Maternal Child Nursing Care in Canada 3rd edition [Third edition] 9780323759199, 9780323549387

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Lisa Keenan-Lindsay, RN, MN, PNC(C)

US 6th Edition Authors

Professor, School of Nursing Seneca College of Applied Arts and Technology Toronto, Ontario

Maternity

Cheryl A. Sams, RN, BScN, MSN

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

Professor Emerita, School of Nursing Seneca College of Applied Arts and Technology Toronto, Ontario

Constance (Connie) O’Connor, MN, RN(EC) Nurse Practitioner Ehlers-Danlos Syndrome (EDS) Clinic & Connective Tissue Disorders Program The Hospital for Sick Children (SickKids®) Toronto, Ontario

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

Mary Catherine (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

Pediatrics 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 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

PERRY’S MATERNAL CHILD NURSING CARE IN CANADA, THIRD EDITION

ISBN: 978-0-323-75919-9

Copyright © 2022 by Elsevier, Inc. All rights reserved. Adapted from Maternal Child Nursing Care, Sixth Edition, by Shannon E. Perry, Marilyn J. Hockenberry, Deitra Leonard Lowdermilk, David Wilson, Mary Catherine (Kitty) Cashion, Cheryl C. Rodgers, Kathryn Rhodes Alden, and associate editor, Ellen Olshansky. Copyright © 2018 Elsevier Inc. All rights reserved. Previous editions copyrighted 2014, 2010, 2006, 2002, and 1998. 978-0-323-54938-7 (hardcover) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Reproducing passages from this book without such written permission is an infringement of copyright law. Requests for permission to make copies of any part of the work should be mailed to: College Licensing Officer, access ©, 1 Yonge Street, Suite 1900, Toronto, ON M5E 1E5. Fax: (416) 868-1621. All other inquiries should be directed to the publisher, www.elsevier.com/permissions. Every reasonable effort has been made to acquire permission for copyrighted material used in this text and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings.

Notice 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.

Library of Congress Control Number: 2021947669 We are honoured to have received permission to reproduce the work “A Mother’s Love,” by Order of Canada award-winning Indigenous artist, Maxine Noel (Ioyan Mani), for the cover of this third Canadian edition of Perry’s Maternal Child Nursing Care in Canada. Maxine has lent her voice and art to projects to improve the health and well-being of Indigenous women and girls, in projects related to maternal and infant health and, in collaboration with the Native Women’s Association of Canada (NWAC), in their work to raise awareness of the brutal dangers facing Indigenous women. “A Mother’s Love” Copyright © MAXINE NOEL, ARTIST, COURTESY OF CANADIAN ART PRINTS AND WINN DEVON ART GROUP, INC.

Managing Director, Global ERC: Kevonne Holloway Senior Content Strategist (Acquisitions): Roberta A. Spinosa-Millman Director, Content Development Manager: Laurie Gower Content Development Specialist: Lenore Gray Spence Publishing Services Manager: Julie Eddy Senior Project Manager: Abigail Bradberry Copy Editor: Jerrolyn Hurlbutt Design Direction: Brian Salisbury Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1

CONTENTS About the Authors, xxiii Contributors, xxv Reviewers, xxvii Preface, xxix Acknowledgements, xxxiii

Theories as Guides to Understanding and Working With Families, 17 Family Assessment, 18 Family Nursing as Relational Inquiry, 19 Cultural factors related to health, 20 Multiculturalism in Canada, 20 Cultural Context of the Family, 21 Providing Culturally Competent Nursing Care, 21 Spirituality, 23 Communication, 23 Personal Space, 24 Time Orientation, 24 Family Roles, 24 Key points, 25 References, 26 Additional resources, 26

PART 1 Maternal Child Nursing UNIT 1 Introduction to Maternal Child Nursing 1

Contemporary Perinatal and Pediatric Nursing in Canada, 2 Erica Hurley

2

Perinatal and pediatric nursing, 2 The history and context of health care in Canada, 2 Contemporary issues and trends, 3 Social Determinants of Health, 3 Trauma- and Violence-Informed Care, 6 Adverse Childhood Experiences, 7 Indigenous People, 7 Lesbian/Gay/Bisexual/Transsexual/Queer/2-Spirited (LGBTQ2) Health, 7 Culture, 8 Integrative Healing and Alternate Health Practices, 8 High-Technology Care, 8 Social Media, 8 Health Literacy, 9 Specialization and evidence-informed nursing practice, 9 Evidence-Informed or Research-Based Practice, 9 Standards of Practice and Legal Issues in Delivery of Care, 10 Patient Safety and Risk Management, 10 Interprofessional Education, 10 Global health, 10 Sustainable Development Goals, 10 Ethical issues in maternal child nursing, 12 Ethical Guidelines for Nursing Research, 12 Key points, 12 References, 13 Additional resources, 14 The Family and Culture, 15 Karen MacKinnon Originating US Chapter by Shannon E. Perry

The family in cultural and community context, 15 The Family in Society, 15 Defining Family, 15 Family Dynamics, 16 Family nursing, 17

3

Community Care, 27 Judy Buchan

Roles and Functions of Community Health Nurses, 28 Core Competencies, 28 Public Health Decision Making, 28 Community Health Promotion, 29 Communities, 31 Community Nursing Process, 31 Implications for Nursing, 34 Home Care in the Community, 35 Patient Selection and Referral, 35 Nursing Care, 35 Phone and Online Health Support, 37 Key Points, 38 References, 38 Additional Resources, 39

PART 2 Perinatal Nursing UNIT 2 Introduction to Perinatal Nursing 4

Perinatal Nursing in Canada, 42 Lisa Keenan-Lindsay

Perinatal services in canada, 42 Family-centred maternity and newborn care, 44 Promoting Healthy and Normal Birth, 44 Caring for Families, 45 Providing Care in a Culturally Safe Manner, 45 Care Environment, 47 Perinatal health indicators: the canadian perinatal surveillance system, 48 Childbirth-Related Mortality Rate, 49 Maternal Morbidity, 49 Trends in Fertility and Birth Rate, 49 Multiple Birth Rate, 49

vii

viii

CONTENTS

Preterm Birth and Birth Weight, 49 Health Service Indicators, 50 Current issues affecting perinatal nursing practice, 50 Health Inequities Within Perinatal Populations, 50 Interprofessional Care, 51 Breastfeeding in Canada, 51 Community-Based Care, 51 Global Health, 52 Key points, 52 References, 52 Additional resources, 53

6

Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky

UNIT 3 Women’s Health 5

Health Promotion, 54 Kerry Lynn Durnford Originating US Chapter by Ellen F. Olshansky

Reasons for entering the health care system, 54 Wellness Care Across the Lifespan, 54 Approaches to care at specific stages during the lifespan, 56 Fertility Control and Infertility, 56 Preconception Counselling and Care, 56 Pregnancy, 56 Menstrual Concerns, 56 Perimenopause and Menopause, 56 Barriers to receiving health care, 56 Financial Issues, 57 Cultural Issues, 58 Gender Issues, 58 Risk factors that impact health, 58 Substance Use, 58 Nutrition, 61 Lack of Exercise, 62 Stress, 63 Depression, Anxiety, and Other Mental Health Conditions, 63 Sleep Disorders, 63 Environmental and Workplace Hazards, 64 Sexual Practices, 64 Medical Conditions, 64 Gynecological Conditions, 65 Female Genital Cutting, 65 Human Trafficking, 65 Intimate Partner Violence, 65 Health promotion and illness prevention, 68 Health Screening for Women Across the Lifespan, 68 Health teaching, 70 Domains of Learning, 70 Adult Learning, 70 Learning Styles, 70 Teaching Methods, 71 Factors That Influence Learning, 72 Key points, 72 References, 72 Additional resources, 74

Health Assessment, 75

7

Health assessment, 75 History, 75 Physical Examination, 77 Cultural Considerations and Communication Variations in History and Physical, 77 Adolescents (Ages 13 to 19), 78 Women With Disabilities, 78 Women at Risk for Abuse, 78 Transsexuality, 79 Breast Assessment, 79 Pelvic Examination, 79 Laboratory and Diagnostic Procedures, 84 Key points, 84 References, 84 Additional resources, 84 Reproductive Health, 85 Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky

8

Female reproductive system, 85 External Structures, 85 Internal Structures, 86 The Bony Pelvis, 88 Breasts, 89 Menstruation, 90 Menarche and Puberty, 90 Menstrual Cycle, 90 Concerns related to the menstrual cycle, 92 Amenorrhea, 92 Dysmenorrhea, 93 Premenstrual Syndrome, 96 Endometriosis, 97 Alterations in Cyclic Bleeding, 98 Abnormal Uterine Bleeding, 99 Perimenopause and menopause, 99 Infections, 100 Sexually Transmitted Infections, 100 Sexually Transmitted Bacterial Infections, 103 Sexually Transmitted Viral Infections, 107 Vaginal Infections, 112 Concerns of the breast, 114 Benign Problems, 114 Cancer of the Breast, 115 Key points, 118 References, 118 Additional resources, 120 Infertility, Contraception, and Abortion, 121 Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky

Infertility, 121 Incidence, 121 Factors Associated With Infertility, 121 Nursing Care, 123 Nonmedical Treatments, 126 Medical Therapy, 126

CONTENTS

Assisted Human Reproduction, 127 LGBTQ2 Couples, 129 Adoption, 129 Contraception, 129 Nursing Care, 130 Methods of Contraception, 130 LGBTQ2 Issues Regarding Contraception, 145 Abortion, 145 Nursing Care, 145 First-Trimester Abortion, 146 Second-Trimester Abortion, 147 Emotional Considerations Regarding Abortion, 147 Key points, 147 References, 147 Additional resources, 148

11

Nancy Watts Originating US Chapter by Kathryn R. Alden

UNIT 4 Pregnancy 9

Genetics, Conception, and Fetal Development, 149 Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky

10

Genetics, 149 Relevance of Genetics to Nursing, 150 Gene Identification and Genetic Testing, 150 Clinical Genetics, 151 Patterns of Genetic Transmission, 154 Genetic Counselling, 155 Nongenetic Factors Influencing Development, 157 Process of conception, 157 Cell Division, 157 Gametogenesis, 157 Conception, 159 Implantation, 160 The embryo and fetus, 160 Primary Germ Layers, 160 Development of the Embryo, 160 Membranes, 162 Amniotic Fluid, 163 Yolk Sac, 163 Umbilical Cord, 163 Placenta, 163 Fetal Maturation, 165 Multifetal Pregnancy, 169 Key points, 173 References, 174 Additional resources, 174 Anatomy and Physiology of Pregnancy, 175 Lisa Keenan-Lindsay Originating US Chapter by Kathryn R. Alden

Obstetrical terminology, 175 Pregnancy tests, 176 Adaptations to pregnancy, 177 Signs of Pregnancy, 177 Reproductive System and Breasts, 177 General Body Systems, 182 Key points, 191 References, 191

Nursing Care of the Family During Pregnancy, 192

12

Confirmation of pregnancy, 192 Signs and Symptoms, 192 Estimating Date of Birth, 193 Adaptation to pregnancy, 193 Maternal Adaptation, 193 Paternal Adaptation, 195 Adaptation to Parenthood for the Nonpregnant Partner, 196 Sibling Adaptation, 196 Grandparent Adaptation, 197 Nursing care, 198 Initial Visit, 199 Follow-up Visits, 203 Nursing Interventions, 206 Variations in Prenatal Care, 219 Perinatal care choices, 222 Physicians, 222 Midwives, 223 Doula, 223 Birth Setting Choices, 223 Prenatal education, 225 Childbirth Education Classes, 225 Birth Plans, 226 Key points, 226 References, 226 Additional resources, 228 Maternal Nutrition, 229 Jennifer Buccino Originating US Chapter by Ellen F. Olshansky

13

Preconception nutrition, 229 Nutrient needs during pregnancy, 230 Energy Needs, 230 Protein, 233 Fluids, 233 Omega-3 Fatty Acids, 233 Minerals, Vitamins, and Electrolytes, 234 Weight Gain, 236 Nutritional Concerns During Pregnancy, 238 Nursing Care, 239 Key points, 243 References, 243 Additional resources, 244 Pregnancy Risk Factors and Assessment, 245 Nancy Watts Originating US Chapter by Kitty Cashion

Definition and scope of high-risk pregnancy, 245 Determinants of Health as Risk Factors, 246 Regionalization of Health Care Services, 246 Assessment of risk factors, 246 Mental Health Concerns, 246 Intimate Partner Violence (IPV) During Pregnancy, 248 Reducing Infant Morbidity and Mortality, 249

ix

x

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CONTENTS

Antepartum testing in the first and second trimester, 249 Prenatal Screening, 249 Biochemical Assessment, 253 Third-trimester assessment for fetal well-being, 256 Fetal Movement Counting, 257 Antepartum Assessment Using Electronic Fetal Monitoring, 257 Ultrasound for Fetal Well-Being, 260 Nursing role in antenatal assessment for risk, 261 Psychological Considerations, 261 Key points, 263 References, 263 Additional resources, 264 Pregnancy at Risk: Gestational Conditions, 265

15

Melanie Basso Originating US Chapter by Kitty Cashion

Metabolic disorders, 307 Diabetes Mellitus, 307 Pregestational Diabetes Mellitus (PGDM), 309 Thyroid Disorders, 317 Cardiovascular disorders, 318 Congenital Cardiac Diseases, 319 Acquired Cardiac Disease, 320 Ischemic Heart Disease, 321 Other Cardiac Conditions, 321 Nursing Care, 323 Antepartum, 323 Intrapartum, 324 Postpartum, 325 Obesity, 325 Antepartum Risks, 326 Nursing Care, 326 OTHER MEDICAL CONDITIONS IN PREGNANCY, 326 Anemia, 326 Pulmonary Disorders, 328 Integumentary Disorders, 330 Neurological Disorders, 331 Autoimmune Disorders, 333 Spinal Cord Injury, 335 Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome, 335 Substance use, 337 Barriers to Treatment, 337 Legal Considerations, 337 Nursing Care, 338 Key points, 339 References, 340 Additional resources, 342

Melanie Basso Originating US Chapter by Kitty Cashion

Hypertensive disorders in pregnancy, 265 Significance and Incidence, 265 Definition of Hypertensive Disorder of Pregnancy, 265 Morbidity and Mortality, 266 Classification, 266 Nursing Care, 270 Gestational diabetes mellitus, 276 Maternal and Fetal Risks, 276 Screening for Gestational Diabetes Mellitus, 276 Nursing Care, 276 Hyperemesis gravidarum, 278 Etiology, 278 Clinical Manifestations, 279 Nursing Care, 279 Hemorrhagic disorders, 280 Early Pregnancy Bleeding, 280 Late Pregnancy Bleeding, 288 Clotting Disorders in Pregnancy, 293 Infections acquired during pregnancy, 295 Sexually Transmitted Infections, 295 Urinary Tract Infections, 295 Nonobstetrical surgery during pregnancy, 296 Appendicitis, 296 Intestinal Obstruction, 297 Cholelithiasis and Cholecystitis, 297 Gynecological Concerns, 297 Nursing Care, 297 Trauma during pregnancy, 298 Maternal Physiological Characteristics, 298 Fetal Physiological Characteristics, 299 Mechanisms of Trauma, 300 Collaborative Care, 300 Cardiopulmonary Resuscitation of the Pregnant Patient, 302 Perimortem Caesarean Birth, 304 Key points, 304 References, 304 Additional resources, 306

Pregnancy at Risk: Pre-existing Conditions, 307

UNIT 5 Childbirth 16

Labour and Birth Processes, 343 Lisa Keenan-Lindsay Originating US Chapter by Kitty Cashion

Factors affecting labour, 343 Passenger, 343 Passageway, 346 Powers, 348 Position of the Labouring Patient, 350 Process of labour, 350 Signs Preceding Labour, 350 Onset of Labour, 351 Stages of Labour, 351 Mechanism of Labour, 351 Physiological adaptation to labour, 353 Fetal Adaptation, 353 Adaptation of Labouring Person, 353 Key points, 354 References, 355

CONTENTS

17

Nursing Care of the Family During Labour and Birth, 356 Karen Pike Originating US Chapter by Kitty Cashion

18

First stage of labour, 356 Nursing Care During Prelabour and the First Stage of Labour, 357 Supportive Care During Labour and Birth, 373 Emergency Interventions, 378 Second stage of labour, 378 Nursing Care During the Second Stage of Labour, 379 Mechanism of Birth: Vertex Presentation, 385 Perineal Trauma Related to Childbirth, 385 Water Birth, 389 Immediate Assessments and Care of the Newborn, 389 Third stage of labour, 390 Nursing Care During the Third Stage of Labour, 390 Umbilical Cord Blood Banking, 392 Fourth stage of labour, 393 Nursing Care During the Fourth Stage of Labour, 393 Family–Newborn Relationships, 394 Key points, 395 References, 395 Additional resources, 397 Maximizing Comfort During Labour and Birth, 398 Laura Payant Originating US Chapter by Kitty Cashion

19

Pain during labour and birth, 398 Neurological Origins, 398 Perception of Pain, 399 Expression of Pain, 399 Factors Influencing Pain Response, 399 Nonpharmacological Pain Management, 402 Pharmacological Pain Management, 407 Nursing Care, 417 Key points, 422 References, 422 Additional resources, 423 Fetal Health Surveillance During Labour, 424 Lauren B. Rivard

Fetal health surveillance, 424 Basis for monitoring, 424 Fetal Response, 424 Uterine Activity, 425 Fetal Assessment, 426 Monitoring techniques, 426 Intermittent Auscultation, 427 Electronic Fetal Monitoring, 429 Admission Fetal Monitor Strips, 432 Fetal heart rate patterns, 432 Baseline Fetal Heart Rate, 432 Fetal Heart Rate Variability, 434 Periodic and Episodic Changes in Fetal Heart Rate, 434

20

xi

Nursing Care, 440 Additional Methods of Assessment and Intervention, 442 Fetal Scalp Blood Sampling, 442 Umbilical Cord Acid–Base Determination, 443 Amnioinfusion, 443 Documentation, 443 Key points, 444 References, 445 Labour and Birth at Risk, 446 Jodie Bigalky Originating US Chapter by Kitty Cashion

Preterm labour and birth, 446 Preterm Birth Versus Low Birth Weight, 446 Spontaneous Versus Indicated Preterm Birth, 447 Spontaneous Preterm Labour and Birth Risk Factors, 447 Predicting Spontaneous Preterm Labour and Birth, 448 Nursing Care, 448 Premature rupture of membranes, 454 Nursing Care, 454 Chorioamnionitis, 454 Post-term pregnancy, labour, and birth, 455 Post-Term Risks, 455 Collaborative Care, 455 Dystocia, 456 Abnormal Uterine Activity (Alteration in Power), 456 Alterations in Pelvic Structure (Passageway), 457 Fetal Causes (Passenger), 458 Position of the Labouring Patient, 459 Psychological Responses, 459 Nursing Care, 459 Precipitous labour, 460 Obesity, 460 Intrapartum and Postpartum Risks, 460 Nursing Care, 460 Multifetal pregnancy, 461 Obstetrical procedures, 461 Version, 461 Induction of Labour, 462 Augmentation of Labour, 468 Operative Vaginal Births, 469 Caesarean Birth, 470 Trial of Labour After Caesarean (TOLAC), 476 Obstetrical emergencies, 477 Meconium-Stained Amniotic Fluid, 477 Shoulder Dystocia, 478 Prolapsed Umbilical Cord, 479 Rupture of the Uterus, 479 Amniotic Fluid Embolism, 481 Key points, 481 References, 482 Additional resources, 483

xii

CONTENTS

UNIT 6 Postpartum Period 21

Physiological Changes in the Postpartum Patient, 484 Lisa Keenan-Lindsay Originating US Chapter by Kathryn R. Alden

22

Reproductive system and associated structures, 484 Uterus, 484 Cervix, 486 Vagina and Perineum, 486 Abdomen, 486 Endocrine system, 486 Placental Hormones, 486 Metabolic Changes, 487 Pituitary Hormones and Ovarian Function, 487 Urinary system, 487 Urine Components, 487 Fluid Loss, 487 Urethra and Bladder, 488 Gastrointestinal system, 488 Breasts, 488 Breastfeeding Mothers, 488 Nonbreastfeeding Mothers, 488 Cardiovascular system, 488 Blood Volume, 488 Cardiac Output, 489 Varicosities, 490 Respiratory system, 490 Neurological system, 490 Musculoskeletal system, 490 Integumentary system, 490 Immune system, 490 Key points, 490 References, 491 Nursing Care of the Family During the Postpartum Period, 492 Keri-Ann Berga Originating US Chapter by Kathryn R. Alden

23

Transfer from the recovery area, 492 Planning for discharge, 493 Nursing care, 494 Ongoing Physical Assessment, 494 Nursing Interventions, 494 Psychosocial Assessment and Care, 505 Discharge Teaching, 507 Follow-up After Discharge, 509 Key points, 510 References, 510 Additional resources, 511 Transition to Parenthood, 512 Keri-Ann Berga

Parental attachment, bonding, and acquaintance, 512 Assessment of Attachment Behaviours, 513 Parent–infant contact, 516 Early Contact, 516 Extended Contact, 516 Communication between parent and infant, 516 The Senses, 516

24

Entrainment, 517 Biorhythmicity, 517 Reciprocity and Synchrony, 518 Parental role after birth, 518 Transition to Parenthood, 518 Parental Tasks and Responsibilities, 518 Becoming a Mother, 519 Becoming a Father, 520 Adjustment for the Couple, 521 Infant–Parent Adjustment, 521 Rhythm, 521 Behavioural Repertoires, 522 Responsivity, 522 Sibling adaptation, 522 Grandparent adaptation, 523 Diversity in transitions to parenthood, 524 Age, 524 Parenting Among LGBTQ2 Couples, 525 Social Support, 526 Culture, 527 Indigenous Families, 527 Socioeconomic Conditions, 527 Personal Aspirations, 528 Parental sensory impairment, 528 Visually Impaired Parent, 528 Hearing-Impaired Parent, 528 Nursing care, 529 Key points, 530 References, 530 Additional resources, 531 Fathering resources, 531 Postpartum Complications, 532 Janet Andrews Originating US Chapter by Kathryn R. Alden

Postpartum hemorrhage, 532 Definition and Incidence, 532 Etiology and Risk Factors, 533 Collaborative Care, 535 Hemorrhagic (Hypovolemic) Shock, 537 Venous thromboembolic disorders, 539 Incidence and Etiology, 540 Clinical Manifestations, 540 Collaborative Care, 540 Postpartum infections, 541 Endometritis, 541 Wound Infections, 541 Urinary Tract Infections, 542 Mastitis, 542 Nursing Care, 542 Perinatal mood disorders, 543 Perinatal Anxiety Disorders, 544 Perinatal Depression, 544 Postpartum Psychosis, 545 Interdisciplinary and Nursing Care, 545 Loss and grief, 551 Grief Responses, 552 Family Aspects of Grief, 554 Nursing Care, 555 Maternal death, 558

CONTENTS

Key points, 559 References, 559 Additional resources, 560

UNIT 7 Newborn 25

Physiological Adaptations of the Newborn, 561 Jennifer Marandola Originating US Chapter by Kathryn R. Alden

26

Transition to extrauterine life, 561 Physiological adjustments, 561 Respiratory System, 561 Cardiovascular System, 563 Hematopoietic System, 565 Thermogenic System, 566 Renal System, 568 Gastrointestinal System, 568 Hepatic System, 570 Immune System, 573 Integumentary System, 573 Reproductive System, 575 Skeletal System, 576 Neuromuscular System, 578 Behavioural adaptations, 578 Sleep–Wake States, 579 Other Factors Influencing Behaviour of Newborns, 580 Sensory Behaviours, 580 Response to Environmental Stimuli, 581 Key points, 581 References, 581 Additional resource, 582 Nursing Care of the Newborn and Family, 583

28

Birth through the first 2 hours, 583 Nursing Care, 583 Immediate Care After Birth, 583 Interventions, 584 Care of the newborn from 2 hours after birth until discharge, 588 Nursing Care, 588 Common Newborn Concerns, 608 Laboratory and Screening Tests, 612 Interventions, 615 Pain in the Newborn, 618 Promoting Parent–Newborn Interaction, 621 Discharge Planning and Teaching, 622 Key points, 630 References, 630 Additional resources, 632 Newborn Nutrition and Feeding, 633 Marina Green and Kim Dart Originating US Chapter by Kathryn R. Alden

Recommended infant nutrition, 634 Breastfeeding Rates, 634 The Importance of Breastfeeding, 634 Contraindications to Breastfeeding, 634 The Baby-Friendly Initiative, 635

Informed Decisions About Infant Feeding, 636 Cultural Influences on Infant Feeding, 637 Lactation and LGBTQ2 Families, 638 Nutrient needs, 638 Fluids, 638 Energy, 638 Carbohydrates, 638 Fat, 638 Protein, 639 Vitamins, 639 Minerals, 639 Anatomy and physiology of lactation, 639 Breast Anatomy, 639 Lactogenesis, 640 Uniqueness of Human Milk, 641 Nursing care, 641 Pregnancy, 641 Early Postpartum, 641 Common Breastfeeding Concerns, 657 Follow-up After Hospital Discharge, 660 Formula-feeding, 660 Parent Education, 660 Readiness for Feeding, 660 Feeding Patterns, 660 Complementary feeding: introducing solid foods, 664 Key points, 664 References, 664 Additional resources, 666 Human Milk Banking Information, 666 Infants With Gestational Age–Related Conditions, 667 Jennifer Young Originating US Chapter by Debbie Fraser

Jennifer Marandola Originating US Chapter by Kathryn R. Alden

27

xiii

29

Preterm and post-term infants, 667 The Preterm Infant, 667 Late Preterm Infant, 667 Nursing Care, 668 Complications of Prematurity, 681 The Post-Term Infant, 684 Meconium Aspiration Syndrome, 684 Persistent Pulmonary Hypertension of the Newborn, 684 Other concerns related to gestation, 685 Small-for-Gestational-Age Infants and Intrauterine Growth Restriction, 685 Large-for-Gestational-Age Infants, 685 Infants of Diabetic Mothers, 685 Discharge planning and transport, 687 Discharge Planning, 687 Transport to a Regional Centre, 687 Key points, 688 References, 688 Additional resources, 690 The Newborn at Risk: Acquired and Congenital Conditions, 691 Jennifer Young Originating US Chapter by Debbie Fraser

Injuries associated with birth, 691

xiv

CONTENTS

Skeletal Injuries, 691 Peripheral Nervous System Injuries, 692 Central Nervous System Injuries, 693 Newborn infections, 695 Sepsis, 695 Nursing Care, 696 Congenital infections, 697 Chlamydia Infection, 697 Cytomegalovirus Infection, 697 Gonorrhea, 701 Group B Streptococcus, 701 Hepatitis B Virus (HBV), 701 Herpes, 701 Human Immunodeficiency Virus (Type 1), 701 Parvovirus B19, 702 Rubella Infection, 702 Syphilis, 702 Tuberculosis, 702 Varicella Zoster, 702 Zika, 702 Candidiasis, 702 Nursing Care, 703 Adverse exposures affecting newborns, 703 Neonatal Abstinence Syndrome, 703 Opioid Exposure, 704 Alcohol Exposure, 706 Tobacco and Nicotine Exposure, 707 Cannabis Exposure, 707 Cocaine Exposure, 707 Methamphetamine Exposure, 707 Selective Serotonin Reuptake Inhibitors, 708 Nursing Care, 708 Hematological disorders, 708 Blood Incompatibility, 708 Other Hemolytic Disorders, 710 Congenital anomalies, 711 Newborn screening for disease, 711 Inborn Errors of Metabolism, 711 Genetic Evaluation and Counselling, 713 Nursing Care of Parents and Family, 713 Key points, 713 References, 714

PART 3 Pediatric Nursing UNIT 8 Children, Their Families, and the Nurse 30

Pediatric Nursing in Canada, 718 Cheryl Sams and Lisa Keenan-Lindsay

Children’s health in canada, 718 Childhood Mortality, 719 Childhood Morbidity, 719 Social Determinants of Health, 719 Health Inequities Among Children, 720 Food Insecurity, 720 Health Promotion, 720 Immunizations, 720

31

Antimicrobial Resistance, 721 Childhood Injuries, 722 Violence, 722 Toxic Stress, 722 Mental Health, 722 Substance Use, 723 The art of pediatric nursing, 723 Philosophy of Care, 723 Family-Centred Care, 723 Atraumatic Care, 724 Therapeutic Relationships, 725 Family Advocacy and Caring, 730 Disease Prevention and Health Promotion, 730 Health Teaching, 730 Coordination and Collaboration, 732 Health Care Planning, 732 Future Trends, 733 Key points, 733 References, 733 Additional resources, 734 Family, Social, and Cultural Influences on Children’s Health, 735 Valerie Bertoni Originating US Chapter by Marilyn J. Hockenberry

32

Pediatric nursing and the family, 735 Family Nursing Interventions, 735 Families’ Roles, Relationships, and Strengths, 735 Parental Roles, 736 Role Learning, 736 Special Parenting Situations, 737 Social and Cultural factors that impact health, 741 Social Determinant Influences, 741 The Child and Family in North America, 743 Understanding cultures in the health care encounter, 744 Bridging the Gap, 744 Health beliefs and practices, 745 Health Beliefs, 745 Health Practices, 745 Key points, 747 References, 747 Additional resources, 748 Developmental Influences on Child Health Promotion, 749 Constance O’Connor Originating US Chapter by Marilyn J. Hockenberry

Foundations of growth and development, 749 Stages of Development, 749 Patterns of Growth and Development, 749 Biological Growth and Physical Development, 751 Physiological Changes, 753 Nutrition, 753 Temperament, 754 Development of personality and cognitive function, 755 Theoretical Foundations of Personality Development, 756

CONTENTS

Development of Self-Concept, 759 Role of play in development, 759 Content of Play, 759 Social Character of Play, 760 Functions of Play, 761 Toys, 762 Selected factors that influence development, 762 Heredity, 762 Neuroendocrine Factors, 763 Interpersonal Relationships, 763 Socioeconomic Level, 764 Environmental Hazards, 764 Stress and Coping, 764 Mass Media, 764 Key points, 765 References, 766 Additional resources, 766

34

Pain Assessment, 813 Assessment of Acute Pain, 813 Assessment of Chronic (Persistent) and Recurrent Pain, 820 Global Judgement of Improvement and of Satisfaction With Treatment, 821 Pain Assessment in Specific Populations, 821 Pain Management, 822 Physical Recovery, 822 Mind–Body Pain Management Strategies, 822 Complementary and Alternative Medicine (CAM), 824 Pharmacological Management, 824 Common Pain States in Children, 835 Painful and Invasive Procedures, 835 Procedural Sedation and Analgesia, 835 Postoperative Pain, 835 Burn Pain, 836 Recurrent Headaches in Children, 836 Recurrent Abdominal Pain in Children, 837 Pain in Children With Sickle Cell Disease, 837 Cancer Pain in Children, 837 Pain and Sedation in End-of-Life Care, 838 Key Points, 838 References, 839 Additional Resources, 841

Pediatric Health Assessment, 767 Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry

History taking, 767 Performing a Health History, 767 Identifying Information, 767 Presenting Health Issue or Concern, 767 History, 768 Family Health History, 770 Psychosocial History, 772 Review of Systems, 772 Performing a Nutritional Assessment, 773 Developmental assessment, 777 Health supervision guides, 778 Rourke Baby Record, 778 Greig Health Record, 778 General approaches toward examining the child, 778 Sequence of the Examination, 779 Preparation of the Child, 779 Physical Examination, 780 Vital Signs, 783 General Appearance, 788 Skin, 789 Lymph Nodes, 790 Head and Neck, 790 Eyes, 791 Ears, 794 Nose, 798 Mouth and Throat, 798 Chest, 799 Lungs, 800 Heart, 802 Abdomen, 803 Genitalia, 805 Anus, 807 Back and Extremities, 807 Neurological Assessment, 808 Key points, 811 References, 812 Additional resources, 812

Pain Assessment and Management, 813 Jennifer Tyrrell and Lorraine Bird Originating US Chapter by Marilyn J. Hockenberry

UNIT 9 Assessment of the Child and Family 33

xv

UNIT 10 Health Promotion and Developmental Stages 35

Promoting Optimum Health During Childhood, 842 Cheryl Sams, Mollie Lavigne, Lisa Keenan-Lindsay, and With contributions from Cheryl C. Rodgers

Nutrition, 842 Nutrition Across the Lifespan, 843 Vegetarian Diets, 847 Obesity, 847 Etiology and Pathophysiology, 848 Diagnostic Evaluation, 849 Therapeutic Management and Nursing Care, 850 Complementary and alternative medicine, 852 Dental health, 852 Developmental Aspects of Dental Health, 852 Oral Health, 853 Other Dental Conditions, 855 Sleep, Rest, and Activity integration, 855 Infant, 856 Toddler, 856 Preschooler, 857 School-Age, 857 Adolescent, 858 Sexual health, 858 Sex Education, 859 Safety promotion and injury prevention, 860 Injury Prevention Throughout Childhood, 860

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CONTENTS

Motor Vehicle Safety, 862 Pedestrian Safety, 868 All-Terrain Vehicles, 868 Bicycles and Skateboards, 869 Aspiration and Suffocation, 870 Drowning, 870 Burns, 870 Accidental Poisoning, 871 Falls, 872 Firearms, 872 Sports Injuries, 872 Role of the Nurse in Prevention of Injury, 872 Child maltreatment, 874 Factors Predisposing to Child Maltreatment, 875 Child Neglect, 875 Emotional Abuse, 875 Physical Abuse, 875 Sexual Abuse, 876 Munchausen Syndrome by Proxy, 877 Nursing and Interprofessional Care, 877 Immunizations, 882 Vaccine Hesitancy, 882 Schedule for Immunizations, 882 Recommendations for Routine Immunizations, 884 Administration of Immunizations, 888 Reactions, 888 Contraindications, 889 Communicable diseases, 889 Nursing Care, 889 Key points, 901 References, 901 Additional resources, 905 The Infant and Family, 906

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Constance O’Connor Originating US Chapter by Cheryl C. Rodgers

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Promoting optimum growth and development, 933 Biological Development, 933 Psychosocial Development, 934 Cognitive Development, 936 Spiritual Development, 937 Development of Body Image, 938 Development of Gender Identity, 939 Social Development, 939 Coping with concerns related to normal growth and development, 940 Toilet Independence, 940 Temper Tantrums, 942 Negativism, 942 Sibling Rivalry, 943 Regression, 943 Mental Health, 944 Anticipatory guidance for families, 944 Key points, 944 References, 945 Additional resources, 945 The Preschooler and Family, 946 Constance O’Connor Originating US Chapter by Cheryl C. Rodgers

Constance O’Connor Originating US Chapter by Cheryl C. Rodgers

Promoting Optimum Growth and Development, 906 Biological Development, 906 Psychosocial Development, 915 Cognitive Development, 916 Development of Body Image, 917 Social Development, 917 Language Development, 919 Temperament, 919 Coping with Concerns Related to Normal Growth and Development, 919 Separation and Fear of Strangers, 919 Alternative Child Care Arrangements, 920 Limit-Setting and Discipline, 920 Thumb-Sucking and Use of a Pacifier, 920 Teething, 921 Health Promotion and Anticipatory Guidance for Families, 922 Traumatic Head Injury due to Child Maltreatment, 922 Special Health Concerns, 923 Colic (Paroxysmal Abdominal Pain), 923 Failure to Thrive (Growth Failure), 924 Sudden Infant Death Syndrome, 926

Positional Plagiocephaly, 929 Brief Resolved Unexplained Events, 930 Key Points, 930 References, 931 Additional Resources, 932 The Toddler and Family, 933

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Promoting optimum growth and development, 946 Biological Development, 946 Psychosocial Development, 946 Cognitive Development, 948 Moral Development, 948 Spiritual Development, 949 Development of Body Image, 949 Development of Gender and Sexuality, 949 Social Development, 949 Coping with concerns related to normal growth and development, 951 Preschool and Kindergarten Experience, 951 Fears, 952 Stress, 953 Aggression, 953 Speech Issues, 953 Mental Health, 954 Anticipatory guidance—care of families, 954 Key points, 954 References, 955 Additional resources, 955 The School-Age Child and Family, 956 Cheryl Dika Originating US Chapter by Cheryl C. Rodgers

Promoting optimum growth and development, 956 Indigenous Child Development Life Stages, 956 Biological Development, 956 Psychosocial Development, 957

CONTENTS

40

Cognitive Development, 960 Moral Development, 960 Spiritual Development, 961 Social Development, 962 Development of a Self-Concept, 964 Coping with concerns related to normal growth and development, 964 School Experience, 964 Latchkey Children, 966 Limit-Setting and Discipline, 966 Dishonest Behaviour, 966 Stress and Fear, 966 Sports, 967 Acquisition of Skills, 968 Use of Social Media and the Internet, 968 School Health, 968 Special health concerns, 968 Altered Growth and Maturation, 968 Enuresis, 969 Sex Chromosome Abnormalities, 970 Anticipatory guidance for families, 971 Key points, 971 References, 972 Additional resources, 972 The Adolescent and Family, 973 Constance O’Connor Originating US Chapter by Cheryl C. Rodgers

Promoting optimum growth and development, 973 Biological Development, 973 Psychosocial Development, 978 Cognitive Development, 980 Moral Development, 980 Spiritual Development, 980 Social Development, 980 Promoting optimum health during adolescence, 982 Emotional Well-Being, 983 Eating Habits and Behaviour, 983 Hypertension and Dyslipidemia, 984 Personal Care, 984 Vision, 984 Hearing, 984 Posture, 984 Body Art, 984 Tanning, 985 Mental Health, 985 School and Learning Issues, 985 Sexual Health, 986 Safety Promotion and Injury Prevention, 986 Nursing Care, 987 Special health concerns, 988 Disorders of the Female Reproductive System, 988 Disorders of the Male Reproductive System, 988 Key points, 989 References, 989 Additional resources, 990

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UNIT 11 Special Needs, Illness, and Hospitalization 41

Caring for the Child With a Chronic Illness and at the End of Life, 991 Laura Pilla Originating US Chapter by Marilyn J. Hockenberry

Care of children and families living with chronic or complex conditions, 991 Scope of the Issue, 991 Trends in Care, 992 The family of the child with a chronic or complex condition, 993 Impact of the Child’s Chronic Illness and Complex Conditions, 994 Coping With Ongoing Stress and Periodic Crises, 995 Assisting Family Members in Managing Their Feelings, 996 Establishing a Support System, 997 The child with a chronic or complex condition, 998 Developmental Aspects, 998 Coping Mechanisms, 998 Nursing care of the family and child with a chronic or complex condition, 999 Performing an Assessment, 999 Providing Support at the Time of Diagnosis, 1000 Supporting the Family’s Coping Methods, 1000 Teaching About the Disorder and General Health Care, 1001 Promoting Appropriate Development, 1002 Establishing Realistic Future Goals, 1005 Transition to Adult Care, 1005 General concepts of home care, 1006 Home Care Trends and Needs, 1006 Effective Home Care, 1006 Discharge Planning, 1007 Care Coordination (Case Management), 1009 Role of the Nurse, Training, and Standards of Care, 1010 Family-centred home care, 1010 Culturally Safe Care, 1010 Parent–Professional Collaboration, 1010 The Nursing Process, 1011 Safety Issues in the Home, 1011 Caregiver Stress, 1012 Perspectives on the care of children at the end of life, 1012 Principles of Palliative Care, 1012 Decision Making at the End of Life, 1013 Treatment Options for Terminally Ill Children, 1015 Nursing Care of the Child and Family at the End of Life, 1016 Organ or Tissue Donation and Autopsy, 1018 Grief and Mourning, 1018 Nurses’ Reactions to Caring for Dying Children, 1020 Key points, 1020 References, 1021 Additional resources, 1023

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CONTENTS

Impact of Intellectual Disability or Sensory Impairment on the Child and Family, 1024 Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry

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Intellectual disability, 1024 General Concepts, 1024 Down Syndrome, 1029 Fragile X Syndrome, 1031 Communication impairment, 1032 Autism Spectrum Disorders, 1032 Sensory impairment, 1034 Hearing Impairment, 1034 Visual Impairment, 1038 Hearing–Visual Impairment, 1043 Retinoblastoma, 1044 Key points, 1045 References, 1045 Additional resources, 1046 Family-Centred Care of the Child During Illness and Hospitalization, 1047 Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry

44

Stressors of hospitalization and children’s reactions, 1047 Separation Anxiety, 1047 Loss of Control, 1049 Effects of Hospitalization on the Child, 1049 Stressors and reactions of the family of the hospitalized child, 1050 Parental Reactions, 1050 Sibling Reactions, 1051 Caring for the child who is hospitalized, 1051 Preparation for Hospitalization, 1051 Preparing the Child for Admission, 1052 Nursing Care, 1052 Care of the child and family in special hospital situations, 1062 Ambulatory or Outpatient Setting, 1063 Isolation, 1063 Emergency Admission, 1064 Critical Care Unit, 1064 Key points, 1066 References, 1066 Additional resources, 1066 Pediatric Variations of Nursing Interventions, 1067 Monping Chiang With contributions from Marilyn J. Hockenberry

General concepts related to pediatric procedures, 1067 Informed Consent, 1067 Preparation for Diagnostic and Therapeutic Procedures, 1068 Performance of the Procedure, 1072 Postprocedural Support, 1072 Use of Play in Procedures, 1073 Preparing the Family, 1074 Surgical Procedures, 1074 General hygiene and basic care, 1077 Maintaining Healthy Skin, 1077

Bathing, 1078 Oral Hygiene, 1078 Hair Care, 1078 Feeding the Sick Child, 1078 Controlling Elevated Temperatures, 1079 Safety, 1081 Environmental Factors, 1081 Infection Control, 1082 Transporting Infants and Children, 1084 Therapeutic Holding and Restraints, 1084 Positioning for Procedures, 1086 Collection of specimens, 1087 Fundamental Procedure Steps Common to All Procedures, 1087 Urine Specimens, 1087 Stool Specimens, 1089 Blood Specimens, 1089 Respiratory Secretion Specimens, 1090 Administration of medication, 1091 Determination of Medication Dosage, 1091 Identification, 1091 Oral Administration, 1091 Intramuscular Administration, 1092 Subcutaneous and Intradermal Administration, 1095 Intravenous Administration, 1096 Intraosseous Infusion, 1097 Nasogastric, Orogastric, or Gastrostomy Administration, 1098 Rectal Administration, 1098 Optic, Otic, and Nasal Administration, 1098 Aerosol Therapy, 1099 Family Teaching and Home Care, 1100 Maintaining fluid balance, 1100 Measurement of Intake and Output, 1100 Special Needs When the Child Is NPO, 1101 Parenteral fluid therapy, 1101 Site and Equipment, 1101 Safety Catheters and Needleless Systems, 1102 Infusion Pumps, 1102 Securement of a Peripheral Intravenous Line, 1102 Removal of a Peripheral Intravenous Line, 1103 Maintenance, 1103 Complications, 1104 Procedures for maintaining respiratory function, 1104 Inhalation Therapy, 1104 Bronchial (Postural) Drainage, 1106 Chest Physiotherapy, 1106 Intubation, 1106 Tracheostomy, 1107 Chest Tube Procedures, 1109 Alternative feeding techniques, 1110 Gavage Feeding, 1111 Gastrostomy Feeding, 1112 Nasoduodenal and Nasojejunal Tubes, 1113 Total Parenteral Nutrition, 1113 Family Teaching and Home Care, 1114 Procedures related to elimination, 1114

