancy progresses, the nurse inspects the woman's abdomen, palpates fetal size and position, auscultates fetal heart tones, and measures fundal height at each visit.

While the pregnant woman is in the lithotomy position, the nurse must assess for supine hypotension (decrease in blood pressure) caused by the weight of the uterus pressing on the vena cava and aorta. Symptoms of supine hypotension include pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, and

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sweating. To prevent this, the woman who is lying supine should have a pillow or wedge under one hip. She should be positioned on her side until symptoms resolve and vital signs stabilize. The vaginal examination can be done with the woman in the lateral position.

Pelvic Examination After Hysterectomy The pelvic examination after hysterectomy is done much as it is done on a woman with a uterus. Vaginal screening using the Pap test is not recommended in women who have had a total hysterectomy with removal of the cervix for benign disease. Because of the epidemic of human papillomavirus, which causes vaginal intraepithelial neoplasia, sampling of the vaginal walls after hysterectomy may still be practiced, with schedules varying from every year to every 2 to 3 years.

Laboratory and Diagnostic Procedures The following laboratory and diagnostic procedures are ordered at the discretion of the clinician, considering the patient and family history: hemoglobin, fasting blood glucose, total blood cholesterol, lipid profile, urinalysis, syphilis serology (Venereal Disease Research Laboratories [VDRL] or rapid plasma reagent [RPR]) and other screening tests for STIs, mammogram, tuberculosis skin testing, hearing, visual acuity, electrocardiogram, chest x-ray, pulmonary function, fecal occult blood, flexible sigmoidoscopy, and bone mineral density (dual energy x-ray absorptiometry [DEXA] scan). Results of these tests may be reported in person, by phone call, or by letter. Tests hepatitis B, and drug screening may be offered with informed consent in high-risk populations. These test results are usually reported in person. HIV testing is recommended as routine for all adults (women and men), although patients should be told that they will be tested unless they opt out.

Health Screening for Women Across the Life Span To promote wellness and prevent illness, it is imperative that

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women adhere to specific screening guidelines to detect conditions that, if found early, are amenable to treatment and/or cure. Table 3.1 summarizes the screening procedures for women across the life span.

TABLE 3.1 Health Screening Guidelines and Immunization Recommendations for Women 18 Years of Age and Older

Intervention Recommendation* Physical Examination Blood pressure Every visit, but at least every 2 years Height and weight Every visit, but at least every 2 years Pelvic examination Annually until age 70; recommended for any woman who has ever

been sexually active Breast Examination Clinical examination Every 3 years, 20 to 39 years of age; after 40 years of age with periodic

examination, preferably annually High risk Annually after 18 years of age with history of premenopausal breast

cancer in first-degree relative Risk Groups Skin examination Family history of skin cancer or increased exposure to sunlight every

3 years between 20 and 40 years of age; annually after 40 years of age; monthly mole self-examinations also recommended

Oral cavity examination History of mouth lesions or exposure to tobacco or excessive alcohol at least annually

Laboratory and Diagnostic Tests Blood cholesterol (fasting lipoprotein analysis)

Beginning at 45 years of age if level is within normal limits, every 5 years; more often if abnormal levels or have risk factors for coronary artery disease

Papanicolaou (Pap) test Between 21 and 65 years of age—every 3 years with Pap test done Between 30 and 65 years of age—every 5 years if Pap test plus human papillomavirus (HPV) test done After 65 years of age and three negative tests and no risks and after total hysterectomy for benign disease—women may choose to stop screening

Mammography† Every 1 to 2 years between 40 and 49 years of age or earlier if at high risk Annually after 40 years of age Annually after 50 years of age Biennially, 50 to 74 years of age After 75 years of age, discuss with your health care provider

Colon cancer screening Use one of these three methods: Fecal occult blood test annually 50 to 74 years of age Flexible sigmoidoscopy every 5 years 50 to 74 years of age Colonoscopy every 10 years 50 to 74 years of age After 75 years of age, discuss with your health care provider

Hearing screen Starting at 18 years of age, then every 10 years until 49 years of age Every 3 years after 50 years of age Annually with exposure to excessive noise or when loss is suspected

Vision screen At least once between 20 and 29 years of age; at least twice between 30 and 39 years of age;

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Every 2 to 4 years between 40 and 64 years of age; every 1 to 2 years after 65 years of age

Risk Groups Fasting blood sugar Annually with family history of diabetes or gestational diabetes or if

significantly obese; every 3 to 5 years for all women older than 45 years of age

Thyroid-stimulating hormone (TSH) test

As determined by the health care provider

Sexually transmitted infection test (e.g., gonorrhea, syphilis, herpes)

As needed if sexually active with multiple partners and engaging in risky sexual behaviors; be aware of sensitive issues with transgender persons

Chlamydia test If sexually active, yearly until 25 years of age; after 25 years of age, test as needed when sexually active with new or multiple partners

Cholesterol screening Starting at 20 years of age if at increased risk for heart disease; discuss with health care provider

Colorectal cancer screening

Starting at 50 years of age, unless at higher risk; use of fecal occult blood screening, sigmoidoscopy, or colonoscopy

Diabetes screening Routine testing, and especially if blood pressure is over 135/80 Human immunodeficiency virus (HIV) test

At least once between 18 and 64 years of age to determine HIV status; test if there is a high risk for HIV infection

Hepatitis C test Recommended for all persons born between 1945 and 1964, and others based on risk.

Tuberculin skin test Annually with exposure to persons with tuberculosis or in risk categories for close contact with the disease

Endometrial biopsy At menopause for women at risk for endometrial cancer; repeat as needed

Bone mineral density testing

All women 65 years of age and older at least once; repeat testing as needed; younger women with risk for osteoporosis may need periodic screenings

Immunizations Tetanus-diphtheria- pertussis (Td/Tdap)

Tdap vaccine once; then booster is given every 10 years

Measles, mumps, rubella

Once if born after 1956 and no evidence of immunity

Hepatitis A Primary series of two injections for all who are in risk categories Hepatitis B Primary series of three injections for all who are in risk categories Influenza Annually Pneumococcal 1–2 doses between 19 and 64 years of age; 1 dose after 65 years of age Herpes zoster (shingles) One dose at 65 years of age Human papillomavirus (HPV) vaccine

Primary series of three injections for girls 9 years of age to women 26 years of age; intended for those not previously exposed to HPV

*The information in this table is only a guide; health care providers will individualize the timing of tests and immunizations for each woman. †Note: No consensus has been reached regarding mammograms for women between 40 and 49 years of age; therefore various recommendations are listed. Women are urged to discuss circumstances with their health care providers. Data from American Cancer Society. (2015): Cancer prevention and early detection facts and figures, 2015–2016. Atlanta, GA: Author. Retrieved from http://old.cancer.org/acs/groups/content/@editorial/documents/document/acspc- 044552.pdf; Centers for Disease Control and Prevention. Cancer prevention & early detection facts and figures. Retrieved from

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http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc- 045101.pdf; Advisory Committee on Immunization Practices. (2016). Recommended adult immunization schedule, United States. Retrieved from http://www.cdc.gov/vaccines/acip/recs/index.html; Workowski, K. A., Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines 2010, Morbidity and Mortality Weekly Report, 64(RR3), 1–127; Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm; National Women's Health Information Center. (2013). Screening tests for women. Retrieved from http://www.womenshealth.gov/screening-tests-and-vaccines/screening-tests-for- women/; US Preventive Services Task Force. (2014). US preventive services task force issues new cervical cancer screening recommendations. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services- task-force-issues-new-cervical-cancer-screening-recommendations.

References American Cancer Society. Cancer prevention and early detection

facts and figures, 2015-2016. [Atlanta, GA: Author; Retrieved from] https://www.cancer.org/content/dam/cancer- org/research/cancer-facts-and-statistics/cancer-prevention- and-early-detection-facts-and-figures/cancer-prevention- and-early-detection-facts-and-figures-2015-2016.pdf; 2015.

American Cancer Society. Does body weight affect cancer risk?. [Retrieved from] http://www.cancer.org/cancer/cancercauses/dietandphysicalactivity/bodyweightandcancerrisk/body- weight-and-cancer-risk-effects; 2016.

American Cancer Society. Can vulvar cancer be prevented?. [Retrieved from] https://www.cancer.org/cancer/vulvar- cancer/causes-risks-prevention/prevention.html; 2016.

Anxiety and Depression Association of America. Facts and statistics. [Retrieved from] https://www.adaa.org/about- adaa/press-room/facts-statistic; 2016.

Berg JA, Taylor D, Woods NF. Women at midlife. Olshansky EF. Women's health and wellness across the lifespan. Wolters Kluwer: Philadelphia, PA; 2015.

Burkhardt MA, Nagai-Jacobson MG. Spirituality and health. Dossey BM, Keegan L. Holistic nursing: A handbook for practice. ed. 6. Jones & Bartlett: Burlington, MA; 2013:721– 749.

Centers for Disease Control and Prevention. Adult obesity facts.

254

Author: Atlanta, GA; 2015 [Retrieved from] http://www.cdc.gov/obesity/data/adult.html.

Centers for Disease Control and Prevention. Childhood overweight and obesity. Author: Atlanta, GA; 2015 [Retrieved from] http://www.cdc.gov/obesity/childhood/index.html.

Centers for Disease Control and Prevention. Birthweight and gestation. CDC: Atlanta, GA; 2016 http://www.cdc.gov/nchs/fastats/birthweight.htm.

Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. Author: Atlanta, GA; 2016 [Retrieved from] http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/

Centers for Disease Control and Prevention. Infertility. [Retrieved from] https://www.cdc.gov/nchs/fastats/infertility.htm; 2016.

Centers for Disease Control and Prevention. Folic acid. Author: Atlanta, GA; 2016 [Retrieved from] https://www.cdc.gov/ncbddd/folicacid/recommendations.html

Cohen BE, Edmundson D, Kronish IM. State of the art review: Depression, stress, anxiety, and cardiovascular disease. American Journal of Hypertension. 2014;28(11):1295–1302.

Domestic Shelters. When pregnancy triggers violence: Facts to know about the danger of abuse during pregnancy. [Retrieved from] https://www.domesticshelters.org/domestic- violence-articles-information/when-pregnancy-triggers- violence#.WI6x4hsrKqE; 2017.

Douglas MK, Rosenkoetter M, Pacquiao DF, Centers for Disease Control and Prevention. Births: Method of delivery. CDC: Atlanta, GA; 2016 [Retrieved from] http://www.cdc.gov/nchs/fastats/delivery.htm.

Dossey BM. Integral and holistic nursing; Local to global. Dossey BM, Keegan L. Holistic nursing: A handbook for practice. ed. 6. Jones & Bartlett: Burlington, MA; 2013.

England LC, Bunnell RE, Pechacek TF, et al. Nicotine and the developing human: A neglected element in the electronic cigarette debate. American Journal of Preventive Medicine. 2015;49(2):286–293.

Green C. Human trafficking: Preparing for a unique patient

255

population. American Nurse Today. 2016;11(1):9–12. Guttmacher Institute. Unintended pregnancy in the United

States. [New York, NY; Retrieved from] https://www.guttmacher.org/fact-sheet/unintended- pregnancy-united-states; 2016.

Hautala L, Junnila J, Alin J, et al. Uncovering hidden eating disorders using the SCOFF questionnaire: Cross-sectional survey of adolescents and comparison with nurse assessments. International Journal of Nursing Studies. 2009;46(11):1439–1447.

Lin T-F, Chen J. Effect of physician gender on demand for Pap tests. Economics Research International. 2014;2014:647169; 10.1155/2014/647169.

March of Dimes. Eating and nutrition. [Retrieved from] www.marchofdimes.com/pregnancy/caffeine-in- pregnancy.aspx; 2013.

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2015. National Vital Statistics Reports. 2017;66(1) [Division of Vital Statistics; Retrieved from] https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf.

Masters W, Johnson V. Human sexual response. Bantam Books: New York; 1966.

Mohamad K, Jamshidi L, Nouri-Jelyani K. Is age of menarche related with body mass index? Iranian Journal of Public Health. 2013;42(9):1043–1048.

Morgan J, Reid F, Lacey J. The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. BMJ (Clinical Research Ed.). 1999;319(7223):1467–1468.

National Institute on Alcohol Abuse and Alcoholism. Alcohol: A women's health issue. [Retrieved from] https://pubs.niaaa.nih.gov/publications/brochurewomen/women.htm 2016.

National Institute on Drug Abuse. Drug facts: Methamphetamine. [Retrieved from] https://www.drugabuse.gov/publications/drugfacts/methamphetamine 2014.

National Institute on Drug Abuse. Drug facts: Marijuana. [Retrieved from]

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https://www.drugabuse.gov/publications/drugfacts/marijuana 2016.

National Institute on Drug Abuse. What is cocaine?. [Retrieved from] https://www.drugabuse.gov/publications/drugfacts/cocaine 2016.

National Institute on Drug Abuse. What are hallucinogens?. [Retrieved from] https://www.drugabuse.gov/publications/drugfacts/hallucinogens 2016.

Office of Disease Prevention and Health Promotion. 2015-2020 Dietary guidelines for Americans. [Retrieved from] https://health.gov/dietaryguidelines/; 2015.

Office of Women's Health. Female genital cutting. [Retrieved from] http://womenshealth.gov/publications/our- publications/fact-sheet/female-genital-cutting.html; 2015.

Olshansky EF, Zender R. Wellness for special populations of women. Olshansky E. Women's health and wellness across the lifespan. Wolters Kluwer: Philadelphia, PA; 2015.

Rørtveit K, Hansen BS, Leiknes I, et al. Patients' experiences of trust in the patient-nurse relationship: A systematic review of qualitative studies. Open Journal of Nursing. 2015;5(3):195– 209.

Sammarco A. Women's health issues across the life cycle: A quality of life perspective. Jones & Bartlett: Burlington, MA; 2016.

Shaver JLF. Promoting healthy sleep. Olshansky EF. Women's health and wellness across the lifespan. Wolters Kluwer: Philadelphia, PA; 2015.

Substance Abuse and Mental Health Services Administration (SAMHSA). Specific populations and prescription drug misuse and abuse. [Retrieved from] https://www.samhsa.gov/prescription-drug-misuse- abuse/specific-populations; 2015.

US Department of Health & Human Services/National Institute of Child Health & Human Development. What is prenatal care and why is it important?. [Retrieved from] https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/Pages/prenatal- care.aspx; 2013.

257

US Department of Health & Human Services. About the law. [Retrieved from] http://www.hhs.gov/healthcare/about- the-law/; 2015.

US Department of Health & Human Services. Trends in teen pregnancy and childbearing. [Office of Adolescent Health. Rockville, MD; Retrieved from] http://www.hhs.gov/ash/oah/adolescent-health- topics/reproductive-health/teen-pregnancy/trends.html; 2016.

US Department of Health & Human Services. The U.S. opioid epidemic. [Washington, DC; Retrieved from] http://www.hhs.gov/opioids/about-the-epidemic/; 2016.

US Department of Justice, Office on violence against women. Domestic violence. [Washington, DC: Dept. of Justice; Retrieved from] https://www.justice.gov/ovw/domestic- violence; 2015.

US National Library of Medicine, National Institutes of Health. Methamphetamines. [Medline Plus; Retrieved from] https://www.nlm.nih.gov/medlineplus/methamphetamine.html 2016.

US Preventive Services Task Force. Breast cancer screening. [Retrieved from] https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast- cancer-screening; 2016.

World Health Organization. Female genital mutilation. [New York, NY: UNICEF; Retrieved from] http://www.who.int/mediacentre/factsheets/fs241/en/; 2016.

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4

Reproductive System Concerns Ellen F. Olshansky

The reproductive system consists of many components. Problems may occur at any point in the menstrual cycle. Many factors, including anatomic abnormalities, physiologic imbalances, and lifestyle, can affect the menstrual cycle. The average woman is likely to have some concerns related to her menstrual and gynecologic health at some point in her life and will experience bleeding, pain, discharge, or infections associated with her reproductive organs or functions. This chapter provides information on common menstrual problems; sexually transmitted infections, and selected other infections that can affect reproductive functions; abnormal bleeding problems; and problems associated with perimenopause and postmenopause. Benign breast conditions are also discussed. Breast cancer is included because it is the most common reproductive cancer occurring in women.

Menstrual Disorders Knowledge of the normal parameters of menstruation is essential to the assessment of menstrual cycle experiences and disorders. Chapter 3 provides additional information on the menstrual cycle and endocrine physiology.

Once the irregular nature of menses in the first 1 to 2 years after

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menarche subsides and a cyclic, predictable pattern of monthly bleeding is established, women may worry about any deviation from that pattern or from what they have been told is normal for all menstruating women. A woman may be concerned about her ability to conceive and bear children without this monthly evidence. Amenorrhea or excess menstrual bleeding can be a source of severe distress and concern for a woman.

Amenorrhea Amenorrhea, the absence of menstrual flow, is a clinical sign of a variety of disorders. Generally, the following circumstances should be evaluated: (1) the absence of both menarche and secondary sexual characteristics by 13 years of age; (2) the absence of menses by 15 years of age, regardless of normal growth and development (primary amenorrhea); (3) the absence of menstruation within 5 years of breast development, or (4) a 6-month or more cessation of menses after a period of menstruation (secondary amenorrhea) (Lobo, 2017).

A moderately obese girl (20% to 30% above ideal weight) may have early-onset menstruation, whereas delay of onset is known to be related to malnutrition (starvation such as that with anorexia). Girls who exercise strenuously before menarche can have delayed onset of menstruation until about 18 years of age (Lobo, 2017).

Although amenorrhea is not a disease, it is often a sign of one. Still, most commonly and most benignly, amenorrhea is a result of pregnancy. It also can result from anatomic abnormalities such as outflow tract obstruction, anterior pituitary disorders, other endocrine disorders such as polycystic ovary syndrome, hypothyroidism or hyperthyroidism, chronic diseases such as type 1 diabetes, medications such as phenytoin (Dilantin), drug abuse (alcohol, tranquilizers, opiates, marijuana, cocaine), or oral contraceptive use.

Hypogonadotropic Amenorrhea Hypogonadotropic amenorrhea reflects a problem in the central hypothalamic-pituitary axis. In rare instances, a pituitary lesion or genetic inability to produce follicle-stimulating hormone (FSH) and

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luteinizing hormone (LH) is at fault. However, Lobo (2017) has noted that women without a lesion who had a low level of gonadotropins were believed to have primary pituitary failure, which was referred to as hypogonadotropic hypogonadism, but it has been noted that gonadotropin-releasing hormone (GnRH) stimulation results in increased FSH and LH levels. This suggests a hypothalamic defect with lack of adequate GnRH synthesis or a defect in a CNS neurotransmitter.

Hypogonadotropic amenorrhea often results from hypothalamic suppression as a result of stress (in the home, school, or workplace) or a sudden and severe weight loss, eating disorders, strenuous exercise, or mental illness (Wambach & Alexander, 2012). Research on the interaction between nervous system or neurotransmitter functions and hormone regulation throughout the body has demonstrated a biologic basis for the relation of stress to physiologic processes. Women who are more than 20% underweight for height or who have had rapid weight loss and women with eating disorders such as anorexia nervosa may report amenorrhea. Amenorrhea is one of the classic signs of anorexia nervosa; and the interrelation of disordered eating, amenorrhea, and premature osteoporosis has been described as the female athlete triad (Mielke, Parsons, & Greenberg, 2015; Thein- Nissenbaum, 2013). A loss of calcium from the bone, comparable to that seen in postmenopausal women, may occur with this type of amenorrhea.

Exercise-associated amenorrhea can occur in women undergoing vigorous physical and athletic training and is thought to be associated with many factors, including body composition (height, weight, and percentage of body fat); type, intensity, and frequency of exercise; nutritional status; and presence of emotional or physical stressors. Women who participate in sports emphasizing low body weight are at greatest risk, including the following (Lobo, 2017): • Sports in which performance is subjectively scored (e.g., dance,

gymnastics) • Endurance sports favoring participants with low body weight

(e.g., distance running, cycling) • Sports in which body contour–revealing clothing is worn (e.g.,

swimming, diving, volleyball)

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• Sports with weight categories for participation (e.g., rowing, martial arts)

• Sports in which prepubertal body shape favors success (e.g., gymnastics, figure skating)

Assessment of amenorrhea begins with a thorough history and physical examination. Specific components of the assessment process depend on the patient's age—adolescent, young adult, or perimenopausal—and whether she has menstruated previously.

An important initial step, often overlooked, is to be sure that the woman is not pregnant. Once pregnancy has been ruled out by a β- human chorionic gonadotropin (hCG) pregnancy test, diagnostic tests may include a complete blood count (CBC), urinalysis, and serum chemistries in order to rule out any systemic conditions. FSH level, thyroid-stimulating hormone (TSH) and prolactin levels, radiographic or computed tomography (CT) scan of the sellaturcica, a progestational challenge, and possible pelvic sonogram are performed (Lobo, 2017).

Management When amenorrhea is caused by hypothalamic disturbances, the nurse is an ideal health professional to assist women because many of the causes are potentially reversible (e.g., stress, weight loss for nonorganic reasons). Counseling and education are primary interventions and appropriate nursing roles. When a stressor known to predispose a woman to hypothalamic amenorrhea is identified, initial management involves addressing the stressor. Together the woman and nurse plan how the woman can decrease or discontinue medications known to affect menstruation, correct weight loss, deal more effectively with psychologic stress, address emotional distress, and alter exercise routine.

The nurse works with the woman to help her identify, cope with, and eliminate sources of stress in her life. Deep-breathing exercises and relaxation techniques are simple yet effective stress-reduction measures. Referral for biofeedback or massage therapy also may be useful. In some instances, referrals for psychotherapy may be indicated.

If a woman's exercise program is thought to contribute to her amenorrhea, several options exist for management. She may decide

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to decrease the intensity, frequency, or duration of her training or modify her diet to include the appropriate nutrition for her age. Accepting the former alternative may be difficult for one who is committed to a strenuous exercise regimen. The woman and nurse may have several sessions before the woman elects to try exercise reduction. Many young female athletes may not understand the consequences of low bone density or osteoporosis; nurses can point out the connection between low bone density and stress fractures. The nurse and woman should also investigate other factors that may be contributing to the amenorrhea and develop plans for altering lifestyle and decreasing stress.

Research on recommended dosages of calcium, vitamin D, and potassium is inconclusive for women experiencing amenorrhea associated with the female athlete triad. Oral contraceptives may be helpful in amenorrheic women but are usually not used in young women with amenorrhea associated with the female athlete triad unless there are specific issues that warrant such treatment, which are best discussed with the woman's health care provider (Drakh, 2016).

Cyclic Perimenstrual Pain and Discomfort Cyclic perimenstrual pain and discomfort (CPPD) is a useful concept to describe women's experiences of discomfort during the menstrual cycle (Sharp, Taylor, Thomas, et al., 2002; Taylor, 2005). This concept includes dysmenorrhea, premenstrual syndrome (PMS), and premenstrual dysphoric disorder (PMDD) as well as symptom clusters that occur before and after the menstrual flow starts. Symptoms occur cyclically and can include mood swings as well as pelvic pain and physical discomforts. These symptoms can range from mild to severe and can last 1 or 2 days or up to 2 weeks. CPPD is a health problem that can have a significant effect on a woman's quality of life. The following discussion focuses on the three main conditions of CPPD.

Dysmenorrhea Dysmenorrhea, pain during or shortly before menstruation, is one of the most common gynecologic problems in women of all ages.

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Many adolescents have dysmenorrhea in the first 3 years after menarche. Young adult women 17 to 24 years of age are most likely to report painful menses. Approximately 75% of women report some level of discomfort associated with menses, and approximately 15% report severe dysmenorrhea (Mendiratta, 2017). However, the amount of disruption in women's lives is difficult to determine. Researchers have estimated that as many as 10% of women with dysmenorrhea have severe enough pain to interfere with their functioning for 1 to 3 days a month. Menstrual problems, including dysmenorrhea, are relatively more common in women who smoke and are obese. Severe dysmenorrhea is also associated with early menarche, nulliparity, and lack of physical exercise (Mendiratta). Traditionally dysmenorrhea is differentiated as primary or secondary. Symptoms usually begin with menstruation, although some women have discomfort several hours before onset of flow. The range and severity of symptoms are different from woman to woman and from cycle to cycle in the same woman. Symptoms of dysmenorrhea may last several hours or several days.

Pain is usually located in the suprapubic area or lower abdomen. Women describe the pain as sharp, cramping, or gripping, or as a steady dull ache. For some women pain radiates to the lower back or upper thighs.

Primary Dysmenorrhea Primary dysmenorrhea is a condition associated with ovulatory cycles. Research has shown that primary dysmenorrhea has a biochemical basis and arises from the release of prostaglandins with menses. During the luteal phase and subsequent menstrual flow, prostaglandin F2-alpha (PGF2α) is secreted. Excessive release of PGF2α increases the amplitude and frequency of uterine contractions and causes vasospasm of the uterine arterioles, resulting in ischemia and cyclic lower abdominal cramps. Systemic responses to PGF2α include backache, weakness, sweats, gastrointestinal symptoms (anorexia, nausea, vomiting, and diarrhea), and central nervous system symptoms (dizziness, syncope, headache, and poor concentration). Pain usually begins at the onset of menstruation and lasts 12 to 72 hours (Mendiratta, 2017).

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Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established. Anovulatory bleeding, common in the first few months or years after menarche, is painless. Because both estrogen and progesterone are necessary for primary dysmenorrhea to occur, it is experienced only with ovulatory cycles. This problem is more common among women in their late teens and early twenties than in women in older age- groups; the incidence declines with age. Psychogenic factors may influence symptoms, but symptoms are definitely related to ovulation and do not occur when ovulation is suppressed.

Management. Management of primary dysmenorrhea depends on the severity of the problem and the individual woman's response to various treatments. Important components of nursing care are information and support. Because menstruation is so closely linked to reproduction and sexuality, menstrual problems such as dysmenorrhea can have a negative influence on sexuality and self- worth. Nurses can correct myths and misinformation about menstruation and dysmenorrhea by providing facts about what is normal. Women need support to foster their feelings of positive sexuality and self-worth.

Often, nurses can offer more than one alternative for alleviating menstrual discomfort and dysmenorrhea, which gives women options to try to decide which works best for them. Several of these alternatives are discussed in the following paragraphs.

Heat (a patch or wrap) that is applied to the lower abdomen minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia. Aerobic exercise has also been found to help alleviate pain (Mendiratta, 2017). Relaxation training, biofeedback, transcutaneous electrical nerve stimulation (TENS), Lamaze (notably a childbirth method, but also a breathing technique that can help with pain reduction), hypnotherapy, imagery, and desensitization are also used to decrease menstrual discomfort, although evidence is insufficient to determine their effectiveness (Mendiratta). Research findings from Chien and colleagues (2013) concluded that an 8-week yoga intervention decreased serum homocysteine levels, alleviating

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dysmenorrhea in women with primary dysmenorrhea (Fig. 4.1).

FIG 4.1 Yoga asana: triangle pose. Helpful for assisting digestion and stretching and strengthening the spine; also used for dysmenorrheal and pelvic

congestion. (Courtesy of Julie Perry Nelson, Loveland, CO.)

Exercise helps relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia. It also releases endogenous opiates (specifically beta-endorphins), suppresses prostaglandins, and shunts blood flow away from the viscera, resulting in reduced pelvic congestion. One specific exercise that nurses can suggest is pelvic rocking. Pelvic rocking is done by putting one's hands and feet on the floor, with a hand directly under the shoulders. Then breathe in and hollow the back and push out the abdomen, and breathe out and arch the back and contract the abdomen (Healthwise Staff, 2015).

In addition to maintaining good nutrition at all times, specific dietary changes are helpful in decreasing some of the systemic symptoms associated with dysmenorrhea. Decreased intake of salt and refined sugar intake 7 to 10 days before expected menses may reduce fluid retention. Natural diuretics such as asparagus, cranberry juice, peaches, parsley, or watermelon may help reduce edema and related discomforts. A low-fat vegetarian diet and

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vitamin E intake may also help minimize dysmenorrheal symptoms (Mendiratta, 2017).

Medications used to treat primary dysmenorrhea include prostaglandin synthesis inhibitors, primarily nonsteroidal antiinflammatory drugs (NSAIDs) (Mendiratta, 2017) (Table 4.1). NSAIDs are most effective if started several days before menses or at least by the onset of bleeding. All NSAIDs have potential gastrointestinal side effects, including nausea, vomiting, and indigestion. Women taking NSAIDs should be instructed to report dark-colored stool because this may be an indication of gastrointestinal bleeding.

TABLE 4.1 Nonsteroidal Antiinflammatory Agents Used to Treat Dysmenorrhea

Drug Brand Name and Status

Recommended Dosage (Oral)*

Common Side Effects† Comments Contraindications

Diclofenac Cataflam Rx

100 mg initially, then 50 mg q 8 hours

Nausea, diarrhea, constipation, abdominal distress, dyspepsia, heartburn, flatulence, dizziness, tinnitus, itching, rash

Enteric coated; immediate release

For all NSAIDs: Do not give if woman has hemophilia or bleeding ulcers; do not give if woman has had an allergic or anaphylactic reaction to aspirin or another NSAID; do not give if woman is taking anticoagulant medication

Ibuprofen Motrin Rx, Advil OTC, Nuprin OTC, Motrin IB OTC

400 mg q6–8h, 200 mg q4–6h up to 1200 mg/day

See diclofenac

If GI upset occurs, take with food, milk, or antacids; avoid alcoholic beverages; do not take with aspirin; stop taking and call care provider if rash occurs

Ketoprofen Orudis Rx 25–50 mg q6– 8h up to 300 mg/day

See diclofenac

See ibuprofen

Orudis KT 12.5 mg q6–8h

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OTC, Actron OTC

up to 75 mg/day

Meclofenamate Meclomen Rx

100 mg tid up to 300 mg

See diclofenac

See ibuprofen

Mefenamic acid

Ponstel Rx 500 mg initially, then 250 mg q6h/day

See diclofenac

Very potent and effective prostaglandin- synthesis inhibitor; antagonizes already formed prostaglandins; increased incidence of adverse GI side effects

Naproxen Naprosyn Rx

500 mg initially, then 250 mg q6–8h or 500 mg q hr (long-acting formula) not to exceed 1250 mg/day on first day; subsequent doses not to exceeed 100 mg/day

See diclofenac

See ibuprofen

Naproxen sodium

Anaprox Rx

550 mg initially, then 275 mg q6–8h or 550 mg q12h up to 1375 mg/day

See diclofenac

See ibuprofen

Aleve OTC

440 mg initially, then 220 mg q6–8h up to 660 mg/day

Celecoxib Celebrex 400 mg initially, then 200 mg bid

See diclofenac

See ibuprofen

*Dosages are current recommendations and should be verified before use. Recommended doses for over-the-counter preparations are generally less than recommendations for therapeutic doses. As-needed dosing is recommended by manufacturer; scheduled dosing may be more effective. †Risk with all NSAIDs is gastrointestinal ulceration, possible bleeding, and prolonged bleeding time. Incidence of side effects is dose related. Reported incidence is 1% to 10%. Data from Calis, K. A. (2016). Dysmenorrhea medication. Medscape. Retrieved from http://emedicine.medscape.com/article/253812-medication#2; Mendiratta, V. (2017). Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual

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dysphoric disorder. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Philadelphia, PA: Elsevier.

Nursing Alert If one NSAID is ineffective, often a different one may be effective. If the second drug is unsuccessful after a 6-month trial, combined oral contraceptive pills (OCPs) may be used. Women with a history of aspirin sensitivity or allergy should avoid all NSAIDs.

OCPs are a reasonable choice for women who want to use a contraceptive agent. The benefits of their use are attributed to decreased prostaglandin synthesis associated with an atrophic decidualized endometrium. Combined OCPs, which contain both estrogen and progesterone, are effective in relieving symptoms of primary dysmenorrhea for approximately 90% of women. No single OCP, including low-dose and extended-cycle OCPs, has been shown to be superior to another for the relief of primary dysmenorrhea (Mendiratta, 2017). OCPs are a particularly good choice for therapy because they combine contraception with a positive effect on dysmenorrhea, menstrual flow, and menstrual irregularities. Adolescents may benefit from use of the long-acting injectable contraceptive (depot medroxyprogesterone), but more research is needed. Since OCPs have side effects, women may not wish to use them for dysmenorrhea. They may be contraindicated for some women. (See Chapter 5 for a complete discussion of OCPs.)

Over-the-counter (OTC) preparations that are indicated for primary dysmenorrhea contain the same active ingredients (e.g., ibuprofen or naproxen sodium) as prescription preparations. However, the labeled recommended dose may be subtherapeutic. Preparations containing acetaminophen are even less effective because acetaminophen does not have the antiprostaglandin properties of NSAIDs.

Alternative and complementary therapies are increasingly popular and used in developed countries. Therapies such as acupuncture, acupressure, biofeedback, desensitization, hypnosis, massage, reiki, relaxation exercises, and therapeutic touch have been used to treat pelvic pain. Herbal preparations have long been

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used for managing menstrual problems, including dysmenorrhea (Table 4.2). Herbal medicines may be valuable in treating dysmenorrhea. However, it is essential that women understand that these therapies are not without potential toxicity and may cause drug interactions.

TABLE 4.2 Herbal Medicinals Taken Orally for Menstrual Disorders

Symptoms or Indications HerbalTherapy* Action

Menstrual cramping, dysmenorrhea

Black haw Uterine antispasmodic Fennel Uterotonic Catnip Uterine antispasmodic Dong quai Uterotonic; antiinflammatory Ginger Antiinflammatory Motherwort Uterotonic Wild yam Uterine antispasmodic Valerian Uterine antispasmodic

Premenstrual discomfort, tension

Black cohosh root

Estrogen-like luteinizing hormone suppressant; binds to estrogen receptors

Chamomile Antispasmodic Breast pain Chaste tree

fruit Decreases prolactin levels

Bugleweed Antigonadotropic; decreases prolactin levels Menorrhea, metrorrhagia Lady's

mantle Uterotonic

Raspberry Uterotonic Shepherd's purse

Uterotonic

*Many women's herbs do not have rigorous scientific studies backing their use; most uses and properties of herbs have not been validated by the US Food and Drug Administration. Data from Annie's Remedy. (2012). Herbal remedies for dysmenorrhea. Retrieved from www.anniesremedy.com; National Center for Complementary and Alternative Medicine. (2010). Herbs at a glance. Retrieved from https://nccih.nih.gov/health/herbsataglance.htm.

Nursing Alert Nurses must routinely ask women about use of herbal and other alternative therapies and document their use.

Secondary Dysmenorrhea Secondary dysmenorrhea is menstrual pain that develops later in

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life than primary dysmenorrhea, typically after 25 years of age. It is associated with pelvic pathology such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids). Women with secondary dysmenorrhea often have other symptoms that may suggest the underlying cause. For example, heavy menstrual flow with dysmenorrhea suggests a diagnosis of leiomyomata, adenomyosis, or endometrial polyps. Pain associated with endometriosis often begins a few days before menses but can be present at ovulation and continue through the first days of menses or start after menstrual flow has begun. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea is often characterized by dull lower-abdominal aching that radiates to the back or thighs. Often women experience feelings of bloating or pelvic fullness. In addition to a physical examination with a careful pelvic examination, diagnosis may be assisted by ultrasound examination, dilation and curettage (D&C), endometrial biopsy, or laparoscopy. Treatment is directed toward removal of the underlying pathology. Many of the measures described for pain relief of primary dysmenorrhea are also helpful for women with secondary dysmenorrhea.

Premenstrual Syndrome Approximately 75% of women experience premenstrual symptoms at some time in their reproductive lives (Mendiratta, 2017). Establishing a universal definition of premenstrual syndrome (PMS) is difficult, given that so many symptoms have been associated with the condition and at least two different syndromes have been recognized: PMS and premenstrual dysphoric disorder (PMDD).

PMS is a complex, poorly understood condition that includes one or more of a large number (more than 150) of physical and psychologic symptoms beginning in the luteal phase of the menstrual cycle, occurring to such a degree that lifestyle or work is affected, and followed by a symptom-free period. Symptoms include fluid retention (abdominal bloating, pelvic fullness, edema of the lower extremities, breast tenderness, and weight gain), behavioral or emotional changes (depression, crying spells,

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irritability, panic attacks, and impaired ability to concentrate), premenstrual cravings (sweets, salt, increased appetite, and food binges), headache, fatigue, and backache.

All age-groups are affected, with women in their twenties and thirties most frequently reporting symptoms. Ovarian function is necessary for the condition to occur because it does not occur before puberty, after menopause, or during pregnancy. The condition is not dependent on the presence of monthly menses: women who have had a hysterectomy without bilateral salpingo-oophorectomy (BSO) still can have cyclic symptoms.

PMDD is a more severe variant of PMS in which women have marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed (Mendiratta, 2017). The most common symptoms are those associated with mood disturbances, and PMDD is listed as a condition in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric Association [APA], 2014).

A diagnosis of PMS is made when a specific group of symptoms consistent with PMS occur in the luteal phase and resolve within a few days of menses onset. These symptoms can be physical and/or behavioral, including breast tenderness, bloating, and headache; irritability, anxiety, and depression (Mendiratta, 2017).

For a diagnosis of PMDD, the following criteria must be met (APA, 2014): • Five or more affective and physical symptoms are present in the

week before menses and begin to improve in the follicular phase of the menstrual cycle.

• At least one of the symptoms is marked affective lability, marked irritability or anger, depressed mood or feelings of hopelessness or self-deprecating thoughts, or anxiety.

• One or more of the following additional symptoms, reaching a total of 5 symptoms when combined with the above symptoms: decreased interest in usual activities, subjective difficulty concentrating, lethargy, marked change in appetite (overeating, food cravings), hypersomnia or insomnia, feeling overwhelmed, physical symptoms of breast tenderness, muscle pain, bloating, weight gain

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• Symptoms interfere markedly with work or interpersonal relationships.

• Symptoms are not caused by an exacerbation of another condition or disorder.

• Must confirm that symptoms are occurring, evidenced through daily ratings

• Symptoms are not caused by physiologic effects of a substance or a specific medical treatment.

These criteria must be confirmed by prospective daily ratings for at least two menstrual cycles.

The causes of PMS and PMDD continue to be investigated, but there is general agreement that they are distinct psychiatric and medical syndromes rather than an exacerbation of an underlying psychiatric disorder. They do not occur if there is no ovarian function. A number of biologic and neuroendocrine etiologies have been suggested; however, none have been conclusively substantiated as the causative factor. It is likely that biologic, psychosocial, and sociocultural factors contribute to PMS and PMDD.

Management There is little agreement on management. A careful, detailed history and daily log of symptoms and mood fluctuations spanning several cycles may give direction to a plan of management. Any changes that help a woman with PMS exert control over her life have a positive effect. For this reason, lifestyle changes are often effective in its treatment.

Education is an important component of the management of PMS. Nurses can advise women that self-help modalities often result in significant symptom improvement. Women have found a number of complementary and alternative therapies to be useful in managing the symptoms of PMS. Diet and exercise changes can provide symptom relief for some women. Nurses can suggest that women do not smoke and limit their consumption of refined sugar, salt, red meat, alcohol, and caffeinated beverages. Women can be encouraged to include whole grains, legumes, seeds, nuts, vegetables, fruits, and vegetable oils in their diets; reduce the

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amount of salt, sugar, and caffeine in their diets; and incorporate 60 minutes or more of physical exercise daily (a monthly program that varies in intensity and type of exercise according to PMS symptoms is best). Women who exercise regularly seem to have less premenstrual anxiety than do nonathletic women. Researchers believe aerobic exercise increases beta-endorphin levels to offset symptoms of depression and elevate mood.

Use of natural diuretics may also help reduce fluid retention (see the “Management” section on dysmenorrhea earlier in the chapter for more information). Nutritional supplements may assist in symptom relief. Calcium and vitamin B6 have been shown to be moderately effective in relieving symptoms, to have few side effects, and to be safe. Daily supplements of evening primrose oil are reportedly useful in relieving breast symptoms with minimal side effects, but research reports are conflicting. Chasteberry has been found to alleviate symptoms of PMS (Jafari & Orenstein, 2015). Other herbal therapies have long been used to treat PMS; however, research on effectiveness is lacking, or studies are flawed.

Nurses can explain the relation between cyclic estrogen fluctuation and changes in serotonin levels, which can lead to mood changes. Serotonin is one of the brain chemicals that assists in coping with normal life stresses. Different management strategies recommended for PMS help to produce a more stable mood by maintaining serotonin levels. Support groups or individual or couples counseling may be helpful. Stress-reduction techniques also may help with symptom management.

If these strategies do not provide significant symptom relief in 1 to 2 months, medication is often added. Many medications have been used in treatment of PMS, but no single medication alleviates all PMS symptoms. Medications often used in the treatment of PMS include diuretics, prostaglandin inhibitors (NSAIDs), progesterone, and OCPs. These have been used mainly for the physical symptoms. Studies of progesterone have not shown that it is an effective treatment (Mendiratta, 2017). Serotonergic-activating agents, including the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac or Sarafem), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil CR) are approved by the US Food and Drug Administration (FDA)

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as agents for PMS and are the first-line pharmacologic therapy (Mendiratta). Use of these medications during the luteal phase of the menstrual cycle is less expensive and has fewer side effects than drugs used before the development of these serotonergic activating agents. (Mendiratta). Common side effects are headaches, sleep disturbances, dizziness, weight gain, dry mouth, and decreased libido.

Endometriosis Endometriosis is characterized by the presence and growth of endometrial tissue outside of the uterus. The tissue may be implanted on the ovaries; anterior and posterior cul-de-sac; broad, uterosacral, and round ligaments; rectovaginal septum; sigmoid colon; appendix; pelvic peritoneum; cervix; and inguinal area (Fig. 4.2). Endometrial lesions have been found in the vagina and surgical scars and on the vulva, perineum, and bladder. They have also been found on sites far from the pelvic area such as the thoracic cavity, gallbladder, and heart. A cystic lesion of endometriosis found in the ovary is sometimes described as a chocolate cyst because of the dark coloring of the contents of the cyst caused by the presence of old blood.

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FIG 4.2 Common sites of endometriosis. (From Lobo, R.A., Gershenson, D.M., Lentz, G.M., et al. [2017]. Comprehensive gynecology [7th

ed.]. Philadelphia, PA: Elsevier.)

Endometrial tissue contains uterine glands and stroma (connective tissue) and responds to cyclic hormone stimulation in the same way that the uterine endometrium does but often out of phase with it. The tissue grows during the proliferative and secretory phases of the cycle. During or immediately after menstruation the tissue bleeds, resulting in an inflammatory response with subsequent fibrosis and adhesions to adjacent organs.

The overall incidence of endometriosis is 5% to 15% in reproductive-age women, 30% to 45% in infertile women, and 33% in women with chronic pelvic pain (Advincula, Troung, & Lobo, 2017). Although the condition usually develops in the third or fourth decade of life, endometriosis has been found in adolescents with disabling pelvic pain or abnormal vaginal bleeding. Endometriosis may worsen with repeated cycles, or it may remain asymptomatic and undiagnosed, eventually disappearing after menopause. However, it has been reported to occur in about 5% of postmenopausal women receiving menopausal hormone therapy.

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Endometriosis has been thought to be a rare occurrence in adolescents, but currently it is estimated that approximately 50% of teens with pelvic pain are found to have endometriosis (Advincula et al., 2017).

Several theories concerning the cause of endometriosis have been suggested. However, the etiology and pathology of this condition continue to be poorly understood. One of the most widely accepted theories is transplantation or retrograde menstruation. According to this theory, endometrial tissue is refluxed through the uterine tubes (also referred to as fallopian tubes) during menstruation into the peritoneal cavity, where it implants on the ovaries and other organs. Retrograde menstruation has been documented in a number of menstruating women. For most women endometrial tissue outside the uterus is destroyed before it can implant or seed in the peritoneal cavity or elsewhere. A recent theory is that there is an interaction between the amount of retrograde menstruation and an individual woman's immunologic response, which may be influenced by ethnic and genetic variability (Advincula et al., 2017).

There is a wide variation of symptoms among among women with endometriosis. It is interesting that often the extent of pain is not correlated with severity of endometriosis (Advincula et al., 2017). The major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia (painful intercourse). Women may also have chronic noncyclic pelvic pain, pelvic heaviness, or pain radiating into the thighs. Many women report bowel symptoms such as diarrhea, pain with defecation, and constipation caused by avoiding defecation because of the pain. Other symptoms include abnormal bleeding (hypermenorrhea, menorrhagia, or premenstrual staining) and pain during exercise as a result of adhesions (Advincula et al.).

Impaired fertility may result from adhesions around the uterus that pull the uterus into a fixed, retroverted position. Adhesions around the uterine tubes may block the fimbriated ends or prevent the spontaneous movement that carries the ovum to the uterus.

Management Treatment is based on the severity of symptoms and the goals of the woman or couple. Women without pain who do not want to

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become pregnant need no treatment. In women with mild pain who may desire a future pregnancy, treatment may be limited to use of NSAIDs during menstruation (see earlier discussion of these medications).

Suppression of endogenous estrogen production and subsequent endometrial lesion growth is the cornerstone of management of the disease. Two main classes of medications are used to suppress endogenous estrogen levels: GnRH agonists and androgen derivatives. GnRH agonist therapy (leuprolide [Lupron], nafarelin acetate [Synarel], goserelin acetate [Zoladex]) acts by suppressing pituitary gonadotropin secretion. FSH and LH stimulation of the ovary declines markedly, and ovarian function decreases significantly. A medically induced menopause develops, resulting in anovulation and amenorrhea. Shrinkage of already established endometrial tissue, significant pain relief, and interruption in further lesion development follow. The hypoestrogenism results in hot flashes in almost all women. Trabecular bone loss is common, although most loss is reversible within 12 to 24 months after the medication is stopped (Advincula et al., 2017).

Leuprolide (3.75 mg intramuscular injection given once a month) (Medscape, 2017), nafarelin (200 mg administered twice daily by nasal spray) (MedicineNet.com, 2017), and goserelin (3.6 mg every 28 days by subcutaneous implant) (Drugs.com, 2017) are effective and well tolerated. These medications reduce endometrial lesions and pelvic pain associated with endometriosis and have posttreatment pregnancy rates similar to that of danazol (Danocrine) therapy. Common side effects of these drugs are those of natural menopause—hot flashes and vaginal dryness. Occasionally women report headaches and muscle aches. Treatment is usually limited to 6 months to minimize bone loss. Although unlikely, it is possible for a woman to become pregnant while taking a GnRH agonist. Because the potential teratogenicity of this drug is unclear, women should use a barrier contraceptive during treatment.

Danazol, a mildly androgenic synthetic steroid, suppresses FSH and LH secretion, thus producing anovulation and hypogonadotropism. This results in decreased secretion of estrogen and progesterone and regression of endometrial tissue. Danazol can

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produce side effects severe enough to cause a woman to discontinue the drug, including masculinizing traits (weight gain, edema, decreased breast size, oily skin, hirsutism, and deepening of the voice), all of which often disappear when treatment is discontinued. Other side effects are amenorrhea, hot flashes, vaginal dryness, insomnia, and decreased libido. Migraine headaches, dizziness, fatigue, and depression are also reported. Danazol treatment has been reported to adversely affect lipids, with a decrease in high-density lipoprotein levels and an increase in low- density lipoprotein levels. Danazol should never be prescribed when pregnancy is suspected, and barrier contraception should be used with it because ovulation may not be suppressed. Danazol can produce pseudohermaphroditism in female fetuses. The medication is contraindicated in women with liver disease and should be used with caution in women with cardiac and renal disease. Danazol is less frequently used to treat endometriosis than other medical therapies (Advincula et al., 2017).

Women who have early symptomatic disease and who can postpone pregnancy may be treated with continuous OCPs that have a low estrogen-to-progestin ratio to shrink endometrial tissue. The OCPs are taken continuously for 6 to 12 months, without any withdrawal time of the OCP. This approach is believed to lead to a more complete suppression, thus decreasing the endometriosis (Advincula et al., 2017). There can be some breakthrough bleeding, however. Any low-dose OCPs can be used if taken for 15 weeks, followed by 1 week of withdrawal. This therapy is associated with minimal side effects and can be taken for extended periods. Limited data exist on the effectiveness of progestogen-only medications for treating pain related to endometriosis.

Continuous combined hormone therapy (OCPs, estrogen/progestin patch, estrogen/progestin vaginal ring) for menstrual suppression and administration of NSAIDs are the usual treatment for adolescents younger than 16 years of age who have endometriosis. GnRH agonist therapy for severe symptoms may have possible adverse effects on bone mineralization in adolescents, and bone mineral density should be carefully monitored.

Surgical intervention is often needed for severe, acute, or incapacitating symptoms. Decisions regarding the extent and type

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of surgery are influenced by a woman's age, desire for children, and location of the disease. For women who do not want to preserve their ability to have children, the only definite cure is total abdominal hysterectomy (TAH) with bilateral salpingectomy and oophorectomy (BSO). In women who want children and in whom the disease does not prevent bearing children, reproductive capacity should be retained through careful removal by laparoscopic surgery or laser therapy (coagulation, vaporization, or resection) of all endometrial tissue possible with retention of ovarian function (Advincula et al., 2017).

Regardless of the type of treatment (short of TAH with BSO), endometriosis recurs in approximately 40% of women. Thus for many women, endometriosis is a chronic disease with conditions such as chronic pain or infertility. Counseling and education are critical components of nursing care for women with endometriosis. Women need an honest discussion of treatment options, with review of the potential risks and benefits of each option. Because pelvic pain is a subjective, personal experience that can be frightening, support is important. Sexual dysfunction resulting from dyspareunia is common and may necessitate referral for counseling. Support groups for women with endometriosis may be found in some locations. Resolve (www.resolve.org), an organization for infertile couples, or the Endometriosis Association (www.ivf.com/endohtml.html) may also be helpful. The nursing care discussed in the previous section on dysmenorrhea is appropriate for managing chronic pelvic pain and dysmenorrhea experienced by women with endometriosis (see Nursing Care Plan).

Nursing Care Plan The Woman With Endometriosis

Case Study Terri is a 28-year-old married woman who has come to the Well Women's Clinic. She complains of having heavy menstrual periods that are accompanied by severe pelvic and abdominal pain (pain scale rating 7–8) that sometimes radiates down her thighs and that

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the pain has worsened over the last year or so. She has tried over- the-counter ibuprofen for the pain with some relief. She confides that sexual intercourse is often painful and that she no longer enjoys sexual relations. She says this has caused stress for her and tension between her and her husband. She added that they would like to have a child but she has not been able to conceive, although they have been trying to achieve a pregnancy for about 1 year. She states tearfully, “I feel like a failure. I hope that you can find out why I have such bad pain and bleeding and why I can't get pregnant. I am really afraid of what you are going to find and that there is nothing that can be done.”

After further assessment and diagnostic testing, endometriosis is diagnosed. The treatment plan is to suppress endogenous estrogen production and subsequent endometrial lesion growth using GnRH agonist therapy for 6 months.

Assessment

What are the common signs of acute and chronic pain associated with endometriosis?

Defining Characteristics

Self-report of pain characteristics and intensity

Alteration in ability to continue previous activities

Self-focusing

Protective behavior

Alteration in sleep pattern

Nursing Diagnosis

Acute and Chronic Pain related to menstruation secondary to endometriosis

Expected Outcome

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Terri will verbalize a decrease in intensity and frequency of pain during each menstrual cycle.

