Medicine

MEDICAL-SURGICAL PROBLEMS IN PREGNANCY

MEDICAL-SURGICAL PROBLEMS IN PREGNANCY

CARDIOVASCULAR DISORDERS

Prepared by Ass. Prof. N. Petrenko, MD, PhD

 

During a normal pregnancy, the maternal cardiovascular system undergoes many changes that put a physiologic strain on the heart. The normal heart can compensate for the increased workload, so that pregnancy, labor, and birth are generally well tolerated, whereas the diseased heart is challenged hemodynamically. If the cardiovascular changes are not well tolerated, cardiac failure can develop during pregnancy, during labor, or during the postpartum period. In addition, if myocardial disease develops, if valvular disease exists, or if a congenital heart defect is present, cardiac decompensation is anticipated

Approximately 1% of pregnancies are complicated by heart disease, and half of all heart disease cases in pregnancy are congenital heart lesions (Cunningham et al., 2001). Box 1 lists maternal cardiac disease risk groups and their related mortality rates.

 

BOX 1. MatBrnal Cardiac Disease Risk Groups

GROUP I (MORTALITY RATE 1 %)

Corrected tetralogy of Fallot

Pulmonic/tricuspid disease

Mitral stenosis (classes I and II)

Patent ductus

Ventricular septal defect

Atrial septal defect

Porcine valve

GROUP II (MORTALITY RATE 5%-15%)

Mitral stenosis with atrial fibrillation

Artificial heart valves

Mitral stenosis (classes III and IV)

Uncorrected tetralogy

Aortic coarctation (uncomplicated)

Aortic stenosis

GROUP III (MORTALITY RATE 25%-5O%)

Aortic coarctation (complicated)

Myocardial infarction

Marfan syndrome

True cardiomyopathy

Pulmonary hypertension

Source: Gilbert, E., & Harmon, J. (1998). Manual of high risk pregnancy and delivery (2nd ed.). St. Louis: Mosby.

 

The degree of disability experienced by the woman with cardiac disease often is more important in the treatment and prognosis during pregnancy than is the diagnosis of the type of cardiovascular disease. The New York Heart Association's functional classification of organic heart disease, a widely accepted standard, is as follows (New York Heart Association, 1964):

  Class I: asymptomatic at normal levels of activity

  Class II: symptomatic with increased activity

  Class III: symptomatic with ordinary activity

  Class IV: symptomatic at rest

No classification of heart disease can be considered rigid or absolute, but this one offers a basic practical guide for treatment, assuming that frequent prenatal visits, good patient cooperation, and appropriate obstetric care occur. Medical therapy is conducted as a team approach, including the cardiologist, obstetric physician, and nurses. The functional classification may change for the pregnant woman because of the hemodynamic changes that occur in the cardiovascular system, especially increased cardiac output. The functional classification of the disease is determined at 3 months and again at 7 or 8 months of gestation.

The incidence of miscarriage is increased, and preterm labor and birth are more prevalent in the pregnant woman with cardiac problems. In addition, IUGR is common, probably because of low oxygen pressure in the pregnant woman. The risk of congenital heart lesions is increased in children of mothers with congenital heart disease (Mendelson, 1997). A maternal mortality rate of more than 50% during pregnancy has been associated with pulmonary hypertension (Mendelson, 1997).


PERIPARTUM CARDIOMYOPATHY

Peripartum cardiomyopathy is congestive heart failure with cardiomyopathy found in the last month of pregnancy or in the first 5 months postpartum (Easterling & Otto, 2002). The etiology of the disease is unknown; the­ories suggest genetic predisposition, autoimmunity, and viral infections.

Peripartum cardiomyopathy is more likely to occur in African-Americans, in a woman who is 30 years old or more with a twin pregnancy, and in the presence of preeclampsia (Mendelson & Lang, 1995). Maternal mortality rate has been estimated at 25% to 50% (Easterling & Otto, 2002). Clinical findings are those of congestive heart failure (left ventricular failure). Signs include breathless-ness, tachyarrhythmias, and edema with radiologic findings of cardiomegaly. Medical management of cardiomyopathy during pregnancy includes diuretics, potassium, anticoagulants, and digitalis. Intrapartum management includes hemodynamic monitoring; epidural analgesia is ap­propriate for pain control. The prognosis is good if cardiomegaly does not persist for 6 months postpartum (Easterling & Otto, 2002).

 

RHEUMATIC HEART DISEASE

Rheumatic fever usually develops suddenly several symptom-free weeks after an inadequately treated group A beta-hemolytic streptococcal infection of the throat. Episodes of rheumatic fever create an autoimmune reaction in the heart tissue, leading to permanent damage of heart valves (usually the mitral valve) and the chordae tendineae cordis. This damage is referred to as rheumatic heart disease (RHD). RHD may be evident during acute rheumatic fever or discovered years later. Recurrences of rheumatic fever are common, each with the potential to increase the severity of heart damage. If a woman has had rheumatic fever in the past, a recurrence can occur during pregnancy, most likely early in the pregnancy. The American Heart Association recommends lifelong prophylaxis with benzathine penicillin, even during pregnancy. For those with penicillin allergies, erythromycin is an acceptable alterna­tive during pregnancy. Heart murmurs resulting from stenosis, valvular insufficiency, or thickening of the walls of the heart characterize RHD. Abnormal pulse rate and rhythm and congestive heart failure are common.

 

MITRAL VALVE STENOSIS

Mitral valve stenosis (narrowing of the opening of the mitral valve caused by stiffening of valve leaflets, which obstructs blood flow from the atrium to the ventricle) accounts for 90% of RHD seen in pregnancy (McAnulty, Metcalfe, & Ueland, 1995). As the mitral valve narrows, dyspnea worsens, occurring first on exertion and eventually at rest. A tight stenosis plus the increase in blood volume and thus cardiac output of normal pregnancy may cause ventricular failure and pulmonary edema; hemoptysis may occur.

The care of the woman with mitral stenosis typically is managed by reducing her activity, restricting dietary sodium, and increasing bed rest. The pregnant woman with mitral stenosis should be followed clinically for symptoms and by echocardiograms to monitor the atrial and ventricular size, as well as heart valve function. Prophylaxis for intrapartum endocarditis and pulmonary infections is provided.

 

MITRAL VALVE PROLAPSE

Mitral valve prolapse (MVP) is a common, usually benign, condition occurring in nearly 10% of women of reproductive age (Cunningham et al., 2001). The mitral valve leaflets prolapse into the left atrium during ventric­ular systole, allowing some backflow of blood. Midsystolic click and late systolic murmur are hallmarks of this syndrome. Most cases are asymptomatic. A few women have atypical chest pain (sharp and located in the left side of the chest) that occurs at rest and does not respond to nitrates. They may also have anxiety, palpitations, dyspnea on exertion, and syncope. Patients usually are treated with beta-blockers such as propranolol (Inderal). Pregnancy and its associated hemodynamic changes may change or alleviate the murmur and click of MVP, as well as symptoms. Pregnancy usually is well tolerated unless bacterial endocarditis occurs. As with RHD, antibiotic prophylaxis is given before invasive procedures for at-risk patients and for complicated vaginal births in patients with MVP.

 

MARFAN SYNDROME

Marfan syndrome is an autosomal dominant disorder characterized by generalized weakness of the connective tissue, resulting in joint deformities, ocular lens dislocation, and weakness of the aortic wall and root (McAnulty, Metcalfe, & Ueland, 1995). Approximately 90% of individuals with this syndrome have MVP and 25% have aortic insufficiency. There is an increased risk of aortic dissection and rupture during pregnancy. Excruciating chest pain is the most common symptom of aortic dissection. Preconception genetic counseling is recommended to make patients aware of the risks of pregnancy (Shabetai, 1999). Mortality rates may be as high as 50% in women who have significant cardiac disease. If the woman still desires to become pregnant, she should have baseline data gathered about the aortic root. Management during pregnancy is similar to women with class III and IV heart disease.

 

INFECTIVE ENDOCARDITIS

Infective endocarditis (inflammation of the innermost lining-endocardium-of the heart caused by invasion of microorganisms) is an uncommon disorder during pregnancy (Mendelson & Lang, 1995). It may be seen in women taking street drugs intravenously. Bacterial endocarditis, leading to incompetence of heart valves and thus congestive heart failure and cerebral emboli, can result in death. Treatment is with antibiotics.

 

EISENMENGER SYNDROME

Eisenmenger syndrome is a right-to-left or bidirectional shunting that can be at the atrial or ventricular level and is combined with elevated pulmonary vascular resistance (Easterling & Otto, 2002). The syndrome is associated with high mortality rates (30% to 50% in mothers and 50% in fetuses) and thus pregnancy is contraindicated (Kansaria & Salvi, 2000). Contraception is essential, and tubal ligation should be considered because oral contraceptives and intrauterine devices carry considerable risk (Mendelson & Lang, 1995). If pregnancy occurs, termination may be recommended if the woman has significant pulmonary hypertension.

In women who continue pregnancy, physical activity is strictly limited; prophylactic anticoagulation is considered (Mendelson & Lang, 1995). During labor and birth, Swan-Ganz monitoring is essential. Central hypovolemia should be avoided. Oxygen therapy is administered. There is controversy about use of epidural analgesia. If used, serial determinations of arterial oxygen concentrations should be done.