CONTENTS

Enema, 1114 Ostomies, 1114 Family Teaching and Home Care, 1115 Key points, 1115 References, 1116 Additional resources, 1117

UNIT 12 Health Conditions of Children 45

Respiratory Conditions, 1118 Cheryl Sams Originating US Chapter by Cheryl R. Rodgers

Respiratory infection, 1118 General Aspects of Respiratory Infections, 1118 Upper respiratory tract infections, 1121 Nasopharyngitis, 1121 Acute Streptococcal Pharyngitis, 1123 Tonsillitis, 1124 Influenza, 1125 Otitis Media (OM), 1126 Infectious Mononucleosis, 1129 Croup syndromes, 1129 Acute Epiglottitis, 1130 Laryngotracheobronchitis, 1131 Acute Spasmodic Laryngitis, 1132 Bacterial Tracheitis, 1132 Infections of the lower airways, 1132 Bronchitis, 1132 Respiratory Syncytial Virus and Bronchiolitis, 1133 Pneumonias, 1134 Other respiratory tract infections, 1136 Pertussis (Whooping Cough), 1136 Tuberculosis, 1137 Pulmonary dysfunction caused by noninfectious irritants, 1139 Foreign Body Aspiration, 1139 Aspiration Pneumonia, 1140 Pulmonary Edema, 1140 Acute Respiratory Distress Syndrome (ARDS)/Acute Lung Injury (ALI), 1141 Smoke Inhalation Injury, 1142 Environmental Tobacco, Cannabis Smoke Exposure, and Vaping, 1143 Long-Term respiratory dysfunction, 1143 Asthma, 1143 Cystic Fibrosis, 1153 Obstructive Sleep-Disordered Breathing, 1160 Congenital respiratory system anomalies, 1160 Choanal Atresia, 1160 Congenital Diaphragmatic Hernia, 1161 Respiratory emergency, 1161 Respiratory Failure, 1161 Cardiopulmonary Resuscitation, 1162 Key points, 1162 References, 1163 Additional resources, 1165

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Gastrointestinal Conditions, 1166 Constance O’Connor Originating US Chapter by Cheryl C. Rodgers

Gastrointestinal System Structure and Function, 1166 Pediatric Differences Related to the Gastrointestinal System, 1166 Nutritional Disturbances, 1167 Vitamin Imbalances, 1167 Mineral Imbalances, 1171 Severe Acute Malnutrition, 1175 Food Sensitivity, 1175 Distribution of Body Fluids, 1178 Gastroinestinal Dysfunction, 1179 Dehydration, 1179 Disorders of Motility, 1183 Diarrhea, 1183 Constipation, 1189 Hirschsprung Disease, 1191 Vomiting, 1192 Gastroesophageal Reflux, 1193 Intestinal Parasitic Diseases, 1195 Giardiasis, 1195 Enterobiasis (Pinworms), 1196 Inflammatory Disorders, 1197 Acute Appendicitis, 1197 Meckel Diverticulum, 1198 Inflammatory Bowel Disease, 1199 Peptic Ulcer Disease, 1202 Hepatic Disorders, 1203 Hepatitis, 1203 Cirrhosis, 1207 Biliary Atresia, 1208 Structural Defects, 1209 Cleft Lip or Cleft Palate, 1209 Esophageal Atresia and Tracheoesophageal Fistula, 1211 Hernias, 1214 Obstructive Disorders, 1216 Hypertrophic Pyloric Stenosis, 1216 Intussusception, 1218 Malrotation and Volvulus, 1219 Anorectal Malformations, 1219 Malabsorption Syndromes, 1221 Celiac Disease (Gluten-Sensitive Enteropathy), 1221 Lactose Intolerance, 1222 Short-Bowel Syndrome, 1223 Ingestion of Injurious Agents, 1224 Principles of Emergency Treatment, 1224 Heavy Metal Poisoning, 1228 Lead Poisoning, 1228 Key Points, 1232 References, 1233 Additional Resources, 1235

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CONTENTS

Cardiovascular Conditions, 1236 Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry

Cardiovascular dysfunction, 1236 History and Physical Examination, 1236 Diagnostic Evaluation, 1237 Congenital heart disease, 1240 Circulatory Changes at Birth, 1240 Altered Hemodynamics, 1240 Classification of Defects, 1241 Clinical consequences of congenital heart disease, 1245 Heart Failure, 1245 Hypoxemia, 1255 Nursing care of the family and child with congenital heart disease, 1257 Helping the Family Adjust to the Disorder, 1258 Educating the Family About the Disorder, 1258 Helping the Family Manage the Illness at Home, 1259 Preparing the Child and Family for Invasive Procedures, 1259 Providing Postoperative Care, 1260 Planning for Discharge and Home Care, 1262 Acquired cardiovascular disorders, 1262 Infective (Bacterial) Endocarditis, 1262 Acute Rheumatic Fever and Rheumatic Heart Disease, 1263 Hyperlipidemia/Hypercholesterolemia, 1264 Cardiac Dysrhythmias, 1266 Pulmonary Artery Hypertension, 1267 Cardiomyopathy, 1268 Heart transplantation, 1269 Nursing Care, 1269 Vascular dysfunction, 1270 Systemic Hypertension, 1270 Kawasaki Disease, 1271 Shock, 1273 Anaphylaxis, 1275 Septic Shock, 1276 Toxic Shock Syndrome, 1277 Key points, 1277 References, 1278 Additional resources, 1279

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Mandy Rickard Originating US Chapter by Marilyn J. Hockenberry

UNIT 12 Health Conditions of Children 48

Hematological or Immunological Conditions, 1280 Katherine Bertoni Originating US Chapter by Marilyn J. Hockenberry

Hematological and immunological disorders, 1280 Red blood cell disorders, 1280 Anemia, 1280 Iron-Deficiency Anemia, 1284 Sickle Cell Anemia, 1285 Beta Thalassemia (Cooley Anemia), 1289 Aplastic Anemia, 1290 Defects in hemostasis, 1291

Hemophilia, 1291 Immune Thrombocytopenia, 1294 Disseminated Intravascular Coagulation, 1295 Epistaxis (Nose-Bleeding), 1295 Neoplastic disorders, 1296 Leukemias, 1296 Lymphomas, 1301 Immunological deficiency disorders, 1302 HIV Infection and Acquired Immunodeficiency Syndrome, 1303 Severe Combined Immunodeficiency Disease, 1305 Wiskott-Aldrich Syndrome (WAS), 1305 Technological management of hematological and immunological disorders, 1305 Blood Transfusion Therapy, 1305 Hematopoietic Stem Cell (Bone Marrow) Transplantation (HSCT), 1307 Apheresis, 1308 Key points, 1309 References, 1309 Additional resources, 1310 Genitourinary Conditions, 1311

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Urinary system structure and function, 1311 Kidney Structure and Function, 1311 Genitourinary dysfunction, 1312 Clinical Manifestations, 1312 Genitourinary tract disorders and defects, 1315 Urinary Tract Infection, 1315 Obstructive Uropathy, 1319 External Defects, 1319 Glomerular disease, 1323 Nephrotic Syndrome, 1323 Acute Glomerulonephritis, 1325 Miscellaneous renal disorders, 1326 Hemolytic Uremic Syndrome, 1326 Wilms Tumour, 1327 Renal failure, 1328 Acute Kidney Injury, 1328 Chronic Kidney Disease, 1330 Technological management of chronic kidney disease, 1332 Dialysis, 1332 Transplantation, 1333 Key points, 1334 References, 1334 Additional resources, 1335 Neurological Conditions, 1336 Joley Johnstone Originating US Chapter by Cheryl C. Rodgers

Assessment of cerebral function, 1336 General Aspects, 1336 Increased Intracranial Pressure, 1337 Altered States of Consciousness, 1337 Neurological Examination, 1338 Special Diagnostic Procedures, 1341

CONTENTS

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Nursing care of the unconscious child, 1343 Respiratory Management, 1343 Intracranial Pressure Monitoring, 1344 Nutrition and Hydration, 1345 Medications, 1345 Thermoregulation, 1345 Elimination, 1345 Hygienic Care, 1345 Positioning and Exercise, 1346 Stimulation, 1346 Regaining Consciousness, 1346 Family Support, 1346 Cerebral trauma, 1347 Head Injury, 1347 Submersion Injury, 1353 Nervous system tumours, 1355 Brain Tumours, 1355 Neuroblastoma, 1357 Intracranial infections, 1358 Bacterial Meningitis, 1358 Nonbacterial (Aseptic) Meningitis, 1361 Encephalitis, 1361 Reye Syndrome, 1362 Seizure disorders, 1363 Etiology, 1363 Pathophysiology, 1363 Seizure Classification and Clinical Manifestations, 1363 Diagnostic Evaluation, 1363 Therapeutic Management, 1366 Prognosis, 1368 Nursing Care, 1368 Febrile Seizures, 1370 Cerebral malformations, 1371 Cranial Deformities, 1371 Hydrocephalus, 1371 Key points, 1374 References, 1375 Additional resources, 1376 Endocrine Conditions, 1377

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Cheryl Sams

Cheryl Sams and Nancy Caprara Originating US Chapter by Cheryl C. Rodgers

The Endocrine System, 1377 Hormones, 1377 Disorders of Pituitary Function, 1377 Hypopituitarism, 1377 Pituitary Hyperfunction, 1380 Precocious Puberty, 1381 Diabetes Insipidus, 1382 Syndrome of Inappropriate Antidiuretic Hormone, 1382 Disorders of Thyroid Function, 1383 Juvenile Hypothyroidism, 1383 Goitre, 1383 Lymphocytic Thyroiditis, 1384 Hyperthyroidism, 1384 Disorders of Parathyroid Function, 1386 Hypoparathyroidism, 1386

Hyperparathyroidism, 1387 Disorders of Adrenal Function, 1387 Acute Adrenocortical Insufficiency, 1388 Chronic Adrenocortical Insufficiency (Addison Disease), 1389 Cushing Syndrome, 1389 Congenital Adrenal Hyperplasia, 1391 Pheochromocytoma, 1392 Disorders of Pancreatic Hormone Secretion, 1392 Diabetes Mellitus Type 1, 1392 Diabetes Mellitus Type 2, 1404 Key Points, 1405 References, 1405 Additional Resources, 1406 Integumentary Conditions, 1407

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Integumentary anatomy and physiology, 1407 Integumentary dysfunction, 1407 Skin Lesions, 1407 Wounds, 1409 Infections of the skin, 1412 Bacterial Infections, 1412 Viral Infections, 1414 Dermatophytoses (Fungal Infections), 1414 Systemic Mycotic (Fungal) Infections, 1414 Skin disorders related to chemical or physical contacts, 1415 Contact Dermatitis, 1415 Poison Ivy, Oak, and Sumac, 1417 Medication Reactions, 1418 Skin disorders related to animal contacts, 1419 Arthropod Bites and Stings, 1419 Scabies, 1419 Pediculosis Capitis, 1421 Bed Bugs, 1422 Rickettsial Diseases, 1423 Lyme Disease, 1423 Animal Bites, 1424 Miscellaneous skin disorders, 1426 Skin disorders associated with specific age groups, 1426 Diaper Dermatitis, 1426 Atopic Dermatitis (Eczema), 1427 Seborrheic Dermatitis, 1429 Acne, 1429 Thermal injury, 1430 Burns, 1430 Sunburn, 1440 Cold Injury, 1441 Key points, 1441 References, 1442 Additional resources, 1442 Musculoskeletal or Articular Conditions, 1443 Natasha Bath Originating US Chapter by Marilyn J. Hockenberry

The Immobilized Child, 1443 Physiological Effects of Immobilization, 1443

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Psychological Effects of Immobilization, 1446 Effect on Families, 1446 Traumatic Injury, 1448 Soft-Tissue Injury, 1448 Fractures, 1449 The Child Requiring a Cast, 1451 The Child in Traction, 1454 Distraction, 1457 Amputation, 1458 Health Concerns Related To Sports Participation, 1458 Overuse Syndromes, 1458 Congenital Defects, 1459 Arthrogryposis, 1459 Achondroplasia, 1459 Developmental Dysplasia of the Hip, 1460 Clubfoot, 1462 Metatarsus Adductus (Varus), 1463 Skeletal Limb Deficiency, 1464 Osteogenesis Imperfecta, 1464 Acquired Defects, 1465 Legg-Calve-Perthes Disease, 1465 Slipped Capital Femoral Epiphysis, 1466 Kyphosis and Lordosis, 1467 Scoliosis, 1468 Infections of Bones and Joints, 1470 Osteomyelitis, 1470 Septic Arthritis, 1471 Skeletal Tuberculosis, 1471 Bone and Soft-Tissue Tumour, 1472 Clinical Manifestations, 1472 Diagnostic Evaluation, 1472 Prognosis, 1472 Osteosarcoma, 1472 Ewing Sarcoma (Primitive Neuroectodermal Tumour of the Bone), 1473 Rhabdomyosarcoma, 1474 Disorders of Joints, 1475 Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis), 1475

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Systemic Lupus Erythematosus, 1477 Key Points, 1478 References, 1479 Additional Resources, 1480 Neuromuscular or Muscular Conditions, 1481 Jennifer Boyd

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Congenital neuromuscular or muscular disorders, 1481 Cerebral Palsy, 1481 Neural Tube Defects, 1486 Spinal Muscular Atrophy, 1492 Duchenne Muscular Dystrophy, 1494 Acquired neuromuscular disorders, 1496 Guillain-Barre Syndrome, 1496 Spinal Cord Injuries, 1497 Key points, 1501 References, 1501 Additional resources, 1503 Caring for the Mental, Emotional, and Behavioural Health Needs of Children and Adolescents, 1504 Cheryl L. Pollard

Mental, Emotional, and behavioural health, 1504 The Role of the Nurse, 1504 Factors Contributing to Mental Illness in Children and Adolescents, 1506 Specific mental illnesses in children, 1506 Anxiety, 1506 Depression, 1507 Suicide, 1508 Substance Use, 1510 Disturbances in Eating Related Behaviours, 1513 Behavioural health needs, 1514 Nursing Care, 1515 Key points, 1515 References, 1515 Appendix A: Canada’s Food Guide Snapshot, 1517 Appendix B: Common Laboratory Tests and Normal Ranges, 1520 Appendix C: Pediatric Vital Signs and Parameters, 1530 Index, 1532

ABOUT THE AUTHORS Lisa J. Keenan-Lindsay graduated from the University of Toronto for both her BScN and MN degrees. Her clinical work has included pediatrics and perinatal nursing. She has worked as a staff nurse, head nurse, and clinical educator. Currently, Lisa is a professor of nursing at Seneca College teaching in both the baccalaureate and practical nursing programs. She has been involved in all aspects of nursing education, including curriculum development and incorporation of simulation into the curriculum. Lisa has been an active board member of the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN) since its inception and before that was a Section Leader for AWHONN-Canada. She was President of CAPWHN in 2014. Lisa has previously been involved with the Society of Obstetricians and Gynaecologists of Canada (SOGC) as an RN member for the Maternal-Fetal Medicine Committee for many years and has co-authored many SOGC Clinical Practice Guidelines. She maintains her Perinatal Certification through the Canadian Nurses Association and is a member of the Perinatal Exam Committee. Lisa was also a Lamaze-certified childbirth educator for many years. Lisa is also the editor of Leifer’s Introduction to Maternity and Pediatric Nursing in Canada and is passionate about providing a Canadian focus to nursing education and textbooks. Cheryl A. Sams is a graduate of Ryerson University (BScN) and D’Youville College (MSN). She has worked at the Hospital for Sick Children (SickKids®) in Toronto since she graduated from nursing school. She has held many positions there, including staff nurse, clinical educator, manager, director, and clinical nurse specialist. Cheryl has held many teaching positions at Ryerson University in the Post RN Program and the Nurse Practitioner Program. She has also taught at the University of Toronto in the BScN program. Cheryl taught at Seneca College in the York University Collaborative BScN program until her recent retirement. As an author, Cheryl enjoys contributing to the nursing body of literature. She has contributed chapters to the Canadian publication of Lewis et al.’s Medical-Surgical Nursing in Canada and Potter and Perry’s Canadian Fundamentals of Nursing. She was one of the editors for Mosby’s Comprehensive Review for the Canadian RN Exam. Constance (Connie) O’Connor, RN (EC), MN, is a nurse practitioner at the Hospital for Sick Children (SickKids®) who currently works in the Ehlers-Danlos Syndrome (EDS) and Connective Tissue Disorders Program. Connie obtained both her Bachelor of Science in Nursing and Master of Nursing degrees at the University of Toronto, where she is a clinical adjunct instructor in the Lawrence S. Bloomberg Faculty of Nursing. Connie has held various nursing roles in general pediatrics, respiratory medicine, and gastroenterology. Connie was Canada’s first pediatric hepatology nurse practitioner specializing in chronic viral hepatitis and cholestatic liver disease. Connie has contributed to several committees for national and international organizations, including the Canadian Nurses’ Association, Alpha-1 Antitrypsin Deficiency Canada, the Canadian Liver Foundation, and the International Consortium on the Ehlers-Danlos Syndromes. She has authored several peer-reviewed publications and has been invited to speak both locally and at national and international conferences.

US 6th Edition 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 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 2010, the East Carolina University College of Nursing named the Neonatal Intensive Care and Midwifery Laboratory in honour of Dr. Lowdermilk. In 2011, she was named as one of the first 40 nurses inducted into the College of Nursing Hall of Fame. Mary Catherine (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 parentchild 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

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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 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 counselling. 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 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 authored many book chapters and editorials. Pediatrics: 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. 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 hematological and oncological diseases.

CONTRIBUTORS Janet Andrews, RN, BScN, MN

Jennifer Buccino, MEd, RD

Joley Johnstone, RN, MN, NP

Professor, School of Nursing Seneca College of Applied Arts and Technology Toronto, Ontario

Registered Dietitian Dietitians of Canada Toronto, Ontario

Nurse Practitioner Neurology SickKids® Hospital Toronto, Ontario

Judy Buchan, RN, BSCN, MN, PMP Melanie Basso, RN, BSN, MSN, PNC(C) Senior Practice Leader–Perinatal BC Women’s Hospital and Health Centre Vancouver, British Columbia

Natasha Bath, BScN, MScN, NP–Paediatrics Nurse Practitioner Paediatrics Orthopaedics SickKids® Hospital Toronto, Ontario

Keri-Ann Berga, RN, BScN, MScN, IBCLC, PNC(C) Perinatal Consultant Champlain Maternal Newborn Regional Program (CMNRP) Children’s Hospital of Eastern Ontario Ottawa, Ontario

Katherine Bertoni, BScN, MN, NP-F, CDE Family Nurse Practitioner Health Care on Yates PCC Assistant Teaching Professor NP Program School of Nursing Faculty of Human and Social Development University of Victoria Victoria, British Columbia

Jodie Bigalky, RN, BSN, MN, PhD, PNC(C)

Director of Public Heath Emergencies and Chief Nursing Officer Region of Peel Public Health Mississauga, Ontario

Nancy Caprara, RN, BScN, MN Professor, School of Nursing Seneca College of Applied Arts and Technology Toronto, Ontario

Monping Chiang, RN(EC), BScN, MS, FNP Nurse Practitioner–Pediatrics General and Thoracic Surgery SickKids® Hospital Toronto, Ontario

Kim Dart, RN, PNC, BScN, MSN, IBLCC Perinatal Nurse Clinician Mount Sinai Hospital Toronto, Ontario

Patient Safety Specialist Quality Management Nurse Practitioner Paediatric Medicine SickKids® Hospital Toronto, Ontario

Karen Mackinnon, RN, BScN, MN, PhD Associate Professor School of Nursing University of Victoria Victoria, British Columbia

Jennifer Marandola, BSN, MN, IBCLC, PNC(C) Advanced-Practice Nurse Consultant Directorate of Nursing CIUSSS du l’Ouest-de-l’Île-de-Montr
eal Montreal, Quebec

Laura Payant, BScN, MScN Cheryl Dika, RN, MN, NP Director, Curriculum Integrity and Faculty Development Nurse Practitioner/Instructor College of Nursing Faculty of Health Science University of Winnipeg Winnipeg, Manitoba

Kerry Lynn Durnford, MN, RN

College of Nursing University of Saskatchewan Regina, Saskatchewan

Nursing Faculty School of Health and Human Services Aurora College Yellowknife, Northwest Territories

Lorraine Bird, RN, BScN, MSc

Marina Green, RN, MSN

Clinical Nurse Specialist Anaesthesia and Pain Medicine SickKids® Hospital Toronto, Ontario

Chair Baby Friendly Initiative Assessment Committee Breastfeeding Committee for Canada North Vancouver, British Columbia

Jennifer Boyd, RN, MHSc, CNN(C), MSCN

Erica Hurley, RN, CCNE, MN, PhD(c)

Clinical Nurse Specialist Neurology SickKids® Hospital Toronto, Ontario

Mollie Lavigne, BScN, MSN NP–Paediatrics

Nurse Educator Western Regional School of Nursing Grenfell Campus–Memorial University of Newfoundland Corner Brook, Newfoundland

Medical Analyst Safe Medical Care Canadian Medical Protective Association Ottawa, Ontario

Karen Pike, RN, BSN, PNC(C) Clinical Resource Nurse Maternal Newborn Program BC Women’s Hospital and Health Centre Vancouver, British Columbia

Laura Pilla, RN(EC), MN, NP–Paediatrics Paediatric Nurse Practitioner Complex Care SickKids® Hospital Toronto, Ontario

Cheryl L. Pollard, BScN, MN, PhD, RPN, RN, ANEF Associate Dean & Professor Faculty of Nursing University of Regina Regina, Saskatchewan

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CONTRIBUTORS

Mandy Rickard, BScN, MN, NP–Paediatrics Paediatric Nurse Practitioner Urology SickKids® Hospital Toronto, Ontario

Lauren Rivard, RN, BScN, MSc Perinatal Consultant Champlain Maternal Newborn Regional Program Kingston, Ontario

Jennifer Tyrrell, BScN, MN

Nancy Watts, RN, MN, PNC(C)

Clinical Nurse Specialist Anaesthesia and Pain Medicine SickKids® Hospital Toronto, Ontario

Clinical Nurse Specialist Perinatal Mount Sinai Hospital Toronto, Ontario

Jennifer Young, RN(EC), MN, NP–Pediatrics, NNP-BC Professor, Sally Horsfall Eaton School of Nursing George Brown College Neonatal Nurse Practitioner SickKids® Hospital Toronto, Ontario

Contributors to the US Sixth Edition 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

Mary Catherine (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

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

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

Shannon E. Perry, RN, PhD, FAAN 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 Durham, North Carolina

Professor Emerita School of Nursing San Francisco State University San Francisco, California

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

REVIEWERS Kathryn I. Banks, BN, RN, CCNE, MSN, PhD Assistant Professor School of Nursing Thompson Rivers University Kamloops, British Columbia

Krystal Hoople BScN, RN Nurse Educator Maternal-Child Health MacEwan University Edmonton, Alberta

Linda Chipp, RN, BScN Nursing Instructor Vanier College Saint Laurent, Quebec

Shelly Ikert, RN, BScN Professor Nursing Lambton College Sarnia, Ontario

Nicola Eynon-Brown, RN(EC), BNSc, MN, NP–Paediatrics, CPNP-PC Professor Paediatric Nurse Practitioner School of Baccalaureate Nursing St. Lawrence College Brockville, Ontario

Cheyenne Joseph, RN, BScK, BScN, MPH, CCHN(C) Executive Director Rising Sun Treatment Centre Natoaganeg First Nation Eel Ground, New Brunswick

Tracey Fallak, RN, BScN, MN, CAE Curriculum Coordinator, Theory Instructor Mentor Nursing Red River College Winnipeg, Manitoba

Kelly Kidd, RN, BScN, MN Professor, Nursing Studies Coordinator Year 1 Practical Nursing Program Coordinator Clinical Education Health and Community Studies Algonquin College Pembroke, Ontario

Laurie Ann Graham, MN, NP–Pediatrics Nurse Practitioner–Pediatrics Faculty of Graduate Studies School of Nursing Dalhousie University Halifax, Nova Scotia

Caitlin Mathewson, RN, BScN, MN, PNC(C) Professor School of Health and Community Services Mohawk College Hamilton, Ontario

Mona Haimour, BScN, MSN, MPH, RN Assistant Professor Department of Nursing Science MacEwan University Edmonton, Alberta

Nicole Lewis-Power, RN, BN, MN, PhD(c) Lecturer School of Nursing Memorial University of Newfoundland St. John’s, Newfoundland

Lynn Haslam-Larmer, RN(EC), PhD Nurse Practitioner – Adult PhD, Aging & Health Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Term Adjunct School of Rehabilitation Therapy Queen’s University Kingston, Ontario Part time Faculty Sally Horsfall Eaton School of Nursing George Brown College Toronto, Ontario

Lynn Carole Smith, PhD, RN-EC, NP–Pediatrics Professor and Nurse Practitioner Health Sciences and Emergency Services East End Family Health Team Northern College Timmins, Ontario Nancy Watts, RN, MN, PNC(C) Clinical Nurse Specialist Women’s & Infant’s Program Mount Sinai Hospital Toronto, Ontario

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PREFACE

This third edition of Perry’s Maternal Child Nursing Care in Canada combines essential perinatal and pediatric nursing information into one text. The text focuses on the care of childbearing persons during their reproductive years and the care of children from birth through adolescence. The first section of the text focuses on important issues related to perinatal and pediatric nursing in Canada, including an overview of family and culture, as well as community nursing care. The second section discusses the promotion of wellness and the care of women experiencing common health concerns throughout the lifespan and care of the childbearing person. The health care of children and child development in the context of the family is the focus for the third section. The text provides a family-centred care approach that recognizes the importance of collaboration with families when providing care. This third edition of Perry’s Maternal Child Nursing Care in Canada is designed to address the changing needs of Canadian persons during their childbearing years and those of children during their developing years. Perry’s Maternal Child Nursing Care in Canada 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 third edition reflects the Canadian health care system, the importance of family-centred care, the significance of Indigenous health, and the cultural diversity throughout the country. 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 perinatal and pediatric nursing and to improve the way in which care is given. Increasingly, nursing care must be artfully constructed using research to inform the care provided. 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-Informed Practice boxes are included throughout the text. Consumers of perinatal 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 centres, homes, clinics, health care providers’ offices, shelters for the homeless or for adults and children who require protection, and other communitybased settings. The focus in the chapters is on nursing care, along with collaboration with other health care disciplines, as this combination provides the most comprehensive care possible to childbearing patients and children. Included on the Evolve site for this edition are the Nursing Process boxes and the Nursing Care Plans. The Nursing Process boxes include assessments, analysis, planning, implementation, and evaluation of nursing care, and the Nursing Care Plans reinforce the problem-solving approach to patient care. Throughout the discussion

of assessment and care, warning signs and emergency situations are also highlighted, to alert the nurse to signs of potential problems. Patient education is an essential component of nursing care of childbearing persons and children. Family-Centred Care boxes incorporate family considerations important to care to perinatal patients and children. Issues concerning grandparents, siblings, and various family constellations are also addressed. In the pediatric chapters (Part 3), these boxes focus on the special learning needs of families caring for their child. Legal Tips are integrated throughout the maternity section to emphasize these issues as they relate to the care of childbearing patients and infants. This third edition features a contemporary layout with logical, easyto-follow headings and an attractive four-colour design that highlights important content and increases visual appeal. Hundreds of colour photographs and drawings throughout the text 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, students are encouraged to apply critical thinking in real-life scenarios presented in the Clinical Reasoning Case Studies.

NEW TO THIS EDITION • A new chapter specifically focused on pediatric health promotion throughout childhood • A new chapter focused on pediatric mental health • A specific chapter that focuses on caring for the child with a complex chronic condition or at the end of life, with a focus on providing care in the home • Expanded coverage with a focus on global health perspectives and health care in the LGBTQ2, Indigenous, immigrant, and other vulnerable populations. • New and updated references, sources, and guidelines are provided, including the following: • Society of Obstetrician and Gynaecologists of Canada (SOGC) guidelines • Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN) • Public Health Agency of Canada, Sexually transmitted infection (STI) guidelines • Canadian Paediatric Society (CPS) standards • Canadian Association of Midwives (CAM) • Health Canada • Family-Centred Maternity and Newborn Care Guidelines from the Public Health Agency of Canada • Registered Nurses’ Association of Ontario (RNAO) • Perinatal Services BC • American College of Obstetricians and Gynecologists (ACOG) • Centers for Disease Control and Prevention (CDC) • World Health Organization (WHO) • There is increased emphasis on health promotion in the Perinatal and Pediatric sections of the text.

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PREFACE

• Additional case studies and clinical reasoning/clinical judgementfocused practice questions in the printed text and on the Evolve companion website promote critical thinking and prepare students for exam licensure. • New Evolve PN Case Studies for Clinical Judgement reflect current PN competencies including for Ontario and British Columbia on Evolve • Next-Generation NCLEX™ (NGN)-Style Case Studies for Maternity and Pediatric on Evolve

• Key Points, located at the end of each chapter, help the reader summarize major points, make connections, and synthesize information. The Key Points are also available in a downloadable format and can be found on this book’s Evolve site. • Additional Resources, including websites and contact information for organizations and educational resources available for the topics discussed, are listed throughout. • A highly detailed, cross-referenced index enables readers to quickly access needed information.

SPECIAL FEATURES

SUPPLEMENTAL RESOURCES

• Objectives focus students’ attention on the important content to be mastered. • Atraumatic Care boxes emphasize the importance of providing competent care while minimizing undue physical and psychological distress for the child and family.

A comprehensive ancillary package is available to students and instructors using Perry’s Maternal Child Nursing Care in Canada. The following supplemental resources have been thoroughly revised for this edition and can significantly assist in the teaching and learning of perinatal and pediatric nursing in classroom and clinical settings.

•

Study Guide – NEW!

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

•

Clinical Reasoning Case Studies present students with reallife situations and encourage students to make appropriate clinical judgements. Answer guidelines are provided on the book’s Evolve site.

•

Cultural Awareness boxes describe beliefs and practices about pregnancy, childbirth, parenting, women’s health concerns, and caring for sick children.

•

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

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Family-Centred Care boxes highlight the needs of families that should be addressed when family-centred care is provided.

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

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Medication Guide boxes include key information about medications used in maternity and newborn care, including their indications, adverse effects, and nursing considerations. • Patient Teaching boxes assist students to help patients and families become involved in their own care with optimal outcomes. • Evidence-Informed Practice boxes are incorporated throughout the book. Findings that confirm effective practices or that identify practices with unknown, ineffective, or harmful effects are located within the narrative. • Legal Tips are integrated throughout Part 1 to provide students with relevant information to address important legal areas in the context of perinatal nursing. •

Medication Alerts provide important information regarding the safety of medications, including interactions with other medications and important nursing considerations.

•

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

•

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

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. • Thinking Critically case-based activities require students to apply the concepts found in the chapters to solve problems, make clinicaljudgement decisions concerning care management, and provide responses to patient questions and concerns. • Reviewing Key Concepts questions in various formats give students ample opportunities to assess their knowledge and comprehension of information covered in the text. Activities, including matching, fill-in-the-blank, true/false, short-answer, and multiple-choice, help students identify the core content of the chapter and test their understanding after reading the chapter. • Learning Key Terms matching and fill-in-the-blank questions let students test their ability to define all key terms highlighted in the corresponding textbook chapter.

Evolve Website Located at http://evolve.elsevier.com/Canada/Perry/maternal, the Evolve website for this book includes the following elements.

For Students

• More than 500 Review Questions for Exam Preparation • Answers to Clinical Reasoning Case Studies from the book • Key Points •

•

Nursing Care Plans provide commonly encountered situations and disorders. Nursing diagnoses are included, as are rationales for nursing interventions that might not be immediately evident to students.

Nursing Processes help students to easily identify information on some major diseases and conditions. • Nursing Skills teach students how to implement concepts presented in the textbook and use them in real-life situations. This will enhance student knowledge and give students a better understanding of concepts they learn while reading the textbook. • Audio Glossary • PN Case Studies for Clinical Judgement reflect current PN competencies, including for Ontario and British Columbia

PREFACE

• Next-Generation NCLEX™ (NGN)-Style Case Studies for Maternity and Pediatrics

For Instructors

• Next-Generation NCLEX™ (NGN)-Style Case Studies for Maternity and Pediatric • Case studies • TEACH for Nurses Lesson Plans that focus on the most important content from each chapter and provide innovative strategies for student engagement and learning. These new Lesson Plans include strategies for integrating nursing curriculum standards, conceptbased learning examples, relevant student and instructor resources, and an original instructor-only Case Study in most chapters. • ExamView® Test Bank that features more than 1 500 examinationformat test questions (including alternate-item questions), rationales, and answers. The robust ExamView® testing application, provided at no cost to faculty, allows instructors to create new tests; edit, add, and delete test questions; sort questions by category, cognitive level, and nursing process step; and administer and grade tests online, with automated scoring and gradebook functionality. • PowerPoint® Lecture Slides consisting of more than 2 100 customizable text slides for instructors to use in lectures • An Image Collection with over 500 full-colour images from the book for instructors to use in lectures • Access to all student resources listed above

Simulation Learning System (SLS) The Simulation Learning System (SLS) is an online toolkit that helps instructors and facilitators effectively incorporate medium- to highfidelity 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.

Sherpath Sherpath’s book-organized collections offer digital lessons, mapped chapter-by-chapter to the textbook, so the reader can conveniently find applicable digital assignment content. Sherpath features convenient teaching materials that are aligned to the textbook, and the lessons are organized by chapter for quick and easy access to invaluable class activities and resources.

Elsevier eBooks This exciting program is available to faculty who adopt a number of Elsevier texts, including Perry’s Maternal Child Nursing Care in Canada. Elsevier eBooks is an integrated electronic study centre consisting of a collection of textbooks made available online. It is carefully designed to “extend” the textbook for an easier and more efficient

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teaching and learning experience. It includes study aids such as highlighting, e-note taking, and cut-and-paste capabilities. Even more importantly, it allows students and instructors to do a comprehensive search within the specific text or across a number of titles. Please check with your Elsevier Canada sales representative for more information.

Next Generation NCLEX™ (NGN) The National Council for the State Boards of Nursing (NCSBN) is a notfor-profit organization whose members include nursing regulatory bodies. In empowering and supporting nursing regulators in their mandate to protect the public, the NCSBN is involved in the development of nursing licensure examinations, such as the NCLEX-RN®. In Canada, the NCLEX-RN® was introduced in 2015 and is as of the writing of this text the recognized licensure exam required for practising RNs in Canada. As of 2023, the NCLEX-RN® will be changing to ensure that its item types adequately measure clinical judgement, critical thinking, and problem-solving skills on a consistent basis. The NCSBN will also be incorporating into the examination the Clinical Judgement Measurement Model (CJMM), which is a framework the NCSBN has created to measure a novice nurse’s ability to apply clinical judgement in practice. These changes to the examination come as a result of findings indicating that novice nurses have a much higher than desirable error rate with patients (errors causing patient harm) and, upon NCSBN’s investigation, discovering that the overwhelming majority of these errors were caused by failures of clinical judgement. Clinical judgement has been a foundation underlying nursing education for decades, based on the work of a number of nursing theorists. The theory of clinical judgement that most closely aligns with what NCSBN is basing their CJMM on is the work by Christine A. Tanner. The new version of the NCLEX-RN® is identified loosely as the “Next-Generation NCLEX” or “NGN” and will feature the following: • Six key skills in the CJMM: recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes • Approved item types as of March 2021: multiple response, extended drag and drop, cloze (drop-down), enhanced hot-spot (highlighting), matrix/grid, bowtie and trend. More question types may be added. • All new item types are accompanied by mini-case studies with comprehensive patient information—some of it relevant to the question, and some of it not. • Case information may present a single, unchanging moment in time (a “single episode” case study) or multiple moments in time as a patient’s condition changes (an “unfolding” case study). • Single-episode case studies may be accompanied by one to six questions; unfolding case studies are accompanied by six questions. For more information (and details) regarding the NCLEX-RN® and changes coming to the exam, visit the NCSBNs website: https://www. ncsbn.org/11447.htm and https://ncsbn.org/Building_a_Method_for_ Writing_Clinical_Judgment_It.pdf. For further NCLEX-RN® examination preparation resources, see Elsevier’s Canadian Comprehensive Review for the NCLEX-RN Examination, Second Edition, ISBN 9780323709385. Prior to preparing for any nursing licensure examination, please refer to your provincial or territorial nursing regulatory body to determine which licensure examination is required in order for you to practice in your chosen jurisdiction.

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ACKNOWLEDGEMENTS

The authors and contributors of the text recognize and acknowledge the diverse histories of the First Peoples of the lands now referred to as Canada. It is recognized that individual communities identify themselves in various ways; within this text, the term Indigenous will be used to refer to all First Nations, Inuit, and Metis people within Canada. In the text, gender-neutral language is used, to be respectful of and consistent with the values of equality recognized in the Canadian Charter of Rights and Freedoms. Using gender-neutral language is professionally responsible and mandated by the Canadian Federal Plan for Gender Equality. This text also recognizes that childbirth is experienced not only by women but also by others who do not identify as female or who find the term woman to not be representative of how they identify themselves. The terms patient, person, and parent are used when possible in the text. Woman/women is used when the research is specifically done with a population that identifies as a woman. I would like to offer thanks to the many perinatal contributors who worked diligently to provide this text with an updated and uniquely Canadian perspective as well as to the perinatal nurses across the country who continue to provide high-quality, family-centred care to childbearing persons and their families. I thank my students, who always keep me on my toes and ensure that I provide the most current information in a way that is engaging. To my family, who always provide their support and encouragement, I thank you. Most importantly I would like to dedicate this text to the memory of both of my parents (Ross and Ruby Keenan), who encouraged me to always strive for the best. Lisa Keenan-Lindsay

I would like to thank the many pediatric experts who have not only contributed to the “peds” part of this text but also made major contributions to the field of pediatric nursing in Canada. You make a difference every day to children and their families. I would also like to thank my husband, Stuart Sams, and my family for cheering me on. Cheryl Sams Thank you to my nursing colleagues who generously shared their knowledge and time in contributing to this text. I would also like to thank my family and friends for their support and encouragement. Constance (Connie) O’Connor A special thank you goes to Lenore Gray Spence, Jerri Hurlbutt, Abigail Bradberry, Roberta A. Spinosa-Millman, and the rest of the group at Elsevier for all of their exceptional support and encouragement throughout the development of this book. We also would like to thank all our chapter contributors and reviewers whose advice, expertise, insight, and dedication greatly assisted us in completing this edition. We appreciate all your time and guidance. Lisa, Cheryl, and Connie

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PART

1

Maternal Child Nursing

Unit 1. Introduction to Maternal Child Nursing, 2 Chapter 1. Contemporary Perinatal and Pediatric Nursing in Canada, 2 Chapter 2. The Family and Culture, 15 Chapter 3. Community Care, 27

1

UNIT 1 Introduction to Maternal Child Nursing

1 Contemporary Perinatal and Pediatric Nursing in Canada Erica Hurley http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the scope of perinatal and pediatric nursing in Canada today. 2. Examine the historical context of health care in Canada. 3. Identify social determinants of health and other factors that influence the health of childbearing persons, families and children, and explore approaches needed to address health inequities in Canada. 4. Explore trauma-informed care.

5. Describe the impact of colonialism on the health of Indigenous people. 6. Consider the role of research in perinatal and pediatric nursing. 7. Identify strategies to enhance interprofessional communication. 8. Describe how the Sustainable Development Goals (SDGs) are focused on improving the health of people worldwide. 9. Explore ethical issues in contemporary perinatal and pediatric nursing.

The focus of the first part of this book is to provide an overview of perinatal and pediatric nursing in Canada from a national and global perspective. The role of social, cultural, and family influences on health promotion will also be discussed, as will the role of nurses in the community. Chapters 4 through 29 focus on the care of childbearing patients and families, or perinatal nursing, as well as women’s health promotion (Chapters 5 to 8). Chapters 30 to 55 address the issues and trends related to the health care of children.

(see discussion below). Most nurses working in hospitals provide acute care, while nurses working in a community setting may provide care that focuses on health promotion, rehabilitation, and palliative care. Nurses who provide care for childbearing persons as well as children can influence the health care system by drawing attention to the needs of the patients in their care. Through professional associations, nurses can have a voice in setting standards and influencing health policy by actively participating in the education of the public and that of local, provincial, and federal legislators. Nurses throughout history have developed strategies to improve the well-being of childbearing persons and their newborns and children, and they have led efforts to develop and implement clinical practice guidelines that draw on current evidence and research.

PERINATAL AND PEDIATRIC NURSING Nurses care for childbearing persons, for children, and for families in many settings, including the hospital, the home, and a variety of ambulatory and community settings. Nurses also work collaboratively with other health and social care providers, such as physicians, midwives, dietitians, doulas, and social workers, to name a few. Perinatal nurses are those nurses who work collaboratively with patients and families from the preconception period throughout the childbearing year. Pediatric nurses care for children from birth up to age 18 years. Nurses caring for children also provide care for the family. Nursing care is provided in many settings, including inner-city, urban, or rural communities. The setting where nursing care is provided may have implications for the services that are offered, as remote and rural communities may not have all services necessary to provide comprehensive care

2

THE HISTORY AND CONTEXT OF HEALTH CARE IN CANADA Canada’s government-funded health insurance program (Medicare) provides universal medical and hospital services for all Canadians, although health services in Canada are organized provincially and territorially. Indigenous people within Canada may have different access to services funded through the federal government, although this funding is not at the same level as for provincial health services. Additionally, new immigrants to Canada may have to wait 90 days for

CHAPTER 1

Contemporary Perinatal and Pediatric Nursing in Canada

government health coverage, depending on which province or territory they live in. The Interim Federal Health Program provides temporary health coverage for certain groups of refugees before they are covered under provincial or territorial health insurance plans. The principles of the Canada Health Act include public administration, comprehensive “medically necessary” care, universality, portability, and accessibility. Home care, extended care, pharmaceuticals, and dental care are not currently covered under Medicare provisions, although different provinces do cover some of these items. For example, the province of Ontario covers the cost of over 4 400 medications for anyone age 24 years or younger who is not covered by a private plan, and Nova Scotia has a provincial drug insurance plan that is designed to help residents with the cost of their prescription medications if needed. Thus, to some extent, Canada’s Medicare program shapes the health services offered to Canadians. In an effort to control health care costs, interest has grown in restructuring health services and developing communitybased programs and preventive health services. For example, pharmacists in Nova Scotia are able to prescribe birth control, thus eliminating the need for a visit to another health care provider. Since the Lalonde Report was released in 1974, Canada has been a global leader in health promotion. In 1986, Canada hosted the first international conference on health promotion, which resulted in the Ottawa Charter. Three challenges for Canadians were identified: reducing health inequities, increasing disease prevention, and enhancing people’s capacities to live with chronic disease and disability. The Charter also acknowledged the need for intersectoral collaboration, or looking beyond health, to include other sectors (e.g., income security, employment, education, housing, and transportation) (Corbin, 2017). In the late 1990s, interest expanded to creating evidenceinformed programs that address all factors that impact health. With the HIV/AIDS epidemic, increasing rates of tuberculosis and other infectious diseases, the threat of bioterrorism, the severe acute respiratory syndrome (SARS) epidemic, and Ebola outbreaks, Canadians were reminded of the importance of immunizations and public health measures. In 2004, the federal government created the Public Health Agency of Canada (PHAC). While the PHAC initially focused on population health and health promotion, the emergence of avian influenza shifted the focus toward planning for a pandemic, such as that with COVID-19, along with health promotion. The delivery of health care within each community, province, and territory contains unique elements as each level of government tries to balance human resources, funding, and liability concerns with regulatory, educational, political, and demographic issues. Inequities in health care have developed and been identified as existing between rural, remote, inner-city, and Indigenous communities and other Canadian communities.