Nursing Interventions Rationales Assess location, type, and duration of pain and history of discomfort.

To determine severity of dysmenorrhea

Administer nonsteroidal antiinflammatory drugs as indicated.

To assist with pain relief

Administer hormone-altering medications as ordered.

To suppress ovulation and subsequently suppress endometrial tissue lesion growth

Provide information about use of nonpharmacologic methods such as heat.

To increase blood flow to the pelvic region

Assessment

What factors interfere with Terri's understanding of endometriosis and its treatment?

Defining Characteristics

Insufficient information about endometriosis

Verbalization of problem

Inappropriate or exaggerated behavior

Nursing Diagnosis

Deficient Knowledge related to insufficient understanding about disease process and prescribed therapy and the effects on self- care

Expected Outcome

Terri will verbalize correct understanding of endometriosis and the use of self-care methods and prescribed therapies.

Nursing Interventions Rationales Assess woman's current understanding of the disorder and related therapies.

To validate the accuracy of knowledge base

Give information to woman regarding the disorder and treatment regimen.

To empower the woman to become a partner in her own care

Assessment

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What characteristics of low self-esteem are manifested by Terri?

Defining Characteristics

Self-negating statements of feeling like a failure

Situational challenge to self-worth

Underestimates ability to deal with situation

Nursing Diagnosis

Situational Low Self-Esteem related to inability to get pregnant

Expected Outcome

Terri will verbalize positive feelings of self-worth.

Nursing Interventions Rationales Provide therapeutic communication. Include husband as appropriate.

To validate feelings and provide support

Refer to support group. To enhance feelings of self-worth through group communication

Assessment

What are common signs of anxiety for women who have endometriosis?

Defining Characteristics

Fear of what is wrong with her

Feeling of inadequacy

Helplessness

Awareness of physiologic symptoms

Nursing Diagnosis

Anxiety related to stressors, unmet needs, current health status, and

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unknown outcomes of diagnosis and treatment

Expected Outcome

Terri will report a decreased number of anxious feelings.

Nursing Interventions Rationales Provide opportunity to discuss feelings. To identify source of anxiety. Provide and reinforce information about endometriosis and the prescribed therapy.

To keep expectations realistic and dispel myths or inaccuracies.

Provide emotional support. To encourage verbalization of feelings.

Assessment

What types of stressors does Terri exhibit?

Defining Characteristics

Negative impact from stress

Tension

Impaired functioning

Nursing Diagnosis

Stress Overload related to emotional and physiologic effects of having endometriosis and infertility

Expected Outcome

Terri will verbalize understanding and accept the emotional and physiologic responses to 1 disorder.

Nursing Interventions Rationales Provide therapeutic communication.

To validate feelings of the effects of pain and stress on her life.

Alterations in Cyclic Bleeding Women often experience changes in amount, duration, interval, or regularity of menstrual cycle bleeding. Commonly women worry

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about menstruation that is infrequent (oligomenorrhea), is scanty at normal intervals (hypomenorrhea), is excessive (menorrhagia), or occurs between periods (metrorrhagia).

Treatment depends on the cause and may include education and reassurance. For example, the nurse or health care provider informs women that OCPs can cause scanty menstrual flow and midcycle spotting. Progestin intramuscular injections and implants can also cause midcycle bleeding. A single episode of heavy bleeding may signal an early pregnancy loss such as a miscarriage or ectopic pregnancy. This type of bleeding is often thought to be a period that is heavier than usual, perhaps delayed, and is associated with abdominal pain or pelvic discomfort. When early pregnancy loss is suspected, hematocrit and pregnancy tests are indicated.

Uterine leiomyomas (fibroids or myomas) are a common cause of menorrhagia. Fibroids are benign tumors of the smooth muscle of the uterus with an unknown cause. Fibroids occur in approximately 70% of women, with about 50% having symptoms (Ryntz & Lobo, 2017). Other uterine growths ranging from endometrial polyps to adenocarcinoma and endometrial cancer are common causes of heavy menstrual bleeding and intermenstrual bleeding.

Nursing Alert If the woman herself considers the amount or duration of bleeding to be excessive, the problem should be investigated.

Treatment for menorrhagia depends on the cause of the bleeding. If the bleeding is related to the contraceptive method (e.g., an intrauterine device [IUD]), the health care professional provides factual information and reassurance and discusses other contraceptive options.

If there is no known cause for the bleeding and anatomic causes have been ruled out, therapy is aimed at reducing the amount of heavy bleeding using medical rather than surgical approaches. Current options for treatment include estrogens, progestogen, NSAIDS, antifibrinolytic agents, and GnRH (Ryntz & Lobo, 2017). Nurses focus on the correct administration of these treatments and reducing potential adverse side effects, such as gastrointestinal distress with NSAIDS.

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If bleeding is related to the presence of fibroids, the degree of disability and discomfort associated with the fibroids and the woman's plans for childbearing influence treatment decisions. Treatment options include medical and surgical management. Most fibroids can be monitored by frequent examinations to judge growth, if any, and correction of anemia if present. It is important to warn women with metrorrhagia to avoid using aspirin because of its tendency to increase bleeding. Medical treatment is directed toward temporarily reducing symptoms, shrinking the myoma, and reducing its blood supply. This reduction is often accomplished with the use of a GnRH agonist. There is evidence that following cessation of treatment, blood loss may return to levels that existed prior to treatment (Ryntz & Lobo, 2017). If the woman wishes to retain childbearing potential, a myomectomy may be performed. Myomectomy, or removal of the tumors only by laparoscopic or hysteroscopic resection or laser surgery, is particularly difficult if multiple myomas must be removed. One in four women will have a hysterectomy performed within 20 years of having a myomectomy. If the woman does not want to preserve her childbearing function or if she has severe symptoms (severe anemia, severe pain, considerable disruption of lifestyle), uterine artery embolization (UAE) (procedure that blocks blood supply to fibroid), or hysterectomy (removal of uterus) may be performed. Neither procedure is considered to be very effective unless the cause of the excessive bleeding is fibroids (Ryntz & Lobo). Important nursing roles include reassurance, counseling, education, and support.

Dysfunctional Uterine Bleeding Abnormal uterine bleeding (AUB) is any form of uterine bleeding that is irregular in amount, duration, or timing and is not related to regular menstrual bleeding. Box 4.1 lists possible causes of AUB. Although often used interchangeably, the terms AUB and dysfunctional uterine bleeding (DUB) are not synonymous. AUB can have organic causes such as systemic diseases, reproductive tract disease, as well as hormonal causes, while DUB occurs in the absence of organic, systemic causes.

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Box 4.1 Possible Causes of Abnormal Uterine Bleeding Pregnancy-Related Conditions

• Threatened or spontaneous miscarriage

• Retained products of conception after elective abortion

• Ectopic pregnancy

• Placenta previa/placental abruption

• Trophoblastic disease

Lower Reproductive Tract Infections

• Cervicitis

• Endometritis

• Myometritis

• Salpingitis

Benign Anatomic Abnormalities

• Adenomyosis

• Leiomyomata

• Polyps of the cervix or endometrium

Neoplasms

• Endometrial hyperplasia

• Cancer of cervix and endometrium

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• Hormonally active tumors (rare)

• Vaginal tumors (rare)

Malignant Lesions

• Cervical squamous cell carcinoma

• Endometrial adenocarcinoma

• Estrogen-producing ovarian tumors

• Testosterone-producing ovarian tumors

• Leiomyosarcoma

Trauma

• Genital injury (accidental, coital trauma, sexual abuse)

• Foreign body

• Lacerations

Systemic Conditions

• Adrenal hyperplasia and Cushing's disease

• Blood dyscrasias

• Coagulopathies

• Hypothalamic suppression (from stress, weight loss, excessive exercise)

• Polycystic ovary disease

• Thyroid disease

• Pituitary adenoma or hyperprolactinemia

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• Severe organ disease (renal or liver failure)

Iatrogenic Causes

• Medications with estrogenic activity

• Anticoagulants

• Exogenous hormone use (oral contraceptives, menopausal hormone therapy)

• Selective serotonin reuptake inhibitors

• Tamoxifen

• Intrauterine devices

• Herbal preparation (ginseng)

Modified from Albers, J. R., Hull, S. K., Wesley, R. M. (2004). Abnormal uterine bleeding, American Family Physician, 69, 1915–1926, 1931–1932; Ryntz, T., & Lobo, R. A. (2017). Abnormal uterine bleeding: Etiology and management of acute and chronic excessive bleeding. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Philadelphia, PA: Elsevier.

DUB can be anovulatory or ovulatory but is most commonly caused by anovulation. When no surge of LH occurs or if insufficient progesterone is produced by the corpus luteum to support the endometrium, it will begin to involute and shed. This process most often occurs at the extremes of a woman's reproductive years, when the menstrual cycle is just becoming established at menarche or when it draws to a close at menopause. DUB also occurs with any condition that gives rise to chronic anovulation associated with continuous estrogen production. Such conditions include obesity, hyperthyroidism and hypothyroidism, polycystic ovary syndrome, and any of the endocrine conditions discussed in the sections on amenorrhea and oligomenorrhea. A diagnosis of DUB is made only after ruling out all other organic causes of abnormal menstrual bleeding.

Management

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The most effective medical treatment of acute bleeding episodes of DUB is administration of oral or intravenous estrogen. Dilation and curettage (D&C) may be done if the bleeding has not stopped in 12 to 24 hours. An oral conjugated estrogen and progestin regimen is usually given for at least 3 months after the acute phase has passed. Such long-term treatment will help prevent recurrence of the pattern of DUB and hemorrhage. If the woman wants contraception, she should continue to take OCPs. If she has no need for contraception, the treatment may be stopped to assess the woman's bleeding pattern. If her menses does not resume, a progestin regimen (e.g., medroxyprogesterone, 10 mg each day for 10 days before the expected date of her menstrual period) may be prescribed after ruling out pregnancy. This is done to prevent persistent anovulation with chronic unopposed endogenous estrogen hyperstimulation of the endometrium, which can result in eventual atypical tissue changes. This approach usually successfully leads to regular withdrawal bleeding (Ryntz & Lobo, 2017).

If the recurrent, heavy bleeding is not controlled by hormone therapy or D&C, ablation of the endometrium through laser treatment may be performed. Nursing roles include informing patients of their options, counseling and education as indicated, and referring to the appropriate specialists and health care services.

Nursing assessments for women who have a menstrual disorder include the following: • Taking a thorough menstrual, obstetric, sexual, and contraceptive

history. • Exploring the woman's perceptions of her condition, cultural or

ethnic influences, lifestyle, and patterns of coping. • Evaluating the amount of pain or bleeding experienced and its

effect on daily activities. • Noting any home remedies and prescriptions to relieve

discomfort. A symptom diary, in which the woman records emotions, behaviors, physical symptoms, diet, and exercise and rest patterns, is a useful diagnostic tool.

In addition to the medical, surgical, and nursing interventions discussed with each problem, additional nursing interventions may include the following:

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• Accepting the woman's symptoms as valid. • Correlating data from the daily diary of emotional status,

subjective feelings, and physical state with physiologic changes. • Encouraging the woman to express her feelings about her

symptoms. • Providing information about therapeutic options (pharmacologic

and nonpharmacologic) so the woman (couple) makes (make) choices considered best for her (them).

• Providing information about local support groups.

Infections Infections of the reproductive tract can occur throughout a woman's life and are often the cause of significant reproductive morbidity, including ectopic pregnancy and tubal factor infertility. The direct economic costs of these infections can be substantial, and the indirect cost is equally overwhelming. Some consequences of maternal infection such as infertility last a lifetime. The emotional costs may include damaged relationships and lowered self-esteem. Nurses and other health care personnel must be aware of universal precautions to prevent transmission of infections.

Sexually Transmitted Infections Sexually transmitted infections (STIs) are infections or infectious disease syndromes transmitted primarily by sexual contact. The term sexually transmitted infection includes more than 25 infectious organisms that are transmitted through sexual activity and the dozens of clinical syndromes that they cause (Box 4.2). STIs are among the most common health problems in the United States today, with increases seen in 2014 in the three nationally reportable STIs (chlamydia, gonorrhea, and syphilis) (CDC, 2017b). The following discussion focuses on the most common STIs in women. Chapter 25 discusses neonatal effects.

Box 4.2

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Sexually Transmitted Infections Bacteria

• Chlamydia

• Gonorrhea

• Syphilis

• Group B streptococci

Protozoa

• Trichomoniasis

Viruses

• Human immunodeficiency virus

• Herpes simplex virus, types 1 and 2

• Viral hepatitis A and B

• Human papillomavirus

Prevention Preventing infection (primary prevention) is the most effective way of reducing the adverse consequences of STIs for women. Prompt diagnosis and treatment of current infections (secondary prevention) also can prevent complications and transmission to others. Preventing the spread of STIs requires that women at risk for transmitting or acquiring infections change their behavior. A critical first step is to include questions about a woman's sexual history, sexual risk behaviors, and drug-related risky behaviors as a part of her assessment. The CDC (2017a) has created the “five Ps” as a guide to questions that help to assess risky behaviors: partners, practices, prevention of pregnancy, protection from STIs, and past history of STIs (Box 4.3). Identification of risk factors or risky

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behaviors is followed by prevention counseling. Techniques that are effective in providing prevention counseling include using open-ended questions, using understandable language, and reassuring the woman that treatment will be provided regardless of considerations such as ability to pay, language spoken, or lifestyle. Prevention messages should include descriptions of specific actions to prevent contracting or transmitting STIs (e.g., refraining from sexual activity when STI-related symptoms are present) and should be individualized for each woman, giving attention to her specific risk factors.

Box 4.3 Assessing Sexually Transmitted Infection and Human Immunodeficiency Virus Risk Behaviors: The Five Ps Partners

• Have your partners been men, women, both?

• Ever thought that a sex partner put you at risk for AIDS or an STI (IV drug user, bisexual)?

Practices

• Are you sexually active now?

• If no, have you had sex in the past?

• Ever had an oral, vaginal, or anal sexual experience with another person?

• With how many different people? 1? 2 or 3? 4 to 10? More than 10?

Prevention of Pregnancy

• Do you use male condoms? Female condoms? Other barriers?

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Protection From STIs

• Ever injected drugs using shared equipment, including street drugs, steroids?

• Ever had sex with a person who uses and shares?

• Ever had sex while so stoned, high, or drunk that you can't remember the details?

• Ever exchanged sex for drugs, money, shelter?

• Ever had sex against your will?

• What do you do to protect yourself from HIV and STIs?

• Ever had a blood transfusion?

• Ever had sex with a person who had a blood transfusion?

• Ever had sex with a person with hemophilia?

• Ever received donor semen, egg, transplanted organ or tissue?

• Ever shared equipment for tattoo, body piercing?

Past History of STIs

• Ever had an STI (herpes, gonorrhea, genital warts, chlamydia)?

• Ever had a test for HIV?

• Ever worried about AIDS and would like to talk with someone about it?

From Centers for Disease Control and Prevention. (2017). Sexually transmitted disease treatment guidelines. Retrieved from https://www.cdc.gov/std/tg2015/clinical.htm.

To be motivated to take preventive actions, a woman must believe that acquiring a disease will be serious for her and that she is at risk for infection. Most individuals tend to underestimate their

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personal risk for infection in a given situation. Thus many women may not perceive themselves as being at risk for contracting an STI, and telling them that they should carry condoms may not be well received. Although levels of awareness of STIs are generally high, widespread misconceptions or specific gaps in knowledge also exist. Therefore nurses have a responsibility to provide their patients with accurate, comprehensive information about transmission and symptoms of STIs and the behaviors that place them at risk for contracting an infection.

Primary preventive measures are individual activities aimed at avoiding infection. Risk-free options include complete abstinence from sexual activities that transmit semen, blood, or other body fluids or that allow for skin-to-skin contact (CDC, 2017b). Involvement in a mutually monogamous relationship with an uninfected partner also eliminates the risk for contracting STIs.

Sexually Transmitted Infections/Human Immunodeficiency Virus Prevention Strategies An essential component of primary prevention is counseling the woman regarding sexual practices so she can avoid acquiring or transmitting STIs, including attaining knowledge of her partner, reducing her number of partners, practicing low-risk sex, avoiding the exchange of body fluids, and vaccination.

Reducing the number of partners and avoiding partners who have had many previous sexual partners decrease a woman's chances of contracting an STI. Discussing each new partner's previous sexual history and exposure to STIs augments other efforts to reduce risk; however, sexual partners are not always truthful about their sexual history.

Women should be taught low-risk sexual practices and which sexual practices to avoid. Sexual fantasizing is safe, as are caressing, hugging, body rubbing, and massage. Mutual masturbation is low risk as long as there is no contact with a partner's semen or vaginal secretions. All sexual activities are safe when both partners are monogamous, trustworthy, and known (by testing) to be free of disease. Anal-genital intercourse, anal-oral contact, and anal-digital activity are high-risk sexual behaviors and should be avoided.

The physical barrier promoted for the prevention of sexual

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transmission of human immunodeficiency virus (HIV) and other STIs is the latex male condom. The nurse should remind women to use a condom with every sexual encounter; to use latex or plastic male condoms rather than natural skin condoms for STI protection; to use a condom with a current expiration date; to use each one only once; and to handle it carefully to avoid damaging it with fingernails, teeth, or other sharp objects. Condoms should be stored away from high heat. Although it is not ideal, women may choose to safely carry condoms in wallets, shoes, or inside a bra. They can be taught the differences among condoms: price ranges, sizes, and where they can be purchased. Explicit instructions for how to apply a male condom are included in Chapter 5.

The female condom (i.e., a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina) has been shown in laboratory studies to be an effective mechanical barrier to viruses, including HIV. Studies suggest that, while more costly than the male condom, the female condom is managed by the woman, adding to its effectiveness in preventing transmission of STIs (CDC, 2017b). What is important and should be stressed by nurses is the consistent use of condoms for every act of sexual intimacy when there is the possibility of transmission of disease.

Evidence has shown that vaginal spermicides do not protect against certain STIs (e.g., chlamydia, cervical gonorrhea) and that frequent use of spermicides containing nonoxynol-9 has been associated with genital lesions and may increase HIV transmission. Condoms lubricated with nonoxynol-9 are not recommended (CDC, 2017b).

Vaccination is an effective method for the prevention of some STIs such as hepatitis B and human papillomavirus (HPV). Hepatitis B vaccine is recommended for women at high risk for STIs. A vaccine is available for HPV types 6, 11, 16, and 18 for girls and women 9 to 26 years of age and for boys 9 to 21 years of age (CDC, 2017b) (see later discussion).

It is important to counsel women to be alert for situations that make it hard to talk about and practice risk reduction. These situations include romantic times when condoms are not available and when alcohol or drugs make it difficult to make wise decisions.

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Sexually Transmitted Bacterial Infections Chlamydia Chlamydia trachomatis is the most frequently reported infectious disease in the United States, yet many cases are asymptomatic (CDC, 2017a). These infections are often silent and highly destructive; their sequelae and complications are very serious. In women, chlamydial infections are difficult to diagnose; the symptoms, if present, are nonspecific, and the organism is expensive to culture.

Acute salpingitis, or pelvic inflammatory disease, is the most serious complication of chlamydial infections. Past chlamydial infections are associated with an increased risk for ectopic pregnancy and tubal factor infertility. Furthermore, chlamydial infection of the cervix causes inflammation, resulting in microscopic cervical ulcerations that may increase the risk for acquiring HIV infection. More than one-half of infants born to mothers with chlamydia will develop conjunctivitis or pneumonia after perinatal exposure to the mother's infected cervix. C. trachomatis is the most common infectious cause of ophthalmia neonatorum.

Sexually active women younger than 25 years of age are the ones most likely to become infected with chlamydia (CDC, 2017b). Women older than 30 years of age have the lowest rate of infection. Risky behaviors, including multiple partners and not using barrier methods of birth control, increase a woman's risk for chlamydial infection.

Screening and Diagnosis In addition to obtaining information regarding the presence of risk factors (e.g., women younger than 25 years of age, older women who do not use barrier contraceptives, women with new or multiple partners), the nurse inquires about the presence of any symptoms. Although infection is usually asymptomatic, some women may experience spotting or postcoital bleeding, mucoid or purulent cervical discharge, or dysuria. Bleeding results from inflammation and erosion of the cervical columnar epithelium.

Laboratory diagnosis of chlamydia is by culture (expensive and labor-intensive), DNA probe (relatively less expensive but less

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sensitive), enzyme immunoassay (also relatively less expensive but less sensitive), and nucleic acid amplification tests (NAATs) (expensive but have relatively higher sensitivity) of urine specimens or specimens from the endocervix/vagina (CDC, 2017a). All pregnant women should have cervical cultures for chlamydia at the first prenatal visit. Screening late in the third trimester (36 weeks) may be carried out if the woman was positive previously or if she is younger than 25 years of age, has a new sex partner, or has multiple sex partners.

Management The CDC (2015b) recommendations for the treatment of chlamydial infections include doxycycline or azithromycin (Table 4.3). Azithromycin is often prescribed when compliance is a problem because only one dose is needed. Because chlamydia is often asymptomatic, women must take all prescribed medication. All exposed sexual partners should be treated. Women treated with doxycycline or azithromycin do not need to be retested unless symptoms continue (CDC, 2017b).

TABLE 4.3 Sexually Transmitted Infections and Drug Therapies for Women*

Disease Nonpregnant Women (13–17 Years)

Nonpregnant Women (>18 Years)

Pregnant Women LactatingWomen†

Chlamydia Recommended: Recommended: Recommended: Recommended: Azithromycin, 1 g orally once

Azithromycin, 1 g orally once

Azithromycin, 1 g orally once

Azithromycin, 1 g orally onceor or

Doxycycline, 100 mg orally bid for 7 days

Doxycycline, 100 mg orally bid for 7 days

Alternatives: Alternatives: Alternatives: Alternatives: Erythromycin base 500 mg orally qid for 7 days

Erythromycin base 500 mg orally qid for 7 days

Amoxicillin, 500 mg orally tid for 7 days

Amoxicillin, 500 mg orally tid for 7 days

or or or or Erythromycin ethylsuccinate 800 mg orally qid for 7 days

Erythromycin ethylsuccinate 800 mg orally qid for 7 days

Erythromycin base 500 mg orally qid for 7 days

Erythromycin base 500 mg orally qid for 7 days

or or or or Levofloxacin Levofloxacin 500 Erythromycin base 250 mg Erythromycin

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500 mg orally once a day for 7 days

mg orally once a day for 7 days

orally qid for 14 days base 250 mg orally qid for 14 days

or or or or Ofloxacin 300 mg orally bid for 7 days

Ofloxacin 300 mg orally bid for 7 days

Erythromycin ethylsuccinate 800 mg orally qid for 7 days

Erythromycin ethylsuccinate 800 mg orally qid for 7 days

or or Erythromycin ethylsuccinate 400 mg orally qid for 14 days

Erythromycin ethylsuccinate 400 mg orally qid for 14 days

Gonorrhea Recommended: Recommended: Recommended: Recommended: Ceftriaxone, 125 mg IM once (adolescents who weigh >45 kg can be treated with any regimen recommended for adults)

Ceftriaxone, 250 mg IM once

Ceftriaxone, 250 mg IM once

Ceftriaxone, 250 mg IM once

Plus treatment for chlamydia as above

Plus Azithromycin 1 gm orally in a single dose

Plus Azithroymycin 1 gm orally in a single dose

Plus Azithromycin 1 gm orally in a single dose

Syphilis Primary, secondary, early-latent disease:

Primary, secondary, early-latent disease:

Primary, secondary, early- latent disease:

Primary, secondary, early-latent disease:

Recommended: Recommended: Recommended: Recommended: Benzathine penicillin G, 2.4 million units IM once

Benzathine penicillin G, 2.4 million units IM once

Benzathine penicillin G, 2.4 million units IM once (some experts recommend a second dose of benzathine penicillin, 2.4 million units, 1 week later)

Benzathine penicillin G, 2.4 million units IM once

Late-latent or unknown- duration disease:

Late-latent or unknown- duration disease:

Late-latent or unknown- duration disease:

Recommended: Recommended: Recommended: Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1-week intervals

Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1-week intervals

Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1-week intervals No proven alternatives to penicillin in pregnancy Pregnant women who have a history of allergy to penicillin should be desensitized and treated with penicillin

Penicillin allergy:

Penicillin allergy:

Doxycycline, Doxycycline, 100

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100 mg orally qid for 14 days

mg orally qid for 14 days

or or

Tetracycline, 500 mg orally qid for 14 days

Tetracycline, 500 mg orally qid for 14 days

Human papillomavirus

Recommended for external genital warts:

Recommended for external genital warts:

Recommended for external genital warts:

Recommended for external genital warts:

Patient-applied: Patient-applied: Provider applied: Provider applied:

Podofilox, 0.5% solution, or gel to wart bid for 3 days followed by 4-day rest for ≤4 cycles

Podofilox, 0.5% solution, or gel to wart bid for 3 days followed by 4-day rest for ≤4 cycles

Cryotherapy with liquid nitrogen or cryoprobe

Cryotherapy with liquid nitrogen or cryoprobe

or or or or Imiquimod, 5% cream, hs 3 times a week for ≤16 weeks

Imiquimod, 5% cream, hs 3 times a week for ≤16 wk

TCA or BCA 80%–90% weekly

TCA or BCA 80%–90% weekly

Imiquimod, podophyllin (Podocon-25), sinecatechins, and podofilox should not be used in pregnancy

Imiquimod, podophyllin, sinecatechins, and podofilox should not be used during lactation

or or Sinecatechins 15% ointment tid for ≤16 weeks

Sinecatechins 15% ointment tid for ≤16 wk

Provider- applied:

Provider- applied:

Cryotherapy with liquid nitrogen or cryoprobe

Cryotherapy with liquid nitrogen or cryoprobe

or or Podophyllin resin, 10%–25% in tincture of benzoin compound weekly (wash off in 1–4 hours). Repeat weekly as necessary

Podophyllin resin, 10%–25% in tincture of benzoin compound weekly (wash off in 1–4 hours). Repeat weekly as necessary

or or Trichloracetic acid (TCA) or bichloracetic acid (BCA)

TCA or BCA 80%–90% weekly

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80%–90% weekly

Genital herpes simplex virus (HSV-1 or HSV-2)

Primary infection:

Primary infection:

No increase in birth defects beyond the general population has been found with acyclovir use in pregnancy Acyclovir, 400 mg orally tid for 7 days for first episode or severe recurrent infection; may be given IV if infection is severe Suppression therapy with acyclovir 400 ms orally tid or valacyclovir 500 mg orally bid; if taken 4 weeks before the birth, women with recurrent infections can reduce the need for a cesarean birth

Acyclovir usually is considered compatible with breastfeeding Acyclovir, 400 mg tid for 7 days

Acyclovir, 400 mg orally tid for 7–10 days

Acyclovir, 400 mg orally tid for 7–10 days

or or Acyclovir, 200 mg orally 5 times a day for 7–10 days

Acyclovir, 200 mg orally 5 times a day for 7-10 days

or or Valacyclovir, 1 g orally bid for 7– 10 days

Valacyclovir, 1 g orally bid for 7– 10 days

or or Famciclovir, 250 mg orally tid for 7–10 days

Famciclovir, 250 mg orally tid for 7–10 days

Recurrent infection:

Recurrent infection:

Acyclovir, 400 mg orally tid for 5 days

Acyclovir, 400 mg orally tid for 5 days

or or Acyclovir, 800 mg orally bid for 5 days

Acyclovir, 800 mg orally bid for 5 days

or or Acyclovir, 800 mg orally tid for 2 days

Acyclovir, 800 mg orally tid for 2 days

or or Valacyclovir, 500 mg orally bid for 3 days

Valacyclovir, 500 mg orally bid for 3 days

or or Valacyclovir, 1 g orally once a day for 5 days

Valacyclovir, 1 g orally once a day for 5 days

Famciclovir, 125 mg orally bid for 5 days

Famciclovir, 125 mg orally bid for 5 days

or or Famciclovir 1000 mg orally bid for 1 day

Famciclovir, 1000 mg orally bid for 1 day

or or Famciclovir, 500 mg once, then 250 mg bid for 2 days

Famciclovir 500 mg once, then 250 mg bid for 2 days

Suppression Suppression

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therapy: therapy: Take daily for 1 year or more:

Take daily for 1 year or more:

Acyclovir, 400 mg orally bid

Acyclovir, 400 mg orally bid

or or

Famciclovir, 250 mg orally bid

Famciclovir, 250 mg orally bid

or or Valacyclovir, 500 mg orally once a day

Valacyclovir, 500 mg orally once a day

or or Valacyclovir, 1 g orally once a day

Valacyclovir, 1 g orally once a day

*List is not inclusive of all drugs that may be used as alternatives. †These medications are usually compatible with breastfeeding. bid, Twice daily; hs, at bedtime; HSV, herpes simplex virus; IM, intramuscularly; IV, intravenously; qid, four times daily; tid, three times daily. Data from Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases treatment guidelines. Retrieved from http://www.cdc.gov/std/tg2015/clinical.htm.

Gonorrhea Gonorrhea is probably the oldest communicable disease in the United States. An estimated 820,000 American men and women contract gonorrhea each year (CDC, 2017a). The incidence of drug- resistant cases of gonorrhea, in particular penicillinase-producing Neisseria gonorrhoeae, is increasing dramatically in the United States.

Gonorrhea is caused by the aerobic, gram-negative diplococci N. gonorrhoeae. It is almost exclusively transmitted by sexual contact. The principal means of transmission is genital-to-genital contact during sexual activity; however, it is also spread by oral-genital and anal-genital contact. There is also evidence that infection may spread in females from vagina to rectum. Although the organism has been recovered from inanimate objects artificially inoculated with the bacteria, there is no evidence that natural transmission occurs this way.

Age is probably the most important risk factor associated with gonorrhea. In the United States, the highest reported rates of

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infection are among sexually active teenagers and young adults. The majority of those contracting gonorrhea are younger than 20 years of age and engage in sexual activities with multiple partners. Routine screening is advised for all sexually active women younger than 25 years of age and older women who are at risk due to multiple sex partners or a new sex partner.

Women are often asymptomatic; but, when they are symptomatic, they may have a greenish-yellow purulent endocervical discharge or may experience menstrual irregularities. Women may complain of pain (i.e., chronic or acute severe pelvic or lower abdominal pain) or menses that last longer or are more painful than normal. Gonococcal rectal infection may occur in women after anal intercourse. Individuals with rectal gonorrhea may be completely asymptomatic or may experience severe symptoms with profuse purulent anal discharge, rectal pain, and blood in the stool. Rectal itching, fullness, pressure, and pain are also common symptoms, as is diarrhea. A diffuse vaginitis with vulvitis is the most common form of gonococcal infection in prepubertal girls. Signs of infection may include vaginal discharge, dysuria, or swollen, reddened labia.

Gonococcal infections in pregnancy potentially affect both mother and infant. Women with cervical gonorrhea may develop salpingitis in the first trimester. Perinatal complications of gonococcal infection include premature rupture of the membranes, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restriction, and maternal postpartum sepsis. Amniotic infection syndrome—manifested by placental, fetal, and umbilical cord inflammation following premature rupture of the membranes —may result from gonorrheal infection during pregnancy.

Screening and Diagnosis All pregnant women should be screened at the first prenatal visit, and infected women and those identified with risky behaviors rescreened at 36 weeks of gestation. Gonococcal infection cannot be diagnosed reliably by clinical signs and symptoms alone. Individuals may have “classic” symptoms, vague symptoms that may be attributed to a number of conditions, or no symptoms at all. Cultures should be obtained from the endocervix, the rectum, and

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when indicated, the pharynx. Thayer-Martin cultures are recommended to diagnose gonorrhea in women. Because coinfection is common, any woman suspected of having gonorrhea should have a chlamydial culture and serologic test for syphilis unless one has been done within the past 2 months.

Management Management of gonorrhea is becoming more challenging as drug- resistant strains are increasing. The treatment of choice for uncomplicated urethral, endocervical, and rectal infections in pregnant and nonpregnant women is ceftriaxone given intramuscularly once. The CDC also recommends concomitant treatment for chlamydia because coinfection is common (CDC, 2017b) (see Table 4.3). All women with both gonorrhea and syphilis should also be treated for syphilis according to CDC guidelines (see discussion of syphilis in the “Syphilis” section later in this chapter).

Gonorrhea is highly communicable. Recent (past 30 days) sexual partners should be examined, cultured, and treated with appropriate regimens. Most treatment failures result from reinfection. The woman needs to be informed of this and of the consequences of reinfection in terms of chronicity, complications, and potential infertility. Women are counseled to use condoms. All women with gonorrhea should be offered confidential counseling and testing for HIV infection.

Syphilis Syphilis, one of the earliest described STIs, is caused by Treponema pallidum, a motile spirochete. Transmission is thought to be by entry through microscopic abrasions in the subcutaneous tissue, which can occur during sexual intercourse. The disease can also be transmitted through kissing, biting, or oral-genital sex. Transplacental transmission may occur at any time during pregnancy; the degree of risk is related to the quantity of spirochetes in the maternal bloodstream. Syphilis rates increased in women and men in 2014-2015, with an increase of 18.1% in men and 27.3% in women. This increase in syphilis rates in women raises concerns about congenital syphilis (CDC, 2017b). In 2013–2014, the rate rose for men by 14.5% and for women by 22.7% (CDC, 2017b).

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Syphilis is a complex disease that can lead to serious systemic disease and even death when untreated. Infection manifests itself in distinct stages with different symptoms and clinical manifestations. Primary syphilis is characterized by a primary lesion, the chancre, which appears 5 to 90 days after infection (Fig. 4.3, A). This lesion often begins as a painless papule at the site of inoculation and erodes to form a nontender, shallow, indurated, clean ulcer several millimeters to centimeters in size. Secondary syphilis occurs 6 weeks to 6 months after the appearance of the chancre. It is characterized by a widespread, symmetric, maculopapular rash on the palms and soles and generalized lymphadenopathy. The infected individual also may experience fever, headache, and malaise. Condylomata lata (broad, painless, pink-gray, wartlike infectious lesions) may develop on the vulva, perineum, or anus (see Fig. 4.3, B). If the woman is untreated, she enters a latent phase that is asymptomatic for the majority of individuals. Left untreated, about one-third of these women will develop tertiary syphilis. Neurologic, cardiovascular, musculoskeletal, or multiorgan system complications can develop in the third stage.

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FIG 4.3 Syphilis. A, Primary stage: chancre with inguinal adenopathy. B, Secondary stage:

condylomata lata.

Screening and Diagnosis All women who are diagnosed with another STI or with HIV should be screened for syphilis. All high-risk pregnant women should be screened for syphilis at the first prenatal visit, again in the late third trimester, and at the time of giving birth if high risk. Diagnosis depends on microscopic examination of primary and secondary lesion tissue and serology during latency and late infection. A test for antibodies may not be reactive in the presence of active infection because it takes time for the immune system of the body to develop antibodies to any antigens. Up to one-third of

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people with early primary syphilis may have nonreactive serologic tests. Two types of serologic tests are used: nontreponemal and treponemal. Nontreponemal antibody tests such as Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) are used as screening tests. False-positive results are not unusual, particularly when conditions such as acute infection, autoimmune disorders, malignancy, pregnancy, and drug addiction exist and after immunization or vaccination. The treponemal tests, fluorescent treponemal antibody absorbed, and microhemagglutination assays for antibody to T. pallidum are used to confirm positive results. Test results in patients with early primary or incubating syphilis may be negative. Seroconversion usually takes place 6 to 8 weeks after exposure; thus testing should be repeated in 1 to 2 months when a suggestive genital lesion exists.

Tests (e.g., wet preparations and cultures) for concomitant STIs (e.g., chlamydia, gonorrhea) should be done. HIV testing is also offered if indicated.

Management Penicillin G is the preferred drug for treating patients with all stages of syphilis, including pregnant women (see Table 4.3). Although doxycycline, tetracycline, and erythromycin are alternative treatments for penicillin-allergic patients, both tetracycline and doxycycline are contraindicated in pregnancy, and erythromycin is unlikely to cure a fetal infection. Therefore if necessary, pregnant women should receive skin testing and be treated with penicillin or be desensitized. Specific protocols are recommended by the CDC (2017b).

Nursing Alert Patients treated for syphilis may experience a Jarisch-Herxheimer reaction. This is an acute febrile reaction often accompanied by headache, myalgias, and arthralgias that develop within the first 24 hours of treatment. The reaction may be treated symptomatically with analgesics and antipyretics. If treatment precipitates this reaction in the second half of pregnancy, women are at risk for preterm labor and birth. They should be advised to contact their

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health care provider if they notice any change in fetal movement or have any contractions.

Monthly follow-up is mandatory, so repeated treatment may be given if needed. The nurse should emphasize the necessity of long- term serologic testing even in the absence of symptoms. The woman should be advised to practice sexual abstinence until treatment is completed, all evidence of primary and secondary syphilis is gone, and serologic evidence of a cure is demonstrated. Women should be told to notify all partners who may have been exposed. They should be informed that the disease is reportable. Preventive measures should be discussed.

Legal Tip Reporting a Communicable Disease

Both gonorrhea and syphilis are reportable communicable diseases (CDC, 2015). Health care providers are legally responsible for reporting all cases of gonorrhea and syphilis to health authorities, usually the local health department in the patient's county of residence. Women should be informed that the case will be reported, told why, and informed of the possibility of being contacted by a health department epidemiologist.

Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine tubes, causing salpingitis; the uterus, causing endometritis; and, more rarely, the ovaries and peritoneal surfaces. Multiple organisms have been found to cause PID. In the past, the most common causative organisms were N. gonorrhoeae and C. trachomatis, as well as a wide variety of anaerobic and aerobic bacteria. PID encompasses a wide variety of pathologic processes; the infection can be acute, subacute, or chronic and can have a wide range of symptoms.

Most PID results from the ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. This spread most commonly occurs at the end of or just after menses

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following reception of an infectious agent. During the menstrual period, several factors facilitate the development of an infection: the cervical os is slightly open, the cervical mucus barrier is absent, and menstrual blood is an excellent medium for growth. PID also may develop after a miscarriage or an induced abortion, pelvic surgery, or childbirth.

Risk factors for acquiring PID are those associated with the risk for contracting an STI, including young age, multiple partners, high rate of new partners, and a history of STIs. Women who use IUDs may be at increased risk for PID if they have more than one sexual partner or if the partner has other sexual partners because they are at higher risk for acquiring an STI. Most of this risk occurs at the time of placement and in the 3 weeks after IUD insertion (Gardella et al., 2017). PID tends to recur.

Women who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. After a single episode of PID, a woman's risk for ectopic pregnancy increases sevenfold compared with the risk for women who have never had it. Other problems associated with PID include dyspareunia, pyosalpinx (pus in the uterine tubes), tubo-ovarian abscess, and pelvic adhesions.

The symptoms of PID vary, depending on whether the infection is acute, subacute, or chronic; however, pain is common to all types of infection. It may be dull, cramping, intermittent (subacute) or severe, persistent, and incapacitating (acute). Women may also report one or more of the following: fever, chills, nausea and vomiting, increased vaginal discharge, symptoms of a urinary tract infection, and irregular bleeding. Abdominal pain is usually present.

Screening and Diagnosis PID is difficult to diagnose because of the accompanying wide variety of symptoms. The CDC (2017b) recommends treatment for PID in all sexually active young women and others at risk for STIs if the following criteria are present and no other cause or causes of the illness are found: lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness. Other criteria for diagnosing PID include an oral temperature of 38.3° C (100.9° F) or

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above, abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. Elevated C-reactive protein is not considered to be reliable in guiding treatment (Gardella, Eckert, & Lentz, 2017).

Management Perhaps the most important nursing intervention is prevention counseling. Primary prevention includes education in avoiding contracting STIs; secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. Instructing women in self-protective behaviors such as practices to avoid contracting STIs and using barrier methods is critical. Women using hormonal contraception or an IUD and those who have chosen tubal ligation must be reminded to use a condom with intercourse when indicated. Also important is the detection of asymptomatic gonorrheal and chlamydial infections through routine screening of women who practice risky behaviors or have specific risk factors such as age.

Although treatment regimens vary with the infecting organism, generally a broad-spectrum antibiotic is used (Gardella et al., 2017). Treatment for mild-to–moderately severe PID may be oral (e.g., ceftriaxone plus doxycycline with or without metronidazole) or parenteral (e.g., cefotetan or cefoxitin plus doxycycline [oral]), and regimens can be administered in inpatient or outpatient settings. It was previously recommended that pregnant women be hospitalized and given parenteral antibiotics, but current guidelines do not support this practice (Gardella et al.).

The woman with acute PID should be on bed rest in a semi- Fowler's position. Comfort measures include analgesics for pain and all other nursing measures applicable to a patient confined to bed. Few pelvic examinations should be done during the acute phase of the disease. During the recovery phase, the woman should restrict her activity and make every effort to get adequate rest and a nutritionally sound diet. Follow-up laboratory work after treatment should include endocervical cultures for a test of cure.

Health education is central to effective management of PID. Nurses should explain the nature of the disease to women and

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encourage them to comply with all therapy and prevention recommendations, emphasizing the need to take all medication, even if symptoms disappear. Any potential problems (such as a lack of money for prescriptions or a lack of transportation to return for follow-up appointments) that would prevent a woman from completing a course of treatment should be identified, referrals made for assistance as needed, and the importance of follow-up visits stressed. Women should be counseled to refrain from sexual intercourse until their treatment is completed. Contraceptive counseling, including information on barrier methods such as condoms, the contraceptive sponge, and the diaphragm, should be provided.

The potential or actual loss of reproductive capabilities can be devastating and can adversely affect the woman's self-concept. Part of the nurse's role is to help the woman adjust her self-concept to fit reality and accept alterations in a way that promotes health. Because PID is so closely tied to sexuality, body image, and self- concept, the woman diagnosed with it needs supportive care. Her feelings should be discussed, and her partner(s) included when appropriate.

Sexually Transmitted Viral Infections Human Papillomavirus Human papillomavirus (HPV), also known as condylomata acuminata or genital warts, is the most common viral STI seen in ambulatory health care settings. There are approximately 100 types of HPV, which is a double-stranded DNA virus, with about 40 of these types found to be causes of anogenital infections. There are several that can cause genital cancers, with two specific types (16 and 18) that are highly oncogenic, meaning they are highest risk for causing cancers of the cervix, vagina, vulva, penis, and oropharyngeal area (CDC, 2017b). HPV is the primary cause of cervical neoplasia.

In women, HPV lesions are most commonly seen in the posterior part of the introitus. Lesions also are found on the buttocks, vulva, vagina, anus, and cervix (Fig. 4.4). Typically the lesions are small (2 to 3 mm in diameter and 10 to 15 mm in height), soft, papillary

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swellings occurring singly or in clusters on the genital and anal- rectal region. Infections of long duration may appear as a cauliflower-like mass. In moist areas such as the vaginal introitus, the lesions may appear to have multiple fine, fingerlike projections. Vaginal lesions are often multiple. Flat-topped papules, 1 to 4 mm in diameter, are seen most often on the cervix. Often these lesions are visualized only under magnification. Warts are usually flesh colored or slightly darker on Caucasian women, black on African- American women, and brownish on Asian women. The lesions are usually painless; but they may be uncomfortable, particularly when very large, inflamed, or ulcerated. Chronic vaginal discharge, pruritus, or dyspareunia can occur.

FIG 4.4 Human papillomavirus infection. Genital warts or condylomataacuminata.

HPV infections are thought to be more common in pregnant than in nonpregnant women, with an increase in incidence from the first trimester to the third trimester. Furthermore, a significant proportion of preexisting HPV lesions enlarge greatly during pregnancy, a proliferation presumably resulting from the relative state of immunosuppression present during this period. Lesions may become so large during pregnancy that they affect urination, defecation, mobility, and fetal descent, although birth by cesarean is rarely necessary. Cesarean birth may be performed when extensive growths are present. Initial observation of large growths can be

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misleading, suggesting that the entire vagina is involved. However, all of the growth may derive from one stalk; and in such cases it may be possible to push the large mass to the side, allowing the baby to pass through.

Screening and Diagnosis A woman with HPV lesions may complain of symptoms such as a profuse, irritating vaginal discharge; itching; dyspareunia; or postcoital bleeding. She also may report “bumps” on her vulva or labia. History of a known exposure is important; however, because of the potentially long latency period and the possibility of subclinical infections in men, the lack of a history of known exposure cannot be used to exclude a diagnosis of HPV infection.

Physical inspection of the vulva, the perineum, the anus, the vagina, and the cervix is essential whenever HPV lesions are suspected or seen in one area. Because speculum examination of the vagina may block some lesions, it is important to rotate the speculum blades until all areas are visualized. When lesions are visible, the characteristic appearance previously described is considered diagnostic. However, in many instances cervical lesions are not visible, and some vaginal or vulvar lesions also may be unobservable to the naked eye. Because of the potential spread of vulvar or vaginal lesions to the anus, gloves should be changed between vaginal and rectal examinations.

Viral screening and typing for HPV are available but not standard practice. History, evaluation of signs and symptoms, Papanicolaou (Pap) test, and physical examination are used in making a diagnosis. The HPV-DNA test can be used in women older than 30 years of age in combination with the Pap test to screen for types of HPV that are likely to cause cancer or in women with abnormal Pap test results American Cancer Society (ACS, 2016). (ACS, 2016b). The only definitive diagnostic test for presence of HPV is histologic evaluation of a biopsy specimen.

Management Untreated warts may resolve on their own in young women since their immune systems may be strong enough to fight the HPV infection. Treatment of genital warts, if needed, is often difficult. No

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therapy has been shown to eradicate HPV. Therefore the goal of treatment is removal of warts and relief of signs and symptoms. The patient often must make multiple office visits; frequently many different treatment modalities will be used.

Treatment of genital warts should be guided by preference of the woman, available resources, and experience of the health care provider. No one of the treatments is superior to all other treatments, and no one treatment is ideal for all warts (CDC, 2017b). Imiquimod, podophyllin, and podofilox are common treatments but should not be used during pregnancy because there is limited data on the safety of such treatments (see Table 4.3). Because the lesions can proliferate and become friable during pregnancy, many experts recommend their removal using cryotherapy or various surgical techniques, and providers must be specifically trained in such techniques (CDC).

Women who have discomfort associated with genital warts may find that bathing with an oatmeal solution and drying the area with cool air from a hair dryer provides some relief. Keeping the area clean and dry also decreases the growth of the warts. Cotton underwear and loose-fitting clothes that decrease friction and irritation may lessen discomfort. Women should be advised to maintain a healthy lifestyle to aid the immune system and be counseled regarding diet, rest, stress reduction, and exercise.

Patient counseling is essential. Women must understand the virus, how it is transmitted, that no immunity is conferred with infection, and that reinfection is likely with repeated contact (CDC, 2017b). Counseling includes all sexually active women with multiple partners or a history of HPV to use latex condoms for intercourse to decrease acquisition or transmission of the infection. Semiannual or annual health examinations are recommended to assess disease recurrence and screening for cervical cancer. Women who have been treated for HPV infections should have at least annual Pap tests.

Prevention Preventive strategies that have been suggested include abstinence from all sexual activity, staying in a long-term monogamous relationship, and prophylactic vaccination. Two vaccines, Cervarix

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and Gardasil, are available; other vaccines continue to be investigated. Cervarix prevents infection from HPV viruses 16 and 18, whereas Gardasil prevents infection from viruses 6, 11, 16, and 18. Both can be administered to girls and women 9 to 26 years of age. The CDC recommends 2 doses for girls ages 9 to 14, and 3 doses for girls and young women ages 15 to 26 (Meites, Kempe, & Markowitz, 2016). Boys, too, can be vaccinated, beginning at 9 to 21 years of age (CDC, 2017b). Practitioners should stay current with results of these clinical trials and make recommendations about vaccination based on the outcomes of the research.

Herpes Simplex Virus Unknown until the middle of the twentieth century, herpes simplex virus (HSV) infection is now widespread in the United States, especially in women. It results in painful, recurrent ulcers. It is caused by two different antigen subtypes of HSV: HSV type 1 (HSV-1) and HSV type 2 (HSV-2). HSV-2 is usually transmitted sexually, and HSV-1 nonsexually. Although HSV-1 is more commonly associated with gingivostomatitis and oral labial ulcers (fever blisters) and HSV-2 with genital lesions, neither type is exclusively associated with the respective sites.

Although HSV infection is not a reportable disease, it is estimated that approximately 75% of people who have sex with an infected partner will become infected themselves with this incurable virus (Gardella et al., 2017). Women between 15 and 34 years of age are most likely to become infected, especially if they have multiple partners. Recurrent HSV infections are much more common. Most persons infected with HSV-2 have not been diagnosed, and most infections are transmitted by persons who are unaware that they are infected.

An initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. Women generally have a more severe clinical course than do men. Women with primary genital herpes have many lesions that progress from macules to papules; they then progress to form vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 4.5). These ulcers are extremely tender, and primary infections may be bilateral. Women also may have itching,

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inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis is common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy, watery-to-purulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root.

FIG 4.5 Herpes genitalis.

Women with recurrent episodes of HSV infections commonly have only local symptoms that are usually less severe than those associated with the initial infection. Systemic symptoms are usually absent, although the characteristic prodromal genital tingling is common. Recurrent lesions are unilateral, are less severe, and usually last 5 to 7 days. Lesions begin as vesicles and progress rapidly to ulcers. Few women with recurrent disease have cervicitis.

During pregnancy, maternal infection with HSV-2 can have adverse effects on both the mother and fetus. Viremia occurs during the primary infection, and congenital infection is possible although rare. Primary infections during the first trimester have been associated with increased miscarriage rates (CDC, 2017b).

Screening and Diagnosis Although a diagnosis of herpes infection may be suspected from the history and physical examination, it is confirmed by laboratory

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studies. A viral culture is obtained by swabbing exudate during the vesicular stage of the disease.

Management Genital herpes is a chronic and recurring disease for which there is no known cure. Management is directed toward specific treatment during primary and recurrent infections, prevention, self-help measures, and psychologic support.

Oral medications used for treating the first clinical HSV infection include acyclovir, famciclovir, and valacyclovir. These medications are considered for episodic or suppressive therapy for recurrent HSV. Intravenous acyclovir may be used for women with severe disease . The safety of acyclovir, valacyclovir, and famciclovir therapy during pregnancy has not been established; however, acyclovir may be used to reduce the symptoms of HSV if the benefits to the woman outweigh the potential harm to the fetus, and this decision to treat must be discussed with the woman's health care provider . Continued investigation of HSV therapy with these medications during pregnancy is needed.

Cleaning lesions twice a day with saline helps prevent secondary infection. Bacterial infection must be treated with appropriate antibiotics. Measures that may increase comfort for women when lesions are active include warm sitz baths with baking soda; keeping lesions dry by using cool air from a hair dryer or patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydrogen peroxide, Burow's solution, or oatmeal baths; and applying cool, wet, black tea bags to lesions. Women can also apply compresses with an infusion of cloves or peppermint oil and clove oil to lesions.

Oral analgesics such as aspirin or ibuprofen may be used to relieve pain and systemic symptoms associated with initial infections. Because the mucous membranes affected by herpes are extremely sensitive, any topical agents should be used with caution. Nonantiviral ointments, especially those containing cortisone, should be avoided. A thin layer of lidocaine ointment or an antiseptic spray may be applied to decrease discomfort, especially if walking is difficult.