CARE MANAGEMENT

Assessment and Nursing Diagnoses

The presence of cardiac disease makes the decision to become pregnant more difficult. Planned pregnancy requires that the woman understand the peripartum risks. If the pregnancy is unplanned, the nurse needs to explore the woman's desire to continue the pregnancy after examining the risks in relation to the status of her cardiac condition. The woman's partner and family should be included in the discussion.

The pregnant woman with cardiac disease requires de­tailed assessment to determine the potential for optimal maternal health and a viable fetus throughout the peripartum period. If she chooses to continue the pregnancy, the high risk pregnant woman's condition may be assessed as often as weekly.

Interview

The nurse assesses for factors that would increase stress on the heart, such as anemia, infection, and edema, and how the woman is adapting to the physiologic changes of pregnancy. Special attention is given to the review of the cardiovascular and pulmonary systems. The nurse should determine whether the woman has experienced chest pain at rest or on exertion; edema of the face, hands, or feet; hypertension; heart murmurs; palpitations; paroxysmal nocturnal dyspnea; diaphoresis; pallor; or syncope. Pulmonary symptoms such as cough, hemoptysis, shortness of breath, and orthopnea can be signs of cardiac disease. Table 4 lists normal and abnormal cardiovascular signs during pregnancy.

 

Table 4 Cardiovascular Signs and Symptoms During Pregnancy

NORMAL

ABNORMAL

SIGNS

Neck vein pulsation

Neck vein distention

Diffuse/displaced apical pulse

Cardiomegaly; heave

Split Su accentuated S2

Loud P2; wide split of S2

Third heart sound

Summation gallop

Systolic murmur (1-2/6)

Loud systolic murmur(4-6/6)

Venous hum

Diastolic murmur

Sinus dysrhythmia

Sustained dysrhythmia

Peripheral edema

Clubbing/cyanosis

SYMPTOMS

Fatigue

Symptoms at rest

Chest pain

Exertional chest pain

Dyspnea

Exertional severe dyspnea

Orthopnea

Orthopnea (progressive)

Hyperpnea

Paroxysmal nocturnal dyspnea

Palpitations

Tachycardia (>120 beats/min); dysrhythmia

Syncope (vasovagal)

Exertional syncope

 

Adapted from Mendelson, M. (1997). Congenital cardiac disease and pregnancy. Clin Perinatal, 24(1), 467-482.

 

The nurse documents all medication taken by the woman—including over-the-counter (OTC) medications such as supplemental iron—and is alert to their potential side effects and interactions. The woman is also assessed for undue emotional stress that might further compromise her cardiac status. Examples are depression, anxiety/fear of morbidity or mortality for herself and her fetus, financial concerns related to extended hospitalization, anger be­cause of impaired social interaction, and feelings of inadequacy regarding her inability to meet family and household demands.

The woman's cultural background may affect the amount of support that she is able to receive from significant others. Family size (number of children and extended family members in the home), as well as role expectations within the family, may be dictated by cultural norms. For the woman with cardiac impairment, family expectations may prove to be a cause of major stress if she is unable to bear the expected number of children or if it is unacceptable to receive help with domestic chores.

 

SIGN of POTENTIAL COMPLICATIONS

Cardiac Decompensation

PREGNANT WOMAN: SUBJECTIVE SYMPTOMS

   Increasing fatigue or difficulty breathing, or both, with her usual activities

   Feeling of smothering

   Frequent cough

   Palpitations; feeling that her heart is "racing"

   Generalized edema: swelling of face, feet, legs, fingers (e.g., rings do not fit anymore)

NURSE: OBJECTIVE SIGNS

   Irregular, weak, rapid pulse (>100 beats/min)

   Progressive, generalized edema

   Crackles at base of lungs after two inspirations and exhalations that do not clear after coughing

   Orthopnea; increasing dyspnea

   Rapid respirations (>25 breaths/min)

   Moist, frequent cough

   Cyanosis of lips and nail beds

 

Physical assessment

Routine assessments continue during the prenatal period, including monitoring the amount and pattern of weight gain, edema, vital signs, and discomforts of pregnancy. Additionally, the woman is observed for signs of cardiac decompensation, that is, progressive generalized edema, crackles at the base of the lungs, or pulse irregularity (see Signs of Potential Complications box). Symptoms of cardiac decompensation may appear abruptly or gradually. Medical intervention must be instituted immediately to maintain optimal cardiac status. Dyspnea, palpitations, syncope, and edema occur commonly in pregnant women and can mask the symptoms of a developing or worsening cardiovascular disorder. A woman's sudden inability to perform activities that she previously was comfortable doing may indicate cardiac decompensation.

 

Laboratory and diagnostic tests

Routine urinalysis and blood work (complete blood cell count and blood chemistry) are done during the initial visit. The woman with cardiac impairment requires a baseline electrocardiogram (ECG) at the beginning of her pregnancy, if not before pregnancy, which permits vital diagnostic comparisons of subsequent ECGs. Echocardiograms and pulse oximetry studies may be performed as indicated. Chest films may be necessary during late pregnancy, provided the abdomen is carefully shielded. In addition, fetal ultrasound, fetal movement studies, or fetal nonstress tests may be used to determine fetal well-being.

 

The following nursing diagnoses may be appropriate for the pregnant woman with cardiac disease:

  Fear related to

-increased peripartum risk

  Risk for ineffective individual/family coping related to

-the woman's cardiac condition

-changes in relationships

  Risk for ineffective tissue perfusion related to

-hypotensive syndrome

  Activity intolerance related to

-cardiac condition

  Deficient knowledge related to

-cardiac condition

-pregnancy and how it affects cardiac condition -requirements to alter self-care activities

  Impaired home maintenance related to

-woman's confinement to bed or limited activity level

Self-care deficit (bathing, grooming, dressing) related to

-fatigue or activity intolerance

-need for bed rest

 

Expected Outcomes of Care

The pregnant woman with cardiovascular problems faces curtailment of her activities. These restrictions can have physical and emotional implications. The community health nurse, social worker, and physical or occupational therapist are some of the resource people whose services may need to be incorporated into the plan of care. Expected outcomes for the pregnant woman (and family, if appropriate) may include that she (they) will do the following:

  Verbalize understanding of the disorder, management, and probable outcome

  Describe her role in management, including when and how to take medication, adjust diet, and prepare for and participate in treatment

  Cope with emotional reactions to the pregnancy and infant at risk

  Adapt to the physiologic stressors of pregnancy and labor and birth

  Identify and use support systems

  Carry her fetus to the point of viability or to term

 

PLAN OF CARE AND INTERVENTIONS

Antepartum

Therapy for the pregnant woman with heart disease is focused on minimizing stress on the heart, which is greatest between 28 and 32 weeks as the hemodynamic changes reach their maximum. The workload of the cardiovascular system is reduced by appropriate treatment of any coexist­ing emotional stress, hypertension, anemia, hyperthyroidism, or obesity.

Signs and symptoms of cardiac decompensation are reviewed during the prenatal period. The woman with class

I or II heart disease requires 8 to 10 hours of sleep every day and should take 30-minute naps after eating. Her activities are restricted, with housework, shopping, and exercise limited to the amount allowed for the functional classification of her heart disease. Information on how to cope with activity limitations is important in meeting emotional needs of the woman. Referral to a support group may help the woman and her family handle stress (Lowdermilk & Grohar, 1998).

The pregnant woman with class II cardiac disease should avoid heavy exertion and should stop any activity that causes even minor signs and symptoms of cardiac decompensation. She may be admitted to the hospital near term (earlier if signs of cardiac overload or arrhythmia develop) for evaluation and treatment.

Bed rest for much of each day is necessary for pregnant women with class III cardiac disease. Approximately 30% of these women experience cardiac decompensation during pregnancy. With this possibility the woman may require hospitalization for the remainder of the pregnancy.

Because decompensation occurs even at rest in persons with class IV cardiac disease, a major initial effort must be made to improve the cardiac status of the pregnant woman in this category who chooses to continue her pregnancy (see Teaching Guidelines box).

 

TEACHING GUIDELINES

The Pregnant Woman at Risk for Cardiac Decompensation

·  Assess lifestyle patterns, emotional status, and environment of woman.

·  Arrange for consultations as needed (i.e., dietitian, home care, child care, social work).

·  Determine woman's and her family's understanding of her heart disease and how the disease affects her pregnancy.

·  Determine stressors in the woman's life. Assist woman in identifying effective coping strategies.

·  Instruct woman to report signs of cardiac decompensation or congestive heart failure: generalized edema, distention of neck veins, dyspnea, pulmonary crackles, cough, palpitations, weight gain of 2.0 kg in 1 day.

·  Instruct woman to be watchful for signs of thromboembolism, such as redness, tenderness, pain or swelling of the legs. Instruct woman to seek medical help immediately if such symptoms occur.

·  Instruct woman to avoid constipation and thus straining with bowel movements (Valsalva maneuver) by taking in adequate fluids and fiber. A stool softener may be ordered.

·  Explore with woman ways to obtain the needed rest throughout the day. Depending on the level of her cardiac disease, she may need to sleep 10 hours per night and rest 30 minutes after meals (class I or II) or rest for most of the day (class III or IV).

·  Help woman make use of community resources, including support groups, as indicated.

·  Emphasize the importance of keeping her prenatal visits.

Source: Gilbert, E., & Harmon, J. (1998). Manual of high risk pregnancy and delivery (2nd ed.). St. Louis: Mosby.