CONTEMPORARY ISSUES AND TRENDS Social Determinants of Health The emphasis in health care has shifted from treatment of illnesses to health promotion and disease prevention. In order to promote good health, the many complex influences on health need to be investigated and understood. To this end, the federal government has outlined the social determinants of health (Box 1.1). The social determinants of health are the social and economic factors that influence people’s health, either positively or negatively. These determinants provide a blueprint for health care policies and help direct population health research with the goal of improving health for its citizens (PHAC, 2016). They relate to an individual’s place in society, such as income, education, or employment. Experiences of discrimination, racism,

BOX 1.1

3

Social Determinants of Health

The main determinants of health include the following: • Income and social status • Employment and working conditions • Education and literacy • Childhood experiences • Physical environments • Social supports and coping skills • Healthy behaviours • Access to health services • Biology and genetic endowment • Gender • Culture • Race/Racism Source: Adapted from Public Health Agency of Canada. (2020). Social determinants of health and health inequalities. https://www.canada.ca/ en/public-health/services/health-promotion/population-health/whatdetermines-health.html

and historical trauma are important social determinants of health for certain groups, such as Indigenous peoples, LGBTQ2 persons, and Black Canadians (Government of Canada, 2020b). The Canadian Nurses Association (CNA) (2018) position statement regarding the social determinants of health states that nurses in all domains of practice can address social inequities by: • Addressing policies related to income, employment, education, housing, transportation, and other factors; these should be evaluated in their planning stages for their impact on health • Collaborating with others both within and outside the health sector, striving to reduce and, ultimately, eliminate health inequity • Including the social determinants of health in their assessments and interventions with individuals, families and communities • Incorporating the analysis of the social determinants of health, starting with a critical understanding of the political, economic and social factors that are the root causes of health inequities into nursing education. Health inequity refers to health inequalities that are unfair or unjust, and modifiable. For example, Canadians who live in remote or northern regions do not have the same access to nutritious foods such as fruits and vegetables as other Canadians. Health equity is the absence of unfair systems and policies that cause health inequalities (Government of Canada, 2020b). Advocates of health equity seek to reduce inequalities and increase access to opportunities and conditions that are conducive to good health for all. Many health inequities also result from a lack of access to the social determinants of health that promote good health, creating conditions of vulnerability to experiencing poor health. For example, poverty has the most significant influence on the development of compromised maternal and child health (Abraha et al., 2019). Furthermore, continued examination is needed regarding how specific populations, alternate health care practices, and technology differ in terms of health determinants and overall health status.

Socioeconomic Status. There is strong and growing evidence that higher social and economic status is associated with better health. The term poverty implies both visible and invisible impoverishment. It is a condition in which families live without adequate resources (May & Standing Committee, 2017). Visible poverty refers to lack of money or material resources, which includes insufficient clothing, poor sanitation, and deteriorating housing. Invisible poverty refers to social and cultural deprivation, such as limited employment opportunities,

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inferior educational opportunities, lack of or inferior medical services and health care facilities, and an absence of public services. The sum of all aspects of a low-income family’s living situation can contribute to and compound health problems, such as crowded living conditions and poor sanitation, which facilitate transfer of disease (e.g., tuberculosis or COVID-19). Lack of funds or inaccessibility to health services can inhibit treatment for any but severe illness or injury. Sometimes health care is inadequate because of lack of information; individuals may not have information regarding causes, treatment, or outcomes of illness or preventive measures. Although Canada has no official definition of poverty, it is typically measured using the low income cut-offs (LICO)—before and after taxes, the low income measures (LIM)—before and after taxes, and the market basket measures (MBM) (Statistics Canada, 2015a). The LICO is meant to express the income level at which a family faces constraints because it has to spend a higher percentage of its income on basic resources—for example, shelter, clothes, food—than the average similar-size family. In 2017, Statistics Canada, using the LIM, reported no significantly different rate from 2016 to 2017. However, the LIM for children was significantly lower in 2017 at 12.1%, down 1.9 percentage points from 2016 (Statistics Canada, 2019a). Low-income rates are more prevalent among certain subgroups of women. Poverty rates among Indigenous Canadians are 3.8 times higher than for nonracialized, non-Indigenous children (Beedie et al., 2019). Compared to lone male-parent families, lone mothers are more likely to have incomes that fall below the LICO (Statistics Canada, 2019b).

Health Inequity Within Certain Populations. In Canada, survival rates among childbearing patients and infants and children are among the best in the world. This is in part due to relatively high levels of education, economic and social well-being, and an effective universal health care system. However, it is important to recognize that Canada does have vulnerable populations who face significant health inequities. There are many families in this country who do not have ideal outcomes and face considerable challenges and health risks. Rates of adverse pregnancy outcomes, including preterm birth and intrauterine growth restriction, generally rise with greater socioeconomic disadvantage. For example, one contributing factor is that socioeconomically vulnerable patients are less likely to initiate early prenatal care, for a variety of reasons. All of these factors can translate into poor pregnancy outcomes. Poor fetal development is associated with many chronic diseases in later life (Baird et al., 2017). This means that the impact of being disadvantaged can last a lifetime. Vulnerable childbearing patients also face a higher risk of death after birth (Verstraeten et al., 2015). The high burden of illness responsible for premature loss of life arises in large part from the conditions in which people are born, grow, live, work, and age (National Academies of Sciences, Engineering & Medicine, 2017). Overall, there are significant health inequalities among Indigenous peoples, sexual and racial minorities, immigrants, and people living with functional limitations, as well as inequalities based on socioeconomic status (income, education levels, employment, and occupation status) (PHAC, 2018). People affected include patients with mental health issues, those who work in the sex-trade industry, pregnant and parenting adolescents, and patients whose newborn has been taken into custody by child protection services. The offspring of persons belonging to these populations are also at increased risk for poor outcomes. Many of these poor outcomes are preventable through access to adequate nutrition, good prenatal care, and use of preventive health practices. Clearly, comprehensive, community-based care that is culturally relevant and accessible for all childbearing persons and for children and families is needed.

Health experiences differ within and between social groups. For example, immigrants; Indigenous women; women in remote and rural areas; women with disabilities; women living with mental illness; women living in low-income situations; and lesbian, bisexual, queer, and transgender people have differential access to health services and differing health care needs. Many persons belonging to these vulnerable population groups struggle to find health care practitioners who are knowledgeable and respectful of their specific needs and who provide care that is both culturally and socially sensitive and safe. Indigenous people. Historical impacts of colonization have had a negative impact on the health of Indigenous people (Truth and Reconciliation Commission of Canada, 2015). Additionally, social determinants of health specific to Indigenous people have been identified that have had a unique impact on this population, such as a history of children being forced to reside at and attend residential schools, poverty, racism, and social exclusion (Figure 1.1). Indigenous families living in poverty consistently have poorer health outcomes and are at greater risk of adverse pregnancy and poor infant and child health outcomes. See further discussion of Indigenous people below. Immigrants and refugees. While Canada has been home to immigrants and refugees since its creation, within the last decade there has been a steady increase in the number of immigrants moving to Canada. In 2011, 21% of all women living in Canada were born outside the country (Hudon, 2016). Among recent immigrant women, the largest share has come from the People’s Republic of China, followed by the United Kingdom, India, the Philippines, and the United States (Hudon, 2016). New immigrants often find themselves either underemployed or unemployed because of discrimination, complications around accreditation of foreign degrees, lack of available and affordable child care, and social isolation. Immigrant women’s rate of participation in the labour force is considerably lower than that of immigrant men and Canadian-born women. For instance, newly arrived immigrant women, those who arrived up to 5 years prior to the 2006 Census, were more likely to be unemployed than those who had spent more time in Canada. However, among immigrant women aged 25 to 54, the challenge of finding work eased the longer they lived in Canada (Hudon, 2016). Many of the conditions or illnesses that immigrants and refugees acquire contribute to the persistence of disparities in their health outcomes. Refugee status imposes a particular type of vulnerability on affected individuals and groups. Of primary significance are the precipitating factors by which people are displaced suddenly or forced to leave their country of origin: persecution, civil unrest, or war. Families are forced from their homes to seek residence and employment elsewhere. Often these groups are extremely impoverished and face extreme physical and emotional stress and trauma when they arrive in Canada. In general, refugees are more likely to live in poverty than are immigrants. Immigrants typically arrive in Canada with better health than that of the Canadian-born population. This is because immigrants are screened on medical and other health-related criteria before they are admitted to the country. However, over time, this “healthy immigrant effect” tends to diminish as their health status converges with that of the host population. Some medical problems may arise as immigrants age, as well as when they integrate and adopt behaviours that have negative health impacts. Other health issues may arise from the stress of immigration itself, which involves finding suitable employment and establishing a new social support network. Some immigrants and refugees also have decreased access to social supports and may have a hard time navigating the health care system, often due to language difficulties, which can ultimately impact overall health. Adolescents. Adolescent girls are considered vulnerable because of the increased probability of being involved in high-risk behaviours.

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Contemporary Perinatal and Pediatric Nursing in Canada

5

Web of Being: Social Determinants and Indigenous People’s Health

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Girls from low-income or disrupted families are more likely to engage in early sexual activity and other high-risk behaviours, with both immediate and long-term health consequences (Ryan, 2015). In Canada, 2.9% of women aged 15 to 19 become pregnant each year (Dunn et al., 2019). Declining teen pregnancy rates for Canada in general are indicative of better sexual and reproductive health among young people. This decline in teen pregnancy can be attributed largely to more sexually active young people using reliable contraception such as condoms and birth control pills. However, the incidence of sexually transmitted infections (STIs), primarily chlamydia, syphilis, and gonorrhea, is on the rise in Canada, with the highest rates occurring in adolescents and young adult females (Government of Canada, 2017) (see Chapter 6). Adolescent health is another broad target area for community health promotion efforts, including health education and policy

initiatives. Because adolescents often fail to perceive their own vulnerability, they need help navigating a complex environment and dealing with risky behaviours through preventive strategies that enhance decision making and increase protective factors. Older women. Women aged 65 and over constitute one of the fastest growing segments of the female population in Canada. In addition, women now predominate in the ranks of Canadian older persons, in large part because the life expectancy of women has risen more rapidly than that of men during most of the last century. The percentage of the female population accounted for by older women is expected to continue to rise during the next several decades. Over 6 million Canadians were aged 65 or older in 2014 (Government of Canada, 2014/2019). The average life expectancy for a 65-year-old is projected to increase by 1.8 years for women (to 88.8 years) between 2014 and 2036. While

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this is higher than the life expectancy projected for men (86.5 years), women still tend to be the most vulnerable to serious health conditions and the most likely to experience socioeconomic difficulties. While most older women report that their overall health is relatively good, almost all have a chronic health condition as diagnosed by a health care provider. Arthritis or rheumatism and high blood pressure are the most common chronic health issues reported by older women. However, there are preventive interventions that are effective in delaying or controlling age-related changes. Improving self-management activities such as diet and exercise are important health-promotion elements for this population. Homelessness. Homelessness is an increasing social and health challenge in Canada. Women are at increased risk for hidden homelessness, living in overcrowded conditions or having insufficient money for shelter (Gaetz et al., 2013). Family violence is a major cause of homelessness, a significant reason attributing to the use of homeless shelters. Homeless people comprise a population that is at high risk for chronic and infectious diseases and premature death. While both homeless women and men experience similar health issues, homeless women have distinct characteristics, vulnerabilities, and treatment needs. Homeless women may also be pregnant or have young children in their custody. Some of the health issues of particular significance to this group include access to birth control, prenatal care, breast and cervical cancer screening, and STIs. Homeless people are also disproportionately represented among those with mental health challenges and substance use disorders. Poverty is the primary cause of homelessness. While homeless people are a heterogeneous group, they do share a number of similar features that may contribute to their overall poor health status. These include low income, unemployment, low levels of education, insufficient material resources, fear and mistrust of the health care system and of health care providers, and limited social support. Canada urgently needs to find new and innovative strategies that will address the barriers to health care that homeless people face both in cities and in more remote rural areas. Children. Research conducted over the past two decades has emphasized the significance of the early years in the growth and development of children. The World Health Organization (WHO) has identified early child development as a social determinant of health and as the most important period of overall development throughout a

BOX 1.2

person’s lifespan. The period from prenatal development to 8 years of age is critical for cognitive, social, emotional, and physical development (Lannen & Ziswiler, 2014). All facets of children’s early development—those involving physical, social, emotional, and cognitive opportunities for growth—shape children’s learning, school success, economic participation, social citizenry, and health. It is important to identify where children are most at risk for adversity and to intervene accordingly. In terms of child well-being, Canada has room for improvement. UNICEF recently ranked Canada for children’s health and well-being at 29 out of 41, of the world’s richest nations (UNICEF Office of Research, 2017). In 2017, 622 000 children under 18 years of age, or 9%, lived below the poverty line (Statistics Canada, 2019a). Indigenous children stand out as being disproportionately burdened in Canada. In 2019, 47% of 254 100 First Nations children lived in poverty (Beedie et al., 2019). These children are growing up in deplorable conditions—some without running water, access to affordable nutritious food, housing, and a proper education, all of which are the responsibility of the federal government according to the Indian Act. Clearly, Canadian children are not doing as well as they could be. Of great concern is the high rate of obesity (twenty-ninth of 30 countries) and the high rate of bullying (twenty-seventh of 31 countries). Canada’s children also self-report that they have low life satisfaction; in fact, they are among the unhappiest children in the industrialized world (UNICEF Office of Research, 2017).

Trauma- and Violence-Informed Care Trauma- and violence-informed care involves an approach that embraces an understanding of trauma and violence at every step in the health care system. This approach recognizes the connections between violence, trauma, negative health outcomes, and behaviours (Government of Canada, 2018b). Many people are at risk of experiencing violence and trauma, making it important for health care providers to gain the knowledge and skills required to assist patients in receiving the best care possible. Box 1.2 outlines the principles of how to integrate trauma-informed care. The goal of trauma- and violence-informed approaches is to minimize harm to all people, whether or not there is a known experience of violence; therefore, a universal traumainformed approach is key for all people (Government of Canada,

Four Principles of Trauma-Informed Care

Understand trauma and violence and their impacts on people’s lives and behaviours: • Acknowledge the root causes of trauma without probing. • Listen, believe, and validate victims’ experiences. • Recognize their strengths. • Express concern. Create emotionally and physically safe environments: • Communicate in nonjudgemental ways so that people feel deserving, understood, recognized, and accepted. • Foster an authentic sense of connection to build trust. • Provide clear information and consistent expectations about services and programs. • Encourage patients to bring a supportive person with them to meetings or appointments. Foster opportunities for choice, collaboration, and connection: • Provide choices for treatment and services, and consider the choices together.

• Communicate openly and without judgement. • Provide the space for patients to express their feelings freely. • Listen carefully to the patient’s words and check in to make sure that you have understood correctly. Provide a strengths-based and capacity-building approach to support patient coping and resilience: • Help patients identify their strengths, through techniques such as motivational interviewing, a communication technique that improves engagement and empowerment. • Acknowledge the effects of historical and structural conditions on peoples’ lives. • Help people understand that their responses are normal. • Teach and model skills for recognizing triggers, such as calming, centring, and staying present.

Source: Adapted from Government of Canada. (2018). Trauma and violence-informed approaches to policy and practice. https://www.canada.ca/en/ public-health/services/publications/health-risks-safety/trauma-violence-informed-approaches-policy-practice.html

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2018b). Trauma- and violence-informed approaches are not about “treating” trauma, for example, through counselling. Instead, the focus is on minimizing the potential for harm and re-traumatization and to enhance safety, control, and resilience for all patients (Government of Canada, 2018b). Not all patients will disclose trauma or violence in their lives, but they do require respectful and safe care.

NURSING ALERT Universal trauma precautions are important for all patients in order to provide safe care. Embedding trauma- and violence-informed approaches into all aspects of policy and practice creates universal trauma precautions that can reduce harm and provide positive supports for all people (Government of Canada, 2018b).

Adverse Childhood Experiences It is important for nurses to be aware of adverse childhood experiences (ACEs) in their patients. These ACE’s are negative, stressful, traumatizing events that occur before the age of 18, and of the effects these can have on health risk across the lifespan (Alberta Family Wellness Initiative, 2021). These experiences can include adversities that children face in their home environment, such as various forms of physical and emotional abuse, neglect, and household dysfunction. Exposure to these experiences cause excessive activation of the stress response system. The more ACEs a child experiences, the more likely they will develop conditions like heart disease and diabetes, will have poor academic achievement, and may develop substance use disorders later in life (Center on the Developing Child at Harvard University, 2020). These experiences can occur across all socioeconomic groups. People who have experienced significant adversity (or many ACEs) are not irreparably damaged; through the implementation of three approaches—reducing stress, building responsive relationships, and strengthening life skills—the long-term effects of ACEs can be prevented or minimized (Center on the Developing Child at Harvard University, 2020). See Chapter 30 for further discussion of ACEs.

Indigenous People In 2016, the number of Indigenous people in Canada, which includes First Nations, Metis, and Inuit, was 1 673 785, accounting for 4.9% of the total population (Statistics Canada, 2017a). The average age of Indigenous people was 32.1 years in 2016—almost a decade younger than that of the non-Indigenous population (40.9 years) (Statistics Canada, 2017a). In 2016, around one-third of First Nations people (29.2%) were 14 years of age or younger. For Metis, 22.3% of the population were 14 years of age or younger, and among Inuit, one-third (33.0%) were 14 years of age or younger (Statistics Canada, 2017a). The history of Indigenous peoples is important to acknowledge, as it is the original history of the country—they are the first peoples of Canada and continue to play important roles in the country’s development and its future. They have a vibrant and strong culture, arts practice, and heritage. Indigenous people have their own systems of health knowledge within their own specific ways of knowing and being, thus it is important to acknowledge and utilize this information when providing care. It is also important to acknowledge the negative impacts that influence the lives of Indigenous people. As stated earlier, colonization continues to have a negative and lasting effect on all aspects of Indigenous people’s health, along with specific health determinants that have been identified for Indigenous people (see Figure 1.1). Living in remote locations and lack of access to some of the positive social determinants of health account for some of these health inequities. Improving access to nutritious food, clean water, and safe and secure housing could be fundamental to the improvement of Indigenous people’s long-term health.

7

Beginning in Ontario in 1831 and continuing until the closure of the last school in 1996 in Saskatchewan, the Canadian government, in partnership with a number of Christian churches, operated a residential school system for Indigenous children. The government-funded, usually church-run schools and residences were set up to force Indigenous children to assimilate into the Canadian mainstream by eliminating parental and community involvement in the intellectual, cultural, and spiritual development of Indigenous children in their own communities. More than 150 000 Indigenous children were placed in these residential schools (Truth and Reconciliation Commission [TRC], n.d.). The TRC has worked to reveal the history and ongoing legacy of church-run residential schools in a manner that fully documents the harms perpetrated against Indigenous people and that can lead the way toward respect, through reconciliation (TRC, 2012). In the TRC report, survivors describe what happened after they left the schools: They no longer felt connected to their parents or their families; some said they felt ashamed of themselves, their parents, and their culture; some children found it difficult to forgive their parents for sending them to residential school. Parents also reported the difficulties of having their children away from home and the issues that resulted when they returned home (TRC, 2012). In these schools, children were often forbidden to speak their Indigenous language or engage in their cultural and spiritual practices. Most children were abused—mentally, spiritually, physically, and/or sexually. Generations of children were severely traumatized by the experience, resulting in an ongoing legacy of intergenerational trauma. Intergenerational trauma is defined as untreated trauma that carries through generations and continues to have an impact on subsequent generations. One example of the trauma that was incurred by these children is the abuse they suffered. This abuse by their caregivers was their role model for parenting, one which the victims often repeated when they became parents. Also, when these children got older, they often coped with the post-traumatic stress they suffered by drinking or using other substances. This vicious cycle has continued as individuals, families, and communities cope with intergenerational trauma, leaving its impact on generations of families through parenting difficulties and other stresses. The TRC highlighted that Indigenous people need specialized health supports available near where they live. Many Indigenous people have to navigate services from the federal and provincial government, specifically those living on reservations. The need for health supports is especially acute in the northern and more isolated regions of Canada. It is imperative that health care providers become knowledgeable of Indigenous health and their view of health and illness, as well as of Indigenous healing practices in order to provide care that is culturally safe. The TRC (2015) final report calls on health care providers to acknowledge the necessity of Indigenous-led health and healing practices and to support these practices when requested. Such recognition is crucial to reconciliation.

Lesbian/Gay/Bisexual/Transsexual/Queer/2-Spirited (LGBTQ2) Health LGBTQ2 people have higher rates of illness due to discrimination, minority stress, avoidance of health care providers, and irregular access to health care services (Gahagan & Subirana-Malaret, 2018). This situation may be due in part to negative past experiences. Many LGBTQ2 people may delay or avoid seeking health care or choose to withhold personal information from health care providers. In general, LGBTQ2 people end up receiving less good-quality health care than the population as a whole (Rainbow Health Ontario [RHO], 2014). People who identify as LGBTQ2 also have some unique health concerns and may be at increased risk for certain health issues,

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including mental health challenges; substance use; intimate partner violence; higher rates of smoking and cancer; and diet, weight, and body image concerns (RHO, 2014). Many health care providers are not trained in these LGBTQ2 health needs and may not have the knowledge required in how to care for individuals in this population and are thus unable to provide the safest care possible. Nurses and other health care providers must provide care that is not seen as heteronormative and that is inclusive of people of any gender or sexuality and of those who choose to not state either. In providing care, questions need to be asked in a manner that does not make assumptions about sexuality or gender. Nurses should also be aware of their use of language and be careful not to genderize patients through the language that is used. They also need to be aware of how to be gender inclusive. Nurses caring for pediatric patients must also be conscious of LGBTQ2 concerns. Children and adolescents may have questions about their sexuality and gender, and if the nurse develops a therapeutic relationship with the child, the child may feel comfortable enough to ask questions and seek appropriate resources. Throughout this text, an attempt has been made to integrate LGBTQ2 issues into the respective sections. Although a comprehensive discussion is beyond the scope of this text, additional resources are also included, when available.

Culture Another factor that affects the delivery and quality of health care is the fact that the Canadian population is diverse in terms of culture, ethnicity, race, and age. According to the 2016 census, more than one fifth of Canadians were born in another country (Statistics Canada, 2019b). Statistics Canada predicts that by 2031, between 29 and 32% of Canadians will identify as belonging to a visible minority, and as many as three out of five people living in Toronto and Vancouver will identify as visible minorities (Statistics Canada, 2015b). Significant disparity exists in health outcomes among people of various racial and ethnic groups in Canada. People also have different health needs, practices, and health service preferences related to their ethnic or cultural backgrounds. They may have dietary preferences and health practices that are not understood by their caregivers. To meet the health care needs of a culturally diverse society, nurses must provide culturally safe and responsive care (see Chapter 2).

Integrative Healing and Alternate Health Practices Integrative healing encompasses complementary and alternative health modalities (CAM) that are sometimes used in combination with conventional biomedical modalities of treatment. Many popular healing modalities offer human-centred care based on philosophies that honour the individual’s beliefs, values, and desires. The focus of these modalities is on the whole person, not just on a disease complex. Many patients often find that integrative modalities are more consistent with their own belief systems and allow for more autonomy in health care decisions. It is important that nurses understand the beliefs of patients to ensure that their health care needs are met. Individuals may also have health practices based on their spirituality, culture, or race. Health care providers who practise cultural humility and acknowledge that they do not need to know all of these various alternatives but be open and receptive to gaining such knowledge are in a good position to assist in the patient’s care.

High-Technology Care Advances in scientific knowledge have contributed to a health care system that emphasizes high-technology care. For example, maternity care has extended to preconception counselling, more scientific techniques to monitor the childbearing person and fetus, more definitive tests for

hypoxia and acidosis, and neonatal intensive care units, which have often saved the lives of premature children. Enhanced technology has also increased the life expectancy of many children with chronic illnesses. Internet-based information is available to the public that can promote interactions among health care providers, families, and community providers. Point-of-care testing is also available. Personal data assistants are used to enhance comprehensive care; the medical record is increasingly in electronic form. Health information technology is also having a profound impact on the ways in which health services are delivered. Telehealth is an umbrella term for the use of communication technologies and electronic information to provide or support health care when participants are separated by distance. It enables specialists, including nurses, to provide health care and consultation to those needing care. While this technology can increase access to health services for people living in geographically isolated communities, nurses must use caution and evaluate the effects of such emerging technologies. Another Web-based resource is Healthlink, which provides people in several provinces with medically approved information on many health topics, medications, and tips for promoting healthy lifestyles (see Additional Resources).

Social Media Social media is a form of Internet-based technologies that allow users to create their own content and participate in dialogue. Common social media platforms are Facebook, Instagram, Snapchat, Twitter, and LinkedIn (Tandoc et al., 2019). In addition to their own personal use of these technologies, nurses can connect with nurses with similar interests, share and exchange information about patient care, obtain training, and provide a space for collaboration (Hao & Gao, 2017). However, there are pitfalls for nurses using this technology. Patient privacy and confidentiality can be violated, and institutions and colleagues can be cast in an unfavourable light, with negative consequences for those posting the information. Nursing students have been expelled from school and nurses have been fired or reprimanded by their provincial regulatory body for injudicious posts. To help make nurses aware of their responsibilities when using social media, the International Nurse Regulator Collaborative (INRC) published the six P’s for social media use (Box 1.3). Their report details 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 related problems. The Canadian Nurses Protective Society (2012) states that before nurses communicate on a social media website, it is important to consider what is said, who might read it, and the impact it might have if viewed by an employer, a patient, or licensing body.

BOX 1.3

Six P’s of Social Media Use

Professional—Act professionally at all times. Positive—Keep posts positive. Patient/Person-free—Keep posts patient or person free. Protect yourself—Protect your professionalism, your reputation, and yourself. Privacy—Keep your personal and professional life separate; respect privacy of others. Pause before you post—Consider implications; avoid posting in haste or anger. Source: Adapted from International Nurse Regulator Collaborative. (2016). Position statement: Social media use: Common expectations for nurses. http://www.cno.org/globalassets/docs/prac/incr-social-mediause-common-expectations-for-nurses.pdf

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While patients may identify social media as having positive benefits, many also know that they are at risk of negative health impacts from social media. Harmful behaviours displayed on social media platforms such as the Tide Pod Challenge and showing condom snorting have resulted in children being harmed. The most documented negative consequences have been cyberbullying, depression, social anxiety, and exposure to developmentally inappropriate content (Subrahmanyam & Smahel, 2011). Health care providers must be aware of social media impacts both positive and negative.

Health Literacy Health literacy involves the simultaneous use of a more complex and interconnected set of abilities: to read and act on written health information, to communicate needs to health providers, and to understand health instructions. Without adequate health literacy skills, illinformed decisions may be taken, health conditions may go unchecked or worsen, questions may go unasked or remain unanswered, accidents may happen, and people may get lost in the health care system (Canadian Council on Learning, 2008). Recent findings show that 60% of adults and 88% of older persons in Canada are not health literate (ABC Life Literacy Canada, 2018). People who are not health literate have difficulty using the everyday health information that is routinely available in health care facilities, grocery stores, retail outlets, and schools; through the media; and in their communities. They may also have difficulty reading appointment slips and determining the proper way to take medication. As a result of the increasingly multicultural nature of the Canadian population, there is an urgent need to address health literacy as a component of culturally and linguistically competent care. Canadians with low health-literacy skills were found to be more likely to be in poorer health (Berkman et al., 2011). Individuals and groups for whom English is a second language often lack the skills necessary to seek medical care and navigate the health care system. Health care providers can contribute to health literacy by speaking slowly and using simple, common words; avoiding jargon; using pictures and diagrams to illustrate key points; and assessing whether the patient understands the discussion. The skillful use of an interpreter or telephone interpretation service can promote understanding and informed consent (see Chapter 2).

Evidence-Informed or Research-Based Practice Evidence-informed practice (EIP) is the collection, interpretation, and integration of valid, important, and applicable patient-reported, nurse-observed, and research-derived information. Evidence-informed nursing practice combines knowledge with clinical experience and intuition. It provides a rational approach to decision making that facilitates best practice. Although not all practice can be evidence-informed, nurses must use the best available information to guide their interactions and interventions. Practising nurses should contribute to research because they are the individuals observing human responses to health and illness. The current emphasis on measurable outcomes to determine the efficacy of interventions (often in relation to the cost) demands that nurses know whether clinical interventions result in positive outcomes for their patients. This demand has influenced the current trend toward EIP, which involves questioning why something is effective and whether a better approach exists. The concept of EIP also involves analyzing published clinical research and translating it into the everyday practice of nursing. When nurses base their clinical practice on science and research and document their clinical outcomes, they are better able to validate their contributions to health, wellness, and cure—not only to their patients and institutions but also to the nursing profession. Evaluation is essential to the nursing process, and research is one of the best ways to accomplish this. Research plays a vital role in establishing perinatal, women’s health, and child health science. It can validate that nursing care makes a difference. For example, although prenatal care is associated with healthier infants, no one knows exactly which interventions produce this outcome. In the past, medical researchers rarely included women in their studies; thus more research in this area is crucial. Many possible areas of research exist in maternity and women and children’s health care. The clinician can identify problems in the health and health care of childbearing persons and of children. Through research, nurses can make a difference for these patients. Nurses should promote research funding and conduct research on perinatal, pediatric, and women’s health, especially concerning the effectiveness of nursing strategies for these patients (see Evidence-Informed Practice box: Searching for and Evaluating the Evidence).

EVIDENCE-INFORMED PRACTICE Searching for and Evaluating the Evidence

SPECIALIZATION AND EVIDENCE-INFORMED NURSING PRACTICE The increasing complexity of care required by childbearing persons and their newborns, as well as children who are sick, has contributed to the growth of specialized knowledge and skills needed by nurses working in the areas of perinatal and pediatric nursing. This specialized knowledge is gained through experience, advanced degrees, and certification programs. Advanced practice nurses, such as clinical nurse specialists, provide care for adults as well as children with complex health challenges. Nurse practitioners may provide primary care throughout the life of many patients. Lactation consultants, many of whom are nurses, provide services in the hospital, on an outpatient basis, or in the patient’s home. Maternal child nurses work collaboratively with public health nurses and an increasing array of health care providers. An example is working with registered midwives who may provide primary care during pregnancy and the early postpartum period. Public health nurses may also work with teachers in schools to provide quality education experiences for children with a chronic illness that affects their ability to attend school.

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Throughout this text you will see Evidence-Informed Practice boxes. These boxes provide examples of how a nurse might conduct an inquiry into an identified practice question. Curiosity, access to a virtual or real library, and research critique skills are needed for nurses to be confident that their practice is informed by a sound foundation of evidence. Nurses construct their practice informed by research from many different sources. Categorizing evidence by “levels” is being replaced with embracing multiple ways of knowing that include personal knowledge. Experienced nurses have practice knowledge that they need to share with other nurses through publication. Indigenous ways of knowing are increasingly being recognized within Westernized health care, and patients are being acknowledged as experts in their own health care experiences (Hyett et al., 2018). Quantitative and qualitative research has added to our understanding of a patient’s experience with the health care system, whether during illness or wellness care. Provided the professional organization is well respected and the process is rigorous, clinical practice guidelines and consensus statements reflect the current state of knowledge. Nurses need to also develop an inquiring mind and questioning attitude toward all forms of current evidence. In this way, the knowledge base required for perinatal and pediatric nursing will continue to grow and develop.

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Standards of Practice and Legal Issues in Delivery of Care Nursing standards of practice reflect current knowledge, represent levels of practice agreed on by leaders in the specialty and can be used for clinical benchmarking. In perinatal and women’s health nursing, there are several organizations that publish standards of practice and education. These include the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN) and the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), which publish standards of practice and education for perinatal nurses; and the National Association of Neonatal Nurses (NANN), which publishes standards of practice for neonatal nurses. The Canadian Association of Paediatric Nurses is the voice of pediatric nurses in Canada and has developed national standards. The Canadian Nurses Association (CNA) Certification Program also has competencies developed for perinatal, community, general pediatric, pediatric critical care nurses, and neonatal nurses that guide certification exams for each of these specialties. Certification with the CNA demonstrates specialized knowledge and enhances a nurse’s professional credibility, which is valued by employers. In addition to these more formalized standards, agencies have their own policy and procedure books 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.

LEGAL TIP: Standard of Care When there is uncertainty about how to perform a procedure, the nurse should consult the agency procedure book and follow the guidelines printed therein. These guidelines are the standard of care for that agency.

Patient Safety and Risk Management Medical errors are a leading cause of death in the hospital or at home. According to the Canadian Adverse Events Study (Baker Study), the most quoted study in Canada regarding medical errors, 7.5% of hospitalized patients had an adverse event and of these, 16% died as a result (Baker et al., 2004). The cost of adverse events is staggering; the economic burden of adverse events is $1.1 billion, including $397 million for preventable adverse events (Etchells et al., 2012). The actual numbers of adverse events are difficult to determine, as there is a culture of silence surrounding patient errors. The Canadian Patient Safety Institute (CPSI) was developed as an integrated strategy for improving patient safety in Canadian health care (Box 1.4). The CPSI facilitates collaboration among governments and care

BOX 1.4 Goals of the Canadian Patient Safety Institute (CPSI) The CPSI’s four goals to improve patient safety: • The CPSI will provide leadership on the establishment of a National Integrated Patient Safety Strategy. • The CPSI will inspire and sustain patient safety knowledge within the system and, through innovation, enable transformational change. • The CPSI will build and influence patient safety capability (knowledge and skills) at organizational and system levels. • The CPSI will engage all audiences across the health system in the national patient safety agenda. Source: The Canadian Patient Safety Institute. (2020). Patient safety forward with four. http://www.patientsafetyinstitute.ca/English/About/ PatientSafetyForwardWith4/Pages/default.aspx

providers to enhance patient safety and provides a number of useful resources, including the Canadian disclosure guidelines, an incident analysis framework, and the safety competencies framework. Achieving a culture of patient safety requires open, honest, and effective communication between health care providers and their patients. Patients are entitled to information about themselves and about their medical condition or illness, including the risks inherent in health care delivery (CPSI, 2011).

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-centred care will improve when health professionals work together (WHO, 2010). Six competency domains highlight the knowledge, skills, attitudes, and values that shape the judgements essential for interprofessional collaborative practice (Canadian Interprofessional Health Collaborative, 2010). See Box 1.5 for a description of the practice competencies related to IPE.

GLOBAL HEALTH As the world becomes a smaller place 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; provide obstetrical, surgical, ophthalmological, orthopedic, or other services; 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. The WHO (2020) has stated that nurses and midwives make up about 50% of the global health care workforce. Increasingly, Canadian nurses are working internationally in global health settings (Figure 1.2). This role is supported by the CNA (2012), which believes that nurses have the right and the responsibility to contribute to the advancement of global health and equity.

Sustainable Development Goals In the year 2000, the member nations of the United Nations (UN) developed the Millennium Development Goals (MDGs), which were eight international goals that focus on improving the health and education of the global community. The original plan was to reach these by the year 2015. The MDGs were drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations and signed by 147 heads of state and governments during the United

BOX 1.5 Competency Domains for Interprofessional Education (IPE) The six competency domains are as follows: • Interprofessional communication • Patient/client/family/community-centred care • Role clarification • Team functioning • Collaborative leadership • Interprofessional conflict resolution Source: Adapted from Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework. https://drive. google.com/file/d/1Des_mznc7Rr8stsEhHxl8XMjgiYWzRIn/view

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Fig. 1.2 Canadian Nurses for Africa provide free medical field care and preventative health care to communities in rural Kenya. (Permission Gail Wolters.)

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Nations Millennium Summit, in September 2000 (http://www.un.org/ millenniumgoals/). These goals were an ambitious pledge to uphold the principles of human dignity, equality, and equity and free the world from extreme poverty. Much work had been done on the MDGs, and they have made a profound difference in the lives of many people across the world (UN, 2015). According to the UN (2015), global poverty has been halved; 90% of children in developing regions now enjoy primary education, and disparities between boys and girls in enrollment have narrowed. There are decreased rates of malaria and tuberculosis, and the likelihood of a child dying before age 5 has been nearly cut in half over the last two decades. The number of people who do not have access to good water sources has also been halved. Despite the significant gains that have been made for many of the MDG targets worldwide, the progress has been uneven across regions and countries, leaving significant gaps (UN, 2015). In 2015 the UN endorsed the Sustainable Development Goals (SDGs) (Figure 1.3), which are a blueprint to achieve a better and more sustainable future for all. They address current global challenges, including those related to poverty, inequality, climate, environmental degradation, prosperity, and peace and justice, with a target of 2030 for achieving these (Government of Canada, 2018a). SDG #3 focuses on good health and well-being, and many of the goals related to this are focused on improving maternal and child health. Therefore, in the countdown to 2030 the aim is to support the monitoring and measurement of women’s, children’s, and adolescents’ health in 81 countries (Boerma et al., 2018). While acknowledging success in the countdown to 2015, it is clear that there is still much work to be done to improve intervention coverage, equity, and reproductive, maternal, newborn, and child health.

Fig. 1.3 Sustainable Development Goals. The United Nations has developed 17 goals to improve the health and well-being of the global community. (From United Nations. [2015]. Sustainable Development Goals kick off with start of new year. https://www.un.org/sustainabledevelopment/blog/2015/12/sustainable-development-goalskick-off-with-start-of-new-year/)

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In 2010, with the signature of the Muskoka Declaration, the Canadian government promised to assist developing countries in addressing health inequities that affect mothers and infants (Government of Canada, 2014). With its additional $1.1 billion commitment to maternal, newborn, and child health, Canada’s total commitment to reducing child mortality and improving maternal health was $3.25 billion from 2015 to 2020 (Government of Canada, 2020a).

ETHICAL ISSUES IN MATERNAL CHILD NURSING 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 childbearing persons who thought they would never bear children, including some who are menopausal or postmenopausal. Should scarce resources be devoted to achieving pregnancies in older patients? Is giving birth 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 childbearing person who is HIV positive have access to assisted reproduction services? Who should pay for reproductive technologies, such as the use of induced ovulation and in vitro fertilization? Other examples of ethical dilemmas within nursing include the use of life-saving measures for very low birth weight (VLBW) newborns, the terminally ill child’s right to refuse treatment, access to abortion, substance use of patients, informed consent, barriers to services, and confidentiality. Nurses may struggle with questions involving truthfulness, balancing their rights and responsibilities in caring for children with AIDS, whistle-blowing, or allocating resources. 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 VLBW babies. For example, discussion is required when a 23-week gestation baby is born alive, and decisions need to be made regarding what treatment will be provided, based on the wants of the parents and the knowledge of health care providers. The introduction of long-acting contraceptives has created moral choices and policy dilemmas for health care providers and legislators (e.g., whether some patients [substance users or patients who are HIV positive] should be required to take the contraceptives). With the potential for great good that can come 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, as well as scientists, physicians, lawyers, lawmakers, ethicists, and clergy, must be involved in the discussions. Nurses must prepare themselves systematically for collaborative ethical decision making. This can be accomplished through taking formal coursework and continuing education, reading contemporary literature, and working to establish an environment conducive to ethical discourse. Moreover, nurses need to be educated in the mechanisms for dispute resolution, case review by ethics committees, procedural safeguards, Canadian legislation, and case law. The nurse can also use the professional code of ethics for guidance and as a means for professional self-regulation. The Code of Ethics for Registered Nurses, by the CNA, provides the framework and core responsibilities for nursing practice. The Code of Ethics focuses on the nurse’s accountability and responsibility to the patient (CNA, 2017) and emphasizes the nursing role as an independent professional, one that upholds its own legal liability (see Additional Resources).

Ethical Guidelines for Nursing Research Research with women and children may create ethical dilemmas for the nurse. For example, participating in research may cause additional stress for a person concerned about outcomes of genetic testing or for one who is waiting for an invasive procedure. Obtaining amniotic fluid samples or performing cordocentesis poses risks to the fetus (see Chapter 13). Research on children must be conducted in ways that ensure informed consent of parents and for children, when possible (see Chapter 44, Consent for Health Research in Children). Nurses must protect the rights of human participants in all research; women and children are already vulnerable, so they need to be reassured that their rights are being protected. For example, nurses may need to collect data on or care for patients who are participating in clinical trials. The nurse should ensure that the participants are fully informed and aware of their rights as participants. The nurse may be involved in determining whether the benefits of research outweigh the risks to the parent and the fetus or to children and needs to ensure that all research conducted has been approved by the appropriate research ethics board. Research involving Indigenous people involves specific ethical guidelines because of their history. The Canadian Institute of Health Research (CIHR) is an example of an organization that outlines ethical guidelines of health research involving Indigenous people in Canada (CIHR, 2013).

KEY POINTS • Perinatal nursing focuses on caring for patients and their families throughout the childbearing years, and pediatric nurses care for children from birth to 18 years of age. • Nurses can play an active role in shaping health policy and health systems to be responsive to the needs of Canadian women and children. • The social determinants of health have an impact on the health of all people. • Of the determinants of health, poverty remains the most important factor resulting in conditions of vulnerability such as homelessness. • Families and children living in rural, remote, and Indigenous communities and in poverty in inner cities experience significant health challenges. • Universal trauma precautions can assist in providing safe care to all patients. • Indigenous patients have unique health care issues that require health care providers to understand the historical context and impact of the social determinants of health affecting these patients. • LGBTQ2 patients require health care providers who understand their specific health care needs. • Nurses must provide comprehensive, respectful care to all people, and knowledge about different cultural and diversity issues will assist in providing this care. • Integrative healing combines modern technology with ancient healing practices and encompasses the whole body, mind, and spirit. • Technology has had a tremendous influence on health care through use of high-technology care modalities as well as access to other health care providers and to patients through social media. • Perinatal and pediatric nursing practice is increasingly informed by research. • Nurses must ensure that safe care is provided to childbearing patients and children by communicating with other members of the health care team in a manner that ensures clear understanding. • While the Millennium Development Goals have improved the health of many people worldwide, much work still needs to be done to reduce poverty, promote gender equality, and improve perinatal

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and child health. The Sustainable Development Goals are focused on achieving a better and more sustainable future for all. • Ethical concerns have multiplied with the increasing use of technology and scientific advances.