Counseling and education are critical components of the nursing

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care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. The nurse should explain that each woman is unique in her response to herpes and emphasize the variability of symptoms. Women should be helped to understand when viral shedding and thus transmission to a partner are most likely. They should be counseled to refrain from sexual contact from the onset of prodrome until complete healing of lesions.

Some authorities recommend consistent use of condoms for all persons with genital herpes. Condoms may not prevent transmission, particularly male-to-female transmission; however, this does not mean that the partners should avoid all intimacy. Women can be encouraged to maintain close contact with their partners while avoiding contact with lesions. They should be taught how to look for herpetic lesions using a mirror and good light source and a wet cloth or finger covered with a finger cot to rub lightly over the labia. The nurse should ensure that women understand that, when lesions are active, sharing intimate articles (e.g., washcloths or wet towels) that come into contact with the lesions should be avoided. Only plain soap and water are needed to clean hands that have come in contact with herpetic lesions; isolation is neither necessary nor appropriate.

Stress, menstruation, trauma, febrile illnesses, chronic illness, and ultraviolet light have all been found to trigger genital herpes. Women may wish to keep a diary to identify stressors that seem to be associated with recurrent herpes attacks so they can avoid these stressors when possible. The role of exercise in reducing stress can be discussed. Referral for stress-reduction therapy, yoga, or meditation classes may be indicated. Avoiding excessive heat, sun, and hot baths and using a lubricant during sexual intercourse to reduce friction also may be helpful. Women in their childbearing years should be counseled regarding the risk for herpes infection during pregnancy. They should be instructed to use condoms if there is any risk for contracting an STI from a sexual partner. If they become pregnant while taking acyclovir, the risk for birth defects does not appear to be higher than for the general population; however, continued use should be based on whether the benefits for the woman outweigh the possible risks to the fetus. Acyclovir

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does enter breast milk, but the amount of medication ingested during breastfeeding is very low and usually not a health concern (CDC, 2017c).

Because neonatal HSV infection is such a devastating disease, prevention is critical. Women with a history of HSV are often placed on acyclovir for suppression during the last few weeks of pregnancy to try to prevent an outbreak at the time of labor and birth. This could prevent the need for cesarean birth and also decrease the risk of neonatal infection. Current recommendations include carefully examining and questioning all women about symptoms at onset of labor (CDC, 2017c). If visible lesions or prodromal symptoms are not present at onset of labor, vaginal birth is acceptable. Cesarean birth within 4 hours after labor begins or membranes rupture is recommended if visible lesions are present. Infants who are born through an infected vagina should be observed carefully and cultured. Some experts recommend presumptive treatment of infants who were exposed to HSV during birth. Because HSV infection may be associated with cervical dysplasia, women must be encouraged to have annual Pap tests and gynecologic examinations.

The emotional effect of contracting an incurable STI such as herpes is considerable. At diagnosis, many emotions may surface— helplessness, anger, denial, guilt, anxiety, shame, or inadequacy. Women need the opportunity to discuss their feelings and help in learning to live with the disease. Herpes can affect a woman's sexuality, her sexual practices, and her current and future relationships. She may need help in raising the issue with her partner or future partners.

Hepatitis Five different viruses (hepatitis viruses A, B, C, D, and E) account for almost all cases of viral hepatitis in humans. Hepatitis viruses A, B, and C are discussed here. Hepatitis D and E viruses, common among users of intravenous drugs and recipients of multiple blood transfusions, are not included in this discussion.

Hepatitis A Hepatitis A virus (HAV) infection is acquired primarily through the

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fecal-oral route by ingestion of contaminated food, particularly milk, shellfish, or polluted water, or via person-to-person contact. Influenza-like symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and upper–right-quadrant pain characterize HAV infection. Serologic testing to detect the immunoglobulin M (IgM) antibody confirms acute infections. Because HAV infection is self- limited and does not result in chronic infection or chronic liver disease, treatment is usually supportive. Women who become dehydrated from nausea and vomiting or who have fulminating hepatitis A may need to be hospitalized. Medications that might cause liver damage or that are metabolized in the liver should be used with caution. No specific diet or activity restrictions are necessary. Hepatitis A vaccine and immunoglobulin (IG) for intramuscular administration are effective in preventing most hepatitis A infections (CDC, 2017c).

Hepatitis B Hepatitis B virus (HBV) infection is an STI and is the virus most threatening to the fetus and neonate. It is caused by a large DNA virus and is associated with three antigens and their antibodies: hepatitis B surface antigen (HBsAg), HBV antigen (HBeAg), HBV core antigen (HBcAg), antibody to HBsAg (anti-HBs), antibody to HBeAg (anti-HBe), and antibody to HBcAg (anti-HBc). Screening for active or chronic disease or disease immunity is based on testing for these antigens and their antibodies.

Populations at risk include women of Asian, Pacific Island (Polynesian, Micronesian, Melanesian), or Alaskan-Eskimo descent and those born in Haiti or sub-Saharan Africa. Women who have a history of acute or chronic liver disease, who work or receive treatment in a dialysis unit, or who have household or sexual contact with a hemodialysis patient are at greater risk. Women who work or live in institutions for the mentally handicapped are considered to be at risk, as are those with a history of multiple blood transfusions. Health care workers and public safety workers exposed to blood in the workplace are at risk. Behaviors such as multiple sexual partners and a history of intravenous drug use increase the risk for contracting HBV infections.

HBsAg has been found in blood, saliva, sweat, tears, vaginal

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secretions, and semen. Drug abusers who share needles are at risk. Perinatal transmission most often occurs in infants of mothers who have acute hepatitis infection late in the third trimester or during the intrapartum or postpartum periods from exposure to HBsAg- positive vaginal secretions, blood, amniotic fluid, saliva, and breast milk. HBsAg has also been transmitted by artificial insemination. Although it can be transmitted by blood transfusion, the incidence of such infections has decreased significantly since testing of blood for HBsAg became routine.

HBV infection is a disease of the liver and is often a silent infection. In the adult, its course can be fulminating and the outcome fatal. Symptoms of HBV infection are similar to those of hepatitis A: arthralgias, arthritis, lassitude, anorexia, nausea, vomiting, headache, fever, and mild abdominal pain. Later the woman may have clay-colored stools, dark urine, increased abdominal pain, and jaundice. Between 5% and 10% of individuals with HBV have persistent HBsAg and become chronic hepatitis B carriers.

Screening and diagnosis. All women at high risk for contracting HBV should be screened on a regular basis. However, screening only individuals at high risk may not identify up to 50% of HBsAg-positive women. Screening for the presence of HBsAg is recommended on all pregnant women at the first prenatal visit, regardless of whether they have been tested previously; screening should be done on admission for labor and birth for women at high risk for infection during pregnancy or if prenatal test results are not available (CDC, 2017c).

The HBsAg screening test is usually performed, given that a rise in HBsAg occurs at the onset of clinical symptoms and usually indicates an active infection. If HBsAg persists in the blood, the woman is identified as a carrier. If the HBsAg test result is positive, further laboratory studies may be ordered: anti-HBe, anti-HBc, serum glutamic-oxaloacetic transaminase (SGOT), alkaline phosphatase, and liver panel.

Management. There is no specific treatment for hepatitis B. Recovery is usually

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spontaneous in 3 to 16 weeks. Pregnancies complicated by acute viral hepatitis are managed on an outpatient basis. Women should be advised to increase bed rest; eat a high-protein, low-fat diet; and increase their fluid intake. They should avoid medications metabolized in the liver and alcohol. Pregnant women with a definite exposure to HBV should be given HBIG and begin the hepatitis B vaccine series within 14 days of the most recent contact to prevent infection (CDC, 2017c). Vaccination during pregnancy is not thought to pose risks to the fetus.

All nonimmune women at high or moderate risk for hepatitis should be informed of the availability of hepatitis B vaccine. Vaccination is recommended for all individuals who have had multiple sex partners within the past 6 months (CDC, 2017b). In addition, intravenous drug users, residents of correctional or long- term care facilities, persons seeking care for an STI, prostitutes, women whose partners are intravenous drug users or bisexual, and women whose occupation exposes them to high risk should be vaccinated. The vaccine is given in a series of three (four if rapid protection is needed) doses over a 6-month period, with the first two doses given at least 1 month apart. The vaccine is given in the deltoid muscle.

Patient education includes explaining the meaning of hepatitis B infection, including transmission, state of infectivity, and sequelae. The nurse also should explain the need for immunoprophylaxis for household members and sexual contacts. To decrease transmission of the virus, women with hepatitis B or those who test positive for HBV should be advised to maintain a high level of personal hygiene (e.g., wash hands after using the toilet; carefully dispose of tampons, pads, and bandages in plastic bags; avoid sharing razor blades, toothbrushes, needles, or manicure implements; have male partner use a condom if unvaccinated and without hepatitis; avoid sharing saliva through kissing or sharing silverware or dishes; and wipe up blood spills immediately with soap and water). They should inform all health care providers of their carrier state. Postpartum women should be reassured that breastfeeding is not contraindicated if their infants received prophylaxis at birth and are currently on the immunization schedule.

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Hepatitis C Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States and is responsible for nearly 50% of the cases of chronic viral hepatitis. It is estimated that 6% of infants born to HCV-infected pregnant women will actually become infected with HCV, with transmission occurring during the birth process. However, there is no known way to prevent such transmission (CDC, 2017b). The most common risk factor for pregnant women is a history of intravenous drug use. Other risk factors include STIs such as HBV and HIV, multiple sex partners, and a history of blood transfusions. HCV is readily transmitted through exposure to blood.

Currently there is no vaccine to prevent HCV. Its transmission through breastfeeding has not been reported. The CDC (2017b) does not recommend routine testing for HCV in pregnant women unless they are considered to be at high risk.

The Food and Drug Administration (US FDA, 2017) has approved several drugs for the treatment of hepatitis C, although more study is needed to determine the safety of these drugs during pregnancy.

Human Immunodeficiency Virus Approximately 25% of people currently living with HIV are women, but over the past 10 years, there has been an estimated decrease of 40% of newly diagnosed cases of HIV in women (CDC, 2017c). The largest proportion of HIV is found in African-American women, followed by Caucasian and Hispanic/Latinas (CDC). There is also a high prevalence rate of HIV in transgender women (CDC).

Severe depression of the cellular immune system associated with HIV infection characterizes acquired immunodeficiency syndrome (AIDS). Although behaviors that place women at risk have been well documented, all women should be assessed for the possibility of HIV exposure. The most commonly reported opportunistic diseases are Pneumocystis (jirovecii) pneumonia (PCP), Candida esophagitis, and wasting syndrome. Other viral infections such as HSV and cytomegalovirus infections seem to be more prevalent in women than in men. There is a higher incidence of adnexal masses in women with PID who are also HIV positive, but antibiotics are

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often as effective in HIV-positive women with PID as they are in HIV-negative women with PID (Gardella et al., 2017). The clinical course of HPV infection in women with HIV infection is accelerated, and recurrence is more frequent in non–HIV-infected women.

Once HIV enters the body, seroconversion to HIV positivity usually occurs within 6 to 12 weeks. Although HIV seroconversion may be totally asymptomatic, it usually is accompanied by a viremic, influenza-like response. Symptoms include fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgias, nausea, diarrhea, weight loss, sore throat, and rash.

Laboratory studies may reveal leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. HIV has a strong affinity for surface-marker proteins on T lymphocytes. This affinity leads to significant T-cell destruction. Both clinical and epidemiologic studies have shown that declining CD4 levels are strongly associated with increased incidence of AIDS-related diseases and death in many different groups of HIV-infected persons.

Screening and Diagnosis Screening, teaching, and counseling regarding HIV risk factors; indications for being tested; and testing are major roles for nurses caring for women today. A number of behaviors place women at risk for HIV infection, including intravenous drug use, high-risk sex partners, multiple sex partners, and a previous history of multiple STIs. HIV infection is usually diagnosed by using HIV-1 and HIV-2 antibody tests. Antibody testing is done first with a sensitive screening test such as the enzyme immunoassay. Reactive screening tests must be confirmed by an additional test such as the Western blot or an immunofluorescence assay. If a positive antibody test is confirmed by a supplemental test, it means that a woman is infected with HIV and is capable of infecting others. HIV antibodies are detectable in at least 95% of patients within 3 months after infection. Although a negative antibody test usually indicates that a person is not infected, antibody tests cannot exclude recent infection.

The FDA has approved six methods of rapid testing for HIV, variously using a blood sample obtained by fingerstick or

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venipuncture, serum, or plasma or an oral fluid sample. The tests have accuracy rates of 98% to 99%. If the results are reactive, further testing is done. Quick results mean that patients do not have to make extra visits for follow-up standard tests, and the oral test provides an option for patients who do not want to have a blood test.

The CDC (2016b) recommends offering HIV testing to all women whose behavior places them at risk for HIV infection. It may be useful to allow women to self-select for HIV testing. On entry to the health care system, a woman can be handed written information about the risk factors for the AIDS virus and asked to inform the nurse if she believes she is at risk. She should be told that she does not have to say why she may be at risk, only that she thinks she might be.

Counseling for HIV Testing All pregnant women should receive HIV risk-reduction counseling and be notified that they will be tested for antibody to HIV as part of the routine prenatal testing unless the test is declined (American Academy of Pediatrics [AAP] & ACOG, 2012) (Box 4.4). Counseling before and after HIV testing is standard nursing practice today. It is a nursing responsibility to assess a woman's understanding of the information such a test would provide and to be sure the woman thoroughly understands the emotional, legal, and medical implications of a positive or negative test before the test is performed.

Box 4.4 Human Immunodeficiency Virus Screening

• Pregnant women are ethically obligated to seek reasonable care during pregnancy and to avoid causing harm to the fetus. Women's health nurses should be advocates for the fetus while also showing acceptance of the pregnant woman's decision regarding testing and/or treatment for HIV.

• Without treatment, the incidence of perinatal transmission from

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an HIV-positive mother to her fetus is approximately 25%. Triple- drug antiviral or highly active antiretroviral therapy (HAART) during pregnancy decreases perinatal transmission to less than 1% (CDC, 2014).

• The Centers for Disease Control and Prevention (CDC, 2014) recommend testing for HIV infections for all pregnant women as early as possible in pregnancy and a second test in the third trimester for women in certain geographic areas and those who are at high risk for HIV infection.

• Testing has the potential to identify HIV-positive women who can then be treated. Health care providers have an obligation to ensure that pregnant women are well informed about HIV symptoms, testing, and methods of decreasing maternal-fetal transmission. The CDC and the American College of Obstetricians and Gynecologists (ACOG) recommend universal opt-out screening, which means that all pregnant women are offered HIV screening but have the opportunity to opt-out if desired (ACOG, 2011; CDC, 2014). The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2008) supports this system of HIV screening that allows all pregnant women to be offered screening.

From American College of Obstetricians and Gynecologists. (2011). Committee opinion no. 418. Prenatal and perinatal human immunodeficiency virus testing—Expanded recommendations. Obstetrics & Gynecology, 104(5 Part 1), 1119–1124; AWHONN. (2008). HIV screening procedures for pregnant women and newborns—Policy position statement. Washington, DC: Author; Centers for Disease Control and Prevention. (2014). Reducing HIV transmission from mother-to-child: An opt-out approach to HIV screening. Retrieved from www.cdc.gov/hiv/group/gender/pregnantwomen/opt-out.html.

Nursing Alert Counseling associated with HIV testing has two components: pretest and posttest. During pretest counseling, a personalized risk assessment is conducted, the meaning of positive and negative test results is explained, informed consent for HIV testing is obtained, and women are helped to develop a realistic plan for reducing risk and preventing infection. Posttest counseling includes informing the patient of the test results, reviewing the meaning of the results,

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and reinforcing prevention messages. All pretest and posttest counseling should be documented.

Given the strong social stigma attached to HIV infection, nurses must consider the issue of confidentiality and documentation before providing counseling and offering HIV testing to patients.

Legal Tip HIV Testing

If HIV test results are placed in the patient's medical record, the appropriate place for all health information, they are available to all who have access to the medical record. The woman is informed of this availability before testing. Informed consent must be obtained before an HIV test is performed. In some states, written consent is mandated. In many sites, HIV testing is performed unless a patient declines to be tested (i.e., opt-out testing). Nurses must know which procedures are being used for informed consent in their facility.

Unless rapid testing is done, there is generally a 1- to 3-week waiting period after testing for HIV before test results become available; this can be a very anxious time for the woman. It is helpful if the nurse informs her that this time period between blood drawing and test results is routine. Test results must always be communicated in person, and the woman should be informed in advance that this is the procedure. Whenever possible, the person who provided the pretest counseling should also tell the woman her test results.

When some women are informed of negative results, they may escalate risk behaviors because they equate negativity with immunity. Others may believe that negative means “bad” and positive means “good.” The woman's reaction to a negative test should be explored by asking, “How do you feel?” Counseling sessions for women with an HIV-negative result are another opportunity to provide education. Emphasis can be placed on ways in which a woman can remain HIV free. She should be reminded

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that, if she has been exposed to HIV in the past 6 months, she should be retested, and that she should have ongoing testing if she continues high-risk behaviors.

In posttest counseling of an HIV-positive woman, privacy with no interruptions is essential. Adequate time for the counseling sessions also should be provided. The nurse should make sure that the woman understands what a positive test means and review the reliability of the test results. Risk-reduction practices should be reemphasized. Referral for appropriate medical evaluation and follow-up should be made, and the need or desire for psychosocial or psychiatric referrals should be assessed.

The importance of early medical evaluation so a baseline assessment can be made and prophylactic medication begun should be stressed. If possible, the nurse should make a referral or appointment for the woman at the posttest counseling session.

Management During the initial contact with an HIV-infected woman, the nurse should establish what the woman knows about HIV infection and that she is being cared for by a health care provider or facility with expertise in caring for persons with HIV infections, including AIDS. Psychologic referral also may be indicated. Resources such as counseling for financial assistance, legal advocacy, suicide prevention, and death and dying may be appropriate. All women who are drug users should be referred to a substance-abuse program. A major focus of counseling is prevention of transmission of HIV to partners.

Nurses counseling seropositive women wishing contraceptive information can recommend oral contraceptives and latex condoms or tubal sterilization or vasectomy and latex condoms. The nurse can suggest female condoms or abstinence to women whose male partners refuse to use condoms.

No cure is available for HIV infections at this time. Rare and unusual diseases are characteristic of HIV infections. Opportunistic infections and concurrent diseases are managed vigorously with treatment specific to the infection or disease. Routine gynecologic care for HIV-positive women should include a pelvic examination every 6 months. Thorough Pap screening is essential because of the

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greatly increased incidence of abnormal findings on examination. In addition, HIV-positive women should be screened for syphilis, gonorrhea, chlamydia, and other vaginal infections and treated if infections are present. General prevention strategies are an important part of care (e.g., smoking cessation, sound nutrition) as is antiretroviral therapy. Discussion of the medical care of HIV- positive women or women with AIDS is beyond the scope of this chapter because of the rapidly changing recommendations. The reader is referred to the CDC (www.cdc.gov), AIDS hotline (800- 342-2437), and Internet websites such as HIV/AIDS Treatment Information Service (www.hivatis.org) for current information and recommendations.

Pregnancy and Human Immunodeficiency Virus Transmission of the virus from mother to infant can occur throughout the perinatal period. Exposure may occur to the fetus through the maternal circulation as early as the first trimester of pregnancy, to the infant during labor and birth by inoculation or ingestion of maternal blood and other infected fluids, or to the infant through breast milk. Because the HIV antibody crosses the placenta, definite diagnosis of HIV in children younger than 18 months of age is based on laboratory evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection. With proper treatment and adherence to prescribed medication for both the pregnant women and, later, for her neonate, HIV-positive women can have a less than 1% chance of transmitting HIV to their babies (CDC, 2017c).

HIV counseling and testing should be offered to all women at their initial entry into prenatal care as part of routine prenatal testing unless the woman opts out of the screening. Universal testing versus selective testing for maternal HIV is recommended because it results in a greater number of women being screened and treated and can reduce the likelihood of perinatal transmission and maintain the health of the woman. The CDC (2017b) also recommends retesting in the third trimester for women known to be at high risk for HIV and rapid HIV testing in labor for women with unknown HIV status.

Perinatal transmission of HIV has decreased significantly in the

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past decade because of the administration of antiretroviral prophylaxis (e.g., zidovudine) to pregnant women in the prenatal and the perinatal periods. Treatment of HIV-infected women with the triple-drug antiviral therapy or highly active antiretroviral therapy (HAART) during pregnancy should be used for all HIV- infected women regardless of their CD4 cell counts (Hughes & Cu- Uvin, 2016). Women who are infected with HIV and need treatment for their own health should start the therapy as soon as possible, even in the first trimester, and continue throughout the pregnancy. Women who are taking the therapy as prophylaxis usually start therapy after the first trimester.

Antiviral therapy is administered orally and continued throughout pregnancy. The major side effect of this therapy is bone marrow suppression. Periodic hematocrit, white blood cell count, and platelet count assessments should be performed. Women who are HIV positive should also be vaccinated against hepatitis B, pneumococcal infection, Haemophilus influenzae type B, and viral influenza. To support any pregnant woman's immune system, appropriate counseling is provided about optimal nutrition, sleep, rest, exercise, and stress reduction. Use of condoms is encouraged to minimize further exposure to HIV if her partner is the source.

In the intrapartum period, antiretroviral therapy is recommended and the decision to have a cesarean birth versus a vaginal birth is dependent on the amount of viral load (Hughes & Cu-Uvin, 2016). The US Department of Health and Human Services Clinical Guidelines Portal (2015) recommends a scheduled cesarean birth at 38 weeks of gestation for women with a viral load of more than 1000 copies/mL. A vaginal birth may be an option for HIV-infected women who have a viral load of less than 1000 copies/mL at 36 weeks, if a woman has ruptured membranes and labor is progressing rapidly, or if she declines a cesarean birth. Intravenous zidovudine is recommended for all HIV-infected pregnant women during the intrapartum period, except for those with a low viral load (<1000 copies) who have been on highly active anti-retroviral therapy (HAART) during pregnancy (Choudhary, 2015). The drug is administered 3 hours before a scheduled cesarean birth and continued until the baby is born. It should be given during labor if the woman is having a vaginal birth, and to the infant for 6 weeks

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after birth (Hughes & Cu-Uvin). Fetal scalp electrode and scalp pH sampling should be avoided because these procedures may result in inoculation of the virus into the fetus. Similarly, the use of forceps or a vacuum extractor should be avoided when possible. Avoidance of breastfeeding is recommended in the United States and most developed countries (Hughes & Cu-Uvin).

Women who have HIV but who are without symptoms may have an unremarkable postpartum course. Immunosuppressed women with symptoms may be at increased risk for postpartum urinary tract infections (UTIs), vaginitis, postpartum endometritis, and poor wound healing. Good perineal hygiene should be stressed. Women who are HIV positive but who were not on antiretroviral drugs before pregnancy should be tested in the postpartum period to determine whether therapy that was initiated in pregnancy should be continued. After the initial bath, the newborn can be with the mother. In planning for discharge, comprehensive care and support services need to be arranged. After discharge, the woman and her infant are referred to health care providers who are experienced in the treatment of HIV and AIDS and associated conditions for intensive monitoring and follow-up.

Zika Virus The Zika virus is spread by bites from the Aedes mosquito. It is also spread via sexual contact through semen. Women who become pregnant and are infected by the Zika virus have an increased risk for giving birth to an infant with microcephaly. Zika virus has also been associated with risk for Guillain-Barré syndrome, a neurologic condition that can lead to muscle weakness and possibly paralysis. The Aedes mosquito has been found predominantly in Africa, Southeast Asia, the Caribbean, Central America, South America, and the Pacific Islands, with a few recent cases found in the southeastern United States (CDC, 2016a). Pregnant women and women considering becoming pregnant should avoid traveling to areas that are known to have the Aedes mosquito. Women should use condoms with male partners who may have been exposed to the Zika virus (CDC, 2016a).

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Vaginal Infections Vaginal discharge and itching of the vulva and vagina are among the most common reasons a woman seeks help from a health care provider. More women complain of vaginal discharge than any other gynecologic symptom. Women who have adequate endogenous or exogenous estrogen have vaginal secretions. Vaginal discharge resulting from infection must be distinguished from normal secretions. Normal vaginal secretions (or leukorrhea) are clear to cloudy in appearance. The discharge may turn yellow after drying; is slightly slimy; is nonirritating; and has a mild, inoffensive odor. Normal vaginal secretions are acidic, with a pH range of 4 to 5. The amount of leukorrhea differs with phases of the menstrual cycle, with greater amounts occurring at ovulation and just before menses. Leukorrhea is also increased during pregnancy. Normal vaginal secretions contain lactobacilli and epithelial cells.

Vaginitis, or abnormal vaginal discharge, is an infection caused by a microorganism. The most common vaginal infections are bacterial vaginosis (BV), candidiasis, and trichomoniasis. Although streptococcus B is considered normal vaginal flora, it may also cause infection. Vulvovaginitis (i.e., inflammation of the vulva and vagina) may be caused by vaginal infection; copious leukorrhea, which can cause maceration of tissues; and chemical irritants, allergens, and foreign bodies, which may produce inflammatory reactions.

Bacterial Vaginosis Bacterial vaginosis (BV), formerly called nonspecific vaginitis, Haemophilus vaginitis, or Gardnerella, is the most common type of symptomatic vaginitis today (Gardella et al., 2017). It is associated with preterm labor and birth. The exact cause of BV is unknown. It is a syndrome in which normal, hydrogen peroxide–producing lactobacilli are replaced with high concentrations of anaerobic bacteria (e.g., Gardnerella, Mobiluncus). With the increase of anaerobes, the level of vaginal amines is raised, and the normal acidic pH of the vagina is altered. Epithelial cells slough, and numerous bacteria attach to their surfaces (clue cells). When the amines are volatilized, the characteristic odor of BV occurs.

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Many women with BV complain of a characteristic “fishy odor.” The odor may be noticed by the woman or her partner after heterosexual intercourse because semen releases the vaginal amines. When present, the BV discharge is usually profuse; thin; and white, gray, or milky in appearance. Some women also may experience mild irritation or pruritus.

Screening and Diagnosis A focused history may help distinguish BV from other vaginal infections if the woman is symptomatic. Reports of fishy odor and increased thin vaginal discharge are most significant, and a report of increased odor after intercourse is also suggestive of BV. The nurse should question women with previous occurrence of similar symptoms, diagnosis, and treatment because women with BV often have been treated incorrectly because of misdiagnosis.

Microscopic examination of vaginal secretions is always performed (Table 4.4). Both normal saline and 10% potassium hydroxide (KOH) smears are made. The presence of clue cells (vaginal epithelial cells coated with bacteria) on wet saline smear is highly diagnostic because the phenomenon is specific to BV. Vaginal secretions are tested for pH and amine odor. Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum.

TABLE 4.4 Wet Smear Tests for Vaginal Infections

Infection Test Positive Findings Trichomoniasis Saline wet smear (vaginal secretions mixed

with normal saline on a glass slide) Presence of many white blood cell protozoa

Candidiasis Potassium hydroxide (KOH) preparation (vaginal secretions mixed with KOH on a glass slide)

Presence of hyphae and pseudohyphae (buds and branches of yeast cells)

Bacterial vaginosis

Normal saline smear Presence of clue cells (vaginal epithelial cells coated with bacteria)

Whiff test (vaginal secretions mixed with KOH)

Release of fishy odor

Management

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Treatment of BV with oral metronidazole (Flagyl) or trinidazole or intravaginal metronidazole gel (Metrogel) or clindamycin cream (Cleocin) are comparable, and the decision regarding which to use is based on the preference of the woman (Gardella et al., 2017).

Several adverse outcomes are associated with BV during pregnancy: preterm labor and birth, premature rupture of the membranes, intraamniotic infection, and postpartum endometritis. Therefore, pregnant women should be treated to relieve vaginal symptoms and the signs of infection. Metronidazole is not recommended if the woman is breastfeeding. If it is necessary to prescribe it, she can suspend breastfeeding temporarily (pump and discard milk to maintain supply) and resume breastfeeding 12 to 24 hours after taking the last dose.

Candidiasis Vulvovaginal candidiasis, or yeast infection, is the second most common type of vaginal infection in the United States (Up-to-Date, 2017). Although vaginal candidiasis infections are common in healthy women, those seen in women with HIV infection are often more severe and persistent. Genital candidiasis lesions may be painful, and coalescing ulcerations necessitate continuous prophylactic therapy.

The most common organism is Candida albicans. It is estimated that 90% of yeast infections in women are caused by this organism. However, in the past 10 years the incidence of non–C. albicans infections has increased steadily. It is common for as many as 80% of women to experience chronic or recurrent infections; those with recurrent vulvovaginal infections are those women with four or more infections per year (Gardella et al., 2017). Numerous factors have been identified as predisposing a woman to yeast infections. These include antibiotic therapy, particularly broad-spectrum antibiotics such as ampicillin, tetracycline, cephalosporins, and metronidazole; diabetes, especially when uncontrolled; pregnancy; obesity; diets high in refined sugars or artificial sweeteners; use of corticosteroids and exogenous hormones; and immunosuppressed states. Clinical observations and research have suggested that tight- fitting clothing and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can

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grow. The most common symptom of yeast infection is vulvar and

possibly vaginal pruritus. The itching may be mild or intense, interfere with rest and activities, and occur during or after intercourse. Some women report a feeling of dryness. Others may have painful urination as the urine flows over the vulva. The latter usually occurs in women who have excoriations resulting from scratching. Most often the discharge is thick, white, lumpy, and cottage cheese–like. The discharge may be found in patches on the vaginal walls, cervix, and labia. Commonly the vulva is red and swollen, as are the labial folds, vagina, and cervix. Although there is no odor characteristic of yeast infections, sometimes a yeasty or musty smell is noted.

Screening and Diagnosis In addition to noting the onset and course of the woman's symptoms, the history is a valuable screening tool for identifying predisposing risk factors. Physical examination should include a thorough inspection of the vulva and vagina. A speculum examination is always done. Commonly saline and KOH wet smear and vaginal pH are obtained (see Table 4.4). Vaginal pH is normal (less than 4.5) with a yeast infection. The characteristic pseudohypha (bud or branching of a fungus) may be seen on a wet smear done with normal saline; however, they may be confused with other cells and artifacts.

Management A number of antifungal preparations are available for the treatment of C. albicans. Many of these medications (e.g., miconazole [Monistat] and clotrimazole [Gyne-Lotrimin]) are available as over- the-counter (OTC) agents. Exogenous lactobacillus (in the form of dairy products [yogurt] or powder, tablet, capsule, or suppository supplements) and garlic have been suggested for prevention and treatment of vulvovaginal candidiasis, but have not been found to be effective (Gardella et al., 2017). The first time a woman suspects that she may have a yeast infection, she should see a health care provider for confirmation of the diagnosis and treatment recommendation. If she has another infection, she may wish to

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purchase an OTC preparation and self-treat. If she elects to do this, she should always be counseled to seek care for numerous recurrent or chronic yeast infections. If vaginal discharge is extremely thick and copious, vaginal debridement with a cotton swab followed by application of vaginal medication may be effective.

Women who have extensive irritation, swelling, and discomfort of the labia and vulva may find sitz baths helpful in decreasing inflammation and increasing comfort. Adding colloidal oatmeal powder to the bath may also increase the woman's comfort. Not wearing underpants to bed may help decrease symptoms and prevent recurrences. Completing the full course of treatment prescribed is essential to removing the pathogen. Medication should be continued even during menstruation. Women should be counseled not to use tampons during menses because the medication will be absorbed by the tampon. If possible, intercourse is avoided during treatment; if this is not feasible, the woman's partner should use a condom to prevent introduction of more organisms. Suggested measures to prevent genital tract infections are listed in Box 4.5.

Box 4.5 Patient Teaching Prevention of Genital Tract Infections in Women

• Practice genital hygiene (e.g. avoid douching and hard soaps, wash using singular front-to-back motion).

• Choose underwear or hosiery with a cotton crotch.

• Avoid tight-fitting clothing (especially tight jeans).

• Select cloth car seat covers instead of vinyl.

• Limit the time spent in damp exercise clothes (especially swimsuits, leotards, and tights).

• Limit exposure to bath salts or bubble bath.

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• Avoid colored or scented toilet tissue.

• If sensitive, discontinue use of feminine hygiene deodorant sprays.

• Use condoms.

• Void before and after intercourse.

• Decrease dietary sugar.

• Drink yeast-active milk and eat yogurt (with lactobacilli).

• Do not douche.

Trichomoniasis Trichomonas vaginalis is almost always an STI and is also a common cause of vaginal infection (5% to 50% of all vaginitis) and discharge (Gardella et al., 2017).

Trichomoniasis is caused by T. vaginalis, an anaerobic, one-celled protozoan with characteristic flagella. Although trichomoniasis may be asymptomatic, women commonly experience characteristically yellowish-to-greenish, frothy, mucopurulent, copious, malodorous discharge. Inflammation of the vulva, vagina, or both may be present, and the woman may complain of irritation and pruritus. Dysuria and dyspareunia are often present. Typically the discharge worsens during and after menstruation. The cervix and vaginal walls may demonstrate characteristic “strawberry spots” or tiny petechiae, although this does not occur in the majority of women with trichomoniasis, and the cervix may bleed on contact. In severe infections, the vaginal walls, the cervix, and occasionally the vulva are acutely inflamed.

Screening and Diagnosis In addition to obtaining a history of current symptoms, it is important to obtain a history of similar symptoms and previous treatment. A thorough sexual history includes information about the treatment of her partner or partners and if she has had subsequent sexual contact with new partners.

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A speculum examination is always performed, even though it may be uncomfortable for the woman. Any of the classic signs may or may not be seen on physical examination. The typical one-celled flagellate trichomonads are easily distinguished on a normal saline wet preparation (see Table 4.4). The pH of the discharge is greater than 5.0. Because trichomoniasis is an STI, once diagnosis is confirmed, the appropriate laboratory studies for other STIs should be carried out.

Management The recommended treatment is a class of drugs called nitroimidazoles, including metronidazole or tinidazole orally in a single dose. For pregnant women, metronidazole is considered safe, but tinidazole is a category C drug (Gardella et al., 2017). Although the male partner is usually asymptomatic, he should receive treatment also because he often harbors the trichomonads in the urethra or prostate. Nurses need to discuss the importance of partner treatment with their patients. If partners are not treated, the infection will likely recur.

Women with trichomoniasis need to understand the sexual transmission of this disease. The woman should know that the organism can be present without symptoms, perhaps for several months, and that determining when she became infected is impossible.

Group B Streptococcus Group B streptococcus (GBS) may be considered a normal vaginal flora in a woman who is not pregnant. It is estimated to be present in 25% of healthy pregnant women (CDC, 2016b). However, GBS infection is associated with poor pregnancy outcomes. These infections are an important factor in perinatal and neonatal morbidity and mortality, usually resulting from vertical transmission from the birth canal of the infected mother to the infant during birth (CDC, 2016b).

Risk factors for neonatal GBS infection include positive prenatal culture for GBS in the current pregnancy; preterm birth of less than 37 weeks of gestation; premature rupture of membranes for longer than 18 hours; intrapartum maternal fever higher than 38° C (100.4°

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F); and a positive history for early-onset neonatal GBS (CDC, 2016b). To decrease the risk for neonatal GBS infection, it is recommended that all women be screened at 35 to 37 weeks of gestation for GBS using a rectovaginal culture and that intravenous antibiotic prophylaxis (IAP) be offered to all who test positive. If a culture is not available at onset of labor or if risk factors are present, IAP is also offered. A rapid polymerase chain reaction (PCR) test for GBS is available for use in laboring women when GBS culture results are not available. This possibly avoids unnecessary IAP. It is not recommended before a cesarean birth if labor or rupture of membranes has not occurred. The recommended treatment is penicillin G, 5 million units in an intravenous loading dose and then 2.5 million units intravenously every 4 hours during labor. Ampicillin, 2 g intravenous loading dose, followed by 1 g intravenously every 4 hours, is an alternative therapy (CDC, 2016b).

Concerns of Lesbian, Gay, Bisexual, Transsexual, Queer (LGBT) Community It is important to note that persons in the LGBT community are at risk for STIs. In women's health, it is particularly important to understand the specific issues related to women who have sex with women (WSW). The CDC (2017c) has issued guidelines that are specific to WSW as well as other populations. WSW are at risk for acquiring bacterial, viral, and protozoal infections from current and prior partners, both male and female. They should not be presumed to be at low or no risk for STIs because of their sexual orientation. It is critical for effective screening that health care providers discuss sexual orientation with their patients in an open, accepting manner.

Effects of Sexually Transmitted Infections on Pregnancy and the Fetus STIs in pregnancy are discussed in Chapter 12. Table 4.5 describes the effects of several common STIs on pregnancy and the fetus. It is difficult to predict these effects with certainty. Factors such as co- infection with other STIs and at what point in pregnancy the infection was treated can affect outcomes.

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TABLE 4.5 Pregnancy and Fetal Effects of Common Sexually Transmitted Infections

Infection Maternal Effects Fetal Effects Chlamydia Premature rupture of membranes

Preterm labor Low birth weight

Postpartum endometritis Gonorrhea Miscarriage

Preterm labor Preterm birth IUGR

Amniotic infection syndrome Chorioamnionitis Postpartum endometritis Postpartum sepsis Premature rupture of membranes

Group B streptococci Urinary tract infection Preterm birth Chorioamnionitis Postpartum endometritis Sepsis Meningitis (rare)

Herpes simplex virus Intrauterine infection (rare) Congenital infection (rare)

Human papillomavirus (HPV)

Dystocia from large lesions Excessive bleeding from lesions after birth trauma

Syphilis Miscarriage IUGR Preterm labor Preterm birth

Stillbirth Congenital infection

Zika virus Microcephaly

IUGR, Intrauterine growth restriction. Data from Gilbert, E. (2011). Manual of high risk pregnancy and delivery (5th ed.). St. Louis, MO: Mosby; Duff, P., Sweet, R., & Edwards, R. (2013). Maternal and fetal infections. In R. K. Creasy, R. Resnik, J. D. Iams, et al. (Eds), Creasy and Resnik's maternal-fetal medicine: Principles and practice (7th ed.). Philadelphia, PA: Saunders; Gardella, C., Eckert, L.O., & Lentz G. M. (2017). Genital tract infections: Vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. Comprehensive gynecology (7th ed.). Philadelphia, PA: Elsevier.

Infection Control Infection-control measures are essential to protect care providers and prevent health care–associated infection of patients, regardless of the infectious agent. The risk for occupational transmission varies with the disease. Even when the risk is low as with HIV, the existence of any risk warrants reasonable precautions. Precautions

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against airborne disease transmission are available in all health care agencies. Standard Precautions (precautions to use in care of all persons for infection control) are listed in Box 4.6.

Box 4.6 Standard Precautions Medical history and examination cannot reliably identify all persons infected with human immunodeficiency virus (HIV) or other bloodborne pathogens. Therefore Standard Precautions should be used consistently in the care of all persons. These precautions apply to blood; body fluids; and all secretions and excretions, except sweat, nonintact skin, and mucous membranes. The following infection-control practices should be applied during the delivery of health care to reduce the risk for transmission of microorganisms from known and unknown sources of infection:

1. Hand hygiene. During the delivery of health care, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Wash dirty or contaminated hands with either a nonantimicrobial or an antimicrobial soap and water. If hands are not visibly soiled, decontaminate them with an alcohol-based hand rub, or they may be washed with an antimicrobial soap and water. Perform hand hygiene (1) before having direct contact with patients; (2) after contact with blood, body fluids, excretions, mucous membranes, nonintact skin, or wound dressings; (3) after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient); (4) if hands will be moving from a contaminated to a clean body site during patient care; (5) after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and (6) after removing gloves. Wash hands with nonantimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is

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recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes.

2. Personal protective equipment (PPE). Observe the following principles of use:

• Gloves. Wear gloves when a reasonably anticipated possibility exists that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) might occur. Gloves should be worn during infant eye prophylaxis, care of the umbilical cord, care of the circumcision site, parenteral procedures, diaper changes, contact with colostrum, and postpartum assessments. Wear gloves with fit and durability appropriate to the task. Remove gloves after contact with a patient or the surrounding environment (including medical equipment), using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Change gloves during patient care if the hands will move from a contaminated (e.g., perineal area) to a clean (e.g., face) body site.

• Gowns. Wear a gown that is appropriate to the task to protect the skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood,

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body fluids, secretions, or excretions is anticipated. Remove the gown and perform hand hygiene before leaving the patient's environment. Do not reuse gowns, even for repeated contacts with the same patient. Routine donning of gowns on entrance into a high-risk unit (e.g., intensive care unit [ICU], neonatal intensive care unit [NICU]) is not indicated.

• Mouth, nose, eye protection. Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.

• Respiratory hygiene and cough etiquette. Post signs at entrances and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their mouth and nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions. Provide tissues and no-touch receptacles (e.g., foot pedal–operated lid or open, plastic-lined wastebasket) for disposal of tissues. Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and

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inpatient settings; provide conveniently located dispensers of alcohol-based hand rubs and, where sinks are available, supplies for handwashing. During periods of increased prevalence of respiratory infections in the community, offer masks to coughing patients and other symptomatic persons (e.g., persons who accompany ill patients) on entry into the facility, and encourage them to maintain special separation, ideally a distance of at least 3 feet, from others in common waiting areas.

3. Safe injection practices. The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems:

• Use aseptic technique to prevent contamination of sterile injection equipment. Needles, cannulas, and syringes are sterile, single-use items; they should not be reused for another patient. Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only, and dispose of appropriately after use. Use single-dose vials for parenteral medications whenever possible. If multidose vials must be used, both the needle (or cannula) and the syringe used to access the multidose vial must be sterile. Do not keep multidose vials in the immediate patient treatment area, and store in accordance with manufacturer recommendations; discard if sterility is compromised or questionable.

Modified from Wisconsin Department of Health Services. (2016). Infection control and

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prevention: Standard precautions. Retrieved from https://www.dhs.wisconsin.gov/ic/precautions.htm.

Problems of the Breast Benign Problems Fibrocystic Changes Women often experience a benign breast problem at some point in adulthood, with fibrocystic changes being very common (Sandadi, Rock, Orr, et al., 2017). Fibrocystic changes occur in varying degrees in breasts of healthy women. The etiologic agent responsible for these changes has not been found. One theory is that estrogen excess and progesterone deficiency in the luteal phase of the menstrual cycle may cause changes in breast tissue.

Fibrocystic changes are characterized by lumpiness, with or without tenderness, in both breasts. Single simple cysts can also occur. Symptoms are often cyclical, usually developing approximately 1 week before menstruation begins and subsiding approximately 1 week after menstruation ends. Symptoms include dull heavy pain and a sense of fullness and tenderness often in the upper outer quadrants of the breasts. Physical examination may reveal excessive nodularity that often feels like peas (Sandadi et al., 2017). Larger cysts are often described as feeling like water-filled balloons. Women in their twenties report the most severe pain. Women in their thirties have premenstrual pain and tenderness; small multiple nodules are usually present. Women in their forties usually do not report severe pain, but cysts are tender and often regress in size (Sandadi et al.).

Steps in the workup of a breast lump may begin with ultrasonography to determine whether it is fluid filled or solid. Fluid-filled cysts are aspirated, and the woman is monitored on a routine basis for the development of other cysts. If the lump is solid, a mammogram is obtained. A fine-needle aspiration (FNA) is performed, regardless of the woman's age, to determine the nature of the lump (Sandadi et al., 2017).

Management depends on the severity of the symptoms. A low- fat, nutrient-dense diet with decreased saturated fat is advised, and

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sometimes, despite lack of clear evidence, eliminating methylxanthines (colas, coffee, tea, chocolate) is also advised. Some practitioners suggest that women take mild diuretics shortly before menses, as well as decreasing alcohol intake (Sandadi et al., 2017). Other pain-relief measures include taking analgesics or NSAIDs, wearing a supportive bra, and applying heat or cold to the breasts.

Evening primrose oil and vitamin E supplements may be effective for some women, although more research is needed. Oral contraceptives, danazol, bromocriptine, and tamoxifen have also been used with varying degrees of success.

Fibroadenoma The next most common benign neoplasm of the breast is a fibroadenoma. It is the single most common type of tumor seen in the adolescent population, although it can also occur in women in their thirties. Fibroadenomas are discrete, usually solitary lumps averaging 2.5 cm in diameter (Sandadi et al., 2017). Occasionally the woman with a fibroadenoma experiences tenderness in the tumor during the menstrual cycle. Fibroadenomas do not increase in size in response to the menstrual cycle as cysts do. They increase in size during pregnancy and decrease in size as the woman ages. The cause of fibroadenomas is unknown.

Diagnosis is made by reviewing patient history and physical examination. Mammography, ultrasound, or magnetic resonance imaging (MRI) helps determine the type of lesion. Fine needle aspiration (FNA) may be used to determine underlying pathologic conditions. Surgical excision may be necessary if the lump is suspicious or if the symptoms are severe. Periodic observation of masses by professional physical examination or mammography may be all that is necessary for masses not needing surgical intervention (Sandadi et al., 2017). Women need to recognize changes in their breasts and seek further evaluation from a clinician.

Nipple Discharge Nipple discharge is a common occurrence that concerns many women. Although most nipple discharge is physiologic, it is important to evaluate each woman who has this problem

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thoroughly because some women will be found to have a serious endocrine disorder or malignancy. Most nipple discharge is elicited (i.e., discharge is a result of the breast being compressed or stimulated) and is usually not a concern unless the woman is postmenopausal or a mass is present in the breast (Sandadi et al., 2017).

Another form of breast discharge not related to malignancy is galactorrhea, a bilaterally spontaneous, milky, sticky discharge. It is a normal finding in pregnancy. It can also occur as the result of elevated prolactin levels caused by a thyroid disorder, pituitary tumor, or chest wall surgery or trauma. Obtaining a complete medication history on each woman is essential, as some medications can precipitate galactorrhea in some women (Sandadi et al., 2017).

Diagnostic tests that may be indicated include a physical examination, mammography, ultrasound or magnetic resonance imaging (MRI), as well as ductoscopy to microscopically evaluate the discharge (Sandadi et al., 2017).

Mammary Duct Ectasia Mammary duct ectasia is a benign inflammation of the ducts behind the nipple. It occurs most often in perimenopausal women. In mammary duct ectasia, nipple discharge is thick; sticky; and colored white, brown, green, or purple. The woman frequently experiences a burning pain, an itching, or a palpable mass behind the nipple (American Cancer Society, 2016a).

The workup includes a mammogram and aspiration and culture of fluid. Treatment is usually symptomatic; mild pain relievers, warm compresses applied to the breast, or wearing a supportive bra may provide relief. If a mass is present or an abscess occurs, treatment may include a local excision of the affected duct or ducts (Sandadi et al., 2017).

Intraductal Papilloma Intraductal papilloma is a rare benign condition that develops within the terminal nipple ducts. The cause is unknown. It usually occurs in women between 30 and 50 years of age. The papilloma is usually too small to be palpated, and the characteristic sign is

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spontaneous unilateral nipple discharge that is serous, serosanguineous, or bloody. After eliminating the possibility of malignancy, the affected segments of the ducts and breasts are surgically excised (Sandadi et al., 2017). Table 4.6 compares manifestations of benign breast diseases.

TABLE 4.6 Comparison of Common Manifestations of Benign Breast Masses

Fibrocystic Changes Fibroadenoma Lipoma IntraductalPapilloma Mammary Duct Ectasia

Multiple lumps Single lump Single lump

Single or multiple Mass behind nipple

Nodular Well delineated

Well delineated

Not well delineated Not well delineated

Palpable Palpable Palpable Nonpalpable Palpable Movable Movable Movable Nonmobile Nonmobile Round, smooth Round,

lobular Round, lobular

Small, ball-like Irregular

Firm or soft Firm Soft Firm or soft Firm Tenderness influenced by menstrual cycle

Usually asymptomatic

Nontender Usually nontender Painful, burning, itching

Bilateral Unilateral Unilateral Unilateral Unilateral May or may not have nipple discharge

No nipple discharge

No nipple discharge

Serous or bloody nipple discharge

Thick, sticky nipple discharge

Nursing Care The history should focus on risk factors for breast diseases, events related to the breast mass, and health maintenance practices. Risk factors for breast cancer are discussed later in this chapter. Information related to the breast mass should include how, when, and by whom the mass was discovered. The following patient information is documented: presence of pain, whether symptoms increase with menses, dietary habits, smoking habits, and use of oral contraceptives. The woman's emotional status, including her stress level, fears, and concerns and her ability to cope, also should be assessed.

Physical examination may include assessment of the breasts for symmetry, masses (size, number, consistency, mobility), and nipple discharge.

Nursing actions might include the following: • Discuss the intervals for and facets of breast screening, including

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professional examination and mammography (see Table 3.3). Women with breast implants may need special views of the breast, and precautions might have to be taken to prevent rupturing the implant during mammography.

• Provide written educational materials. • Encourage the verbalization of fears and concerns about treatment

and prognosis. • Provide specific information regarding the woman's condition

and treatment, including dietary changes, drug therapy, comfort measures, stress management, and surgery.

• Demonstrate correct breast self-examination technique if the woman desires to practice.

• Describe pain-relieving strategies in detail, and collaborate with the primary health care provider to ensure effective pain control.

• Encourage discussion of feelings about body image. • Refer to a support group or stress-management resource if needed

to cope with long-term consequences of benign breast conditions.

Cancer of the Breast The United States has one of the highest rates of carcinoma in the world. After skin cancer, breast cancer is the most frequently diagnosed cancer and the leading cause of cancer deaths in Hispanic women, and the second-leading cause of cancer deaths in white, black, Asian/Pacific Islander, and American Indian/Alaskan Native women (CDC, 2016c). One in eight American women will develop breast cancer in her lifetime (Sandadi et al., 2017). No clear method for prevention has been formulated. The prognosis for and survival of the woman are improved with early detection. Therefore, women must be educated about risk factors, early detection, and screening.

Although the exact cause of breast cancer is still unknown, researchers have identified certain factors that increase a woman's risk for developing a malignancy. Box 4.7 lists these factors. The most important predictor for breast cancer is age; the risk increases as the woman ages.

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Box 4.7 Risk Factors for Breast Cancer* Risks That Are Not Modifiable

• Age—risk increases with age

• Previous history of breast cancer

• Family history of breast cancer, especially a mother or sister (particularly significant if premenopausal)

• Inherited genetic mutations in BRCA1 and BRCA2 genes

• Previous history of ovarian, endometrial, colon, or thyroid cancer

• High breast tissue density

• Early menarche (before 12 years of age)

• Late menopause (after 55 years of age)

• Previous history of benign breast disease with epithelial hyperplasia

• Race (Caucasian women have highest incidence)

Lifestyle and Modifiable Risks

• Nulliparity or first pregnancy after 30 years of age

• Not breastfeeding

• Postmenopausal use of combined estrogen-progestin replacement therapy

• Obesity after menopause

• Alcohol consumption of more than one drink per day

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• Sedentary lifestyle

• Vitamin D—low levels increase risk

Risk factors are cumulative (i.e., the more risk factors that are present, the greater is the likelihood of breast cancer occurring).

Data from American Cancer Society. (2011). Breast cancer. Retrieved from www.cancer.org; American Cancer Society. (2012). Cancer facts and figures. Atlanta, GA: Author.

Much discussion has taken place about possible links between breast cancer and hormone therapy; several large research studies, including the Women's Health Initiative, have found that the risk for breast cancer increases when a woman is taking combined estrogen and progesterone but declines quickly once therapy is stopped. No consensus about possible links has been reached (Sandadi et al., 2017).