 

Infections are treated promptly because respiratory, urinary, or gastrointestinal (GI) tract infections can complicate the condition by accelerating the heart rate and by direct spread of organisms (e.g., streptococci) to the heart structure. The woman should notify her physician at the first sign of infection or exposure to an infection. Hospitalization may be required until the infection is cured. Women who have valvular disorders may receive prophylactic antibiotics against bacterial endocarditis during labor (Easterling & Otto, 2002).

Nutrition counseling is necessary, optimally with the woman's family present. The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories to gain weight. The iron supplements tend to cause constipation. The pregnant woman should increase her intake of fluids and fiber. A stool softener may be prescribed. It is important for the cardiac woman to avoid straining during defecation, thus causing the Valsalva maneuver. Sodium and fluid intake may be restricted and accompanied by careful monitoring for hyponatremia. The woman's intake of potassium is monitored to prevent hypokalemia, which is associated with heart and other muscular weakness and dysfunction.

Cardiac medications are prescribed as needed for the pregnant woman, with attention to fetal well-being. The hemodynamic changes that occur during pregnancy, such as increased plasma volume and increased renal clearance of drugs, can alter the amount of medication needed to es­tablish and maintain a therapeutic drug level.

If anticoagulant therapy is required during pregnancy, heparin should be used because this large-molecule drug does not cross the placenta. The nurse should closely monitor the woman's blood work, including clotting factors. The woman may need to learn to self-administer heparin by injection or continuous subcutaneous infusion. She also requires specific nutritional teaching to avoid foods high in vitamin K, such as raw, dark green, and leafy vegetables, which counteract the effects of the heparin. In addition, she will require a folic acid supplement.

Tests for fetal maturity and well-being, as well as placental sufficiency, may be necessary. Other therapy is directly related to the functional classification of heart disease. The nurse may need to reinforce the need for close medical supervision.

 

Intrapartum

For all pregnant women the intrapartum period is the one that evokes the most apprehension in patients and caregivers. The woman with impaired cardiac function has additional reasons to be anxious because labor and giving birth place an additional burden on her already compromised cardiovascular system.

Assessments include the routine assessments for all laboring women, as well as assessments for cardiac decompensation. In addition, arterial blood gases may be needed to assess for adequate oxygenation. A Swan-Ganz catheter may be inserted to accurately monitor hemodynamic status during labor and birth.

 

NURSE ALERT A pulse rate of 100 beats per minute or greater or respirations 25 breaths per minute or greater are a concern. Respiratory status is checked frequently for developing dyspnea, coughing, or crackles at the base of the lungs. The color and temperature of the skin are noted. Pale, cool, clammy skin may indicate cardiac shock.

 

Nursing care during labor and birth focuses on the promotion of cardiac function. Anxiety is minimized by maintaining a calm atmosphere in the labor and birth rooms. The nurse provides anticipatory guidance by keeping the woman and her family informed of labor progress and events that will probably occur, as well as answering any questions they have. The woman's childbirth prepara­tion method should be supported to the degree it is feasible for her cardiac condition. Nursing techniques that promote comfort, such as back massage, are used.

Cardiac function is supported by keeping the woman's head and shoulders elevated and body parts resting on pillows. The side-lying position usually facilitates hemodynamics during labor. Discomfort is relieved with medication and supportive care. Epidural regional anesthesia provides better pain relief than narcotics and causes fewer alterations in hemodynamics (Cunningham et al., 2001). Hypotension must be avoided.

The woman may require other types of medication (e.g., anticoagulants, prophylactic antibiotics). If evidence of cardiac decompensation appears, the physician may order deslanoside (Cedilanid-D) for rapid digitalization, furosemide (Lasix) for rapid diuresis, and oxygen by intermittent positive pressure to decrease the development of pulmonary edema.

 

Legal tip Cardiac and Metabolic Emergencies

The management of emergencies such as maternal cardiopulmonary distress or arrest or maternal meta­bolic crisis should be documented in policies, procedures, and protocols. Any independent nursing actions appropriate to the emergency should be clearly identified.

 

Beta-adrenergic agents (e.g., ritodrine, terbutaline) should not be used for tocolysis because they are associated with myocardial ischemia. Syntocinon, a synthetic oxytocin, can be used for induction of labor. This drug does not appear to cause significant coronary artery constriction in doses prescribed for labor induction or control of postpartum uterine atony.

If there are no obstetric problems, vaginal birth is recommended and may be accomplished with the woman in the side-lying position. If the supine position is used, a pad is positioned under the right hip to laterally displace the uterus and minimize the danger of supine hypotension; stirrups are usually not used. The Valsalva maneuver must be avoided when pushing because it reduces diastolic ventricular filling and obstructs left ventricular outflow. Mask oxygen is important. Episiotomy and the use of outlet forceps may be used, because these procedures also decrease the work of the heart. Cesarean birth is not routinely recommended for women who have cardiovascular disease because there is risk of dramatic fluid shifts, hemodynamic changes that are sustained, and increased blood loss.

Penicillin prophylaxis may be ordered for nonallergic pregnant women with class II or higher cardiac disease to protect against bacterial endocarditis in labor and during the early puerperium. Dilute IV oxytocin immediately after delivery of the placenta may be used to prevent post-birth hemorrhage. Ergot products should not be used because they increase blood pressure.

 

Postpartum

Monitoring for cardiac decompensation in the postpartum period is essential. The first 24 to 48 hours postpartum are the most hemodynamically difficult for the woman. Hemorrhage or infection, or both, may worsen the cardiac condition. The woman with a cardiac disorder may continue to require a Swan-Ganz catheter and arterial blood gas monitoring.

 

NURSE ALERT The immediate postbirth period is hazardous for a woman whose heart function is compromised. Cardiac output increases rapidly as extravascular fluid is remobilized into the vascular compartment. At the moment of birth intraabdominal pressure is re­duced drastically; pressure on veins is removed, the splanchnic vessels engorge, and blood flow to the heart is increased. When blood flow increases to the heart, a reflex bradycardia may result.

 

Care in the postpartum period is tailored to the woman's functional capacity. Routine postpartum assessments are done. The head of the bed is elevated, and the woman is encouraged to lie on her side. Bed rest may be ordered, with or without bathroom privileges. Progressive ambulation may be permitted as tolerated. The nurse may need to help the woman meet her grooming and hygiene needs and other activities. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluids.

The woman may need a family member to help in the care of the infant. Breastfeeding is not contraindicated, but not all women with heart disease (particularly those with life-threatening disease) will be able to do it (Lawrence, 1999). The woman who chooses to breastfeed will need the support of her family and the nursing staff to be successful. For example, the woman may need assistance in positioning herself or the infant for feeding. To further conserve the woman's energy, the infant may need to be brought to the mother and taken from her after the feeding. If the woman is unable to breastfeed and her energies do not allow her to bottle-feed the infant, the baby can be kept at the bedside so she can look at and touch her baby to establish an emotional bond with her baby with a low expenditure of energy.

Preparation for discharge is carefully planned with the woman and family. Provision of help for the woman in the home by relatives, friends, and others must be addressed. If necessary, the nurse refers the family to community resources (e.g., for homemaking services). Rest and sleep periods, activity, and diet must be planned. The couple may need information about reestablishing sexual relations and contraception or sterilization.

 

Cardiopulmonary resuscitation of the pregnant woman

Trauma, pulmonary embolism, anesthesia complications, drug overdose, hypovolemia, or septic shock may result in cardiopulmonary arrest. Preexisting disorders such as heart or pulmonary disease, hypertension, or autoim­mune collagen vascular disease increase this risk (Luppi, 1999). Some modifications of the procedure for cardiopulmonary resuscitation (CPR) (see Emergency box) are needed during pregnancy.

 

EMERGENCY

Cardiopulmonary Resuscitation for the Pregnant Woman

CARDIOPULMONARY RESUSCITATION (CPR)

Airway

Determine unresponsiveness.

Activate emergency medical system and get the auto­mated external defibrillator (AED) if available.

Position woman on flat, firm surface with uterus displaced laterally with a wedge (e.g., a rolled towel placed under her hip) or manually, or place her in a lateral position.

Open airway with head tilt-chin lift maneuver.

Breathing

Determine breathlessness (look, listen, feel).

If the woman is not breathing, give two slow breaths.

Circulation

Determine pulselessness by feeling carotid pulse.

If there is no pulse, begin chest compressions at rate of 100 per minute. Chest compressions may be performed slightly higher on the sternum if the uterus is enlarged enough to displace the diaphragm into a higher position.

After four cycles of 15 compressions and two breaths, check her pulse. If pulse is not present, continue CPR.

Defibrillation

Use an AED according to standard protocol to analyze heart rhythm and deliver shock if indicated.

Relief of Foreign-body Airway Obstruction

If the pregnant woman is unable to speak or cough, perform chest thrusts. Stand behind the woman and place your arms under her armpits to encircle her chest. Press backward with quick thrusts until the foreign body is expelled (Fig. 5). If the woman be­comes unresponsive, follow the steps for victims who become unresponsive, but use chest thrusts instead of abdominal thrusts.

From Stapleton, E. et al. (2001). Fundamentals of BLS for healthcare providers. Dallas: American Heart Association.

 

Fig. 5 Heimlich maneuver. Clearing airway obstruction in woman in late stages of pregnancy (can also be used in markedly obese victim).