REFERENCES ABC Life Literacy Canada. (2018). Health literacy still an issue in Canada. https://www.newswire.ca/news-releases/health-literacy-still-an-issue-incanada-694482791.html. Abraha, A., Myleus, A., Byass, P., et al. (2019). Social determinants of under-5 child health: A qualitative study in Wolkayit Woreda, Tigray Region, Ethiopia. PLOS ONE, 14(6). https://doi.org/10.1371/journal.pone.0218101. Alberta Family Wellness Initiative. (2021). Adverse childhood experiences (ACEs). https://www.albertafamilywellness.org/what-we-know/aces. Baker, G. R., Norton, P. G., Flintoft, V., et al. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678–1686. Baird, J., Jacob, C., Barker, M., et al. (2017). Developmental origins of health and disease: A lifecourse approach to the prevention of non-communicable diseases. Healthcare (Basel, Switzerland), 5(1), 14. https://doi.org/10.3390/ healthcare5010014. Beedie, N., Macdonald, D., & Wilson, D. (2019). Towards justice: Tackling Indigenous child poverty in Canada. Upstream. https://www.afn.ca/wpcontent/uploads/2019/07/Upstream_report_final_English_June-24-2019. pdf. Berkman, N. D., Sheridan, S. L., Donahue, K. E., et al. (2011). Health literacy interventions and outcomes: An updated systematic review. AHRQ Publication No. 11-E006. Evidence Report/Technology Assessment No. 199. http://www.ahrq.gov/downloads/pub/evidence/pdf/literacy/literacyup.pdf. Boerma, T., Requejo, J., Victora, C. G., et al. (2018). Countdown to 2030: Tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. The Lancet, 391(10129), 1538–1548. Canadian Council on Learning. (2008). Health literacy in Canada: A healthy understanding. http://www.en.copian.ca/library/research/ccl/health/health. pdf. Canadian Institutes of Health Research (CIHR). (2013). CIHR guidelines for health research involving Aboriginal people (2007–2010). http://www.cihrirsc.gc.ca/e/29134.html. Canadian Nurses Association (CNA). (2012). CNA Global health partnerships: Retrospective. https://www.cna-aiic.ca/
/media/cna/page-content/pdf-fr/ global_health_partnership_program_2012_e.pdf?la¼en. Canadian Nurses Association (CNA). (2017). Code of ethics for registered nurses. https://www.cna-aiic.ca/
/media/cna/page-content/pdf-en/code-of-ethics2017-edition-secure-interactive. Canadian Nurses Association (CNA). (2018). Position statement: Social determinants of health. https://www.cna-aiic.ca/-/media/cna/page-content/ pdf-en/social-determinants-of-health-position-statement_dec-2018.pdf? la¼en&hash¼CCD26634EF89E493DA64F60345A3AAB399089797. Canadian Nurses Protective Society. (2012). Social media. InfoLaw, 19(3). https://cnps.ca/article/social-media/. Canadian Patient Safety Institute (CPSI). (2011). Canadian disclosure guidelines: Being open and honest with patients and families. Author. Center on the Developing Child at Harvard University. (2020). ACEs and toxic stress: Frequently asked questions. https://developingchild.harvard.edu/ resources/aces-and-toxic-stress-frequently-asked-questions/. Corbin, J. H. (2017). Health promotion, partnership and intersectoral action. Health Promotion International, 32(6), 923–929. https://doi.org/10.1093/ heapro/dax084. Dunn, S., Xioung, A., Nurenberger, K., et al. (2019). Non-use of contraception by Canadian youth aged 15 to 24: Findings from the 2009–2010 Canadian community health survey. Journal of Obstetrics and Gynaecology Canada, 41 (1), 29–37. Etchells, E., Mittmann, N., Koo, M., et al. (2012). The economics of patient safety in acute care: Technical report. Canadian Patient Safety Institute. https:// www.patientsafetyinstitute.ca/en/toolsResources/Research/ commissionedResearch/EconomicsofPatientSafety/Documents/Economics

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%20of%20Patient%20Safety%20-%20Acute%20Care%20-%20Final% 20Report.pdf. Gaetz, S., Donaldson, J., Richter, T., et al. (2013). The state of homelessness in Canada 2013. Canadian Homelessness Research Network Press. http://www. wellesleyinstitute.com/wp-content/uploads/2013/06/SOHC2103.pdf. Gahagan, J., & Subirana-Malaret, M. (2018). Improving pathways to primary health care among LGBTQ populations and health care providers: Key findings from Nova Scotia, Canada. International Journal for Equity in Health, 17(1), 76. https://doi.org/10.1186/s12939-018-0786-0. Government of Canada. (2014). Action for seniors report. Modified 2019. https:// www.canada.ca/en/employment-social-development/programs/seniorsaction-report.html. Government of Canada. (2014). The Muskoka initiative: Background. http:// mnch.international.gc.ca/en/topics/leadership-muskoka_background.html. Government of Canada. (2017). Report on sexually transmitted infections in Canada: 2013–2014. https://www.canada.ca/en/public-health/services/ publications/diseases-conditions/report-sexually-transmitted-infectionscanada-2013-14.html. Government of Canada. (2018a). Canada’s implementation of the 2030 agenda for sustainable development: Voluntary national review. https:// sustainabledevelopment.un.org/content/documents/20312Canada_ ENGLISH_18122_Canadas_Voluntary_National_ReviewENv7.pdf. Government of Canada. (2018b). Trauma and violence-informed approaches to policy and practice. https://www.canada.ca/en/public-health/services/ publications/health-risks-safety/trauma-violence-informed-approachespolicy-practice.html. Government of Canada. (2020a). Improving the health and rights of women and children. https://www.international.gc.ca/world-monde/issues_ development-enjeux_developpement/global_health-sante_mondiale/ improving_health-ameliorer_sante.aspx?lang¼eng. Government of Canada. (2020b). Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/healthpromotion/population-health/what-determines-health.html. Hao, J., & Gao, B. (2017). Advantages and disadvantages for nurses of social media. Journal of Primary Health Care and General Practice, 1(1), 1–3. https://scientonline.org/open-access/advantages-and-disadvantages-fornurses-of-using-social-media.pdf. Hudon, T. (2016). Immigrant women. Statistics Canada. https://www150. statcan.gc.ca/n1/pub/89-503-x/2015001/article/14217-eng.htm. Hyett, S., Marjerrison, S., & Gabel, C. (2018). Improving health research among Indigenous Peoples in Canada. Canadian Medical Association Journal, 190 (20), E616–E621. Lannen, P., & Ziswiler, M. (2014). Potential and perils of the early years: The need to integrate violence prevention and early child development (ECD +). Aggression and Violent Behavior, 19(6), 625–628. May, B., & Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities. (2017). Breaking the cycle: A study on poverty reduction. https://www.ourcommons.ca/ Content/Committee/421/HUMA/Reports/RP8982185/humarp07/ humarp07-e.pdf. National Academies of Sciences, Engineering, and Medicine. (2017). Communities in action: Pathways to health equity. The National Academies Press. Public Health Agency of Canada. (2016). Public Health Agency of Canada 2016– 17: Report on plans and priorities. https://www.canada.ca/content/dam/ canada/health-canada/migration/healthy-canadians/publications/ department-ministere/phac-report-plans-priorities-2016-2017-rapportplans-priorites-aspc/alt/phac-report-plans-priorities-2016-2017-rapportplans-priorites-aspc-eng.pdf. Public Health Agency of Canada. (2018). Key health inequalities in Canada: A national portrait—Executive summary. https://www.canada.ca/en/publichealth/services/publications/science-research-data/key-health-inequalitiescanada-national-portrait-executive-summary.html. Rainbow Health Ontario (RHO). (2014). About LGBTQ health. http://www. rainbowhealthontario.ca/about-lgbtq-health/. Ryan, R. M. (2015). Nonresident fatherhood and adolescent sexual behavior: A comparison of siblings approach. Developmental Psychology, 51(2), 211–223. https://doi.org/10.1037/a0038562.

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Statistics Canada. (2015a). Low income definitions. https://www150.statcan.gc. ca/n1/pub/75f0011x/2012001/notes/low-faible-eng.htm. Statistics Canada. (2015b). The ethnocultural diversity of the Canadian population. Catalogue no. 89-638-X no. 2010004. http://www.statcan.gc.ca/ pub/91-551-x/2010001/hl-fs-eng.htm. Statistics Canada. (2017a). Aboriginal peoples in Canada: Key results from the 2016 census. https://www150.statcan.gc.ca/n1/daily-quotidien/171025/ dq171025a-eng.htm. Statistics Canada. (2019a). Canadian income survey 2017. https://www150. statcan.gc.ca/n1/daily-quotidien/190226/dq190226b-eng.htm. Statistics Canada. (2019b). Data table, 2016 census. https://www12.statcan.gc.ca/ census-recensement/2016/dp-pd/dt-td/index-eng.cfm. Subrahmanyam, K., & Smahel, D. (2011). Digital youth: The role of media in development. Springer. Tandoc, E. C., Lou, C., & Min, V. L. H. (2019). Platform-swinging in a polysocial-media context: How and why users navigate multiple social media platforms. Journal of Computer-Mediated Communication, 24(1), 21–35. https://doi.org/10.1093/jcmc/zmy022. Truth and Reconciliation Commission of Canada (TRC). (n.d.). Residential school locations. http://www.trc.ca/about-us/residential-school.html. Truth and Reconciliation Commission of Canada (TRC). (2012). Truth and Reconciliation Commission of Canada: Interim report. https://www. falconers.ca/wp-content/uploads/2015/07/TRC-Interim-Report.pdf. Truth and Reconciliation Commission of Canada (TRC). (2015). Truth and Reconciliation Commission of Canada: Calls to action. https://static1. squarespace.com/static/5ac510114611a0bcce082fac/t/ 5b92b141f950b758a9a5b2f2/1536340329039/TRC+Calls+to+Action +Pocket+booklet+.pdf. UNICEF Office of Research. (2017). Building the future: Children and the Sustainable Development Goals in rich countries. Innocenti Report Card 14. UNICEF Office of Research, Innocenti, Florence. https://www.unicef.ca/ sites/default/files/2017-06/UNICEF%20Innocenti%20Report%20Card% 2014%20EN.pdf. United Nations (UN). (2015). The Millennium Development Goals report 2015. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG% 202015%20rev%20%28July%201%29.pdf. Verstraeten, B. S., Mijovic-Kondejewski, J., Takeda, J., et al. (2015). Canada’s pregnancy-related mortality rates: Doing well but room for improvement. Clinical and Investigative Medicine, 38(1), E15–E22.

World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. https://www.who.int/ hrh/resources/framework_action/en/. World Health Organization (WHO). (2020). Nursing and midwifery. https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery.

ADDITIONAL RESOURCES Alberta Health Services Healthlink. http://www.albertahealthservices.ca/default. aspx. Best Start: A child becomes strong: Journeying through each stage of the life cycle (Indigenous child development/child rearing in Ontario). https://resources. beststart.org/wp-content/uploads/2019/01/K12-A-child-becomes-strong2020.pdf. Canadian Association of Schools of Nursing: Nursing informatics: Entry to practice competencies for registered nurses. https://www.casn.ca/wp-content/ uploads/2014/12/Nursing-Informatics-Entry-to-Practice-Competenciesfor-RNs_updated-June-4-2015.pdf. Canadian Nurses Association: CNA certification process. https://www.cna-aiic. ca/en/certification. Canadian Nurses Association: Code of ethics for registered nurses. (2017). https:// www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing-ethics. Healing the Hurt - Caring for Indigenous Mothers and Infants. https://www. indigenousmomandbaby.org/enter. Rainbow Health Ontario Resource Database—Reliable, up-to-date health resources to LGBT2SQ communities, service providers, and others with an interest in LGBT2SQ health. https://www. rainbowhealthontario.ca. St Michael’s Hospital—Transgender health resources. https://guides.hsict. library.utoronto.ca/TransgenderHealth. TransCare BC: Intro to working with transgender clients. https://rise.articulate. com/share/9XFuAqbV1rdLa2RaM18h31fK1q6gBk37#/. Truth and Reconciliation Commission of Canada. http://www.trc.ca. United Nations: Sustainable Development Goals. https://www.un.org/ sustainabledevelopment/. Upstream—Addresses the social determinants of health in order to build a healthier society. http://www.thinkupstream.net/.

UNIT 1 Introduction to Maternal Child Nursing

2 The Family and Culture Karen MacKinnon Originating US Chapter by Shannon E. Perry http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the variety of family forms encountered by nurses in Canada today. 2. Identify the principles that underpin interprofessional familycentred care. 3. Explore and describe theories and models developed as guides to family nursing in Canada. 4. Describe how different lenses or perspectives contribute to our understanding of family health promotion and relational nursing practice.

THE FAMILY IN CULTURAL AND COMMUNITY CONTEXT Perinatal and pediatric nurses have important professional responsibilities to families. Despite modern stresses and strains, the family still forms a social network that acts as a potent support system for its members. Family health practices and relationships with providers are influenced by culturally related health beliefs and values. Ultimately, all of these factors have the power to affect perinatal and child health outcomes. Nurses work collaboratively with families to achieve their goals related to wellness and family development. Because the Canadian population has become increasingly diverse in terms of culture, ethnicity, and socioeconomic status, it is essential that nurses become culturally competent in order to provide appropriate nursing care.

The Family in Society The social context for the family can be viewed in relation to social and demographic trends that reflect the population as a whole. Each family sets up boundaries between itself and society. People are conscious of the difference between “family members” and “outsiders,” or people without kinship status. Some families isolate themselves from the outside community; others have a wide community network that they can turn to in times of stress. Although boundaries exist for every family, family members set up channels through which they interact with society.

5. Explore and discuss how spirituality influences the health of individuals and their families. 6. Define culture, ethnocentrism, cultural safety, and cultural humility. 7. Describe what is meant by cultural competence and culturally safe care and reflect on how this will influence nursing practice. 8. Explore ways to provide culturally responsive family nursing care.

Defining Family The family has traditionally been viewed as the primary unit of socialization—the basic structural unit within a community. The family plays a pivotal role in health care and is often the central focus for nursing care. 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. The term family has been defined in many different ways according to the individual’s own frame of reference, value judgement, or discipline. There is no universal definition of family; a family is what an individual considers it to be. Biologists describe the family as fulfilling the biological function of perpetuation of the species. Psychologists emphasize interpersonal aspects of family and its responsibility for personality development. Economists view the family as a productive unit providing for material needs. In sociology, the family is depicted as a social unit interacting with the larger society, creating contexts within which cultural values and identity are formed. Others define family in terms of the relationships of the persons who make up the family units. Some of the common types of family relationships are consanguineous (blood relationships), affinal (marital relationships), and family of origin (family unit a person is born into). Earlier definitions of family emphasized that family members were related by legal ties or genetic relationships and lived in the same household with specific roles. Later definitions have been broadened to reflect structural and functional changes. A family can be defined as an

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institution in which individuals, related through biology or enduring commitments and representing similar or different generations and genders, participate in roles involving mutual socialization, nurturance, and emotional commitment.

Family Organization and Structure. Individuals define their own family and support system by choosing who is included and who is excluded. The definition of family may include two or more different people such as parents, siblings, grandparents, partners, aunts and uncles, or friends (Table 2.1). The nuclear family consists of male and female partners and their children living as an independent unit sharing roles, responsibilities, and economic resources (Figure 2.1). In 2016, 73.3% of children under the age of 15 were living with two biological or adoptive parents in a nuclear family structure (Statistics Canada, 2019a). Multigenerational or extended families, consisting of grandparents, children, and grandchildren living in the same household, are becoming increasingly common (Figure 2.2). Caring for aging parents can create stress for parents who are also caring for their own children. In other situations, the grandparents support the children and grandchildren or are sole caregivers for the grandchildren. For some groups, such as Indigenous peoples, the family network is an important resource for promoting health and healing.

TABLE 2.1

Definitions of Family

Type of Family

Description

Nuclear

Male and female parents with children May be biological or adoptive parents May be married or common-law

Multigenerational or extended family

Grandparents, children, and grandchildren living in same household

Blended families

Unrelated family members join to make a new household as result of death or divorce and remarriage

Lone-parent families

One biological or adoptive parent living with their child or children. They may or may not be living with other adults.

Same-sex parent families

May be married or common-law

Fig. 2.2 Extended (multigenerational) family. (Courtesy Makeba Felton, Wake Forest, NC.)

Blended families, those formed as a result of divorce and remarriage, consist of unrelated family members (step-parents, stepchildren, and stepsiblings) who join to create a new household. These family groups frequently involve a biological or adoptive parent whose spouse may or may not have adopted the child. In 2016, almost 10% of Canadian children under 15 were living in blended families (Statistics Canada, 2019a). Lone-parent families comprise an unmarried biological or adoptive parent who may or may not be living with other adults. The lone-parent family may result from the loss of a spouse by death, divorce, separation, or desertion; from either an unplanned or planned pregnancy; or from the adoption of a child by an unmarried person. This family structure has become common, with Statistics Canada (2019a) reporting that 19.2% of all children under the age of 15 were living in a loneparent family. More than 80% of lone-parent families were femaleheaded lone-parent families, while 18.7% were headed by males (Statistics Canada, 2019a). This gender difference is significant because female-headed lone-parent families are more likely to have lower incomes and to experience poverty than male lone-parent families, which in turn can affect the health status of family members. Same-sex couple families may live together with or without children. Children in lesbian and gay families may be the offspring of previous heterosexual unions, conceived by one member of a lesbian couple through therapeutic insemination, or adopted. Overall, same-sex couples accounted for 0.9% of all couples in Canada in 2016; this number has increased significantly since 2006. In 2016, 12% of same-sex couples in Canada had children under 15 living with them, compared to about half of heterosexual couples (Statistics Canada, 2019b). Transgendered couples also form families and often become parents, either through the use of fertility drugs, adoption, or transmen discontinuing the hormones they are taking so they can become pregnant themselves.

Family Dynamics

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

Ideally, the family uses its resources to provide a safe, intimate, and nurturing environment that supports the biopsychosocial development of family members. The family provides for the nurturing and socialization of children. Children form their earliest and closest relationships with their parents or parenting persons; these affiliations continue throughout a lifetime. Parent–child relationships may influence selfworth and the child’s ability to form later relationships. The family also influences the child’s perceptions of the outside world. The family provides the growing child with an identity that has both a past and a sense of the future. Cultural and religious beliefs, values, and rituals are passed from one generation to the next through the family.

CHAPTER 2 Over time, the family develops protocols for problem-solving, particularly those regarding important decisions such as having a baby or buying a house. The criteria used in making decisions are based on family values and attitudes about the appropriateness of the behaviour and influenced by social, moral, political, and economic messages. The power to make critical decisions is given to a family member through tradition or negotiation. All families have strengths and the potential for growth. It is important for the nurse to identify those strengths and potential in order to facilitate the growth of the family (Gottlieb, 2013).

FAMILY NURSING Families play a pivotal role in health care, representing the primary focus of health care delivery for perinatal and pediatric nurses. In treating the family with respect and dignity, nurses listen to and honour perspectives and choices of the family. They share information with families in ways that are positive, useful, timely, complete, and accurate. The family is supported to participate in their care and decision making at the level of their choice. 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. Families may 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. Nurses must learn to incorporate these family beliefs into the care that is provided. In most perinatal and pediatric contexts family nursing could be understood as nursing with childbearing and child-rearing families. Family-focused nursing practice foregrounds the family in relation to the individual person within a holistic orientation to health that recognizes the importance of environmental and community contexts. From this perspective the nurse works with families by relating to them as people in a way that is meaningful to them, draws on a relational inquiry stance of learning with people, identifies patterns of experience that influence health and well-being, enacts professional responsibilities and social commitments, and addresses social determinants that influence health and result in health inequities. In summary, family nursing practice is collaborative and directed by the family’s needs and goals; growth oriented, building on family and community strengths (capacities and resources); respectful of family knowledge and expertise; and congruent with the principles of multidisciplinary family-centred care (Box 2.1) (Public Health Agency of

TABLE 2.2

The Family and Culture

17

BOX 2.1 Principles of Family-Centred Interprofessional Health Care Family-centred care (FCC) is a collaborative, complex, and dynamic process of providing safe, skilled, and individualized care. Such care responds to the physical, emotional, psychosocial, and spiritual needs of the person and family. FCC is health oriented and recognizes the importance of family participation and informed choice. 1. FCC is important in all health care contexts. 2. FCC is informed by research evidence. 3. FCC requires a holistic approach. 4. FCC requires collaboration among care providers. 5. Culturally appropriate care is important in a multicultural society. 6. Indigenous people and communities have distinctive knowledge, health needs, and experiences. 7. Providing care to families as close to home as possible is ideal. 8. The attitudes and language of health care providers affect the family’s experiences with health care. 9. FCC functions within a health care system that requires ongoing evaluation. 10. Learning about FCC practices globally may offer valuable options for consideration in Canada. Adapted from Public Health Agency of Canada. (2017). Chapter 1: Familycentred maternity and newborn care in Canada: Underlying philosophy and principles. https://www.canada.ca/content/dam/phac-aspc/ documents/services/publications/healthy-living/maternity-newborn-care/ maternity-newborn-care-guidelines-chapter-1-eng.pdf

Canada [PHAC], 2017; Registered Nurses’ Association of Ontario [RNAO], 2015). An informed advocacy framework may also be helpful for perinatal and pediatric nurses in advancing the practice of familycentred nursing care (Marcellus & MacKinnon, 2016).

Theories as Guides to Understanding and Working With Families 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. A brief synopsis of several theories useful for working with families is given in Table 2.2. Application of these concepts can guide assessment and interventions for the family and can be used when providing care in many perinatal and pediatric situations.

Theories and Models Relevant to Family Nursing Practice

Theory

Synopsis of Theory

Family Systems Theory (Wright & Leahy, 2013)

The family is viewed as a unit, and interactions among family members are studied, rather than individuals. A family system is part of a larger supra-system and is composed of many subsystems. The family as a whole is greater than the sum of its individual members. A change in one family member affects all family members. The family is able to create a balance between change and stability. Family members’ behaviours are best understood from a view of circular rather than linear causality.

Family Life Cycle (Developmental) Theory (Carter & McGoldrick, 1999)

Families move through stages. The family life cycle is the context in which to examine the identity and development of the individual. Relationships among family members go through transitions. Although families have roles and functions, a family’s main value is in relationships that are irreplaceable. The family involves different structures and cultures organized in various ways. Developmental stresses may disrupt the life cycle process.

Family Stress Theory (Boss, 2002)

This theory is concerned with ways that families react to stressful events. Family stress can be studied within the internal and external contexts in which the family is living. The internal context involves elements that a family can change or control, such as family structure, psychological defences, and philosophical values and beliefs. The external context consists of the time and place in which a particular family finds itself and over which the family Continued

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TABLE 2.2

Introduction to Maternal Child Nursing

Theories and Models Relevant to Family Nursing Practice—cont’d

Theory

Synopsis of Theory has no control, such as the culture of the larger society, the time in history, the economic state of society, the maturity of the individuals involved, the success of the family in coping with stressors, and genetic inheritance.

McGill Model of Nursing (Allen, 1997)

This model of situation-responsive nursing has a strength-based focus in clinical practice with families rather than a deficit approach. Identification of family strengths and resources, provision of feedback about strengths, and assistance given to the family to develop and elicit strengths and use resources are key interventions. The McGill model is particularly relevant for working with childbearing families, as pregnancy can be considered a “teachable moment” for promoting the health of the entire family.

The Collaborative Partnership Approach (Gottlieb & Feeley, 2006)

This model builds on the McGill model of nursing and more fully develops a collaborative partnership approach to family nursing. A collaborative partnership is defined as “the pursuit of person-centred goals through a dynamic process that requires the active participation and agreement of all partners.” Features of a collaborative partnership include mutual identification of an agreement on goals; sharing expertise and power; being respectful, accepting, and nonjudgemental; being open to learning together and learning to live with ambiguity; and being reflective and self-aware.

Another source for information about family nursing practice models is the International Family Nursing Association: https://internationalfamilynursing. org/resources-for-family-nursing/practice/practice-models/

Family Assessment When selecting a family assessment framework, it is important to consider the focus of nursing care. An appropriate model for a perinatal nurse is one that is health promoting rather than an illness-care model. The family can be assisted in fostering a healthy pregnancy, childbirth, and integration of the newborn into the family. Patients experiencing perinatal health challenges or conditions of vulnerability (e.g., poverty) or families with ill children have additional needs that the nurse may need to address while also promoting the health of the family.

The Calgary Family Assessment Model. A family assessment tool such as the Calgary Family Assessment Model (CFAM) (Box 2.2) 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. The CFAM consists of three major categories: structural, developmental, and functional. There are several subcategories within each category. The three assessment categories and the many subcategories can be conceptualized as a branching diagram (Figure 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 plan of care. The nurse asks questions of family members about themselves to gain understanding of the structure, development, and function of the family at that point in time. Not all questions within the subcategories should be asked at the first interview, and some 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.

Graphic Representations of Families. A family genogram, which is a family-tree format depicting relationships of family members over at least three generations (Figure 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 individual and family, may also help the nurse understand the social environment of the family and identify support systems available to them (Figure 2.5).

BOX 2.2

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 Figures 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 developmental life cycle—that is, the typical trajectory most families 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, among others.) Sample Questions • Which one of the family is best at ensuring that your grandmother 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.). FA Davis.

CHAPTER 2

Structural

Internal

Family composition Gender Sexual orientation Rank order Subsystems Boundaries

External

Extended family Larger systems

Context

Ethnicity Race Social class Religion and/or spirituality Environment

Stages Family assessment

Developmental

The Family and Culture

19

Tasks Attachments Instrumental

Functional Expressive

Activities of daily living Emotional communication Verbal communication Nonverbal communication Circular communication Problem solving Roles Influence and power Beliefs Alliances and coalitions

Fig. 2.3 Branching diagram of Calgary Family Assessment Model (CFAM). (From Leahy, M., & Lorraine, W. [2013]. Nurses and families: A guide to family assessment and intervention [6th ed.]. FA Davis, with permission.)

David 60

Mary 59

Jim 60

Family Nursing as Relational Inquiry

Betty 57

1945-2005 Heart attack M 2006

Barry 35 Computer programmer Asthma Tom 2

Sue 33

D 2004

Fred 36

Teacher

2008

Jenny 2 days

Healthy toddler

Fred, Jr. 6 Healthy

Legend

Identified patient

Death

Marriage

Separation

Divorce

Unmarried

Adoption or foster child

Miscarriage

Twins

Household membership

Male Female

Fig. 2.4 Example of a family genogram.

Relational nursing challenges nursing practices based on structured assessment frameworks and proposes that nurses need to be “in relation” with patients and family members, taking cues from the family and collaboratively identifying capacity and adversity patterns and building knowledge together for health promotion (Doane & Varcoe, 2015). Recognizing that families are socially located in historical, cultural, and environmental contexts helps nurses to understand the factors that have a significant impact on family members’ experiences of health and childbearing. Relational nursing moves beyond a health service provision approach toward one that is more congruent with holistic health promotion (Box 2.3). This approach is understood as a process of inquiry, and this process forms the framework for thoughtful, interpretive, critical, and spiritual inquiry. Nurses learn together with the family members about what matters most to them, about family strengths and health challenges, and about how to work toward better health for the family. A relational inquiry approach also considers the family from four lenses or perspectives: (1) a phenomenological lens, (2) a sociopolitical lens, (3) a spiritual lens, and (4) a socioecological health promotion perspective. The phenomenological lens cues the nurse to learn more about the family members’ experiences of health and illness. How does the family view illness? What do they do to enhance wellness? What is meaningful and significant to the family? The sociopolitical lens attends to power and gender, class, ethnic, racial, and professional relationships. The spiritual lens reminds us that health (e.g., childbearing or child-rearing) has particular personal, cultural, and religious meanings and significance. A socioecological perspective of health promotion is an understanding of health and health promotion that focuses on the family in their environmental context. It reminds nurses that nursing

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Introduction to Maternal Child Nursing

Preschool 2021— Doing well

Maternal grandparents 2017—Babysit once a week 2021—Help with Tommy during labour and birth

Church 2015—Married 2017—Tommy baptized 2018—Sue is member of women’s guild Barry is usher

Family or Household

Work Construction worker 3 close friends

33

35

4

Poker club Barry plays once a week

2

wk

Book club Sue meets with group once a month

Lactation consultant 2021— Help establish breastfeeding

Birth centre 2017—Tommy 2021—Kim

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

BOX 2.3

Relational Nursing Practice

Principles Underlying a Relational Inquiry Approach Relational inquiry acknowledges that: • Each person and family has a unique social location that shapes their identity and experiences. • People are influenced by their context through a relational web (a socioecological perspective). • All knowledge is limited, and knowing is considered to be relational action. • Knowledge is useful when it allows nurses to be more responsive to the people and the situation at hand. A relational inquiry approach to nursing practice: • Involves attending to relational experiences of family, community, and culture. • Calls on nurses to be compassionate, curious, committed to health equity, competent, and responsive in particular practice situations. • Requires humility and reflection on oneself and how one enacts nursing practice. • Involves theorizing which becomes a practical activity that is central to every nursing moment. • Is guided by an ethic of social justice in addition to being health promoting. • Involves habits of mind that support relational inquiry, including an inquiry stance of knowing and not knowing, and looking with fresh eyes. Adapted from Doane, G., & Varcoe, C. (2015). How to nurse: Relational inquiry with individuals and families in changing health and health care contexts. Wolters Kluwer/Lippincott Williams & Wilkins.

assessment and intervention are primarily about supporting individuals’ and family choices and enhancing their capacity to live healthy, meaningful lives within their particular personal, physical or material, and social context.

CULTURAL FACTORS RELATED TO HEALTH The concept of “culture” has been defined in diverse ways. Historically, the word culture evolved from anthropology and referred to the beliefs, values, and traditions of the exotic and essentialized “other” (someone not like me). Culture is now understood as constructed historically by the person’s life experiences, and by their gender and social position. Culture also can be thought of as a complex relational process or network of meanings and identities. Since the identity of a person or family is complex and not limited to race, ethnicity, or religion, it is now recognized that people express their cultural identity in many different ways that go beyond population groupings. Furthermore, culture is dynamic and changing throughout one’s life. One way to think about culture is to explore the multiple “identities” that make up our own cultural backgrounds. A relational view of culture requires attention to the dynamic interplay of intrapersonal and interpersonal beliefs, values, and practices of all the people involved in the practice setting.

Multiculturalism in Canada In 1971, Canada adopted multiculturalism as an official policy that affirmed the following: • The value and dignity of all Canadians, regardless of their racial or ethnic origins, their language, or their religious affiliations • The rights of Indigenous peoples • The status of Canada’s two official languages: French and English The Canadian government’s multiculturalism policy promotes multiculturalism by encouraging Canadians to participate in all aspects of life, including social, cultural, economic, and political affairs. Everyone is equal and has a right to be heard. However, government intentions have not been sufficient to achieve equity and integration. Racism

CHAPTER 2

The Family and Culture

21

and cultural oppression have been realities for many minority groups living in Canada, especially for Indigenous people, who have experienced the long-standing impacts of poverty, poor health, loss of identity, and marginalization (Canadian Nursing Students Association [CNSA], 2015; RNAO, 2007). See Chapter 1 for further discussion on Canada’s history and its impact on Indigenous people.

Cultural Context of the Family The culture of an individual and family is influenced by their religion, environment, and historical events and plays a powerful role in the individual’s health practices and patterns of human interaction. Culture is not static; it is an ongoing process that influences people throughout their entire lives, from birth to death. It is also important to remember that the social determinants of health (Box 1.1) will shape people’s health experiences, as well as nursing practice. These determinants must include multiple dynamic interacting historical, economic, sociopolitical, physical, and linguistic structures and processes (Doane & Varcoe, 2015). 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, art, health and healing practices, kinship relationships, and all other aspects of community, family, and individual life. Culture also has been shown to have a direct effect on health practices. Values, attitudes, and beliefs that are culturally acquired may influence perceptions of illness as well as health care–seeking behaviour and responses to treatment. Learning about the person’s cultural background can provide insight into how a person might react to illness, pain, and invasive medical procedures, as well as patterns of human interaction and expressions of emotion. The impact of these influences must be assessed by health care providers when giving health care. A more complex relational or socioecological understanding of the family’s environment and contexts for care is also required for responsive, culturally appropriate, family nursing practice. For example, nurses working with childbearing and child-rearing families also need to be aware of the impact that highly technological health care environments (such as those commonly seen in birthing and critical care units) may have on the ways that family members experience health care and nursing practices. Simply acknowledging the person before attending to the machine alarm or creating special moments for the parent with the child or infant within this foreign space can be incredibly meaningful for families.

Acculturation. In a multicultural society, many groups can influence traditions and practices. As cultural groups come in contact with each other, varying degrees of acculturation may occur. Acculturation refers to changes that occur within one group or among several groups when people from different cultures come in contact with one another (Figure 2.6). This familiarization among cultural groups can result in some overt similarities in dress, lifestyle, and mannerisms. Language patterns, food choices, and health practices in particular manifest differently among cultural groups. While acculturation can occur in Canada, the diversity and multiculturalism of people are highly valued. Ethnocentrism is the view that one’s own way of doing things is best while all other ways are unnatural or inferior. Ethnic stereotyping or labelling stems from ethnocentric views of people. Ethnocentrism is a common attitude among a dominant ethnic group and strongly influences the ability of one person to evaluate the beliefs and behaviours of others. This viewpoint tends to bias the individual’s interpretation and understanding of the behaviour of others. The culturally competent

Fig. 2.6 Teenagers from different cultural backgrounds interact within the larger culture. (iStock.com/izusek)

nurse should be empathetic and aware of their own views and how they may differ from another person’s, based on culture or social location. The nurse should be willing to ask questions that will provide a better understanding of the individual’s or family’s experiences and needs. Nurses are obligated to respect the cultural and spiritual beliefs and values of the person and family (Canadian Nurses Association [CNA], 2018). Frequently, nurses and other health care workers are not aware of their own cultural values and how those values influence their thoughts and actions. Understanding one’s own worldview and that of the “other” can help to avoid stereotyping and the misapplication of scientific knowledge (RNAO, 2007). Self-awareness is the first step in achieving cultural competence. Evidence has shown that attitudes, whether one is conscious of them or not, have a direct and significant impact on the people around them. Through self- reflection, nurses are better able to acknowledge their own cultural beliefs and values, which will aid them in achieving cultural competence in practice (CNA, 2018).

Providing Culturally Competent Nursing Care As our society becomes more culturally diverse, nurses have a professional and ethical responsibility to respect and be mindful of the culture of each person during every encounter (CNA, 2018). Nurses must examine their own beliefs so that they have a better appreciation and understanding of the beliefs of their patients. Values that underpin the provision of culturally competent care include respect, valuing difference, inclusivity, equity, and a commitment to providing culturally safe nursing care (CNA, 2018). To provide culturally competent care, the nurse must assess the beliefs, values, and practices of individuals and their families. Individuals and their families can be asked about their expectations so that nurses can learn collaboratively with the particular person and family (Box 2.4). It is also important for nurses to understand and value diversity and avoid stereotyping the individuals and families they care for. The concept of cultural competence refers to the practices of health professionals, including nurses. Cultural competence is an ongoing, interactive process that has been described as a set of congruent behaviours, attitudes, and policies that come together to enable a system, organization, or professionals to work effectively in cross-cultural situations. Recent collaborative work with Indigenous people and communities has highlighted the limits of traditional understandings of cultural competence. This concept has been critiqued for a tendency to

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BOX 2.4

Nursing Actions Important to Providing Culturally Safe Care • Reflect and recognize the influence of your own ethnicity and culture and their effects on your life. • Recognize the diversity of needs and experiences of the persons you serve. • Obtain details based on personal information actually given by the patient or family members rather than making assumptions. • Use simple language when discussing procedures, if necessary. • Explore what is acceptable and suited to the patient or family for their care. • Involve family members with the consent of the patient. • Work out a mutually acceptable schedule of caring for the patient. Adapted from Best Start Resource Centre. (2009). Giving birth in a new land: Strategies for service providers working with newcomers. https:// resources.beststart.org/wp-content/uploads/2018/12/E26-E.pdf

instill a false sense of confidence by fitting all Indigenous people into one stereotypical mould and for failing to consider diversity within the Indigenous population. In a joint document with Canadian Association of Schools of Nursing (CASN) and the Canadian Nurses Association (CNA), the Aboriginal Nurses Association of Canada (2009) identified two foundations of culturally appropriate nursing care: a constructivist understanding of culture—that culture is a complex shifting relational process—and cultural safety, which requires understanding power differentials in the health care system and addressing these inequities. Cultural competence can also be understood as a lifelong process of relational inquiry (CNA, 2018; Doane & Varcoe, 2015). Work is just beginning in efforts to improve Indigenous perinatal and children’s health care, by working with Indigenous communities across Canada. Promising practices for working with Indigenous people and communities have been identified and include the Aboriginal Prenatal Wellness Program, in Wetaskiwin, Alberta; the Inuulitsivik Health Centre Midwifery Initiative, in Northern Quebec; and the Strengthening Families Maternal Child Health Program, in Manitoba (Yeung, 2016). The Health Council of Canada (2011) has also described a number of processes for culturally competent care that involve a constructivist understanding of culture and cultural safety. In this context, cultural competence is defined as the ability of nurses to self-reflect on their own cultural values and how these impact the way nursing care is provided (CNA, 2018). Recognizing the importance of culture and the presence of cultural differences and unique needs is required for the provision of promising practices for community-based programs and health services. Common features of such practices for improving Indigenous maternal and child health in Canada include the following: • A holistic approach, which is vital to Indigenous maternal and child health. The physical, mental, social, spiritual, and emotional components of health are inseparable. Indigenous mothers and children cannot be considered in isolation; they are part of a larger family unit and a network of relationships in their community. The entire community—a healthy community—must be involved in connecting and supporting mothers and children (Health Council of Canada, 2011, p. 23). • Embodying mutual respect, addressing what matters most to the person and family, and integrating traditional healing practices. These are essential nursing practices. Cultural safety is the goal and outcome of practising in a culturally competent environment (CNA, 2018). Originally developed by Irihapeti Ramsden, a Maori nurse from New Zealand, the concept of

cultural safety extends beyond the cultural understanding of the health care provider by highlighting the power imbalance that is present within the provider–patient or nurse–patient relationship. The term shifts the authority to determine if the care provided is culturally safe to the person receiving care (CNA, 2018). Nurses are studying ways to embed cultural safety within a relational practice approach to nursing care situations (Doane & Varcoe, 2015). Cultural safety results in an environment free of discrimination and racism, where people feel safe when receiving health care. It is an outcome based on respectful engagement that recognizes and strives to address power imbalances built into the health care system (First Nations Health Authority, 2016). Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. It is the process of self-reflection in order to raise awareness of personal and systemic biases and to maintain respectful relationships that are based in mutual trust (First Nations Health Authority, 2016). The need for cultural humility arose within the broader multicultural community. This concept highlights how difficult it can be for a health care provider to truly understand the person’s or family’s cultural identity. It begins with acknowledging that our own cultural practices are not always the “best” and should not always be used as the standard for judging health practices. One example that is salient for nurses who work with childbearing families is that many families around the world have cultural practices that provide extra support for new mothers during the first month following childbirth, sometimes referred to as “doing the month,” when extended family members care for the new parent. The absence of this support has been articulated by many new Canadian women, exposing the limitations of our highly individualistic understanding of nuclear families within consumer-oriented North American cultures.

NURSING ALERT Cultural knowledge helps nurses better understand the behaviour of individuals and families. This knowledge helps to ensure that nurses are not making assumptions about patients’ behaviour in a clinical context. By performing a cultural assessment, the nurse can elicit the patient’s and family’s understanding of their illness and individualize the patient’s care plan.

To begin to understand and work effectively with families in a multicultural community, nurses need to recognize the barriers to transcultural communication and work toward removing those barriers. Nurses, too, are a product of their own cultural background. They need to recognize that they are part of the “nursing culture.” Nurses function within the framework of a professional culture with its own values and traditions and, as such, become socialized into their professional culture in their educational program and later in their work environments and professional associations. Developing cultural competence means that the nurse becomes aware of their own cultural attributes and biases, and their impact on others. Cultural beliefs and values, family structure and function, and experience with health care may influence a family’s feelings and attitudes toward health, their children, and health care delivery systems. It is often difficult for nurses to be nonjudgemental when working with families whose behaviours and attitudes differ from or conflict with their own. Nurses need to understand how their own cultural background influences the way in which they deliver care, and they need to be responsible and accountable for incorporating culturally appropriate and culturally safe care into their nursing practice.

CHAPTER 2 A holistic view of nursing practice also includes respect for and responsiveness to the spiritual beliefs and values of the person and family. Nurses should consider all aspects of culture, including spirituality, communication, space, time orientation, and family roles, when working with families.

Spirituality Spirituality may be defined as “whatever or whoever gives ultimate meaning and purpose in one’s life, that invites particular ways of being in the world in relation to others, oneself and the universe” (Wright, 2005). Spirituality is important in all phases of life; it relates to deep and important issues 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. Spirituality is a component of holistic nursing and thus a professional responsibility. The CNA states that spirituality is an integral dimension of an individual’s health and that being attentive to an individual’s spirituality is a component of a holistic nursing assessment and nursing practice. When planning for and providing care, nurses have an ethical responsibility to be aware of and adjust for an individual’s spiritual beliefs (CNA, 2010). Openness to a range of spiritual perspectives (or lack thereof) is part of ethical nursing practice. Nurses do not need to be knowledgeable in particular spiritual traditions, but they do need to be open to inviting or allowing reflection by the individual on the spiritual dimension of their experience of illness and suffering (CNA, 2010). Nurses should also reflect on their own spiritual beliefs in order to provide beneficial nursing care. 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, counselling, or visits from clergy. 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 through their presence. Spirituality also plays an important role in providing meaning to nursing work (Pesut, 2013). For example, the Pause, which originated in an emergency room after the death of a patient, involves taking a minute or two, to acknowledge a lost human life, and is an example of recognizing the individual in this sad time. The Pause also lends 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 are able to be together and achieve some type of closure or resolution surrounding the unsuccessful efforts to resuscitate the individual. Use of the Pause is growing and is gaining advocates.

Spiritual Care. Spiritual care can be defined as a form of relational practice with the aim of increasing the spiritual well-being of the person and family. Brussat and Brussat (1996) described characteristics of the spiritually literate person as being present, having compassion, being

The Family and Culture

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connected, having hope, being kind, listening, having meaning and openness, and using silence. Relational inquiry and therapeutic communication skills are what make nurses ideal for attending to the spiritual dimensions of an individual’s health. Spirituality is of relevance for all of nursing, not just for those in palliative care or for dying patients (Giske & Cone, 2015). 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 2.5. To provide spiritual care, the nurse must understand the meaning of spirituality to the person for whom care is being provided (Gordon et al., 2011). The nurse must listen attentively to learn what is important to the patient, what gives meaning to their life, what gives hope and strength, and what are their fears and concerns (Burkhardt & NagaiJacobson, 2015). Only then can the nurse respond appropriately and provide spiritual care that is healing.

Communication Communication sometimes creates a challenging obstacle for nurses working with individuals from diverse cultural groups. 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) appreciation of individual differences in interpersonal style; and (3) accurate interpretation of the volume of speech, as well as the meanings of touch and gestures. For example, members of some cultural groups tend to speak more loudly, with great emotion, and with vigorous and animated gestures when they are excited; this is true whether their excitement is related to positive or negative events or emotions. Therefore, it is important for the nurse to avoid rushing to judgement regarding an individual’s intent when the individual is speaking, especially in a language not understood by the nurse. In these situations, it is critical that the nurse avoid instantaneous responses that may be based on an incorrect interpretation of the person’s gestures and meaning. Instead, the nurse should withhold an interpretation of what has been communicated until it is possible to clarify the person’s intent. The nurse needs to enlist the assistance of a person who can help verify with the person the true intent and meaning of their communication (see Clinical Reasoning Case Study).

BOX 2.5 • • • • • • • • • • • • • •

Spiritual Assessment Questions

Who or what provides the patient with strength and hope? Does the patient use prayer in their life? How does the patient express their spirituality? How would the patient describe their philosophy of life? What type of spiritual or religious support does the patient desire? What is the name of the patient’s clergy, minister, chaplain, pastor, or 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 or 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 their family?