Although studies have shown no correlation between breast implants and the development of breast cancer, recently the Food and Drug Administration has found a small correlation between breast implants and anaplastic large cell lymphoma (ALCL), which can occur in other parts of the body, but also very rarely in the breast (Pruthi, 2015). The incidence of ALCL is very small, but is something for a woman to consider when deciding to have breast implants.

Although most breast cancers are not related to genetic factors, the identification of the BRCA1 and BRCA2 genes has demonstrated the role of heredity and genetic mutations in this disease. Only approximately 5% to 10% of all breast cancers are attributed to heredity. Women who have abnormalities in the BRCA1 and BRCA2 genes and develop cancer, tend to develop it earlier in life and in a usually more aggressive, bilateral form (Sandadi et al., 2017). Other genetic mutations that can cause breast cancer include Li-Fraumeni syndrome, which is related to the p53 gene, and Cowden syndrome, which is related to the PTEN gene (Sandadi et al.).

Information about breast cancer risks can be confusing, and women can overestimate or underestimate their risks. Women and health professionals can use the Breast Cancer Risk Assessment

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Tool to calculate risk. This tool was developed and verified by the National Cancer Institute (NCI) to predict the risk for breast cancer in 5 years and over the lifetime (to 90 years of age) of a woman. The risk factors used are listed in Box 4.8. The tool is available at https://www.cancer.gov/bcrisktool/. Although the clinical applicability of risk factors has limits, it is important to screen women more frequently if they are at higher risk and help them to change risks that are modifiable, such as losing weight and limiting alcohol intake.

Box 4.8 Risk Factors Included in the Breast Cancer Risk Assessment Tool

• Woman's age

• Number of first-degree relatives affected

• Age of woman at menarche

• Age of woman at first live birth

• Number of breast biopsies

• History of atypical hyperplasia in biopsy specimens

Prevention Chemoprevention is the use of medications to reduce cancer risk. Tamoxifen and raloxifene block the effect of estrogen on breast tissue. Studies have shown that these two drugs can reduce the risk for breast cancer, and the FDA has approved them for such use (Sandadi et al., 2017) (see Medication Guides for tamoxifen and raloxifene). The role of aromatase inhibitors (e.g., anastrozole) also is being examined to see if these drugs are effective for prevention.

Medication Guide

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Tamoxifen (Nolvadex)

Action Antiestrogenic effects; attaches to hormone receptors on cancer cells and prevents natural hormones from attaching to the receptors

Indications For treatment of advanced-stage or metastatic breast cancer; for treatment of early-stage breast cancer after breast cancer surgery and radiation therapy; to reduce the incidence of breast cancer in women at high risk

Dosage 20 mg orally daily for 5 years

Adverse Reactions Common side effects include hot flashes, night sweats, nausea, vaginal bleeding or discharge, and mood swings. Hair loss is an uncommon effect. Serious side effects include deep vein thrombosis, increased risk for endometrial cancer, and stroke.

Nursing Considerations The medication may be taken on an empty stomach or with food. Missed doses should be taken as soon as possible, but taking two doses at once is not recommended. A barrier or nonhormonal form of contraception is recommended in premenopausal women because tamoxifen may be harmful to the fetus if pregnancy should occur.

Data from Medscape (2017). Tamoxifen. Retrieved from http://reference.medscape.com/drug/nolvadex-soltamox-tamoxifen-342183.

Medication Guide Raloxifene Hydrochloride (Evista)

Action A selective estrogen receptor modulator, serving as an agonist and

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antagonist to estrogen receptor sites

Indications Treatment and prevention of osteoporosis; reduction in the risk for invasive breast cancer in postmenopausal women with osteoporosis; and reduction of risk for invasive breast cancer in postmenopausal women at high risk for invasive breast cancer

Dosage 60 mg orally daily for 5 years

Adverse Reactions Common side effects include hot flashes, nausea, peripheral edema, joint pain, leg cramps, flulike symptoms, and sweating. Serious and life-threatening side effects can occur from existing condition. Women who have had or are at risk for a heart attack have increased risk for dying from a stroke. Risk for blood clots in the legs and lungs is increased. Raloxifene is contraindicated in women with an active or past history of venous thromboembolism.

Nursing Considerations The medication may be taken on an empty stomach or with food. Missed doses should be taken as soon as possible, but taking two doses at once is not recommended. The woman should contact her health care provider if leg pain or feeling of warmth in lower legs, swelling of hands and feet, sudden chest pain or shortness of breath, or sudden changes in vision occur. Calcium 1500 mg plus vitamin D 400 to 800 International Units daily are recommended.

Data from Medscape (2017). Raloxifene. Retrieved from http://reference.medscape.com/drug/evista-raloxifene-342794.

Surgical prophylaxis (bilateral mastectomy, oophorectomy) can reduce the risk for breast cancer, but it should be considered only for people who are at very high risk (Sandadi et al., 2017).

Screening and Diagnosis Breast cancer in its earliest form can be detected by a mammogram before it is felt by a woman. More than half of all lumps are

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discovered in the upper outer quadrant of the breast. The most common presenting symptom is a lump or thickening of the breast. The lump may feel hard and fixed or soft and spongy. It may have well-defined or irregular borders. It may be fixed to the skin, thereby causing dimpling to occur. A nipple discharge that is bloody or clear also may be present.

Early detection and diagnosis reduce the risk for mortality because cancer is found when it is smaller, lesions are more localized, and the tendency is to have a lower percentage of positive nodes. However, cultural factors may influence a woman's decision to participate in breast cancer screening. Knowledge of these factors and use of culturally sensitive messages and materials that appeal to the unique concerns, beliefs, and reading abilities of target groups assist the nurse in helping women overcome barriers to seeking care. It is important to understand the perspectives of women from various ethnic groups in terms of how they view the health care system and why they choose or do not choose to seek health screening, such as mammograms. Other barriers to breast cancer screening include older age, expense, lack of health insurance, fear, lack of knowledge, and organizational barriers such as scheduling problems and lack of available services.

Clinical examination by a qualified health care provider and screening mammography (X-ray film examination of the breast) (Fig. 4.6) may aid in the early detection of breast cancers. A diagnostic mammogram is performed when a screening mammogram identifies something that needs further inspection or when the woman or examiner finds a breast symptom that is new.

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FIG 4.6 Patient undergoing mammography. (Courtesy of Shannon Perry, Phoenix, AZ.)

When a suspicious finding on a mammogram is noted or a lump is detected, the diagnosis is confirmed by needle aspiration, a core needle biopsy, or surgical excision (Fig. 4.7). Ultrasound may also be used to assess a specific area of abnormality found during a mammogram procedure (Sandadi et al., 2017). Women need specific information regarding advantages and disadvantages of these procedures in making a decision about which one is most appropriate for them.

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FIG 4.7 Diagnosis. A, Needle aspiration. B, Open biopsy. (Redrawn from National Women's Health Resource Center. [1995].

Breast health. National Women's Health Report, 13[5], 3.)

Laboratory examination of breast tissue determines if cancer is present and, if so, the extent. Other tests performed to determine the spread of the cancer include digital mammography, CT, MRI, and three-dimensional mammography (tomosynthesis), among other tests (Sandadi et al., 2017).

An important step in evaluating a breast cancer is to test for the presence of estrogen and progesterone receptors in the biopsied tissue. Cancer cells may contain one, both, or neither of these receptors. Breast cancers that contain estrogen receptors are often called ER-positive cancers, whereas those containing progesterone receptors are called PR-positive cancers. Women with hormone- positive tumors tend to respond better to treatment and have higher survival rates than the general population (Sandadi et al., 2017).

An HER2/neu test also may be performed on the biopsied breast tissue. HER2/neu is a growth-promoting hormone. In approximately 18% to 20% of breast cancers, excessive amounts of the hormone are present, causing the cancer to be more aggressive in spreading than other types of breast cancer (Sandadi et al., 2017).

Medical Management Controversy continues regarding the best treatment for breast cancer. Nodal involvement, tumor size, receptor status, and aggressiveness are important variables for treatment selection. Medical management of breast cancer includes surgery, breast

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reconstruction, radiation therapy, adjuvant hormone therapy, biologic targeted therapy, and chemotherapy. Many women face difficult decisions about the various treatment options. Box 4.9 lists questions that must be addressed in decision making.

Box 4.9 Decision-Making Questions to Ask

1. What kind of breast cancer is it (invasive or noninvasive)?

2. What stage is cancer (i.e., how extensive is the spread)?

3. Did the cancer test positive for hormone (estrogen) (may be slower growing)?

4. Which further tests are recommended?

5. What are the treatment options? (pros and cons of each, including side effects)

6. If surgery is recommended, what will the scar look like?

7. If a mastectomy is done, can breast reconstruction be done (at the time of surgery or later)?

8. How long will the woman be in the hospital? What kind of postoperative care will she need?

9. How long will treatment last if radiation or chemotherapy is recommended? What effects can the woman expect from these treatments?

10. What community resources are available for support?

Most health care providers recommend that the malignant mass and the axillary nodes, specifically the sentinel node, be removed for staging purposes (Sandadi et al., 2017). The treatment can be

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conservative or more radical. The most frequently recommended surgical approaches for the treatment of breast cancer are lumpectomy and total simple mastectomy. Breast-conserving surgery such as a lumpectomy (Fig. 4.8, A) or partial mastectomy (e.g., quadrantectomy, wide excision) (see Fig. 4.8, B) is the removal of the breast tumor and a small amount of surrounding tissue. Sampling of axillary lymph nodes usually occurs through a separate incision at the time of these procedures, and the surgery is usually followed by radiation therapy to the remaining breast tissue (Sandadi et al.). These procedures are for the primary treatment of women with early-stage (I or II) breast cancer. Lumpectomy offers survival equivalent to that with modified radical mastectomy.

FIG 4.8 Surgical alternatives for breast cancer. A,

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Lumpectomy. B, Partial mastectomy (quadrantectomy, wide excision). C, Total (simple) mastectomy. D,

Radical mastectomy.

A total simple mastectomy (see Fig. 4.8, C) is the removal of the breast containing the tumor. A modified radical mastectomy is the removal of the breast tissue, skin, and fascia of the pectoralis muscle and dissection of the axillary nodes. A radical mastectomy (see Fig. 4.8, D), although rarely performed, is the removal of the breast and underlying pectoralis muscles and complete axillary node dissection. After surgery, follow-up treatment may include radiation, chemotherapy, or hormone therapy (Sandadi et al., 2017). The decision to include follow-up therapy is based on the stage of disease, age and menopausal status of the woman, the woman's preference, and her hormone receptor status. Follow-up treatment is usually initiated to decrease the risk for recurrence in women who have no evidence of metastasis.

Radiation is usually recommended as follow-up therapy for women who have stage I or II cancer. Radiation can be external for 5 to 6 weeks or as short as 3 weeks. Internal radiation is in the form of needles, seeds, wires, or catheters filled with a radioactive substance that is inserted into the breast near the tumor. Hormone therapy with tamoxifen, an estrogen agonist, is recommended for women older than 50 years of age for at least 5 years (see Medication Guide for tamoxifen).

Aromatase inhibitors markedly suppress plasma estrogen levels in postmenopausal women by inhibiting or inactivating aromatase, the enzyme responsible for synthesizing estrogens from androgenic substrates. Aromatase inhibitors such as anastrozole, letrozole, and exemestane have been shown to be effective agents in hormone therapy for breast cancer. In early-stage breast cancer, adjuvant therapy with anastrozole appears to be superior to adjuvant therapy with tamoxifen in reducing recurrence in postmenopausal women (see Medication Guide for anastrozole). The aromatase inhibitors appear to be well tolerated, with a lower incidence of adverse effects compared to tamoxifen in postmenopausal women (Sandadi et al., 2017). More research is needed to determine how long a woman should take an aromatase inhibitor. Chlebowski and Budoff (2016) have suggested possibly continued use of an

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aromatase inhibitor for 10 years in postmenopausal women who are hormone receptor–positive, In the past, the only studies conducted looked at 5 years of treatment.

Medication Guide Anastrozole (Arimidex)

Action An aromatase inhibitor; inhibits the conversion of androgens to estrogen

Indication For adjuvant treatment of early breast cancer in postmenopausal women who have received 5 years of tamoxifen therapy, or instead of tamoxifen if a woman cannot tolerate it (e.g., develops deep vein thrombosis); first-line treatment of postmenopausal women with hormone receptor–positive or hormone receptor–unknown locally advanced or metastatic cancer; adjuvant treatment of postmenopausal women with hormone receptor–positive early breast cancer. There is a risk for osteoporosis with aromatase inhibitors.

Dosage and Route 1 mg once a day by mouth for 5 years (with new research suggesting 10 years)

Possibly continued use of an aromatase inhibitor for 10 years in postmenopausal women who are hormone receptor–positiveIn the past, the only studies conducted looked at 5 years of treatment, but recent research (Chlebowski & Gudoff, 2016) suggests a possible benefit of 10 years of treatment. More research is needed as these are very new findings.

Adverse Reactions Common side effects include hot flashes, nausea, increased sweating, joint or muscle pain, fluid retention, vaginal dryness, constipation, dizziness, fatigue, headache; severe side effects include severe allergic reactions (e.g., rash, hives, difficulty

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breathing), vomiting, chest pain, severe bone pain, calf pain or tenderness

Nursing Considerations The medication may be taken on an empty stomach or with food. The woman should use caution if driving or using machinery because this medication may cause drowsiness or dizziness. Advise her that the medicine may decrease bone strength, increase her risk for fractures, and increase cholesterol.

Data from Medscape (2017). Anastrozole. Retrieved from http://reference.medscape.com/drug/arimidex-anastrozole-342208; Chlebowski, R. T., & Budoff, M. J. (2016). Changing adjuvant breast-cancer therapy with a signal for prevention. New England Journal of Medicine, 375(3), 274-275.

Chemotherapy is often given to premenopausal women who have positive nodes. Therapy for more advanced tumors usually includes surgery followed by chemotherapy, radiation, or both (Sandadi et al., 2017).

The goals of surgical breast reconstruction are achievement of symmetry and preservation of body image. Surgical reconstruction can be done immediately or at a later date. Immediate reconstruction at the time of mastectomy does not change survival rates or interfere with therapy or the treatment of recurrent disease.

Surgical options for breast reconstruction include implants and flap procedures. Implants are made of silicone or saline or a combination of both and can be inserted at the same time as a mastectomy or later. They are placed underneath the chest muscle versus on top of it, as in the case of breast augmentation. Silicone implants have been deemed safe and are options for women having breast reconstruction following mastectomy.

Flap procedures are done by plastic and reconstructive surgeons who specialize in microsurgery. During flap reconstruction a breast is created using tissue taken from other parts of the body such as the abdomen, back, or buttocks, or thighs, which is then transplanted to the chest by reconnecting the blood vessels to new ones in the chest region.

After a woman has recovered from initial reconstructive surgery, she may choose to have nipple and areolar reconstruction. Nipple reconstruction is achieved by using an autologous skin graft to

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construct a nipple, either from tissue from the remaining nipple or from a donor site (Sandadi et al., 2017).

Nursing Care Surgery may be performed in an outpatient surgical setting or as an inpatient procedure, depending on which type of surgery is being performed. Nursing care and teaching are focused on the perioperative period. Before surgery, the nurse assesses the woman's psychologic readiness, specific teaching needs related to the procedure, and what to expect after surgery. A visit from a woman who has had a similar experience may be beneficial before and after surgery.

There is a discussion of reconstruction surgery, including the risks and benefits before the surgery if appropriate. A discussion of partial and full external prostheses also may be appropriate, including where to purchase one and the types of bras that may be worn. Local ACS units can provide sources, and volunteers of Reach to Recovery can offer hints and suggestions for wearing apparel and coping with prostheses.

Postoperative nursing care focuses on recovery. Women who had surgery in an outpatient setting usually go home within a few hours after surgery. A 24- to 48-hour stay is usual after modified radical mastectomy.

Nursing Alert Avoid taking blood pressure, giving injections, or taking blood from the arm on the affected side.

The woman may have drainage tubes from the incision site that need to be assessed and drained. Incision care may include dressing changes. If postoperative arm exercises are appropriate, these are initiated during the early postoperative period (Box 4.10).

Box 4.10 Exercises After Breast Surgery It is important to talk to your health care provider before starting

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any exercises. A physical or occupational therapist can help design an exercise program for you.

Exercises in Lying Position These exercises should be performed on a bed or the floor while lying on your back with your knees and hips bent, feet flat.

Wand Exercise This exercise helps increase the forward motion of the shoulders. You will need a broom handle, yardstick, or other similar object to perform it.

• Hold the wand in both hands with palms facing up.

• Lift the wand up over your head (as far as you can), using your unaffected arm to help lift it until you feel a stretch in your affected arm.

• Hold for 5 seconds.

• Lower arms and repeat 5 to 7 times.

Elbow Winging This exercise helps increase the mobility of the front of your chest and shoulder. It may take several weeks of regular exercise before your elbows will get close to the bed (or floor).

• Clasp your hands behind your neck with your elbows pointing toward the ceiling.

• Move your elbows apart and down toward the bed (or floor).

• Repeat 5 to 7 times

Exercises in Sitting Position Shoulder Blade Stretch This exercise helps increase the mobility of the shoulder blades.

• Sit in a chair very close to a table with your back against the chair back.

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• Place the unaffected arm on the table with your elbow bent and palm down. Do not move this arm during the exercise.

• Place the affected arm on the table, palm down with your elbow straight.

• Without moving your trunk, slide the affected arm toward the opposite side of the table. You should feel your shoulder blade move as you do this.

• Relax your arm and repeat 5 to 7 times.

Shoulder Blade Squeeze This exercise also helps increase the mobility of the shoulder blade.

• Facing straight ahead, sit in a chair in front of a mirror without resting on the back of the chair.

• Arms should be at your sides with elbows bent.

• Squeeze shoulder blades together, bringing your elbows behind you. Keep your shoulders level as you do this exercise. Do not lift them up toward your ears.

• Return to the starting position and repeat 5 to 7 times.

Side Bending This exercise helps increase the mobility of the trunk/body.

• Clasp your hands together in front of you and lift your arms slowly over your head, straightening your arms.

• When your arms are over your head, bend your trunk to the right while bending at the waist and keeping your arms overhead.

• Return to the starting position and bend to the left.

• Repeat 5 to 7 times.

Exercises in Standing Position

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Chest Wall Stretch This exercise helps stretch the chest wall.

• Stand facing a corner with toes approximately 8 to 10 inches from the corner.

• Bend your elbows and place forearms on the wall, one on each side of the corner. Your elbows should be as close to shoulder height as possible.

• Keep your arms and feet in position and move your chest toward the corner. You will feel a stretch across your chest and shoulders.

• Return to starting position and repeat 5 to 7 times.

• Be sure you keep your shoulders dropped far away from your ears as you do this stretch.

Shoulder Stretch This exercise helps increase the mobility in the shoulder.

• Stand facing the wall with your toes approximately 8 to 10 inches from it.

• Place your hands on the wall. Use your fingers to “climb the wall,” reaching as high as you can until you feel a stretch.

• Return to starting position and repeat 5 to 7 times.

• Be sure you keep your shoulders dropped far away from your ears as you raise your arms.

Modified from American Cancer Society (2016). Exercises after breast surgery. Retrieved from http://www.cancer.org/cancer/breastcancer/moreinformation/exercises-after-breast- surgery.

The woman is usually discharged to home after being given self- management instructions. Because teaching time is short, providing printed information gives the woman and her family something to

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refer to at home (Box 4.11).

Box 4.11 Patient Teaching After a Mastectomy Without and With Reconstruction

• Wash hands well before and after touching incision area or drains.

• Empty surgical drains twice a day and as needed, recording the date, time, drain sites (if more than one drain is present), and amount of drainage in milliliters in the diary that you will take to each surgical checkup until your drains are removed. (Before discharge you may receive a graduated container for emptying drains and measuring drainage.)

• Avoid driving, lifting more than 10 pounds, or reaching above your head until given permission by the surgeon.

• Take medications for pain as soon as pain begins.

• Perform arm exercises as directed.

• Call health care provider if inflammation of incision or swelling of the incision or the arm occurs.

• Avoid tight clothing, tight jewelry, and other causes of decreased circulation in the affected arm.

• Until drains are removed, wear loose-fitting underwear (camisole or half-slip) and clothes, pinning surgical drains inside of clothing. (You will be taught how to do this safely.)

• After drains are removed and surgical sites are healing and still tender, wear a mastectomy bra or camisole with a cotton-filled, muslin temporary prosthesis. Temporary prostheses of this type are often available from Reach to Recovery.

• Avoid depilatory creams; strong deodorants; and shaving of

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affected chest area, axilla, and arm.

• Sponge bathe for the first 48 hours; then you may shower. Thoroughly dry yourself afterward and reapply fresh dressings.

• Return to the surgeon's office for incision check, drain inspection, and possible drain removal as directed.

• Contact Reach to Recovery or a breast center nursing staff member for assistance in obtaining external prosthesis and lingerie when dressings, drains, and staples are removed and wound is healing and nontender.

• Contact insurance company for information about coverage of prosthesis and wig if needed. Obtain prescriptions for prosthesis and wig to submit with receipts of purchase for these items to the insurance company. If insurance does not pay for these items, contact hospital or agency social worker or local American Cancer Society for assistance.

• Practice breast self-exam (BSE) of unaffected side and affected surgical site and axilla.

• Keep follow-up visits for professional examination, mammography, and testing to detect recurrent breast cancer.

• Expect decreased sensation and tingling at incision sites and in the affected arm for weeks to months after surgery.

• Resume sexual activities as desired.

• Participate in breast cancer survivor support group if desired.

• Encourage mother, sisters, and daughters (if applicable) to learn and practice BSE and have annual professional breast examinations and mammography (if appropriate).

Additional Nursing Care for Women Undergoing Mastectomy With Reconstruction

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• Apply no tight compression of the reconstructed breasts until approved by the plastic surgeon.

• Wear loosely fitting garments for first 3 to 4 weeks.

• Know that surgery is still a work in progress and that final cosmetic result of reconstruction takes many weeks.

• Assess skin for potential of poor peripheral circulation that may cause skin necrosis, and report any skin changes immediately.

• See drain care instructions under axillary dissection section.

Concerns about appearance after breast surgery may affect the woman's self-concept. Before surgery, the woman and her partner need information about the woman's postoperative appearance. They need to be able to discuss feelings and concerns about accepting the changes. Nurses can help the couple communicate these feelings and concerns. Information about community resources and support groups such as Reach to Recovery are often beneficial.

References Advincula A, Troung M, Lobo RA. Endometriosis: Etiology,

pathology, diagnosis, management. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 7th ed. Author: Washington, DC; 2012.

American Cancer Society. Non-cancerous breast conditions: Duct ectasia. [Retrieved from] http://www.cancer.org/healthy/findcancerearly/womenshealth/non- cancerousbreastconditions/non-cancerous-breast- conditions-duct-ectasia; 2016.

American Cancer Society. The American Cancer Society guidelines for the prevention and early detection of cervical

369

cancer. [Retrieved from] http://www.cancer.org/ccervical- cancer/prevention-and-early-detection/cervical-cancer- screening-guidelines.html; 2016.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Author. Arlington: Washington, DC; 2014.

Centers for Disease Control and Prevention. National notifiable diseases surveillance system (NNDSS). [Retrieved from] https://wwwn.cdc.gov/nndss/conditions/notifiable/2015/infectious- diseases/; 2015.

Centers for Disease Control and Prevention. Areas with Zika. [Retrieved from] http://www.cdc.gov/zika/about/index.html; 2016.

Centers for Disease Control and Prevention. Prevention in newborns: Preventing early-onset group B strep disease (GBS). [Retrieved from] http://www.cdc.gov/groupbstrep/about/prevention.html; 2016.

Centers for Disease Control and Prevention. Breast cancer statistics. [Retrieved from] http://www.cdc.gov/cancer/breast/statistics/; 2016.

Centers for Disease Control and Prevention. Sexually transmitted diseases. [Retrieved from] https://www.cdc.gov/std/treatment/; 2017.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. [Retrieved from] https://www.cdc.gov/std/tg2015/clinical.htm; 2017.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines: Special populations. [Retrieved from] https://www.cdc.gov/std/tg2015/specialpops.htm; 2017.

Chien LW, Chang HC, Liu CF. Effect of yoga on serum homocysteine and nitric oxide levels in adolescent women with and without dysmenorrhea. Journal of Complementary and Alternative Medicine. 2013;19(1):20–23.

Chlebowski RT, Budoff MJ. Changing adjuvant breast cancer therapy with a signal for prevention. New England Journal of Medicine. 2016;375(3):274–275.

370

Choudhary MC. Antiretroviral therapy for pregnant HIV-infected patients. [Medscape; Retrieved from] http://emedicine.medscape.com/article/2042311- overview#a2; 2015.

Department of Health and Human Services. Clinical guidelines portal—AIDS info. [Retrieved from] https://aidsinfo.nih.gov/guidelines/html/3/perinatal- guidelines/182/transmission-and-mode-of-delivery; 2015.

Drakh A. Low energy availability in female athletes: Oral contraceptives in athletes. Medscape News and Perspective. [Retrieved from] http://emedicine.medscape.com/article/312312- overview#a10; 2016.

Drugs.com. Goserelin dosage. [Retrieved from] https://www.drugs.com/dosage/goserelin.html; 2017.

Gardella C, Eckert LO, Lentz GM. Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Healthwise Staff. Pelvic rocking. [WebMD; Retrieved from] http://www.webmd.com/fitness-exercise/pelvic-rocking; 2015.

Hughes B, Cu-Uvin S. Use of antiretroviral medications in pregnant HIV-infected patients and their infants in resource-rich settings. [Retrieved from] www.uptodate.com/contents/antiretroviral-treatment-of- pregnant-hiv-infected-women-and-antiretroviral- prophylaxis-of-their-infants-in-resource-rich-settings; 2016.

Jafari M, Orenstein G. Women and herbal medicine. Olshansky EF. Women's health and wellness across the lifespan. Wolters Kluwer: Philadelphia, PA; 2015.

Lobo RA. Primary and secondary amenorrhea and precocious puberty. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

MedicineNet.com. Nafarelin, Synarel. [Retrieved from] http://www.medicinenet.com/nafarelin/page3.htm; 2017.

371

Medscape. Leuprolide. [Retrieved from] http://reference.medscape.com/drug/lupron-leuprolide- 342221; 2017.

Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—Updated recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report. 2016;65:1405–1408.

Mendiratta V. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Mielke R, Parsons K, Greenberg CS. Puberty through early adulthood. Olshansky EF. Women's health and wellness across the lifespan. Wolters Kluwer: Philadelphia, PA; 2015.

Pruthi S. Is there a correlation between breast implants and cancer? And if so, how serious is the risk? Mayo Clinic. [Retrieved from] http://www.mayoclinic.org/healthy- lifestyle/womens-health/expert-answers/breast-implants- and-cancer/faq-20057774; 2015.

Ryntz T, Lobo RA. Abnormal uterine bleeding: etiology and management of acute and chronic excessive bleeding. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Sandadi S, Rock DT, Orr JW, Valea FA. Breast diseases: Detection, management, and surveillance of breast disease. Lobo RA, Gershenson DM, Lentz GM, et al. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Sharp BAC, Taylor DL, Thomas KK, Killeen MB, Dawood MY. Cyclic premenstrual pain and discomfort: the scientific basis for practice. Journal of Obstetrics, Gynecologic, and Neonatal Nursing. 2002;31(6):637–649.

Taylor DL. Premenstrual symptoms and syndromes: guidelines for management and self care. Advanced Studies in Medicine. 2005;5(5):228–241.

Thein-Nissenbaum J. Long term consequences of the female athlete triad. Maturitas. 2013;75(2):107–112.

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UpToDate. Candida vulvovaginitis. [Retrieved from] http://www.uptodate.com/contents/candida- vulvovaginitis; 2017.

Wambach CM, Alexander CJ. Menstrual disorders. DiSaia PJ, Chaudhuri G, Giudice LC, et al. Women's health review: A clinical update in obstetrics-gynecology. Saunders: Philadelphia, PA; 2012.

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5

Infertility, Contraception, and Abortion Ellen F. Olshansky

Infertility Incidence Infertility is a serious concern that affects 1 in 4 couples of reproductive age, with increasing incidence correlated with increased age (Crawford & Steiner, 2015; Lobo, 2017). Commonly infertility is considered to be a diagnosis for couples who have not achieved pregnancy after 1 year of regular, unprotected intercourse when the woman is less than 35 years of age or after 6 months when the woman is older than 35 years of age. Fecundity is the term used to describe the chance of achieving pregnancy and subsequent live birth within one menstrual cycle. Fecundity averages 20% in couples who are not experiencing reproductive problems (American Society of Reproductive Medicine [ASRM], 2012).

Probable causes of infertility include the trend toward delaying pregnancy until later in life, a time when fertility decreases naturally and the prevalence of diseases such as endometriosis and ovulatory dysfunction increases. Questions exist regarding whether

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there has been an increase in male infertility or whether male infertility is more readily identified because of improvements in diagnosis.

For the couple experiencing infertility, diagnosis and treatment strategies require considerable physical, emotional, and financial investment over an extended period of time. Feelings connected with infertility are many and complex, often interfering with quality of life. It is common for infertile couples to experience anxiety from the need to undergo many tests and examinations and from a perception of feeling “different” from their fertile friends and relatives. The following four goals provide a framework for nurses who care for infertile persons: • Provide the couple with accurate information about human

reproduction, infertility treatments, and prognosis for pregnancy. Dispel any myths or inaccuracies from friends or the mass media that the couple may believe to be true.

• Help the couple and the health care team accurately identify and treat possible causes of infertility.

• Provide emotional support. The couple may benefit from anticipatory guidance, counseling, and support group meetings, either face-to-face or online. The organization RESOLVE (www.resolve.org) provides online support, advocacy, and education about infertility for both the infertility community and health care providers.

• Guide and educate those who fail to conceive biologically about other forms of treatment such as in vitro fertilization (IVF), donor eggs or semen, surrogate motherhood, and adoption. Support the couple in their decisions regarding their future family.

It is important for nurses to encourage all healthy women and men to maintain a normal body mass index (BMI) and avoid sexually transmitted infections (STIs) and exposures to substances or habits (such as smoking) that impair reproductive ability. While these health-promoting activities will not ensure fertility, they will enhance overall health as the individual or couple is coping with the stresses of infertility.

Factors Associated With Infertility

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Although exact percentages vary somewhat with populations, approximately 85% to 90% of couples seeking infertility care are treated with medication or surgery, with 3% being treated with in vitro fertilization or other assisted reproductive methods (ASRM, 2016). About 40% of infertility is related to a male factor or a combined male and female factor (ASRM, 2016). About 20% of infertility is unexplained (Lobo, 2017). For those couples and individuals for whom a specific cause of infertility is not detected, the focus of infertility treatment has shifted from attempting to correct a specific pathology to recommending and initiating the treatment that is most effective in achieving pregnancy for this unique couple at this time in their reproductive life span. Assisted reproductive technologies (ARTs) have proven to be effective, even in couples who experience unexplained infertility.

Unassisted human conception requires a normally developed reproductive tract in both the male and female partners. For simplification, each live birth necessitates synchronization of the following: • The male must deposit semen with sperm that has the capacity to

fertilize an egg close to the cervix at the time of ovulation. The sperm must be able to ascend through the uterus and uterine tubes (male factor). The cervix must be sufficiently open to allow semen to enter the uterus and provide a nurturing environment for sperm (cervical factor).

• The uterine tubes must be able to capture the ovum, transport semen to the ovum, and transport the fertilized embryo to the uterus (tubal factor).

• Ovulation of a healthy oocyte must occur, ideally within the parameters of a regular, predictable menstrual cycle (ovarian factor).

• The uterus must be receptive to implantation of the embryo and capable of nourishing the growth and development of the fetus throughout the normal duration of pregnancy (uterine factor).

An alteration in one or more of these structures, functions, or processes results in some degree of impaired fertility. Boxes 5.1 and 5.2 list factors affecting female and male infertility.

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Box 5.1 Factors Affecting Female Fertility Ovarian Factors

• Developmental anomalies

• Anovulation—primary

• Pituitary or hypothalamic hormone disorders

• Adrenal gland disorders (rare)

• Congenital adrenal hyperplasia (rare)

• Anovulation—secondary

• Disruption of hypothalamic-pituitary-ovarian axis

• Anorexia

• Insufficient body fat in athletic women

• Increased prolactin levels

• Thyroid disorders

• Premature ovarian failure

• Polycystic ovary syndrome

• Medications

• Oral contraceptives

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• Progestins

• Antidepressant and antipsychotic drugs

• Corticosteroids

• Chemotherapy

Tubal/Peritoneal Factors

• Developmental anomalies of the tubes (see Fig. 5.1)

FIG 5.1 Abnormal uterus. A, Complete bicornuate uterus with vagina divided by a septum. B, Complete

bicornuate uterus with normal vagina. C, Partial bicornuate uterus with normal vagina. D, Unicornuate

uterus.

• Reduced tubal motility

• Inflammation within the tube

• Tubal adhesions

• Disruption caused by tubal pregnancy

• Endometriosis

Uterine Factors

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• Developmental anomalies of the uterus (see Fig. 5.1)

• Endometrial and myometrial fibroid tumors

• Asherman's syndrome (uterine adhesions or scar tissue)

Vaginal-Cervical Factors

• Vaginal-cervical infections

• Cervical mucus inadequate

• Isoimmunization (development of sperm antibodies)

Other Factors

• Nutritional deficiencies

• Obesity

• Thyroid dysfunction (hyperthyroidism and hypothyroidism)

• Idiopathic conditions

Box 5.2 Factors Affecting Male Fertility Hormonal Disorders

• Congenital disorders

• Tumors of the pituitary gland or hypothalamus

• Trauma to the pituitary gland or hypothalamus

• Hyperprolactinemia

• Excess of androgens, estrogen, or cortisol

• Drugs and substance abuse (recreational and prescribed drugs)

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• Chronic illnesses

• Nutritional deficiencies

• Obesity

• Endocrine disorders (e.g., diabetes)

Testicular Factors

• Congenital disorders

• Undescended testes

• Hypospadias

• Varicocele

• Viral infections (e.g., mumps)

• Sexually transmitted infections (e.g. gonorrhea, chlamydial infection)

• Obstructive lesions of the epididymis and vas deferens

• Environmental toxins

• Trauma

• Torsion

• Castration

• Systemic illnesses

• Antisperm antibodies

• Changes in sperm from cigarette smoking or use of heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, or methaqualone

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• Decrease in libido from use of heroin, methadone, selective serotonin reuptake inhibitors, or barbiturates

• Impotence from use of alcohol or antihypertensive medications

Factors Associated With Sperm Transport

• Drugs

• Sexually transmitted infections of the epididymis

• Ejaculatory dysfunction

• Premature ejaculation

Idiopathic Male Infertility

For conception to occur, both partners must have normal, intact hypothalamic-pituitary-gonadal hormonal axes that support the formation of sperm in the male and ova in the female. Sperm can remain viable within a woman's reproductive tract for at least 3 days and for as long as 5 days. The oocyte can only be successfully fertilized for 12 to 24 hours after ovulation. The couple seeking pregnancy should be taught about the menstrual cycle and ways to detect ovulation (see Chapter 3). They should be counseled to have intercourse 2 to 3 times a week; or, if timed intercourse does not increase anxiety, they should be encouraged to engage in intercourse the day before and the day of ovulation. Fertility decreases markedly 24 hours after ovulation.

Care Management Infertility care management includes a team of health care providers, including an obstetric care provider, fertility specialist, embryologist, genetic counselor, and mental health provider or counselor. The nurse is a key member of the care management team and assists in the assessment and education of the infertile couple. As part of the assessment process, he or she obtains information from the couple through interview and physical examination,

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including if this couple's situation is one of primary (never experienced pregnancy) or secondary (previous pregnancy) infertility. Religious, cultural, and ethnic data may place restrictions on use of available treatments.

In addition, the nurse obtains and monitors results of diagnostic testing. Some of the information and data needed to investigate impaired fertility are of a sensitive, personal nature. The couple may experience feelings of invasion of privacy, and the nurse must exercise tact and express concern for their well-being throughout the interview. The tests and examinations associated with infertility diagnosis and treatment are occasionally painful and often intrusive. The couple's intimacy and feelings of romantic attachment are often impaired as they engage in this process. A high level of motivation is needed to endure the investigation and subsequent treatment. Because multiple factors involving both partners are common, the investigation of impaired fertility is conducted systematically and simultaneously for both male and female partners. Both partners must be interested in the solution to the problem. The medical investigation requires time (3 to 4 months) and considerable financial expense. Box 5.3 describes the status of insurance coverage for infertility treatment.

Box 5.3 Insurance Coverage for Infertility As of October 2016, only 15 states had mandated some form of insurance coverage for infertility. These mandates included in vitro fertilization in some states, whereas others only covered some diagnostic tests. Some states require health maintenance organizations (HMOs) to cover some costs, whereas in others HMOs are exempt. Patients need information about what they can expect from their insurers. The state Insurance Commissioner's office can provide information about an individual state. The website for the American Society for Reproductive Medicine (www.asrm.org) has more complete information.

Assessment of Female Infertility Evaluation for infertility should be offered to couples who have

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failed to become pregnant after 1 year of regular intercourse or after 6 months if the woman is older than 35 years of age. Investigation of impaired fertility begins for the woman with a complete history and physical examination. A complete general physical examination should include height and weight and estimation of BMI. Both obesity and being underweight are associated with anovulation disorders. Signs and symptoms of androgen excess such as excess body hair or pigmentation changes should be noted. The general physical examination is followed by a specific assessment of the reproductive tract. A history of infections of the genitourinary tract and any signs of infections, especially STIs that could impair tubal patency, should be assessed. Bimanual examination of internal organs may reveal lack of mobility of the uterus or abnormal contours of the uterus and tubes. A woman may have an abnormal uterus and tubes as a result of congenital abnormalities during fetal development). These uterine abnormalities increase risk for early pregnancy loss.

Laboratory data, including routine urine and blood tests, are collected. The initial clinic visit serves as a preconceptional visit and as initial assessment of possible causes of infertility. The woman should be taking folic acid supplements, and all immunizations should be current to prepare for possible pregnancy.

Diagnostic Testing The basic infertility survey of the female involves evaluation of the cervix, uterus, tubes, and peritoneum; detection of ovulation; and hormone analysis. Timing and descriptions of common tests are presented in Table 5.1.

TABLE 5.1 General Tests for Impaired Fertility

Test or Examination Timing (Menstrual Cycle Days)

Rationale

Hysterosalpingogram (HSG) (uterine abnormalities, tubal patency)

7–10 Late follicular, early proliferative phase; will not disrupt a fertilized ovum; may open uterine tubes before time of ovulation

Chlamydia immunoglobulin G

Variable Negative antibody test may indicate tubal patency assessment (HSG); not needed in low-risk women

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antibodies (tubal patency) Hysterosalpingo- contrast sonography (uterine abnormalities, tubal patency)

7–10 Late follicular, early proliferative phase; will not disrupt a fertilized ovum; evaluates tubal patency, uterine cavity, and myometrium

Serum progesterone (ovulation)

7 days before expected menses

Midluteal-phase progesterone levels; check adequacy of corpus luteum progesterone production

Assessment of cervical mucus (ovulation)

Variable, ovulation

Cervical mucus should have low viscosity, spinnbarkeit (ability to stretch) during ovulation

Basal body temperature (ovulation)

Chart entire cycle

Elevation occurs in response to progesterone; documents ovulation

Urinary ovulation predictor kit (ovulation)

Variable, ovulation

Detects timing of lutein hormone surge before ovulation

Semen analysis (male factor)

2–7 days after abstinence

Detects ability of sperm to fertilize egg

Sperm penetration assay (male factor)

After 2 days but ≤1 week of abstinence

Evaluates ability of sperm to penetrate egg

Follicle-stimulating hormone (FSH) level (ovarian reserve)

Day 3 High FSH levels (>20) indicate that pregnancy will not occur with woman's own eggs; value <10 indicates adequate ovarian reserve

Clomiphene citrate challenge test (CCCT) (ovarian reserve)

Administer clomiphene 100 mg days 5 through 9

Assess FSH on days 3 and 10 in presence of clomiphene stimulation; high FSH levels (>20) indicate that pregnancy will not occur with woman's own eggs; FSH <15 suggestive of adequate ovarian reserve

From Genetics & IVF Institute. (2013). Fertility: Clomiphene citrate test. Retrieved from http://www.givf.com/fertility/clomidchallengetest.shtml.

Previous status regarding ovulation can be evaluated through menstrual history, serum hormone studies, and use of an ovulation predictor kit. If the woman is older than 35 years of age, the clinician may choose to assess “ovarian reserve” or how many potential ova remain within the ovaries. A common evaluation of ovarian reserve is measurement of follicle-stimulating hormone (FSH) levels on the third day of the menstrual cycle. The uterus and fallopian/uterine tubes can be visualized for abnormalities and tubal patency through hysterosalpingogram (x-ray film examination of the uterine cavity and tubes after instillation of radiopaque contrast material through the cervix). If the woman is at risk for endometriosis (implants of endometrial tissue outside of the uterus) or adhesions, diagnostic laparoscopy may be indicated. Test

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findings favorable for fertility are summarized in Box 5.4.

Box 5.4 Summary of Findings Favorable to Fertility

1. Follicular development, ovulation, and luteal development are supportive of pregnancy:

a. Basal body temperature (presumptive evidence of ovulatory cycles) is biphasic, with temperature elevation that persists for 12 to 14 days before menstruation.

b. Cervical mucus characteristics change appropriately during phases of the menstrual cycle.

c. Days 3 to 10 follicle-stimulating hormone (FSH) levels are low enough to verify the presence of adequate ovarian follicles.

d. Day 3 estradiol levels are low enough to verify the presence of adequate ovarian follicles.

e. Woman reports a history of regular, predictable menses with consistent premenstrual and menstrual symptoms.

2. The luteal phase is supportive of pregnancy:

a. Levels of plasma progesterone are adequate to indicate ovulation.

b. Luteal phase of menstrual cycle is of sufficient

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duration to support pregnancy.

3. Cervical factors are receptive to sperm during expected time of ovulation:

a. Cervical os is open.

b. Cervical mucus is clear, watery, abundant, and slippery and demonstrates good spinnbarkeit and arborization (fern pattern) at time of ovulation.

c. Cervical examination reveals no lesions or infections.

4. The uterus and uterine tubes support pregnancy:

a. Uterine and tubal patency are documented by (1) spillage of dye into the peritoneal cavity, and (2) outlines of uterine and tubal cavities of adequate size and shape with no abnormalities.

b. Laparoscopic examination verifies normal development of internal genitals and absence of adhesions, infections, endometriosis, and other lesions.

5. The male partner's reproductive structures are normal:

a. There is no evidence of developmental anomalies of penis, testicular atrophy, or varicocele (varicose veins on the spermatic vein in the groin).

b. There is no evidence of infection in prostate,

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seminal vesicles, and urethra.

c. Testes are more than 4 cm in largest diameter.

6. Semen is supportive of pregnancy:

a. Sperm (number per milliliter) are adequate in ejaculate.

b. Most sperm show normal morphology.

c. Most sperm are motile, forward moving.

d. No autoimmunity exists.

e. Seminal fluid is normal.

Assessment of Male Infertility The systematic investigation of infertility in the male patient begins with a thorough history and physical examination. Assessment of the male patient proceeds in a manner similar to that of the female patient, starting with noninvasive tests.

Diagnostic Testing and Semen Analysis The basic test for male infertility is semen analysis. A complete semen analysis, study of the effects of cervical mucus on sperm forward motility and survival, and evaluation of the ability of the sperm to penetrate an ovum provide basic information. Sperm counts vary from day to day and depend on emotional and physical status and sexual activity. Therefore, a single analysis may be inconclusive. A minimum of two analyses must be performed several weeks apart to assess male fertility.

Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a spermicidal agent. The specimen is usually collected by masturbation following 2 to 7 days

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of abstinence from ejaculation. The semen is examined at the collection site or taken to the laboratory in a sealed container within 2 hours of ejaculation. Exposure to excessive heat or cold is avoided. Commonly accepted values for semen characteristics are given in Box 5.5. If results are in the fertile range, no further sperm evaluation is necessary. If results are not within this range, the test is repeated. If subsequent results are still in the subfertile range, further evaluation is needed to identify the problem.

Box 5.5 Semen Analysis: Normal Values

• Semen volume at least 1.5 mL

• Semen pH 7.2 or higher

• Sperm density greater than 15 million/mL

• Total sperm count greater than 39 million per ejaculate

• Normal morphologic features greater than 4% (normal oval)

• Motility (important consideration in sperm evaluation)— percentage of forward-moving sperm estimated with respect to abnormally motile and nonmotile sperm, 40%

• Liquification—usually within 15 minutes but no longer than 60 minutes

NOTE: These values are not absolute but are only relative to final evaluation of the couple as a single reproductive unit. Values also differ according to source used as a reference.

Data from World Health Organization. (2010). Laboratory manual for the examination of human semen (5th ed.). Geneva, Switzerland: Author.

Hormone analyses are done for testosterone, gonadotropin, FSH, and luteinizing hormone (LH). The sperm penetration assay and other alternative tests may be used to evaluate the ability of sperm

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to penetrate an egg. Testicular biopsy may be warranted. Scrotal ultrasound may be used to examine the testes for presence of varicoceles and identify abnormalities in the scrotum and spermatic cord. Transrectal ultrasound is used to evaluate the ejaculatory ducts, seminal vesicles, and vas deferens.

Psychosocial Considerations Infertility is recognized as a major life stressor that can affect self- esteem; relations with the spouse or partner, family, and friends; and careers. Psychologic responses to the diagnosis of infertility may tax a couple's capacity for giving and receiving physical and sexual closeness. The prescriptions and taboos for achieving conception may add tension to a couple's sexual functioning. They may report decreased desire for intercourse, orgasmic dysfunction, or midcycle erectile disorders.

To be able to deal comfortably with a couple's sexuality, nurses must be comfortable with their own sexuality so they can better help couples understand why aspects of sexual intimacy need to be shared with health care professionals. Nurses need current factual knowledge about human sexual practices and must be accepting of the preferences and activities of others without being judgmental. They must be skilled in interviewing and therapeutic use of self, sensitive to the nonverbal cues of others, and knowledgeable regarding each couple's sociocultural and religious beliefs (see Clinical Reasoning Case Study).

Clinical Reasoning Case Study Infertility

Diane is a 39-year-old accountant who has recently married for the first time. Charles is 41 years of age and has two children from a previous marriage. Diane has a history of amenorrhea dating back to when she was in college and a member of the track team. Currently her menstrual periods are irregular. She wants to have a baby “before it's too late,” and she and Charles have been having unprotected sex for almost 1 year. They have come to the fertility clinic today for an evaluation. Diane tells the nurse that she has

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heard about the success of in vitro fertilization (IVF) and wants to know if she will be able to have it performed. How should the nurse respond to Diane's comments and questions?

1. Evidence—Is evidence sufficient to draw conclusions about what response the nurse should give?

2. Assumptions—Describe underlying assumptions about the following issues:

a. Age and fertility: Is Diane's age a factor in her concern regarding infertility?

b. Infertility as a major life stressor: To what extent can infertility or the fear of being infertile cause stress?

c. Success rates for IVF pregnancy and birth: Is IVF a reasonable treatment to consider (after having a thorough workup)?

d. Causes of female infertility: What are some of the reasons that Diane may be infertile?

3. What implications and priorities for nursing care can be drawn at this time?

4. Describe the roles and responsibilities of members of the interprofessional health care team who may be caring for Diana and Charles.

The couple facing infertility exhibits behaviors of the grieving process such as those associated with other types of loss. The loss of one's genetic continuity with the generations to come can provoke decreased self-esteem, a sense of inadequacy as a woman or a man, and feelings of loss of control over personal destiny. Infertile

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individuals can perceive dissatisfaction with their marriages or partner relationships. Not all people have all the reactions described, nor can it be predicted how long any reaction will last for an individual. Often a mental health counselor with experience and expertise dealing with infertility can be very helpful to an individual or couple.

If the couple does not conceive, they should be assessed regarding their desire to be referred for help with adoption, donor eggs or semen, surrogacy, or other reproductive alternatives. The couple may choose to continue in a child-free state. Both health care providers and patients should have a list of agencies, support groups, and other resources within their community such as the ASRM (www.asrm.org) and RESOLVE (www.resolve.org).

Nonmedical Treatments Both men and women can benefit from healthy lifestyle changes that result in a BMI within the normal range; moderate daily exercise; and abstinence from alcohol, nicotine, and recreational drugs. For the woman with a BMI >27 and polycystic ovary syndrome, losing just 5% to 10% of body weight can restore ovulation within 6 months. Anovulatory women with a BMI <17 who have eating disorders or intense exercise regimens benefit from weight gain. Nevertheless, this population sometimes is reluctant to alter their behaviors, and counseling should be advised.

Simple changes in lifestyle may be effective in the treatment of subfertile men. Only water-soluble lubricants should be used during intercourse because many commonly used lubricants contain spermicides or have spermicidal properties. Instead of wearing briefs, the male should wear boxer shorts and loose pants because these tend to decrease scrotal temperature and may prevent a decrease in sperm count. High scrotal temperatures can be caused by daily hot tub baths or saunas that keep the testes at temperatures too high for efficient spermatogenesis. These conditions lead to only lessened fertility and should not be used as a means of contraception.

Most herbal remedies have not been proven clinically to promote fertility or to be safe in early pregnancy and should be taken by the woman only as prescribed by a physician or nurse-midwife who

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has expertise in herbology. Relaxation, osteopathy, stress management (e.g., aromatherapy, yoga), and nutritional and exercise counseling have been reported to increase pregnancy rates in some women. Herbs to avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. All supplements or herbs should be purchased from trusted sources to ensure that they do not contain contaminants.

Medical Therapy One goal of infertility assessment and treatment is to determine which couples are likely to respond to conventional therapies in a timely manner. Another goal is early referral of couples who will need ARTs to concieve. In general, any fertility treatment is more likely to result in a live birth in women who are younger than 35 years of age, with successful outcomes decreasing for women older than 40 years of age.

Pharmacologic therapy for female infertility is often directed at treating ovulatory dysfunction by either stimulating or enhancing ovulation so more oocytes mature. These medications include (1) clomiphene citrate as initial therapy for many women with intermittent anovulation; (2) a combination of clomiphene and metformin for women with anovulation and insulin resistance; (3) human menopausal gonadotropin (HMG), FSH, and recombinant FSH (rFSH) to stimulate follicle formation in women who do not respond to clomiphene therapies; (4) human chorionic gonadotropin to induce ovulation when follicles are ripe; (5) gonadotropin-releasing hormone (GnRH) agonists at the beginning of a cycle to sequence HMG therapies; (6) progesterone to support the luteal phase of the cycle; and (7) bromocriptine (Parlodel) for women who have excess prolactin (Lobo, 2017).

Treatment of certain medical conditions may result in improved fertility. The woman who is hypothyroid benefits from thyroid hormone supplementation. Treatment of endometriosis could include trials of danazol, progesterone, continuous combined oral contraceptives, or GnRH agonists to suppress menstruation and shrink endometrial implants. This regimen would be followed by

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ovulation induction. Adrenal hyperplasia is treated with prednisone. Any infections present in the infertile couple should be treated with appropriate antimicrobial therapy.