A, Standing behind victim, place your arms under woman's armpits and across chest. Place thumb side of your clenched fist against middle of sternum, and place other hand over fist.

B, Perform backward chest thrusts until foreign body is expelled or woman becomes unconscious. If pregnant woman becomes unconscious because of foreign body airway obstruction, place her on her back and kneel close to victim's side. (Be sure uterus is displaced laterally by using, for example, a rolled blanket under her hip.) Open mouth with tongue-jaw lift, perform finger sweep, and attempt rescue breathing. If unable to ventilate, position hands as for chest compression. Deliver five chest thrusts firmly to remove obstruction. Repeat above sequence of Heimlich maneuver, finger sweep, and attempt to ventilate. Continue above sequence until pregnant woman's airway is clear of obstruction or help has arrived to relieve you (Stapleton et al., 2001). If woman is unconscious, give chest compressions as for woman without pulse.

 

 

Various protocols exist for CPR during pregnancy. The most widely used guide is the American Heart Association (AHA) Advanced Cardiac Life Support Protocol (AHA, 1992). This protocol recommends 5 to 10 minutes of standard CPR with the uterus displaced laterally, fluid volume restoration, and defibrillation if indicated. If these measures are not successful within 15 minutes of the arrest, open chest heart massage is recommended if the fetus is viable. If there is still no change in maternal status after 15 minutes of open chest cardiac massage or there is fetal distress, immediate cesarean birth is recom­mended. Some protocols recommend cesarean birth within 5 minutes (Kloeck et al., 1997); others recommend cesarean birth based on the gestational age of the fetus (Luppi, 1999). No matter what protocol is used, nurses and other health care providers must be prepared if CPR is to be successful.

In the event of cardiac arrest, standard resuscitative efforts with a few modifications are implemented. To prevent supine hypotension, the pregnant woman is placed on a firm surface with the uterus displaced laterally either manually or with a wedge or rolled blanket or towel under one hip (Association of Women's Health, Obstetric and Neonatal Nurses, 1998; Stapleton et al., 2001). If defibrillation is needed, the paddles must be placed one rib interspace higher than usual because the heart is displacedslightly by the enlarged uterus. If possible, the fetus should be monitored during the cardiac arrest (Bajo, 1997).

Complications may be associated with CPR of a pregnant woman. These complications may include laceration of the liver, rupture of the uterus, hemothorax, or hemoperitoneum. Fetal complications, including cardiac arrhythmia or asystole related to maternal defibrillation and medications, CNS depression related to antiarrhythmic drugs and inadequate uteroplacental perfusion, and onset of preterm labor, may also occur.

If there is successful resuscitation, the woman and her fetus must receive careful monitoring. The woman remains at increased risk for recurrent pulmonary arrest and ar rhythmias (ventricular tachycardia, supraventricular tachycardia, bradycardia). Therefore her cardiovascular, pul­monary, and neurologic status should be assessed continuously. Uterine activity and resting tone must be monitored. Fetal status and gestational age should be determined and used in decision making regarding the continuation of the pregnancy or the timing and route of birth.

 

EVALUATION

The nurse uses the previously stated expected outcomes as criteria to evaluate the care of the woman with cardiac disease (see Plan of Care).


 

PLAN OF CARE

NURSING DIAGNOSIS Activity intolerance related to effects of pregnancy on the patient with rheumatic heart disease with mitral valve stenosis

Expected Outcome Woman will verbalize a plan to change lifestyle throughout pregnancy in order to avoid risk of cardiac decompensation.

Nursing Interventions/Rationales

Assist patient to identify factors that decrease activity toler­ance and explore extent of limitations to establish a baseline for evaluation.

Help woman to develop an individualized program of activity and rest, taking into account the living and working environment as well as support of family and friends to maintain sufficient cardiac output.

Teach woman to monitor physiologic response to activity, (i.e., pulse rate, respiratory rate) and reduce activity that causes fatigue or pain to maintain sufficient cardiac output and prevent potential injury to fetus.

Enlist family and friends to assist woman in pacing activities and to provide support in performing role functions and self-care activities that are too strenuous to increase chances of compliance with activity restrictions.

Suggest that woman maintain an activity log that records activities, time, duration, intensity, and physiologic response to evaluate effectiveness of and adherence to activity program.

Discuss various quiet diversional activities which could be done by the woman to decrease the potential for boredom during rest periods.

 

NURSING DIAGNOSIS Risk for ineffective thera­peutic regimen management related to woman's first pregnancy and perceived sense of wellness

Expected Outcome Woman will participate in an effective therapeutic regimen for pregnancy complicated by heart disease.

Nursing Interventions/Rationales

Identify factors, such as insufficient knowledge about the effect of cardiac disease on pregnancy which could inhibit the woman from participating in a therapeutic regime to promote early interventions, such as teaching about the importance of rest.

Teach woman and family about factors such as lack of rest or not taking prescribed medications that could adversely affect the pregnancy to provide information and promote empowerment over the situation.

Encourage expression of feelings about the disease and its potential effect on the pregnancy to promote a sense of trust.

Identify resources in the community to provide a shared sense of common experiences.

Encourage woman to verbalize her plan for carrying out the regime of care to evaluate the effects of teaching.

 

NURSING DIAGNOSIS Decreased cardiac output related to increased circulatory volume secondary to pregnancy and cardiac disease

Expected Outcome The woman will exhibit signs of adequate cardiac output (i.e., normal pulse and blood pressure, normal heart and breath sounds, normal skin color, tone, and turgor, normal capillary refill, normal urine output, and no evidence of edema).

Nursing Interventions/Rationales

Reinforce the importance of activity/rest cycles to prevent cardiac complications.

Plan with woman a frequent visit schedule to caregiver to provide adequate surveillance of high risk pregnancy.

Teach woman to lie in lateral position to increase uteroplacental blood flow and to elevate legs while sitting to promote venous return.

Monitor intake and output and check for edema to assess for renal complications or venous return problems.

Monitor FHR and fetal activity, perform NST as indicated to assess fetal status and detect uteroplacental insufficiency

 

 


ANEMIA

Anemia is the most common medical disorder of pregnancy, affecting at least 20% of pregnant women. Anemia results in reduction of the oxygen-carrying capacity of the blood. Because the oxygen-carrying capacity of the blood is decreased, the heart tries to compensate by increasing the cardiac output. This effort increases the workload of the heart and stresses ventricular function. Therefore ane­mia that occurs with any other complication (e.g., preeclampsia) may result in congestive heart failure.

An indirect index of the oxygen-carrying capacity is the packed red blood cell (RBC) volume, or hematocrit level. The normal hematocrit range in nonpregnant women is 38% to 45%. However, normal values for pregnant women with adequate iron stores may be as low as 34%. This has been explained by hydremia (dilution of blood), or the physiologic anemia of pregnancy.

At or near sea level, the pregnant woman is anemic when her hemoglobin level is less than 11 g/dl or hematocrit is less than 33%. In areas of high altitude, much higher values indicate anemia; for example, at 1500 m (5000 feet) above sea level, a hemoglobin level less than 14 g/dl indicates anemia (Pagana & Pagana, 2001).

When a woman has anemia during pregnancy, the loss of blood at birth, even if minimal, is not well tolerated. She is at an increased risk for requiring blood transfusions. Women with anemia have a higher incidence of puerperal complications, such as infection, than do pregnant women with normal hematologic values.

Nursing care of the anemic pregnant woman requires that the nurse be able to distinguish between the normal physiologic anemia of pregnancy and the disease states. Approximately 90% of cases of anemia in pregnancy are of the iron deficiency type. The remaining 10% of cases em­brace a considerable variety of acquired and hereditary anemias, including folic acid deficiency, sickle cell anemia, and thalassemia.

 

IRON DEFICIENCY ANEMIA

Pathologic anemia of pregnancy is mainly due to iron deficiency. Without iron therapy even pregnant women who enjoy excellent nutrition will end pregnancy with an iron deficit because iron for the fetus comes from the maternal serum (Duffy, 1995). Diet alone cannot replace gestational iron losses. Inadequate nutrition without therapy will certainly mean iron deficiency anemia during late pregnancy and the puerperium.

Successful iron therapy during pregnancy can be carried out in most cases with oral iron supplements (e.g., ferrous sulfate, 30 to 60 mg per day). It is important to teach the woman the significance of the iron therapy. In addition, it is necessary to instruct the woman in dietary ways to decrease GI side effects of iron. Some pregnant women cannot tolerate the prescribed oral iron because of nausea and vomiting. In such cases the woman should receive parenteral iron such as an iron-dextran complex (Imferon) (Duffy, 1995).

 

FOLATE DEFICIENCY

Even in well-nourished women, it is common to have a folate deficiency. Poor diet, cooking with large volumes of water, or home canning of food (especially vegetables) may lead to folate deficiency. Malabsorption may play a part in the development of anemia caused by a lack of folic acid. Folic acid deficiency anemia is common in multiple gestations. Periconception folate deficiency has been associated with increases in the incidence of neural tube defects, cleft lip, and cleft palate (March of Dimes, 1999). During preg­nancy the recommended daily intake is 600 /Ag of folic acid per day; women who have a deficiency may need a supplement.