Source: The Joint Commission. Standards FAQ details, medical record— Spiritual assessment. Excerpted from https://www.jointcommission.org/ standards/standard-faqs/critical-access-hospital/provision-of-caretreatment-and-services-pc/000001669/

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CLINICAL REASONING CASE STUDY

Culturally Competent Care in the Emergency Department Arisha, a 37-year-old woman, accompanied by her 16-year-old son, Mahesh, is admitted to the emergency department (ED) with profuse vaginal bleeding. Arisha’s primary language is Hindi, and she speaks very little English; Mahesh is fluent in Hindi and English. No health care providers present in the ED speak Hindi. The nurse assigned to care for Arisha must obtain a health history and perform an assessment. The nurse wants to provide culturally competent care for Arisha. Questions 1. Evidence—Is there sufficient evidence to determine what culturally competent nursing care consists of? 2. Assumptions—What assumptions can be made about culturally competent care and the role language plays in providing that care?

Use of Interpreters. Inconsistencies between the language of family members and that of providers presents a significant barrier to effective health care. Because of the diversity of cultures and languages within the Canadian population, 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 to provide linguistically appropriate health care. Finding the best possible interpreter in these circumstances is critically important. A number of personal attributes and qualifications contribute to an interpreter’s potential to be effective. 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 individual and the health care provider. The person interpreting should be mature enough to be trusted with private information. It is not appropriate to use a child or another family member to interpret health care information. However, because the nature of nursing care is not always predictable and because nursing care provided in a home or community setting does not always allow expert, experienced, or mature adult interpreters, ideal interpretive services are sometimes impossible to find when they are needed. In crisis or emergency situations or when family members are experiencing extreme stress or emotional upset, it may be necessary to use family members as interpreters. If this situation occurs, the nurse must ensure that the person is in agreement and comfortable with using the available interpreter to assist. Another alternative that has become more available in many settings is to access professional interpreters over the telephone when someone is not available in person. Most health care institutions have lists of staff members who may be available to interpret when required, although professional interpreters are the ideal. When using an interpreter, the nurse needs to respect the family by creating an atmosphere of respect and privacy (Box 2.6). Questions should be addressed to the person 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 the ideal place for interpretive services to take place. In addition, culturally and linguistically appropriate educational materials that are easy to read, with appropriate text and graphics, should be available to assist the individual and family in understanding health care information. When using interpretive services, the nurse demonstrates respect for the person and helps maintain a sense of dignity by taking care to do all of the following:

a. How the nurse, who speaks no Hindi, might effectively communicate with Arisha b. How the nurse can obtain a health history with questions about vaginal bleeding, sexual activity, and pregnancy if Mahesh is the only person available who speaks Hindi c. How the nurse can provide culturally competent teaching d. What teaching materials and resources are appropriate; what questions are appropriate to gain information about sexual activity and the possibility of pregnancy 3. What implications and priorities for nursing care are most important at this time? 4. What evidence supports your plan for culturally responsive nursing care?

• Respect the person’s wishes. • Involve the person in the decisions about who will be the most appropriate person to interpret under the circumstances. • Provide as much privacy as possible.

Personal Space Cultural traditions define the appropriate personal space for 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 person in proximity to others, taking away personal possessions, and making decisions for the individual can decrease personal security and heighten anxiety. Conversely, respecting the need for distance allows the person to maintain control over personal space and support personal autonomy, thereby increasing a sense of security. Nurses must touch patients, but they frequently do so without any awareness of the emotional distress they may be causing individuals. It is important to ask permission before touching any person.

Time Orientation Time orientation is a fundamental way in which culture affects health behaviours. People in various 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 may have little motivation for formulating future 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 the beat of their own drummer.” Individuals oriented toward the future maintain a focus on achieving long-term goals. The time orientation of the 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 that 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 and thinks 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 may be equally concerned for the well-being of its newborn.

Family Roles Family roles involve the expectations and behaviours associated with a member’s position in the family (e.g., mother, father, grandparent). Social class and cultural norms also affect these roles, with distinct

CHAPTER 2

BOX 2.6

The Family and Culture

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Working With an Interpreter

Step 1: Before the Interview A. Outline your statements and questions. List the key pieces of information you want or need to know. Step 2: Meeting With the Interpreter A. Introduce yourself to the interpreter and converse informally. This is the time to find out how well they speak English. No matter how proficient or what age the interpreter is, be respectful. Some ways to show respect are to acknowledge that you can learn from the interpreter or learn one word or phrase from the interpreter. B. Emphasize that you would like to encourage the person to ask questions if they have any concerns and to feel comfortable doing so, as some cultures consider asking questions to be inappropriate. C. Make sure that the interpreter is comfortable with the technical terms you need to use. If not, take some time to explain them. Step 3: During the Interview A. Ask your questions and explain your statements (see Step 1) directly to the person and maintain eye contact. B. 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. C. Try to get a “feel” for how much is “getting through.” No matter what the language is, if in relating information to the person the interpreter uses far fewer or far more words than you do, “something else” is going on. D. Stop every 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. E. Ask the interpreter to elicit questions. This may be difficult, but it is worth the effort. F. Identify cultural issues that may conflict with your requests or instructions. G. Use the interpreter to give insight into possibilities for solutions. Step 4: After the Interview A. Speak to the interpreter and try to get an idea of what went well and what could be improved related to the interpretation service. This will help you to be more effective with this or another interpreter. B. Make notes on what you learned for your future reference or to help a colleague. Remember: Your interview is a collaboration between you and the interpreter. Listen as well as speak. Notes 1. Be sensitive to cultural and situational differences (e.g., an interview with someone from an urban city will likely be different from an interview with someone from a transitional refugee camp). 2. 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 Elizabeth Whalley, PhD, San Francisco State University.

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 practitioners 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 some very traditional families, who usually view the birthing experience as a female affair. Family roles may also dictate who in the family makes the major decisions regarding health care, for example which family member decides treatment options for a sick child. It is important to know this information, as it may dictate who is given information first. The way that health care practitioners facilitate such a family’s care may influence the family’s experience and perception of the Western health care system.

• • • • •

KEY POINTS • A family is two or more people who are related through enduring commitments. • Contemporary Canadian society recognizes, accepts, and values diverse family forms. • The family is a social network that acts as an important support system for its members. • Family theories and practice models provide nurses with useful guidelines for working with childbearing and child-rearing families. • Poverty and environmental factors, family resources and support systems, health challenges and responses to stress, and cultural

• • • •

and religious beliefs and practices are important factors influencing the health of the whole family. The beliefs and values of a culture are embedded in its economic, religious, kinship, and political structures and are reproduced through health and social practices. To provide quality care to perinatal and pediatric patients, nurses should be aware of the cultural beliefs, values, and practices important to particular families. No cultural group is homogenous; social identities are complex and reflect great diversity. Nurses need to listen to the stories that individuals and family members tell them about their culture, their health care experiences, their resources, and their needs. Cultural competence is a complex relational process of mutual learning that is a professional responsibility of nurses. Nurses can facilitate this process by recognizing cultural differences, integrating cultural knowledge, being aware of their own beliefs and practices, and acting in a respectful manner. Cultural safety results in an environment free of discrimination and racism, where people feel safe when receiving health care. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. Attention to and respect for the spiritual beliefs and values of the person and family is an important component of culturally responsive nursing. Because verbal and nonverbal forms of communication are important cultural considerations, nurses need to acknowledge and respect their patients’ practices for productive interaction to occur.

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REFERENCES Aboriginal Nurses Association of Canada. (2009). Cultural competence and cultural safety in nursing education: A framework for First Nations, Inuit and Metis nursing. https://www.cna-aiic.ca/
/media/cna/page-content/pdf-en/ first_nations_framework_e.pdf. Allen, M. (1997). Comparative theories of the expanded role in nursing and implications for nursing practice: A working paper. Nursing Papers, 9(2), 38–45. Bartels, J. B. (2014). The pause. Critical Care Nurse, 34(1), 74–75. Boss, P. (2002). Family stress management (2nd ed.). Sage. Brussat, F., & Brussat, M. (1996). Spiritual literacy: Reading the sacred in everyday life. Scribner. Burkhardt, P., & Nagai-Jacobson, M. G. (2015). Tips for spiritual care-giving. Beginnings (American Holistic Nurses’ Association), 35(5), 6–7. Canadian Nurses Association. (2010). Position statement: Spirituality, health, and nursing practice. https://www.cna-aiic.ca/
/media/cna/page-content/ pdf-en/ps111_spirituality_2010_e.pdf?la¼en. Canadian Nurses Association. (2018). Position statement: Promoting cultural competence in nursing. https://www.cna-aiic.ca/-/media/cna/page-content/ pdf-en/position_statement_promoting_cultural_competence_in_nursing. pdf?la¼en&hash¼4B394DAE5C2138E7F6134D59E505DCB059754BA9. Canadian Nurses Students’ Association. (2015). Position statement: Cultural safety in the context of Aboriginal health in nursing education. https://static1. squarespace.com/static/5fd251097a98ce4ff8622356/t/60e73ee4b7ff41666e716 227/1625767653439/All+CNSA+Position+and+Resolution+Statements.pdf. Carter, B., & McGoldrick, M. (1999). The expanded family life cycle: Individual, family, and social perspectives (3rd ed.). Allyn & Bacon. Doane, G., & Varcoe, C. (2015). How to nurse: Relational inquiry with individuals and families in changing health and health care contexts. Lippincott, Williams & Wilkins. First Nations Health Authority. (2016). Creating a climate for change: Cultural safety and humility in health services delivery for First nations and Aboriginal peoples in British Columbia. https://www.fnha.ca/Documents/FNHACreating-a-Climate-For-Change-Cultural-Humility-Resource-Booklet.pdf. Giske, T., & Cone, P. H. (2015). Discerning the healing path—how nurses assist patient spirituality in diverse health care settings. Journal of Clinical Nursing, 24, 2926–2935. Gordon, T., Kelly, E., & Mitchell, D. (2011). Spiritual care for healthcare professionals: Reflecting on clinical practice. Radcliffe Publishing. Gottlieb, L. (2013). Strengths-based nursing care: Health and healing for person and family. Springer. Gottlieb, L., & Feeley, N. (2006). The collaborative partnership approach to care—A delicate balance. Mosby Elsevier. Health Council of Canada. (2011). Understanding and improving Aboriginal maternal and child health in Canada—Conversations about promising practices across Canada. https://healthcouncilcanada.ca/files/2.01-HCC_ AboriginalHealth_FINAL1.pdf.

Marcellus, L., & MacKinnon, K. (2016). Using an informed advocacy framework to advance the practice of family-centered care. Journal of Perinatal and Neonatal Nursing, 30(3), 240–242. Pesut, B. (2013). Nursing’s need for the idea of spirituality. Nursing Inquiry, 20(1), 5–10. Public Health Agency of Canada (PHAC). (2017). Chapter 1: Family-centred maternity and newborn care in Canada: Underlying philosophy and principles. https://www.canada.ca/content/dam/phac-aspc/documents/ services/publications/healthy-living/maternity-newborn-care/maternitynewborn-care-guidelines-chapter-1-eng.pdf. Registered Nurses’ Association of Ontario (RNAO). (2007). Embracing cultural diversity in health care: Developing cultural competence. http://rnao.ca/bpg/ guidelines/embracing-cultural-diversity-health-care-developing-culturalcompetence. Registered Nurses’ Association of Ontario (RNAO). (2015). Person- and familycentred care. https://rnao.ca/sites/rnao-ca/files/FINAL_Web_Version_0.pdf. Statistics Canada. (2019a). Portrait of children’s family life in Canada in 2016. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/ 2016006/98-200-x2016006-eng.cfm. Statistics Canada. (2019b). Same-sex couples in Canada in 2016. https://www12. statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016007/98-200x2016007-eng.cfm. Wright, L. M. (2005). Spirituality, suffering, and illness: Ideas for healing. FA Davis. Wright, L. M., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). FA Davis. Yeung, S. (2016). Conceptualizing cultural safety: Definitions and applications of safety in health care for Indigenous mothers in Canada. Journal for Social Thought, 1(1), 1–13.

ADDITIONAL RESOURCES Best Start: Atuaqsijut: Following the path sharing Inuit specific ways. A resource for service providers working with parents/caregivers of Inuit children aged 0–6. https://resources.beststart.org/product/k84a-atuaqsijut-inuit-manual/. Best Start—A source of many resources appropriate for use with different cultures. http://www.beststart.org/. Canadian Nurses Association. http://www.cna-aiic.ca/en. Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN): Position statement on cultural safety/humility. https://capwhn.ca/wpcontent/uploads/2019/10/CAPWHN_Position_Statement_on_Cultural_ Safety_Humility_Final.pdf. Family Nursing Resources. http://www.familynursingresources.com/. First Nations Health Authority. https://www.fnha.ca/. Indigenous Cultural Competency Training Program. http://www.sanyas.ca/. International Family Nursing Association: Practice models for nursing practice with families. https://internationalfamilynursing.org/resources-for-familynursing/practice/practice-models/.

UNIT 1 Introduction to Maternal Child Nursing

3 Community Care Judy Buchan http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Compare community-based home visiting programs and community health (population or aggregate-focused) care. 2. List indicators of community health status and their relevance to perinatal and children’s health. 3. Identify the various roles and functions that nurses have in the community. 4. Describe three levels of preventive care and the differences between them. 5. Discuss selected aspects of the epidemiological process. 6. Explain the purpose of an economic evaluation.

7. Discuss the components of the community nursing process. 8. Describe data sources and methods for obtaining information about community health status. 9. Identify key components of the community assessment process. 10. Explore telephone contact centres and use of social media applications for nursing care options in perinatal and pediatric nursing in Canada. 11. Describe the nurse’s role in perinatal and pediatric home visiting. 12. List the potential advantages and disadvantages of home visits. 13. Discuss safety and infection control principles as they apply to the care of patients in their homes.

Health care in Canada has evolved rapidly in recent years, with notable shifts in both the nature of health priorities and the ways in which health care is delivered to individuals, families, and populations. Today, greater emphasis is placed on health promotion and disease prevention than on the curative focus of past decades. This is in part a response to the skyrocketing costs of medical care and the realization that Canada’s current health care system is unsustainable. Hospital stays are increasingly shorter, and patients are discharged home earlier with the expectation that they will receive care in the community. Knowing how health care is organized and governed within the community setting is of importance for perinatal and pediatric nurses. At the national level, the Public Health Agency of Canada’s (PHAC) mission is to promote and protect the health of Canadians through leadership, partnership, innovation, and action in public health (PHAC, 2021). This is done by promoting health; preventing and controlling chronic diseases, injuries, and infectious diseases; and preparing and responding to public health emergencies. The PHAC acts as a central hub through which Canada’s expertise is shared with the rest of the world. The agency applies international research to Canada’s public health programs and strengthens intergovernmental collaboration on public health, as well as facilitating national approaches to public health policy and planning (PHAC, 2021). By focusing on the health of the population at both the individual and the community level, the Government of Canada works to improve

the health of Canadians, reduce health disparities, and build the capacity to deliver on and support public health activities (PHAC, 2021). A population health approach considers the economic, social, and physical environmental factors that contribute to one’s health—in essence it is the capacity of people to adapt to, respond to, or control life’s changes (Frankish et al., 2001). Underpinning this are the determinants of health—the broad range of personal, social, economic, and environmental factors that determine individual and population health (Government of Canada, 2020). Determinants of health include income and social status; social support networks; education; employment and working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; gender; and culture (see Box 1.1). These are factors that contribute to a person’s current state of health and well-being. By applying a health equity lens, public health policies and programs work to reduce health inequalities in the population by providing everyone the same opportunities and conditions to be healthy, no matter who they are or where they live (Government of Canada, 2020). Nurses who work in the community promote, protect, and preserve the health and well-being of individuals, families, groups, communities, populations, and systems in settings where they work, live, and play (Community Health Nurses of Canada [CHNC], 2019). They practice in diverse urban, rural, and remote settings, which may include health centres, homes, clinics, schools, shelters, and other community-based

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settings. By using a capacity-building and strengths-based approach, nurses provide, facilitate, and coordinate care and link people to community resources (CHNC, 2019). There are many different roles that nurses have in the community, ranging from primary prevention, health promotion and protection, health education, surveillance, screening, and staffing immunization clinics to disaster management and emergency preparedness. Home health care nurses typically provide specific nursing care in the home or at a clinic; such care will be discussed later in this chapter. Public health and community health nurses have a broader role and bring a unique set of knowledge and skills needed to plan, implement, and evaluate both targeted and population-level public health interventions. The terms public health nurse and community health nurse are used in many different ways across the various jurisdictions in Canada. In some places, the term community health nurse means the same as, or is used instead of, the term public health nurse (Canadian Public Health Association [CPHA], 2010). In other areas, community health nurse is an overarching term that refers to the complete range of nurses working in the community, of which public health nurses are one group (CPHA, 2010). Throughout this chapter, community health nurse refers to nurses who provide public health nursing in the community. Home health care nurse refers to nurses who provide care in a patient’s home.

ROLES AND FUNCTIONS OF COMMUNITY HEALTH NURSES To understand the role of the nurse in public health, it is critical to examine the role of nurses who have the title of community health nurse and to look at the types of activities they engage in to promote the health of populations. Community nurses are equipped with knowledge of disease prevention and health promotion that is based on both their education and experience and includes an understanding of the clinical implications of public health interventions as well as the etiology and natural history of disease. Community health nursing practice is grounded in a holistic approach and considers the health of individuals, families, communities, and the population as a whole. The roles and functions of the community health nurse continue to evolve as more health care is delivered outside of the hospital system. Community health nursing is a synthesis of nursing theory and public health science. The foundation for community health nursing includes a range of models and theories, such as population health promotion, illness and injury prevention, community participation, and community development (CPHA, 2010). Community health nurses work in the community to partner with people where they live, work, learn, meet, and play, in order to promote health and well-being. The goal for nurses who work with families and individuals in the community is to promote health, build individual and community capacity, connect with and care for patients, facilitate access, promote health equity, and demonstrate professional responsibility and accountability (CHNC, 2019). In community-based health care settings, both the aggregate (group of people who have shared characteristics) and the population may become the focus of interventions. Health care providers are required to collaborate in order to determine health priorities for communities and develop successful plans of care to be delivered in a variety of settings, including health clinics, community health centres, patients’ homes, or other settings. Community-based health care, including public health services, is often under-resourced and is challenged to meet the demands of growing populations. Thus, it is sometimes difficult to fully compensate for the gaps in health care service that currently exist.

Core Competencies The PHAC has developed core competencies for all public health care providers, which outline 36 competencies deemed essential to all disciplines practising in public health (PHAC, 2008). To support the core competencies outlined by the PHAC, the Community Health Nurses of Canada (CHNC) has developed discipline-specific practice competencies for community health nursing. There are two sets of competencies set out by the CHNC: one set for community health nurses (CHNC, 2009) and one for home health nurses (CHNC, 2010). Together, these competencies identify the required knowledge, abilities, attributes, and judgement for community health nursing practice within Canada. In 2010, the Canadian Public Health Association (CPHA), in collaboration with the CHNC and PHAC, clarified and described the role and functions of community health nurses in Canada with the release of Public Health/Community Health Nursing in Canada: Roles and Activities, fourth edition (CPHA, 2010). Whereas previous editions had described public health/ community health nursing roles as relating to communities, families, and individuals across the lifespan, the fourth edition has shifted its focus to populations and the broad determinants of health (CPHA, 2010). Community health nurses can also become certified through the Canadian Nurses Association (CNA). This certification credential, part of a respected national certification program, is an important indicator to patients, employers, the public, and professional licensing bodies that the certified nurse is qualified, competent, and current in community health nursing practice.

NURSING ALERT Nurses are required to work interprofessionally, speaking a common language laid out in the PHAC and CHNC core competencies, as their work crosses many disciplines. This includes being able to understand terms used by demographers, epidemiologists, physicians, health promoters, social scientists, researchers, and economists.

Public Health Decision Making The use of research evidence plays an important role in public health decision making. The process of evidence-informed decision making guides public health care decision making by using the best research evidence available. However, research evidence is only one part of a larger picture. Decision makers must interpret and apply the research evidence in the context of four other sources of evidence (Figure 3.1). Public health expertise signifies that the public health practitioner contributes to the overall decision-making process. All the factors need to be weighed and balanced to make the most appropriate decision. When considering a policy or program change, it is important for the practitioner to understand the magnitude of the health issue in the local setting and how important this health issue is in comparison to other issues. This can help to ensure that those issues affecting the overall health status of the population receive priority over those which have a more limited impact on the public good (community health issues, local context). Community and political preferences and actions in Figure 3.1 refer to the need to understand the political climate at the municipal, provincial, and federal level; it is important to know the community’s views on an issue. Public health resources include budget, staff, and technological infrastructure. Decision makers must determine whether or not there are sufficient resources, both in terms of personnel and technology and in terms of funding, to successfully implement a program or policy. Finally, research evidence empowers the public health practitioner with an understanding of what the best available research says about an issue. All these considerations help to bring evidence into practice, but they can only work as part of a comprehensive process and not independently of one another.

CHAPTER 3 Community Care

Community Health Issues Local Context

Community and Political Preference and Actions

Public Health Expertise Research Evidence

Public Health Resources

Fig. 3.1 A model for evidence-informed decision making in public health. (Source: NCCMT National Collaborating Centres of Methods and Tools. http://www.nccmt.ca/eiph/index-eng.html)

Community Health Promotion Best practices in community-based health initiatives involve a thorough understanding of a community’s health needs and priorities, the environmental context, power relationships, and available resources, as well as participation of community leaders. A community-based framework helps to bring together multiple perspectives and diverse community resources to address a specific health priority. The emphasis on community-based health promotion has grown in recent years, with the recognition that many health issues require the collaborative efforts of a diverse community network to achieve public health goals.

Economics. A basic understanding of the economics of health care enables the nurse to participate in decision making about the cost and benefits of health programs. Economists theorize that individuals and societies view health as a basic utility, that is, something that is perceived as valuable. Other basic utilities include food, shelter, and clothing. People may be willing to trade resources, such as money and time, for a program or intervention that will improve their health. Economists measure the amount of resources that individuals and communities are willing to pay for good health. Economic evaluation provides objective information to establish a program’s value to the community. Demography. Demography is the study of population characteristics. Demographic characteristics include age, gender, race and ethnicity, socioeconomic status, and education. Individuals, families, and communities may have demographic characteristics that affect their health risks (McFarlane & Gilroy, 2015). Risk is an increased probability of developing a disease, injury, or illness. Age is one of the most important risk factors for disease prevention and certain health conditions. For example, infants are more likely to die as a result of congenital malformations; children and adolescents, as a result of accidents; and middleage adults, as a result of cancer (Statistics Canada, 2021). Gender also plays an important role. Males are at greater risk than females of having hemophilia A and B. Race and ethnicity have long been associated with increased risk for disease and disability, but it is now understood that, aside from genetic predisposition, there is a complicated relationship between minority status and socioeconomic status that increases the risk for disease and disability (PHAC, 2018). Low socioeconomic status, an important determinant of health, predisposes adults and especially children to a variety of health challenges. Children represent one out of four low-income persons in Canada,

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which translates to approximately 1.2 million children living in a low-income household (Statistics Canada, 2017). This rate is even higher for Indigenous children, with more than one in three living in poverty, and even higher on reserves where over 60% of children live in poverty (O’Brien Institute for Public Health, 2018). Brain development happens quickly in the early years of life, and a small child’s brain development can be adversely affected by poverty, putting these children at increased risk of lifelong physical and mental health challenges (Center on the Developing Child at Harvard University, 2016). Poor children are more likely go hungry, to be overweight, and to have untreated dental problems. They are more likely to be treated in emergency departments because they do not have a regular health care provider, and they are more at risk for not reaching their developmental potential (Blair & Raver, 2016).

Epidemiology. Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. Through the epidemiological process, the distribution and causes of disease or injury across a population are identified (McFarlane & Gilroy, 2015). Epidemiology serves as an important component in developing health programs. For example, the Community Action Program for Children incorporated an epidemiological process to develop programs that promote the healthy development of young children from birth to 6 years (PHAC, 2020). Health care providers in community, provincial, and national organizations use the epidemiological process to guide the development of programs that will have the greatest impact on children’s health. Distribution of disease, injury, or illness. Morbidity rates are used to measure disease and injury and, along with birth and mortality rates, present an objective picture of a community’s health status. There are two types of morbidity rates: incidence and prevalence. Incidence measures the occurrence of new events in a population during a period of time. Prevalence measures existing events in a population during a period of time. For example, the incidence of type 1 diabetes in a community is estimated by counting the new cases of type 1 diabetes in a population and dividing that figure by the size of the population at risk. The prevalence of type 1 diabetes is estimated by counting the existing cases of type 1 diabetes in a population and dividing that figure by the size of the population at risk. Both incidence and prevalence are usually given as rates per 1 000, 10 000, or 100 000 population, depending on their frequency. Box 3.1 presents frequently used mortality and morbidity rates. Epidemiological triangle. Three factors form the epidemiological triangle, and their interrelationship alters the risk of acquiring a disease or condition. These factors are agent, host, and environment (Figure 3.2). An agent is responsible for causing a disease. The agent may be an infectious agent, such as Mycobacterium tuberculosis; a chemical agent, such as lead in paint; or a physical agent, such as fire. Host factors are those that are specific to an individual or group. These may be genetic factors, which cannot be controlled, or they may be lifestyle factors, such as food selections or exercise patterns. Environmental factors provide a setting for the host and include the climatic conditions in which the host lives and factors related to the home, neighbourhood, and school. Levels of Preventive Care. Population-based care may involve disease prevention activities focused on specific needs that are identified through the community assessment process. These levels of prevention provide a framework for nursing interventions. Primary prevention. Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life. Primary prevention precedes disease or dysfunction and encourages individuals to achieve the

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BOX 3.1

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Introduction to Maternal Child Nursing

Frequently Used Mortality and Morbidity Rates

Crude Birth Rate

Age-Specific Death Rate

Number of births in a population within a time period  1000 Total population

Number of deaths in a population in a certain age group within a time period  1000 Total population in that age group

Crude Death Rate

Number of deaths in a population within a time period  1000 Total population Cause-Specific Death Rate

Number of deaths in a population due to a certain disease within a time period  1000 Total population

Incidence of Disease

Number of new events in a population within a time period  1000 Total at-risk population Prevalence of Disease

Number of existing events in a population within a time period  1000 Total at-risk population

Environment

Agent

Host Fig. 3.2 The epidemiological triangle.

optimal level of health possible. Examples of primary prevention include health education and counselling about healthy lifestyle behaviours, including those related to nutrition and exercise. Other examples include well-child care clinics, immunization programs, water fluoridation, safety programs (use of bike helmets, car seats, seat belts, childproof containers), nutrition programs, environmental efforts (clean air programs), sanitation measures (chlorinated water, garbage removal, sewage treatment), and community parenting classes. Educational programs that teach children and adolescents about healthy sexuality behaviours that reduce risk or convey the dangers of smoking, vaping, and drug use are also examples of primary prevention. Early childhood presents an ideal time for primary prevention strategies, as these programs and services can provide families with the support they need to build protective factors and prevent development of risk factors and vulnerabilities for their children. Childhood immunization programs are another excellent example of primary prevention. By supporting parents and caregivers, primary prevention programs help to ensure that children have stable and healthy living environments in which to grow, develop, and thrive.

Secondary prevention. Secondary prevention is aimed at early detection of a disease and prompts treatment to either cure the disease or slow its progression and prevent subsequent disability. Screening programs to detect disease while persons are asymptomatic are the most frequent forms of secondary prevention. Examples of this level of prevention are newborn screening tests that are conducted after birth. Babies with one of the tested diseases may appear healthy at birth and, without newborn screening, might not be identified before irreversible damage has occurred. Another example of secondary prevention is a Pap (Papanicolaou) test, which is used to screen patients to detect premalignant and malignant cells on the cervix opening. If this condition is treated early, cervical cancer can be successfully prevented or cured. The goal of secondary prevention is to shorten disease duration and severity, thus enabling an individual to return to normal function as quickly as possible. However, screening is not appropriate for every condition. Although screening may bring benefits, a certain amount of risk is associated with any intervention, and it is critical that the patient and/or caregiver make an informed decision. For example, during pregnancy, there are two diagnostic screening tests that are considered to be invasive. Both amniocentesis and chorionic villus sampling will provide expectant parents with definitive information about the health of their fetus; however, these procedures may also induce miscarriage. It is essential to determine the evidence for a proposed screening program prior to initiating it. The benefits of screening should exceed the risks and costs. It is also important to ensure there are adequate resources available to support and treat persons with positive screening results. Tertiary prevention. Tertiary prevention follows the occurrence of a disease or disability and is aimed at preventing disability through restoration of optimal functioning. Persons who have developed disease are provided treatment and rehabilitation to prevent complications and further deterioration. Examples of tertiary prevention are early treatment and management of diabetes to reduce subsequent health problems. Pregnant patients may experience gestational diabetes mellitus (GDM) during their pregnancy, putting both their fetus and them at risk. In the long term, patients with GDM are seven times more likely to develop type 2

CHAPTER 3 Community Care diabetes later in life, and exposure to GDM predisposes the child to increased fat accumulation over time, which is an important risk factor for obesity and diabetes development (Canadian Institutes for Health Information [CIHI], 2018). Other examples of tertiary interventions include rehabilitation and disease management programs for stroke, asthma, sickle cell disease, cancer, and anorexia as well as special education programs for children.

COMMUNITIES There are many ways to define a community. A community can be a group of individuals with shared characteristics or interests who interact with each other. A community can also be a system that includes children and families, the physical environment, educational facilities, safety and transportation resources, political and governmental agencies, health and social services, communication resources, economic resources, and recreational facilities. The community itself is within the scope of practice of the community health nurse. The core of the community is the people, characterized by their age, sex, socioeconomic status, educational level, occupation, ethnicity, and religion. The community is often defined by geography or geopolitical boundaries, which can be used to determine the location of service delivery (Anderson & McFarlane, 2019). Community health initiatives are directed at either the general health of the community as a whole or specific populations within the community that have unique needs. In this context, populations can be described as groups of people who live in a community, for example, pregnant women or school-age children. Priority populations or subpopulations are more narrowly defined groups (e.g., unimmunized preschoolers, or middle-school children who have obesity) which are the focus of activities to improve the health status of individuals in the group. Common values often guide behaviours of populations and subpopulations in relation to health promotion and disease prevention (Stanhope et al., 2017). A wide variety of strategies have been used to engage families and groups in health-promoting activities or community health programs. Some are more successful than others. Engaging participants in the planning process and empowering them to create internal solutions are considered key factors in developing effective interventions. Many communities have organized coalitions to address specific health promotion agendas related to sharing information, educating community members, or advocating for health policies around perinatal and child health issues such as child and school safety zones. The benefits of partnership with faith-based organizations for community health improvement have been demonstrated in health promotion efforts aimed at lifestyle choices, health education, and perinatal and children’s health outcomes.

Community Nursing Process In community nursing, the nursing process shifts its focus from the individual patient and family to the community or target population (Box 3.2). The stages of the process (assessment, diagnosis, planning, implementation, and evaluation) are similar, whether the patient is one individual or a whole community.

Assessing the Community. A community health assessment is used to identify and measure the health status of the population of a given health authority or region. It is a complex but well-defined process through which the unique characteristics of the population, its assets,

BOX 3.2

31

The Community Nursing Process

Assessment and diagnosis—The nurse collects subjective and objective information about a community and analyzes this information based on community needs and problems to develop priorities. Planning—The nurse develops community-centred goals to address the identified needs and concerns. Intervention—The nurse implements a program that enables community members to reach their goals. Evaluation—The nurse conducts a systematic evaluation to determine that goals and program objectives were met by developing measurable outcomes.

and needs are identified in order to facilitate collaborative action planning to improve community health status and quality of life. The purpose of this process is to identify direct service and advocacy needs of the prioritized aggregate or group and to improve the health of the community. Engaging the community and key stakeholders in the process increases buy-in and ultimately leads to better outcomes for the proposed services. During a community health assessment, data are collected, analyzed, and used to inform, educate, and mobilize communities; identify priorities; garner resources; and plan actions to improve the health of the public. Many models and frameworks of community assessment are available, but the actual process often depends on the extent and nature of the assessment to be performed, the time and resources available, and the way in which the information is intended to be used. For examples of community assessment tools, see the Additional Resources section at the end of the chapter. The community asset mapping approach provides an overview of community attributes and strengths that may facilitate long-term change and improved quality of life for community residents. Understanding community capacity involves looking at a community’s ability to address social and health issues or to develop knowledge, systems, and resources that contribute to a community’s health status. These approaches help to direct the health promotion process by identifying community priorities and areas of needed change. The community health nurse may assist with community capacity building by working with the community to develop skills in accessing resources, developing social networks, and learning from the experience of others (CPHA, 2010). Data collection and sources of community health data. Data collection is often the most time-consuming phase of the community assessment process, but it provides an important understanding and description of the community. Measures of community health include health status data, access to health care, access to healthy food, level of provider services available, and other social and economic factors. Consideration of individual, interpersonal, community, organizational, and policy-level data and the interaction of these factors are important in providing a comprehensive framework for community health promotion. A community assessment model (Figure 3.3) is often used to provide a comprehensive guide to data collection. Some important community indicators of perinatal and children’s health are as follows: maternal and infant mortality rates, low birth weight (LBW), number of stillbirths, level of first-trimester prenatal care, number of enhanced 18-month well-baby visits, immunization rates, the Early Developmental Instrument (EDI), and rates for other screening tests. Nurses may use these indicators as a reflection of access, quality, and continuity of health care in a community. Lower

Introduction to Maternal Child Nursing

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Health personnel S Extended care e rv Di ice agencies ag s Health H reh nos departments H eal ab is E eal th c ilita Tre Hospitals S pid th p ou tio atm Clinics en E an em la ns n i d t i a o n e t Funds u ca tio log ning lling tio n y n Resources He al

t h C a r e D e li v e r y S y s t e m

Fig. 3.3 Community health assessment wheel. (From Clemen-Stone, S. [2002]. Community assessment and diagnosis. In S. Clemen-Stone, S. McGuire, & D. Eigsti [Eds.], Comprehensive community health nursing: Family, aggregate, and community practice [6th ed.]. Mosby.)

neighbourhood income has been found to be associated with higher child vulnerability, as measured by EDI scores. Based on data collected across Canadian provinces between 2007 and 2012, 34.9% of children living in a low-income neighbourhood experienced higher health vulnerability, compared to 19.5% in high-income neighbourhoods (O’Brien Institute for Public Health, 2018). Vulnerability is an important determinant of child health as it has implications for lifelong health and well-being. For all people, access to a consistent source of health care is critical. Not having a regular medical doctor or nurse practitioner is associated with fewer health care visits with general practitioners and specialists who can play a role in screening and treating medical conditions early (Glazier et al., 2008). Over the past decade, the percentage of Canadians who report having a primary care practitioner has declined slightly; remote areas in Canada report the lowest numbers of people with family doctors. In 2017, 15.3% of Canadians reported not having a primary care practitioner, with the highest rates reported in Quebec, Saskatchewan, and British Columbia (Statistics Canada, 2019). When people do not have access to a primary health care provider, they use walk-in clinics, hospital emergency departments, or community health centres.

The growing numbers of nurse practitioners in Canada have helped to address the shortage of family physicians. Access to health care is also an important measure of community health. This indicator relates to the availability of health department services, home health care services, hospitals, birth centres, walk-in clinics, community health centres, or other sources of care, as well as the accessibility of that care. In many areas where facilities and providers are available, geographic and transportation barriers render the care inaccessible for certain populations. This is particularly true in rural areas or other remote locations. Other barriers to care should also be evaluated, including cultural and language barriers and lack of providers for specialty care. Local health departments provide varied levels and types of services, which are mandated by their respective provincial/territorial ministries of health. Depending on the level of funding received, they may or may not meet the needs of the populations they serve. For example, primary care services are limited in many areas, although health education is offered by most health departments in Canada. Health departments at the municipal, regional, and provincial/ territorial level are a valuable resource for annual reports of births

CHAPTER 3 Community Care and deaths and other important health status data. Maternal and infant death rates are particularly important as they reflect health outcomes that may be preventable. Local health departments also compile extensive statistics about birth complications, causes of death, and leading causes of morbidity and mortality for each age group. Local, provincial, and territorial health data are compiled and reported through various agencies, including Health Canada, Statistics Canada, the Canadian Institute for Health Information (CIHI), and the PHAC. However, national data are only as accurate and reliable as the local data on which they are based, thus caution is needed in interpreting the data and applying them to specific population groups. The Canadian government census provides data on population size, age ranges, sex, racial and ethnic distribution, socioeconomic status, educational level, employment, and housing characteristics. Summary data are available for most large metropolitan areas, arranged by postal code and census tract, which usually correspond to a neighbourhood comprising approximately 2 000 to 8 000 people. Assessment of individual census tracts within a community can help in identifying subpopulations or aggregates whose needs may differ from those of the larger community. For example, women at high risk for inadequate prenatal care according to age, race, and ethnic or cultural group may be readily identified, and outreach activities may be provided as appropriate. Other sources of useful data are hospitals and voluntary health agencies. Community health resources include health care providers or administrators, government officials, religious leaders, and representatives of voluntary health agencies. Community or regional health councils exist in many areas, with oversight of specific health initiatives or programs for that region. These key informants often provide a unique perspective that may not be accessible through other sources. Community gatekeepers who are at the forefront of addressing the social and health care needs of the population are also critical links to population-specific health information. Data may also be retrieved from existing community health program reports, records of preventive health screenings, and other informal data. Established programs often provide reliable indicators of the health-promotion and disease-prevention characteristics of the population. Data collection methods may be either qualitative or quantitative and may include visual surveys that can be completed by walking through a community, participant observation, interviews, focus groups, and analysis of existing data. Potential patients and health care consumers may be asked to participate in focus groups or community forums to present their views on needed community services and programs. Formal surveys conducted by mail, telephone, online, or face-to-face interviews can be a valuable source of information not available from national databases or other secondary sources. However, several drawbacks exist with this method. Surveys are generally expensive to develop and time-consuming to administer. In addition to the cost of such surveys, poor response rates often preclude a sufficiently representative response on which to base nursing interventions. A local walking survey is generally conducted by making a walkthrough observation of the community (see Community Focus box), taking note of specific characteristics of the population, economic and social environment, transportation, health care services, safety, and other resources. This method allows the nurse to collect subjective data and may facilitate other aspects of the assessment. Participant observation is another useful assessment method, in which the nurse actively participates in the community in order to understand the community more fully and to validate observations.

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COMMUNITY FOCUS Community Walk-Through As you observe the community, take note of the following: Physical environment—Older neighbourhood or newer subdivision? Sidewalks for safely walking with children and older persons, streets, and buildings in good or poor repair? Billboards and signs? What are they advertising? Are lawns kept up? Is there garbage in the streets? Parks or playgrounds? Parking lots? Empty lots? Industries? Air quality? People in the area—Older persons, young people, homeless persons, children, predominant ethnicity, language? Is the population homogeneous? What signs do you see of different cultural groups? Are people out and about in the community? Are there natural gathering places for families? Stores and services available—Restaurants: chain, local, ethnic? Grocery stores: neighbourhood or chain? Department stores, gas stations, real estate or insurance offices, travel agencies, pawn shops, liquor stores, discount or thrift stores, convenience stores? Can people walk to shopping or do they need a car? Are there services for families with young children, such as Early Years Centres? Social—Libraries with programming for children, museums, community recreation centres, arenas, clubs, pubs, organizations (e.g., Lions Club, Canadian Legion)? Religious—Churches, synagogues, mosques, temples? What denominations? Do you see evidence of their use other than on religious or holy days? Health services—Drug stores, doctors’ offices, clinics, dentists, mental health services, veterinarians, urgent care facilities, walk-in clinics, hospitals, shelters, long-term care facilities, home health agencies, public health services, well-baby clinics, local laboratory, traditional healers (e.g., herbalists, palmists)? Transportation—Cars, bus, taxi, ride-sharing services, subway, light rail, sidewalks, bicycle paths, access for disabled persons? Education—Schools, before-school and after-school programs, child care centres, libraries, bookstores? What is the reputation of the school or schools? Government—What is the governance structure? Is there a mayor? City council? Are meetings open to the public? Are there signs of political activity (e.g., posters, campaign signs)? Is there a local neighbourhood business community organization? Safety—How safe is the community? What is the crime rate? What types of crimes are committed? Are police visible? Is there a fire station? Are people comfortable walking in their neighbourhood after dark? Parks and recreation facilities—Are there local parks for toddlers and children? Are there recreational facilities for adults and children to participate in sports and recreation activities? Evaluation of the community, based on your observations—What is your impression of the community? Is the environment pleasing? Are services and transportation adequate? How difficult is it for residents to obtain needed services (i.e., how far do they have to travel)? Would you want to live in this community? Why or why not?

Finally, as part of the assessment process, nurses working in multiethnic and multicultural groups need an in-depth assessment of culturally based health behaviours. In some cultures it is common for mothers and their babies to remain at home for the first 30 to 40 days postpartum (postpartum confinement). It is important to consider how postpartum confinement might limit the use of services at well-baby clinics, infant feeding clinics, and other postnatal interventions in the community. Analysis and synthesis of data obtained during the assessment process help in generating a comprehensive picture of the community’s

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Introduction to Maternal Child Nursing

health status, needs, and problem areas, as well as its strengths and resources for addressing these concerns. The goals of this process are to assign priorities to community health needs and to develop a plan of action for correcting them. A comparison of community health data with provincial and national statistics may be useful in the identification of appropriate target populations and interventions to improve health outcomes.

Community Planning. After the assessment is completed, the community nurse can collaborate with team members to analyze the results of surveys and questionnaires and determine whether the needs described by community members can be met by existing community agencies. During the analysis, the community’s demographic characteristics, morbidity rates, and mortality rates are compared with a standard. In time comparisons, the nurse contrasts the rates in the current year with the rates during an earlier period. In comparisons of place, the nurse contrasts the rates in the community with those of a standard population. Standard rates may come from another community or from city, province/territory, or national data. For example, the rate of tuberculosis (TB) in a group of preschool children in a community in 2020 could be compared with the rate of TB in preschool children in the province in 2020. Some jurisdictions in Canada have a much higher rate of TB than others due to patterns of immigration and living conditions (Vachon et al., 2018). A community health diagnosis reflects health status, risk, or need. A community diagnosis is similar to that of an individual nursing diagnosis with a problem (need) and an etiology related to that problem (causative agent). An example of a community nursing diagnosis is increased rates of TB related to poor socioeconomic environment and overcrowded living conditions. The nurse can collaborate with community members to develop a plan that addresses the target population’s needs and problems utilizing a population health approach. To maximize the use of community resources, problems should first be prioritized on the basis of their severity, the community’s identified needs, and the community nurse’s ability to bring about change. The nurse or team works with community members to develop at least one goal for each problem. Goals are outcomes that give direction to interventions and provide a measure of the change the interventions produced. Community interventions frequently take the form of health programs for improving the target population’s health status. Community health programs are based on the three levels of prevention: primary, secondary, and tertiary. For example, a goal for preventing bicycle injuries is “Within 1 year all students in the first grade will wear bicycle helmets.” A nurse working within a group along with community members can then plan a program that includes health education about bicycle safety for students and their parents (primary prevention). The planning group will consider the resources that are already available in the community and resources that will be needed for implementing a health program, including location, personnel, supplies, and equipment. Decisions are made about the program’s timeline, the budget, and strategies to obtain funding. Program descriptions are found through professional contacts, online resources, and a review of the literature. Community Intervention. During program implementation, the nurse or team and community members carry out the intervention. Whether the program is simple or complex, oversight is needed to ensure that everyone involved is communicating with one another, adhering to the plan’s guidelines, keeping within the timeline, and documenting daily activities and expenses. The documentation will prove invaluable during the evaluation phase of the process.