Clomiphene citrate (with the possible addition of metformin) is often the initial pharmacologic treatment of the infertile woman because it is inexpensive and the side-effect profile is less than other medications that induce ovulation. There is an increased risk for giving birth to twins or higher order multiples with clomiphene therapy.

The more powerful medications used to induce ovulation include GnRH agonists followed by gonadotropin therapy. These medications are extremely potent and require daily ovarian ultrasonography and monitoring of estradiol levels to prevent hyperstimulation of the ovaries. Combinations of these medications are used with ART to stimulate ovulation before harvesting eggs.

Drug therapy may be indicated for male infertility. As with women, problems with the thyroid or adrenal glands are corrected with appropriate medications. Infections are identified and treated with antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in men with hypogonadism. Men who do not respond to these therapies are candidates for intracytoplasmic sperm injection (ICSI), which is a procedure that injects sperm directly into the egg as part of IVF. ICSI has enabled men with very low sperm counts to achieve biologic reproduction.

The infertility specialist is responsible for fully informing patients about the prescribed medications. The nurse must be ready to answer patients' questions and confirm their understanding of the drug, its administration, potential side effects, and expected outcomes. Because information varies with each drug, the nurse must consult the medication package inserts, pharmacology references, health care provider, and pharmacist as necessary. The nurse should also provide anticipatory guidance regarding the time given for a medication trial before referral to a specialist in ART would be indicated if the couple wants to continue to attempt to become pregnant.

Table 5.2 includes information on selected medications for infertility treatment.

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TABLE 5.2 Medication Guide to Selected Infertility Medications

Drug Indication Mechanism ofAction Dosage Common Side Effects

Clomiphene citrate

Ovulation induction, treatment of luteal-phase inadequacy

Thought to bind to estrogen receptors in the pituitary gland, blocking them from detecting estrogen

Tablets, starting with 50 mg/day by mouth for 5 days beginning on fifth day of menses; if ovulation does not occur, may increase dose next cycle; variable dosage

Vasomotor flushes, abdominal discomfort, nausea and vomiting, breast tenderness, ovarian enlargement

Menotropins (human menopausal gonadotropins)

Ovarian follicular growth and maturation

LH and FSH in 1 : 1 ratio, direct stimulation of ovarian follicle; given sequentially with hCG to induce ovulation

IM injections; dosage regimen variable based on ovarian response Initial dose is 75 International Units of FSH and 75 International Units of LH (1 ampule) daily for 7–12 days (not to exceed 12 days) followed by 5000 to 10,000 International Units hCG (if serum estradiol <2000 pg/mL

Ovarian enlargement, ovarian hyperstimulation, local irritation at injection site, multifetal gestations

Follitropins (purified FSH)

Treatment of polycystic ovary syndrome; follicle stimulation for assisted reproductive techniques

Direct action on ovarian follicle

Subcutaneous or IM injections; dosage regimen variable

Ovarian enlargement, ovarian hyperstimulation, local irritation at injection site, multifetal gestations

Human chorionic gonadotropin (hCG)

Ovulation induction

Direct action on ovarian follicle to stimulate meiosis and rupture of the follicle

5000–10,000 International Units IM 1 day after last dose of menotropins; dosage regimen variable

Local irritation at injection site; headaches, irritability, edema, depression, fatigue

GnRH agonists (nafarelin acetate, leuprolide acetate)

Treatment of endometriosis, uterine fibroids

Desensitization and downward regulation of GnRH receptors of pituitary gland, resulting in suppression of LH, FSH, and ovarian function

Nafarelin, 200 mcg (1 spray) intranasally twice daily for 6 months; leuprolide acetate 3.75 mg IM every month for 3–6 months

Nafarelin— irritation, nosebleeds Both nafarelin and leuprolide— hot flashes, vaginal dryness, myalgia and arthralgia, headaches, mild bone loss (usually reversible within

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12–18 months after treatment)

Progesterone Treatment of luteal-phase inadequacy

Direct stimulation of endometrium

Vaginal gel 8%, 1 prefilled applicator per day; after ovulation induction, continue through 10–12 weeks of pregnancy

Breast tenderness, local irritation, headaches

GnRH antagonists (ganirelix acetate, cetrorelix acetate)

Controlled ovarian stimulation for infertility treatment

Suppress gonadotropin secretion, inhibit premature LH surges in women undergoing ovarian hyperstimulation

250 mcg daily subcutaneously, usually in the early to midfollicular phase of the menstrual cycle; usually followed by hCG administration

Abdominal pain, headache, vaginal bleeding, irritation at the injection site

Metformin Restores cyclic ovulation and menses in many women with polycystic ovary syndrome

Induces ovulation through reducing insulin resistance, thus affecting gonadotropins and androgens; simulates the ovary

Initial dose is 500 mg daily and titrated up over several weeks to 1500 mg/day; administered orally

Nausea, vomiting, diarrhea, lactic acidosis, liver dysfunction

Letrozole Ovulation induction

Aromatase inhibitor that inhibits E2 production, which causes an increase in LH:FHS ratio

2.5- to 5-mg tablets administered orally for 5 days beginning on cycle day 3 to 7

Hot flashes, headaches, breast tenderness; may increase risk for congenital anomalies

Data from American Society for Reproductive Medicine. (2013). Medications for inducing ovulation: A patient guide. Retrieved from www.asrm.org/Factsheetsandbooklets; Facts and Comparisons. (2013). A to Z drug facts. Retrieved from www.factsandcomparisons.com; Casper, R.F., & Mitwally, M.F.M. (2016). Ovulation induction with letrozole. UpToDate. Retrieved from https://www.uptodate.com/contents/ovulation-induction-with-letrozole; Medscape. (2017). Menotropins. Retrieved from http://reference.medscape.com/drug/menopur- repronex-menotropins-342877; Lobo R. (2017). Infertility: Etiology, diagnostic evaluation, management, prognosis. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Philadelphia, PA: Elsevier.

Surgical Therapies A number of surgical procedures may be used for problems causing female infertility. Ovarian tumors must be excised. Whenever possible, functional ovarian tissue is left intact. Scar tissue adhesions caused by chronic infections may cover much of the ovary. These adhesions usually necessitate surgery to free and

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expose the ovary so ovulation can occur. Hysterosalpingography is useful for identification of tubal

obstruction and also for the release of blockage as demonstrated in Fig. 5.2. During laparoscopy, delicate adhesions may be divided and removed, and endometrial implants may be destroyed by electrocoagulation or laser, as illustrated in Fig. 5.3. Laparotomy and microsurgery may be required for extensive repair of the damaged tube. Prognosis depends on the degree to which tubal patency and function can be restored. In general, laparoscopic surgery for tubal patency is most effective in younger women with distal tubal damage. Older women or those with significant proximal disease should be referred for ARTs that bypass the uterine tube.

FIG 5.2 Hysterosalpingography. Note that the contrast medium flows through the intrauterine cannula and out

through the uterine tubes.

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FIG 5.3 Laparoscopy.

In women with uterine abnormalities, reconstructive surgery (e.g., the unification operation for bicornuate uterus) can improve the ability to conceive and carry a fetus to term. Surgical removal of tumors or fibroids involving the endometrium or muscular walls of the uterus may also improve the woman's chance of conceiving and maintaining a pregnancy to viability, depending on the location and size of the fibroid or tumor. Surgical treatment of uterine tumors or maldevelopment that results in successful pregnancy usually necessitates birth by cesarean surgery near term gestation because the enlarging uterus can rupture as a result of weakness in the area of reconstructive surgery.

Chronic inflammation and infection can be eliminated by radial chemocautery (destruction of tissue with chemicals) or thermocautery (destruction of tissue with heat, usually electrical) of the cervix, cryosurgery (destruction of tissue by application of extreme cold, usually liquid nitrogen), or conization (excision of a cone-shaped piece of tissue from the endocervix). When the cervix has been deeply cauterized or frozen or when extensive conization has been performed, the cervix may produce less mucus. Therefore, the absence of a mucus bridge from the vagina to the uterus can make sperm migration difficult or impossible. Therapeutic intrauterine insemination may be necessary to carry the sperm directly through the internal os of the cervix.

Surgical procedures may also be used for problems causing male

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infertility. Surgical repair of varicocele has been relatively successful in increasing sperm count but not fertility rates. Microsurgery to reanastomose (restore tubal continuity) the sperm ducts after vasectomy may restore fertility.

Assisted Reproductive Therapies The Centers for Disease Control and Prevention (CDC) (2014) defines ART as fertility treatments in which both eggs and sperm are handled. In general, these treatments involve removing the eggs from the woman, fertilizing the eggs in the laboratory, and returning the embryo or embryos to the woman or surrogate carrier. Births that were conceived through ART comprise over 1.5% of all infants born in the United States each year since 2013 (Kaplan, 2015).

Some of the ARTs for treatment of infertility include in vitro fertilization–embryo transfer (IVF-ET), gamete intrafallopian transfer (GIFT) (Fig. 5.4), zygote intrafallopian transfer (ZIFT), ovum transfer (oocyte donation), embryo adoption, embryo hosting and surrogate motherhood, therapeutic donor insemination (TDI), ICSI, assisted embryo hatching, and preimplantation genetic diagnosis (PGD).

FIG 5.4 Gamete intrafallopian transfer (GIFT). A, Through laparoscopy a ripe follicle is located, and fluid containing the egg is removed. B, The sperm and egg

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are placed separately in the uterine tube, where fertilization occurs.

Table 5.3 describes these procedures and the possible indications for ARTs. Donor sperm and donor eggs can be used with ARTs. In addition, surrogates may carry the couple's biologic child. ARTs are associated with many ethical and legal issues (Box 5.6).

TABLE 5.3 Assisted Reproductive Therapies

Procedure Definition Indications In vitro fertilization– embryo transfer (IVF-ET)

A woman's eggs are collected from her ovaries, fertilized in the laboratory with sperm, and transferred to her uterus after normal embryo development has occurred.

Tubal disease or blockage; severe male infertility; endometriosis; unexplained infertility; cervical factor; immunologic infertility

Gamete intrafallopian transfer (GIFT)

Oocytes are retrieved from the ovary, placed in a catheter with washed motile sperm, and immediately transferred into the fimbriated end of the uterine tube. Fertilization occurs in the uterine tube.

Same as for IVF-ET, except there must be normal tubal anatomy, patency, and absence of previous tubal disease in at least one uterine tube

IVF-ET and GIFT with donor sperm

This process is the same as described previously except in cases where the male partner's fertility is severely compromised and donor sperm can be used; if donor sperm are used, the woman must have indications for IVF and GIFT.

Severe male infertility; azoospermia; indications for IVF-ET or GIFT

Zygote intrafallopian transfer (ZIFT)

This process is similar to IVF-ET; after IVF the ova are placed in one uterine tube during the zygote stage.

Same as for GIFT

Donor oocyte Eggs are donated by an IVF procedure, and the donated eggs are inseminated. The embryos are transferred into the recipient's uterus, which is hormonally prepared with estrogen/progesterone therapy.

Early menopause; surgical removal of ovaries; congenitally absent ovaries; autosomal or sex-linked disorders; lack of fertilization in repeated IVF attempts because of subtle oocyte abnormalities or defects in oocyte-spermatozoa interaction

Donor embryo (embryo adoption)

A donated embryo is transferred to the uterus of an infertile woman at the appropriate time (normal or induced) of the menstrual cycle.

Infertility not resolved by less aggressive forms of therapy; absence of ovaries; male partner azoospermic or severely compromised

Gestational carrier (embryo host); surrogate

A couple undertakes an IVF cycle, and the embryo(s) is/are transferred to another woman's

Congenital absence or surgical removal of uterus; reproductively impaired uterus, myomas, uterine adhesions, or other

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mother uterus (the carrier), who has contracted with the couple to carry the baby to term. The carrier has no genetic investment in the child. Surrogate motherhood is a process by which a woman is inseminated with semen from the infertile woman's partner and then carries the baby to term.

congenital abnormalities; medical condition that might be life-threatening during pregnancy (e.g., diabetes; immunologic problems; or severe heart, kidney, or liver disease)

Therapeutic donor insemination (TDI)

Donor sperm are used to inseminate the female partner.

Male partner is azoospermic or has very low sperm count; couple has genetic defect; male partner has antisperm antibodies

Intracytoplasmic sperm injection

One sperm cell is selected to be injected directly into the egg to achieve fertilization. It is used with IVF.

Same as TDI

Assisted hatching

The zona pellucida is penetrated chemically or manually to create an opening for the dividing embryo to hatch and implant into the uterine wall.

Recurrent miscarriages; to improve implantation rate in women with previously unsuccessful IVF attempts; advanced age

Data from American Society for Reproductive Medicine. (2016). Assisted reproductive technologies: A guide for patients. Retrieved from https://www.asrm.org/BOOKLET_Assisted_Reproductive_Technologies/.

Box 5.6 Issues to Be Addressed by Infertile Couples Before Treatment

• Risk for multiple gestation

• Possible need for multifetal reduction

• Possible need for donor oocytes, sperm, or embryos or for gestational carrier (surrogate mother)

• Whether or how to disclose facts of conception to offspring

• Freezing embryos for later use and what to do with extra embryos

• Possible risk for long-term effects of medications and treatment on women, children, and families

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• Potential mental health effects (anxiety, depression) related to infertility treatment

The lack of or misleading information about success rates and the risks and benefits of treatment alternatives prevent couples from making informed decisions. Nurses can provide information so couples have an accurate understanding of their chances for a successful pregnancy and live birth. Nurses also can provide anticipatory guidance about the moral and ethical dilemmas regarding the use of ARTs. If a couple is fortunate enough to have multiple embryos available, they may choose to preserve these for later implantation, which has potential legal implications.

Legal Tip Cryopreservation of Human Embryos

Couples who have extra embryos frozen for possible transfer must be fully informed before consenting to the procedure. They must make decisions regarding the disposal of embryos in the event of death or divorce. If they no longer want the embryos, they may consider donating them to other couples, contributing them to research, or disposing of them.

Complications Other than the established risks associated with laparoscopy and general anesthesia, few risks are associated with IVF-ET, GIFT, and ZIFT. The more common transvaginal needle aspiration for egg retrieval requires only local or intravenous analgesia. Congenital anomalies occur no more frequently than among naturally conceived embryos. Multiple gestations are more likely and are associated with increased risks for both the mother and fetuses. Nevertheless, ectopic pregnancies do occur more often and pose significant maternal risk (Lobo, 2017).

Preimplantation Genetic Diagnosis PGD is a form of early genetic testing designed to allow

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identification of embryos with serious genetic abnormalities. Those embryos would not be used in ART. Genetic testing improves the likelihood of successful pregnancy. Micromanipulation allows removal of a single cell from a multicellular embryo for genetic study (i.e., embryo biopsy) (ASRM, 2014). PGD is used clinically in numerous centers around the world. Couples must be counseled about their options and choices and the implications of their choices when genetic analysis is considered.

Adoption Couples may choose to build their family by adopting children who are not their own biologically. With increased availability of birth control and abortion and an increase in single mothers who choose to keep their babies, the availability of healthy newborn infants in the United States is limited (Greenblatt, 2011). Infants with diverse ethnic and racial heritages, infants with special needs, older children, and foreign adoptions are other options (Fig. 5.5).

FIG 5.5 After two miscarriages, this couple chose foreign adoption. (Courtesy of Shannon Perry, Phoenix, AZ.)

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Contraception The CDC noted that the capability of Americans to engage in effective family planning as a result of the modern era of contraception was one of the 10 greatest public health achievements of the 20th century (CDC, 2013). Nevertheless, nearly half of all pregnancies in the United States are not planned (Rivlin & Westhoff, 2017). Among adolescent women who were 19 years of age or younger, more than 80% of those who became pregnant did not intend to do so (CDC, 2015). The nurse can play a vital role in preventing unplanned and/or unwanted pregnancy through counseling and education regarding family planning, contraception, and effective birth control. Family planning is the conscious decision about when to conceive or to avoid pregnancy throughout the reproductive years. Contraception is defined as the intentional prevention of pregnancy during sexual intercourse. Birth control is the device and/or practice used to decrease the risk for conceiving or bearing offspring.

With the wide assortment of birth control options available, it is possible for a woman to use several different contraceptive methods at various stages throughout her fertile years. Nurses provide information about the various methods and help couples compare and contrast available contraceptive options. Providing adequate instruction about how to use a contraceptive method, when to use a backup method, and when to use emergency contraception (EC) can decrease the risk for unintended pregnancy. The Community Focus box presents information about contraceptive education.

Community Focus Education for Contraceptive Use: Student Activity

A suggested activity to learn more about contraceptive use is to observe a nurse doing contraceptive counseling in a family planning clinic. An alternative suggestion is to prepare information on several common contraceptive methods to present to adolescents at a health course in school or at a group meeting, such

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as for the Girl Scouts, Girls Inc., or a church youth group.

Care Management An interprofessional approach may help a woman choose and correctly use an appropriate contraceptive method. Nurses, nurse- midwives, nurse practitioners, other advanced practice nurses, and physicians have the knowledge and expertise to help a woman make decisions about contraception that will satisfy her personal, social, cultural, and interpersonal needs.

Assessment for the couple desiring contraception involves assessment of the woman's medical and reproductive history (menstrual, obstetric, gynecologic, contraceptive), physical examination, and sometimes current laboratory tests. The nurse must determine the woman's knowledge about reproduction, contraception, and STIs and her sexual partner's commitment to any particular method. Fig. 5.6 illustrates contraceptive counseling. The nurse obtains information about the frequency of coitus, number of sexual partners (present and past), and any objections that she or her partner might have about specific birth control methods. In addition, the nurse must determine a woman's willingness to touch her genitals. Religious and cultural factors may influence a couple's choice regarding a particular contraceptive method. The couple may believe in certain reproductive myths. Unbiased patient teaching is fundamental to initiating and maintaining any form of contraception. The nurse counters myths with facts, clarifies misinformation, and fills in gaps in knowledge. The ideal contraceptive should be safe, effective, easily available, economical, acceptable, simple to use, and promptly reversible. Although no method may ever achieve all of these objectives, significant advances in the development of new contraceptive technologies have occurred over the past 30 years.

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FIG 5.6 Nurse counseling a woman about contraceptive methods. (Courtesy of Dee Lowdermilk, Chapel Hill,

NC.)

Contraceptive failure rate refers to the percentage of contraceptive users expected to have an unplanned pregnancy during the first year even when they use a method consistently and correctly. Contraceptive effectiveness varies from couple to couple and depends on both the properties of the method and the characteristics of the user (Box 5.7). Effectiveness of a method can be expressed as theoretic (i.e., how effective the method is with perfect use) and typical (i.e., how effective the method is with typical use). Failure rates decrease over time, either because a user gains experience with and uses a method more appropriately or because the less effective users stop using the method. Safety of a method may be affected by a woman's medical history (e.g., thromboembolic problems and contraceptive methods containing estrogen). Nevertheless, in most instances pregnancy would be more dangerous to the woman with medical problems than a particular contraceptive method. In addition, many contraceptive methods have health promotion effects. Barrier methods such as the male condom offer some protection from acquiring STIs, and oral contraceptives lower the incidence of ovarian and endometrial cancer.

Box 5.7

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Factors Affecting Contraceptive Method Effectiveness

• Frequency of intercourse

• Motivation to prevent pregnancy

• Understanding of how to use the method

• Adherence to the method

• Provision of short- or long-term protection

• Likelihood of pregnancy for the individual woman

• Consistent use of the method

Following assessment and analysis, the couple determines possible contraceptive methods that are appropriate for their unique situation. Factors to consider when determining a contraceptive method are effectiveness, convenience, affordability, duration of action of method, reversibility of method, time of return to fertility, effects on uterine bleeding patterns, side effects, adverse events, health promotion effects of methods, effect of method on transmission of STIs, and medical contraindications for use.

The most effective reversible contraceptive methods at preventing pregnancy are the long-acting, reversible contraceptive (LARC) methods (e.g., contraceptive implants, intrauterine contraception). With these methods, theoretic and typical pregnancy rates are the same because the method requires no user intervention after correct insertion. Effective methods include those that prevent pregnancy through exogenous hormones (estrogen and/or progestins) such as contraceptive injections, oral contraceptive pills, contraceptive patches, and vaginal rings. Each of these methods involves user interventions; thus typical-use pregnancy rates are higher than pregnancy rates with perfect use. The least effective contraceptive methods include the barrier methods and natural family planning. Examples include condoms, diaphragms, cervical caps, spermicides, withdrawal, and periodic

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abstinence during perceived ovulation. Effectiveness rates for these methods vary from user to user, depending on correct application of the method and consistency of use.

Expected outcomes related to contraceptive counseling are that the couple will verbalize understanding about appropriate contraceptive methods, state they are satisfied with the method chosen, use the method correctly and consistently, experience no adverse sequelae as a result of the chosen contraceptive method, and prevent unplanned pregnancy. The nurse assists with obtaining appropriate informed consent concerning contraception or sterilization, provides appropriate education to the couple, and documents the couple's understanding of the contraceptive method chosen. Evaluation involves achievement of patient-centered outcomes when the couple engage in effective use of the chosen contraceptive device, experience no adverse sequelae, and achieve pregnancy only when they desire to do so.

Methods of Contraception The following discussion of contraceptive methods provides the nurse with information needed for patient teaching. After implementing the appropriate teaching for contraceptive use, the nurse supervises return demonstrations and practice to assess patient understanding (see Clinical Reasoning Case Study). The couple is given written instructions, telephone numbers, and/or email contact information for questions. If the woman has difficulty understanding written instructions, she and her partner, if available, are offered graphic material, a telephone number to call as necessary, and an opportunity to return for further instruction.

Clinical Reasoning Case Study Contraception for Adolescents

Maria is a 16-year-old Hispanic female who comes to the family planning clinic seeking contraception. She has recently become sexually active and tells the nurse that she is concerned that her mother will find out. She also has many questions about the type of

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contraception to use. She seeks the nurse's advice to help in her decision making.

1. Evidence—Is there sufficient evidence to draw conclusions about advice to give Maria?

2. Assumptions—What assumptions can be made about contraception for adolescents:

a. Types of contraception: What methods are appropriate (safe and effective) for an adolescent young woman?

b. Legal issues: With whom is this young woman engaging in sexual intercourse? Is it consensual? Does she need parental consent to obtain contraception?

c. Implications of culture on choice: Are there any cultural issues?

3. What implications and priorities for nursing care can be drawn at this time?

4. Describe the roles and responsibilities of members of the interprofessional health care team who may be involved in caring for Maria.

Coitus Interruptus Coitus interruptus (withdrawal) involves the male partner withdrawing his penis from the woman's vagina before he ejaculates. Although coitus interruptus has been criticized as being an ineffective method of contraception, it is a good choice for couples who do not have another contraceptive available. Effectiveness is similar to barrier methods and depends on the man's ability to withdraw his penis before ejaculation. The

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percentage of women who experience an unintended pregnancy within the first year of typical use (failure rate) of withdrawal ranges from 4% when used consistently and correctly to 22% as a typical failure rate (Rivlin & Westhoff, 2017). Coitus interruptus does not protect against STIs or human immunodeficiency virus (HIV) infection.

Fertility Awareness Methods Fertility awareness methods (FAMs) of contraception depend on identifying the beginning and end of the fertile period of the menstrual cycle. When women who want to use FAMs are educated about the menstrual cycle, the following three phases are identified:

1. Infertile phase: Before ovulation

2. Fertile phase: About 5 to 7 days around the middle of the cycle, including several days before and during ovulation and the day after ovulation

3. Infertile phase: After ovulation

Although ovulation can be unpredictable in many women, teaching the woman about how she can directly observe her fertility patterns is an empowering tool. In addition, knowledge about the signs and symptoms of ovulation can be very helpful when the couple desires pregnancy. There are nearly a dozen categories of FAMs. To prevent pregnancy, each one uses a combination of charts, records, calculations, tools, observations, and either abstinence (natural family planning [NFP]) or barrier methods of birth control during the fertile period of the menstrual cycle. The charts and calculations associated with these methods can also be used to increase the likelihood of detecting the optimal timing of intercourse to achieve conception.

Advantages of these methods include low-to-no cost, absence of chemicals and hormones, and lack of alteration in the menstrual flow pattern. Disadvantages of FAMs include adherence needed for strict record keeping, unintentional interference from external influences that may alter the woman's core body temperature and

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vaginal secretions, decreased effectiveness in women with irregular cycles (particularly adolescents who have not established regular patterns of ovulation), decreased spontaneity of coitus, and the necessity of attending possibly time-consuming training sessions by qualified instructors. The typical failure rate for most FAMs is 24% during the first year of use (Rivlin & Westhoff, 2017). FAMs do not protect against STIs or HIV infection.

FAMs involve several techniques to identify high-risk, fertile days. The following discussion includes the most common techniques.

Natural Family Planning (Periodic Abstinence) Natural family planning (NFP), or periodic abstinence, provides contraception by using methods that rely on avoiding intercourse during fertile days. NFP methods are the only methods of contraception acceptable to the Roman Catholic Church. Signs and symptoms of fertility awareness most commonly used with abstinence are menstrual bleeding, cervical mucus, and basal body temperature. Development and marketing of ovulation predictor kits have also been very helpful for couples who choose NFP. Several application products have been developed for smart phones, which make FAM record tracking convenient and portable.

The human ovum can be fertilized no later than 16 to 24 hours after ovulation. Motile sperm have been recovered from the uterus and uterine tubes as long as 7 days after coitus. However, their ability to fertilize the ovum probably lasts no longer than 24 hours. Pregnancy is unlikely to occur if a couple abstains from intercourse for 4 days before and 3 or 4 days after ovulation (fertile period). Unprotected intercourse on the other days of the cycle (safe period) should not result in pregnancy. Nevertheless, the exact time of ovulation cannot be predicted accurately, and couples may find it difficult to abstain from sexual intercourse for several days before and after ovulation. Women with irregular menstrual periods have the greatest risk for failure with this form of contraception.

Calendar Rhythm Method Practice of the calendar rhythm method is based on the number of days in each cycle, counting from the first day of the menstrual

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cycle (first day of menstrual vaginal bleeding). The fertile period is determined after accurately recording the lengths of menstrual cycles for 6 months. The beginning of the fertile period is estimated by subtracting 18 days from the length of the shortest cycle. The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle. If the shortest cycle is 24 days and the longest is 30 days, application of the formula to calculate the fertile period is as follows:

To avoid conception the couple would abstain during the fertile period, days 6 through 19.

If the woman has very regular cycles of 28 days each, the formula indicates the fertile days to be as follows:

To avoid conception, the couple would abstain from days 10 through 17 because ovulation occurs on day 14 ± 2 days. A major drawback of the calendar method is that the couple is attempting to predict future events with past data. The unpredictability of the menstrual cycle is also not taken into consideration. The calendar rhythm method is most useful as an adjunct to the basal body temperature or cervical mucus method.

Standard Days Method The standard days method (SDM) is essentially a modified form of the calendar rhythm method that has a “fixed” number of days of fertility for each cycle (i.e., days 8 to 19). A CycleBeads necklace (i.e., a color-coded string of beads) can be purchased as a concrete tool to track fertility (Fig. 5.7) or as a smart phone application. Day 1 of the menstrual flow is counted as the first day to begin counting. Women who use this device are taught to avoid unprotected

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intercourse on days 8 to 19 (white beads on CycleBeads necklace). Although this method is useful to women whose cycles are 26 to 32 days long, it is unreliable for those who have longer or shorter cycles (Contracept.org, 2016a).

FIG 5.7 CycleBeads. Red bead marks the first day of the menstrual cycle. White beads mark days that are

likely to be fertile days; therefore unprotected intercourse should be avoided. Brown beads are days

when pregnancy is unlikely and unprotected intercourse is permitted. (Courtesy of Dee Lowdermilk, Chapel Hill,

NC.)

Basal Body Temperature Method The basal body temperature (BBT) is the lowest body temperature of a healthy person, taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2° C (97.16° F) to 36.3° C (97.34° F) during menses and for approximately 5 to 7 days afterward (Fig. 5.8).

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FIG 5.8 A, Special thermometer for recording basal body temperature, marked in tenths to enable the

person to read it more easily. B, Basal temperature record shows decrease and sharp increase at time of ovulation. Biphasic curve indicates ovulatory cycle. A

digital thermometer may also be used.

About the time of ovulation a slight drop in temperature (approximately 0.5° C [35.8° F]) may occur in some women, but others may have no decrease at all. After ovulation, in concert with the increasing progesterone levels of the early luteal phase of the cycle, the BBT increases slightly (approximately 0.4° C [36.2° F] to 0.8° C [36.6° F]). The temperature remains on an elevated plateau until 2 to 4 days before menstruation. Then BBT decreases to the low levels recorded during the previous cycle unless pregnancy has occurred. In pregnant women, the temperature remains elevated. If ovulation fails to occur, the pattern of lower body temperature continues throughout the cycle.

To use this method the fertile period is defined as the day of first temperature drop, or first elevation, through 3 consecutive days of elevated temperature. Abstinence begins the first day of menstrual bleeding and lasts through 3 consecutive days of sustained temperature rise. The decrease and subsequent increase in temperature are referred to as the thermal shift. When the temperatures of the entire month are recorded on a graph, the

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pattern described is more apparent. It is more difficult to perceive day-to-day variations without the entire picture (see Guidelines box). Either a glass mercury thermometer or a digital thermometer may be used for BBT, but the thermometer must measure the temperature within one-tenth of a degree. The glass mercury thermometer needs no batteries but is fragile and can break. If a mercury thermometer does break, it is important to put on rubber, nitrile, or latex gloves and pick up all broken pieces and place on a paper towel. Put the folded paper towel with the contents in it securely into a zip-lock bag, label it, and contact the local health department regarding disposal. A digital thermometer requires batteries but may have a history recall function and an audible beep when the temperature assessment is finished. Digital thermometers that monitor temperature throughout the day combined with an accelerometer to monitor movement have been cleared for use by the Food and Drug Administration (FDA). These devices can be wirelessly uploaded to a computer through a companion device. Their use in FAM needs further research. Guidelines for BBT recording is included in the Guidelines box, and Fig. 5.8 depicts a graph of what a BBT recording looks like.

Guidelines Basal Body Temperature

• Discuss basal body temperature (BBT) with the woman.

• Show the woman a diagram depicting the phases of the menstrual cycle.

• Discuss the hormones in the woman's body that are responsible for her menstrual cycle and ovulation. Leave time for questions.

• Show the woman a sample BBT graph (see Fig. 5.8) and the biphasic line seen in ovulatory cycles.

• Show the woman the BBT thermometer and how it is calibrated.

• Provide a demonstration.

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• Encourage the woman to demonstrate taking and reading the thermometer and graphing the temperature while the nurse watches.

• Encourage the woman to start a log to keep track of any other activity that might interfere with determining her true BBT.

Infection, fatigue, less than 3 hours of sleep per night, awakening late, and anxiety may cause temperature fluctuations and alter the expected pattern. If a new BBT thermometer is purchased, this fact is noted on the chart because the readings may vary slightly. Jet lag, alcohol taken the evening before, or sleeping in a heated waterbed must also be noted on the chart because each affects the BBT. Therefore the BBT alone is not a reliable method of predicting ovulation.

Cervical Mucus Ovulation-Detection Method The cervical mucus ovulation-detection method (i.e., Billings method or Creighton model ovulation method) requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes at the time of ovulation. Cervical mucus changes before and during ovulation to facilitate and promote the viability and motility of sperm. Without adequate cervical mucus, coitus does not result in conception. This method requires that a woman check the quantity and character of mucus on the vulva or introitus with her fingers or tissue paper each day for several months. This way she can learn how her cervical mucus responds to ovulation during her menstrual cycles. To ensure an accurate assessment of changes, the cervical mucus should be free from semen, contraceptive gels or foams, and blood or discharge from vaginal infections for at least one full cycle. Other factors that create difficulty in identifying mucus changes include douches and vaginal deodorants, being in the sexually aroused state (which thins the mucus), and taking medications such as antihistamines (which dry the mucus). Intercourse is considered safe without restriction beginning the fourth day after the last day of wet, clear, slippery mucus, which would indicate that ovulation has occurred 2 to 3

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days previously. Some women find this method unacceptable if they are

uncomfortable touching their genitals. Whether or not a woman wants to use this method for contraception, it is to her advantage to learn to recognize mucus characteristics at ovulation (see Guidelines box).

Guidelines Cervical Mucus Characteristics

Setting the Stage

• Show charts of the menstrual cycle along with changes in the cervical mucus.

• Have the woman practice assessing mucus using raw egg white.

• Supply her with a basal body temperature (BBT) log and graph if she does not already have one.

• Explain that the assessment of cervical mucus characteristics is best when mucus is not mixed with semen, contraceptive jellies or foams, or discharge from infections.

Benefits of Noting Cervical Mucus Characteristics

• To alert the couple to the reestablishment of ovulation while breastfeeding and after discontinuation of oral contraception

• To note anovulatory cycles at any time and at the beginning of menopause

• To help couples plan a pregnancy

Content Related to Cervical Mucus

• Explain to the woman (or couple) how cervical mucus changes throughout the menstrual cycle.

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• Right before ovulation the watery, thin, clear mucus becomes more abundant and thick. It feels like a lubricant and can be stretched approximately 5 cm between the thumb and forefinger; this is called spinnbarkeit. This characteristic indicates the period of maximum fertility. Sperm deposited in this type of mucus can survive until ovulation occurs.

Assessment Technique

• Stress that good hand washing is imperative to begin and end all self-assessment.

• Start observation from the last day of menstrual flow.

• Assess cervical mucus several times a day for several cycles. Mucus can be obtained from vaginal introitus; there is no need to reach into vagina to cervix.

• Record findings on the same record on which her BBT is entered.

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Symptothermal Method The symptothermal method combines the BBT and cervical mucus methods with awareness of secondary phase–related symptoms of the menstrual cycle. The woman gains fertility awareness as she learns the psychologic and physiologic symptoms that mark the phases of her cycle. Secondary symptoms include increased libido, midcycle spotting, mittelschmerz (cramplike pain before ovulation), pelvic fullness or tenderness, and vulvar fullness.

The woman is taught to palpate her cervix to assess for changes indicating ovulation: the cervical os dilates slightly, the cervix softens and rises in the vagina, and cervical mucus is copious and slippery. The woman notes days on which coitus, changes in routine, illness, and other changes that might affect BBT have occurred (Fig. 5.9). Calendar calculations and cervical mucus changes are used to estimate the onset of the fertile period; changes in cervical mucus or the BBT are used to estimate the end of the fertile period.

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FIG 5.9 Example of completed symptothermal chart.

TwoDay Method of Family Planning Based on monitoring and the recording of cervical secretions, an algorithm for identifying the fertile window has been developed by the Institute for Reproductive Health at Georgetown University (Contracept.org, 2016b). The TwoDay algorithm appears to be simpler to teach, learn, and use than other natural methods. Results suggest that the algorithm can be an effective alternative for low- literacy populations or for programs that find current NFP methods

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too time-consuming or otherwise not feasible to incorporate within their services. Two questions are posed. Each day the woman is to ask herself, (1) “Did I note secretions today?” and (2) “Did I note secretions yesterday?” If the answer to either question is yes, she should avoid coitus or use a backup method of birth control. If the answer to both questions is no, her probability of getting pregnant is low. Further studies are needed to determine the efficacy of the TwoDay algorithm in avoiding pregnancy and to assess its acceptability to users and providers.

Home Predictor Test Kits for Ovulation Although the methods previously discussed are characteristic of ovulation, they do not prove that ovulation actually occurred or indicate the exact timing. The urine predictor test for ovulation is a major addition to the NFP and fertility-awareness methods to help women who want to plan the time of their pregnancies and for those who are trying to conceive (Fig. 5.10). The urine predictor test for ovulation detects the sudden surge of LH that occurs approximately 12 to 24 hours before ovulation. Unlike BBT, this test is not affected by illness, emotions, or physical activity. For home use, a test kit contains sufficient material for several days' testing during each cycle. A positive response indicating an LH surge is noted by a color change that is easy to interpret. Directions for use of urine predictor test kits vary with the manufacturer.

FIG 5.10 Examples of ovulation predictor tests.

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The Marquette Model The Marquette Model (MM) is a natural family planning method that was developed through the Marquette University College of Nursing Institute for Natural Family Planning. The MM uses cervical monitoring along with the ClearPlan Easy Fertility Monitor. The ClearPlan monitor is a handheld device that uses test strips to measure urinary metabolites of estrogen and LH. The monitor provides the user with “low,” “high,” and “peak” fertility readings. The MM incorporates the use of the monitor as an aid to learning NFP and fertility awareness.

Research continues on the efficacy of available home test kits and devices for the prevention of pregnancy (Leiva et al., 2014).With more research and development, women and men will have greater access to pregnancy prevention methods.

Breastfeeding: Lactational Amenorrhea Method The lactational amenorrhea method (LAM) can be a highly effective, temporary method of birth control. The LAM is more popular in underdeveloped countries and traditional societies in which breastfeeding is used to prolong birth intervals. The method has seen limited use in the United States because most American women do not establish breastfeeding patterns that provide maximum protection against pregnancy, and therefore it is recommended that breastfeeding mothers consider another form of reliable contraception (Rivlin & Westhoff, 2017).

When the infant suckles at the mother's breast, a surge of prolactin is released. Prolactin inhibits estrogen production and suppresses ovulation and the return of menses. LAM works best if the mother is exclusively breastfeeding, if she has not had a menstrual flow since birth, and if the infant is younger than 6 months of age. Effectiveness is enhanced by frequent feedings at intervals of less than 4 hours during the day and no more than 6 hours during the night, long duration of each feeding, and no bottle supplementation. The woman should be counseled that disruption of the breastfeeding pattern or formula supplementation can increase the risk for pregnancy. The typical failure rate is 2% if used correctly, which means exclusive breastfeeding for up to 6 months after birth (Rivlin & Westhoff, 2017).

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Barrier Methods Barrier contraceptives have gained in popularity not only as a contraceptive method but also as protection against the spread of STIs such as human papilloma virus and herpes simplex virus (HSV). Some male condoms and female vaginal methods provide a physical barrier to several STIs, and some male condoms provide protection against HIV. Spermicides serve as chemical barriers against semen and inhibit the ability of sperm to fertilize the ovum.

The nurse should remember that any user of a barrier method of contraception must also be aware of emergency contraception (EC) options in case there is a failure of the method. An example of a barrier method failure would be if a condom broke during intercourse. In this instance, EC would be indicated to prevent unplanned pregnancy.

Spermicides Spermicides such as nonoxynol-9 (N-9) work by reducing the mobility of the sperm. The chemicals attack the sperm flagella and body, thereby preventing the sperm from reaching the cervical os. N-9, the most commonly used spermicidal chemical in the United States, is a surfactant that destroys the sperm cell membrane. Results from data analyses now suggest that frequent use (more than 2 times a day) of N-9 or the use of N-9 as a lubricant during intercourse may increase the transmission of HIV and can cause lesions (World Health Organization, 2016). There is no evidence that the addition of spermicides to male condoms decreases the risk for subsequent pregnancy. Women with high-risk behaviors that increase their likelihood of contracting HIV and other STIs are advised to avoid the use of spermicidal products containing N-9, including lubricated condoms, diaphragms, and cervical caps to which N-9 is added.

Intravaginal spermicides are marketed and sold without prescriptions as aerosol foams, tablets, suppositories, creams, films, and gels (Fig. 5.11). Preloaded, single-dose applicators small enough to be carried in a small purse are available. Effectiveness of spermicides depends on consistent and accurate use. Not more than 1 hour before sexual intercourse, the spermicide should be inserted high into the vagina so it makes contact with the cervix. Spermicide

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must be reapplied for each additional act of intercourse, even if a barrier method is used. Studies have shown varying effectiveness rates for spermicidal use alone. The typical failure rate is 15% to 29% (Rivlin & Westhoff, 2017). Some female barrier methods (e.g., diaphragm, cervical caps) offer more effective protection against pregnancy with the addition of spermicides.

FIG 5.11 Spermicides. (Courtesy of Marjorie Pyle, RNC, Life Circle, Costa Mesa, CA.)

Condoms The male condom is a thin, stretchable sheath that covers the penis before genital, oral, or anal contact and is removed when the penis is withdrawn from the partner's orifice after ejaculation. Condoms are made of latex rubber, which, if intact, provides a barrier to sperm and STIs (including HIV); polyurethane (strong, thin plastic); or natural membranes (animal tissue). In addition to providing a physical barrier for sperm, nonspermicidal latex condoms also provide a barrier for STIs (particularly gonorrhea, chlamydia, and trichomonas) and HIV transmission. Condoms lubricated with N-9 are not recommended for preventing STIs or HIV and do not increase protection against pregnancy, as noted earlier. Latex condoms break down with oil-based lubricants (e.g., petroleum

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jelly and suntan oil) and should be used only with water-based or silicone lubricants. Because of the growing number of people with latex allergies, condom manufacturers have begun using polyurethane, which is thinner and stronger than latex.

Nursing Alert All patients should be questioned about the potential for latex allergy. Latex condom use is contraindicated for patients with latex sensitivity.

Although polyurethane condoms are as effective for STI prevention as latex condoms, they are more likely to slip or lose contour when compared to latex condoms. Therefore, with perfect use latex condoms offer better protection against pregnancy as compared with polyurethane condoms. Polyurethane condoms do offer pregnancy protection equivalent to that of most barrier products. A small percentage of condoms are made from lamb cecum (natural skin). Natural skin condoms do not provide the same protection against STIs and HIV infection as latex condoms. Natural skin condoms contain small pores that may allow passage of viruses such as hepatitis B, HSV, and HIV and are not generally recommended.

A functional difference in condom shape is the presence or absence of a sperm reservoir tip. To enhance vaginal stimulation, some condoms are contoured and rippled or have ribbed or roughened surfaces. Thinner construction increases heat transmission and sensitivity; a variety of colors increases condom acceptability and attractiveness. A wet jelly or dry powder lubricates some condoms. The typical failure rate for the use of the male condom is approximately 15% (Rivlin & Westhoff, 2017). Effective condom use is a skill that must be taught.

Box 5.8 summarizes advantages and disadvantages of male condoms and nursing considerations.

Box 5.8 Male Condoms

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Mechanism of Action Sheath is applied over the erect penis before insertion or loss of preejaculatory drops of semen. If used correctly, condoms prevent sperm from entering the cervix. Spermicide-coated condoms cause ejaculated sperm to be immobilized rapidly, thus increasing contraceptive effectiveness.

Advantages

• Safe

• No side effects

• Readily available

• Premalignant changes in cervix can be prevented or ameliorated in women whose partners use condoms

• Method of male nonsurgical contraception

Disadvantages

• Sexual activity must be interrupted to apply sheath.

• Sensation may be altered.

• If used improperly, spillage of sperm can result in pregnancy.

• Condoms occasionally may tear during intercourse.

Sexually Transmitted Infection Protection If a condom is used throughout the act of intercourse and there is no unprotected contact with female genitals, a latex rubber condom, which is impermeable to viruses, can act as a protective measure against sexually transmitted infections.

Nursing Considerations Teach the male patient to do the following:

• Use a new condom (check expiration date) for each act of sexual

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intercourse or other acts between partners that involve contact with the penis.

• Place the condom after the penis is erect and before intimate contact.

• Place the condom on the head of the penis (A) and unroll it all the way to the base (B).

• Leave an empty space at the tip (A); remove any air remaining in the tip by gently pressing air out toward the base of the penis.

• If a lubricant is desired, use water-based products such as K-Y lubricating jelly. Do not use petroleum-based products because they can cause the condom to break.

• After ejaculation, carefully withdraw the still-erect penis from the vagina, holding onto the condom rim; remove and discard the condom.

• Store unused condoms in a cool, dry place.

• Do not use condoms that are sticky, brittle, or obviously damaged.

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Nursing Alert It is a false assumption that everyone knows how to use condoms. To prevent unintended pregnancy and the spread of STIs, it is essential that condoms be used correctly. Proper instruction in use must be provided. The sheath is applied over the erect penis before insertion and before the loss of preejaculatory drops of semen. All types of condoms must be discarded after each single use. Condoms are available without prescription from a variety of sources, including vending machines.

The female condom is a vaginal sheath made of nitrile, a nonlatex, synthetic rubber and has flexible rings at both ends (Fig. 5.12, A). The closed end of the pouch is inserted into the vagina and anchored around the cervix; the open ring covers the labia. A woman whose partner will not wear a male condom can use this device as a protective mechanical barrier. Rewetting drops or oil- or water-based lubricants may be used to help decrease the distracting noise that is produced while penile thrusting occurs. The female condom is available in one size, is intended for single use only, and is sold over the counter. Male condoms should not be used concurrently because the friction from both sheaths can increase the likelihood of either or both tearing. The typical failure rate in the first year of female condom use is 21% (Rivlin & Westhoff, 2017).

FIG 5.12 Barrier methods. A, Female condom (FC2). B, FemCap. C, Contraceptive sponge. (A, Courtesy of The

Female Health Company, Chicago, IL. B, Courtesy of FemCap, Del Mar, CA. C,

Courtesy of Allendale Pharmaceuticals, Allendale, NJ.)

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Diaphragm The contraceptive diaphragm is a shallow, dome-shaped, latex or silicone device with a flexible rim that covers the cervix. The diaphragm is a mechanical barrier to the meeting of sperm with the ovum. By holding spermicide in place against the cervix for the 6 hours it takes to destroy the sperm, the diaphragm also provides a chemical barrier to pregnancy. Diaphragms are available in a wide range of diameters (50 to 95 mm) and differ in the inner construction of the circular rim. The types of rims are coil spring, arcing spring, and wide-seal rim. The diaphragm should be the largest size the woman can wear without being aware of its presence. The typical failure rate of the diaphragm combined with spermicide ranges from 13% to 17%, but it is possible that the failure rate can be reduced to 4% to 8% with correct and consistent use (Rivlin & Westhoff, 2017).

The woman using a diaphragm needs an annual gynecologic examination to assess its fit, seeking the largest size that does not cause discomfort. Rivlin & Westhoff (2017) note that no data exist that support a correlation between fit and effectiveness, despite the fact that it has commonly been believed that weight change (gain or loss), birth, miscarriage, or abdominal and pelvic surgery may change the appropriate fit. Because various types of diaphragms are on the market, the nurse uses the package insert when teaching the woman how to use and care for the diaphragm (see Patient Teaching box). A newer diaphragm, called Caya, that is sold over- the-counter and comes in only one size, has been approved by the FDA (Rivlin & Westhoff, 2017).

Patient Teaching Use and Care of the Diaphragm

Positions for Insertion of Diaphragm Squatting

• Squatting is the most commonly used position, and most women

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find it satisfactory.

Leg-Up Method

• Another position is to raise the left foot (if right hand is used for insertion) on a low stool and, while in a bending position, insert the diaphragm.

Chair Method

• Another practical method for diaphragm insertion is to sit far forward on the edge of a chair.

Reclining

• You may prefer to insert the diaphragm while in a semireclining position in bed.

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Inspection of Diaphragm Your diaphragm must be inspected carefully before each use. The best way to do this is:

• Hold the diaphragm up to a light source. Carefully stretch it at the area of the rim, on all sides, to make sure that there are no holes. Remember, it is possible to puncture the diaphragm with sharp fingernails.

• Another way to check for pinholes is to carefully fill the diaphragm with water. If there is any problem, it will be seen immediately.

• If your diaphragm is puckered, especially near the rim, this could mean thin spots.

• The diaphragm should not be used if you see any of these; consult your health care provider.

Preparation of Diaphragm

• Rinse off cornstarch (see section, below, on care of diaphragm, noting that it should be dusted with cornstarch when stored). Your diaphragm must always be used with a spermicidal lubricant to be effective. Pregnancy cannot be prevented effectively by the diaphragm alone.

• Always empty your bladder before inserting the diaphragm. Place about 2 tsp of contraceptive jelly or contraceptive cream on the side of the diaphragm that will rest against the cervix (or whichever way you have been instructed). Spread it around to coat the surface and the rim. This aids in insertion and offers a more complete seal. Many women also spread some jelly or cream on the other side of the diaphragm (Fig. A).

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Insertion of Diaphragm

• The diaphragm can be inserted as long as 6 hours before intercourse. Hold it between your thumb and fingers. The dome can be either up or down, as directed by your health care provider. Place your index finger on the outer rim of the compressed diaphragm (Fig. B).

• Use the fingers of the other hand to spread the labia (lips of the vagina). This will aid in guiding the diaphragm into place.

• Insert the diaphragm into the vagina. Direct it inward and downward as far as it will go to the space behind and below the cervix (Fig. C).

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• Tuck the front of the rim of the diaphragm behind the pubic bone so the rubber hugs the front wall of the vagina (Fig. D).

• Feel for your cervix through the diaphragm to be certain that it is placed properly and covered securely by the rubber dome (Fig. E).

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General Information

• Regardless of the time of the month, you must use your diaphragm every time intercourse takes place. It must be left in place for at least 6 hours after the last intercourse. If you remove it before the 6-hour period, your chance of becoming pregnant could be greatly increased. If you have repeated acts of intercourse, you must add more spermicide for each act.

Removal of Diaphragm

• The only proper way to remove the diaphragm is to insert your forefinger up and over the top side of the diaphragm and slightly to the side.

• Next turn the palm of your hand downward and backward, hooking the forefinger firmly on top of the inside of the upper rim of the diaphragm, breaking the suction.

• Pull the diaphragm down and out. This avoids the possibility of tearing it with the fingernails. You should not remove it by trying to catch the rim from below the dome (Fig. F).

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Care of Diaphragm

• When using a vaginal diaphragm, avoid using oil-based products such as certain body lubricants, mineral oil, baby oil, vaginal lubricants, or vaginitis preparations. These products can weaken the rubber.

• A little care means longer wear for your diaphragm. After each use, wash it in warm water and mild soap. Do not use detergent soaps, cold-cream soaps, deodorant soaps, and soaps containing oil products because they can weaken the rubber.

• After washing, dry the diaphragm thoroughly. All water and moisture should be removed with a towel. Dust the diaphragm with cornstarch. Scented talc, body powder, baby powder, and the like should not be used because they can weaken the rubber.

• To clean the introducer (if one is used), wash with mild soap and warm water, rinse, and dry thoroughly.

• Place the diaphragm back in the plastic case for storage. Do not store it near a radiator or heat source or exposed to light for an extended period.

Disadvantages of diaphragm use include the reluctance of some women to insert and remove it. Although it can be inserted up to 6 hours before intercourse, a cold diaphragm and a cold gel temporarily reduce vaginal response to sexual stimulation if insertion occurs immediately before intercourse. Some women or

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couples object to the messiness of the spermicide. These annoyances associated with diaphragm use, along with failure to insert the device once foreplay has begun, are the most common reasons for failures of this method. Side effects may include irritation of tissues related to contact with spermicides.

The diaphragm is not a good option for women with poor vaginal muscle tone or recurrent urinary tract infections. For proper placement, the diaphragm must rest behind the pubic symphysis and completely cover the cervix. To decrease the chance of exerting urethral pressure, the woman should be reminded to empty her bladder before diaphragm insertion and immediately after intercourse. Diaphragms are contraindicated for women with pelvic relaxation (uterine prolapse) or a large cystocele. Women with a latex allergy should not use latex diaphragms.

Cervical Cap The FemCap is the only type of cervical cap available in the United States (see Fig. 5.12, B). It comes in three sizes and is made of silicone rubber. The cap fits snugly around the base of the cervix close to the junction of the cervix and vaginal fornices. It is recommended that the cap remain in place no less than 6 hours and no more than 48 hours at a time. It is left in place at least 6 hours after the last act of intercourse. The seal provides a physical barrier to sperm; spermicide inside the cap adds a chemical barrier. The extended period of wear may be an added convenience for women.