 

SICKLE CELL HEMOGLOBINOPATHY

Sickle cell hemoglobinopathy is a disease caused by the presence of abnormal hemoglobin in the blood. Sickle cell trait (SA hemoglobin pattern) is sickling of the RBCs but with a normal RBC life span, and it usually causes only mild clinical symptoms. Sickle cell anemia (sickle cell disease) is a recessive, hereditary, familial hemolytic anemia that affects those of African-American or Mediterranean ancestry. These individuals usually have abnormal hemoglobin types (SS or SC). Beginning in childhood, persons with sickle cell anemia have recurrent attacks (crises) of fever and pain in the abdomen or extremities. These attacks are attributed to vascular occlusion (from abnormal cells), tissue hypoxia, edema, and RBC destruction. Crises are associated with normochromic anemia, jaundice, reticulocytosis, a positive sickle cell test, and the demonstration of abnormal hemoglobin (usually SS or SC).

Almost 10% of African-Americans in North America have the sickle cell trait, but fewer than 1% have sickle cell anemia. The anemia often is complicated by iron and folic acid deficiency.

Women with sickle cell trait usually do well in preg­nancy although they are at increased risk for urinary tract infections and may be deficient in iron (Kilpatrick & Laros, 1999). If the woman has sickle cell anemia, the anemia that occurs in normal pregnancies may aggravate the condition and bring on more crises. Fetal complications include being small for gestational age, IUGR, and skeletal changes. Pregnant women with sickle cell anemia are prone to pyelonephritis, leg ulcers, bone abnormalities, strokes, car-diomyopathy, congestive heart failure, and preeclampsia. UTIs and hematuria are common. An aplastic crisis may follow serious infection. Transfusions of the woman have been the usual treatment for symptomatic patients; however, partial exchange transfusions or prophylactic transfusions are common as well and significantly reduce the number of painful crises (Kilpatrick & Laros, 1999).

 

THALASSEMIA

Thalassemia (Mediterranean or Cooley's anemia) is a rela­tively common anemia in which an insufficient amount of hemoglobin is produced to fill the RBCs. The condition eventually manifests itself in severe bone deformities caused by massive marrow tissue expansion (Letsky, 1995). For the infant born with severe thalassemia, death from cardiac failure is common (Letsky, 1995). Thalassemia is a hereditary disorder that involves the abnormal synthesis of the alpha or beta chains of hemoglobin. Beta-thalassemia is the more common variety in the United States and often is diagnosed in persons of Italian, Greek, southern Chinese, Mediterranean, North African, African-American, Middle Eastern, southern Asian, or Indo-Pakistani de­scent. The unbalanced synthesis of hemoglobin leads to premature RBC death, resulting in severe anemia. Thalassemia major is the homozygous form of this disorder; thalassemia minor is the heterozygous form. Couples with the thalassemia trait should seek genetic counseling.

Thalassemia major complicates pregnancy. Preeclampsia is more common and there may be an increase in low-birth-weight infants and fetal death. The frequency of fetal distress from hypoxia is higher in women with thalassemia major. Thalassemia minor may cause a mild persistent anemia but usually does not compromise pregnancy (Kilpatrick & Laros, 1999). Pregnant patients are managed similarly to those who have sickle cell disease.


MWDICAL_SURGICAL PROBLEMS IN PREGNANCY

PULMONARY DISORDERS

As pregnancy advances and the uterus impinges on the thoracic cavity, any pregnant woman may experience increased respiratory difficulty. This difficulty will be compounded by pulmonary disease.

 

ASTHMA

Bronchial asthma is an acute respiratory illness characterized by periods of exacerbations and remissions. Exacerbations are triggered by allergens, marked change in ambient temperature, or emotional tension. In many cases the actual cause may be unknown, although a family history of allergy is common. In response to stimuli, there is widespread but reversible narrowing of the hyperreactive airways, making it difficult for the woman to breathe. The clinical manifestations are expiratory wheezing, productive cough, thick sputum, and dyspnea.

Approximately 0.4% to 1.3% of pregnant women have asthma (Gilbert & Harmon, 1998); however, it is the most common respiratory condition affecting pregnancy. Preg­nancy does not make the woman more prone to asthmatic attacks. Women often experience few symptoms of asthma in the first trimester and in the last weeks of pregnancy. The severity of symptoms usually peaks between 29 and 36 weeks of gestation (Burton & Reyes, 2001).

Therapy for asthma has three objectives: (1) relief of the acute attack, (2) prevention or limitation of later attacks, and (3) adequate maternal and fetal oxygenation. These goals can be achieved in pregnancy by eliminating environmental triggers (e.g., dust mites, animal dander, pollen), drug therapy (e.g., bronchodilators, antiinflammatory agents), and patient education. Respiratory infections should be treated and mist or steam inhalation employed to aid expectoration of mucus. Acute episodes may require albuterol, steroids, aminophylline, beta-adrenergic agents, and oxygen. Almost all asthma med­ications are considered safe in pregnancy (Burton & Reyes, 2001).

Asthma attacks can occur in labor; thus medications for asthma are continued in labor and postpartum. Pulse oximetry should be instituted during labor. Epidurals are recommended for pain relief. Morphine and meperidine are histamine-releasing narcotics and should be avoided (Burton & Reyes, 2001).

During postpartum, women who have asthma are at in­creased risk for hemorrhage. If excessive bleeding occurs, oxytocin is the recommended drug. The woman usually returns to her prepregnancy asthma status within 3 months after giving birth.

 

CYSTIC FIBROSIS

Cystic fibrosis is a common autosomal recessive genetic disorder in which the exocrine glands produce excessive viscous secretions causing problems with both respiratory and digestive functions. Respiratory failure and early death (early twenties) may occur. Genetic counseling is encouraged to identify carriers of the disease.

In women with good nutrition, mild obstructive lung disease, and good chest x-rays, pregnancy is tolerated well (Hilman, Aitken, & Constantinescu, 1996). In those with severe disease, the pregnancy is often complicated by chronic hypoxia and frequent pulmonary infections. Women with cystic fibrosis show a decrease in their residual volume during pregnancy, as do normal pregnant women, and are unable to maintain vital capacity. Presumably the pulmonary vasculature cannot accommodate the increased cardiac output of pregnancy. The results are decreased oxygen to the myocardium, decreased cardiac output, and increased hypoxemia. A pregnant woman with less than 50% of expected vital capacity usually has a difficult pregnancy. Increased risk of maternal and perinatal mortality is related to severe pulmonary infection.

During labor, monitoring for fluid and electrolyte balance is required. The amount of sodium lost through sweat can be significant, and hypovolemia can occur. Conversely, if any degree of cor pulmonale is present, fluid overload is a concern. Oxygen is administered by face mask during labor, and monitoring by pulse oximetry is recommended (Hilman, Aitken, & Constantinescu, 1996). Epidural or local analgesia is the preferred analgesic for birth.

Breastfeeding appears to be safe as long as the sodium content of the milk is not abnormal (Lawrence, 1999). Pumping and discarding the milk is done until the sodium content has been determined.


INTEGUMENTARY DISORDERS

The skin surface may exhibit many physiologic and pathologic conditions during pregnancy. Dermatologic disorders induced by pregnancy include melasma (chloasma), herpes gestationis, noninflammatory pruritus of pregnancy, vascu­lar "spiders," palmar erythema, and epulis (tumors on the gingiva). Skin problems generally aggravated by pregnancy are acne vulgaris (acne) (in the first trimester), erythema multiforme, herpetiform dermatitis (fever blisters and genital herpes), granuloma inguinale (Donovan bodies), condylomata acuminata (genital warts), neurofibromatosis (von Recklinghausen disease), and pemphigus. Dermatologic disorders usually improved by pregnancy include acne vulgaris (in the third trimester), seborrheic dermatitis (dandruff), and psoriasis. An unpredictable course during pregnancy may be expected in atopic dermatitis, lupus ery-thematosus, and herpes simplex.

 

NURSE ALERT Isotretinoin (Accutane), commonly prescribed for cystic acne, is highly teratogenic. There is a risk for craniofacial, cardiac, and CNS malformations in exposed fetuses. This drug should not be taken during pregnancy.

 

Explanation, reassurance, and commonsense measures should suffice for normal skin changes. In contrast, disease processes during and soon after pregnancy may be extremely difficult to diagnose and treat.


NEUROLOGIC DISORDERS

The pregnant woman with a neurologic disorder needs to deal with potential teratogenic effects of prescribed medications, changes of mobility during pregnancy, and ability to care for the baby. The nurse should be aware of all drugs the woman is taking and the associated potential for producing congenital anomalies. As the pregnancy progresses, the woman's center of gravity shifts and causes balance and gait changes. The nurse should advise the woman of these expected changes and suggest safety measures as ap­propriate. Family and community resources may be needed to provide care for the neurologically impaired woman.

 

EPILEPSY

Epilepsy is a disorder of the brain causing recurrent seizures and is the most common neurologic disorder ac­companying pregnancy (Cartlidge, 1995). Epilepsy may result from developmental abnormalities or injury, as well as having no known cause. Convulsive seizures may be more frequent or severe during complications of pregnancy, such as edema, alkalosis, fluid-electrolyte imbalance, cerebral hypoxia, hypoglycemia, and hypocalcemia. However, the effects of pregnancy on epilepsy are unpredictable: some women have no change or even a decrease in seizure frequency (Gilmore, Pennell, & Stern, 1998).