Community Evaluation. Evaluation is used to identify whether the goals and program objectives were met. There are various models for measuring quality of health care. The most common framework used by health care organizations is the structure, process, and outcomes method described by Donabedian (1988). Donabedian conceptualized three quality-of-care dimensions: structure, process, and outcomes. Structure—refers to attributes of the setting where the care is delivered. It is the context in which care is delivered that affects processes and outcomes—that is, the qualifications of personnel; the adequacy of buildings and offices, supplies, and equipment; and the target population’s characteristics. Process—whether or not good health care practices are followed. Outcomes—the impact of the care on health status. Outcomes indicate the combined effects of structure and process—that is, whether program objectives and community goals were met. To monitor outcomes is to monitor performances, which are conditional on structure and process. Only structure and process can be manipulated. Program evaluation should be ongoing so that an improvement in the way health care is delivered will affect the target population’s health status.

Implications for Nursing Working in the community or in the home with the full spectrum of family organizational styles, vulnerable populations, and cultural groups may present challenges for the nurse. Whether nursing care is focused on adults or children or on treatment and prevention of other health conditions in adults and children, such as communicable diseases and sexually transmitted infections, nurses must exhibit a high degree of professionalism and competence. Cultural sensitivity, compassion, and a critical awareness of family strengths, dynamics, and social stressors that affect health-related decision making are critical components in developing an effective plan of care. It is also important for nurses to have knowledge of health inequities related to the populations they provide care for. Some examples of the importance of cultural sensitivity include working with immigrant families and the homeless population. Successful health promotion for new immigrants depends on the resources, benefits, and policies that ensure their healthy development and successful social adjustment. Culturally competent health care and involvement of the immigrant community in health care programs are recommended strategies for improving access to and effectiveness of health care for this population. Nurses also work with homeless people and can be challenged to locate these patients on a regular basis and to establish a therapeutic relationship with them. Nurses and other health care providers may lack sufficient knowledge and sensitivity around the circumstances and special needs of this population and may inadvertently provide ineffective care. Many homeless people delay seeking health care or avoid it altogether because of having previous negative encounters with and lack of trust in health care providers. Case management is recommended for coordinating the services and disciplines that may be involved in meeting the complex needs of these families. Whenever possible, general screening and preventive services must be provided when the family member seeks treatment, as this may be the only opportunity to provide health information and intervention. Building on existing coping strategies and strengths, the health care provider can help the patient to reconnect with a social support system. Nurses also have an important role in advocating for funding to support homeless health services and to improve access to preventive care for all homeless populations.

CHAPTER 3 Community Care

HOME CARE IN THE COMMUNITY Within the current health care system, home care is an important component of health care delivery, along the perinatal and child continuum of care. The growing demand for home care is based on several factors: • Shortened hospital stays • Increase use of outpatient procedures and surgeries • New technologies that facilitate home-based assessments and treatments particularly for children with complex medical conditions • Desire for the patient and family to be at home Home care is the provision of technical, psychological, and other therapeutic support in the patient’s home rather than in an institution. The scope of nursing care delivered in the home is necessarily limited to practices 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 provincial 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. Home health care can be viewed as an extension of in-hospital care. Essentially, the major 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 health issue and/or provides care onsite for fewer than 4 hours at a time. For example, a new postpartum patient who requires dressing changes or other complex postpartum care may be eligible for home care. 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. 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 kilometres away. Home care agencies are subject to regulation by governmental and professional organizations and provide interprofessional services including social work, nutrition, occupational therapy, and physiotherapy. Increasingly, their caseloads are made up of patients who require high-technology care, such as parenteral nutrition for pregnant patients with hyperemesis or children requiring care of central lines for chemotherapy. Although the home health nurse develops the care plan, all care must be ordered by a physician or a nurse practitioner.

Patient Selection and Referral The office or hospital-based nurse is often the key person making referrals to home care. When considering a referral to home care, the following factors are evaluated: • Health status of patient: 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 patient’s community. • Family resources, including psychosocial, social, and economic resources: Will the family be able to provide care between nursing visits? Are relationships supportive? Does the family have health benefits to support their care? Could a voluntary community agency provide needed care without payment? • Cost-effectiveness: Is it more reasonable for the patient to receive these services at home or to go to a local outpatient facility to receive them?

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Community referrals should not be limited to patients with physiological complications that require medical treatment. Patients at risk (e.g., patients with a perinatal mood disorder, young adolescents, families with a history of abuse, members of vulnerable population groups, developmentally disabled individuals) may need follow-up care at home. With the growing types of interprofessional health care now available, it is crucial that nurses communicate with social workers to tap into valuable community resources that patients can use in their own communities once discharged home. High-technology home care requires additional information to be collected from the chart and consultation with the referring health care provider 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, drugdosing information, potential ancillary supplies, type of infusion and access device, and the available systems of social support for the patient 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.

Nursing Care Home Visiting. The community health or home health nurse will review the home visiting referral, including documents such as screening tool results, record of birth, available clinical data, demographic information, and any other relevant information, prior to setting up the visit with the patient. During the telephone call to arrange a mutually convenient visiting time, the nurse will determine the goals of the visit. During this contact, the nurse should identify themselves and begin to build rapport with the patient. The nurse should briefly explain what will occur during the visit and approximately how long the visit will last. The patient and family should be asked to restrain any pets that may be present during the visit. The nurse needs to review relevant policies and procedures, professional literature about any potential diagnosis, and community resources as part of the previsit preparation work (Box 3.3). First home visit. Making the first home visit can be stressful for both the nurse and the family. The home visiting nurse is faced with an unknown environment controlled by the patient and the family. The patient and the family can 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 community health or home health nurse is to establish a nurse–patient relationship and provide the prescribed services within the time provided for the initial home visit. One of the most important tasks of the home health nurse is modelling health-related behaviours for the patient and others who are in the home during the visit. During the first visit, after introductions have been made, the nurse will complete an extensive assessment documentation with the patient. If the nurse needs to consult with the patient’s physician, nurse practitioner, or other health care providers, a consent form will need to be signed by the patient. All patients have the right to participate actively in their plan of care. If the patient is a child, the parents or guardians will make decisions regarding the care of their child. Explanation of these patient rights and responsibilities should begin the discussion about the nurse and patient roles during this initial visit. Assessment. The primary goals of the assessment phase are to develop a trusting relationship and collect data by various methods to obtain a comprehensive patient profile. The major areas of the assessment are demographics, medical history, general health history, medication history, psychosocial assessment (Box 3.4), home and community environment, and physical assessment. It may not be feasible or appropriate to collect in-depth information about all areas of

36 BOX 3.3

UNIT 1

Introduction to Maternal Child Nursing

Protocol for Home Visits

Previsit Interventions 1. Contact the family to arrange details for a home visit. a. Identify self, credentials, and role of the community health or home health nurse. b. Review the purpose of the home visit. c. Schedule a convenient time for the visit. d. Confirm address and route to the family home. 2. Review and clarify appropriate data. a. Review all available assessment data for the patient or family (e.g., referral forms, hospital discharge summaries, family-identified learning needs). b. Review records of any previous nursing contacts. c. Contact other professional caregivers as necessary to clarify data (e.g., physician, midwife, nurse, referring source). 3. Identify community resources and teaching materials that are appropriate to meet needs already identified. 4. Plan the visit and prepare any resources required for the visit. In-Home Interventions: Establishing a Relationship 1. Reintroduce self and establish the purpose of the visit for the parents, child, and family; offer the family an opportunity to clarify their expectations of contact. 2. Spend a brief time socially interacting with the family to become acquainted and establish a trusting relationship. In-Home Interventions: Working With a Family 1. Conduct a systematic assessment of the patient to determine physiological adjustment and any existing complications. 2. Throughout the visit, collect data to assess the emotional adjustment of individual patient and family members to illness or lifestyle changes. 3. Determine adequacy of the support system if appropriate. a. To what extent does someone help with cooking, cleaning, and other home management tasks? b. To what extent is help being provided in caring for the patient or other family members? c. Are support persons encouraging the patient to care for themselves and get adequate rest?

BOX 3.4

4. Throughout the visit, observe the home environment for adequacy of resources (if appropriate): a. Space: privacy, safe play of children, sleeping b. Overall cleanliness and state of repair c. Number of steps the patient must climb d. Adequacy of cooking arrangements e. Adequacy of refrigeration and other food storage areas f. Adequacy of bathing, toilet, and laundry facilities 5. Throughout the visit, observe the home environment for overall state of repair and existence of safety hazards: a. Storage of medications, household cleaners, and other substances hazardous to children b. Presence of peeling paint on furniture, walls, or pipes c. Factors that contribute to falls, such as dim lighting, broken steps, scatter rugs d. Presence of vermin e. Use of crib or playpen that fails to meet safety guidelines f. Existence of emergency plan in case of fire; fire alarm or extinguisher 6. Provide care to the patient. 7. Provide teaching on the basis of previously identified needs. 8. Refer the family to appropriate community agencies or resources, such as telephone contact information lines and community support groups. 9. Ascertain that the patient and family know potential problems to watch for and whom to call if they occur. In-Home Interventions: Ending the Visit 1. Summarize the activities and main points of the visit. 2. Clarify future expectations, including scheduling of the next visit. 3. Review the teaching plan and highlight important points. 4. Provide information about reaching the nurse or public health department if needed before the next scheduled visit. Postvisit Interventions 1. Document the visit thoroughly, using the required agency forms. 2. Initiate the plan of care on which the next encounter with the patient or family will be based. 3. Communicate appropriately to other staff assigned to care for the family. This may include follow-up with other health care providers, if warranted.

Psychosocial Assessment

Language Identify the primary language spoken in the home. Assess whether there are any language barriers to receiving support. Assess health literacy.

Interpersonal Relationship Identify the way in which decisions are made in the family. Identify the family’s perception of the need for home visiting. Identify roles of adults in caring for family members.

Community Resources and Access to Care Identify primary and secondary means of transportation. Identify community agencies that the family currently uses for health care and support. Assess cultural and psychosocial barriers to receiving care.

Caregiver Identify the primary caregiver for the patient. Identify other caregivers and their roles. Assess the caregiver’s knowledge of care required for the patient and the purpose of home visits. Identify potential strain from the caregiver role. Identify the level of satisfaction with the caregiver role.

Social Support Determine the people living with the patient. Identify who assists with household chores. Identify who assists with child care and parenting activities. Identify who the patient turns to with problems or during a crisis. Determine social networks both formal and informal.

Stress and Coping Identify what the patient perceives as lifestyle changes and their impact on self and the family. Identify the changes that the patient and family have made to adjust to the illness or life transition.

CHAPTER 3 Community Care assessment during the first visit. However, in many instances the nurse may be limited to one visit and must obtain information pertinent to the current situation during that visit. Establishing a trusting relationship begins with the previsit telephone call. An interview style that reflects sensitivity, conveys a nonjudgemental, accepting attitude, and shows respect for the patient’s rights facilitates development of that trusting relationship. A skillful interviewer avoids barriers to communication, such as false reassurance, advice-giving, excessive talking, and showing approval or disapproval. This nurse–patient relationship will continue to develop over the course of each home visit. The nurse is a guest in the patient’s home and should show respect for the patient’s belongings. Some adaptation of the home visit schedule may need to be made if numerous distractions interrupt a visit, such as caring for the needs of small children. The nurse may ask to have the volume of the television reduced or suggest moving to another room where it is quieter and more private. Plan of care and implementation. The nursing plan of care is developed in collaboration with the patient, based on the health care and learning needs of the individual. Home visiting nurses work from a standard care plan and make adjustments to meet the needs of each individual patient. The frequency of the skilled nursing visit may vary with the individual plan of care, and a family visitor or lay home visitor may be recommended if additional support is suggested and available. There are several areas of concern when caring for a patient in the home. In home care, the patient or family members may be responsible for administration of medications in the absence of the nurse. A careful medication history should be obtained to see if the patient is taking the medications correctly and understands their desired action and potential adverse effects. It is important that patients and caregivers have a clear understanding of medication regimens and are notified when medications change in any way. Even more important is ensuring that the patient and caregivers fully understand the information they are given by health care providers. It is also important that nurses be aware of how to use and educate patients and families on the use of all home care equipment, such as infusion pumps and phototherapy lights. Although most newborn phototherapy is usually done in the hospital, sometimes jaundiced babies are treated at home. The nurse should be familiar with the types of phototherapy equipment (e.g., Bili Therapy Pad) they may encounter in the home setting. Nurses also must be skilled at performing various procedures, such as venipuncture and administration of intravenous medications or fluids. In addition to teaching about medications and equipment, nurses must be sure that patients and families know how to respond in emergency situations. The provision of education during a home visit is a key component of the visit. Verbal explanations should be supplemented with clearly written instructions if the patient has difficulty remembering or if there is a language barrier. Many written resources are available in multiple languages to facilitate the transfer of information and knowledge. Finally, as soon as home care has been provided, it is essential that the nurse document the assessment findings, care provided, recommendations for change, and any patient or family teaching done. Nursing documentation should reflect an objective description of the nursing assessment data collected at each visit and the associated outcomes. Once the home visiting outcomes are achieved or the patient is discharged from the program, documentation should include information about the patient’s status at the time of discharge, progress toward attaining health care goals, and plans for any follow-up care. Appropriate care should be taken to complete the necessary home health care records accurately and in a timely manner and ensure appropriate privacy rules are maintained. Documentation guidelines are agency

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specific but may include writing or dictating notes or using eDocumentation shortly after the visit. Safety issues for the home visiting nurse. Nurse safety and infection control are two important aspects specific to home care. The nurse should be fully aware of the home environment and the neighbourhood in which the home care will be provided. Unlike hospitals, where the environment is more predictable and controlled, the patient’s neighbourhood and home have the potential for uncertainty. Home visiting nurses should take necessary safety precautions and avoid dangerous situations. Personal strategies recommended for nurses visiting families with a history of violence or substance use include (1) self-awareness, (2) environmental assessment, (3) using listening and observation skills with patients to be aware of behavioural changes that indicate aggression or lack of impulse control, (4) planning for dealing with aggressive behaviour (i.e., allowing personal space and taking a nonaggressive stance), (5) making visits in pairs, and (6) having access to a cell phone at all times. Personal safety. The home care nurse must be aware of personal safety behaviours before going on a home visit. Dress should be casual but professional in appearance, with a first-name-only identification tag. Limited jewellery should be worn. Carrying an extra set of car keys in the nursing home care bag saves time and frustration if the nurse becomes locked out of the automobile. Home visiting nurses should follow the same common-sense behaviours and precautions that guide behaviour when alone in any setting. The community health nurse should ensure that their employer knows their itinerary by keeping their electronic calendar up to date as per protocol. Many nurses carry agency-provided cell phones that allow the department to contact the nurse throughout the day in order to give information about patient updates or schedule changes. A cell phone is also useful for notifying patients when the nurse is delayed. Patient’s home. Once inside the person’s home, the nurse may encounter unsafe situations, such as the presence of weapons, abusive behaviour, or a health hazard. Each potentially hazardous situation must be dealt with according to agency policies and procedures. If abuse or neglect is reasonably suspected, the home care nurse should follow the department’s and the province’s regulations for reporting and documenting the situation. Nurses should maintain their own safety first and act accordingly throughout the visit. Infection control. The importance of infection control does not diminish because nursing care is being provided in the patient’s home. Patients are not likely to become infected because of their home environment, but the nurse may become exposed to an infectious disease. Hand hygiene remains the single most important infection control procedure, and the caregiver is in a position to educate the family about the importance of this practice in preventing disease. Hands should be washed before and after each patient contact; wearing gloves does not eliminate the necessity for hand hygiene. If running water or clean facilities are unavailable, hands can be cleaned with hand sanitizer.

Phone and Online Health Support Frequent and brief contacts with health care providers are required during the perinatal and early child development periods, making services that link patients to care important. There are several different ways in which these linkages can be made. Most public health departments in Canada offer telephone support lines or social media connections with families (Facebook, Twitter, text messaging) to provide parents with support and education about pregnancy, infant feeding, and parenting information and resources. Another Web-based resource are provincial websites that provide people with medically approved information on many health topics, medications, and tips

38

UNIT 1

Introduction to Maternal Child Nursing

BOX 3.5

Telephone Triage Guidelines for Assessment Date and time Background • Name, age, sex • Chronic illness • Allergies, current medications, treatments, or recent immunizations Chief health concern General symptoms • Severity • Duration • Other symptoms • Pain Systems review Steps taken • Advised to call emergency medical services (911) • Advised to see practitioner • Advice given for home care • Call back if symptoms worsen or fail to improve

for promoting health lifestyles, for example, HealthlinkBC. More and more providers are using the Internet to communicate with their patients. Telephonic nursing care through services such as nurse advice lines and telephonic nursing assessments is a valuable means of managing health care issues and bridging the gaps between acute, outpatient, and home care services. Nursing care via telephone is interactive and responsive to a patient’s immediate health care questions about particular health care needs. Telehealth is another option in which nurses guide callers through urgent health care situations, suggest treatment options, and provide health education.

Telephone Triage and Counselling. Telephone triage care management has increased access to high-quality health care services and empowered parents to participate in their own health care. Consequently, patient satisfaction has significantly improved. Unnecessary emergency department and clinic visits have decreased, saving health care costs and time (with less absence from work) for families in need of health care. Most often, health issues are assessed and prioritized according to urgency, and treatment is judiciously provided via telephone services. Telehealth nurses need to have communication skills training in telephone consultation and learn how to structure a call. A well-designed telephone triage program is essential for safe, prompt, and consistentquality health care. Typically, guidelines for telephone triage include asking screening questions; determining when to immediately refer to emergency medical services (dial 911); and determining when to refer to same-day appointments, appointments in 24 to 72 hours, appointments in 4 days or more, or home care (Box 3.5).

KEY POINTS • A community is defined as a locality-based entity composed of systems of societal institutions, informal groups, and aggregates that are interdependent and whose function is to meet a wide variety of collective needs.

• Caring for perinatal patients and children in their community requires nurses to utilize an interprofessional approach, as well as working with the families themselves. • Community health nursing focuses on promoting and maintaining the health of individuals, families, and groups in the community setting. • Economic evaluations provide objective information to establish a program’s value to society. • Individual families and communities may have demographic characteristics that affect their risk for disease or injury. • Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. • Community health programs are based on three levels of intervention: primary, secondary, and tertiary. • A community needs assessment involves collection of subjective and objective information about the community. • A community health diagnosis is a concern with a defined cause related to a community issue. • Most changes aimed at improving community health involve partnerships between community residents, key stakeholders, and health care workers, among others. Community nurses are well positioned to facilitate partnership development. • Evaluation of effective community programs includes consideration of the structure, process, and outcomes related to the program. • Methods of collecting data useful to the nurse working in the community include walking surveys, analysis of existing data, informant interviews, and participant observation. • Community health nurses must be aware of vulnerable populations within the community who may require additional care. • Nurses play an important role in perinatal and children’s health home visiting through the provision of evidenceinformed care that includes consideration of community assets and resources and connecting families to the services and supports they require. • Nurses who provide care in the community incorporate knowledge from community health nursing, acute care nursing, family therapy, health promotion, and patient education. • Home visiting nurses should incorporate personal safety and infection control practices in the nursing plan of care. • Telephone contact centres, credible websites, and social media platforms are low-cost health care services that facilitate continuous patient education, support, and health care decision making, even though health care is delivered in multiple sites.

REFERENCES Anderson, E. T., & McFarlane, J. (2019). Community assessment. Using a model for practice. In E. T. Anderson, & J. McFarlane (Eds.), Community as partner: Theory and practice in nursing (8th ed.). Lippincott Williams & Wilkins. Blair, C., & Raver, C. C. (2016). Poverty, stress, and brain development: New directions for prevention and intervention. Academic Pediatrics, 16(3 Suppl), S30–S36. https://doi.org/10.1016/j.acap.2016.01.010. Canadian Institutes for Health Information (CIHI). (2018). Gestational diabetes: An invisible maternal and infant health issue. https://cihr-irsc.gc.ca/e/49943. html. Canadian Public Health Association (CPHA). (2010). Public health/community health nursing practice in Canada: Roles and activities (4th ed.). https://www. cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf.

CHAPTER 3 Community Care Center on the Developing Child at Harvard University. (2016). Applying the science of child development in child welfare systems. https://developingchild. harvard.edu/resources/child-welfare-systems/. Community Health Nurses of Canada (CHNC). (2009). Public health nursing discipline specific competencies, version 1.0. https://phabc.org/wp-content/ uploads/2015/07/Community-Health-Nurses-Public-Health-CoreCompetencies.pdf. Community Health Nurses of Canada (CHNC). (2010). Home health nursing competencies, version 1.0. https://www.chnc.ca/en/competencies. Community Health Nurses of Canada. (CHNC). (2019). 2019 Canadian community health nursing and professional practice model and standards of practice. https://www.chnc.ca/en/standards-of-practice. Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA: The Journal of the American Medical Association, 121(11), 1145–1150. https:// doi.org/10.1001/jama.1988.03410120089033. Frankish, C. J., Green, L. W., Ratner, P. A., et al. (2001). Health impact assessment as a tool for population health (pp. 405–437). World Health Organization. Glazier, R. H., Moineddin, R., Agha, M. M., et al. (2008). The impact of not having a primary care physician among people with chronic conditions. In ICES Investigative Report. Institute for Clinical Evaluative Studies. https://www.ices. on.ca/Publications/Atlases-and-Reports/2008/The-impact-of-not-having. Government of Canada. (2020). Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/healthpromotion/population-health/what-determines-health.html. McFarlane, J., & Gilroy, H. (2015). Epidemiology, demography and community health. In E. T. Anderson, & J. McFarlane (Eds.), Community as partner: Theory and practice in nursing (7th ed.). Lippincott Williams & Wilkins. O’Brien Institute for Public Health. (2018). Raising Canada: A report on children in Canada, their health and wellbeing. https://static1.squarespace.com/static/ 5669d2da9cadb69fb2f8d32e/t/5b8e12e121c67c87038b4cbf/1536037605886/ Raising+Canada+Report.pdf. Public Health Agency of Canada (PHAC). (2008). Core competencies for public health in Canada, release 1.0. https://www.canada.ca/content/dam/ phac-aspc/documents/services/public-health-practice/skills-online/ core-competencies-public-health-canada/cc-manual-eng090407.pdf. Public Health Agency of Canada (PHAC). (2018). Key health inequalities in Canada: A national portrait. https://www.canada.ca/content/dam/ phac-aspc/documents/services/publications/science-research/key-healthinequalities-canada-national-portrait-executive-summary/key_health_ inequalities_full_report-eng.pdf.

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Public Health Agency of Canada (PHAC). (2020). Community Action Program for Children (CAPC). http://www.phac-aspc.gc.ca/hp-ps/dca-dea/prog-ini/ capc-pace/index-eng.php. Public Health Agency of Canada (PHAC). (2021). Public health agency of Canada mandate. https://www.canada.ca/en/public-health/corporate/ mandate/about-agency.html. Stanhope, M., Lancaster, J., Jakubec, S., et al. (2017). Community health nursing in Canada (3rd Canadian ed.). Elsevier. Statistics Canada. (2017). Children living in low-income households: Census of population, 2016. Catalogue No.: 98-200-X2016012. https://www12.statcan. gc.ca/census-recensement/2016/as-sa/98-200-x/2016012/98-200-x2016012eng.pdf. Statistics Canada. (2019). Health fact sheets—Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/pub/82-625-x/2019001/article/ 00001-eng.htm. Statistics Canada. (2021). Leading causes of death, total population by age group. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401. Vachon, J., Gallant, V., & Siu, W. (2018). Tuberculosis in Canada, 2016. The Canada Communicable Disease Report 2018, 44(3/4), 75–81. https://doi.org/ 10.14745/ccdr.v44i34a01.

ADDITIONAL RESOURCES Community Assessment Tools Centers for Disease Control and Prevention (CDC): What is a community health assessment? http://www.cdc.gov/stltpublichealth/cha/plan.html. Winnipeg Health Region Community Health Assessment. (2019). https://wrha. mb.ca/files/cha-2019-full-report.pdf.

Community Health Organizations Canadian Public Health Association (CPHA). https://www.cpha.ca/. Community Health Nurses of Canada (CHNC). https://www.chnc.ca/en/. HealthlinkBC. http://www.healthlinkbc.ca/.

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PART

2

Perinatal Nursing

Unit 2. Introdution to Perinatal Nursing, 42 Chapter 4. Perinatal Nursing in Canada, 42 Unit 3. Women’s Health, 54 Chapter 5. Health Promotion, 54 Chapter 6. Health Assessment, 75 Chapter 7. Reproductive Health, 85 Chapter 8. Infertility, Contraception, and Abortion, 121 Unit 4. Pregnancy, 149 Chapter 9. Genetics, Conception, and Fetal Development, 149 Chapter 10. Anatomy and Physiology of Pregnancy, 175 Chapter 11. Nursing Care of the Family During Pregnancy, 192 Chapter 12. Maternal Nutrition, 229 Chapter 13. Pregnancy Risk Factors and Assessment, 245 Chapter 14. Pregnancy at Risk: Gestational Conditions, 265 Chapter 15. Pregnancy at Risk: Pre-existing Conditions, 307 Unit 5. Childbirth, 343 Chapter 16. Labour and Birth Processes, 343

Chapter 17. Nursing Care of the Family During Labour and Birth, 356 Chapter 18. Maximizing Comfort During Labour and Birth, 398 Chapter 19. Fetal Health Surveillance During Labour, 424 Chapter 20. Labour and Birth at Risk, 446 Unit 6. Postpartum Period, 484 Chapter 21. Physiological Changes in the Postpartum Patient, 484 Chapter 22. Nursing Care of the Family During the Postpartum Period, 492 Chapter 23. Transition to Parenthood, 512 Chapter 24. Postpartum Complications, 532 Unit 7. Newborn, 561 Chapter 25. Physiological Adaptations of the Newborn, 561 Chapter 26. Nursing Care of the Newborn and Family, 583 Chapter 27. Newborn Nutrition, 633 Chapter 28. Infants with Gestational Age–Related Problems, 667 Chapter 29. The Newborn at Risk: Acquired and Congenital Problems, 691 41

UNIT 2 Introduction to Perinatal Nursing

4 Perinatal Nursing in Canada Lisa Keenan-Lindsay http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the current scope of perinatal nursing in Canada. 2. Describe the history and context for perinatal care in Canada. 3. Discuss guiding principles for working with childbearing patients and their families.

4. Examine current trends in perinatal health and compare epidemiological data among groups and populations. 5. Explore current issues affecting perinatal nursing practice and envision creative alternatives. 6. Discuss the global health issues that impact the care that perinatal nurses provide.

This chapter presents a general overview of Canadian issues and trends related to the health and health care of patients, newborns, and families during the childbearing year. Perinatal nursing is a recognized specialty in Canada. Perinatal nurses work collaboratively with childbearing persons and their families throughout the childbearing year, from preconception through pregnancy and childbirth, and over the postpartum transition period. This care is provided in many settings, including the hospital, the home, and a variety of ambulatory and community settings. Nurses also work collaboratively with other health and social care providers, such as physicians, midwives, dietitians, doulas, and social workers, to name a few. Perinatal nurses promote the physical, emotional, social, and spiritual well-being of the whole family and work to address health inequities that influence health outcomes. In Canada, the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN) is the voice of women’s health and perinatal nurses. CAPWHN has developed practice standards for perinatal nurses. The values and guiding principles for these standards are listed in Box 4.1. The Canadian Association of Schools of Nursing (CASN, 2017) has developed entry-to-practice competencies for nursing care of the childbearing family for baccalaureate programs in nursing (see Additional Resources at the end of this chapter). These represent the core competencies related to the nursing care of childbearing families that all baccalaureate nursing students in Canada should acquire over the course of their undergraduate education. The Canadian Nurses Association (CNA) offers a specialty certification for perinatal nurses. Nurses who obtain this certification are recognized nationally for their practice excellence and commitment to lifelong learning (CNA, 2019).

Perinatal nurses use evidence-informed practice to guide their interactions and interventions. The Society of Obstetricians and Gynaecologists of Canada (SOGC) consists of obstetricians, gynecologists, family physicians, nurses, midwives, and allied health professionals working in the field of women’s sexual and reproductive health. The goals of the SOGC are to promote excellence in the practice of obstetrics and gynecology and to advance the health of women through leadership, advocacy, collaboration, and education. Many of the SOGC clinical practice guidelines are used by nurses to support their practice. Many regional health authorities have also developed guidelines for providing care— for example, Perinatal Services BC, and the Champlain Maternal Newborn Regional Program (see Additional Resources). Perinatal units often adapt these recommendations to their specific institutions, enabling nurses to become more informed about current evidence and provide more effective care for childbearing families.

42

PERINATAL SERVICES IN CANADA In Canada, maternal and newborn services have changed from those of our colonial and Indigenous roots to the current system of regionalized perinatal and newborn care. Box 4.2 provides an overview of the history of perinatal services over the past two centuries and shows the progress that has been made, though there is still room for improvement in many areas. The delivery of maternity care within each community, province, and territory contains unique elements as each level of government tries to balance human resources, funding, and liability concerns with regulatory, educational, political, and demographic issues. Inequities in access to good-quality maternity care have developed particularly in

CHAPTER 4 Perinatal Nursing in Canada

BOX 4.1

43

Values and Guiding Principles for Perinatal Nursing in Canada

Caring: Perinatal nurses foster caring relationships with childbearing persons and families by providing safe, compassionate, competent, and ethical care; promoting family health and development; and assisting when childbearing challenges occur. Caring is demonstrated through authentic presence, which is achieved by addressing physical, emotional, spiritual, and psychosocial needs throughout the care trajectory. Health and well-being: Perinatal nurses promote health and well-being by assisting childbearing persons and their families to strengthen their knowledge and skills to achieve their optimal level of well-being throughout the childbearing continuum. Justice: Perinatal nurses uphold principles of justice by safeguarding human rights, equity and gender inclusivity, and fairness with childbearing persons, families, and newborns.

Informed decision making: Perinatal nurses recognize the rights of patients to make informed choices that are congruent with their own beliefs and values, and advocate for them to act on this right. Dignity: Perinatal nurses share the intimacy of childbirth with childbearing persons and their families. Knowing that childbirth creates lasting memories of this important developmental transition, they strive to positively influence the childbearing experience by creating a healing environment that promotes and protects human dignity. Confidentiality: Perinatal nurses recognize the importance of privacy, confidentiality, and maintaining the trust of childbearing persons and their families. Accountability: Perinatal nurses act with integrity and in a manner consistent with their professional obligations, responsibilities, and standards of practice.

Adapted from Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN). (2018). Perinatal nursing standards in Canada. https://capwhn. ca/wp-content/uploads/2019/10/PERINATAL_NURSING_STANDARDS_IN_CANADA.pdf

BOX 4.2

Historic Milestones in the Care of Mothers and Infants

1847—Ether used in Scotland for an internal podalic version (first reported use of obstetric anaesthesia) 1848—Soeurs de Misericorde (Montreal) provide maternity care for unwed mothers 1861—Ignaz Semmelweis writes The Etiology, Concept, and Prophylaxis of Childbed Fever 1892—A law is passed making it illegal to sell or advertise contraceptives in Canada 1897—Victoria Order of Nurses (VON) established to improve maternal and infant health and to train nurses 1908—Childbirth classes started and prenatal care provided by outpost and public health nurses working in cities, small towns, and rural communities 1911—First milk bank in the United States, established in Boston 1912—Medical Council of Canada formed and makes midwifery illegal in most locations 1916—Margaret Sanger establishes the first American birth control clinic, in Brooklyn, New York 1920—Midwifery legalized in the colony of Newfoundland 1923—First US hospital centre for premature infant care, established in Chicago 1929—Modern tampon (with an applicator) invented and patented 1933—Sodium pentothal used as anaesthesia for childbirth; Natural Childbirth published by Grantly Dick-Read 1934—Dionne quintuplets born in Ontario and survive partly due to donated breast milk 1935—Sulfonamides introduced as cure for puerperal fever; Parents Information Bureau opened in Ontario to provide contraceptive information 1940—Canadian Mother and Child book first published and distributed free to Canadian mothers 1941—Penicillin used as treatment for infection; Papanicolaou (Pap) test introduced 1944—Society of Obstetricians and Gynaecologists of Canada (SOGC) formed 1953—Apgar scoring system of neonatal assessment published by Virginia Apgar 1956—Oxygen determined to cause retinopathy of prematurity 1957—Hospital Insurance and Diagnostic Services Act passed in Canada 1958—First fetal electrocardiogram from the maternal abdomen reported (first commercial electronic fetal monitor produced in the late 1960s); first clinical use of ultrasound to examine the fetus reported 1959—Agnes Higgins joins the Montreal Diet Dispensary and later develops an approach for improving nutrition for disadvantaged pregnant patients (Higgins

method); cytological studies demonstrate that Down syndrome is associated with a particular form of nondisjunction (trisomy 21); Thank You, Dr. Lamaze published by Marjorie Karmel 1960—American Society for Psychoprophylaxis in Obstetrics (ASPO/Lamaze) and the International Childbirth Education Association (ICEA) formed; birth control pill introduced for “menstrual regulation” since contraceptives could not be legally prescribed in Canada 1962—Thalidomide found to cause birth defects 1963—Testing for phenylketonuria (PKU) begun 1967—Rho(D) immune globulin produced for treatment of Rh incompatibility; Reva Rubin publishes article on maternal role attainment 1968—The Medical Care Act passed and provinces begin to implement health insurance plans; rubella vaccine available 1969—Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) founded in the United States; some Canadian nurses join this organization; contraception decriminalized in Canada; mammogram becomes available 1970s—Total of 20 human milk banks across Canada receive donated breast milk 1974—LaLonde Report recommends more attention to health promotion and disease prevention 1975—The Pregnant Patient’s Bill of Rights published by ICEA 1976—First home pregnancy kits approved 1978—First test-tube baby born in Britain; outpost nursing program at Memorial University, Newfoundland, includes a 10-month nurse-midwifery program 1980—Canadian Obstetrical Gynaecological and Neonatal Nurses (COGNN) formed as a special interest group within NAACOG 1986—Ottawa Charter for Health Promotion recommends more attention to health determinants; midwifery education program in Povungnituk, Quebec, begins preparing Inuit midwives 1987—Safe Motherhood Initiative launched by the World Health Organization and other international agencies 1988—Abortion decriminalized in Canada; SOGC launches International Women’s Health Program 1991—Canadian Paediatric Society recommends that a minimum of one person skilled in neonatal resuscitation be present at every birth 1993—Midwifery education program launched in Ontario; human embryos cloned in the United States; first Canadian statement on reducing risk of sudden infant death syndrome (SIDS) released by Health Canada Continued

44 BOX 4.2

UNIT 2

Introduction to Perinatal Nursing

Historic Milestones in the Care of Mothers and Infants—cont’d

1994—Midwifery legalized in Ontario; zidovudine guidelines published to reduce mother-to-fetus transmission of HIV; DNA sequences of BRCA1 and BRCA2 identified 1995—Canadian Perinatal Surveillance System (CPSS) launched 1998—Mandatory folic acid fortification of all breads and cereals sold in Canada 1998—COGNN becomes AWHONN Canada (Association of Women’s Health, Obstetric and Neonatal Nurses Canada) and proposes to have perinatal nursing recognized as a specialty by the Canadian Nurses Association (CNA) 1999—First emergency contraceptive pill for pregnancy prevention (Plan B) approved; midwifery legalized in Quebec with midwives practising in birth centres 2000—National Guidelines for Family-Centred Maternal and Newborn Care published; first CNA Perinatal Nursing Certification exam; Canadian Association of Midwives (CAM) formed 2001—Joint statement on shaken baby syndrome released by Health Canada 2005—The Canadian Association of Neonatal Nurses (CANN) formed 2006—Human papillomavirus (HPV) vaccine first available 2008—Joint Policy Statement on Normal Birth released by SOGC; emergency contraception (Plan B) available over the counter in pharmacies; National Aboriginal Council of Midwives (NACM) officially established 2009—What Mothers Say: The Maternity Experiences Survey, published by the Public Health Agency of Canada, discusses Canadian patients’ experience of childbearing

rural, remote, inner-city, and Indigenous communities, compared with access to such care in other Canadian communities. Many of these health inequities result from conditions of vulnerability and the social determinants of health (see Box 1.1; Social Determinants of Health). Childbearing patients and their families are affected by geography and the availability of social resources and programs in their communities. For instance, rural, remote, and Indigenous communities may have well-developed social networks but have less access to specialized health services. Maternity services, an important part of primary health care services, are often more difficult to provide in rural and remote locations. In many remote areas patients have access to a hospital, but often there are not care providers who are knowledgeable about pregnancy for birth available in the area. Both the Canadian Perinatal Health Report (Canadian Perinatal Surveillance System [CPSS], 2008) and the Maternity Experiences Survey (Public Health Agency of Canada [PHAC], 2009) note that women living with poverty (those living below the low-income cut-off) and young women with less education consistently have the poorest perinatal outcomes. Indigenous women also have outcomes lower than the national averages, often related to government-imposed poverty and limited access to appropriate health care services. Limited maternal education, young maternal age, poverty, and the lack of prenatal care appear to be associated with higher infant mortality rates. Poor nutrition, smoking, alcohol use, and overall poor health or chronic conditions such as hypertension are also important contributors. To address the factors associated with infant mortality, there needs to be more focus on health promotion, improved access to appropriate care, strategies to decrease poverty, and preventive care for low-income families and childbearing patients experiencing conditions of vulnerability.

FAMILY-CENTRED MATERNITY AND NEWBORN CARE The Public Health Agency of Canada (PHAC) (2017a) has published the Family-Centred Maternal and Newborn Care: National Guidelines,

2010—Midwifery recognized as a legal and regulated profession in many Canadian provinces and territories; SOGC releases policy statement Returning Birth to Aboriginal, Rural, and Remote Communities 2011—AWHONN Canada becomes the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN) 2012—Breastfeeding Committee for Canada develops the Integrated Ten Steps Practice Outcome Indicators for Baby Friendly Initiative (BFI) 2013—Millennium Development Goals (MDGs)—Canada commits to reducing child mortality (MDG 4) and improving maternal health (MDG 5) through major monetary contributions and recommitment beyond 2015 2015—Four milk banks open in Canada with more under development; United Nations endorses the Sustainable Development Goals (SDGs) to improve global health 2016—Zika virus discovered, spread by mosquitos, and sexually transmitted by sperm if a male is infected, affects the fetus/newborn (microcephaly); Canadian Association of Schools of Nursing (CASN) publishes Entry-to-Practice Competencies for Nursing Care of the Childbearing Family for baccalaureate programs in nursing 2018—The first neonatal certification exam is offered by CNA; CAPWHN publishes perinatal nursing standards for Canadian nurses; Universal Pharmacare program is investigated by the federal government; revised family-centred maternity and newborn care guidelines published by the Public Health Agency of Canada

which is based on 17 guiding principles (Box 4.3). Perinatal nurses use these principles when providing care to childbearing persons, families, and newborns. Overall, family-centred maternity and newborn care (FCMNC) is about increasing the participation of patients and their families in the decision-making process concerning their pregnancy, birth, and early postpartum experiences in order to promote optimal health and well-being for the childbearing person, newborn, and family. This is sustained by an environment that values diversity and promotes collaboration, partnership, respect, and information-sharing between patients and families and their health care providers (PHAC, 2017a). In order to provide family-centred care it is important to have a holistic, relationship-based model of care that is patient centred. Patient-centred care is grounded in the assumption that people know their own bodies and their health needs are defined by the person themselves, thus the person’s choice must be respected. Health care providers are included in the patient’s care according to the health needs, values, and preferences of the patient, taking into account their social and cultural context as they define it (PHAC, 2017a). Practitioners of patient-centred care also recognize that childbearing experiences vary, respect the many differences among people, and acknowledge that gender is an important determinant of health.

Promoting Healthy and Normal Birth Family-centred maternity and newborn care is based on respect for pregnancy as a state of health and for childbirth as a normal physiological process. The central objective of care for childbearing persons, babies, and families is to maximize the probability of a healthy person giving birth to a healthy baby. Health care providers share this aim and recognize each patient as an individual. To promote the normal physiological process of childbirth, medical interventions should be judicious and appropriate and not routinely used. Many patients who labour in hospital settings are monitored electronically despite the lack of evidence that supports this practice. Pregnancy and childbirth within a biomedical perspective are viewed as processes with inherent risks that are most appropriately

CHAPTER 4 Perinatal Nursing in Canada

BOX 4.3

45

Guiding Principles of Family-Centred Maternal and Newborn Care

1. A family-centred approach to maternal and newborn care is optimal. 2. Pregnancy and birth are normal, healthy processes. 3. Early parent–infant attachment is critical for newborn and child development and the growth of healthy families. 4. Family-centred maternal and newborn care applies to all care environments. 5. Family-centred maternal and newborn care is informed by research evidence. 6. Family-centred maternal and newborn care requires a holistic approach. 7. Family-centred maternal and newborn care involves collaboration among care providers. 8. Culturally appropriate care is important in a multicultural society. 9. Indigenous people have distinctive needs during pregnancy and birth.

10. Care as close to home as possible is ideal. 11. Individualized maternal and newborn care is recommended. 12. Women and their families require knowledge about their care. 13. Women and their families play an integral role in decision making. 14. The attitudes and language of health care providers have an impact on a family’s experience of maternal and newborn care. 15. Family-centred maternal and newborn care respects reproductive rights. 16. Family-centred maternal and newborn care occurs within a system that requires ongoing evaluation. 17. Family-centred maternal and newborn care best practices from global settings may offer valuable options for Canadian consideration.

Source: Public Health Agency of Canada. (2017). Chapter 1: Family-centred maternity and newborn care in Canada: Underlying philosophy and principles. In Family-centered maternity and newborn care: National guidelines. Author. https://www.canada.ca/content/dam/phac-aspc/documents/services/ publications/healthy-living/maternity-newborn-care/maternity-newborn-care-guidelines-chapter-1-eng.pdf

managed by using scientific knowledge and advanced technology. This medical perspective toward childbirth stands in direct contrast to the belief systems of many cultures. Among many patients, birth is viewed as a completely normal process that can be managed with a minimum of involvement from health care practitioners. When encountering behaviour in patients unfamiliar with the biomedical model or those who reject it, the nurse may become frustrated and impatient and may label the patient’s behaviour as inappropriate and believe that it conflicts with “good” health practices. If a Euro-centric health care system provides the nurse’s only standard for judgement, the behaviour of the nurse will be ethnocentric (see Chapter 2, Providing Culturally Competent Nursing Care). The language that health care providers use to describe patients and their concerns also needs to be reviewed (see Principle #14, Box 4.3). For example, practitioners may describe childbearing patients as having an “incompetent cervix,” “failing to progress,” or having an “arrest” of labour. They may describe a fetus as having intrauterine growth “retardation.” They also may “allow” patient a “trial” of labour. The use of these phrases implies failure or inadequacy on the part of the patient or fetus, and there is now more emphasis being placed on incorporating more positive language into the practitioner’s vocabulary.