Instructions for the actual insertion and use of the cervical cap closely resemble the instructions for use of the contraceptive diaphragm. Some of the differences are that the cervical cap can be inserted hours before sexual intercourse without a later need for additional spermicide, the cervical cap requires less spermicide than the diaphragm when initially inserted, and no additional spermicide is required for repeated acts of intercourse. Effectiveness of the first-generation FemCap has been found to be comparable to that of the diaphragm (Rivlin & Westhoff, 2017).

Although reported in very small numbers, toxic shock syndrome (TSS) can occur in association with the use of the contraceptive diaphragm and cervical caps. The nurse should instruct the woman about ways to reduce her risk for TSS. These measures include

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prompt removal 6 to 8 hours after intercourse, not using the diaphragm or cervical caps during menses, and learning and watching for danger signs of TSS.

Nursing Alert The nurse should alert the woman who uses a diaphragm or cervical cap as a contraceptive method for signs of TSS. The most common signs include a sunburn type of rash, diarrhea, dizziness, faintness, weakness, sore throat, aching muscles and joints, sudden high fever, and vomiting.

The angle of the uterus, the vaginal muscle tone, and the shape of the cervix may interfere with the ease of fitting and use of the cervical cap. Correct fitting requires time, effort, and skill of both the woman and the clinician, although the FemCap may be easier to fit than previous types of cervical caps.

Because of the potential risk for TSS associated with the use of the cervical cap, another form of birth control is recommended for use during menstrual bleeding and up to at least 6 weeks after birth. The cap should be refitted after any gynecologic surgery or birth and after major weight losses or gains. Otherwise the size should be checked at least once a year.

Women who are not good candidates for wearing the cervical cap include those with abnormal Papanicolaou (Pap) test results, those who cannot be fitted properly with the existing cap sizes or who find the insertion and removal of the device too difficult, those with a history of TSS or with vaginal or cervical infections, and those who experience allergic responses to the cap or to spermicide.

Contraceptive Sponge The vaginal sponge is a small, round, polyurethane sponge that contains N-9 spermicide (see Fig. 5.12, C). It is designed to fit over the cervix (one size fits all). The side that is placed next to the cervix is concave for better fit. The opposite side has a woven polyester loop to be used for removal of the sponge.

The sponge must be moistened with water before it is inserted into the vagina to cover the cervix. It provides protection for up to

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24 hours and for repeated instances of sexual intercourse. It should be left in place for at least 6 hours after the last act of intercourse and no more than 24 to 30 hours. Wearing it longer than 24 to 30 hours may put the woman at risk for TSS. The typical failure rate of the vaginal sponge is greater than that of the diaphragm (Center for Young Women's Health, 2016).

Hormonal Methods Many different hormonal contraception therapies using different delivery methods are available in the United States today. General classes are described in Table 5.4. Because of the wide variety of preparations available, the woman and nurse must read the package insert for information about specific products prescribed. Formulations include combined estrogen-progestin steroidal medications or progestational agents. The formulations are administered orally, transdermally, vaginally, by implantation, or by injection.

TABLE 5.4 Hormonal Contraception

Composition Route ofAdministration Duration of Effect

Combination Estrogen and Progestin Synthetic estrogens and progestins in varying doses and formulations

Oral 24 hours (extended cycle possible with daily pill for 12 weeks)

Transdermal patch 7 days Vaginal ring insertion

3 weeks

Progestin Only • Norethindrone, norgestrel Oral 24 hours • Medroxyprogesterone acetate Intramuscular or

subcutaneous injection

3 months

• Etonogestrel Subdermal implant Up to 3 years • Levonorgestrel Intrauterine device 1 year

Combined Estrogen-Progestin Contraceptives

Oral contraceptives. The normal menstrual cycle is maintained through hormonal feedback mechanisms. FSH and LH are secreted in response to

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fluctuating levels of ovarian estrogen and progesterone. Regular ingestion of combined oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary gland, leading to insufficient secretion of FSH and LH; therefore follicles do not mature, and ovulation is inhibited.

Other contraceptive effects are induced by the combined steroids. Maturation of the endometrium is altered, making the uterine lining a less favorable site for implantation. COCs also have a direct effect on the endometrium; thus from 1 to 4 days after the last COC is taken the endometrium sloughs and bleeds as a result of hormone withdrawal. The withdrawal bleeding is usually less profuse than that of normal menstruation and may last only 2 to 3 days. Some women have no bleeding at all. The cervical mucus remains thick from the effect of the progestin. Cervical mucus under the effect of progesterone does not provide as suitable an environment for sperm penetration as does the thin, watery mucus that the healthy reproductive woman produces before and during ovulation.

Monophasic pills provide fixed dosages of estrogen and progestin. They alter the amount of progestin and sometimes estrogen within each cycle. These preparations reduce the total dosage of hormones in a single cycle without sacrificing contraceptive efficacy. To maintain adequate hormone levels for contraception and enhance compliance, COCs should be taken at the same time each day. Taken exactly as directed, COCs prevent ovulation, and pregnancy cannot occur. The overall user effectiveness rate of COCs is 91% (CDC, 2011).

Because taking the pill does not relate directly to the sexual act, COC acceptability may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For many women, it is convenient to know when to expect the next menstrual flow.

Contraindications for COC use include a history of thromboembolic disorders, cerebrovascular or coronary artery disease, breast cancer, estrogen-dependent tumors, pregnancy, impaired liver function, liver tumor, lactation less than 6 weeks postpartum, smoking if older than 35 years of age, migraine with aura, surgery with prolonged immobilization or any surgery on the

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legs, hypertension (≥160/100), and diabetes mellitus (of more than 20 years' duration) with vascular disease.

The effectiveness of oral contraceptives is decreased when the following medications are taken simultaneously: • Anticonvulsants such as barbiturates, oxcarbazepine, phenytoin,

phenobarbital, carbamazepine, primidone, and topiramate • Systemic antifungals such as griseofulvin • Antituberculosis drugs such as rifampicin and rifabutin • Anti-HIV protease inhibitors such as nelfinavir and amprenavir

After discontinuing oral contraception, fertility usually returns quickly, but fertility rates may be slightly lower the first 3 to 12 months after discontinuation.

Nursing considerations. Many different preparations of oral hormonal contraceptives are available. Because of these wide variations in pills, each woman must be clear about the unique dosage regimen for the preparation prescribed for her and follow directions on the package insert. Directions for care after missing one or two tablets also vary. A simple recommendation is to implement EC after two missed pills, regardless of dose.

Signs of potential complications associated with the use of oral contraceptives must be reviewed with the woman, as noted in Box 5.9. Oral contraceptives do not protect a woman against STIs. Male condoms used in combination with COCs provide protection against STIs, and this combination gives excellent protection against unplanned pregnancy.

Box 5.9 Signs of Potential Complications: Oral Contraceptives Before oral contraceptives are prescribed and periodically throughout hormone therapy, the woman is alerted to stop taking the pill and report immediately any of the following symptoms to the health care provider. The mnemonic ACHES helps in remembering this list:

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A—Abdominal pain: may indicate a problem with the liver or gallbladder

C—Chest pain or shortness of breath: may indicate a possible clot problem within the lungs or heart

H—Headaches (sudden or persistent): may be caused by cerebrovascular accident or hypertension

E—Eye problems: may indicate vascular accident or hypertension

S—Severe leg pain: may indicate a thromboembolic process

Transdermal contraceptive system. The contraceptive patch delivers continuous levels of progesterone and ethynyl estradiol. The patch can be applied to the lower abdomen, upper outer arm, buttock, or upper torso (except the breasts). Application is on the same day once a week for 3 weeks but not at the same site, followed by a week without the patch. Withdrawal bleeding occurs during the “no patch” week. Mechanisms of action, contraindications, and side effects are similar to those of COCs. The typical failure rate during the first year of use is less than 9% (CDC, 2011).

Vaginal contraceptive ring. The vaginal ring (made of ethylene vinyl acetate co-polymer) delivers continuous levels of progesterone and ethynyl estradiol. Mechanisms of action, contraindications, and side effects are similar to those of COCs. One vaginal ring is worn for 3 weeks, followed by 1 week without the ring. Withdrawal bleeding occurs during the “no ring” week. The ring can be inserted by the woman and does not have to be fitted. Some wearers may experience vaginal discomfort, usually related to increased vaginal discharge; but other wearers report that the ring alleviates symptoms of vaginitis. Some couples say that the ring can be felt during intercourse. Although it is not recommended that the ring be removed for intercourse, contraceptive effectiveness would not decrease if it were replaced within 3 hours. The typical failure rate of the vaginal contraceptive ring is less than 9% during the first year of use (CDC, 2011).

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Progestin-Only Contraception Progestin-only methods impair fertility by inhibiting ovulation, thickening and decreasing the amount of cervical mucus, thinning the endometrium, and altering cilia in the uterine tubes. Because progestin-only methods do not contain estrogen, they may be used in certain instances such as lactation, when estrogen would not be recommended.

Oral progestins (minipill). Progestin-only pills are less effective than COCs. Because minipills contain such a low dose of progestin, they must be taken at the same time every day. If the pill is taken more than 3 hours late (27 hours after the last pill), a backup contraceptive method must be initiated. Much of the contraceptive effectiveness of the minipill depends on progestin-induced changes in cervical mucus, and this effect lasts about 24 hours after oral ingestion of the pill. Users often complain of irregular vaginal bleeding. Effectiveness is increased if minipills are taken correctly. There are two instances in which the minipill is quite effective: in lactating women and women older than 40 years of age. The reduced fecundity of lactation and the perimenopause period enhance the contraceptive effects of the minipill.

Injectable progestins. Depot medroxyprogesterone acetate (DMPA; Depo-Provera) is given subcutaneously or intramuscularly in the deltoid or gluteus maximus muscle. It should be initiated during the first 5 days of the menstrual cycle and administered every 11 to 13 weeks.

Nursing Alert When administering an injection of progestin (e.g., DMPA), the site should not be massaged after the injection because this action can hasten the absorption and shorten the period of effectiveness.

Advantages of DMPA include a contraceptive effectiveness comparable to that of combined oral contraceptives, long-lasting effects, requirement of injections only 4 times a year, and the

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unlikelihood of lactation being impaired. Side effects at the end of 1 year include decreased bone mineral density, weight gain, lipid changes, increased risk for venous thrombosis and thromboembolism, irregular vaginal spotting, decreased libido, and breast changes. Other disadvantages include no protection against STIs (including HIV). Return to fertility may be delayed as long as up to 18 months after discontinuing DMPA, with the median time being 10 months. The typical failure rate is 6% in the first year of use (CDC, 2011).

Nursing Alert Women who use DMPA may lose significant bone mineral density with increasing duration of use. It is unknown if this effect is reversible. It is unknown if use of DMPA during adolescence or early adulthood, a critical period of bone accretion, will reduce peak bone mass and increase the risk for osteoporotic fracture in later life. Women who receive DMPA should be counseled about calcium intake and exercise.

Implantable progestins. Contraceptive implants consist of one or more nonbiodegradable flexible tubes or rods that are inserted under the skin of a woman's arm. These implants contain a progestin hormone and are effective for contraception for at least 3 years. They must be removed at the end of the recommended time. The only available implant in the United States is a single-rod etonogestrel implant (Implanon, Nexplanon), which is FDA approved. Three other devices are also used globally, but they are unavailable in the United States. One of these implants is Norplant, which used to be commonly used in the United States, but due to difficulties in insertion and removal (because it contains 6 rods), it is no longer used (Rivlin & Westhoff, 2017).

Insertion and removal of the single-rod etonogestrel capsule are minor surgical procedures involving a local anesthetic, a small incision, and no sutures. The capsule is placed subdermally in the inner aspect of the nondominant upper arm. The progestin prevents some, but not all, ovulatory cycles and thickens cervical mucus.

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Other advantages of the single-rod implant are that it provides long-term continuous contraception that is not related to frequency of coitus and is quickly reversible. The single-rod implant can be inserted immediately after the birth in breastfeeding women without affecting lactation. Irregular menstrual bleeding is the most common side effect. Less common side effects include headache, nervousness, nausea, skin changes, and vertigo. The implant does not protect against STIs. As in other hormonal contraception methods, condoms should be used for protection against STIs. Implants are considered to be as effective or even more effective than sterilization and IUDs, making them some of the most effective contraceptive methods (Rivlin & Westhoff, 2017).

Emergency Contraception Emergency contraception (EC) offers protection against pregnancy after intercourse occurs in instances such as broken condoms, sexual assault, dislodged cervical cap, disruption of use of any other method, or any other case of unprotected intercourse. Methods that are available in the United States that could provide postcoital contraception include the following: • Ella (Ulipristal): single 30-mg pill containing an antiprogestin • Plan B One-Step: single progestin-only pill containing 1.5 mg

levonorgestrel • Next Choice: two levonorgestrel 0.75-mg tablets taken orally 12

hours apart or both together • Combined oral: estrogen-progestin contraceptive pills (e.g., 100-

mcg ethinyl estradiol plus 0.5 mg levonorgestrel); two doses given 12 hours apart (Yuzpe regimen)

• Copper intrauterine device (IUD) insertion within 120 hours of intercourse

Plan B One-Step and Next Choice are approved by the FDA for over-the-counter sale to women 17 years of age and older with proof of age. Adolescents 16 years of age and younger require a prescription. Ella is available only with a prescription. States vary in the ability of pharmacists to dispense EC, and some states have implemented refusal legislation (Guttmacher Institute, 2016a).

In general, for the most effectiveness, EC should be taken by a

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woman as soon as possible but within 72 hours of unprotected intercourse or a birth control mishap (e.g., broken condom, dislodged ring or cervical cap, missed oral contraceptive pills, late for injection) to prevent unintended pregnancy. Research has shown a moderate amount of effectiveness between 72 and 120 hours, but no data are available for effectiveness after 120 hours (Rivlin & Westhoff, 2017).

If taken before ovulation, EC prevents ovulation by inhibiting follicular development. If taken after ovulation occurs, there is little effect on ovarian hormone production or the endometrium. To minimize the side effect of nausea that occurs with high doses of estrogen and progestin (Yuzpe regimen), the woman can be advised to take an over-the-counter antiemetic 1 hour before each dose. Nausea is not as common with the Plan B (One-Step regimen). Women with contraindications for estrogen use should use progestin-only EC. No medical contraindications for EC exist, except pregnancy and undiagnosed abnormal vaginal bleeding. If the woman does not begin menstruation within 21 days after taking the pills, she should be evaluated for pregnancy. EC is ineffective if the woman is pregnant since the pills do not disturb an implanted pregnancy. Risk for pregnancy is reduced by approximately 75% with EC (Rivlin & Westhoff, 2017).

Nursing Alert EC will not protect the woman against pregnancy if she engages in unprotected intercourse in the days or weeks that follow treatment. Because ingestion of EC pills may delay ovulation, the woman should be cautioned that she needs to establish a reliable form of birth control to prevent unintended pregnancy. Information about EC method options and access to providers is available on the Internet at www.NOT-2-LATE.com or by calling 888-NOT-2-LATE.

IUDs containing copper (see later discussion) provide another EC option. The IUD should be inserted within 5 days of unprotected intercourse, resulting in an estimated 99% effectiveness in preventing pregnancy (Rivlin & Westhoff, 2017). This method is suggested only for women who wish to have the benefit of long- term contraception. The risk for pregnancy is reduced by as much

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as 99% with emergency insertion of the copper-releasing IUD. Contraceptive counseling should be provided to all women

requesting EC, including a discussion of modification of risky sexual behaviors to prevent STIs and unwanted pregnancy.

Intrauterine Devices An intrauterine device (IUD) is a small T-shaped device with bendable arms for insertion through the cervix into the uterine cavity. Two strings hang from the base of the stem through the cervix and protrude into the vagina for the woman to feel for assurance that the device has not been dislodged (Fig. 5.13). There is one FDA-approved copper-bearing IUD in the United States. This is the Copper T380A (ParaGard, Frazier, Pennsylvania) IUD, which is made of radiopaque polyethylene and fine solid copper and is approved for 10 years of use. The copper primarily serves as a spermicide and inflames the endometrium, preventing fertilization. Sometimes women experience an increase in bleeding and cramping within the first year after insertion, but nonsteroidal antiinflammatory drugs (NSAIDs) can provide pain relief. The cumulative failure rate over 12 years of use of the copper IUD is 1.7% (Rivlin & Westhoff, 2017).

FIG 5.13 Intrauterine devices. A, Copper T380A. B, Levonorgestrel-releasing intrauterine device.

Another type of IUD releases levonorgestrel from its vertical reservoir. This is the levonorgestrel intrauterine system (IUS) (Mirena, Bayer, New Jersey), which is effective for up to 5 years. It works by impairing sperm motility, irritating the lining of the

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uterus, and exerting some anovulatory effects. Uterine cramping and uterine bleeding are usually decreased with this device, although irregular spotting is common in the first few months following insertion. The cumulative failure rate over 5 years of use is 1.1% (Rivlin & Westhoff, 2017). IUDs offer constant contraception without the need to remember to take pills each day or engage in other manipulation before or between coital acts. If pregnancy can be excluded, either device (the Copper T380A or the levonorgestrel intrauterine system) can be placed at any time during the menstrual cycle. These devices may be inserted immediately after childbirth or following a first-trimester abortion. The contraceptive effects are reversible. When pregnancy is desired, the health care provider removes the device.

Disadvantages of IUD use include increased risk for pelvic inflammatory disease within the first 20 days after insertion, especially if infection is present at the time of insertion. There is also a slight risk for uterine perforation. Neither the Copper T380A nor the levonorgestrel intrauterine system offers protection against STIs or HIV. The Copper T380A is more likely to be associated with regular menses that may have heavier flow. Women who have the levonorgestrel intrauterine system are more likely to experience scant, irregular episodes of vaginal bleeding or amenorrhea.

Nursing Considerations The woman should be taught to check for the presence of the IUD thread after menstruation to rule out expulsion of the device. If pregnancy occurs with the IUD in place, the IUD should be removed immediately in the first trimester if the strings are visible. Later in pregnancy ultrasound examination should be used to localize the IUD and rule out placenta previa. Retention of the IUD during pregnancy increases the risk for septic miscarriage and ectopic pregnancy. Some women allergic to copper develop a rash, necessitating removal of the copper-bearing IUD. Signs of potential complications of intrauterine contraception are listed in Box 5.10.

Box 5.10 Signs of Potential Complications:

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Intrauterine Devices Signs of potential complications related to intrauterine devices can be remembered using the pains mnemonic:

P—Period late, abnormal spotting or bleeding

A—Abdominal pain, pain with intercourse

I—Infection exposure, abnormal vaginal discharge

N—Not feeling well, fever, or chills

S—String missing: shorter or longer

Sterilization Sterilization refers to surgical procedures intended to render the person infertile. Most procedures involve the occlusion of the passageways for the ova and sperm (Fig. 5.14). For the woman the uterine tubes are occluded; for the man the sperm ducts (vas deferens) are occluded. Only surgical removal of the ovaries (oophorectomy) or uterus (hysterectomy) or both results in absolute sterility for the woman. All other sterilization procedures have a small but definite failure rate (i.e., pregnancy may result).

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FIG 5.14 Sterilization. A, Uterine tubes ligated and severed (tubal ligation). B, Sperm duct ligated and

severed (vasectomy).

Female Sterilization Female sterilization (bilateral tubal ligation) may be done immediately after giving birth (within 24 to 48 hours), concomitantly with abortion, or as an interval procedure (during any phase of the menstrual cycle). Half of all female sterilization procedures are performed immediately after a pregnancy. Sterilization procedures can be done safely on an outpatient basis. The failure rate for methods of female sterilization vary by the method and the woman's age, but this is a very effective and safe

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method, with one study demonstrating a failure rate of 57 out of 1000 in the first year. However, it is important to emphasize that this form of birth control is considered to be permanent (Rivlin & Westhoff, 2017).

Tubal occlusion. A laparoscopic approach or a minilaparotomy may be used for tubal ligation (Fig. 5.15), tubal electrocoagulation, or the application of bands or clips. Electrocoagulation and ligation are considered to be permanent methods. Essure is another permanent method in which a soft insert is placed into each fallopian tube, forming a barrier that grows around the inserts. The couple is told to use a backup contraceptive method for the first 3 months. Another method, the bands or clips, has the theoretic advantage of possible removal and return of tubal patency (see Patient Teaching box).

FIG 5.15 Use of minilaparotomy to gain access to uterine tubes for occlusion procedures. Tenaculum is

used to lift uterus upward (arrow) toward incision.

Patient Teaching

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What to Expect After Tubal Ligation

• You should expect no change in hormones and their influence.

• Your menstrual period will be about the same as before the sterilization.

• You may feel pain at ovulation.

• It is highly unlikely that you will become pregnant.

• You should not have a change in sexual functioning; you may enjoy sexual relations more because you will not be concerned about becoming pregnant.

• Sterilization offers no protection against sexually transmitted infections; therefore, you may need to use condoms.

Tubal reconstruction. Restoration of tubal continuity (reanastomosis) and function is technically feasible except after laparoscopic tubal electrocoagulation. Sterilization reversal is costly, difficult (requiring microsurgery), and uncertain. The success rate varies with the extent of tubal destruction and removal. The risk for ectopic pregnancy after tubal reanastomosis is approximately 10%, significantly higher than the risk of 3% in the general population (Tubal Reversal, 2017).

Laws and regulations. All states have strict regulations for informed consent. Many states permit voluntary sterilization of any mature, rational woman without reference to her marital or pregnancy status. Although the partner's consent is not required by law, the woman is encouraged to discuss the situation with her partner, and health care providers may request the partner's consent. Sterilization of minors or mentally incompetent individuals is restricted by most states and often requires the approval of a board of eugenicists or other court- appointed individuals.

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Legal Tip Sterilization

If federal funds are used for sterilization, the person must be at least 21 years of age on the day the consent form is signed. Informed consent must include an explanation of the risks, benefits, and alternatives; a statement that describes sterilization as a permanent, irreversible method of birth control; and a statement that mandates a 30-day waiting period between giving consent and the sterilization. Informed consent must be in the person's native language, or an interpreter must be provided to read the consent form to the person. Signed consent forms expire after 180 days, so they must be re-signed if the sterilization procedure is still desired but has not yet been performed.

Male Sterilization Vasectomy is the sealing, tying, or cutting of a man's vas deferens so the sperm cannot travel from the testes to the penis. Vasectomy is the easiest and most commonly used operation for male sterilization. The surgery can be performed with local anesthesia on an outpatient basis. Pain, bleeding, infection, and other postsurgical complications are considered to be possible disadvantages to the surgical procedure.

Two methods are used for scrotal entry: conventional and no- scalpel vasectomy. The surgeon identifies and immobilizes the vas deferens through the scrotum. Then the vas is ligated or cauterized (see Fig. 5.14, B). Surgeons vary in their techniques to occlude the vas deferens: ligation with sutures, division, cautery, application of clips, excision of a segment of the vas, fascial interposition, or some combination of these methods.

Vasectomy has no effect on potency (ability to achieve and maintain erection) or volume of ejaculate. Endocrine production of testosterone continues, so secondary sex characteristics are not affected. Sperm production continues, but sperm are unable to leave the epididymis and are lysed by the immune system. Vasectomy does not change the man's transmission of the HIV virus if he is infected. He will need to be instructed to engage in a

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number of ejaculations until there are no viable sperm remaining above the area of the surgery. Until this occurs, as documented by semen analysis, the couple should use backup contraception.

Complications after bilateral vasectomy are uncommon and usually not serious. They include bleeding (usually external), suture reaction, and reaction to the anesthetic agent. Men occasionally develop a hematoma, infection, or epididymitis. Less common are painful granulomas from accumulation of sperm. Vasectomy is highly effective and safe. It is estimated that 5% to 7% of men in the United States request reversal of vasectomy (Rivlin & Westhoff, 2017), and although reanastomosis is possible, it is important to emphasize that men should view the decision to have vasectomy as permanent.

Tubal reconstruction. Microsurgery to reanastomose (restore tubal continuity) the sperm ducts can be accomplished successfully (i.e., sperm in the ejaculate) in 86% of cases; however, the fertility rate following reanastomosis is only about 50% (Baker & Sabanegh, 2013). The rate of success decreases as the time since the procedure was initially performed increases. The vasectomy may result in permanent changes in the testes that leave men unable to father children. The changes are those ordinarily seen only in older adults (e.g., interstitial fibrosis [scar tissue between the seminiferous tubules]). In addition, some men develop antibodies against their own sperm (autoimmunization).

Nursing Considerations The nurse plays an important role in helping people make decisions so all requirements for informed consent are met. The nurse also provides information about alternatives to sterilization such as contraception.

Information must be given about what is entailed in the various procedures, how much discomfort or pain can be expected, and what type of care is needed. Many individuals fear sterilization procedures because of imagined effects on sexual functioning. They need reassurance concerning the hormonal and psychologic basis of sexual functioning. The fact that uterine tube occlusion or

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vasectomy has no biologic sequelae in terms of sexual adequacy needs to be communicated and reinforced. If sex drive is affected, it can be a sign of emotional or other physical issues and should discussed with a physician or nurse practitioner.

Preoperative care includes health assessment, which includes a psychologic assessment, physical examination, and laboratory tests. The nurse confirms that the individual understands printed instructions. Ambivalence and extreme fear of the procedure should be reported to the health care provider.

Postoperative care depends on the procedure performed (e.g., laparoscopy, laparotomy for tubal occlusion, or vasectomy). General care includes recovery after anesthesia, vital signs, fluid- electrolyte balance (intake and output, laboratory values), prevention of or early identification and treatment of infection or hemorrhage, control of discomfort, and assessment of emotional response to the procedure and recovery.

Discharge planning depends on the type of procedure performed. In general, the patient is given written instructions about observing for and reporting symptoms and signs of complications, the type of recovery to be expected, and the date and time for a follow-up appointment.

Abortion Induced abortion is the purposeful interruption of a pregnancy before 20 weeks of gestation. (Spontaneous abortion or miscarriage is discussed in Chapter 12.) If the abortion is performed at the woman's request, the term elective abortion is usually used; if performed for reasons of maternal or fetal health or disease, the term therapeutic abortion applies. Many factors contribute to a woman's decision to have an abortion. Indications include (1) preservation of the life or health of the mother, (2) genetic disorders of the fetus, (3) rape or incest, and (4) the pregnant woman's request. The control of birth, dealing as it does with human sexuality and the question of life and death, is one of the most emotional components of health care. It has been the most controversial social issue in the last half of the twentieth century and continues to be so today. Regulations exist to protect the

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mother from the complications of abortion. Abortion is regulated in most countries, including the United

States. Before 1970 legal abortion was not widely available in the United States. However, in January 1973 the US Supreme Court set aside previous antiabortion laws and legalized it. This decision established a trimester approach to abortion, but controversy remains, and there are continuing attempts to change this law.

Following the US Supreme Court ruling in 1973 in the case of Roe versus Wade, the decision of first-trimester abortion was deemed to be between the pregnant woman and her health care provider, and state laws determining abortion to be illegal were struck down. During the second trimester, abortion is left to the discretion of the individual states to regulate procedures as long as these regulations are reasonably related to the woman's health. In the third trimester, abortions may be limited or even prohibited by state regulation unless the restriction interferes with the life or health of the pregnant woman (Roe v. Wade, 1973). Hospitals maintained by Roman Catholics and some of those maintained by strict fundamentalists forbid abortion (and often sterilization) despite legal challenges.

Currently 38 states legislate that abortion be performed by a licensed physician. Nurse practitioners can perform aspiration abortions in six states: California, Montana, New Hampshire, New York, Rhode Island, and Vermont. In these states plus six additional states, nurse practitioners can prescribe medication abortions (Guttmacher Institute, 2016b; Levi et al., 2015). Congress has legislated that Medicaid funds can only be used to pay for abortion when a woman's life is endangered. States vary on the financing of abortions, with 17 states using their own funds to pay for them, depending on the circumstances surrounding the procedure. States also vary regarding parental notification and/or consent regarding abortion, with 37 states providing legislation for some type of parental involvement in the abortion of a pregnant daughter who is a minor. Individual health care providers may refuse to participate in abortion in 45 states (Guttmacher Institute).

In the United States it is estimated that 50% of pregnancies are unintended, with about 40% of those unintended pregnancies ending in elective abortion (Rivlin & Westhoff, 2017). The number

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of abortions in the United States has decreased by 13% since 2008 (Rivlin & Westhoff). Most abortions occur in women who already have children, and abortion rates tend to be higher in women whose income is below the poverty level.

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2016) supports a nurse's right to choose whether to participate in abortion procedures in keeping with her or his “personal, moral, ethical, or religious beliefs.” AWHONN also advocates that “nurses have a professional obligation to inform their employers, at the time of employment, of any attitudes and beliefs that may interfere with essential job functions.” Levi and colleagues (2015) describe why they choose to provide abortion services and why this is an important role for nursing.

Rates of biologic complications after abortions such as ectopic pregnancy, infection, or hemorrhage tend to be low if the woman aborts during the first trimester. Psychologic sequelae of induced abortion are uncommon and may be related to circumstances and support systems surrounding the pregnant woman such as the attitudes reflected by friends, family, and health care workers. The woman facing an abortion is pregnant and exhibits the emotional responses shared by all pregnant women, including the possibility of depression.

Nurses and other health care providers often struggle with the same values and moral convictions as those of the pregnant woman. The conflicts and doubts of the nurse can be readily communicated to women who are already anxious. Regardless of personal views on abortion, nurses who provide care to women seeking abortion have an ethical responsibility to counsel women about their options and make appropriate referrals.

Legal Tip Institutional Policies for Nurses' Rights and Responsibilities Related to Abortion

Nurses' rights and responsibilities related to caring for abortion patients should be protected through policies that describe how the institution accommodates the nurse's ethical or moral beliefs and

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what the nurse should do to avoid patient abandonment in such situations. Nurses should know what policies are in place in their institutions and encourage such policies to be written. Nurses and nurse practitioners play an important role in the care of a woman choosing to have an elective abortion.

Care Management A thorough assessment is conducted through history, physical examination, and laboratory tests. The length of pregnancy and the condition of the woman must be determined to select the appropriate type of abortion procedure. An ultrasound examination should be performed before a second-trimester abortion is done. If the woman is Rh-negative, she is a candidate for prophylaxis against Rh isoimmunization. She should receive Rho(D) immune globulin within 72 hours after the abortion if she is D-negative and if Coombs' test results are negative (if the woman is unsensitized or isoimmunization has not developed).

The woman's understanding of alternatives, the types of abortions, and expected recovery is assessed. Misinformation and gaps in knowledge are identified and corrected. The record is reviewed for the signed informed consent, and the woman's understanding is verified. General preoperative, operative, and postoperative assessments are performed.

Analysis of data leads to identification of the appropriate nursing diagnoses for the woman undergoing elective abortion. Potential nursing diagnoses are listed in Box 5.11. Counseling about abortion includes helping the woman identify how she perceives the pregnancy, providing information about the choices available (i.e., having an abortion or carrying the pregnancy to term and then either keeping the infant or placing the baby for adoption), and informing about the types of abortion procedures and risks.

Box 5.11 Selected Nursing Diagnoses for Women Having Elective Abortion

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• Decisional conflict related to

• Value system

• Fear related to

• Abortion procedure

• Potential complications

• Implications for future pregnancies

• What others might think

• Grieving related to

• Distress at loss or feelings of guilt

• Risk for infection related to

• Effects of the procedure

• Lack of understanding of preoperative and postoperative self-care

• Acute pain related to

• Effects of the procedure or postoperative events

First-Trimester Abortion Methods for performing early elective abortion (up to 10 weeks of gestation) include surgical (aspiration) and medical methods (mifepristone with prostaglandin and methotrexate with misoprostol). The earlier an abortion is performed, the safer it is, reducing the need for later-term abortions.

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Surgical (Aspiration) Abortion Aspiration (vacuum or suction curettage) is the most common procedure in the first trimester. Aspiration abortion is usually performed under local anesthesia in a health care provider's office, a clinic, or a hospital. The ideal time for performing this procedure is 8 to 12 weeks after the last menstrual period (gestational age of 10 weeks) (Rivlin & Westhoff, 2017). The suction procedure for performing an early elective abortion usually requires less than 5 minutes.

A bimanual examination is done before the procedure to assess uterine size and position. A speculum is inserted, and the cervix is anesthetized with a local anesthetic agent. The cervix is dilated if necessary, and a cannula connected to suction is inserted into the uterine cavity. The products of conception are evacuated from the uterus.

During the procedure, the woman is kept informed about what to expect next (e.g., menstrual-like cramping and sounds of the suction machine). The nurse assesses the woman's vital signs. The aspirated uterine contents must be inspected carefully to ascertain whether all fetal parts and adequate placental tissue have been evacuated. After the abortion, the woman rests on the table until she is ready to stand. She remains in the recovery area or waiting room for 1 to 3 hours for detection of excessive cramping or bleeding; then she is discharged.

Bleeding after the operation is normally about the equivalent of a heavy menstrual period, and cramps are rarely severe. Excessive vaginal bleeding and infection such as endometritis or salpingitis are the most common complications of induced abortion. Retained products of conception are the primary cause of vaginal bleeding. Evacuation of the uterus, uterine massage, and administration of oxytocin or methylergonovine (Methergine) may be necessary to decrease vaginal bleeding. Prophylactic antibiotics to decrease the risk for infection are commonly prescribed. Generally, postabortion pain can be relieved with NSAIDs such as ibuprofen.

Nursing considerations. Instructions following a surgical abortion differ among health care providers. For example, there is disagreement as to whether

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tampons should not be used for at least 3 days or should be avoided for up to 3 weeks, or whether resumption of sexual intercourse may be permitted within 1 week or discouraged for 2 weeks. The woman may shower daily. Instruction is given to watch for excessive bleeding and other signs of complications and to avoid douches of any type. The woman can expect her menstrual period to resume 4 to 6 weeks after the day of the procedure. The nurse offers information about the birth control method the woman prefers if contraceptive counseling has not been done during the counseling interview that usually precedes the decision to have an abortion. The woman must be strongly encouraged to return for her follow-up visit so complications can be detected and an acceptable contraceptive method prescribed. A pregnancy test may also be performed to determine if the pregnancy has been terminated successfully.

Safety Alert The woman who has an induced abortion should be given clear instructions to return immediately to the health care facility or emergency department for any of the following symptoms:

• Fever greater than 38° C (100.4° F)

• Chills

• Bleeding greater than two saturated pads in 2 hours or heavy bleeding lasting a few days

• Foul-smelling vaginal discharge

• Severe abdominal pain, cramping, or backache

• Abdominal tenderness (when pressure applied)

Data from Paul, M., & Stein, T. (2011). Abortion. In R. A. Hatcher, J. Trussell, & A. L. Nelson (Eds.), Contraceptive technology. Atlanta, GA: Ardent Media.

Medical Abortion Early abortion using medication rather than surgery has been

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popular in Canada and Europe for more than 15 years, but medical abortion is a relatively new procedure in the United States. Medical abortions are available for use in the United States for up to 9 weeks after the last menstrual period. Methotrexate, misoprostol, and mifepristone are the drugs used in the current regimens to induce early abortion. Medication abortions increased from 6% in 2011 to 31% in 2014. However, the overall abortion rate has declined (Guttmacher Institute, 2017).

Misoprostol and Mifepristone Misoprostol (Cytotec) is a prostaglandin analog that acts directly on the cervix to soften and dilate and on the uterine muscle to stimulate contractions. Mifepristone, formerly known as RU 486, was approved by the FDA in 2000. It works by preventing progesterone from binding to receptors, thereby blocking the action of progesterone, which is necessary for maintaining pregnancy (Rivlin & Westhoff, 2017).

Mifepristone may be taken up to 7 weeks after the last menstrual period. The FDA-approved regimen is that the woman takes 600 mg of mifepristone orally; 48 hours later she returns to the office and takes 400 mcg of misoprostol orally (unless abortion has already occurred and been confirmed) (Rivlin & Westhoff, 2017). Two weeks after the administration of mifepristone, the woman must return to the office for a clinical examination or ultrasound to confirm that the pregnancy has been terminated.

With any medical abortion regimen, the woman usually experiences bleeding and cramping. Side effects of the medications include nausea, vomiting, diarrhea, headache, dizziness, fever, and chills. These are attributed to misoprostol and usually subside in a few hours after administration.

Second-Trimester Abortion Because the great majority of induced abortions in the United States occur in the first trimester, only about 10% are performed in the second trimester. Second-trimester abortion is associated with more complications and costs than first-trimester abortions. Dilation and evacuation (D&E) accounts for almost all procedures performed in the United States. This term is also often referred to as dilation and

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curettage (D&C). In general, medical administration of second-trimester abortions

involves the same drugs (misoprostol and mifepristone) used in medical termination of pregnancy during the first trimester. The D&E procedure is often chosen by patients because it has a lower risk for retained products of conception and a decreased hospitalization time (Rivlin & Westhoff, 2017).

Dilation and Evacuation D&E can be performed at any point up to 20 weeks of gestation, although it is more often performed between 13 and 16 weeks. After 16 weeks, the cervix requires more dilation because the products of conception are larger. Often laminaria are inserted several hours or several days before the procedure, or misoprostol can be applied to the cervix to soften the tissue. The procedure is similar to that of vaginal aspiration, except that a larger cannula is used and other instruments may be needed to remove the fetus and placenta. Nursing care includes monitoring vital signs, providing emotional support, administering analgesics, and postoperative monitoring. Disadvantages of D&E include possible long-term harmful effects on the cervix.

Nursing Considerations The woman considering an abortion will need help to explore the meaning of the various alternatives for elective abortion and consequences to herself and her significant others. It is often difficult for a woman to express her true feelings (e.g., what abortion means to her now and in the future and what support or regret her friends and peers may demonstrate). A calm, matter-of- fact approach on the part of the nurse can be helpful. Clarifying, restating, and reflecting statements; open-ended questions; and feedback are communication techniques that can be used to maintain a realistic focus on the situation and bring the woman's problems into the open. Sometimes the partner or family are involved and may also need support as there may be conflicting feelings among family members of the partner. The woman may have been a victim of human trafficking (see Chapter 3). If family or friends cannot be involved, scheduling time for nursing personnel

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to give the necessary support is an essential component of the care plan.

Information about alternatives to abortion such as referral to adoption agencies or support services if the woman chooses to keep her baby is provided. If a decision is made to have an abortion, the woman must be assured of continued support. Information about what is entailed in various procedures, how much discomfort or pain can be expected, and what type of care is needed must be given. A discussion of the various feelings, including depression, guilt, regret, and relief, that the woman might experience after the abortion is needed. Information about community resources for postabortion counseling may be needed.

Evidence of long-term depression after elective abortion has been inconclusive. Guilt and anxiety may occur more with young women, women with poor social support, multiparous women, and women with a history of psychiatric illness. Women having second- trimester abortions may have more emotional distress than women having abortions in the first trimester. Because symptoms can vary among women who have had abortions, nurses must assess women for grief reactions and facilitate the grieving process through active listening and nonjudgmental support and care.

References American Society for Reproductive Medicine. Age and fertility.

[Retrieved from] https://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/agefertility.pdf 2012.

American Society for Reproductive Medicine. Preimplantation genetic testing. [Retrieved from] http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/PGT_2014.pdf 2014.

American Society for Reproductive Medicine. Quick facts about infertility. [Retrieved from] https://www.asrm.org/detail.aspx?id=2322; 2016.

Association of Women's Health, Obstetric and Neonatal Nurses. Position statement: Midwifery. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2016;45(3):454–457.

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Baker K, Sabanegh E. Obstructive azoospermia: Reconstructive techniques and results. Clinics (Sao Paulo). 2013;68(1 suppl):61–73 [Retrieved from] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583161/.

Center for Young Women's Health. Contraceptive sponge. [Division of Adolescent and Young Adult Medicine, Division of Gynecology, Boston Children's Hospital; Retrieved from] http://youngwomenshealth.org/2013/08/22/contraceptive- sponge/; 2016.

Centers for Disease Control and Prevention. Effectiveness of family planning methods. [Retrieved from] https://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/agefertility.pdf 2011.

Centers for Disease Control and Prevention. Ten great public health achievements in the 20th century. [Retrieved from] https://www.cdc.gov/about/history/tengpha.htm; 2013.

Centers for Disease Control and Prevention. What is assisted reproductive technology?. [Retrieved from] https://www.cdc.gov/art/whatis.html; 2014.

Centers for Disease Control and Prevention. Unintended pregnancy prevention. [Retrieved from] https://www.cdc.gov/reproductivehealth/unintendedpregnancy/ 2015.

Contracept.org. Fertility awareness methods: Standard days method. [Retrieved from] http://www.contracept.org/calendar.php; 2016.

Contracept.org. Fertility awareness methods: The TwoDay method. [Retrieved from] http://www.contracept.org/twoday-method.php; 2016.

Crawford NM, Steiner AZ. Age-related infertility. Obstetrics and Gynecology Clinics of North America. 2015;42(1):15–25.

Greenblatt A. Fewer babies available for adoption by US parents. National Public Radio. [Retrieved from] http://www.npr.org/2011/11/17/142344354/fewer-babies- available-for-adoption-by-u-s-parents; 2011.

Guttmacher Institute. Emergency contraception. [Retrieved from]

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https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_EC.pdf 2016.

Guttmacher Institute. An overview of abortion laws, as of August 1, 2016. [Retrieved from] https://www.guttmacher.org/state- policy/explore/overview-abortion-laws; 2016.

Guttmacher Institute. Induced abortion in the US. [Retrieved from] https://www.guttmacher.org/fact-sheet/induced- abortion-united-states; 2017.

Kaplan K. More than 1.5% of American babies owe their births to IVF, report says. [Los Angeles Times; Retrieved from] http://www.latimes.com/science/sciencenow/la-sci-sn-ivf- live-births-success-rate-20150303-story.html; 2015.

Leiva R, Burhan U, Kyrillos E, Fehring R, McLaren R, Dalzell C, et al. Use of ovulation predictor kits as adjuncts when using fertility awareness methods (FAMs): A pilot study. Journal of the American Board of Family Medicine. 2014;27(3):427–429.

Levi AJ, Banks E, Dieseldorff J, Tueros VS. The clinician speaks: Why I am an abortion provider. [Women's Healthcare, May, 46- 49; Retrieved from] http://npwomenshealthcare.com/wp- content/uploads/2015/05/Comm_M15.pdf; 2015.

Lobo RA. Infertility: Etiology, diagnostic evaluation, management, prognosis. Lobo RA, Gershenson DM, Lentz GM, Valea FA. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Rivlin K, Westhoff C. Family planning. Lobo RA, Gershenson DM, Lentz GM, Valea FA. Comprehensive gynecology. 7th ed. Mosby: Philadelphia, PA; 2017.

Roe v. Wade, 410 US 113, 154 (1973). Tubal Reversal. Risks of tubal reversal surgery. [Retrieved from]

https://www.tubal-reversal.net/tubal-reversal/risks-of- tubal-reversal-surgery/; 2017.

World Health Organization. Nonoxynol-9 ineffective in preventing HIV infection. [Retrieved from] http://www.who.int/mediacentre/news/notes/release55/en/; 2016.

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UNIT 3

Pregnancy OUTLINE

6 Genetics, Conception, and Fetal Development 7 Anatomy and Physiology of Pregnancy 8 Nursing Care of the Family During Pregnancy 9 Maternal and Fetal Nutrition 10 Assessment of High-Risk Pregnancy 11 High-Risk Perinatal Care Preexisting Conditions 12 High-Risk Perinatal Care Gestational Conditions

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6

Genetics, Conception, and Fetal Development Ellen F. Olshansky

This chapter presents a brief discussion of genetics and the role of the nurse in genetics. It also provides an overview of the process of fertilization and of the development of the normal embryo and fetus.

Genetics Recent advances in molecular biology and genomics have revolutionized the field of health care by providing the tools needed to determine the hereditary component of many diseases as well as improve our ability to predict susceptibility to disease, onset and progression of disease, and response to medications (Calzone, Jenkins, Nicoli, et al., 2013; McCarthy, McLeod, & Ginsburg, 2013).

Since the human genome was sequenced, there has been a gradual shift from genetics to genomics. Genetics refers to the study of a particular gene, whereas genomics refers to the study of the entire genome. Genes are the basic physical units of inheritance that are passed from parents to offspring and contain the information needed to specify traits. The genome is the entire set of

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genetic instructions found in a cell. For these and other definitions of genetic terms, check out the Talking Glossary of Genetic Terms (www.genome.gov/Glossary).

With growing public interest in personalized genomic information (information about much or all of an individual's genome), increasing development of practice guidelines, mounting commercial pressures, and ever-increasing opportunities for individuals, families, and communities to participate in the direction and design of their genomic health care, genetic services are rapidly becoming an integral part of routine health care (Manolio, Chisholm, Ozenberger, et al., 2013). Moreover, many individuals and families have participated in direct-to-consumer genetic testing (testing marketed directly to consumers through television, print advertisements, and websites). Although much of the information provided by direct-to-consumer testing companies is recreational (ancestry information, information about types of ear wax, and bitter taste perception), some of the information provided is health related and could be interpreted as diagnostic. Because of this, direct-to-consumer testing that is provided without the involvement of competent health care professionals may be not only unhelpful, but also harmful (Beery, 2013). However, recently it has been reported that more negotiation is occurring between direct-to-consumer testing and the FDA to create regulations (Gever, 2015).

More recently, attention has turned toward “precision medicine” or “personalized medicine,” which emphasizes a focus away from the notion that “one size fits all” and toward the understanding that each individual's uniqueness influences how best to determine medical treatment (US Food and Drug Administration [FDA], 2016). Personalized medicine holds promise for tailored treatments for individuals based on their own personal makeup.

Epigenetics is another more recent concept. Epigenetics refers to the variations in phenotype that occur due to the influence of the environment and our lifestyle on genetics. Moore (2015) has written eloquently on this new concept that he believes is key to understanding an individual's development as a unique human being.

Genetic disorders affect people of all ages, from all socioeconomic

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levels, and from all racial and ethnic backgrounds. Genetic disorders affect not only individuals but also families, communities, and society. Advances in genetic testing and genetically based treatments have altered the care provided to affected individuals. Improvements in diagnostic capability have resulted in earlier diagnosis and enabled individuals who previously would have died in childhood to survive into adulthood. However, for most genetic conditions, therapeutic or preventive measures do not exist or are very limited. Consequently, the most useful means of reducing the incidence of these disorders is by preventing their transmission. It is standard practice to assess all pregnant women for heritable disorders to identify potential problems.

Nursing Expertise in Genetics and Genomics Because of their front-line position in the health care system and their long-standing history of providing holistic family-centered care, nurses are likely to be one of the first health care professionals to whom individuals and families turn with questions about genetic risk and susceptibility and to seek guidance regarding the complexities of genetic testing and interpretation. Nowhere is this more apparent than in maternity and women's health care. A growing number of maternity and women's health nurses provide information about the availability of genetic tests, answer questions about them, and order and interpret genetic tests. Although most of these tests are used to determine a patient's risk for having a child affected by a genetic condition such as Down syndrome (DS), cystic fibrosis (CF), or sickle cell disease, the number of genetic tests used to determine the presence of, or susceptibility to, adult-onset disorders (e.g., hereditary colorectal cancer, hereditary breast and ovarian cancer, and Huntington's disease [HD]) continues to rise. Additionally, nurses working in maternity and women's health are caring for an increasing number of individuals and families who are dealing with complex ethical, legal, and social issues associated with genetic testing and the experience of living with someone who has a genetic condition (Wilke, Gallo, Yao, et al., 2013).

Essential Competencies in Genetics and Genomics for

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All Nurses Nearly 50 organizations, including the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN), have endorsed the Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics (www.genome.gov/17517146). According to these guidelines, which were developed by an independent panel of nurse leaders (consensus panel) from clinical, research, and academic settings and published by the American Nurses Association and the National Human Genome Research Institute (NHGRI) of the National Institutes of Health (NIH) (Greco, Tinley, & Seibert, 2011), all nurses need to have minimal competencies in genetics and genomics regardless of their academic preparation, practice setting, or specialty. Some of the competencies most relevant to nurses in the area of maternity and women's health include the following: • Construct a pedigree from collected family history information

using standardized symbols and terminology • Develop a plan of care that incorporates genetic and genomic

assessment information • Recognize when one's own attitudes and values related to

genetics and genomic science may affect care provided to patients • Provide patients with credible, accurate, appropriate, and current

genetic and genomic information, resources, services, and/or technologies that facilitate decision making

• Demonstrate in practice the importance of tailoring genetic and genomic information and services to patients based on their culture, religion, knowledge level, literacy, and preferred language

• Assess patients' knowledge, perceptions, and responses to genetic and genomic information

• Facilitate referrals for specialized genetic and genomic services for patients as needed

Expanded Roles for Maternity and Women's Health Nurses Expanded roles for nurses with expertise in genetics and genomics

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are developing in many areas of maternity and women's health nursing. These areas include but are not limited to prenatal screening and testing; carrier testing during pregnancy; newborn screening; palliative care for infants with life-threatening genetic conditions and their families; the identification and care of individuals with genetic conditions and their families; and the care of women with genetic conditions who require specialized care during pregnancy, such as women with neuromuscular disease, CF, and factor V Leiden deficiency (DeLuca, Zanni, Bonhomme, et al., 2013; Frazer, Porter, & Gross, 2013; Johnson, Giarelli, Lewis, et al., 2013; Prows, Hopkin, Barnoy, et al., 2013; Wilke et al., 2013). As an example, the Oncology Nursing Society (ONS) (www.ons.org) has taken an active role in providing oncology nurses with the education and resources they need to integrate genetics and genomics into all phases of care for individuals and families affected by cancer, including information specifically related to cancers affecting women.

Human Genome Project and Implications for Clinical Practice The Human Genome Project was a publicly funded international effort coordinated by the NIH and the US Department of Energy (www.doegenomes.org). When the Human Genome Project was initiated in 1990, the ultimate goal of the project was to map the human genome (the complete set of genetic instructions in the nucleus of each human cell) by 2005. Considering that the human genome consists of approximately 3 billion base pairs of DNA, many people regarded this as an impossible task. However, by 2003 a substantially complete version of the human genome was announced.

The Human Genome Project found that all human beings are 99.9% identical at the DNA level (NHGRI, 2016). This finding that human beings are 99.9% identical at the DNA level should help discourage the use of science as a justification for drawing precise racial boundaries around certain groups of people. A more recent effort by the NHGRI called the Encyclopedia of DNA Elements, or the ENCODE Project, was organized to identify the genome's

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functional elements (ENCODE, 2016). Researchers found that more than 80% of the human genome is linked to a specific biologic function, and that proteins interact with DNA in more than 4 million regulatory regions. This finding made clearer the active genome in which genes are turned on and off by proteins using sites that may be at a great distance from the genes. Identification of regulatory regions will help explain varied functions of different types of cells. (www.genome.gov/pfv.cfm?pageID=27549810).