The differential diagnosis between epilepsy and eclampsia may pose a problem. Epilepsy and eclampsia can coexist. However, a history of seizures and a normal plasma uric acid level, as well as the absence of hypertension, gen­eralized edema, or proteinuria, point to epilepsy.

During pregnancy, the risk of vaginal bleeding is dou­bled, and there is a threefold risk of abruptio placentae. Abnormal presentations are more common in labor and birth, and there is an increased possibility that the fetus will experience seizures in utero (Aminoff, 1999).

Metabolic changes in pregnancy usually alter pharmacokinetics. In addition, nausea and vomiting may interfere with ingestion and absorption of medication. Failure to take medications is a common factor leading to worsening of seizure activity during pregnancy. This is largely due to the message that drugs for epilepsy are harmful to the fetus (Gilmore, Pennell, & Stern, 1998). Teratogenicity of antiepileptic drugs (AEDs) has been described thoroughly, but the risk of occurrence of anomalies in the fetus has been exaggerated. Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects (Gilmore, Pennell, & Stern, 1998). AEDs prescribed in pregnancy should be monotherapeutic and should be used in the smallest therapeutic dose. Daily folic acid supplementa­tion is important because of the depletion that occurs when taking anticonvulsants (Cartlidge, 1995).

 

MULTIPLE SCLEROSIS

Multiple sclerosis (MS), a patchy demyelinization of the spinal cord and CNS, may be a viral disorder. MS has a greater prevalence in females and is more common during the childbearing years, between ages 20 and 40 years (Cartlidge, 1995). Infertility, miscarriage, stillbirth, and fetal anomalies do not appear to be increased in women with MS (Eggum, 2001).

MS may occasionally complicate pregnancy, but exacerbations and remissions are unrelated to the pregnant state. Some women experience flare-up in the third trimester and the postpartum period, whereas others have fewer symptoms. Bowel and bladder problems, increased difficulty in walking, and fatigue may be more pronounced in women with MS. Medications such as interferon /3-la (Avonex), interferon beta /3-lb (Betaseron), and glatiramer acetate (Copaxone) that are given to reduce the frequency and intensity of attacks and slow the progression of disease should not be taken during pregnancy. Breastfeeding is contraindicated if these medications are resumed after the birth (National Women's Health Resource Center, 2001). Nursing care of the pregnant woman with MS is similar to the care of the normal pregnant woman.

 

BELL'S PALSY

The incidence of Bell's palsy (idiopathic facial paralysis) in pregnancy is approximately 57 per 100,000 per year. The incidence usually peaks during the third trimester and the puerperium (Cartlidge, 1995).

No effects of maternal Bell's palsy have been observed in infants. Maternal outcome is generally good unless there is a complete block in nerve conduction. Steroids sometimes are prescribed for the condition, but they do not has­ten recovery. In most affected women, 90% or more of facial function can be expected to return (Cunningham et al., 2001). Supportive care includes prevention of injury to the exposed cornea, facial muscle massage, careful chewing and manual removal of food from inside the affected cheek, and reassurance that return of neurologic function is likely.

 


AUTOIMMUNE DISORDERS

Autoimmune disorders make up a large group of diseases that disrupt the function of the immune system of the body. In these types of disorders the body develops antibodies that attack its normally present antigens, causing tis­sue damage. Autoimmune disorders have a predilection for women in their reproductive years; therefore associations with pregnancy are not uncommon (Bennett & Brown, 1999). Pregnancy may affect the disease process. Some disorders adversely affect the course of pregnancy or are detrimental to the fetus. Autoimmune disorders of concern in pregnancy are systemic lupus erythematosus and immunologic thrombocytopenic purpura.

 

SYSTEMIC LUPUS ERYTHEMATOSUS

One of the most common serious disorders of childbearing age, systemic lupus erythematosus (SLE) is a chronic, multisystem inflammatory disease characterized by autoimmune antibody production that affects the skin, joints, kidneys, lungs, CNS, liver, and other body organs (Bennett & Brown, 1999). The exact cause is unknown, but viral infection and hormonal and genetic factors may be related.

Early symptoms, such as fatigue, weight loss, skin rashes, and arthralgias, may be overlooked. Pericarditis is often the initial symptom. Eventually all organs become involved. The condition is characterized by a series of exacerbations and remissions.

If the diagnosis has been established and the woman desires a child, she is advised to wait until she has been in remission for at least 6 months before attempting to get pregnant (Gilbert & Harmon, 1998). An exacerbation of SLE during pregnancy or postpartum often occurs. Women are at increased risk for complications such as preeclampsia, HELLP syndrome, and preterm labor (Bennett & Brown, 1999).

Medical therapy is kept to a minimum in women who are in remission or who have a mild form of SLE. Antiinflammatory drugs such as prednisone and aspirin may be used. Immunosuppressive drugs are not recommended during pregnancy but may be used in some situations when there is more risk in not treating SLE. Nursing care focuses on early recognition of signs of SLE exacerbation and pregnancy complications, education and support of the woman and her family, and assessment of fetal well-being.

Vaginal birth is preferred, but cesarean birth is common because of maternal and fetal complications. During labor, efforts are aimed at reducing the risk of infection, which is the leading cause of death in women with SLE.

During the postpartum period, the mother should rest as much as possible to prevent an exacerbation of SLE. Breastfeeding is encouraged unless the mother is on immunosuppressive agents. Women with SLE should limit their number of pregnancies because of increased adverse perinatal outcomes, as well as the guarded maternal prognosis (Cunningham et al., 2001). Family planning is important. Oral contraceptives are used with caution because vascular disease commonly accompanies SLE; however, progestin implants have no known effects on flare-ups of lupus. Intrauterine devices may increase the risk of infection. Barrier methods are the safest option (Bennett & Brown, 1999).


GASTROINTESTINAL DISORDERS

Compromise of GI function during pregnancy is a concern. Obvious physiologic alterations, such as the greatly enlarged uterus, and less apparent changes, such as hormonal differences and hypochlorhydria (deficiency of hydrochloric acid in the stomach's gastric juice), require understanding for proper diagnosis and treatment. Gallbladder disease and inflammatory bowel disease are two GI disorders that may occur during pregnancy.

 

CHOLELITHIASIS AND CHOLECYSTITIS

Women are twice as likely to have cholelithiasis (presence of gallstones in the gallbladder) as men (Baker, 1995), and pregnancy seems to make the woman more vulnerable to gallstone formation (see Self-Care box). Decreased muscle tone allows gallbladder distention, thickening of the bile, and prolonged emptying time. Increased progesterone levels result in a slight hypercholesterolemia. Multiparous obese women are usually without symptoms.

 

Patient Instructions for Self-Care

Nutrition for the Pregnant Woman with Cholecystitis or Cholelithiasis

Assess diet for foods that cause discomfort and flatulence and omit foods that trigger episodes.

Reduce dietary fat intake of 40 to 50 g per day.

Limit protein to 10% to 12% of total calories.

Choose foods so that most of the calories come from carbohydrates.

Prepare food without adding fats or oils as much as possible.

Avoid fried foods

 

 

Women with acute cholecystitis (inflammation of the gallbladder) usually have colicky abdominal pain in the right upper quadrant and nausea and vomiting, especially after eating a meal high in fat. Fever and an increased leukocyte count may also be present. Ultrasound is often used to detect the presence of stones or for dilation of the common bile duct (Samuels, 2002).

The woman with cholelithiasis or cholecystitis in the first trimester should be treated conservatively with IV flu­ids, bowel rest, nasogastnc suctioning, and antibiotics. Meperidine or atropine alleviates ductal spasm and pain. Generally, gallbladder surgery should be postponed until the puerperium.

 

INFLAMMATORY BOWEL DISEASE

Treatment of inflammatory bowel disease is the same for the pregnant woman as it is for the nonpregnant woman. Medicines include prednisone and sulfasalazine. Vitamin and folic acid supplementation is especially important be­cause of problems with malabsorption. Effects of inflam­matory bowel disease on pregnancy are usually minimal; however, if the woman is severely debilitated, miscarriage, preterm birth, or fetal death can occur.


HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNODEFICIENCY SYNDROME

Infection with the human immunodeficiency virus (HIV) and the resultant acquired immunodeficiency syndrome (AIDS) are increasingly occurring in women. Although HIV and AIDS have been traditionally associated with homosexual populations, women are now the  fastest growing population of persons with HIV and AIDS in the United States. Approximately 7000 pregnancies per year are complicated by HIV infection (Minkoff, 1999). Women of color are disproportionately affected; approximately 75% of HIV-infected women in the United States are African-American or Hispanic (Duff, 2002). This section addresses management of the pregnant woman who is HIV positive or has developed full-blown AIDS. See Chapter 5 for more information about the diagnosis and management of nonpregnant women with HIV and Chapter 27 for a discussion of HIV and AIDS in infants.

 

PRECONCEPTION COUNSELING

Pregnancy is not encouraged in HIV-positive women; however, many women who have HIV do get pregnant. Preconception counseling is recommended because exposure to the virus has a significant impact on the pregnancy, neonatal feeding method, and neonatal health status. HIVpositive women should be counseled about use of contraceptive methods to decrease the chance of unintended pregnancy, the risk of perinatal transmission and possible obstetric complications, initiation of or change in antiretroviral therapy if pregnancy occurs, and the need to be evaluated for presence of opportunistic infections. HIVpositive women should be encouraged to seek prenatal care immediately if they suspect pregnancy to maximize chances for a positive outcome.