Caring for Families Use of the collaborative patient- and family-centred framework for perinatal nursing has brought greater understanding of how families need to be included in maternity care. Perinatal nurses’ commitment to working in partnership with families can enhance the health and well-being of the whole family. Thus nurses must become competent in working collaboratively with families in a variety of contexts and settings. Relationships between childbearing patients, their families, and health care providers are based on mutual respect and trust. Such mutual respect and collaborative partnerships will help patients give birth safely, with power and dignity, in a way that promotes the health of the whole family. As well, it is crucial that the patient and family respect and trust nurses and other health care providers who will be providing care during times of vulnerability and change or transition. The core concepts of patient- and family-centred care include the need for respect and cultural safety, involvement and participation, information sharing and collaboration, and active involvement in shared decision-making processes. When treating the patient and family with respect and dignity, health care providers listen to and honour their perspectives and choices. They share information with families in ways that are positive, useful, timely, complete, and accurate. The

family is supported in participating in their care and decision making at the level of their choice. Collaboration with patients and their families in the development, implementation, and evaluation of policy and programs, facility design, professional education, and delivery of care by all involved is essential for providing family-centred care. This may be in contrast with the approach by some care providers who continue to focus on the medical nature of birth. Nurses need to advocate for change in caring for families to ensure that families are encouraged and allowed to make their own decisions about their birth.

Providing Care in a Culturally Safe Manner The population of Canada is increasing in diversity, with one in five people identifying as coming from a visible minority (Statistics Canada, 2018); therefore, many patients giving birth may have cultural traditions and beliefs that are different from that of the perinatal nurse. Family-centred maternal and newborn care respects cultural differences between individuals, families, and communities (PHAC, 2017a). Perinatal nurses must integrate a cultural safety perspective into their practice which allows them to develop a critical understanding of culture and how this relates to maternal-child health (PHAC, 2017a). Cultural safety promotes partnership in a person’s care and requires the practitioner to reflect on their own beliefs and also to be aware of the power disparities in health care delivery (see Box 2.4; Nursing Actions Important to Providing Culturally Safe Care). It is important to acknowledge that many childbearing patients may feel that health care providers are more knowledgeable and powerful than they are and will therefore sometimes feel coerced into decisions based on this power. These power differentials must be acknowledged with attempts to ensure this imbalance does not occur. Providing care that meets the needs of the family can only occur when the individual’s and family’s cultural values, expressions, or patterns regarding care are known and used appropriately and in meaningful ways by health care providers. It is the childbearing patient who determines if the care provided is culturally appropriate. Nurses need to ask patients questions about their hopes and expectations regarding childbearing, about their capacities, and about their needs for nursing assistance. In perinatal nursing, the nurse supports and nurtures beliefs that promote health, including those related to physical or emotional adaptation to childbearing. Table 4.1 provides examples of some cultural beliefs and practices surrounding childbearing. Rather than simply identifying particular cultural or ethnic groups, this table has been organized in a way that invites exploration of traditional beliefs and

46

UNIT 2

Introduction to Perinatal Nursing

TABLE 4.1

Cultural Practices and Successful Nursing Strategies During Childbearing and Parenting Stage

Strategies

Pregnancy • In some cultures, the announcement of the pregnancy may be done in a specific manner (e.g., by a specific family member).

• Find out from the person what their wishes are around the announcement of the pregnancy and respect these wishes.

• Rituals may be performed to protect the pregnant person and child (e.g., reading from a sacred text, not going out at night, covering the person’s head, wearing an amulet, giving to charity).

• Begin by asking each person about beliefs and practices around health and acknowledge these without judging them.

• Parents may not have the social support they would have had in their home country.

• Highlight the benefits of building social support prior to the birth to reduce the risk of postpartum mood disorders and to facilitate breastfeeding. Show the person specific ways of doing this through community, cultural, and religious groups, for example.

• In many cultures, pregnant patients learn what they will need for pregnancy and childbirth through their grandmothers, mothers, sisters, and aunts.

• With the person’s permission, allow their partner, family, friends, and elders to accompany them to prenatal classes and appointments. • Respect the possibility that the partner may choose not to attend prenatal classes and that a family member will attend instead. • During the prenatal class, offer opportunities for participants to discuss their values and rituals related to pregnancy and birth as various topics come up. • Assist participants in developing a birth and breastfeeding plan in class. • Clarify when the labouring person should come to the hospital and what they should bring. • Ensure that a supportive environment is created in the prenatal classes to help pregnant persons build a social network.

• Language may be a barrier for some newcomers.

• If possible, use prenatal educators from linguistic communities similar to those of patients.

• Pregnancy information may be obtained from elders (e.g., grandmother, mother, mother-in-law).

• Collaborate with elders, friends, and relatives to provide consistent and appropriate education.

• Many prenatal tests and the concept of regular prenatal appointments may be unknown to the pregnant person.

• Explain the importance of prenatal care. • Explain the relevance of tests and make sure they are understood.

• Some people may have uncertainties about breastfeeding.

• Ask open-ended questions about the person’s beliefs, knowledge, and concerns about breastfeeding and make sure this information is in their files if it might have an impact on breastfeeding after the baby is born. • Give the person information about where they can get help after the baby is born (breastfeeding clinic, lactation consultant, public health nurses, breastfeeding peer mentor, elders).

• The hospital may be a very unfamiliar setting to many newcomers. In many countries, home births are the norm.

• As with all expectant parents, a tour of the hospital is important to increase comfort levels. • Educate the person and family about the birthing process and Canadian practices (e.g., medications, interventions, newborn care) to enable patients to make informed decisions at the time of birth. • Inform the pregnant person about the possibility of using a midwife for a home birth or a doula as a birth assistant in the hospital.

• Some people may avoid certain foods in pregnancy or may eat certain foods or drink certain beverages during pregnancy.

• Discuss nutrition with the person, focusing on promoting a healthy pregnancy. • Ask what foods the patient is eating to maintain a healthy pregnancy.

Labour and Birth • Some people may birth in silence, and others may moan, groan, or scream.

• Respect cultural practices displayed by the person during the birthing process. Ask them what they feel like doing.

• Some labouring patients may squat or sit to assist in the birthing process.

• Encourage the labouring patient to use the most comfortable position for them during the birthing process.

• Some people might avoid pain-relieving medications such as epidurals and spinal medication.

• Explain the procedures with diagrams and models. • Suggest nonintrusive alternatives (e.g., warm towel on the back). • Ensure that the person provides informed consent.

• In some cultures, female genital cutting (FGC) is a routine practice, involving the stitching of the inner layers of the labia minor or majora, the removal of the clitoris or other parts of the genitalia, or both.

• Educate yourself about the practice of female genital cutting and the care required during childbirth. Continued

CHAPTER 4 Perinatal Nursing in Canada

47

TABLE 4.1 Cultural Practices and Successful Nursing Strategies During Childbearing and Parenting—cont’d Stage • Some cultures may believe a Caesarean birth is not safe.

Strategies • During pregnancy, educate the person and their partner about the reasons for the procedure and the consequences of refusal. • Ensure informed consent at birth.

• Some patients may prefer same-gender health care providers.

• Incorporate patient preferences in health-related decisions where possible and appropriate. • During pregnancy, let the person know that it may not be possible to accommodate their preferences, depending on the staff on duty when they are admitted to the hospital.

Postpartum • There may be specific rituals performed to welcome the newborn.

• Accommodate the rituals, if possible, keeping in mind that these rituals may be particularly important for couples who are isolated from their extended families and removed from their culture.

• In many religions, the outcome of the birth (e.g., disability, Down syndrome, birth defect) is seen to be determined by God.

• These potential outcomes should be discussed during pregnancy. • Explain the short- and long-term consequences of the situation and the support options available. • Provide the family time to cope with the situation.

• Some postpartum patients may expect nurses to do everything related to newborn care.

• During the prenatal stage, educate the person about the roles and responsibilities of health care providers and other service providers in postpartum care. Encourage involvement of family members in caregiving after the birth.

• The baby may sleep with the postpartum patient in bed.

• Educate the parents about safe sleeping guidelines and co-sleeping and ensure that they make informed decisions regarding sleeping methods.

• Personal hygiene practices may vary widely depending on the culture. Some postpartum patients may not bathe or wash their hair or may bathe only once a week.

• Try to understand cultural hygiene practices and be understanding of a person’s preferences. • Explain the signs and symptoms of infection and the importance of contacting a health care provider if this occurs.

Adapted from Best Start Resource Centre. (2009). Giving birth in a new land: Strategies for service providers working with newcomers. https:// resources.beststart.org/product/e26e-giving-birth-in-new-land-manual/. Adapted with permission by the Best Start Resource Centre.

health practices and offers some strategies for nurses. The aim of these strategies is to help nurses and other maternity care providers view these practices from a patient-centred perspective while taking into account Canadian practices and regulations. In using Table 4.1 as a guide, nurses should exercise sensitivity in working with every family, being careful to assess the ways in which they adopt and adapt their cross-cultural nursing practice. Nurses are also reminded to reflect on the ways in which their own cultural practices (including the culture of nursing) may be interpreted by patients and family members. Nurses may not agree with all cultural practices of a patient, but it is important to respect the patient’s decisions. Perinatal nurses need to listen to the stories that patients and family members tell them about their culture, their childbearing experiences, and their needs.

Care Environment Family-centred maternity and newborn care applies to all care environments where childbearing patients and babies receive care, whether in a low-risk labour unit, the neonatal intensive care unit (NICU), or the home (PHAC, 2017a). Perinatal nurses must continue to work to promote normal birth within highly technological birth environments for patients and newborns who require this level of care. Family-centred care in the NICU may involve promoting skin-to-skin contact, breastfeeding, and rooming-in to help optimize outcomes for both families and babies.

Since childbirth is a normal life process, many people choose birthing centres or home birth as the location for giving birth. In support of this trend, the SOGC states that childbearing persons should have the choice of birthing location and that this right should be respected (SOGC, 2017). Patients who are low risk can safely give birth at home. There is evidence that patients who are low risk and who intend to give birth at home do not appear to have a different risk of fetal or newborn loss compared to a population of similarly low-risk patients intending to give birth in hospital (Hutton et al., 2019). In Canada, planning a home birth with a registered midwife or an appropriately trained physician is a reasonable choice for persons with a low degree of risk where the birth is anticipated to be uncomplicated and neither the childbearing person nor the newborn will require resources beyond the local capacity (Campbell et al., 2019). For patients who live in rural and remote communities, registered nurses are essential to the provision of high-quality rural maternity care throughout pregnancy, birth, and the postpartum period. Maternity nursing skills should be recognized as a fundamental part of generalist rural nursing skills (Miller et al., 2017). Most perinatal care in Canada is provided by physicians, with obstetricians providing the majority of perinatal care, although the number of midwifery-led births is increasing. In 2016/2017, midwives supported 10.8% of the births in Canada. Currently, British Columbia leads the country in highest percentage of midwifery-led births (22.4%)

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Introduction to Perinatal Nursing

(Canadian Association of Midwives, 2018). This number remains lower than in many other countries in the world but the number has been increasing. Most births in Canada take place in hospitals (98%), some occur in birth centres (1%), and home births account for approximately 1% of births (PHAC, 2018).

Midwifery. Midwives play a significant role in the delivery of maternity care. Although midwives have been in existence for years, it is only recently that midwives have been legislated in Canada and integrated into the health care system. Since the early 1990s, when midwifery legislation was first passed, most provinces and territories have gradually implemented midwifery-oriented health policy, including legalization of the profession, standardization of training, and the fees that are remunerated through their respective provincial insurance plans. In some provinces, for example, Ontario, childbearing patients who do not have provincial health care may be able to access free midwifery care. Midwifery care may be provided differently across jurisdictions. Whereas many midwives are fully funded and work in independent practice, some provinces have developed programs that enhance interdisciplinary care in order to provide midwifery care to patients who would not otherwise have access to it. An example is in Alberta, where the Rocky Mountain House midwives team up with the local primary care network, providing care to patients in three First Nations communities. In some jurisdictions where there are minimal numbers of midwives, a nurse will be the second care provider at the birth. See discussion below (Indigenous Women) regarding Indigenous midwifery. The Canadian Association of Midwives (CAM) is the national voice for midwifery in Canada. Midwives in Canada have their own regulations and education separate from nursing education. Patients often choose midwifery care because of the philosophy behind midwifery practice that include supporting normal physiological birth, promoting informed choice, and optimizing the patient’s childbirth experiences (Box 4.4).

BOX 4.4 Seven Core Principles of Canadian Midwifery Model of Care • Professional autonomy: Canadian midwives are autonomous primary health care providers who provide comprehensive care during pregnancy, labour, postpartum, and the newborn period. • Partnership: Midwives engage in a nonauthoritarian and supportive partnership with patients throughout their care. • Continuity of care provider: Midwives provide continuity of care providers in order to build trust and partnership with women. • Informed choice: Midwives recognize the right of each person to be the primary decision maker about their care. • Choice of birthplace: Midwives recognize that everyone has the right to choose where they will give birth. • Evidence-informed practice: Midwives support physiological birth and provide care that is informed by research, evidence-informed guidelines, clinical experience, and the unique values and needs of those in their care. • Collaborative care: Midwives are autonomous health care providers, working independently and in collaboration with other health care providers as needed. Adapted from Canadian Association of Midwives. (2015). The Canadian midwifery model of care position statement. https://canadianmidwives. org/wp-content/uploads/2018/10/FINALMoCPS_O09102018.pdf

PERINATAL HEALTH INDICATORS: THE CANADIAN PERINATAL SURVEILLANCE SYSTEM The Canadian Perinatal Surveillance System (CPSS) was developed in 1995 to monitor maternal and infant health across Canada. The CPSS collects data from a number of sources (e.g., vital statistics and the Canadian Institute for Health Information [CIHI]), analyzes and interprets the data, and provides studies and reports to be used as the basis for health policy and action. The CPSS has identified more than 50 perinatal health indicators and ranked many of these indicators for importance on the basis of current research evidence and knowledge about the determinants of health and impact of health outcomes. The CPSS plays an important role in monitoring the quality of epidemiological (population) data available to assist with health and social service planning. Through data collection it has been determined that not every province or territory has the same birth registration practices. The CPSS has thus been working with some data collection agencies to improve the quality of the data collected so that provincial and international comparisons are more meaningful. Another organization that collects, interprets, and shares data regarding births in Ontario is Better Outcomes and Registry Network (BORN Ontario). The goal of BORN is to enhance the health of childbearing patients and newborns. Nurses need to be aware that there are important differences in definitions for health indicators. An example is infant mortality rates, which have been identified as one of the best indicators of a nation’s health status (CPSS, 2008). However, the infant mortality rate is a complex health indicator that is dependent on how “live births” are defined and registered and on how fetal and neonatal deaths are recorded. For example, Canada and the United States have adopted the World Health Organization (WHO) definition of live birth to include all products of conception that show signs of life at birth, without reference to birth weight or gestational age of the fetus. Many European countries have adopted different definitions; for example, in Sweden live births are considered to be at least 27 weeks’ gestation and fetal deaths (stillbirths) are not recorded before 28 weeks’ gestation. In Canada there has been a recent trend to include as “live births” more newborns born at less than 500 grams and 20 weeks’ gestation, which may result in Canada and the United States comparing poorly with many European countries (Conference Board of Canada, 2019). Box 4.5 defines maternal and infant health indicators commonly used for reporting in Canada.

BOX 4.5

Common Perinatal Health

Indicators Birth rate—Number of live births in 1 year per 1 000 population Fertility rate—Number of births per 1 000 women between the ages of 15 and 44 (inclusive), calculated on a yearly basis Infant mortality rate—Number of deaths of infants under 1 year of age per 1 000 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 Neonatal mortality rate—Number of deaths of infants under 28 days of age per 1 000 live births Perinatal mortality rate—Number of stillbirths and number of neonatal deaths per 1 000 live births Stillbirth—An infant who died in utero and at birth and demonstrates no signs of life, such as breathing, heartbeat, or voluntary muscle movements, with a birth weight of greater than 500 g or gestational age of 20 weeks or more

CHAPTER 4 Perinatal Nursing in Canada The CPSS releases a new report every 3 to 5 years and focuses on several perinatal health indicators that are deemed to be most important at the time. The 2017 edition of the CPSS report includes the top 16 perinatal health indicators for which there is currently sufficient national data available. Some of these indicators are discussed below.

Childbirth-Related Mortality Rate Worldwide, approximately 830 childbearing patients die each day from complications related to pregnancy or childbirth (World Health Organization [WHO], 2019). In Canada in 2014–15, the annual maternal mortality rate (number of maternal deaths per 100 000 live births) was 7.4 (PHAC, 2017b). 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 access to and use of prenatal care services. The leading causes of maternal death attributable to pregnancy differ around the world. The following complications account for 75% of maternal deaths worldwide (WHO, 2019): • Severe bleeding (mostly after childbirth) • Infections (usually after childbirth) • Hypertensive disorders during pregnancy (pre-eclampsia and eclampsia) • Complications from the birth • Unsafe abortion 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 (WHO, 2019). Currently, the leading causes of maternal mortality in Canada are diseases of the circulatory system, other indirect causes (e.g., disease of the digestive system), mental disorders and diseases of the nervous system, postpartum hemorrhage, hypertension, and obstetric embolism (PHAC, 2017b).

Maternal Morbidity Although mortality is the traditional measure of maternal health and maternal health is often measured by newborn outcomes, pregnancy complications are important to consider. In 2014–15, the rate of severe maternal morbidity in Canada was 14.2 per 1 000 births, although this statistic does not include Quebec. The most common severe maternal morbidities included blood transfusion with or without comorbidity (e.g. postpartum hemorrhage); cardiac arrest or failure, myocardial infarction or pulmonary edema; embolization or ligation of pelvic vessels or suturing of uterus and postpartum hemorrhage; and hysterectomy (PHAC, 2017b). Another factor that influences maternal morbidity is the impact of assisted reproductive technologies (ART). Patients who undergo infertility treatment, particularly in vitro fertilization, are at somewhat higher risk of severe maternal morbidity or death (Dayan et al., 2019). Maternal morbidity results in a high-risk pregnancy. The diagnosis of high risk imposes a situational crisis on the family. The combined efforts of medical and nursing personnel are required to care for these patients, who often need the expertise of physicians and nurses trained in both critical care obstetrics and intensive care medicine or nursing.

Trends in Fertility and Birth Rate Fertility trends and birth rates reflect childbearing patients’ needs for health services. Canada’s total fertility rate has been falling; in 2016 the rate was 1.54 children per woman, the lowest level observed since

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2003 (Provencher et al., 2018). Indigenous fertility rates are different from these rates: 2.9 for First Nations women, 2.2 for Metis, and 3.4 for Inuit women (Smylie, 2011). These different rates may reflect cultural norms for certain populations. In recent years, more persons living in Canada have delayed childbearing until they are 35 years of age or older, and the rate of persons conceiving over age 35 has steadily increased since 2005 (PHAC, 2017b). In Canada, the average age of mothers at first birth was 28.7 years in 2012 and 29.2 years in 2016, although these ages are lower for Indigenous people, who often have their first child at a younger age (Provencher et al., 2018). The age of first birth is often culturally determined. Childbearing patients who conceive at older ages are more likely to experience chronic illnesses, placental issues, and multiple pregnancy, and their fetuses are more likely to have chromosomal abnormalities (e.g., Down syndrome). However, older patients also tend to be better educated, have higher income levels (less poverty), and seek early prenatal care. The rate of live births to teenagers in Canada has been steadily decreasing since 2005, although there are significant geographic variations in adolescent fertility rates, with low rates in British Columbia to the highest in Nunavut, which may reflect significant cultural differences (PHAC, 2017b). The decline in teen pregnancy may be attributed to the accessibility and use of reliable contraception, such as condoms and birth control pills. Health issues associated with teen pregnancy include anemia and poor weight gain and twice the risk of giving birth to a preterm or low–birth weight baby (see Chapter 5). Teenage pregnancy can also influence the likelihood that the adolescent will not complete high school, which may result in underemployment and poverty.

Multiple Birth Rate Multiple birth rates in Canada have fluctuated around 3% since 2005 and in 2014 were 3.3% of total births (PHAC, 2017b). Such pregnancies often occur in patients who are an older age at conception and are more likely to have used assisted reproductive technologies such as in vitro fertilization (IVF) (see Chapter 8). Multiple pregnancy can result in health issues for both the childbearing patient (anemia, pre-eclampsia, Caesarean birth) and their babies (preterm birth, low birth weight, perinatal death). There is growing evidence that decreasing the number of embryos may help decrease the poor health outcomes associated with higher-order (more than twins) multiple pregnancies.

Preterm Birth and Birth Weight The proportion of preterm infants (born before 37 completed weeks’ gestation) was 8.1 per 100 live births in 2014 (PHAC, 2017b). In industrialized nations, 60 to 80% of deaths of infants born without congenital anomalies are the result of preterm birth. Preterm birth is also associated with cerebral palsy and other long-term health issues. From 2010 to 2014, preterm birth rates ranged from 6.5 per 100 live births in the Northwest Territories to 11.9 per 100 live births in Nunavut (PHAC, 2017b). Babies born both small (less than tenth percentile for sex-specific standardized birth weights) and large (greater than ninetieth percentile) for gestational age experience significant health challenges (see Chapter 28). Maternal cigarette smoking accounts for about 30 to 40% of small-for-gestational-age (SGA) babies born in industrialized countries, where malnutrition is not a predominant factor. Largefor-gestational-age (LGA) babies and their mothers are more likely to experience birth trauma (shoulder dystocia, nerve injuries, and postpartum hemorrhage). Maternal diabetes is another important risk factor (see Chapter 15).

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Health Service Indicators The CPSS also monitors a number of health service indicators, including, for example, rates of labour induction and Caesarean birth. The proportion of patients giving birth by Caesarean delivery has increased steadily, from 17.6% in 1995 to 28.4% in 2014–15 (PHAC, 2017b). Most of this increase is due to a higher rate of primary (first-time) Caesarean births, although the vaginal birth after Caesarean (VBAC) rate also decreased over the same time period. The overall trend is concerning, as evidence documents a higher risk of significant maternal morbidity (e.g., infection, thromboembolism, hysterectomy) for patients who have a Caesarean birth.

CURRENT ISSUES AFFECTING PERINATAL NURSING PRACTICE Health Inequities Within Perinatal Populations Patients must be viewed holistically and in the context in which they live; their physical, emotional, and social environment must be considered, because these interdependent factors influence health and illness. One of the primary factors compromising childbearing patients’ health is lack of access to acceptable-quality health care. Therefore, recognition of the challenges experienced by both childbearing persons and maternity care providers who live and work in rural, remote, Indigenous, and inner-city communities must continue. The barriers to care may take many forms: living in a medically underserved area, or an inability to obtain needed services, particularly basic services such as prenatal care. For example, some rural and remote areas have few physicians and midwives; pregnant patients may have to travel hundreds of kilometres for this kind of care. Infant mortality is also higher for infants of mothers without a high school education than for those of mothers with such education. Nurses must continue to address health inequities by working to create health policy and services that focus on the resources needed for health and access to health services. Some perinatal factors related to vulnerable populations are discussed below. Further discussion of vulnerable populations is provided in Chapter 1.

Indigenous Women. Canada’s history has influenced the health and experience of pregnancy, childbirth, and parenting for Indigenous persons (see Chapter 1, Indigenous People). Having a healthy experience throughout pregnancy, childbirth, and parenting includes fostering positive mental and emotional health. Supporting individual resilience, creating supportive environments, and addressing the influence of the determinants of health are important considerations in promoting such an experience (British Columbia Reproductive Mental Health Program, 2011). Some Indigenous patients face unique challenges in having healthy pregnancies, birth, and parenting experiences, often because of culturally insensitive or unsafe care. Many of these patients live in an underserved area and with imposed poverty, which can reduce their ability to access healthy food and other supports. Thus supportive environments and relationships are especially important for Indigenous patients as they become pregnant, go through childbirth, and become parents (British Columbia Reproductive Mental Health Program, 2011). The people around pregnant patients can also help pass on important traditional practices. Many Indigenous patients live in rural and remote communities and must often leave their communities in order to give birth. They must then experience labour and birth without the presence and support of family and community members, which can cause disruption and loss of cultural support, rather than strengthening families and communities (SOGC, 2017). The SOGC (2017) believes that

childbearing persons should have the choice of birth place and supports and promotes the return of birth to rural and remote communities for patients at low risk of complications. While giving birth in a remote community may decrease access to immediate surgical backup available and to emergency air-evacuation, some patients are willing to take this risk in order to be closer to home when giving birth. Childbearing patients must be fully informed of the risks and benefits so they can make an informed choice about where to give birth. The National Council of Aboriginal Midwives (NACM) is working to provide access to culturally safe sexual and reproductive health care for Indigenous families, the return of birth to Indigenous communities, and a reduction in the number of medical evacuations for births in remote areas (NACM, 2020). When care is provided in the community by an Indigenous midwife, families are kept together and important traditions and values about health are passed down to the next generation, which will ultimately improve early child development as well as the health and well-being of communities. The NACM has developed core competencies for Indigenous midwives and is also working at enhancing education opportunities for Indigenous people who would like to become a midwife. Presently, there are two paths to becoming an Indigenous midwife: a 4-year university degree program or a community-based program. The community-based programs are in Six Nations in Ontario and in Northern Quebec. In these programs, students learn alongside the midwives in the community (for more information see Additional Resources at the end of this chapter). The core competencies for Indigenous midwives include the following (NACM, 2020): • Provide culturally safe care • Support rites of passage • Communicate • Develop the profession • Support Indigenous health and well-being • Manage prenatal care • Manage labour and birth • Manage postpartum care • Provide newborn care

Homelessness and Pregnancy. Although little is known about pregnancy in this population, some homeless people do become pregnant. Pregnancy is linked to a whole host of health issues for homeless persons. Compared with women with housing, women who are homeless live with greater rates of depression and greater severity of mental health symptoms, and they are more prone to infection and to poorer maintenance of chronic conditions during pregnancy (Azarmehr et al., 2018). The homeless person is at risk for pregnancy complications because of many barriers to access in prenatal care, poor nutrition, stress, and exposure to violence. Homeless persons face multiple barriers to prenatal care, including lack of transportation, lack of knowledge of resources, negative perceptions of health care providers’ communication styles and attitudes, inconvenient clinic hours, and psychosocial barriers, which include fear of having the child apprehended or fear of gynecological procedures due to previous history of trauma (Azarmehr et al., 2018). Nursing strategies for prenatal care of homeless pregnant persons are complex and include traumainformed approaches, therapeutic communication, focused assessment, and upstream interdisciplinary approaches (Azarmehr et al., 2018). Having access to supportive care during pregnancy and labour may improve outcomes for homeless patients. An example of this is a nonprofit organization called Birthmark Support, a service available in Toronto and Hamilton, Ontario, which serves the needs of precariously housed people who are pregnant. This agency supplies the patient with a free doula who provides labour and pregnancy support, as well as

CHAPTER 4 Perinatal Nursing in Canada postpartum and breastfeeding support. Birthmark staff often attend appointments and assist in bridging the gap between these vulnerable people and the healthcare system. See Additional Resources for more information.

LGBTQ2 Concerns. Perinatal nurses may provide care to people who identify as LGBTQ2, and it is essential that their health care needs are appropriately met (see Chapter 1, Lesbian/Gay/Bisexual/Transsexual/ Queer/2-Spirited (LGBTQ2) Health). Many lesbian, gay, and transsexual couples may become parents. They deserve respectful care during the childbearing experience as well as during health screening and wellness care. Their health care priorities are often similar to those of cisgender and heterosexual groups. While this text does not go into extensive detail regarding LGBTQ2 health care, whenever possible, LGBTQ2 concerns are integrated throughout the chapters. LGBTQ2 people face challenges getting their reproductive health needs met, as health care providers may lack knowledge about LGBTQ2 health needs relevant to reproductive health priorities and treatment. LGBTQ2 patients may also experience discriminatory comments and treatment when receiving care (Wimbo et al., 2018). This discrimination and lack of appropriate quality care may affect health outcomes for these groups across the reproductive lifespan. Presently, perinatal care is based on that for nuclear cisgendered families, thus research and education must be done to ensure that the health care needs of persons not identifying as such are also met.

Interprofessional Care A philosophy of respectful and collaborative work relationships between all different care providers underpins the framework for perinatal nursing in Canada (PHAC, 2017a). Nurses work with many different health care providers, including (but not limited to) obstetricians, family doctors, midwives, neonatologists, pediatricians, anaesthetists, childbirth and parenting educators, breastfeeding advisors, doulas, dietitians, social workers, and community support workers, to provide appropriate care for families undergoing the childbirth experience. It is important that perinatal nurses’ knowledge and skills are recognized, and there must be mutual respect for all team members’ scope of practice as well as respectful communication among all members. Interprofessional collaboration is key to ensuring good outcomes for perinatal patients, families, and newborns, as well as to

ensuring successful practices for all member of the care team (Hutton et al., 2016). Important to this collaboration is undertaking interprofessional education (IPE) together as members of the health care team (see Chapter 1, Interprofessional Education). Teamwork and communication are key aspects of IPE; failure to communicate is a major cause of errors in health care.

Breastfeeding in Canada Breastfeeding is recognized internationally as the optimal method of infant feeding; 6 months of exclusive breastfeeding with continuation for up to 2 years or longer with complementary foods is currently recommended (Critch, & Canadian Pediatric Society [CPS], Nutrition and Gastroenterology Committee, 2013/2018). The Breastfeeding Committee for Canada (BCC) has identified the WHO/UNICEF Baby Friendly Initiative (BFI) as a primary strategy for the protection, promotion, and support of breastfeeding. Many health care institutions and community centres have set the BFI strategy as the standard to achieve in Canada. The role of the perinatal nurse is to promote a culture of breastfeeding that also recognizes that breastfeeding may not be the right infant feeding option for all childbearing persons (see further discussion on breastfeeding and BFI in Chapter 27).

Community-Based Care As health care costs continue to rise, Canada is faced with the challenge of providing safe and effective perinatal care that is innovative and costeffective and meets the expectations of an increasingly educated public. Some childbearing patients who experience pregnancy complications are now cared for in the home by antepartum home care nurses. Portable fetal monitors and other forms of technology previously available only in the hospital are used. This change has affected the organizational structure of care, the costs of care, and the skills required to provide nursing care (Figure 4.1). With the shorter length of hospital stay after birth, childbearing patients and their babies are often discharged home before they are successfully breastfeeding, before they have mastered basic baby care activities, and without sufficient supports at home. Public health departments and community agencies across the country must try to meet the needs of these new families. Changing demands on the community-based nurse have evolved out of these societal, economic, and health-related trends. Acuity of illness of home care patients is far

12–14 months Single patient

Perinatal Period

Preconception

Locus of Care

Home/ community

Intensity of Care

Independent self-care

1st Trimester

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2nd Trimester

3rd Trimester

• Independent self-care (low risk) • Home care (high risk) Fig. 4.1 Perinatal continuum of care.

Labour and Birth

Postpartum/ Newborn

Hospital/ birthing centre/ home

Home/ community

• Low-risk • Independent hospitalization/home self-care • High-risk (low risk) hospitalization • Home care • Neonatal (high risk) intensive care

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greater than in the past, requiring the community nurse to become more adept at assessment, direct care, and health teaching (see Chapter 3 for further discussion of Community Health Nursing). Perinatal nurses need to assess the resources that childbearing persons have to support them during the postpartum period at home. In many cultures, the childbearing person is cared for by extended family members so that the parent’s primary responsibility is to breastfeed and recover from childbirth. In our independent North American culture, patients may need to be encouraged to ask for help. At times, perinatal nurses may need to advocate for a delay of hospital discharge until the needed supports are put in place. Nursing care has become more community based, with nurses providing care for childbearing patients and infants in homeless shelters and for adolescents in school-based clinics, and promoting health at community centres, churches, and shopping malls (see Community Focus box).

COMMUNITY FOCUS Availability of Maternal Child Services in Your Community To understand what services are available in your community, a good place to start is the Internet. Use the Internet to identify where the closest health department is located. Research what services are offered to childbearing families. • How many other agencies provide services for childbearing families? Are they located in the area? What services do they offer? • Are there registered nurses employed there? If not, what are the credentials of the people providing the services? Are there midwives and doulas also available? • Is service provided in more than just English? If so, in what languages? Are interpreters available if needed? • Do the agencies ever accept referrals for patients who cannot pay? Are there any bursaries or provisions made for families who cannot pay? • Is there a maternal child home visiting program available in the community? Based on the information you have gathered, are there adequate and appropriate services for pregnant patients and their families in your area? If not, is there a postpartum care clinic where new parents can access support for breastfeeding, hearing and dental screening, immunizations, well-baby care, and other related services?

Global Health The United Nations has been working with countries around the world to improve maternal health. In 2015, the UN endorsed the Sustainable Development Goals (SDGs), which are a blueprint to achieve a better and more sustainable future for all (see Chapter 1, Figure 1.3). Two important targets of SDG #3 focused on perinatal nursing are to reduce the global maternal mortality ratio to less than 70 per 100,000 live births and to ensure universal access to sexual and reproductive health care services, including for family planning, information and education, by the year 2030 (Government of Canada, 2019). Access to appropriate health care in the event of a complication can decrease the maternal and infant mortality rate. Some simple interventions to decrease the infant mortality rate include keeping the newborn warm, ensuring that the newborn is breathing, starting exclusive breastfeeding immediately, preventing malaria and tetanus, washing hands before touching the newborn, and enabling early recognition of illness and care seeking (WHO, 2020). Two global health concerns that nurses in Canada might encounter are female genital cutting (FGC) and human trafficking. FGC includes procedures that intentionally alter or cause injury to the female external genitalia for nonmedical reasons and can negatively affect maternal

health (WHO, 2018). More than 200 million girls and women alive today have been subjected to FGC, mainly in countries in Africa, the Middle East, and Asia. It is mainly done on young girls between infancy and age 15 years. With the growing number of Canadian immigrants from countries where FGC is practised, nurses will increasingly encounter women who have undergone the procedure. These women are significantly more likely to have adverse obstetric outcomes. The WHO, the International Council of Nurses, and other health professionals have spoken out against the procedures as harmful to women’s health and a violation of the human rights of girls and women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to 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, 2018) (see Chapter 5 and 17 for further discussion). Human trafficking is a serious crime, an illegal business that exists in Canada and internationally, in which mostly women and children are “trafficked,” or forced into hard labour, sex work, and even organ donation (Budiani-Saberi et al., 2014; United Nations Office on Drugs & Crime, 2019). Health care providers may interact with victims who are in captivity. If health care providers are appropriately trained, they may have the opportunity to identify victims, intervene to help them obtain necessary health services, and provide information about ways to escape from their situation. See Chapter 5 for further discussion of human trafficking.

KEY POINTS • Perinatal nursing focuses on care for childbearing persons, their newborns, and families during the childbearing cycle. • Childbirth practices have changed to become more person- and family-centred and include more alternatives in provider, birth place, and care. • Collaborative family-centred maternal and newborn care is based on respect for pregnancy as a state of health and for childbirth as a normal physiological process. • Perinatal nurses need to listen to the stories that childbearing patients and family members tell about their culture, their childbearing experiences, their resources, and their needs. • Patients must be supported in the decisions they make regarding place of birth. • Preterm birth and high Caesarean birth rates are current challenges in Canada. • Childbearing persons living in rural, remote, and Indigenous communities and in poverty in inner cities experience significant health challenges and have increased difficulty accessing appropriate care. • Nurses must continue to work toward decreasing health inequities among certain populations. • The Baby Friendly Initiative (BFI) is a primary strategy to improve breastfeeding rates and support across the country. • Perinatal nurses may encounter women who have undergone female genital cutting or who are victims of human trafficking and must ensure that appropriate care is provided.

REFERENCES Azarmehr, H., Lowry, K., Sherman, A., et al. (2018). Nursing practice strategies for prenatal care of homeless pregnant women. Nursing for Women’s Health, 22(6), 489–498. https://doi.org/10.1016/j.nwh.2018.09.005. British Columbia Reproductive Mental Health Program. (2011). Celebrating the circle of life: Coming back to balance and harmony. http://www.bcmhsus.ca/ Documents/celebrating-the-circle-of-life-coming-back-to-balance-andharmony.pdf.

CHAPTER 4 Perinatal Nursing in Canada Budiani-Saberi, D. A., Raja, K. R., Findley, K. C., et al. (2014). Human trafficking for organ removal in India: A victim-centered, evidence-based report. Transplantation, 97(4), 380–384. Campbell, K., Carson, G., Azzam, H., et al. (2019). SOGC clinical practice guideline: Statement on planned homebirth. Journal of Obstetrics and Gynaecology Canada, 41(2), 223–227. Canadian Association of Midwives. (2018). Midwifery-led births per province and territory. The Pinard, 8(1), 6–7. https://canadianmidwives.org/2018/06/ 19/pinard-spring-2018/. Canadian Association of Schools of Nursing. (2017). Entry-to-practice competencies for nursing care of the childbearing family for baccalaureate programs in nursing. https://www.casn.ca/wp-content/uploads/2016/09/ FINAL-CHILDBEARING-FAMILY-COMPETENCIES-revised.pdf. Canadian Nurses Association (CNA). (2019). CNA certification program. https://www.cna-aiic.ca/en/certification. Canadian Perinatal Surveillance System. (2008). Canadian perinatal health report: 2008 edition. http://www.phac-aspc.gc.ca/publicat/2008/cphr-rspc/ pdf/overview-apercu-eng.pdf. Conference Board of Canada. (2019). Infant mortality. https://www. conferenceboard.ca/hcp/Details/Health/infant-mortality-rate.aspx. Critch, J. N., Canadian Paediatric Society, & Nutrition and Gastroenterology Committee. (2013). Nutrition for healthy term infants, six to 24 months: An overview. Paediatric & Child Health, 18(4), 206–207. Reaffirmed 2018. https://www.cps.ca/en/documents/position/nutrition-healthy-term-infantsoverview. Dayan, N., Joseph, J., Fell, D., et al. (2019). Infertility treatment and risk of severe maternal morbidity: A propensity score–matched cohort study. Canadian Medical Association Journal, 191(5), E118–E127. https://doi.org/10.1503/ cmaj.181124. Government of Canada. (2019). Canada takes action on the 2030 agenda for sustainable development. https://www.canada.ca/en/employment-socialdevelopment/programs/agenda-2030.html. Hutton, E., Farmer, M., Carson, G., et al. (2016). The roles of multidisciplinary team members in the care of pregnant women. Journal of Obstetrics and Gynaecology Canada, 38(11), 1068–1069. Hutton, E., Reitsma, A., Simioni, J., et al. (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. EClinical Medicine. https:// doi.org/10.1016/j.eclinm.2019.07.005. https://www.sciencedirect.com/ science/article/pii/S2589537019301191?via%3Dihub. Miller, K. J., Couchie, C., Ehman, W., et al. (2017). SOGC clinical practice guideline: Rural maternity care. Journal of Obstetrics and Gynaecology Canada, 39(12), e558–e565. National Aboriginal Council of Midwives (NACM). (2020). Core competencies. https://indigenousmidwifery.ca/core-competencies/. Provencher, C., Milan, A., Hallman, S., et al. (2018). Fertility: Overview, 2012 to 2016. Statistics Canada https://www150.statcan.gc.ca/n1/pub/91-209-x/ 2018001/article/54956-eng.htm. Public Health Agency of Canada (PHAC). (2009). What mothers say: The Canadian maternity experiences survey. http://www.phac-aspc.gc.ca/rhs-ssg/ survey-eng.php. Public Health Agency of Canada (PHAC). (2017a). Chapter 1: Family-centred maternity and newborn care in Canada: Underlying philosophy and principles. In Family-centred maternity and newborn care: National guidelines. https://www.canada.ca/content/dam/phac-aspc/documents/ services/publications/healthy-living/maternity-newborn-care/maternitynewborn-care-guidelines-chapter-1-eng.pdf. Public Health Agency of Canada (PHAC). (2017b). Perinatal health indicators for Canada 2017: A report of the Canadian Perinatal Surveillance System. https://www.canada.ca/en/public-health/services/injury-prevention/healthsurveillance-epidemiology-division/maternal-infant-health/perinatalhealth-indicators-2017.html.

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Public Health Agency of Canada (PHAC). (2018). Chapter 4: Care during labour and birth. In Family-centred maternity and newborn care: National guidelines. https://www.canada.ca/content/dam/phac-aspc/documents/ services/publications/healthy-living/maternity-newborn-care/maternitynewborn-care-guidelines-chapter-4-eng.pdf. Smylie, J. (2011). Our babies, our future: Aboriginal birth outcomes in British Columbia. National Collaborating Centre for Aboriginal Health https://www.nccah-ccnsa.ca/docs/health/FS-OurBabiesOurFutureSmylie-EN.pdf. Society of Obstetricians and Gynecologists of Canada (SOGC). (2017). SOGC clinical practice guideline: Returning birth to Aboriginal, rural, and remote communities. Journal of Obstetrics and Gynaecology Canada, 39(10), e395–e397. Statistics Canada. (2018). Immigration and ethnocultural diversity in Canada. https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010x2011001-eng.cfm. United Nations Office on Drugs and Crime. (2019). Human trafficking. https:// www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking. html. Wimbo, E., Ingraham, N., & Roberts, S. (2018). Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: A qualitative study. Women’s Health Issues, 28(4), 350–357. https:// doi.org/10.1016/j.whi.2018.03.002. World Health Organization. (2018). Female genital mutilation. https://www. who.int/en/news-room/fact-sheets/detail/female-genital-mutilation. World Health Organization. (2019). Maternal mortality. https://www.who.int/ news-room/fact-sheets/detail/maternal-mortality. World Health Organization. (2020). Fact sheet: Children: Improving survival and well-being. http://www.who.int/mediacentre/factsheets/fs178/en/.

ADDITIONAL RESOURCES Association of Ontario Midwives: Tip sheet for providing care to trans men and all “trans masculine spectrum” clients. https://genderminorities.com/ wp-content/uploads/2016/06/midwives-tip-sheet-for-working-with-transclients.pdf. Birthmark Support—Provides support for vulnerable patients in Toronto and Ottawa. https://birthmarksupport.com/. Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN). http://www.capwhn.ca. Canadian Association of Schools of Nursing (CASN): Entry to practice competencies for nursing care of the childbearing family for baccalaureate programs in nursing. https://www.casn.ca/wp-content/uploads/2016/09/ FINAL-CHILDBEARING-FAMILY-COMPETENCIES-revised.pdf. Canadian Nurses Association: Certification. https://www.cna-aiic.ca/en/ certification. Canadian Perinatal Surveillance System. http://www.phac-aspc.gc.ca/rhs-ssg/ index-eng.php. Champlain Maternal Newborn Regional Program. http://www.cmnrp.ca/en/ cmnrp/Home_p2974.html. Healing the Hurt - Caring for Indigenous Mothers and Infants. https://www. indigenousmomandbaby.org/enter. National Council of Aboriginal Midwives. https://indigenousmidwifery.ca/. Our sacred journey—Aboriginal pregnancy passport. https://www.fnha.ca/ WellnessSite/WellnessDocuments/AboriginalPregnancyPassport.pdf. Perinatal Services BC: http://www.perinatalservicesbc.ca/. Provincial Council on Maternal Child Health. https://www.pcmch.on.ca/. Public Safety Canada: Human trafficking. http://www.publicsafety.gc.ca/cnt/ cntrng-crm/hmn-trffckng/index-eng.aspx. Society of Obstetricians and Gynaecologists of Canada (SOGC). http://www. sogc.org.