Importance of Family History Completion of the Human Genome Project and the resultant identification of the inherited causes for many diseases has resulted in renewed interest in family history. Although it is easy to be impressed by the more than 3600 genetic tests currently available through the Genetic Testing Registry (GTR), which can be accessed at its website (www.ncbi.nlm.nih.gov/gtr), family history will most likely continue to be the single most cost-effective piece of genetic information. In 2008, Solomon, Jack, and Feero described a complete three-generation family history that includes ancestry information concerning both sides of family as the best genetic “test” applicable to preconception care. When nurses and other clinicians conduct a family history, they can gain not only valuable information about the structure of the family and diseases that affect various individuals in the family, but also a rich understanding of family relationships, social context, occupations, lifestyle, and health habits (American College of Obstetricians and Gynecologists [ACOG], 2011a). The process of collecting this information often facilitates the development of a relationship between the patient/family and the clinician. In 2004, the US Department of Health and Human Services launched the Family History Initiative by designating Thanksgiving Day as National Family History Day. The US Surgeon General encouraged families to use their family gatherings as a time to talk about and collect important family health history. A number of family history tools are available free of charge online. One of the most widely used family history tools is the My Family Health Portrait (https://familyhistory.hhs.gov). Another helpful tool is the family

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health history tool, Does it run in the family? that was developed by the Genetic Alliance (www.doesitruninthefamily.org). The Centers for Disease Control and Prevention (CDC) also provides links to family history resources (https://www.cdc.gov/genomics/famhistory/index.htm).

The preconception period is an ideal time to review family history and provide personalized recommendations based on family history (ACOG, 2011a). It is also one of the best times to counsel couples about carrier testing options that are based on known population-specific risks (Bodurtha & Strauss, 2012). Finally, the preconception period is an optimal time to refer couples, when appropriate, to specialists in high-risk pregnancy and genetics.

Gene Identification and Testing Initial efforts to sequence and analyze the human genome have proven invaluable in the identification of genes involved in disease and in the development of genetic tests. In an effort to bridge the transition from discovery to diagnostics and treatments, the NIH launched the Genetic Testing Registry (GTR) in 2012. The GTR (www.ncbi.nlm.nih.gov/gtr) is a free online tool that can be used to obtain a list of available genetic tests. The GTR website also includes links to other resources such as GeneReviews and Online Mendelian Inheritance in Man (OMIM). GeneReviews is a collection of expert-authored, peer-reviewed disease descriptions presented in a standardized format and focused on clinically relevant and medically actionable information on the diagnosis, management, and genetic counseling of individuals and families with specific inherited conditions. OMIM is an online catalog of human genes and genetic disorders.

Genetic testing involves the analysis of human DNA, ribonucleic acid (RNA), which has a major role in protein synthesis, chromosomes (threadlike packages of genes and other DNA in the nucleus of a cell), or proteins to detect abnormalities related to an inherited condition. Genetic tests can be used to directly examine the DNA and RNA that make up a gene (direct or molecular testing), look at markers that are coinherited with a gene that causes a genetic condition (linkage analysis), examine the protein products

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of genes (biochemical testing), or examine chromosomes (cytogenetic testing). Cytogenetic analysis of malignant tissue has become a mainstay of oncology.

Most of the genetic tests now offered in clinical practice are tests for single-gene disorders in patients with clinical symptoms or who have a family history of a genetic disease (http://iml.dartmouth.edu/education/cme/Genetics). Some of these genetic tests are prenatal tests or tests used to identify the genetic status of a pregnancy at risk for a genetic condition. Current prenatal testing options include maternal serum screening (a blood test used to see if a pregnant woman is at increased risk for carrying a fetus with a neural tube defect or a chromosomal abnormality such as DS, trisomy 18, or trisomy 13), fetal ultrasound or sonogram (an imaging technique using high-frequency sound waves to produce images of the fetus inside the uterus), invasive procedures (chorionic villus sampling and amniocentesis), and noninvasive prenatal testing for fetal aneuploidy (a blood test that uses cell-free DNA from the plasma of pregnant women to screen for DS and, in some cases, trisomy 13 and trisomy 18 (see Chapter 10 for more in- depth information).

Another type of genetic test is the carrier screening test used to identify individuals who have a gene mutation for a genetic condition but do not show symptoms of the condition because it is an autosomal recessive condition (e.g., CF, sickle cell disease, and Tay-Sachs disease). A third type of genetic testing is predictive testing, which is used to clarify the genetic status of asymptomatic family members. The two types of predictive testing are presymptomatic and predispositional. Mutation analysis for Huntington disease (HD), a neurodegenerative disorder, is an example of presymptomatic testing. If the gene mutation for HD is present, symptoms of HD are certain to appear if the individual lives long enough. Testing for a BRCA1 gene mutation to determine breast cancer susceptibility is an example of predispositional testing. Predispositional testing differs from presymptomatic testing in that a positive result (indicating that a BRCA1 mutation is present) does not indicate a 100% risk for developing the condition (breast cancer).

In addition to using genetic tests to test for single-gene disorders

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in patients with clinical symptoms or who have a family history of a genetic disease, genetic tests are used for population-based screening. For example, each year in the United States, approximately 4 million infants undergo newborn screening (Bodurtha & Strauss, 2012). Newborn screening is a mandatory, state-supported public health program. Initially, newborn screening in the United States was only concerned with a few conditions such as phenylketonuria (PKU). However, with the advent of tandem mass spectrometry, the number of conditions included in newborn screening grew rapidly (DeLuca et al., 2013). Currently, most states test newborns for 31 core disorders and 26 secondary disorders (McCarthy et al., 2013). A complete list of conditions tested for in each state is available on the National Newborn Screening and Genetics Resource website (http://genes-r-us.uthscsa.edu). (See Chapter 23.)

Another type of population-based screening is carrier screening for single-gene disorders such as CF, sickle cell disease, and Tay- Sachs disease either preconceptionally or prenatally. In 2001, ACOG and the American College of Medical Genetics (ACMG) recommended that clinicians offer carrier screening for CF to individuals with a family history of CF, reproductive partners of individuals who have CF, and couples in whom one or both partners are Caucasian and are planning a pregnancy or seeking prenatal care. Ten years later, in 2011, ACOG updated its recommendations and emphasized that it is not a straightforward or easy task to assign an ethnicity to a person and, therefore, the recommendation was updated to offer to screen all women of reproductive age to determine if they are carriers of CF (ACOG, 2011b). Recommendations for newborn screening for CF appeared in 2004, and soon after this many newborn screening programs in the United States began offering newborn screening for CF. One outcome of this broader carrier and newborn screening for CF is that more and more individuals are being informed they have a CF mutation. However, the correlation between genotype (an individual's collection of genes) and phenotype (an individual's observable traits) is poor for many of the more than 1900 CF mutations identified to date. That is, whereas some CF mutations are associated with significant health problems (poor growth,

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greasy stools, and chronic respiratory problems), others are not. Because of this, the significance of many CF mutations is uncertain. As a result, nurses and other health care professionals are increasingly being asked to communicate results with uncertain significance to individuals and families during the preconception, prenatal, and newborn periods. A coherent and systematic approach is needed for the introduction of new tests into population-based screening programs.

The use of genome sequencing (e.g., whole-genome sequencing and next-generation sequencing) has entered the clinical setting (Conley, Biesecker, Gonsalves, et al., 2013; McCarthy et al., 2013; Wade, Tarini, & Wilfond, 2013). It is difficult to determine the cost for sequencing a particular genome as there are many factors to consider (National Human Genome Research Institute, 2016).

Pharmacogenomics One of the most promising clinical applications of the Human Genome Project has been pharmacogenomic testing (the use of genetic information to guide a patient's drug therapy). Associations between genetic variation and drug effect have been observed for a number of commonly used drugs, including warfarin, an anticoagulant commonly used to reduce the risk for thromboembolic events in patients with a history of deep vein thrombosis, pulmonary embolism, myocardial infarction, or atrial fibrillation (McCarthy et al., 2013). Warfarin is a drug with a narrow therapeutic index; it can result in serious bleeding with supratherapeutic doses and thromboembolic events with subtherapeutic doses. Because of this and the fact that there is a great deal of interpatient and intrapatient dose variation, warfarin is one of the most common causes of serious adverse drug reactions. There is mounting evidence that genotype-guided warfarin dosing may not only help reduce the serious adverse drug reactions commonly associated with its use, but also increase dosing accuracy, shorten the time to dose stabilization, and help identify individuals who may require more frequent monitoring. In August 2007, the FDA approved updated labeling for warfarin. The updated labeling acknowledges that individuals with variations in

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their CYP2C9 and VKORC1 genes may require a lower initial dose of warfarin. However, there are not enough clinical data yet to recommend that this type of testing be mandatory, but there are some FDA-approved drugs with pharmacogenomic labeling (US Department of Health and Human Services, 2016).

Pharmacogenomic testing can also be used to target therapies. Trastuzumab (Herceptin), a monoclonal antibody that specifically targets HER2/neu overexpressing breast tumors, is an example of a drug for which an obligatory genetic test has been developed (McCarthy et al., 2013). The purpose of this obligatory genetic test is to identify the subset of women with breast cancer who overexpress HER2/neu. Women who overexpress HER2/neu are most likely the only breast cancer patients who will benefit from taking trastuzumab (www.herceptin.com/index.jsp).

Gene Therapy The aim of gene therapy is to correct defective genes that are responsible for disease development. Generally, gene therapy involves inserting a healthy copy of the defective gene into the somatic cells (any cell of the body except sperm and egg cells) of the affected individual. Although the early optimism about gene therapy was probably never fully justified, gene therapy has now moved from preclinical to clinical studies for many diseases. These diseases range from hemophilia and other single-gene disorders to complex disorders such as cancer, HIV, and cardiovascular disorders. Major challenges to gene therapy include determining how to target the right gene to the right location in the right cells, expressing the transferred gene at the right time, and minimizing adverse reactions.

Ethical, Legal, and Social Implications Because of widespread concern about misuse of the information gained through genetics research, a percentage of the Human Genome Project budget was designated for the study of the ethical, legal, and social implications (ELSI) of human genome research (Genetics Home Reference, 2017a). Two large ELSI programs were created to identify, analyze, and address the ELSIs of human

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genome research at the same time that the basic science issues were being studied. During the past decade, issues of high priority for these programs were as follows: • Privacy and fairness in the use and interpretation of genetic

information • Clinical integration of new genetics technologies • Issues surrounding genetics research, such as possible

discrimination and stigmatization • Education for professionals and the general public about genetics,

genetics health care, and ELSI of human genome research Both ELSI programs have excellent websites that include much

educational information, as well as links to other informative sites (www.genome.gov/10001618; www.ornl.gov/sci/techresources/Human_Genome/elsi/elsi.shtml; https://www.genome.gov/elsi/).The major risk associated with genetic testing concerns what happens with the information gained through testing.It may result in increased anxiety and altered family relationships; it may be difficult to keep confidential; and it may result in discrimination and stigmatization. More important, there is a large gap between the ability to test for a genetic condition and the ability to treat that same condition. Informed consent is difficult to ensure when some of the outcomes, benefits, and risks of genetic testing remain unknown.

Factors Influencing the Decision to Undergo Genetic Testing The decision to undergo genetic testing is seldom autonomous and based solely on the needs and preferences of the individual being tested. Instead, it is often a decision based on feelings of responsibility and commitment to others. For example, a woman who is receiving treatment for breast cancer may undergo BRCA1/BRCA2 mutation testing not because she wants to find out if she carries a BRCA1 or BRCA2 mutation but, instead, because her two unaffected sisters have asked her to be tested and she feels a sense of responsibility and commitment to them. A female airline pilot with a family history of HD, who has no desire to find out if

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she has the gene mutation associated with HD, may undergo mutation analysis for HD because she feels she has an obligation to her family, her employer, and the people who fly with her.

Decisions about genetic testing are shaped and, in many instances, constrained by factors such as social norms where care is received and socioeconomic status. Most pregnant women in the United States now have at least one ultrasound examination, many undergo some type of multiple-marker screening, and a growing number undergo other types of prenatal testing (see Chapter 8). The range of prenatal testing options available to a pregnant woman and her family may vary, based on where the pregnant woman receives prenatal care and her socioeconomic status. Certain types of prenatal testing may not be available in smaller communities and rural settings (e.g., chorionic villus sampling and fluorescent in situ hybridization [FISH] analysis). In addition, certain types of genetic testing may not be offered in conservative medical communities (e.g., preimplantation diagnosis). Some types of genetic testing are expensive and typically not covered by health insurance. Because of this, these tests may be available only to a relatively small number of individuals and families—those who can afford to pay for them (Badzek, Henaghan, Turner, et al., 2013). (See Chapter 10 for more information on prenatal testing).

Cultural and ethnic differences also have a significant impact on decisions about genetic testing. When prenatal diagnosis was first introduced, the principal constituency was a self-selected group of Caucasian, well-informed, middle- to upper-class women. Today the widespread use of genetic testing has introduced prenatal testing to new groups of women, women who had not previously considered genetic services. The fact that many of the women currently undergoing prenatal testing may not share mainstream US views about the role of medicine and prenatal care, the meaning of disability, or how to respond to scientific risks and uncertainties, further amplifies the complexity of ethical issues associated with prenatal testing.

Clinical Genetics Genetic Transmission

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Human development is a complicated process that depends on the systematic unraveling of instructions found in the genetic material of the egg and the sperm. Development from conception to birth of a normal, healthy baby occurs without incident in most cases; occasionally, however, some anomaly in the genetic code of the embryo creates a birth defect or disorder.

Genes and Chromosomes The hereditary material carried in the nucleus of each of the somatic cells determines an individual's characteristics. This material, called DNA (deoxyribonucleic acid), forms threadlike strands known as chromosomes. Each chromosome is composed of many smaller segments of DNA referred to as genes. Genes or combinations of genes contain coded information that determines an individual's unique characteristics. The code is found in the specific linear order of the molecules that combine to form the strands of DNA. Genes control both the types of proteins that are made and the rate at which they are produced. Genes never act in isolation; they always interact with other genes and the environment.

All normal human somatic cells contain 46 chromosomes arranged as 23 pairs of homologous (matched) chromosomes; one chromosome of each pair is inherited from each parent. There are 22 pairs of autosomes, which control most traits in the body, and one pair of sex chromosomes. The larger female chromosome is called the X; the smaller male chromosome is the Y. Whereas the Y chromosome is primarily concerned with sex determination, the X chromosome contains genes that are involved in much more than sex determination. Generally, the presence of a Y chromosome causes an embryo to develop as a male; in the absence of a Y chromosome, the individual develops as a female. Thus in a normal female, the homologous pair of sex chromosomes are XX, and in a normal male, the homologous pair are XY.

Homologous chromosomes (except the X and Y chromosomes in males) have the same number and arrangement of genes. In other words, if one chromosome has a gene for hair color, its partner chromosome also will have a gene for hair color and these hair- color genes will have the same loci or be located in the same place on the two chromosomes. Although both genes code for hair color,

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they may not code for the same hair color. Genes at corresponding loci on homologous chromosomes that code for different forms or variations of the same trait are called alleles. An individual having two copies of the same allele for a given trait is said to be homozygous for that trait. With two different alleles, the individual is heterozygous for the trait.

The term genotype typically is used to refer to the genetic makeup of an individual when discussing a specific gene pair, but at times, genotype is used to refer to an individual's entire genetic makeup or all the genes that the individual can pass on to future generations. Phenotype refers to the observable expression of an individual's genotype, such as physical features, a biochemical or molecular trait, and even a psychologic trait. A trait or disorder is considered dominant if it is expressed or phenotypically apparent when only one copy of the gene is present. It is considered recessive if it is expressed only when two copies of the alleles associated with the trait are present.

As more is learned about genetics and genomics, the concepts of dominance and recessivity have become more complex, especially in X-linked disorders. For example, traits considered to be recessive may be expressed even when only one copy of a gene located on the X chromosome is present. This occurs frequently in males because males have only one X chromosome; thus they have only one copy of the genes located on the X chromosome. Whichever gene is present on the one X chromosome determines which trait is expressed. Females, conversely, have two X chromosomes, so they have two copies of the genes located on the X chromosome. However, in any female somatic cell, only one X chromosome is functioning (otherwise there would be inequality in gene dosage between males and females). This process, known as X-inactivation or the Lyon hypothesis, is generally a random occurrence. That is, there is a 50-50 chance as to whether the maternal X or the paternal X is inactivated. Occasionally the percentage of cells that have the X with an abnormal or mutant gene is very high. This helps explain why hemophilia, an X-linked recessive disorder, can clinically manifest itself in a female known to be a heterozygous carrier (a female who has only one copy of the gene mutation). It also helps explain why traditional methods of carrier detection are less

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effective for X-linked recessive disorders; the possible range for enzyme activity values can vary greatly, depending on which X chromosome is inactivated.

Chromosomal Abnormalities Chromosomal abnormalities are a major cause of reproductive loss, congenital problems, and gynecologic disorders. Errors resulting in chromosomal abnormalities can occur in mitosis (cell division occurring in somatic cells that results in two identical daughter cells containing a diploid number of chromosomes) or meiosis (division of a sex cell into two and four haploid cells). These errors can occur in either the autosomes or the sex chromosomes. Even without the presence of obvious structural malformations, small deviations in chromosomes can cause problems in fetal development.

The pictorial analysis of the number, form, and size of an individual's chromosomes is known as a karyotype. Cells from any nucleated, replicating body tissue (not red blood cells, nerves, or muscles) can be used. The most commonly used tissues are white blood cells and fetal cells in amniotic fluid. The cells are grown in a culture and arrested when they are in metaphase (during metaphase, the chromosomes are condensed and visible with a light microscope), and then the cells are dropped onto a slide. This breaks the cell membranes and spreads the chromosomes, making them easier to visualize. Next, the cells are stained with special stains (e.g., Giemsa stain) that create striping or “banding” patterns. These patterns aid in the analysis because they are consistent from person to person. Once the chromosome spreads are photographed or scanned by a computer, they are cut out and arranged in a specific numeric order according to their length and shape. The chromosomes are numbered from largest to smallest, 1 to 22, and the sex chromosomes are designated by the letter X or Y. Each chromosome is divided into two “arms” designated by p (short arm) and q (long arm). A female karyotype is designated as 46,XX, and a male karyotype is designated as 46,XY. Fig. 6.1 illustrates the chromosomes in a body cell and a karyotype.

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FIG 6.1 Chromosomes during cell division. A, Example of a photomicrograph. B, Chromosomes

arranged in karyotype; female and male sex- determining chromosomes.

Autosomal Abnormalities Autosomal abnormalities involve differences in the number or structure of autosome chromosomes (pairs 1 to 22). They result from unequal distribution of the genetic material during gamete (egg and sperm) formation.

Abnormalities of Chromosome Number A euploid cell is a cell with the correct or normal number of chromosomes within the cell. Because most gametes are haploid (1N, 23 chromosomes) and most somatic cells are diploid (2N, 46 chromosomes), they are both considered euploid cells. Deviations from the correct number of chromosomes per cell can be one of two types: (1) polyploidy, in which the deviation is an exact multiple of the haploid number of chromosomes or one chromosome set (23 chromosomes); or (2) aneuploidy, in which the numeric deviation is not an exact multiple of the haploid set. A triploid (3N) cell is an example of a polyploidy. It has 69 chromosomes. A tetraploid (4N) cell, also an example of a polyploidy, has 92 chromosomes.

Aneuploidy is the most commonly identified chromosome abnormality in humans and the leading genetic cause of intellectual disability. A monosomy is the product of the union between a normal gamete and a gamete that is missing a chromosome.

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Monosomic individuals have only 45 chromosomes in each of their cells. The product of the union of a normal gamete with a gamete containing an extra chromosome is a trisomy. The most common autosomal aneuploid conditions involve trisomies. Trisomic individuals have 47 chromosomes in most or all of their cells.

The vast majority of trisomies occur during oogenesis (the process by which a premeiotic female germ cell divides into a mature egg); the incidence of these types of chromosomal errors increases exponentially with advancing maternal age. Although variation exists among trisomies with regard to the parent and stage of origin of the extra chromosome, most trisomies are maternal meiosis I (MI) errors. This means that most trisomies are caused by nondisjunction during the first meiotic division. The first meiotic division involves the segregation of homologous or similar chromosomes. One pair of chromosomes fails to separate. One resulting cell contains both chromosomes, and the other contains none. The fact that most trisomies are maternal MI errors is not that surprising, because maternal MI occurs over a long time span. It is initiated in precursor cells during fetal development, but it is not completed until the time those cells undergo ovulation after menarche.

The most common trisomy abnormality is DS. Approximately 1 in every 691 newborns has DS; there are over 400,000 individuals with DS living in the United States (Prows et al., 2013; CDC, 2016; www.cdc.gov/ncbddd/birthdefects/DownSyndrome.html; http://ndsccenter.org; www.ndss.org). Ninety-five percent of individuals with DS have trisomy 21 (nondisjunction) or an extra chromosome 21 (47,XX+21, female with DS; or 47,XY+21, male with DS) (CDC, 2016). Another type of DS, translocation, occurs when extra chromosome 21 material is present in every cell of the individual but it is attached to another chromosome. In the third type of DS, mosaicism, extra chromosome 21 material is found in some but not all of the cells.

Although the risk for having a child with DS increases with maternal age (incidence is approximately 1 in 1200 for a 25-year-old woman; 1 in 350 for a 35-year-old woman; and 1 in 10 for a 49-year- old woman), children with DS can be born to mothers of any age. The risk for a mother over age 40 of having a second child with DS

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is about 1% (Sole-Smith, 2014). Other autosomal trisomies that maternity nurses might see are

trisomy 18 (Edwards syndrome) and trisomy 13 (Patau syndrome). Trisomy 18 is more common than trisomy 13; it occurs in about 1 of 5000 live births versus 1 of 16,000 live births for trisomy 13 (Genetics Home Reference, 2017b). Infants with trisomy 18 and trisomy 13 usually have severe to profound intellectual disabilities. Although both conditions have a poor prognosis, with the vast majority of affected infants dying before they reach their first birthday, a growing number of infants with these trisomies are living longer, and a small number are actually living into their 40s and 50s.

Nondisjunction can also occur during mitosis. If this occurs early in development, when cell lines are forming, the individual has a mixture of cells, some with a normal number of chromosomes and others either missing a chromosome or containing an extra chromosome. This condition is known as mosaicism. The most common form of mosaicism in autosomes is mosaic DS.

Abnormalities of Chromosome Structure Structural abnormalities can occur in any chromosome. Types of structural abnormalities include translocation, duplication, deletion, microdeletion, and inversion. Translocation results when there is an exchange of chromosomal material between two chromosomes. Exposure to certain drugs, viruses, and radiation can cause translocations, but often they arise for no apparent reason.

The two major types of translocation are reciprocal and robertsonian. Reciprocal translocations are the most common. In a reciprocal translocation, either the parts of the two chromosomes are exchanged equally (balanced translocation) or a part of a chromosome is transferred to a different chromosome, creating an unbalanced translocation because there is extra chromosomal material—extra of one chromosome but correct amount or deficient amount of the other chromosome. In a balanced translocation, the individual is phenotypically normal because there is no extra chromosome material; it is just rearranged. In an unbalanced translocation, the individual will be both genotypically and phenotypically abnormal.

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In a robertsonian translocation, the short arms (p arms) of two different acrocentric chromosomes (chromosomes with very short p arms) break, leaving sticky ends that then cause the two long arms (q arms) to stick together. This forms a new, large chromosome that is made of the two long arms. The individual with a balanced robertsonian translocation has 45 chromosomes. Because the short arm of acrocentric chromosomes contains genes for ribosomal RNA and these genes are represented elsewhere, the individual usually does not show any symptoms. The individual may produce an unbalanced gamete (sperm or egg with too many or two few genes). This can lead to reproductive difficulties such as miscarriages or birth defects.

In duplication, there is an extra chromosomal segment within the same homologous or another nonhomologous chromosome. Clinical findings are highly variable and depend on which of the chromosomal segments are involved.

Deletions result in the loss of chromosomal material and partial monosomy for the chromosome involved. Microdeletions are deletions too small to be detected by standard cytogenetic techniques. Whenever a portion of a chromosome is deleted from one chromosome and added to another, the gamete produced may have either extra copies of genes or too few copies. The clinical effects produced may be mild or severe depending on the amount of genetic material involved. Two of the more common conditions are the deletion of the short arm of chromosome 5 (cri du chat syndrome) and the deletion of the long arm of chromosome 18.

Inversions are deviations in which a portion of the chromosome has been rearranged in reverse order. Few birth defects have been attributed to the presence of inversions, but it is suspected that inversions may be responsible for problems with infertility and miscarriages.

Sex Chromosome Abnormalities Several sex chromosome abnormalities are caused by nondisjunction during gametogenesis in either parent. The most common deviation in females is Turner syndrome, or monosomy X (45,X). The affected female exhibits juvenile external genitalia with undeveloped ovaries. She is short in stature and often has webbing

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of the neck, a low hairline in the back, low-set ears, and lymphedema of her hands and feet. Intelligence may be impaired. Most affected embryos miscarry spontaneously. In most cases of Turner syndrome, it is the paternal X or Y that is lost. Turner syndrome is a common cause of infertility (Genetics Home Reference, 2017c).

The most common deviation in males is Klinefelter syndrome, or trisomy XXY. The affected male has poorly developed secondary sexual characteristics and small testes. He is infertile, usually tall, and effeminate and may be slow to learn. Males who have mosaic Klinefelter syndrome may be fertile.

Patterns of Genetic Transmission Heritable characteristics are those that can be passed on to offspring. The patterns by which genetic material is transmitted to the next generation are affected by the number of genes involved in the expression of the trait. Many phenotypic characteristics result from two or more genes on different chromosomes acting together (referred to as multifactorial inheritance); others are controlled by a single gene (unifactorial inheritance). Specialists in genetics (e.g., geneticists, genetic counselors, and nurses with advanced expertise in genetics) predict the probability of the presence of an abnormal gene from the known occurrence of the trait in the individual's family and the known patterns by which the trait is inherited.

Multifactorial Inheritance Most common congenital malformations result from multifactorial inheritance, a combination of genetic and environmental factors. Examples are cleft lip, cleft palate, congenital heart disease, neural tube defects, and pyloric stenosis. Each malformation can range from mild to severe, depending on the number of genes for the defect present or the amount of environmental influence. A neural tube defect can range from spina bifida (a bony defect in the lumbar region of the vertebrae with little or no neurologic impairment) to anencephaly (absence of brain development, which is always fatal). Some malformations occur more often in one sex. For example, pyloric stenosis and cleft lip are more common in males, and cleft

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palate is more common in females.

Unifactorial Inheritance If a single gene controls a particular trait or disorder, its pattern of inheritance is referred to as unifactorial mendelian or single-gene inheritance. The number of single-gene disorders far exceeds the number of chromosomal abnormalities. Potential patterns of inheritance for single-gene disorders include autosomal dominant, autosomal recessive, and X-linked dominant and recessive modes of inheritance (Fig. 6.2).

FIG 6.2 Possible offspring in three types of matings. A, Homozygous-dominant parent and homozygous-

recessive parent. Children: all heterozygous, displaying dominant trait. B, Heterozygous parent and

homozygous-recessive parent. Children: 50% heterozygous, displaying dominant trait; 50%

homozygous, displaying recessive trait. C, Both parents heterozygous. Children: 25% homozygous,

displaying dominant trait; 25% homozygous, displaying recessive trait; 50% heterozygous, displaying dominant

trait.

Autosomal Dominant Inheritance Autosomal dominant inheritance disorders are those in which only one copy of a variant allele is needed for phenotypic expression. The variant allele may be a result of a mutation—a spontaneous and permanent change in the normal gene structure in which case the disorder occurs for the first time in the family. Usually an affected individual comes from multiple generations having the disorder. An affected parent who is heterozygous for the trait has a 50% chance of passing the variant allele to each offspring (see Fig.

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6.2, B and C). There is a vertical pattern of inheritance (i.e., there is no skipping of generations; if an individual has an autosomal dominant disorder such as HD, so must one of his or her parents). Males and females are equally affected.

Autosomal dominant disorders are not always expressed with the same severity of symptoms. For example, a woman who has an autosomal dominant disorder may show few symptoms and may not become aware of her diagnosis until after she gives birth to a severely affected child. Predicting whether an offspring will have a minor or severe abnormality is not possible. Sometimes an individual can acquire a de novo mutation (new mutation that spontaneously occurred in a gene carried by an individual germ cell) that can result in an autosomal dominant disorder (Prows et al., 2013). Examples of autosomal dominant disorders are HD, Marfan syndrome, neurofibromatosis, myotonic dystrophy, Stickler syndrome, Treacher Collins syndrome, and achondroplasia (dwarfism).

Autosomal Recessive Inheritance Autosomal recessive inheritance disorders are those in which both genes of a pair associated with the disorder must be abnormal for the disorder to be expressed. Heterozygous individuals have only one variant allele and are unaffected clinically because their normal gene overshadows the variant allele. They are known as carriers of the recessive trait. Because these recessive traits are inherited by generations of the same family, an increased incidence of the disorder occurs in consanguineous matings (closely related parents). For the trait to be expressed, two carriers must each contribute a variant allele to the offspring (see Fig. 6.2, C). The chance of the trait occurring in each child is 25%. A clinically normal offspring may be a carrier of the gene. Autosomal recessive disorders have a horizontal pattern of inheritance rather than the vertical pattern seen with autosomal dominant disorders. That is, autosomal recessive disorders are usually observed in one or more siblings but not in earlier generations. Males and females are equally affected.

Inborn Errors of Metabolism

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More than 350 inborn errors of metabolism have been recognized. Most inborn errors of metabolism (IEMs), such as phenylketonuria, galactosemia, maple syrup urine disease, Tay-Sachs disease, sickle cell anemia, and CF, are autosomal recessive inherited disorders. IEMs occur when a gene mutation reduces the efficiency of encoded enzymes to a level at which normal metabolism cannot occur. Defective enzyme action interrupts the normal series of chemical reactions from the affected point onward. The result may be an accumulation of a damaging product, such as phenylalanine in PKU, or the absence of a necessary product, such as the lack of melanin in albinism caused by lack of tyrosinase. Diagnostic and carrier testing is available for a growing number of IEMs. In addition, many states in the United States have started screening for specific IEMs as part of their expanded newborn screening programs using tandem mass spectrometry. However, many of the deaths caused by IEMs are the result of enzyme variants not currently screened for in many of the newborn screening programs. (See discussion of IEMs in Chapter 25.)

X-Linked Dominant Inheritance X-linked dominant inheritance disorders occur in males and heterozygous females, but because of X inactivation, affected females are usually less severely affected than affected males and they are more likely to transmit the variant allele to their offspring. Heterozygous females (females who have one wild-type allele and one variant allele) have a 50% chance of transmitting the variant allele to each offspring. The variant allele is often lethal in affected males since, unlike affected females, they have no normal gene (wild-type allele). Mating of an affected male and an unaffected female is uncommon as a result of the tendency for the variant allele to be lethal in affected males. Relatively few X-linked dominant disorders have been identified. Two examples are vitamin D–resistant rickets and Rett syndrome.

X-Linked Recessive Inheritance Abnormal genes for X-linked recessive inheritance disorders are carried on the X chromosome. Females may be heterozygous or homozygous for traits carried on the X chromosome because they

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have two X chromosomes. Males are hemizygous because they have only one X chromosome, which carries genes with no alleles on the Y chromosome. Therefore X-linked recessive disorders are most commonly manifested in the male with the abnormal gene on his single X chromosome. Hemophilia, color blindness, and Duchenne muscular dystrophy are X-linked recessive disorders.

The male with an X-linked recessive disorder receives the disease-associated allele from his carrier mother on her affected X chromosome. Female carriers (those heterozygous for the trait) have a 50% probability of transmitting the disease-associated allele to each offspring. An affected male can pass the disease-associated allele to his daughters but not to his sons. The daughters will be carriers of the trait if they receive a normal gene on the X chromosome from their mother. They will be affected only if they receive a disease-associated allele on the X chromosome from both their mother and their father.

Genetic Counseling It is standard practice in obstetrics to determine whether a heritable disorder exists in a couple or in anyone in either of their families. The goal of screening is to detect or define risk for disease in low- risk populations and identify those for whom diagnostic testing may be appropriate. A nurse can obtain a genetics history using a questionnaire or checklist such as the one in Fig. 6.3.

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FIG 6.3 Questionnaire for identifying couples having increased risk for offspring with genetic disorders.

(Courtesy of American College of Obstetricians and Gynecologists. [2010]. Your

pregnancy and childbirth month to month [5th ed.]. Washington, DC: Author.)

Genetic counseling is a professional service that provides genetics information, education, and support to individuals and families with ongoing or potential genetic health concerns. It is typically provided by a team of genetics specialists that includes clinical geneticists (physicians), medical geneticists, genetics fellows, genetics counselors, and, advanced practice genetics nurse

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specialists. Cytogeneticists, biochemical geneticists, and molecular geneticists support the clinical genetics team by providing laboratory expertise that helps with the diagnosis and management of individuals and families affected by genetic conditions.

Genetic counseling occurs in regional genetics centers, major medical centers, outreach or satellite genetics clinics, public health clinics, some community hospitals, and now that genetics has entered the mainstream of health care, in a wide variety of other settings. These include but are not limited to managed health care organizations, commercial facilities, and private practices. A number of specialized groups provide genetics education and counseling for individuals and families affected by specific genetic disorders, such as DS, CF, diabetes, muscular dystrophy, HD, and cancer. Genetic counseling also is offered over the Internet.

Individuals and families seek out or are referred for genetic counseling for a wide variety of reasons and at all stages of their lives. Some seek preconception or prenatal information; others are referred after the birth of a child with a birth defect or a suspected genetic condition or after a pregnancy loss. Still others seek information because they have a family history of a genetic condition. Regardless of the setting or the individual's and family's stage of life, genetic counseling should be offered and available to all individuals and families who have questions about genetics and their health. However, there is a shortage of appropriately trained genetics professionals who can provide genetic counseling. This means that many individuals and families will not be offered genetic counseling when they undergo genetic testing. Moreover, some of the genetics education and counseling that is provided will be inadequate (see Community Focus box).

Community Focus Resources for Genetic Disorders

• Select a hereditary disorder such as CF, muscular dystrophy, hemophilia, Tay-Sachs disease, or sickle cell anemia. Visit the website of the national organization. Locate accredited care centers that are in your community. Do the centers offer

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preconception counseling?

• Visit the Genetic Alliance website at www.geneticalliance.org. Select a disorder, and go to the disease information search link. Review the patient information sections about clinical description, insurance issues, research, and treatment.

• Share your findings with your classmates in a clinical conference.

• Existing genetics resources include the following:

• Centers for Disease Control and Prevention (www.cdc.gov/genetics/activities/ogdp.htm)

• Genetic Alliance (www.geneticalliance.org/)

• National Coalition for Health Professional Education in Genetics (www.nchpeg.org/)

• Genetics Education Program for Nurses at Cincinnati Children's Hospital Medical Center (www.cincinnatichildrens.org/ed/clinical/gpnf/default.htm

• NHGRI Education (www.genome.gov/Education/)

• National Center for Biotechnology Information (www.ncbi.nlm.nih.gov/)

• Other websites, such as www.hsl.unc.edu/Services/Guides/focusonclingen.cfm

Some of these resources may be in health care professionals' own communities, but others are regional, national, and international resources.

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Estimation of Risk Most families with a history of genetic disease want an answer to the following question: What is the chance that our future children will have this disease? Because the answer to this question may have profound implications for individual family members and the family as a whole, health care professionals must be able to answer this question as accurately as they can in a timely manner. In some cases, estimation of risk is rather straightforward; in other cases, it is complicated.

If a couple has not yet had children but they are known to be at risk for having children with a genetic disease, they will be given an occurrence risk. Once the mating of a couple has produced one or more children with a genetic disease, the couple will be given a recurrence risk. Both occurrence and recurrence risks are determined by the mode of inheritance for the genetic disease in question. For genetic diseases caused by a factor that segregates during cell division (genes and chromosomes), risk can be estimated with a high degree of accuracy by application of mendelian principles.

In an autosomal dominant disorder, both the occurrence and recurrence risk is 50%, or one in two, that a subsequent offspring will be affected when one parent is affected and the other is not. The recurrence risk for autosomal recessive disorders is 25%, or 1 in 4, if both parents are carriers (they each have one recessive disease gene and one normal gene). Occasionally an individual homozygous for a recessive disease gene mates with an individual who is a carrier of the same recessive gene. In this case, the recurrence risk is 50%, or 1 in 2. If two individuals affected by an autosomal recessive disorder mate, all of their children will be affected. For X-linked disorders, recurrence risk is related to the sex of the child. Translocation chromosomes have a high risk for recurrence.

A number of autosomal disorders display fairly complex patterns of inheritance, making estimation of risk somewhat difficult. For example, if a child is born with a genetic disease and there has been no history of the disease in the family, the disease may have been caused by a new mutation (this is more likely if the disease in question is an autosomal dominant disorder, such as

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achondroplasia). If the child's genetic disease has been caused by a new mutation, the recurrence risk for the parents' subsequent children is low (1% to 2%), but it is not as low as that for the general population. Offspring of the affected child may have a substantially elevated occurrence risk.

The risk for recurrence for multifactorial conditions can be estimated empirically. An empiric risk is based not on genetics theory but, rather, on experience and observation of the disorder in other families. Recurrence risks are determined by applying the frequency of a similar disorder in other families to the case under consideration.

An important concept to be emphasized to individuals and families during a genetic counseling session is that each pregnancy is an independent event. For example, in monogenic disorders in which the risk factor is 1 in 4 that the child will be affected, the risk remains the same no matter how many affected children are already in the family. Families may maintain the erroneous assumption that the presence of one affected child ensures that the next three will be free of the disorder. However, “chance has no memory.” The risk is 1 in 4 for each pregnancy. Conversely, in a family with a child who has a disorder with multifactorial causes, the risk increases with each subsequent child born with the disorder.

Interpretation of Risk The guiding principle for genetics counselors has traditionally been nondirectiveness. According to the principle of nondirectiveness, the individual who is providing genetic counseling respects the right of the individual or family being counseled to make autonomous decisions. Counselors using a nondirective approach avoid making recommendations, and they try to communicate genetics information in an unbiased manner. The first step in providing nondirective counseling is becoming aware of one's own values and beliefs. Another important step is recognizing how one's values and beliefs can influence or interfere with the communication of genetics information.

If the individual who is providing genetic counseling has

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difficulty being nonjudgmental and objective, he or she may either intentionally or unintentionally influence the decision-making process. Individuals and families also may pressure the counselor to make decisions for them with questions such as “What would you do if you were me?” Families and individuals need education, guidance, and support throughout the counseling process. They should be given the facts and possible consequences as well as all of the assistance they need in problem solving, but the final decision regarding a course of action must be their own.

Multiple Roles for Nurses in Genetics Nurses play many roles in genetics. Some nurses play a key role in the identification of families in need of genetic counseling, and they collaborate with other health care professionals as part of interprofessional teams to make referrals to specialists in genetics. Other nurses take a more active role in genetic counseling.

Probably the most important of all nursing functions is to provide emotional support during all aspects of the counseling process. Feelings that are generated under the real or imagined threat posed by a genetic disorder are as varied as the individuals being counseled. Responses may include a variety of stress reactions, such as apathy, denial, anger, hostility, fear, embarrassment, grief, and loss of self-esteem. Guilt and self-blame are universal reactions. Many look on the disorder as a stigma, especially if the disorder is visible to others. Old wives' tales, superstitions, and long-held misconceptions may influence a family's reaction to a genetic disorder.

Nurses are ideally positioned to help individuals and families maximize the benefits of the genetics revolution, but first, nurses need (1) a working knowledge of human genetics, (2) an awareness of recent advances in genetics and genomics, and (3) an understanding of the potential effects of genomic discoveries on individual and family well-being. More research is needed concerning the family experience of genetic testing. Nurses must understand why individuals and families decide to undergo or to forgo genetic testing. Nurses also need to be aware of how individuals and families define and manage ethical, legal, and

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social issues that emerge during the genetic testing experience.

Cell Division and Conception Cell Division Cells are reproduced by two different methods: mitosis and meiosis. In mitosis, the body cells replicate to yield two cells with the same genetic makeup as the parent cell. First the cell makes a copy of its DNA, and then it divides. Each daughter cell receives one copy of the genetic material. Mitotic division facilitates growth and development or cell replacement.

Meiosis, the process by which germ cells divide and decrease their chromosomal number by half, produces gametes (eggs and sperm). Each homologous pair of chromosomes contains one chromosome received from the mother and one from the father; thus meiosis results in cells that contain one of each of the 23 pairs of chromosomes. Because these germ cells contain 23 single chromosomes, half of the genetic material of a normal somatic cell, they are called haploid. This halving of the genetic material is accomplished by replicating the DNA once and then dividing twice. When the female gamete (egg or ovum) and the male gamete (spermatozoon) unite to form the zygote, the diploid number of human chromosomes (46, or 23 pairs) is restored.

The process of DNA replication and cell division in meiosis allows different alleles (genes on corresponding loci that code for variations of the same trait) for genes to be distributed at random by each parent and then rearranged on the paired chromosomes. The chromosomes then separate and proceed to different gametes. Because the two parents have genotypes derived from four different grandparents, many combinations of genes on each chromosome are possible. This random mixing of alleles accounts for the variation of traits seen in the offspring of the same two parents.

Gametogenesis Oogenesis, the process of egg (ovum) formation, begins during fetal

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life of the female. All the cells that may undergo meiosis in a woman's lifetime are contained in her ovaries at birth. The majority of the estimated 2 million primary oocytes (the cells that undergo the first meiotic division) degenerate spontaneously. Only 400 to 500 ova will mature during the approximately 35 years of a woman's reproductive life. The primary oocytes begin the first meiotic division (i.e., they replicate their DNA) during fetal life, but they remain suspended at this stage until puberty (Fig. 6.4, A). Then, usually monthly, one primary oocyte matures and completes the first meiotic division, yielding two unequal cells: the secondary oocyte and a small polar body. Both contain 22 autosomes and one X sex chromosome.

FIG 6.4 Gametogenesis and fertilization. A, Oogenesis. Gametogenesis in the female produces

one mature ovum and three polar bodies. Note relative difference in overall size between ovum and sperm. B,

Spermatogenesis. Gametogenesis in the male produces four mature gametes, the sperm. C,

Fertilization results in the single-cell zygote and restoration of the diploid number of chromosomes.

At ovulation, the second meiotic division begins. However, the

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ovum does not complete the second meiotic division unless fertilization occurs. At fertilization, when the sperm is united with the mature ovum, a second polar body and the zygote (the united egg and sperm) are produced (see Fig. 6.4, C). The three polar bodies degenerate.

When a male reaches puberty, his testes begin the process of spermatogenesis. The cells that undergo meiosis in the male are called spermatocytes. The primary spermatocyte, which undergoes the first meiotic division, contains the diploid number of chromosomes. The cell has already copied its DNA before division, so four alleles for each gene are present. The cell is still considered diploid because the copies are bound together (i.e., one allele plus its copy on each chromosome).

During the first meiotic division, two haploid secondary spermatocytes are formed. Each secondary spermatocyte contains 22 autosomes and one sex chromosome; one contains the X chromosome (plus its copy) and the other, the Y chromosome (plus its copy). During the second meiotic division, the male produces two gametes with an X chromosome and two gametes with a Y chromosome, all of which will develop into viable sperm (see Fig. 6.4, B).

Conception Conception, defined as the union of a single egg and sperm, marks the beginning of a pregnancy. Conception occurs not as an isolated event but as part of a sequential process. This sequential process includes gamete (egg and sperm) formation, ovulation (release of the egg), union of the gametes (which results in an embryo), and implantation in the uterus.

Ovum Meiosis occurs in the female in the ovarian follicles and produces an egg, or ovum. Each month one ovum matures with a host of surrounding supportive cells. At ovulation, the ovum is released from the ruptured ovarian follicle. High estrogen levels increase the motility of the uterine tubes so that their cilia can capture the ovum and propel it through the tube toward the uterine cavity. An ovum

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cannot move by itself. Two protective layers surround the ovum (Fig. 6.5). The inner

layer is a thick, acellular layer called the zona pellucida. The outer layer, called the corona radiata, is composed of elongated cells.

FIG 6.5 Ovum and sperm.

Ova are considered fertile for about 24 hours after ovulation. If unfertilized by a sperm, the ovum degenerates and is resorbed.

Sperm Ejaculation during sexual intercourse normally propels about a teaspoon of semen containing as many as 200 to 500 million sperm into the vagina. The sperm swim by means of the flagellar movement of their tails. Some sperm can reach the site of fertilization within 5 minutes, but average transit time is 4 to 6 hours. Sperm remain viable within the woman's reproductive system for an average of 2 to 3 days. Most sperm are lost in the vagina, within the cervical mucus, or in the endometrium; or they enter the tube that contains no ovum.

As sperm travel through the female reproductive tract, enzymes are produced to aid in their capacitation. Capacitation is a physiologic change that removes the protective coating from the heads of the sperm. Small perforations then form in the acrosome (a cap on the sperm) and allow enzymes (e.g., hyaluronidase) to escape (see Fig. 6.5). These enzymes are necessary for the sperm to

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penetrate the protective layers of the ovum before fertilization.

Fertilization Fertilization takes place in the ampulla (the outer third) of the uterine tube. When a sperm successfully penetrates the membrane surrounding the ovum, both sperm and ovum are enclosed within the membrane and the membrane becomes impenetrable to other sperm; this process is termed the zona reaction. The second meiotic division of the secondary oocyte is then completed, and the nucleus of the ovum becomes the female pronucleus. The head of the sperm enlarges to become the male pronucleus, and the tail degenerates. The nuclei fuse and the chromosomes combine, restoring the diploid number (46) (Fig. 6.6). Conception, the formation of the zygote (the first cell of the new individual), has been achieved.

FIG 6.6 Fertilization. A, Ovum fertilized by X-bearing sperm to form female zygote. B, Ovum fertilized by Y-

bearing sperm to form male zygote.

Mitotic cellular replication, called cleavage, begins as the zygote travels the length of the uterine tube into the uterus. This voyage takes 3 to 4 days. Because the fertilized egg divides rapidly with no increase in size, successively smaller cells, called blastomeres, are formed with each division. A 16-cell morula, a solid ball of cells, is produced within 3 days and is still surrounded by the protective zona pellucida (Fig. 6.7, A). Further development occurs as the morula floats freely within the uterus. Fluid passes through the zona pellucida into the intercellular spaces between the

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blastomeres, separating them into two parts: the trophoblast (which gives rise to the placenta) and the embryoblast (which gives rise to the embryo). A cavity forms within the cell mass as the spaces come together, forming a structure called the blastocyst cavity. When the cavity becomes recognizable, the whole structure of the developing embryo is known as the blastocyst. Stem cells are derived from the inner cell mass of the blastocyst. The outer layer of cells surrounding the cavity is the trophoblast. The trophoblast differentiates into villous and extravillous trophoblast (Fig. 6.8).

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FIG 6.7 First weeks of human development. A, Follicular development in ovary, ovulation, fertilization, and transport of early embryo down uterine tube and into uterus, where implantation occurs. B, Blastocyst embedded in endometrium. Germ layers forming. (A,

From Carlson, B.M. [2013]. Human embryology and developmental biology [5th

ed.]. St. Louis, MO: Mosby; B, Adapted from Langley, L.L., Telford, I.R.,

Christensen, J.B. [1980]. Dynamic human anatomy and physiology [5th ed.]. New

York, NY: McGraw-Hill.)

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FIG 6.8 Extravillous trophoblasts are found outside the villus and can be subdivided into endovascular and

interstitial categories. Endovascular trophoblasts invade and transform spiral arteries during pregnancy

to create low-resistance blood flow that is characteristic of the placenta. Interstitial trophoblasts invade the decidua and surround spiral arteries. (From Cunningham, F., Leveno, K., Bloom, S., et al. [2014]. Williams obstetrics [24th

ed.]. New York, NY: McGraw-Hill.)

Implantation The zona pellucida degenerates, the trophoblast cells displace endometrial cells at the implantation site, and the blastocyst embeds in the endometrium, usually in the anterior or posterior fundal region. Between 6 and 10 days after conception, the trophoblast secretes enzymes that enable it to burrow into the endometrium until the entire blastocyst is covered. This is known as implantation. Endometrial blood vessels erode, and some women have implantation bleeding (slight spotting and bleeding at the time of the first missed menstrual period). Chorionic villi, fingerlike projections, develop out of the trophoblast and extend into the blood-filled spaces of the endometrium. These villi are vascular processes that obtain oxygen and nutrients from the maternal bloodstream and dispose of carbon dioxide and waste products into the maternal blood.

After implantation, the endometrium is called the decidua. The portion directly under the blastocyst, where the chorionic villi tap into the maternal blood vessels, is the decidua basalis. The portion

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covering the blastocyst is the decidua capsularis, and the portion lining the rest of the uterus is the decidua vera (Fig. 6.9).

FIG 6.9 Development of fetal membranes. Note gradual obliteration of intrauterine cavity as decidua

capsularis and decidua vera meet. Also note thinning of uterine wall. Chorionic and amnionic membranes are in apposition to each other but may be peeled

apart.

The Embryo and Fetus Pregnancy lasts approximately 10 lunar months, 9 calendar months, 40 weeks, or 280 days. Length of pregnancy is computed from the first day of the last menstrual period (LMP) until the day of birth. However, conception occurs approximately 2 weeks after the first day of the LMP. Thus the postconception age of the fetus is 2 weeks less, for a total of 266 days or 38 weeks. Postconception age is used in the discussion of fetal development.

Intrauterine development is divided into three stages: ovum or preembryonic, embryo, and fetus (see Fig. 6.19). The stage of the

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ovum lasts from conception until day 14. This period covers cellular replication, blastocyst formation, initial development of the embryonic membranes, and establishment of the primary germ layers.

Primary Germ Layers During the third week after conception, the embryonic disk differentiates into three primary germ layers: the ectoderm, the mesoderm, and the endoderm (or entoderm) (see Fig. 6.7, B). All tissues and organs of the embryo develop from these three layers.

The ectoderm, the upper layer of the embryonic disk, gives rise to the epidermis, glands (anterior pituitary, cutaneous, and mammary), nails and hair, central and peripheral nervous systems, lens of the eyes, tooth enamel, and floor of the amniotic cavity.

The mesoderm, the middle layer, develops into the bones and teeth, muscles (skeletal, smooth, and cardiac), dermis and connective tissue, cardiovascular system and spleen, and urogenital system.

The endoderm, the lower layer, gives rise to the epithelium lining the respiratory tract and digestive tract, including the oropharynx, liver and pancreas, urethra, bladder, and vagina. The endoderm forms the roof of the yolk sac.

Development of the Embryo The stage of the embryo lasts from day 15 until approximately 8 weeks after conception, when the embryo measures approximately 3 cm from crown to rump. The embryonic stage is the most critical time in the development of the organ systems and the main external features. Developing areas with rapid cell division are the most vulnerable to malformation caused by environmental teratogens (substances or exposure that causes abnormal development). At the end of the eighth week, all organ systems and external structures are present and the embryo is unmistakably human. (See Fig. 6.19 and Visible Embryo, www.visembryo.com, for a pictorial view of normal and abnormal development.)

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Membranes At the time of implantation, two fetal membranes that will surround the developing embryo begin to form. The chorion develops from the trophoblast and contains the chorionic villi on its surface. The villi burrow into the decidua basalis and increase in size and complexity as the vascular processes develop into the placenta. The chorion becomes the covering of the fetal side of the placenta. It contains the major umbilical blood vessels that branch out over the surface of the placenta. As the embryo grows, the decidua capsularis stretches. The chorionic villi on this side atrophy and degenerate, leaving a smooth chorionic membrane.