 

PREGNANCY RISKS

Perinatal transmission

Approximately 90% of all pediatric AIDS cases are due to transmission of the virus from mother to child during 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. Factors that increase the likelihood of perinatal viral transmission are listed in Box 2.

 

BOX 2 Factors That Increase the Risk of Perinatal HIV Transmission

• Previous history of a child with HIV infection

• AIDS

• Preterm birth

• Decreased maternal CD4 count

• Firstborn twin

• Chorioamnionitis

• Intrapartum blood exposure

• Failure to treat mother and fetus with zidovudine during the perinatal period

From Perinatal HIV Guidelines Working Group. (2001). Public Health Service Task Force recommendations: Use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States [Online]. Available atwww.hivatis.org. Accessed May 4, 2001.

 

The frequency of perinatal transmission has been reported from a low of 5% to 10% to a high of 50% to 60%. The incidence has declined since 1994 when the U.S. Public Health Service recommended routine voluntary prenatal testing for HIV and treatment of HIV-infected women with the antiviral drug zidovudine (AZT) during pregnancy and intrapartum and treatment of their infants for the first 6 weeks of life with zidovudine (Lindegren et al., 1999). Planned cesarean birth at 38 weeks of gestation for women on zidovudine therapy has further reduced transmission rates (ACOG Committee on Obstetric Practice, 1999); thus women with HIV should be given the option of having a scheduled cesarean birth.

 

Obstetric complications

It is difficult to determine obstetric risk in persons with HIV infection because many confounding variables are often present. Many HIV-positive women also suffer from drug and alcohol addiction, poor nutrition, limited access to prenatal care, or concurrent STIs. HIV-positive women are probably at risk for preterm labor and birth, PROM, IUGR, perinatal mortality, and postpartum endometritis (Duff, 2002).

 

Antepartum care

HIV counseling and testing should be offered to all women at their initial entry into prenatal care (Centers for Disease Control and Prevention, 1998). Most states in the United States have enacted legislation to ensure that this is offered. Identification of HIV-positive pregnant women is especially important, because antepartum and intrapartum antiviral drug therapy has been shown to greatly decrease the risk of viral transmission to the fetus (see Research box).

 

RESEARCH

Pregnant Women's Perspectives on HIV Screening in Pregnancy

Screening for human immunodeficiency virus (HIV) in pregnancy can be valuable for detecting disease and initiating treatment to prevent transmission from mother to fetus. However, the testing interval can be anxiety provoking, and a positive result can be a devastating shock to a woman who is poorly prepared for the result. Women's attitudes about prenatal HIV screening vary: women may approve of testing others, but do not feel they need it; they may claim or assume they have been tested in the past when they have not; many do not return for results.

In this Canadian study, a nurse researcher interviewed 32 pregnant women who were offered HIV screening about their thoughts about this procedure. Of these women, 21 consented to screening and 11 declined. None of the women screened were found to be HIV positive. Themes that emerged from analysis of the interviews included the following:

• Many women were surprised to find out that HIV screening was optional.They had received little or no written information or discussion about HIV or what happened if a positive result were found.

• Many who consented to screening decided to have the test for the baby's benefit.Those that declined the test had tested negative in the past.

• A minority of women worried about the outcome of the test while awaiting the results. Some asked about the results; others were more passive, assuming they would be told if anything was wrong.

• Attitudes about screening varied. Some felt it was foolish not to test. Some felt it should be on par with other tests, such as syphilis. Others worried about intimidation and erosion of choice.

IMPLICATION FOR PRACTICE

There is evidence that if an HIV-positive pregnant woman is treated with antiretroviral drugs and offered a planned cesarean birth near term, the risk of maternalfetal transmission of HIV is greatly reduced. However, this study suggests that information about HIV screening given to pregnant women varies and may not provide the woman with sufficient information to make an informed decision. Nurses in prenatal clinics and physicians' offices need to review their policies and procedures about how information about screening is provided to patients. Risks and benefits of both screening and available treatments need to be discussed. If the woman is fully informed, the nurse can understand and support her decision, knowing that whatever the woman decides, it is the right choice for her

Source: Katz, A. (2001). HIV screening in pregnancy: What women think. J Obstet Gynecol Neonatal Nurs, 30(2), 184-191.

 

HIV-infected women should also be tested for other STIs, such as gonorrhea; syphilis; chlamydial infection; hepatitis B, C, and D; and herpes. Cytomegalovirus and toxoplasmosis antibody testing should be done because both infections can cause significant maternal and fetal complications and can be successfully treated with antimicrobial agents. Any history of vaccination and immune status should be documented, and chickenpox (varicella) and rubella titers should be determined. A tuberculin skin test should be performed; a positive test necessitates a chest xray film to identify active pulmonary disease. A Papanicolaou (Pap) smear should also be done (Duff, 2002).

All HIV-infected women who have been informed about the risks and benefits of antiretroviral therapy and have made a decision to take the medication should be treated with zidovudine or other antiretroviral drug during pregnancy, regardless of their CD4 counts (Perinatal HIV Guidelines Working Group, 2001). Zidovudine, administered orally, is usually started after the first trimester and continued throughout pregnancy. The major side effect of this drug is bone marrow suppression; periodic hematocrit, white blood cell count, and platelet count assessments should be performed (Duff, 2002). Women with CD4 counts less than 200 cells/mm3 should receive prophylactic treatment for Pneumocystis carinii pneumonia with daily trimethoprim-sulfamethoxazole (Duff, 2002). Any other opportunistic infections should be treated with medications specific for the infection; often dosages must be higher for women with HIV infection or AIDS.

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. The HIV-infected woman needs nutritional support and counseling about diet choices, food preparation, and food handling. Weight gain or maintenance in pregnancy is a challenge with the HIV-infected patient. The infected patient is counseled regarding safer sex techniques. Use of condoms is encouraged to minimize further exposure to HIV if her partner is the source. Orogenital sex is discouraged.

 

Intrapartum care

Several therapy regimens are available. The standard has been IV zidovudine, although there are ongoing clinical trials testing other antiretroviral drugs. A loading dose is initiated on the woman's admission in labor, followed by a continuous maintenance dose throughout labor. If a cesarean birth is to be performed, IV zidovudine is started 3 hours before the surgery is scheduled (Perinatal HIV Guidelines Working Group, 2001).

Every effort should be made during the birthing process to decrease the neonate's exposure to infected maternal blood and secretions. If feasible, the membranes should be left intact until the birth. Women who give birth within 4 hours after membrane rupture are less likely to transmit the virus to their neonates than women who experience a longer interval between rupture and birth (Gilbert & Harmon, 1998). Fetal scalp electrode and scalp pH sampling should be avoided, because these procedures may result in inoculation of the virus into the fetus. Likewise, the use of forceps or vacuum extractor should be avoided when possible.

 

Postpartum and newborn care

Immediately after birth, infants should be wiped free of all body fluids and then bathed as soon as they are in stable condition. All staff members working with the mother or infant must adhere strictly to infection control techniques and observe Standard Precautions for blood and body fluid.

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 hemorrhage or infection. 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 (Perinatal HIV Guidelines Working Group, 2001).

After the initial bath, the newborn can be with the mother after birth, but breastfeeding is discouraged because of possible HIV transmission in breast milk. In planning for discharge, comprehensive care and support services will need to be arranged. Support services such as case management, child care, and respite care may be needed by the family. Contraception and safer sex practices may need to be reviewed. The woman and her infant are usually referred to physicians who are experienced in the treatment of HIV and associated conditions (Perinatal HIV Guidelines Working Group, 2001).


SUBSTANCE ABUSE

Substance abuse refers to the continued use of substances despite related problems in physical, social, or interpersonal areas (American Psychiatric Association, 2000). Recurrent abuse results in failure to fulfill major role obligations, and there may be substance-related legal problems. Any use of alcohol or illicit drugs during pregnancy is considered abuse (American Psychiatric Association, 2000). Chapter 4 discusses the commonly abused illicit and prescription drugs, and Chapter 27 discusses neonatal effects of maternal substance abuse. This discussion focuses on care of the pregnant woman who is a substance abuser.

The damaging effects of alcohol and illicit drugs on pregnant women and their unborn babies are well documented. Alcohol and other drugs easily pass from a mother to her baby through the placenta. Smoking during pregnancy has serious health risks, including bleeding complications, miscarriage, stillbirth, prematurity, low birth weight, and sudden infant death syndrome (National Women's Health Resource Center, 1998). Congenital abnormalities have occurred in infants of mothers who have taken drugs (Stuart & Laraia, 1998; Woods, 1998). The safest pregnancy is one in which the woman is drug and alcohol free.

Pregnant women who abuse substances commonly have little understanding of the ways in which these substances affect them, their pregnancies, or their babies. Often, pregnant mothers who use psychoactive substances receive negative feedback from society, as well as from health care providers, who may not only condemn them for endangering the life of their fetus, but may even withhold support as a result (Selleck & Redding, 1998). Substance-abusing women are often viewed as sexually promiscuous, weak willed, negligent of their children, and irresponsible in their decision to bear more children (Finkelstein, 1994). Numerous studies have reported that lack of services for mothers and children together and lack of child care and children's treatment are major barriers to treatment for substanceabusing mothers (Finkelstein, 1994).