The inner cell membrane, the amnion, develops from the interior cells of the blastocyst. The cavity that develops between this inner cell mass and the outer layer of cells (trophoblast) is the amniotic cavity (see Fig. 6.7, B). As it grows larger, the amnion forms on the side opposite the developing blastocyst (see Fig. 6.7, B, and Fig. 6.9). The developing embryo draws the amnion around itself to form a fluid-filled sac. The amnion becomes the covering of the umbilical cord and covers the chorion on the fetal surface of the placenta. As the embryo grows larger, the amnion enlarges to accommodate the embryo/fetus and the surrounding amniotic fluid. The amnion eventually comes in contact with the chorion surrounding the fetus (see the Critical Reasoning Case Study).

Clinical Reasoning Case Study Ingestion of Alcohol During Pregnancy

Sandra is 12 weeks pregnant, confirmed by ultrasound, and has just come for her first prenatal visit. She stated that she drinks wine with dinner almost every night. Now that she has a confirmed pregnancy, she is worried about her alcohol and medication intake during the first trimester of pregnancy. What information should the nurse provide Sandra?

1. Evidence—Is there sufficient evidence to draw conclusions about what information the nurse should provide Sandra?

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2. Assumptions—Describe an underlying assumption about the following factors:

a. Sandra's motivation to learn about fetal development

b. Sandra's understanding of fetal development

c. Sandra's knowledge about alcohol intake and medication use during pregnancy

d. Why dating the pregnancy is important

e. Sandra being worried about possible negative effects on the fetus of alcohol intake and medications

3. What implications and priorities for nursing care can be drawn at this time?

4. What are the opportunities for interprofessional practice? Which members of the interprofessional health care team might be involved in providing care for Sandra?

Amniotic Fluid The amniotic cavity initially derives its fluid by diffusion from the maternal blood. Fluid secreted by the respiratory and gastrointestinal tracts of the fetus also enters the amniotic cavity (Moore, Persaud, & Torchia, 2013). The amount of fluid increases weekly, and 700 to 1000 mL of transparent liquid is normally present at term. The volume of amniotic fluid changes constantly. The fetus swallows fluid, and fluid flows into and out of the fetal lungs. Beginning in week 11, the fetus urinates into the fluid, increasing its volume.

Amniotic fluid serves many functions. It helps maintain a

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constant body temperature. It serves as a source of oral fluid and as a repository for waste and assists in maintenance of fluid and electrolyte homeostasis. It cushions the fetus from trauma by blunting and dispersing outside forces. It allows freedom of movement for musculoskeletal development. It acts as a barrier to infection and allows fetal lung development (Moore et al., 2013). The fluid keeps the embryo from tangling with the membranes, facilitating symmetric growth. If the embryo does become tangled with the membranes, amputations of extremities or other deformities can occur from constricting amniotic bands.

Yolk Sac When the amniotic cavity and amnion are forming, another blastocyst cavity forms on the other side of the developing embryonic disk (see Fig. 6.7, B). This cavity becomes surrounded by a membrane, forming the yolk sac. The yolk sac aids in transferring maternal nutrients and oxygen, which have diffused through the chorion, to the embryo. Blood vessels form to aid transport. Blood cells and plasma are manufactured in the yolk sac during the second and third weeks while uteroplacental circulation is being established and is forming primitive blood cells until hematopoietic activity begins. At the end of the third week, the primitive heart begins to beat and circulate the blood through the embryo, the connecting stalk, the chorion, and the yolk sac.

The folding in of the embryo during the fourth week results in incorporation of part of the yolk sac into the embryo's body as the primitive digestive system. Primordial germ cells arise in the yolk sac and move into the embryo. The shrinking remains of the yolk sac degenerate (see Fig. 6.7, B), and by the fifth or sixth week, the remnant has separated from the embryo.

Umbilical Cord By day 14 after conception, the embryonic disk, the amniotic sac, and the yolk sac are attached to the chorionic villi by the connecting stalk. During the third week, the blood vessels develop to supply the embryo with maternal nutrients and oxygen. During the fifth week, the embryo has curved inward on itself from both ends,

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bringing the connecting stalk to the ventral side of the embryo. The connecting stalk becomes compressed from both sides by the amnion and forms the narrower umbilical cord (see Fig. 6.7). Two arteries carry blood from the embryo to the chorionic villi, and one vein returns blood to the embryo. Approximately 1% of umbilical cords contain only two vessels: one artery and one vein. This occurrence is sometimes associated with congenital malformations (Kaiser Permanente, 2017).

The cord rapidly increases in length. At term, the cord is 2 cm in diameter and ranges from 30 to 90 cm in length (with an average of 55 cm). It twists spirally on itself and loops around the embryo/fetus. A true knot is rare, but false knots occur as folds or kinks in the cord and may jeopardize circulation to the fetus. Connective tissue called Wharton's jelly prevents compression of the blood vessels and ensures continued nourishment of the embryo/fetus. Compression can occur if the cord lies between the fetal head and the pelvis or is twisted around the fetal body. When the cord is wrapped around the fetal neck, it is called a nuchal cord.

Because the placenta develops from the chorionic villi, the umbilical cord is usually located centrally. A peripheral location is less common and is known as a battledore placenta (see Chapter 12 for more information). The blood vessels are arrayed out from the center to all parts of the placenta (Fig. 6.10).

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FIG 6.10 Term placenta. A, Maternal (or uterine) surface, showing cotyledons and grooves. B, Fetal (or

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amniotic) surface, showing blood vessels running under amnion and converging to form umbilical vessels at attachment of umbilical cord. C, Amnion and smooth

chorion are arranged to show that they are (1) fused and (2) continuous with margins of placenta. (Courtesy of

Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)

Placenta Structure The placenta begins to form at implantation. During the third week after conception, the trophoblast cells of the chorionic villi continue to invade the decidua basalis. As the uterine capillaries are tapped, the endometrial spiral arteries fill with maternal blood. The chorionic villi grow into the spaces with two layers of cells: the outer syncytium and the inner cytotrophoblast. A third layer develops into anchoring septa, dividing the projecting decidua into separate areas called cotyledons. In each of the 15 to 20 cotyledons, the chorionic villi branch out and a complex system of fetal blood vessels forms. Each cotyledon is a functional unit. The whole structure is the placenta (see Fig. 6.10).

The maternal-placental-embryonic circulation is in place by day 17, when the embryonic heart starts beating. By the end of the third week, embryonic blood is circulating between the embryo and the chorionic villi. In the intervillous spaces, maternal blood supplies oxygen and nutrients to the embryonic capillaries in the villi (Fig. 6.11). Waste products and carbon dioxide diffuse into the maternal blood.

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FIG 6.11 Schematic drawing of placenta illustrating how it supplies oxygen and nutrition to embryo and removes its waste products. Deoxygenated blood

leaves fetus through the umbilical arteries and enters placenta, where it is oxygenated. Oxygenated blood

leaves placenta through the umbilical vein, which enters the fetus via the umbilical cord.

The placenta functions as a means of metabolic exchange. Exchange is minimal at this time because the two cell layers of the villous membrane are too thick. Permeability increases as the cytotrophoblast thins and disappears; by the fifth month, only the single layer of syncytium is left between the maternal blood and the fetal capillaries. The syncytium is the functional layer of the placenta. By the eighth week, genetic testing may be done on a sample of chorionic villi obtained by aspiration biopsy; however, limb defects have been associated with chorionic villi sampling done before 10 weeks. The structure of the placenta is complete by the twelfth week. The placenta continues to grow wider until 20 weeks, when it covers about half of the uterine surface. It then continues to grow thicker. The branching villi continue to develop within the body of the placenta, increasing the functional surface area.

Functions One of the early functions of the placenta is as an endocrine gland

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that produces four hormones necessary to maintain the pregnancy and support the embryo/fetus. The hormones are produced in the syncytium.

The protein hormone human chorionic gonadotropin (hCG) can be detected in the maternal serum by 8 to 10 days after conception, shortly after implantation. This hormone is the basis for pregnancy tests. The hCG preserves the function of the ovarian corpus luteum, ensuring a continued supply of estrogen and progesterone needed to maintain the pregnancy. Miscarriage occurs if the corpus luteum stops functioning before the placenta can produce sufficient estrogen and progesterone. The hCG reaches its maximum level at 50 to 70 days and then begins to decrease.

The other protein hormone produced by the placenta is human chorionic somatomammotropin (hCS) or human placental lactogen (hPL). This substance is similar to a growth hormone and stimulates maternal metabolism to supply needed nutrients for fetal growth. hCS increases the resistance to insulin, facilitates glucose transport across the placental membrane, and stimulates breast development to prepare for lactation (Fig. 6.12).

FIG 6.12 Distinct profile for the concentrations of human chorionic gonadotropin (hCG) and human chorionic somatomammotropin (hCS) in serum of

women through normal pregnancy. IU, International units. (Adapted from Cunningham, F., Leveno, K., Bloom, S., et al. [2014].

Williams obstetrics [24th ed.]. New York, NY: McGraw-Hill.)

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The placenta eventually produces more of the steroid hormone progesterone than the corpus luteum does during the first few months of pregnancy. Progesterone maintains the endometrium, decreases the contractility of the uterus, and stimulates maternal metabolism and development of breast alveoli.

By 7 weeks after fertilization, the placenta is producing most of the maternal estrogens, which are steroid hormones. The major estrogen secreted by the placenta is estriol, whereas the ovaries produce mostly estradiol. Estriol levels may be measured to determine placental functioning. Estrogen stimulates uterine growth and uteroplacental blood flow. It causes a proliferation of the breast glandular tissue and stimulates myometrial contractility. Placental estrogen production increases greatly toward the end of pregnancy. One theory for the cause of the onset of labor is the decrease in circulating levels of progesterone and the increased levels of estrogen (Fig. 6.13).

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FIG 6.13 Plasma levels of progesterone, estradiol, estrone, and estriol in women during the course of gestation. (From Cunningham, F., Leveno, K., Bloom, S., et al. [2014].

Williams obstetrics [24th ed.]. New York, NY: McGraw-Hill.)

The metabolic functions of the placenta are respiration, nutrition, excretion, and storage. Oxygen diffuses from the maternal blood across the placental membrane into the fetal blood, and carbon dioxide diffuses in the opposite direction. In this way, the placenta functions as lungs for the fetus.

Carbohydrates, proteins, calcium, and iron are stored in the placenta for ready access to meet fetal needs. Water, inorganic salts, carbohydrates, proteins, fats, and vitamins pass from the maternal blood supply across the placental membrane into the fetal blood, supplying nutrition. Water and most electrolytes with a molecular weight less than 500 readily diffuse through the membrane. Hydrostatic and osmotic pressures aid in the flow of water and some solutions. Facilitated and active transport assist in the transfer of glucose, amino acids, calcium, iron, and substances with higher molecular weights. Amino acids and calcium are transported against the concentration gradient between the maternal blood and fetal blood.

The fetal concentration of glucose is lower than the glucose level in the maternal blood because of its rapid metabolism by the fetus. This fetal requirement demands larger concentrations of glucose than simple diffusion can provide. Therefore maternal glucose moves into the fetal circulation by active transport.

Pinocytosis is a mechanism used for transferring large molecules, such as albumin and gamma globulins, across the placental membrane. This mechanism conveys the maternal immunoglobulins that provide early passive immunity to the fetus.

Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them. Many viruses can cross the placental membrane and infect the fetus. Some bacteria and protozoa first infect the placenta and then infect the fetus. Drugs can also cross the placental membrane and may harm the fetus. Caffeine, alcohol, nicotine, carbon monoxide and other toxic substances in cigarette smoke, and prescription and recreational

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drugs (e.g., marijuana, cocaine) readily cross the placenta (Box 6.1).

Box 6.1 Developmentally Toxic Exposures in Humans

• Aminopterin

• Androgens

• Angiotensin-converting enzyme inhibitors

• Carbamazepine

• Cigarette smoking

• Cocaine

• Coumarin anticoagulants

• Cytomegalovirus

• Diethylstilbestrol

• Ethanol (>1 drink/day)

• Etretinate

• Hyperthermia

• Iodides

• Ionizing radiation (>10 rads)

• Isotretinoin

• Lead

• Lithium

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• Methimazole

• Methyl mercury

• Parvovirus B19

• Penicillamine

• Phenytoin

• Radioiodine

• Rubella

• Syphilis

• Tetracycline

• Thalidomide

• Toxoplasmosis

• Trimethadione

• Valproic acid

• Varicella

Although no direct link exists between the fetal blood in the vessels of the chorionic villi and the maternal blood in the intervillous spaces, only one cell layer separates them. Breaks occasionally occur in the placental membrane. Fetal erythrocytes then leak into the maternal circulation, and the mother may develop antibodies to the fetal red blood cells. This is often the way the Rh-negative mother becomes sensitized to the erythrocytes of her Rh-positive fetus (see the discussion of isoimmunization in Chapter 19).

Although the placenta and fetus are analogous to living tissue transplants, they are not destroyed by the host mother (Mor & Abrahams, 2014). Either the placental hormones suppress the

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immunologic response, or the tissue evokes no response. Placental function depends on the maternal blood pressure

supplying the circulation. Maternal arterial blood, under pressure in the small uterine spiral arteries, spurts into the intervillous spaces (see Fig. 6.11). As long as rich arterial blood continues to be supplied, pressure is exerted on the blood already in the intervillous spaces, pushing it toward drainage by the low-pressure uterine veins. At term gestation, 10% of the maternal cardiac output goes to the uterus.

If there is interference with the circulation to the placenta, the placenta cannot supply the embryo or fetus. Vasoconstriction, such as that caused by hypertension or cocaine use, diminishes uterine blood flow. Decreased maternal blood pressure or decreased cardiac output also diminishes uterine blood flow.

When a woman lies on her back with the pressure of the uterus compressing the vena cava, blood return to the right atrium is diminished (see Fig. 16.5 and the discussion of supine hypotension in Chapter 16). Excessive maternal exercise that diverts blood to the muscles away from the uterus compromises placental circulation. Optimum circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction of the fetus and infants who are small for gestational age.

Braxton Hicks contractions seem to enhance the movement of blood through the intervillous spaces, aiding placental circulation. However, prolonged contractions or intervals that are too short between contractions during labor can reduce the blood flow to the placenta.

Fetal Maturation This stage of the fetus lasts from 9 weeks (when the fetus becomes recognizable as a human being) until the pregnancy ends. Changes during the fetal period are not as dramatic, because refinement of structure and function is taking place. The fetus is less vulnerable to teratogens except for those that affect central nervous system functioning.

Viability refers to the capability of the fetus to survive outside the

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uterus. With modern technology and advances in maternal and neonatal care, infants who are 22 to 25 weeks of gestation are now considered to be on the threshold of viability (Cunningham, Leveno, Bloom, et al., 2014). The limitations on survival outside the uterus when an infant is born at this early stage are based on central nervous system function and oxygenation capability of the lungs.

Fetal Circulatory System The cardiovascular system is the first organ system to function in the developing human. Blood vessel and blood cell formation begins in the third week and supplies the embryo with oxygen and nutrients from the mother. By the end of the third week, the tubular heart begins to beat and the primitive cardiovascular system links the embryo, connecting stalk, chorion, and yolk sac. During the fourth and fifth weeks, the heart develops into a four-chambered organ. By the end of the embryonic stage, the heart is developmentally complete.

The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the ductus arteriosus, bypasses the lungs. Oxygen-rich blood from the placenta flows rapidly through the umbilical vein into the fetal abdomen (Fig. 6.14). When the umbilical vein reaches the liver, it divides into two branches; one branch circulates some oxygenated blood through the liver. Most of the blood passes through the ductus venosus into the inferior vena cava. There it mixes with the deoxygenated blood from the fetal legs and abdomen on its way to the right atrium. Most of this blood passes straight through the right atrium and through the foramen ovale, an opening into the left atrium. There it mixes with the small amount of deoxygenated blood returning from the fetal lungs through the pulmonary veins.

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FIG 6.14 Schematic illustration of fetal circulation. The colors indicate the oxygen saturation of the blood, and

the arrows show the course of the blood from the placenta to the heart. The organs are not drawn to scale. Observe that three shunts permit most of the

blood to bypass the liver and lungs: (1) ductus venosus, (2) foramen ovale, and (3) ductus arteriosus. A small amount of highly oxygenated blood from the

inferior vena cava remains in the right atrium and mixes with poorly oxygenated blood from the superior

vena cava. This medium oxygenated blood then passes into the right ventricle. The poorly oxygenated blood returns to the placenta for oxygen and nutrients through the umbilical arteries. (From Moore, K.L., Persaud, T.V.N., Torchia, M.G. [2016]. The developing human: Clinically oriented embryology [10th

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ed.]. Philadelphia, PA: Elsevier.)

The blood flows into the left ventricle and is squeezed out into the aorta, where the arteries supplying the heart, head, neck, and arms receive most of the oxygen-rich blood. This pattern of supplying the highest levels of oxygen and nutrients to the head, neck, and arms enhances the cephalocaudal (head-to-rump) development of the embryo/fetus.

Deoxygenated blood returning from the head and arms enters the right atrium through the superior vena cava. This blood is directed downward into the right ventricle, where it is squeezed into the pulmonary artery. A small amount of blood circulates through the resistant lung tissue, but the majority follows the path with less resistance through the ductus arteriosus into the aorta, distal to the point of exit of the arteries supplying the head and arms with oxygenated blood. The oxygen-poor blood flows through the abdominal aorta into the internal iliac arteries, where the umbilical arteries direct most of it back through the umbilical cord to the placenta. There the blood gives up its wastes and carbon dioxide in exchange for nutrients and oxygen. The blood remaining in the iliac arteries flows through the fetal abdomen and legs, ultimately returning through the inferior vena cava to the heart.

The following three special characteristics enable the fetus to obtain sufficient oxygen from the maternal blood: • Fetal hemoglobin carries 20% to 30% more oxygen than maternal

hemoglobin. • The hemoglobin concentration of the fetus is about 50% greater

than that of the mother. • The fetal heart rate (FHR) is 110 to 160 beats/min, making the

cardiac output per unit of body weight higher than that of an adult.

Hematopoietic System Hematopoiesis, the formation of blood, occurs in the yolk sac (see Fig. 6.7, B) beginning in the third week. Hematopoietic stem cells seed the fetal liver during the fifth week, and hematopoiesis begins there during the sixth week. This accounts for the relatively large

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size of the liver between the seventh and ninth weeks. Stem cells seed the fetal bone marrow, spleen and thymus, and lymph nodes between weeks 8 and 11. (For more information about stem cells, see https://stemcells.nih.gov.)

The antigenic factors that determine blood type are present in the erythrocytes soon after the sixth week. For this reason, the Rh- negative woman is at risk for isoimmunization in any pregnancy that lasts longer than 6 weeks after fertilization.

Respiratory System The respiratory system begins development during embryonic life and continues through fetal life and into childhood. The development of the respiratory tract begins in week 4 and continues through week 17 with formation of the larynx, trachea, bronchi, and lung buds. Between 16 and 24 weeks, the bronchi and terminal bronchioles enlarge and vascular structures and primitive alveoli are formed. Between 24 weeks and term birth, more alveoli form. Specialized alveolar cells, type I and type II cells, secrete pulmonary surfactants to line the interior of the alveoli. After 32 weeks, sufficient surfactant is present in developed alveoli to provide infants with a good chance of survival.

Pulmonary Surfactants The detection of the presence of pulmonary surfactants, surface- active phospholipids, in amniotic fluid has been used to determine the degree of fetal lung maturity, or the ability of the lungs to function after birth. Lecithin (L) is the most critical alveolar surfactant required for postnatal lung expansion. It is detectable at approximately 21 weeks and increases in amount after week 24. Another pulmonary phospholipid, sphingomyelin (S), remains constant in amount. Thus the measure of lecithin in relation to sphingomyelin, or the L/S ratio, is used to determine fetal lung maturity. When the L/S ratio reaches 2 : 1, the infant's lungs are considered to be mature. This occurs at approximately 35 weeks of gestation (Mercer, 2014).

Certain maternal conditions that cause decreased maternal placental blood flow, such as maternal hypertension, placental

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dysfunction, infection, or corticosteroid use, accelerate lung maturity. This apparently is caused by the resulting fetal hypoxia, which stresses the fetus and increases the blood levels of corticosteroids that accelerate alveolar and surfactant development.

Conditions such as gestational diabetes and chronic glomerulonephritis can slow fetal lung maturity. The use of intrabronchial synthetic surfactant in the treatment of respiratory distress syndrome in the newborn has greatly improved the chances of survival for preterm infants (see Chapter 25).

Fetal respiratory movements have been seen on ultrasound as early as week 11. These fetal respiratory movements may aid in development of the chest wall muscles and regulate lung fluid volume. The fetal lungs produce fluid that expands the air spaces in the lungs. The fluid drains into the amniotic fluid or is swallowed by the fetus.

Shortly before birth, secretion of lung fluid decreases. Absorption of lung fluid begins during labor as fetal catecholamines and endogenous steroids are released in response to labor. The normal birth process squeezes out approximately one third of the fluid. Infants born by cesarean do not benefit from this squeezing process; thus they may have more respiratory difficulty at birth. The fluid remaining in the lungs at birth is usually resorbed into the infant's bloodstream within 2 hours of birth.

Gastrointestinal System During the fourth week, the shape of the embryo changes from being almost straight to a C shape as both ends fold in toward the ventral surface. A portion of the yolk sac is incorporated into the body from head to tail as the primitive gut (digestive system).

The foregut produces the pharynx, part of the lower respiratory tract, the esophagus, the stomach, the first half of the duodenum, the liver, the pancreas, and the gallbladder. These structures evolve during the fifth and sixth weeks. Malformations that can occur in these areas include esophageal atresia, hypertrophic pyloric stenosis, duodenal stenosis or atresia, and biliary atresia (see Chapter 41).

The midgut becomes the distal half of the duodenum, the

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jejunum and ileum, the cecum and appendix, and the proximal half of the colon. The midgut loop projects into the umbilical cord between weeks 5 and 10. A malformation, omphalocele, results if the midgut fails to return to the abdominal cavity, causing the intestines to protrude from the umbilicus. Meckel diverticulum is the most common malformation of the midgut. It occurs when a remnant of the yolk stalk that failed to degenerate attaches to the ileum, leaving a blind sac.

The hindgut develops into the distal half of the colon, the rectum and parts of the anal canal, the urinary bladder, and the urethra. Anorectal malformations are the most common abnormalities of the digestive system.

The fetus swallows amniotic fluid beginning in the fifth month. Gastric emptying and intestinal peristalsis occur. Fetal nutrition and elimination needs are taken care of by the placenta. As the fetus nears term, fetal waste products accumulate in the intestines as dark-green to black, tarry meconium. Normally this substance is passed through the rectum within 24 hours of birth. Sometimes with a breech presentation or fetal hypoxia, meconium is passed in utero into the amniotic fluid. The failure to pass meconium after birth may indicate atresia somewhere in the digestive tract; an imperforate anus (Fig. 6.15); or meconium ileus, in which a firm meconium plug blocks passage (seen in infants with CF).

FIG 6.15 Anorectal malformation (imperforate anus). (From Moore, K.L., Persaud, T.V.N., Torchia, M.G. [2016]. The developing human:

Clinically oriented embryology [10th ed.]. Philadelphia, PA: Elsevier.)

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The metabolic rate of the fetus is relatively low, but the infant has great growth and development needs. Beginning in week 9, the fetus synthesizes glycogen for storage in the liver. Between 26 and 30 weeks, the fetus begins to lay down stores of brown fat in preparation for extrauterine cold stress. Thermoregulation in the neonate requires increased metabolism and adequate oxygenation (see Chapter 22).

The gastrointestinal system is mature by 36 weeks. Digestive enzymes (except pancreatic amylase and lipase) are present in sufficient quantity to facilitate digestion. The neonate cannot digest starches or fats efficiently. Little saliva is produced.

Hepatic System The liver and biliary tract develop from the foregut during the fourth week of gestation. Hematopoiesis begins during the sixth week and requires that the liver is large. The embryonic liver is prominent, occupying most of the abdominal cavity. Bile, a constituent of meconium, begins to form in the twelfth week.

Glycogen is stored in the fetal liver beginning at week 9 or 10. At term, glycogen stores are twice those of the adult. Glycogen is the major source of energy for the fetus and for the neonate stressed by in utero hypoxia, extrauterine loss of the maternal glucose supply, the work of breathing, or cold stress.

Iron is also stored in the fetal liver. If maternal intake is sufficient, the fetus can store enough iron to last for 5 months after birth.

During fetal life, the liver does not have to conjugate bilirubin for excretion because the unconjugated bilirubin is cleared by the placenta. Therefore the glucuronyl transferase enzyme needed for conjugation is present in the fetal liver in amounts less than those required after birth. This predisposes the neonate, especially the preterm infant, to hyperbilirubinemia.

Coagulation factors II, VII, IX, and X cannot be synthesized in the fetal liver because of the lack of vitamin K synthesis in the sterile fetal gut. This coagulation deficiency persists after birth for several days and is the rationale for the prophylactic administration of vitamin K to the newborn (see Chapter 23).

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Renal System The kidneys form during the fifth week and begin to function approximately 4 weeks later. Urine is excreted into the amniotic fluid and forms a major part of the amniotic fluid volume. Oligohydramnios is indicative of renal dysfunction. Because the placenta acts as the organ of excretion and maintains fetal water and electrolyte balance, the fetus does not need functioning kidneys while in utero. At birth, however, the kidneys are required immediately for excretory and acid-base regulatory functions.

A fetal renal malformation can be diagnosed in utero. Corrective or palliative fetal surgery may treat the malformation successfully, or plans can be made for treatment immediately after birth.

At term, the fetus has fully developed kidneys. However, the glomerular filtration rate (GFR) is low, and the kidneys lack the ability to concentrate urine. This makes the newborn more susceptible to both overhydration and dehydration.

Neurologic System The nervous system originates from the ectoderm during the third week after fertilization. The open neural tube forms during the fourth week. It initially closes at what will be the junction of the brain and spinal cord, leaving both ends open. The embryo folds in on itself lengthwise at this time, forming a head fold in the neural tube at this junction. The cranial end of the neural tube closes, and then the caudal end closes. During week 5, different growth rates cause more flexures in the neural tube, delineating three brain areas: the forebrain, the midbrain, and the hindbrain.

The forebrain develops into the eyes (cranial nerve II) and cerebral hemispheres. The development of all areas of the cerebral cortex continues throughout fetal life and into childhood. The olfactory system (cranial nerve I) and thalamus also develop from the forebrain. Cranial nerves III and IV (oculomotor and trochlear) form from the midbrain. The hindbrain forms the medulla, the pons, the cerebellum, and the remainder of the cranial nerves. Brain waves can be recorded on an electroencephalogram by week 8.

The spinal cord develops from the long end of the neural tube. Another ectodermal structure, the neural crest, develops into the

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peripheral nervous system. By the eighth week, nerve fibers traverse throughout the body. By week 11 or 12, the fetus makes respiratory movements, moves all extremities, and changes position in utero. The fetus can suck his or her thumb, swim in the amniotic fluid pool, and turn somersaults and can occasionally tie a knot in the umbilical cord.

At term, the fetal brain is approximately one-fourth the size of an adult brain. Neurologic development continues. Stressors on the fetus and neonate (e.g., chronic poor nutrition or hypoxia, drugs, environmental toxins, trauma, disease) damage the central nervous system long after the vulnerable embryonic time for malformations in other organ systems. Neurologic insult can result in cerebral palsy, neuromuscular impairment, intellectual disability, and learning disabilities.

Sensory Awareness Purposeful movements of the fetus have been demonstrated in response to a firm touch transmitted through the mother's abdomen. Because it can feel, the fetus requires anesthesia when invasive procedures are done.

Fetuses respond to sound by 24 weeks. Different types of music evoke different movements. The fetus can be soothed by the sound of the mother's voice. Acoustic stimulation can be used to evoke a fetal heart rate response. The fetus becomes accustomed (habituates) to noises heard repeatedly. Hearing is fully developed at birth.

The fetus is able to distinguish taste. By the fifth month, when the fetus is swallowing amniotic fluid, a sweetener added to the fluid causes the fetus to swallow faster. The fetus also reacts to temperature changes. A cold solution placed into the amniotic fluid can cause fetal hiccups.

The fetus can see. Eyes have both rods and cones in the retina by the seventh month. A bright light shone on the mother's abdomen in late pregnancy causes abrupt fetal movements. During sleep time, rapid eye movements (REMs) have been observed similar to those occurring in children and adults while dreaming.

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Endocrine System The thyroid gland develops along with structures in the head and neck during the third and fourth weeks. The secretion of thyroxine begins during the eighth week. Maternal thyroxine does not readily cross the placenta; therefore the fetus that does not produce thyroid hormones will be born with congenital hypothyroidism. If untreated, hypothyroidism can result in severe intellectual disability. Screening for hypothyroidism is typically included in newborn screening after birth.

The adrenal cortex is formed during the sixth week and produces hormones by the eighth or ninth week. As term approaches, the fetus produces more cortisol. This is believed to aid in initiation of labor by decreasing the maternal progesterone and stimulating production of prostaglandins.

The pancreas forms from the foregut during the fifth through eighth weeks. The islets of Langerhans develop during the twelfth week. Insulin is produced by week 20. In fetuses of mothers with uncontrolled diabetes, maternal hyperglycemia produces fetal hyperglycemia, stimulating hyperinsulinemia and islet cell hyperplasia. This results in a macrosomic (large) fetus. The hyperinsulinemia also blocks lung maturation, placing the neonate at risk for respiratory distress and hypoglycemia when the maternal glucose source is lost at birth. Control of the maternal glucose level before and during pregnancy minimizes problems for the fetus and infant.

Reproductive System Sex differentiation begins in the embryo during the seventh week. Female and male external genitalia are indistinguishable until after the ninth week. Distinguishing characteristics appear around the ninth week and are fully differentiated by the twelfth week. When a Y chromosome is present, testes are formed. By the end of the embryonic period, testosterone is being secreted and causes formation of the male genitalia. By week 28, the testes begin descending into the scrotum. After birth, low levels of testosterone continue to be secreted until the pubertal surge.

The female, with two X chromosomes, forms ovaries and female

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external genitalia. By the sixteenth week, oogenesis has been established. At birth, the ovaries contain the female's lifetime supply of ova. Most female hormone production is delayed until puberty. However, the fetal endometrium responds to maternal hormones, and withdrawal bleeding or vaginal discharge (pseudomenstruation) may occur at birth when these hormones are lost. The high level of maternal estrogen also stimulates mammary engorgement and secretion of fluid (“witch's milk”) in newborn infants of both sexes.

Musculoskeletal System Bones and muscles develop from the mesoderm by the fourth week of embryonic development. At that time, the cardiac muscle is already beating. The mesoderm next to the neural tube forms the vertebral column and ribs. The parts of the vertebral column grow toward each other to enclose the developing spinal cord. Ossification, or bone formation, begins. If there is a defect in the bony fusion, various forms of spina bifida can occur. A large defect affecting several vertebrae may allow the membranes and spinal cord to pouch out from the back, producing neurologic deficits and skeletal deformity.

The flat bones of the skull develop during the embryonic period, and ossification continues throughout childhood. At birth, connective tissue sutures exist where the bones of the skull meet. The areas where more than two bones meet (called fontanels) are especially prominent. The sutures and fontanels allow the bones of the skull to mold, or move during birth, enabling the head to pass through the birth canal.

The bones of the shoulders, arms, hips, and legs appear in the sixth week as a continuous skeleton with no joints. Differentiation occurs, producing separate bones and joints. Ossification will continue through childhood to allow growth. Beginning in the seventh week, muscles contract spontaneously. Arm and leg movements are visible on ultrasound examination, although the mother does not perceive them until sometime between 16 and 20 weeks.

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Integumentary System The epidermis begins as a single layer of cells derived from the ectoderm at 4 weeks. By the seventh week, there are two layers of cells. The cells of the superficial layer are sloughed and become mixed with the sebaceous gland secretions to form the white, cheesy vernix caseosa, the material that protects the skin of the fetus. The vernix is thick at 24 weeks but becomes scant by term.

The basal layer of the epidermis is the germinal layer, which replaces lost cells. Until 17 weeks, the skin is thin and wrinkled, with blood vessels visible underneath. The skin thickens, and all layers are present at term. After 32 weeks, as subcutaneous fat is deposited under the dermis, the skin becomes less wrinkled and red in appearance.

By 16 weeks, the epidermal ridges are present on the palms of the hands, the fingers, the bottoms of the feet, and the toes. These handprints and footprints are unique to that infant.

Hairs form from hair bulbs in the epidermis that project into the dermis. Cells in the hair bulb keratinize to form the hair shaft. As the cells at the base of the hair shaft proliferate, the hair grows to the surface of the epithelium. Very fine hairs, called lanugo, appear first at 12 weeks on the eyebrows and upper lip. By 20 weeks, they cover the entire body. At this time, the eyelashes, eyebrows, and scalp hair are beginning to grow. By 28 weeks, the scalp hair is longer than the lanugo, which thins and may disappear by term gestation.

Fingernails and toenails develop from thickened epidermis at the tips of the digits beginning during the tenth week. They grow slowly. Fingernails usually reach the fingertips by 32 weeks, and toenails reach toe tips by 36 weeks.

Immunologic System During the third trimester, albumin and globulin are present in the fetus. The only immunoglobulin (Ig) that crosses the placenta, IgG, provides passive acquired immunity to specific bacterial toxins. The fetus produces IgM by the end of the first trimester. This is produced in response to blood group antigens, gram-negative enteric organisms, and some viruses. IgA is not produced by the

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fetus; however, colostrum, the precursor to breast milk, contains large amounts of IgA and can provide passive immunity to the neonate who is breastfed.

The normal term neonate can fight infection, but not as effectively as an older child. The preterm infant is at much greater risk for infection.

Table 6.1 summarizes embryonic and fetal development.

TABLE 6.1 Milestones in Human Development Before Birth Since Last Menstrual Period (LMP)

4 Weeks 8 Weeks 12 Weeks External Appearance Body flexed, C shaped; arm and leg buds present; head at right angles to body

Body fairly well formed; nose flat, eyes far apart; digits well formed; head elevating; tail almost disappeared; eyes, ears, nose, and mouth recognizable

Nails appearing; resembles a human; head erect but disproportionately large; skin pink, delicate

Crown-to-Rump Measurement; Weight 0.4–0.5 cm; 0.4 g 2.5–3 cm; 2 g 6–9 cm; 19 g Gastrointestinal System Stomach at midline and fusiform; conspicuous liver; esophagus short; intestine a short tube

Intestinal villi developing; small intestines coil within umbilical cord; palatal folds present; liver very large

Bile secreted; palatal fusion complete; intestines have withdrawn from cord and assume characteristic positions

Musculoskeletal System All somites present First indication of ossification—occiput,

mandible, and humerus; fetus capable of some movement; definitive muscles of trunk, limbs, and head well represented

Some bones well outlined, ossification spreading; upper cervical to lower sacral arches and bodies ossify; smooth muscle layers indicated in hollow viscera

Circulatory System Heart develops, double chambers visible, begins to beat;

Main blood vessels assume final plan; enucleated red cells predominate in blood

Blood forming in marrow

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aortic arch and major veins completed Respiratory System Primary lung buds appear Pleural and pericardial cavities forming;

branching bronchioles; nostrils closed by epithelial plugs

Lungs acquire definite shape; vocal cords appear

Renal System Rudimentary ureteral buds appear

Earliest secretory tubules differentiating; bladder-urethra separates from rectum

Kidneys able to secrete urine; bladder expands as a sac

Nervous System Well-marked midbrain flexure; no hindbrain or cervical flexures; neural groove closed

Cerebral cortex begins to acquire typical cells; differentiation of cerebral cortex, meninges, ventricular foramina, cerebrospinal fluid circulation; spinal cord extends entire length of spine

Brain structural configuration almost complete; cord shows cervical and lumbar enlargements; fourth ventricle foramina are developed; sucking present

Sensory Organs Eye and ear appearing as optic vessel and otocyst

Primordial choroid plexuses develop; ventricles large relative to cortex; development progressing; eyes converging rapidly; internal ears developing

Earliest taste buds indicated; characteristic organization of eyes attained

Genital System Genital ridge appears (fifth week)

Testes and ovaries distinguishable; external genitalia sexless but begin to differentiate

Sex recognizable; internal and external sex organs specific

16 Weeks 20 Weeks 24 Weeks External Appearance Head still dominant; face looks human; eyes, ears, and nose approach typical appearance on gross examination; arm/leg ratio proportionate; scalp hair appears

Vernix caseosa appears; lanugo appears; legs lengthen considerably; sebaceous glands appear

Body lean but fairly well proportioned; skin red and wrinkled; vernix caseosa present; sweat glands forming

Crown-to-Rump Measurement; Weight 11.5–13.5 cm; 100 g 16–18.5 cm; 300 g 23 cm; 600 g Gastrointestinal System Meconium in bowel; some Enamel and dentine depositing; ascending

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enzyme secretion; anus open colon recognizable Musculoskeletal System Most bones distinctly indicated throughout body; joint cavities appear; muscular movements can be detected

Sternum ossifies; fetal movements strong enough for mother to feel

Circulatory System Heart muscle well developed; blood formation active in spleen

Blood formation increases in bone marrow and decreases in liver

Respiratory System Elastic fibers appear in lungs; terminal and respiratory bronchioles appear

Nostrils reopen; primitive respiratory-like movements begin

Alveolar ducts and sacs present; lecithin begins to appear in amniotic fluid (weeks 26–27)

Renal System Kidneys in position; attain typical shape Nervous System Cerebral lobes delineated; cerebellum assumes some prominence

Brain grossly formed; cord myelination begins; spinal cord ends at level of first sacral vertebra (S-1)

Cerebral cortex layered typically; neuronal proliferation in cerebral cortex ends

Sensory Organs General sense organs differentiated

Nose and ears ossify Can hear

Genital System Testes in position for descent into scrotum; vagina open

Testes at inguinal ring in descent to scrotum

28 Weeks 30–31 Weeks 36 and 40 Weeks External Appearance 36 Weeks Lean body, less wrinkled and red; nails appear

Subcutaneous fat beginning to collect; more rounded appearance; skin pink and smooth; has assumed birth position

Skin pink, body rounded; general lanugo disappearing; body usually plump 40 Weeks Skin smooth and pink; scant vernix caseosa; moderate to profuse hair; lanugo on shoulders and upper body only; nasal and alar cartilage apparent

Crown-to-Rump Measurement; Weight 36 Weeks 27 cm; 1100 g 31 cm; 1800–2100 g 35 cm; 2200–2900 g

40 Weeks

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40 cm; 3200+ g Musculoskeletal System 36 Weeks Astragalus (talus, ankle bone) ossifies; weak, fleeting movements, minimum tone

Middle fourth phalanxes ossify; permanent teeth primordia seen; can turn head to side

Distal femoral ossification centers present; sustained, definite movements; fair tone; can turn and elevate head 40 Weeks Active, sustained movement; good tone; may lift head

Respiratory System 36 Weeks Lecithin forming on alveolar surfaces

L/S ratio = 1.2 : 1 L/S ratio ≥2 : 1

40 Weeks Pulmonary branching only two- thirds complete

Renal System 36 Weeks Formation of new nephrons ceases

Nervous System 36 Weeks Appearance of cerebral fissures, convolutions rapidly appearing; indefinite sleep-wake cycle; cry weak or absent; weak suck reflex

End of spinal cord at level of third lumbar vertebra (L-3); definite sleep-wake cycle 40 Weeks Myelination of brain begins; patterned sleep-wake cycle with alert periods; cries when hungry or uncomfortable; strong suck reflex

Sensory Organs Eyelids reopen; retinal layers completed, light receptive; pupils capable of reacting to light

Sense of taste present; aware of sounds outside mother's body

Genital System 40 Weeks Testes descending to scrotum Testes in scrotum;

labia majora well developed

Multifetal Pregnancy Twins The incidence of twinning is 1 in 43 pregnancies. There has been a steady rise in multiple births since 1973, partly attributed to the availability of assisted reproductive technologies and the increasing

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age at which women give birth (Benirschke, 2014). The twin rate was at its highest incidence in 2014 but then declined in 2015 (Martin, Hamilton, Osterman, et al., 2017) . This is partly attributed to the availability of assisted reproductive technologies and the increasing age at which women give birth as well as use of ovulation-enhancing drugs (Benirschke, 2014).

Dizygotic Twins When two mature ova are produced in one ovarian cycle, both have the potential to be fertilized by separate sperm. This results in two zygotes, or dizygotic twins (Fig. 6.16). There are always two amnions, two chorions, and two placentas that may be fused (Fig. 6.17). These dizygotic or fraternal twins may be the same sex or different sexes and are genetically no more alike than siblings born at different times. Dizygotic twinning occurs in families with a history of twinning, more often among African-American women than Caucasian women, and least often among Asian-American women. Dizygotic twinning increases in frequency with maternal age up to 35 years, with parity, and with the use of fertility drugs.

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FIG 6.16 Formation of dizygotic twins. There is fertilization of two ova, two implantations, two

placentas, two chorions, and two amnions.

FIG 6.17 Diamniotic dichorionic (separate) twin placentas. (From Benirschke, K. [2014]. Multiple gestation: The biology of

twinning. In Creasy, R., Resnik, R., Iams, J., et al. [eds.]. Creasy & Resnik's

maternal-fetal medicine: Principles and practice [7th ed.] Philadelphia, PA:

Saunders.)

Monozygotic Twins Identical or monozygotic twins develop from one fertilized ovum, which then divides (Fig. 6.18). They are the same sex and have the same genotype. If division occurs soon after fertilization, two embryos, two amnions, two chorions, and two placentas that may be fused will develop. Most often, division occurs between 4 and 8 days after fertilization, and there are two embryos, two amnions, one chorion, and one placenta. Rarely, division occurs after the eighth day after fertilization. In this case, there are two embryos within a common amnion and a common chorion with one placenta. This often causes circulatory problems because the umbilical cords may tangle together and one or both fetuses may die. If division occurs very late, cleavage may not be complete and

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conjoined or “Siamese” twins may result. Monozygotic twinning occurs in approximately 3.5 to 4 per 1000 births (Benirschke, 2014). There is no association with race, heredity, maternal age, or parity. Fertility drugs increase the incidence of monozygotic twinning.

FIG 6.18 Formation of monozygotic twins. A, One fertilization: blastomeres separate, resulting in two

implantations, two placentas, and two sets of membranes. B, One blastomere with two inner cell

masses, one fused placenta, one chorion, and separate amnions. C, One blastomere with incomplete

separation of cell mass resulting in conjoined twins.

Conjoined Twins Conjoined twins are a type of monozygotic twins in which there is incomplete embryonic division at 13 to 15 days postconception (see Fig. 6.18). The estimated frequency is 1.5 in 100,000 births (Malone & D'Alton, 2014). Prenatal diagnosis is possible with three- dimensional ultrasonography. Cesarean birth minimizes trauma to

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mother and fetuses.

Other Multifetal Pregnancies The occurrence of multifetal pregnancies with three or more fetuses has increased with the use of fertility drugs and in vitro fertilization, but in 2015 it decreased by 9% from the previous year to 103.6 triplets per 100,000 births (Martin et al., 2017). They can occur from the division of one zygote into two, with one of the two dividing again, producing identical triplets. Triplets can also be produced (1) from two zygotes, one dividing into a set of identical twins and the second zygote a single fraternal sibling or (2) from three zygotes. Quadruplets, quintuplets, sextuplets, and so on have similar possible derivations.

Nongenetic Factors Influencing Development Congenital disorders may be inherited or may be caused by environmental factors or by inadequate maternal nutrition. Congenital means that the condition was present at birth. Some congenital malformations may be the result of teratogens, that is, environmental substances or exposures that result in functional or structural disability. In contrast to other forms of developmental disabilities, disabilities caused by teratogens are theoretically totally preventable. Known human teratogens are drugs and chemicals, infections, exposure to radiation, and certain maternal conditions such as diabetes and PKU (Box 6.2). A teratogen has the greatest effect on the organs and parts of an embryo during its periods of rapid growth and differentiation. This occurs during the embryonic period, specifically from days 15 to 60. During the first 2 weeks of development, teratogens either have no effect on the embryo or have effects so severe that they cause miscarriage. Brain growth and development continue during the fetal period, and teratogens can severely affect mental development throughout gestation (Fig. 6.19).

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Box 6.2 Etiology of Human Malformations Environmental

• Maternal conditions

• Alcoholism, diabetes, endocrinopathies, phenylketonuria, smoking, nutritional problems

• Infectious agents

• Rubella, toxoplasmosis, syphilis, herpes simplex, cytomegalic inclusion disease, varicella, Venezuelan equine encephalitis

• Mechanical problems (deformations)

• Amniotic band constrictions, umbilical cord constraint, disparity in uterine size and uterine contents

• Chemicals, drugs, radiation, hyperthermia

Genetic

• Single-gene disorders

• Chromosomal abnormalities

Unknown

• Polygenic/multifactorial (gene-environment interactions)

• “Spontaneous” errors of development

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• Other unknowns

Modified from Parikh, A.S., Mitchell, A.L. (2015). Congenital anomalies. In Martin, R.J., Fanaroff, A.A., Walsh, M.C. (Eds.), Fanaroff and Martin's neonatal-perinatal medicine: Diseases of the fetus and infant (10th ed.). Philadelphia, PA: Saunders.

FIG 6.19 Critical periods in human development. Dark color denotes highly sensitive periods; light color

indicates stages that are less sensitive to teratogens. CNS, Central nervous system. (From Moore, K.L., Persaud, T.V.N.,

Torchia, M.G. [2013]. Before we are born: Essentials of embryology and birth

defects [8th ed.]. Philadelphia, PA: Saunders.)

In addition to genetic makeup and the influence of teratogens, the adequacy of maternal nutrition influences development. The embryo and fetus must obtain the nutrients they need from the mother's diet; they cannot tap the maternal reserves. Malnutrition during pregnancy produces low–birth-weight (LBW) newborns who are susceptible to infection. Malnutrition also affects brain development during the latter half of gestation and can result in learning disabilities in the child. Inadequate folic acid is associated with neural tube defects.

References

541

American College of Obstetricians and Gynecologists. Family history as a risk assessment tool. Obstetrics and Gynecology. 2011;117(3):747–750.

American College of Obstetricians and Gynecologists. Update on carrier screening for cystic fibrosis. [Retrieved from] http://www.acog.org/Resources-And- Publications/Committee-Opinions/Committee-on- Genetics/Update-on-Carrier-Screening-for-Cystic-Fibrosis; 2011.

Badzek L, Henaghan M, Turner M, Monsen R. Ethical, legal, and social issues in the translation of genomics into health care. Journal of Nursing Scholarship. 2013;45(1):15–24.

Beery T. Genetic and genomic testing in clinical practice: What you need to know. Rehabilitation Nursing. 2013;39(2):1–6.

Benirschke K. Multiple gestation: The biology of twinning. Creasy R, Resnik R, Iams J, et al. Creasy and Resnik's maternal-fetal medicine: Principles and practice. 7th ed. Saunders: Philadelphia, PA; 2014.

Bodurtha J, Strauss JF. Genomics and perinatal care. New England Journal of Medicine. 2012;366(1):64–73.

Calzone KA, Jenkins J, Nicoli N, et al. Relevance of genomics to healthcare and nursing practice. Journal of Nursing Scholarship. 2013;45(1):1–2.

Centers for Disease Control and Prevention. Facts about Down syndrome. [Retrieved from] www.cdc.gov/ncbddd/birthdefects/DownSyndrome.html; 2016.

Conley Y, Biesecker LG, Gonsalves S, et al. Current and emerging technology approaches in genomics. Journal of Nursing Scholarship. 2013;45(1):5–14.

Cunningham F, Leveno K, Bloom S, et al. Williams' obstetrics. 24th ed. McGraw-Hill: New York; 2014.

DeLuca J, Zanni KL, Bonhomme N, Kemper AR. Implications of newborn screening for nurses. Journal of Nursing Scholarship. 2013;45(1):25–33.

ENCODE Project. ENCyclopedia Of DNA Elements. [National Human Genome Research Institute, National Institutes of Health, Bethesda, MD; Retrieved from]

542

https://www.genome.gov/10005107/encode-project/; 2016. Frazer KL, Porter S, Goss C. The genetics and implications of

neuromuscular diseases in pregnancy. The Journal of Perinatal & Neonatal Nursing. 2013;27(3):205–214 [quiz 215– 216].

Genetics Home Reference. What were some of the ethical, legal, and social implications addressed by the Human Genome Project?. National Library of Medicine. 2017 https://ghr.nlm.nih.gov/primer/hgp/elsi.

Genetics Home Reference. Trisomy 13. National Library of Medicine. 2017 https://ghr.nlm.nih.gov/condition/trisomy- 13#statistics.

Genetics Home Reference. Turner syndrome. National Library of Medicine. 2017 https://ghr.nlm.nih.gov/condition/turner- syndrome#genes.

Gever J. Update: Direct-to-Consumer genetic testing. Medpage Today. [Retrieved from] http://www.medpagetoday.com/genetics/genetictesting/55439 2015.

Greco KE, Tinley S, Seibert D. Essential genetic and genomic competencies for nurses with graduate degrees. [Consensus Panel, Silver Springs, MD: American Nurses Association] 2011.

Johnson NL, Giarelli E, Lewis C, Rice CE. Genomics and autism spectrum disorder. Journal of Nursing Scholarship. 2013;45(1):69–78.

Kaiser Permanente. Prenatal ultrasound findings: What is a single umbilical artery?. Kaiser Genetics Department. 2017 https://mydoctor.kaiserpermanente.org/ncal/Images/GEN_US%20SUA%20handout_tcm63- 10027.pdf.

Malone F, D'Alton M. Multiple gestation: Clinical characteristics and management. Creasy R, Resnik R, Iams J, et al. Creasy and Resnik's maternal-fetal medicine: Principles and practice. 7th ed. Saunders: Philadelphia, PA; 2014.

Manolio TA, Chisholm RL, Ozenberger B, et al. Implementing genomic medicine in the clinic: The future is here. Genetics in Medicine. 2013;15(4):258–267.

Martin JA, Hamilton BE, Osterman MJK, Driscoll AK,

543

Mathews TJ. Births: Final data for 2015. National Vital Statistics Reports. 2017;66(1):1–69.

McCarthy JJ, McLeod HL, Ginsburg GS. Genomic medicine: A decade of successes, challenges, and opportunities. Science Translational Medicine. 2013;5(189):1–17.

Mercer B. Assessment and induction of fetal pulmonary maturity. Creasy R, Resnik R, Iams J, et al. Creasy and Resnik's maternal-fetal medicine: Principles and practice. 7th ed. Saunders: Philadelphia, PA; 2014.

Moore DS. The developing genome: An introduction to behavioral epigenetics. Oxford University Press; 2015.

Moore KL, Persaud TVN, Torchia MG. Before we are born. Essentials of embryology and birth defects. 8th ed. Saunders: Philadelphia, PA; 2013.

Mor G, Abrahams V, et al. The immunology of pregnancy. Creasy R, Resnik R, Iams J. Creasy and Resnik's maternal-fetal medicine: Principles and practice. 7th ed. Saunders: Philadelphia, PA; 2014.

National Human Genome Research Institute. The cost of sequencing a human genome. [National Institutes of Health; Retrieved from] https://www.genome.gov/sequencingcosts/; 2016.

Prows CA, Hopkin RJ, Barnoy S, Van Riper M. An update of childhood genetic disorders. Journal of Nursing Scholarship. 2013;45(1):34–42.

Sole-Smith