 

CARE MANAGEMENT

The care needed by each woman varies according to her particular circumstances and the substance(s) abused. However, the nursing process is similar for all.

Every pregnant woman should be screened, at least verbally, for substance abuse. Ideally, drug and alcohol use should be identified at the first prenatal visit so that intervention can begin early in pregnancy. Unfortunately, this ideal situation often does not occur. Women who are heavily involved in substance abuse often receive no prenatal care or make only a limited number of visits beginning late in pregnancy.

During the initial prenatal visit, questions about smoking, alcohol, and drug use should be incorporated into the overall prenatal history. Because women frequently deny or greatly underreport usage when asked directly about drug or alcohol consumption, it is crucial that the nurse display a nonjudgmental and matter-of-fact attitude while taking the history m order to gain the woman's trust and elicit a reasonably accurate estimate (Cefalo & Moos, 1995). Information about drug use should be obtained by asking first about the woman's intake of OTC and prescribed medications. Next, her usage of "legal" drugs, such as caffeine, nicotine, and alcohol, should be ascertained. Finally, the woman should be questioned about her use of illicit drugs, such as cocaine, heroin, and marijuana.

Screening for alcohol use is commonly done through the use of self-reporting questionnaires. Urine screening is unreliable because alcohol is undetectable within a few hours following ingestion (Russell et al., 1996). Screening questionnaires generally ask about consequences of heavy drinking, alcohol intake, or both. The Michigan Alcoholism Screening Test (MAST) and the CAGE test are two well-known screens that are often used. Two screening tests, the T-ACE (Box 3) and the TWEAK, have been developed to screen specifically for alcohol use during pregnancy (Russell, et al., 1996).

 

BOX 3 T-ACE Test

• How many drinks can you hold before getting sleepy or passing out? (TOLERANCE)

• Have people ANNOYED you by criticizing your drinking?

• Have you ever felt you ought to CUT DOWN on your drinking?

• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

(EYE-OPENER)

Scoring:Two points are given for theTOLERANCE question for the ability to hold at least a six pack of beer or a bottle of wine. A "yes" answer to any of the other questions receives one point. An overall score of &2 indicates a high probability that the woman is a risk drinker.

Source: Hankin, J., & Sokol, R. (1995). Identification and care of problems associated with alcohol ingestion in pregnancy. Semin Perinatal, /3(4), 286.

 

Urine toxicology testing is often performed to screen for illicit drug use. Drugs may be found in urine days to weeks after ingestion, depending on how quickly they are metabolized and excreted from the body. Meconium (from the neonate) and hair can also be analyzed to determine past drug use over a longer period of time (Gilbert & Harmon, 1998).

Because of the risks to the unborn children, pregnant women who abuse substances may now face criminal charges under expanded interpretations of child abuse and drug-trafficking statutes. Some states prosecute pregnant women on charges of child abuse because they became pregnant while addicted to drugs. Some policy makers have proposed that pregnant women who abuse substances should be jailed, placed under house arrest, or committed to psychiatric hospitals for the remainder of their pregnancies (Stuart & Laraia, 1998). Women's health nurses can play a positive role by advocating primary prevention programs for women and counseling and treatment programs for those women already addicted.

 

LEGAL TIP  Drug Testing During Pregnancy

There is no requirement in the United States for a health care provider to test either the pregnant woman or the newborn for the presence of drugs. However, nurses need to know the practices of the states in which they are working. In some states a woman whose urine drug screen test is positive at the time of labor and birth must be referred to child protective services. If the mother is not in a drug treatment program or is judged unable to provide care, the infant may be placed in foster care. In all states, the U.S. Supreme Court has ruled that it is unlawful to test for drug use without the pregnant woman's permission (Gottlieb, 2001).

 

Although the ideal long-term outcome is total abstinence, it is not likely that the woman will either desire or be able to stop alcohol and drug use suddenly. Indeed, it may be harmful to the fetus for her to do so. In some situations, the goal may be to decrease substance use, and short-term outcomes will be necessary.

Intervention with the pregnant substance abuser begins with education about specific effects on pregnancy, the fetus, and the newborn for each drug used. Consequences of perinatal drug use should be clearly communicated and abstinence recommended as the safest course of action. Women are frequently more receptive to making lifestyle changes during pregnancy than at any other time in their lives (Selleck & Reddick, 1998). The casual, experimental, or recreational drug user is frequently able to achieve and maintain sobriety when she receives education, support, and continued monitoring throughout the remainder of the pregnancy. Periodic screening throughout pregnancy of women who have admitted to drug use may help them to continue abstinence (Gilbert & Harmon, 1998).

Treatment for the substance abuse will be individualized for each woman depending on the type of drug used and the frequency and amount of use. Smoking cessation programs (see Chapter 9) can be successful in decreasing low birth weight, and quitting even in the second and third trimesters can be beneficial to the fetus (Lumley, Oliver, & Waters, 2000; Maloni, 2001). Detoxification, short-term inpatient or outpatient treatment, long-term residential treatment, aftercare services, and self-help support groups are all possible options for alcohol and drug abuse. Women for Sobriety may be a more helpful organization for women than Alcoholics Anonymous or Narcotics Anonymous, which were developed for men who abuse substances (Saulnier, 1996). In general, long-term treatment of any sort is becoming increasingly more difficult to obtain, particularly for women who lack insurance coverage. Although some programs allow a woman to keep her children with her at the treatment facility, far too few of them are available to meet the demand (Gilbert & Harmon, 1998).

Alcohol withdrawal treatment consists of the administration of benzodiazepines, an improvement in the woman's nutritional intake (folic acid and other vitamins), and psychotherapy. Detoxification with disulfiram (Antabuse) is not used in pregnant women because of its teratogenic effects (Woods, 1998).

Methadone treatment for pregnant women dependent on heroin or other narcotics is controversial. If women withdraw from heroin during pregnancy, blood flow to the placenta is impaired. The substitution of methadone for the heroin not only promotes withdrawal from heroin but also does not cause impaired blood flow to the placenta. However, methadone can cause detrimental fetal effects, and withdrawal from it after birth can be worse for the newborn than heroin withdrawal (Gilbert & Harmon, 1998; Stuart & Laraia, 1998).

Although cocaine is powerfully psychologically addictive, use of the drug does not result in physical dependence. Therefore women who abuse cocaine can stop its use abruptly without developing symptoms of withdrawal. Most cocaine abusers will need a great deal of assistance, such as an alcohol and drug treatment program, individual or group counseling, and participation in self-help support groups, to successfully accomplish this major lifestyle change.

Because of the lifestyle often associated with drug use, substance-abusing women are at risk for STIs, including HIV. Laboratory assessments will likely include screening for STIs such as gonorrhea and chlamydial infection and antibody determinations for hepatitis B and HIV. A chest x-ray film may be taken to assess for pulmonary problems such as hilar lymphadenopathy, pulmonary edema, bacterial pneumonia, and foreign-body emboli. A skin test to screen for tuberculosis may also be ordered.

Initial and serial ultrasound studies are usually performed to determine gestational age, because the woman may have had amenorrhea as a result of her drug use or may not know when her last menstrual period occurred. Because of concerns about stillbirth, an increased frequency of the birth of infants who are small for gestational age, and the potential for hypoxia, nonstress testing may be done in the third trimester.

Although substance abusers may be difficult to care for at any time, they are often particularly challenging during the intrapartum and postpartum periods because of manipulative and demanding behavior. Typically, these women display poor control over their behavior and a low threshold for pain. Increased dependency needs and poor parenting skills may also be apparent.

Nurses must understand that substance abuse is an illness and that these women deserve to be treated with patience, kindness, consistency, and firmness when necessary. Even women who are actively abusing drugs will experience pain during labor and after giving birth and may need pain medication, as well as nonpharmacologic interventions. It is helpful to develop a standardized plan of care so that patients have limited opportunities to play staff members against each other. Mother-infant attachment should be promoted by identifying the woman's strengths and reinforcing positive maternal feelings and behaviors. Staffing should be sufficient to ensure strict surveillance of visitors and prevent unsupervised drug use.

Advice regarding breastfeeding must be individualized. Although all abused substances appear in breast milk, some in greater amounts than others (Brody, Larner, & Minneman, 1998), breastfeeding is definitely contraindicated in women who use amphetamines, alcohol, cocaine, heroin, or marijuana. The baby's nutrition and safety needs are of primary importance in this consideration. For some women, a desire to breastfeed may provide strong motivation to achieve and maintain sobriety.

Smoking can interfere with the let-down reflex. Women who smoke in the postpartum period and breastfeed should avoid smoking for two hours before a feeding to minimize the nicotine in the milk and improve the letdown reflex. Mothers should also be discouraged from smoking in the same room with the infant because exposure to secondhand smoke can increase the likelihood of the infant experiencing behavioral and respiratory health problems (Lawrence, 1999; March of Dimes, 2000).

Before a known substance abuser is discharged with her baby, the home situation is assessed to determine that the environment is safe and that someone will be available to meet the infant's needs if the mother proves unable to do so. Usually, the hospital's social services department will be involved in interviewing the mother before discharge to ensure that the infant's needs will be met. Sometimes family members or friends will be asked to become actively involved with the mother and infant after discharge. A home care or public health nurse may be asked to make home visits to assess the mother's ability to care for the baby and provide guidance and support. If serious questions about the infant's well-being exist, the case will probably be referred to the state's child protective services agency for further action.