UNIT 3 Women’s Health

5 Health Promotion Kerry Lynn Durnford Originating US Chapter by Ellen F. Olshansky http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify facilitators and barriers to accessing care in the health care system. 2. Analyze the determinants of health that may affect an individual’s decision to seek and follow through with health care. 3. Describe the need for health promotion across the person’s lifespan. 4. Discuss the importance of preconception counselling. 5. Analyze conditions and factors that increase health risks for patients across the lifespan, including life stage, substance use, eating

REASONS FOR ENTERING THE HEALTH CARE SYSTEM Many people initially enter the health care system because of some reproductive system–related situation, such as pregnancy, irregular menses, a desire for contraception, or an episodic illness, for example, a vaginal infection. It is important for health care providers to recognize the significance of health promotion and preventive health maintenance and to offer these services across the lifespan. This chapter presents an overview of the nurse’s role in encouraging health promotion and illness prevention in women, although some of the information is also focused on people who may not identify as a woman but need specific care that focuses on their individual needs. Included is a schedule of screening tests recommended for women at different stages of their lives. Barriers to seeking health care as well as an overview of conditions and circumstances that increase health risks for patients across the lifespan are also included. Anticipatory guidance suggestions, such as nutrition and stress management, are included. Violence against women and against LGBTQ2 individuals, particularly intimate partner violence (IPV), is discussed because it is often in the health care setting that the person is able to acknowledge being in an abusive relationship.

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7. 8. 9.

disorders, medical and health conditions, pregnancy, and intimate partner violence. Explain the cycle of violence and how an understanding of it can be used in assessment of and intervention for people who are victims of violence. Identify community resources to prevent intimate partner violence. Outline health-screening schedules for women. Discuss how adult learning principles can be used in healthpromotion education with patients and families.

Wellness Care Across the Lifespan Maintaining optimal health is a goal for all people. Essential components of health maintenance are the identification of unrecognized health issues and potential risks, and the education and health promotion needed to reduce them. A holistic approach to women’s health care goes beyond simple reproductive needs; it includes a patient’s health needs throughout their lifetime, with attention to physical, mental or emotional, social, and spiritual health. Patients’ health is considered 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 all forms of cancer, not just reproductive-related cancers, are all components of well-person care. It is important to consider all aspects of a patient’s health, particularly in light of the fact that the leading causes of death in women in Canada include more than just reproductive health–related conditions (Box 5.1). Even when focusing on reproductive health, it is critical to take a holistic approach to the health of patients. This is especially important for persons in their childbearing years because conditions that increase a patient’s health risks are related not only to their well-being but also to

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BOX 5.1

Top 10 Leading Causes of Death in Women in Canada 1. Malignant neoplasm (cancer) 2. Heart disease 3. Cerebrovascular disease (stroke) 4. Chronic lower respiratory disease 5. Accidents (unintentional injuries) 6. Influenza and pneumonia 7. Alzheimer’s disease 8. Diabetes mellitus 9. Nephritis, nephrotic syndrome, nephrosis 10. Chronic liver disease and cirrhosis Source: Statistics Canada. (2020). Leading causes of death, total population, by age group, 2018. https://www150.statcan.gc.ca/t1/tbl1/ en/tv.action?pid=1310039401

the well-being of both mother and newborn in the event of a pregnancy. Prenatal care is an example of prevention that is practised after conception. However, prevention and health maintenance are also needed before conception because many of the patient’s risks can be identified and modified then or perhaps even eliminated. Health care needs vary with culture, religion, age, and personal differences. The changing responsibilities and roles of women, their socioeconomic status, and their personal lifestyles also contribute to differences in the health and behaviour of patients. Employment outside the home, physical disability, lone parenthood, and sexual orientation also can affect a patient’s ability to seek and receive health care in clinical settings. As people age, well-women’s health care should continue to include a complete history, physical examination, ageappropriate screening, and health promotion.

Adolescents. As females progress through developmental ages and stages, they are faced with conditions that are age related. All teens undergo progressive development of sex characteristics. They experience the developmental tasks of adolescence, such as establishing identity and sexual orientation, separating from family, and establishing career goals. Some of these processes can produce great stress for the adolescent. Female teenagers who enter the health care system usually do so for screening or because of a health concern, such as episodic illness or accidents, or gynecological issues associated with menses (either bleeding irregularities or dysmenorrhea), vaginitis or leukorrhea, sexually transmitted infections (STIs), contraception, or pregnancy. The adolescent may also be at risk for use of street drugs, for eating disorders, and for stress, depression, and anxiety. Most young people begin having sex in their mid- to late teens, with the average age in Canada of first intercourse being 15.8 years (Bushnik, 2016). A sexually active teen who does not use contraception has a 90% chance of pregnancy within 1 year. Effective educational programs about sex and family life are imperative to help decrease the rate of teen pregnancy and STIs. Most Canadian public schools have a sexual health and education component in their curriculum. Knowledge of and ability to apply growth and developmental concepts are critical for nurses in their work with adolescents. Involving adolescents in their care is important for establishing the nurse–patient relationship and for focusing on individual adolescents’ strengths and resilience. Teenage pregnancy. The rate of teenage pregnancy in Canada has decreased significantly; from 2001 to 2010, both teen birth and abortion rates decreased (McKay, 2013). The rate of adolescent pregnancies was 1.8% of all births in 2018 (Statistics Canada, 2021). When teenage pregnancy does occur, it often introduces additional stress into an already

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challenging developmental period, and there are greater risks than pregnancies for some other patients (see further discussion in Chapter 11). The emotional level of teens who are less than 16 years of age can be characterized by impulsiveness and self-centred behaviour, and they often place primary importance on the beliefs and actions of their peers. In attempts to establish a personal and independent identity, many teens do not realize the consequences of their behaviour; their thinking processes do not include planning for the future. From a public health perspective, the rate of teenage pregnancy is significant because teen pregnancy is more common among disadvantaged teenagers and may be a predictor of other social, educational, and employment barriers in later life (Bushnik, 2016). The incidence of violence may also be higher among adolescent mothers (see discussion later in chapter). Teenagers often lack the financial and social resources to support a pregnancy and may not have the maturity to avoid teratogens or to have prenatal care and instruction or follow-up care. Pregnant teens have a greater risk of developing health concerns such as anemia, pre-eclampsia postpartum hemorrhage, chorioamnionitis, and depressive disorders, as well as of giving birth to newborns that are preterm or have low birth weight (Fleming et al., 2015; Kawakita et al., 2016). Children of teen mothers may be at risk for abuse or neglect because of the teen’s inadequate knowledge of child growth and development and of parenting. Implementation of specialized adolescent programs in schools, communities, and health care systems is demonstrating continued success in reducing the birth rate among teenagers.

Young and Middle Adulthood. Because people ages 20 to 40 years have a need for contraception, pelvic screening, and pregnancy care, they may prefer to use their gynecological or obstetrical provider as their primary care provider. During these years, the person may be “juggling” family, home, and career responsibilities, with resulting increases in stress-related conditions. Health maintenance includes not only pelvic 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 issues). Common conditions requiring well-woman care include urinary tract infections, menstrual variations, sexual and relationship issues, and pregnancy. Parenthood after age 35. The patient older than 35 years 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. Other chronic or debilitating diseases or conditions increase in severity with time, and these in turn may predispose these patients to increased risks during pregnancy. Of significance to patients in this age group is the risk for certain genetic anomalies (e.g., Down syndrome). The opportunity for genetic counselling should be made available to all patients in this age group who are considering pregnancy (see Chapter 9). Late Reproductive Age. Women of later reproductive age often experience change and a reordering of personal priorities. In general, the goals of education, career, marriage, and family have been achieved; now the person has more 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 a potential increase in depression. Chronic illnesses also become more apparent. Many patients seek health care to discuss concerns 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.

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APPROACHES TO CARE AT SPECIFIC STAGES DURING THE LIFESPAN 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.

Fertility Control and Infertility Although information on unplanned pregnancies is not routinely collected, it is estimated that nearly 50% of all pregnancies in Canada are unplanned (Society of Obstetricians & Gynaecologists of Canada [SOGC], 2020). Education is key to encouraging people to make family planning choices based on preference and actual benefit-to-risk ratios. Health care providers can influence the patient’s motivation and ability to use contraception correctly (see Chapter 8). Individuals also enter the health care system because of their desire to become pregnant. The prevalence of infertility has increased, affecting approximately 16% of Canadian families (Public Health Agency of Canada [PHAC], 2019b). Many couples delay 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 person). In addition, rates of STIs, which can predispose to decreased fertility, are increasing significantly in Canada. From 2008 and 2017, chlamydia rates increased by 39%, gonorrhea increased 109%, and syphilis by 167% (Statistics Canada, 2020b). Many people are in workplaces and home settings where they may be exposed to reproductive environmental hazards. Infertility can cause emotional pain for many couples. The inability to produce a child sometimes results in feelings of failure and places inordinate stress on the couple’s relationship. Much time, money, and emotional investment may have been used for testing and treatment in efforts to build a family. A supportive health care team is important for the couple exploring fertility, struggling with fertility, or making choices for a life and career without children. Steps toward prevention of infertility should be undertaken as part of ongoing routine health care. Such information is especially appropriate in preconception counselling. Primary care providers can undertake initial evaluation and provide counselling before couples are referred to specialists. For additional information about infertility, see Chapter 8.

Preconception Counselling and Care Preconception health promotion provides patients and their partners with information needed to make decisions about their reproductive future. The health of parents prior to conception has an impact on the health of a child; therefore, appropriate preconception care will improve health outcomes for both parents and newborns. Preconception care involves identifying and modifying risk factors in individuals considering pregnancy in order to improve their health. Risk factors may include medical, behavioural, and social factors, many of which may be modifiable. All patients should have an evaluation of their overall health and for opportunities to improve their health. They should also receive education about the effects of social, environmental, nutritional, occupational, behavioural, and genetic factors during pregnancy. Patients at high risk for an adverse pregnancy outcome should be identified. Such evaluation also involves identifying undiagnosed, untreated, or poorly controlled medical conditions. In order to make informed choices about childbearing, all individuals should be counselled regarding the increased risk of infertility, pregnancy complications, and adverse pregnancy outcomes when childbearing is delayed past the age of 35 (Liu & Case, 2017). The goals of the World Health Organization (WHO) for preconception care are to improve the health status of

childbearing persons and their partners before conception, and to reduce those behaviours as well as individual and environmental factors that could contribute to poor maternal and child health outcomes (WHO, 2013). Some areas of focus for all health care providers who provide preconception health care are presented in Figure 5.1. Activities that promote health in 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 already present. Because many patients do not realize that they are pregnant and do not seek prenatal care until well into the first trimester, the rapidly growing fetus may have already been exposed to many types of intrauterine environmental hazards during this most vulnerable developmental phase. These hazards include drugs, viruses, and chemicals. Thus, preconception health care should occur well in advance of an actual pregnancy. The components of preconception care such as health promotion, risk assessment, and interventions are outlined in Box 5.2.

Pregnancy A patient’s entry into health care is often associated with pregnancy, for either confirmation of it or actual care. Early entry into prenatal care (i.e., within the first 12 weeks) enables identification of the patient at risk and initiation of measures to promote a healthy outcome. Early and consistent prenatal care improves outcomes for mothers and infants. More extensive discussion of pregnancy is found in Unit 4.

Menstrual Concerns Irregularities or issues with the menstrual period are among the most common concerns of women and often cause them to seek help from a health care provider. Common menstrual disorders include amenorrhea, dysmenorrhea, premenstrual syndrome, endometriosis, and menorrhagia or metrorrhagia. Simple explanation and counselling 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 7 for an in-depth discussion of menstrual concerns.

Perimenopause and Menopause Perimenopause is the interval between regular cycles of ovulation occurring and menopause (permanent infertility). The body responds to this natural transition in a number of ways, most of which are caused by the decrease in estrogen. Most patients 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, patients are urged to maintain some method of birth control because pregnancies still can occur. All patients need to receive factual information, have myths dispelled, and undergo a thorough examination. During menopause they should have appropriate periodic health screenings.

BARRIERS TO RECEIVING HEALTH CARE The health of Canadians cannot be evaluated without consideration of the social determinants of health (see Box 1.1; Social Determinants of Health). These determinants of health include income and social status, social support networks, education and literacy, employment and working conditions, social environments, physical environments, personal health practices and coping skills, and healthy child development (Canadian Nurses Association, 2018; PHAC, 2016). Deficiencies in determinants of health and detrimental contextual factors may pose difficulties in accessing and receiving health care.

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Fig. 5.1 Preconception care topics. From Public Health Agency of Canada. [2017]. Preconception health. https:// www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/maternity-newborncare/preconception-health-infographic-eng.pdf)

BOX 5.2

Components of Preconception Care

Health Promotion: General Teaching • Nutrition • Healthy diet, including folic acid • Optimal weight • Exercise and rest • Avoidance of use of substances (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 • Prescription medications (especially those contraindicated in pregnancy), overthe-counter medication use, radiation exposure

• • • • • • • • • •

Personal behaviours and exposures Smoking, alcohol consumption, problematic drug use Overweight or underweight; eating disorders 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 • Cessation or reduction in problematic substance use • Immunizations (e.g., rubella, hepatitis, influenza) • Nutrition, diet, weight management • Exercise • Referral for genetic counselling • Referral to and use of: • Family planning services • Family and social services

AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus. HPV, human papillomavirus.

Financial Issues Limited finances can be associated with lack of access to care, delay in seeking care, fewer illness prevention activities, and lack of accurate information about health and the health care system. Poverty is a significant health issue for many Canadian people. It is estimated that

more than 4.9 million Canadians live in poverty, including 21% of lone mothers; 4.6% of Canadians were living in deep income poverty in 2018 (Canada Without Poverty, 2021; Statistics Canada, 2020a). In Canada, disparity among various ethnic groups and socioeconomic classes affects many facets of life, including health.

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Indigenous people in Canada are twice as likely as non-Indigenous people to live in a home in need of major repair, are 90 times more likely to have no piped water, and are 5 times more likely to have no bathroom facilities (Smylie et al., 2010). Waterborne infections are more common in Indigenous communities, and 30% of their water systems are considered high risk for containing microbes that cause infection or toxins that are detrimental to health (Bradford et al., 2016). Infant mortality rates for Indigenous people in Canada have ranged from 1.7 to over 4 times national Canadian rates, and Indigenous children under the age of 6 are less likely to have access to health care than are non-Indigenous Canadian children (Smylie et al., 2010). Socioeconomic status also affects birth outcomes. The rates of perinatal and maternal deaths, preterm births, and low–birth weight babies are considerably higher in disadvantaged populations (PHAC, 2019a). Lone mothers with little to no employment skills are caught in the bind of insufficient income for child care, restricting their ability to search for and obtain more secure employment, and increasing their risks for health concerns. Social isolation, especially among immigrant people, prevents them from accessing health care (Rezazadeh & Hoover, 2018). Multiple roles for women in general produce overload, conflict, and stress, resulting in higher risks for mental health issues.

Cultural Issues As our nation becomes more racially, ethnically, and culturally diverse, the compromised health of minority groups has become a concern. A variety of reasons are given to explain some of the differences in accessing care when financial barriers are adjusted. Some patients experience racial discrimination or disrespectful, disillusioning, or discouraging encounters with community service providers such as social services and health care providers and may not access health care services because of lack of trust in the system. A lack of cross-cultural communication also presents challenges. 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 patients whose background is different from that of the provider. Conversely, patients need to understand the health goals to be achieved and the methods proposed to do so. Language differences can produce profound barriers between patients and providers. Providers must consider culturally based differences that could affect treatment of diverse groups of patients, and the patients themselves must share practices and beliefs that could influence their responses or willingness to undertake treatment. For example, patients in some cultures value modesty to such an extent that they are reluctant to disrobe and as a result avoid physical examination unless it is absolutely necessary. Other patients rely on their partners to make major decisions, including those affecting their own health. Religious beliefs may dictate a plan of care, as with birth control measures or blood transfusions. Some cultural groups prefer traditional medicine, homeopathy, or prayer to Western medicine; others use a combination of some or all of these practices. Recognition of factors that may affect Indigenous people’s health is essential in the establishment of culturally safe policy and programs for Indigenous people. The Truth and Reconciliation Commission of Canada (2015) called for action by federal, provincial, and territorial governments to acknowledge and reduce disparities in the areas of education, child welfare, language, culture, health, and justice for Indigenous people in Canada (see Chapter 1 for further discussion). Despite some provincial and territorial innovations, the call for Indigenous-focused primary health care in Canada has yet to be fully realized (Henderson et al., 2018).

Community collaboration is needed to ensure that health programs and policies are created in a culturally safe manner and that services will meet the needs of and be used by patients and their families (see Chapter 2). It is not enough for health services to merely exist; they must be familiar and accessible to Canadians. This is especially important in the immigrant population, who may be struggling to navigate the Canadian health care system.

Gender Issues Gender affects provider–patient communication and may influence access to health care in general. The most obvious gender consideration is that between men and women. Women tend to use primary care services more often than men and, some investigators believe, use them more effectively. The gender of the provider also plays a role. For instance, the concept of “gender concordance,” in which the patient’s gender matches the health care provider’s gender, was found to be important for patients seeking Pap tests (McAlearney et al., 2011). Sexual orientation may produce another barrier to adequate health care. Nurses need to understand the specific health care needs and issues related to sexual orientation (Brennan et al., 2012). Some LGBTQ2 clients may not disclose their sexual orientation to health care providers 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 patient does not feel welcome (magazines, brochures, and the environment reflect heterosexual couples, or the health care provider shows discomfort interacting with the patient). This can result in lack of medical care, as well as in health care providers giving incorrect advice or not providing appropriate screening for patients. Not all gynecological cancers are related to sexual activity; patients who have never had children may be more at risk for breast, ovarian, and endometrial cancer. At the same time, lesbian and transgender patients’ risk for heart disease, cancer of the lung, and colon cancer is not different from that of heterosexual patients. To offset stereotypes, it is necessary for providers to develop an approach that does not assume that all patients are heterosexual. More education and clinical skills in caring for this population are required (Knight et al., 2014).

RISK FACTORS THAT IMPACT HEALTH In caring for patients at all stages of life, it is important to understand the various and complex risk factors that can affect a patient’s health. This section describes these risk factors.

Substance Use Use of illicit drugs and inappropriate use of prescription medications continue to increase and are found in all age groups, races, and ethnic groups and at all 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. Although women are less likely than men to misuse drugs, the rate of women who misuse drugs has risen significantly. Pregnant patients who overuse substances have increased risk for development of their own health issues, and their offspring have increased risk for potential health challenges, including interference with optimal growth and development and for physical dependence on the drug. Patients who give birth to infants with neonatal abstinence syndrome (NAS) have a higher mortality rate in the years following birth, largely related to poverty, mental health issues, and addiction (Guttmann et al., 2019). See Chapter 15 for further discussion of substance use during pregnancy and Chapter 29 for care of

CHAPTER 5 the newborn with NAS. Nurses must be aware of the potential impact of substance use and how to detect it, as many patients who have addiction issues may not readily access health care or disclose about their addictions.

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. Tobacco contains nicotine, which is an addictive substance that creates physical and psychological dependence. Among both sexes, the number of current smokers has declined between 2015 and 2018 (from 20.4 to 18.6% for males and from 15.0 to 13.0% for females [Statistics Canada, 2019b]). A Canadian national youth survey found that approximately 32% of adolescents in grades 7 to 12 had smoked menthol cigarettes, which may be incorrectly perceived as less harmful, thus encouraging nicotine dependence and a possible predictor of marijuana use and binge drinking (Azagba & Sharaf, 2014; Manske et al., 2014). Recently, alternatives to cigarettes have been used, including electronic cigarettes (e-cigarettes), smokeless tobacco, and water pipes. These alternative methods, however, may cause serious adverse effects due to the chemicals used in them and may have deleterious effects on health (Glauser, 2019). The full impact on health is not yet known, with more monitoring and research required. 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 health issues for the smoker and harm for the nonsmoker. Smoking during pregnancy may have adverse consequences for the infant, such as low birth weight. See the Family-Centred Care box, Smoking Cessation.

FAMILY-CENTRED CARE Smoking Cessation You are the nurse working in a family health team clinic; you observe that many of the young parents with newborns seen in the clinic smoke cigarettes. One new parent said, “I know it’s bad for me but I can’t quit. At least I don’t smoke around the baby.” What advice could you provide for the young parents about the effect of tobacco smoke on young infants, especially those under 6 months of age? Prepare a short presentation that can be shared with the young parents about the effects of tobacco on an infant’s long-term health. Discuss options and resources for smoking cessation that are available from local community agencies.

Caffeine. Caffeine is found in society’s most popular drinks: coffee, tea, soft drinks, and energy drinks. It is a stimulant that can affect mood and interrupt body functions by producing anxiety and sleep interruptions. Heart arrhythmias 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 potentially related to a slight decrease in birth weight and may also increase risk of miscarriage. Pregnant patients should limit their consumption of caffeine to less than 300 mg/day, or a little more than two cups (240 mL) per day (PHAC, 2020). It is important for the nurse to educate the patient on the various sources of caffeine, as it is found in a variety of food and drink products, such as tea, chocolate, and energy drinks.

Alcohol Consumption. The amount and frequency of alcohol consumption among young Canadian women is alarming: in 2012, 74%

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of Canadian women age 15 and older reported drinking alcohol; based on the amount of alcohol abused, 16% of those women are at risk for long-term complications and 10% at risk for acute illness (Canadian Centre on Substance Abuse, 2014). People who are problem drinkers are often depressed, have more motor vehicle injuries, and have a higher incidence of attempted suicide than do people in the general population. They are also at risk for alcohol-related liver damage. Early case finding and treatment are important for addressing alcoholism, for both the ill individual and family members. Prenatal exposure to alcohol can have multiple, permanent cognitive and physical effects on the fetus (Jarmasz et al., 2017). Prenatal alcohol exposure has been found to increase the chance of birth defects significantly and poses a considerable personal, societal, and economic cost due to premature morbidity and mortality rates (Popova et al., 2016). Although fetal alcohol spectrum disorder (FASD) is a known consequence of prenatal alcohol intake, studies also indicate that other consequences include increased risk for miscarriage, stillbirth, preterm birth, and sudden infant death syndrome (SIDS). Clearly, alcohol consumption during pregnancy has wide-reaching effects.

Cannabis. Cannabis, or 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. Cannabis is considered more harmful if smoked because of the impact on the lungs (Centre for Addiction and Mental Health, 2018). Cannabis produces distorted perceptions, difficulty with problem solving and with thinking and memory, altered state of awareness, relaxation, mild euphoria, and reduced inhibition (National Institute on Drug Abuse, 2019). In the pregnant patient, cannabis readily crosses the placenta and causes increased carbon monoxide levels in the mother’s blood, which reduces the oxygen supply to the fetus. Cannabis use is higher among patients who also use alcohol and tobacco during pregnancy and is highest among patients aged 15–24 and persons of lower socioeconomic status (Corsi et al., 2019). Use of cannabis during pregnancy is associated with preterm birth and smaller-for-gestational-age babies (Leemaqz et al., 2016). The legalization of cannabis in 2018 in Canada calls for further research into rates of use among pregnant patients, as well as regarding newborn and long-term child development outcomes. Prescription Medication Use. Women are more likely than men to report taking prescription medications (Rotermann et al., 2014). Such medications can bring relief from undesirable conditions such as insomnia, anxiety, depression, and pain. Because the medications have a mind-altering capacity, misuse can produce psychological 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 of time. Depression and anxiety are the most common mental health challenges in women (depression used to be considered the most common, but recently it has been 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 in pregnant patients. Illicit Drug Use Cocaine. Cocaine is a powerful central nervous system stimulant that is addictive because of the tremendous sense of euphoria it creates. It can be snorted, smoked, or injected. 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

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pleasurable high results that is followed by an uncomfortable low; this increases the urge to repeat using the drug. Predisposing factors and problems associated with cocaine use are polydrug use; poor nutrition; poverty; STIs; hepatitis B infection; dysfunctional family systems; employment difficulties; stress; anger; poor self-esteem; and previous or present physical, emotional, and sexual abuse. The clinical manifestations of cocaine use include tachycardia, pupillary dilation, and hypertension. Cocaine affects all of the 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 stimulation 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. Opioids. The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. Heroin is one of the most commonly used 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 judgement, and drowsiness), constricted pupils, nausea, constipation, slurred speech, and respiratory depression. The incidence of heroin use among pregnant patients is unknown because patients with a dependency on heroin often use multiple drugs. Patients who use opiates during pregnancy are at risk for many obstetrical complications (Stover & Davis, 2015). The recommended treatment is opioid agonist therapy with methadone or buprenorphine, ideally done by stabilizing the treatment before as well as during pregnancy. This treatment must be closely monitored because, methadone is metabolized more rapidly, leading to withdrawal symptoms in less than 24 hours in many patients. NAS is a serious concern for infants born to a parent who chronically uses opioids (see Chapter 29). Methamphetamine. Methamphetamine is a relatively cheap and highly addictive stimulant. Methamphetamine makes many users feel hypersexual and uninhibited, and this may lead to more sex and less protection from pregnancy. 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 state and pleasure as well as increased energy and creates addiction within a short

BOX 5.3

period. It can lead to cardiac concerns, including irregular heartbeat and hypertension and, over time, can create cognitive and mental as well as dental issues (Medline Plus, 2021). Most of the effects of amphetamines are similar to those of cocaine. Other illicit drugs. A number of other 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 “highs.” Hallucinogens alter perception and body function. PCP (“angel dust”) and LSD produce vivid changes in sensation, often with agitation, euphoria, paranoia, and a tendency toward antisocial behaviour. Their use may lead to flashbacks, chronic psychosis, and violent behaviour.

Substance Use Cessation. Patients at all ages will receive substantial and immediate benefits from stopping or decreasing their use of substances. However, this is not easy, and most people will attempt to stop several times before they accomplish their goal. Many are never able to do so. New approaches are needed to increase cessation among smokers and to discourage smoking among young patients, especially in adolescence and during pregnancy. Health care providers can have an impact on smoking behaviour and should attempt to motivate smokers to stop smoking. Raising questions about social consequences (e.g., stained teeth and foul-smelling breath and clothes) is sometimes effective with young people. Those who wish to stop smoking can be referred to a smoking cessation program in which individualized methods can be implemented. Best practice guidelines regarding smoking cessation are also available from the Registered Nurses’ Association of Ontario (RNAO) and the Canadian Smoking Cessation Clinical Practice Guideline, which offer recommendations and strategies for patients who would like to quit smoking (see Additional Resources at the end of this chapter). Box 5.3 includes guidelines for smoking cessation for the pregnant patient. There is good evidence that even brief advice from health providers has a significant effect on smoking cessation rates; advice from a health care provider has been shown to decrease the proportion of people smoking by about 2% per year (RNAO, 2015). While the legal age for drinking alcohol and cannabis use varies among the provinces and territories (age 18 or 19), stronger regulation of advertising as well as health promotion and youth-designed programming, such as Students Against Drunk Driving (SADD), is having

Interventions for Smoking Cessation: The Five A’s

Ask • What was the person’s age when they started smoking? • How many cigarettes do they smoke a day? When was their last cigarette? • Have they tried to quit? • Do they want to quit? Advise • Give the patient information about the effects of smoking on pregnancy and the fetus, on their own future health, and on the members of their household. Assess • What were their reasons for not being able to quit before, or what made them start again? • Does the patient have anyone who can help them? • Does anyone else smoke at home? • Does the patient have friends or family who have quit successfully?

Assist • Provide support; give self-help materials. • Encourage patient to set a quit date. • Refer to a smoking-cessation program, or provide information about nicotine replacement products if they are 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 up with the patient to find out about smoking-cessation status. • Make a phone call around the time of their quit date. Assess their status at every prenatal visit. • Congratulate the patient on their success, or provide support for them if they relapse. • Referral to intensive treatment may be necessary.

Adapted from Fiore, C. (2012). Tobacco use and dependence: A 2011 update of treatments. http://www.medscape.org/viewarticle/757167.

CHAPTER 5 a positive impact. All primary care providers should screen for alcohol and other drug use, with an understanding of the obvious problem with relying on self-reporting of these behaviours. The use of over-thecounter medications by patients should also be explored. Counselling for patients who appear to be drinking excessively or using drugs may include strategies to increase self-esteem and teaching of new coping skills to resist and maintain resistance to alcohol and substance use. Appropriate referrals should be made, with the health care provider arranging the contact and then following up to ensure that appointments are kept. General referral to sources of support should also be provided. Knowledge of harm reduction is important for the health care provider, to ensure that policies and programs exist that support reducing drug-related harm in the absence of abstention and are the first step in potential cessation of drug use. Anticipatory guidance includes teaching about the health and safety risks of alcohol and mind-altering substances and discouraging drug experimentation among preteen and high school students. The use of drugs at an early age tends to predict greater involvement later.

Nutrition Good nutrition is essential for optimal health. A well-balanced diet helps prevent illness and also is used to treat certain health conditions. Conversely, poor eating habits, eating disorders, and obesity are linked to disease and debility. Canada’s Food Guide (see Appendix A) provides a variety of educational tools for patients and health care providers to promote health and reduce risks for chronic diseases through diet and physical activity. The Dietitians of Canada have a number of nutrition resources (see Additional Resources at the end of this chapter). In addition to specific guidelines for healthy eating, environmental factors play an important role in nutrition. It is well known that social conditions and access to nutritious food are important contributors to patients’ health. The availability of resources is a critical factor in nutrition and health. For example, patients who have access to healthy food have decreased levels of obesity (Dubowitz et al., 2012). Food insecurity is the inability to acquire or consume an adequate diet or the uncertainty that one will be able to do so. Household food insecurity is often linked with the household’s limited financial ability to access adequate food (Health Canada, 2020). Early breastfeeding cessation is also a common factor among families struggling with food insecurity (Orr et al., 2018).

Nutritional Deficiencies. Overt disease caused by a lack of certain nutrients is rarely seen in Canada. However, insufficient amounts or imbalances of nutrients do pose health challenges 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 conditions that could be related to poor nutrition and indicate the need for further nutritional assessment. Poor nutrition, especially that related to obesity and high fat and cholesterol intake, may lead to more serious conditions and contribute to heart disease, malignant neoplasms, cerebrovascular diseases, and diabetes—many of the leading causes of morbidity and mortality in Canada. 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 cyclical weight gain and weight loss) result in nutritional imbalances and, in some instances, medical concerns. 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 teen’s own needs for growth and maturation at a time when eating habits are not ideal.

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Obesity. The overall percentage of women in Canada who were overweight or obese in 2018 was 56.7% (Statistics Canada, 2019a). The likelihood of being overweight is greater among families living in low socioeconomic neighbourhoods, where the social environment is often less conducive to physical activity because of lack of safety and lack of available resources and opportunities. There has been some debate over whether the body mass index (BMI) remains an effective diagnostic tool of assessing for obesity, or if waist circumference offers more clinically relevant information. Both BMI and waist circumference (Box 5.4) appear to have their value in assessing the patient for risk of obesity, central obesity, and cardiovascular disease. Waist circumference provides an indicator of abdominal fat. Excess fat around the waist and upper body (also described as an “apple” body shape) is associated with greater health risk than fat located more in the hip and thigh area (described as a “pear” body shape) (Health Canada, 2019). BMI is defined as a measure of an adult’s weight in relation to their height, specifically the adult’s weight in kilograms divided by the square of their height in metres (Table 5.1). Both BMI and waist circumference should be considered because even if BMI is “normal,” a higher waist circumference poses some risks to health (Health Canada, 2019). Overweight and obesity are known risk factors for premature death, diabetes, heart disease, stroke, hypertension, dyslipidemia, gallbladder disease, diverticular disease, constipation, osteoarthritis, gout, osteoporosis, respiratory dysfunction, sleep apnea, and some cancers (esophagus, uterine breast, colorectal, kidney, and endometrial) (Canadian Cancer Society, 2021). In addition, obesity is associated with high BOX 5.4

Waist Circumference

Measure waist with clothing removed from abdomen. Place a measuring tape around waist, just above the hip bones. Waist circumference (WC) ¼ ____________ centimetres. Assess health risk. High Risk A WC measurement of 88 cm or more for women is associated with an increased risk of developing health issues such as type 2 diabetes, coronary heart disease, and high blood pressure. As the cut-off points are approximate, a WC just below this measurement should also be taken seriously. The risk of developing health issues increases as WC measurement increases above the cut-off points. Source: Health Canada (2011). Canadian guidelines for body weight classification in adults. http://www.hc-sc.gc.ca/fn-an/nutrition/weightspoids/guide-ld-adult/qa-qr-pub-eng.php#a4

TABLE 5.1

Body Weight With Body Mass Index and Health Risk BMI Range

Risk of Developing Health Issues

Underweight

30.0

High

BMI, Body mass index. Adapted from Health Canada. (2019). Canadian guidelines for body weight classification in adults. http://www.hc-sc.gc.ca/fn-an/nutrition/ weights-poids/guide-ld-adult/qa-qr-pub-eng.php#a4

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cholesterol, menstrual irregularities, hirsutism (excess body and facial hair), stress incontinence, depression, complications of pregnancy, increased surgical risk, and shortened lifespan. Pregnant women who are morbidly obese are at increased risk for hypertension, diabetes, gallbladder disease, post-term pregnancy, and musculoskeletal issues.

Eating Disorders. 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 individuals, 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 individual but also their family. Treatment must be personalized, including nutritional and behavioural/psychotherapeutic approaches. It is important to assess for and treat people with eating disorders early because they are at increased risk for serious physical conditions 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 people 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. Patients can carry this condition to the point of starvation, with resulting endocrine and metabolic abnormalities. If it is not corrected, significant complications of arrhythmias, amenorrhea, cardiomyopathy, and heart failure occur and, in the extreme, can lead to death. The condition commonly begins during adolescence in young patients who have some degree of personality disorder. They gradually lose weight over several months, have amenorrhea (see Chapter 7), 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 patients at risk for eating disorders. Several tools are available to use in primary care settings. The SCOFF questionnaire, developed by Morgan, et al., (1999), is easy to administer and can help the nurse decide whether an eating disorder is likely and whether the patient needs further assessment and possibly psychiatric and medical intervention. See Box 5.5 for a description of the SCOFF assessment tool. Bulimia nervosa. Bulimia refers to secret, uncontrolled binge eating alternating with methods to prevent weight gain: self-induced vomiting, laxatives or diuretics, strict diets, fasting, and rigorous exercise. During a binge episode, large numbers of calories are consumed, usually consisting of sweets and “junk foods.” Binges occur at least twice per week. Bulimia usually begins in early adulthood (ages 18 to 25) and is found primarily in females. Complications can include dehydration and electrolyte imbalance, gastrointestinal abnormalities, and cardiac arrhythmias. Bulimia is somewhat similar to anorexia in that it is an eating disorder and usually involves some degree of depression. Unlike persons 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 5.5).

BOX 5.5 Screening for Eating Disorders: SCOFF Questions Each question scores 1 point. A score of 2 or more indicates that 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 6 kg 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? Source: 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.

management of chronic conditions such as hypertension, arthritis, diabetes, respiratory disorders, and osteoporosis (Figure 5.2). Exercise also contributes to stress reduction and weight maintenance. Patients 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 increasing amounts of oxygen are delivered to working muscles. Anaerobic exercise such as weight training improves individual muscle mass without stress on the cardiovascular system. Because patients are often concerned about both cardiovascular and bone health, weight-bearing aerobic exercises such as walking, running, racket sports, 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. One particular exercise that is important for women is Kegel exercise, or pelvic muscle exercise. These exercises help patients prevent urinary incontinence that can occur after childbirth and a variety of other

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

Fig. 5.2 Exercise should be part of one’s regular health routine. A cycle class is fun and provides moderate to vigorous exercise. (From wavebreakmedia/Shutterstock.com.)

CHAPTER 5 conditions that may occur with age (Woodley, et al., 2017). This exercise is used to strengthen the muscles that support the pelvic floor and should be practised regularly. Instructions for this exercise are presented in the Family-Centred Care box: Kegel Exercise.

FAMILY-CENTRED CARE 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 person can prevent or reduce accidental urine loss. Technique The person needs to learn how to target the muscles for training and how to contract them correctly. One suggestion for teaching is to have the patient pretend they are trying to stop the flow of urine in midstream or to have them think about how their vagina is able to contract around and move up the length of the penis during intercourse. The patient should avoid straining or bearing-down motions while performing the exercise. They should be taught to avoid straining down by exhaling gently and keeping their mouth open each time they contract the pelvic muscles. Specific Instructions • Each contraction should be as intense as possible without contracting the abdomen, thighs, or buttocks. • Contractions should be held for at least 10 seconds. The person may have to start with as little as 2 seconds per contraction until the muscles get stronger. • They 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 they can make it. • They should feel the pulling up and over the three muscle layers so that the contraction reaches the highest level of the pelvis. • Positive results can be achieved by performing the exercise for 15 minutes twice a day. Sources: 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; Robert, M., & Ross, S. (2018). SOGC clinical practice guideline: Conservative management of urinary incontinence. Journal of Obstetrics & Gynecology of Canada, 40(2), e119–e125; Reynolds, N., & Wilson, I. M. (2019). “There was no real importance put on them”. Experiences of multiparous women and pelvic floor muscle exercise (PFME) prescription. A qualitative study. Physiotherapy Practice and Research, 40, 135–143.

Physical activity and exercise counselling for persons of all ages should be available at schools, work sites, and primary care settings. Specific recommendations include at least 30 minutes of moderate activity at least 5 days of the week for adults, in intervals of 10 minutes or more (Heart and Stroke Foundation, 2020). Few Canadians exercise this often, and physical inactivity increases with age, especially during adolescence and early adulthood. Yet even small increases in activity can be beneficial.

Stress Individuals are facing increasing levels of stress and, as a result, are prone to a variety of stress-induced illnesses. Stress often occurs because of conflict among multiple roles—for example, job and

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financial responsibilities can conflict with parenting and duties at home. To add to this burden, some people 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 to have control over their everyday environments. Some stress is normal and contributes to positive outcomes. Many people 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 exacerbations of arthritis or asthma, frequent colds or infections, gastrointestinal upset, cardiovascular conditions, and infertility. Box 5.6 lists symptoms that may be related to chronic or extreme stress. Psychological symptoms such as anxiety, irritability, eating disorders, depression, insomnia, and substance use have also been associated with stress. Because it is neither possible nor desirable to avoid all stress, people must learn how to manage it. The nurse should assess each patient for signs of stress, using therapeutic communication skills to determine risk factors and the patient’s ability to function. Women are twice as likely as men to suffer from depression, anxiety, or panic attacks. Nurses must be alert to the symptoms of serious mental disorders such as depression and anxiety and make referrals to counselling or other mental health practitioners when necessary. People experiencing major life changes such as separation and divorce, bereavement, serious illness, and unemployment need special attention. A psychosocial assessment for stress and depression is recommended for pregnant patients in each trimester (Kingston et al., 2015). Thorough assessment allows for appropriate referrals and care planning. Social support and good coping skills can improve a patient’s selfesteem and give them a sense of mastery. Anticipatory guidance for developmental or expected situational crises can help people plan strategies for dealing with potentially stressful events. Role-playing, relaxation techniques, biofeedback, meditation, desensitization, healing touch, imagery, assertiveness training, yoga, diet, exercise, and weight control are all techniques that nurses can include in their repertoire of helping skills.

Depression, Anxiety, and Other Mental Health Conditions Many patients experience depression or anxiety frequently. In addition, depression is sometimes described as a co-traveller because it exists comorbidly with other physical conditions. Depression or anxiety creates difficulties for quality of life and, at the extreme, create a risk for suicide. Recent research suggests that patients with comorbid anxiety and depression are at greater risk for developing cardiac disease (Cohen et al., 2014). In addition to depression and anxiety, patients may experience other mental health disorders, such as bipolar disease.

Sleep Disorders Many people are at risk for sleep challenges, including poor sleep quality (Nugent & Black, 2016). During pregnancy and postpartum, many factors can negatively affect sleep, and Willis-Ekbom disease (restless legs syndrome) may result. Sleep disorders are correlated with physical and mental health challenges, including depression, pain, and fibromyalgia. Women tend to experience sleep and sleep issues at various stages across the lifespan (Shaver, 2015). It is important that the nurse talk with the patient about their sleep patterns and discuss ways to improve sleep, such as avoiding alcohol use before going to sleep and sleeping in a regular pattern.

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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 • Premenstrual tension • Pain in neck and lower back • Loss of appetite or overeating • Susceptibility to illness Behavioural • 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

Psychological • Feeling anxious • Feeling scared • Feeling irritable • Feeling moody • Having low self-esteem • Being afraid of failure • Being unable to concentrate • Embarrassed easily • Worrying about the future • Being preoccupied with thoughts or tasks • Forgetful

Adapted from State University of New York Counseling Center (2002). Stress management. University of Buffalo, State University of New York.

Environmental and Workplace Hazards A safe environment is a key determinant of health. 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: • Pathogenic agents (viruses, bacteria, fungi, parasites) • Natural and synthetic chemicals (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 use) • Radiation (radon, heat waves, sound waves) • Food substances (added ingredients that are not necessary for nutrition) • Physical objects (moving vehicles, machinery, weapons, water, and building materials). Environmental hazards can affect fertility, fetal development, live birth, and the child’s future mental and physical development. Children are at special risk for poisoning from lead found in paint and soil. The Canadian government has called for strict guidelines regarding the amount of lead in children’s toys, a regulation that is nonexistent in the rest of the world. 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 carried out to identify and understand environmental problems in public health. Safe drinking water is a basic determinant of health. A significant number of communities are placed under a boil water advisory each year in Canada. While some advisories are preventative of a possible risk, others are based on actual risk. Working with communities to advocate for safe drinking water, lobby for proper sanitation and consistently high quality controls, and educate the public about how to maintain health in the face of a boil water advisory is a key role of the community nurse.

Sexual Practices Potential risks related to sexual activity include undesired pregnancy and STIs. The risks are particularly high for adolescents and young adults.

Adolescents report many reasons for wanting to be sexually active: peer pressure, desire to love and be loved, experimentation, to enhance selfesteem, and to have fun. However, many teens do not have the decisionmaking 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. An important role for the nurse is to ensure that youth have the correct information. Sex & U is an excellent resource for more information for youth and is listed in the Additional Resources. Although some STIs can be cured with antibiotics, many cause significant health concerns. Possible sequelae include infertility, ectopic pregnancy, neonatal morbidity and mortality, genital cancers, AIDS, and even death. The incidence of some STIs is increasing rapidly and reaching epidemic proportions. Choice of contraception has an impact on the risk of contracting an STI; no method of contraception offers complete protection. (See Chapter 7 for a detailed discussion of STIs, and see Chapter 8 for a discussion of contraception.) Prevention of STIs is predicated on the reduction of high-risk behaviours, through educating toward behavioural change. Behaviours that predispose to contracting an STI include having multiple sexual partners and carrying out unsafe sexual practices. Specific selfmanagement measures to prevent STIs are listed in Box 5.7. The overuse of alcohol and drugs is also a high-risk behaviour, as it results in impaired judgement and often thoughtless acts. Behavioural 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 takes into account the language, culture, and lifestyle of the intended listener.

Medical Conditions Most patients of reproductive age are relatively healthy. Heart disease; lung, breast, colon, and other nongynecological cancers; chronic lung disease; and diabetes are all concerns for patients because they are among the leading causes of death. Certain medical conditions present during pregnancy can have deleterious effects on both the patient and the fetus. Of particular concern are risks from all forms of diabetes,

CHAPTER 5

BOX 5.7

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. • Pre-exposure vaccination is one of the most effective methods for preventing transmission of some STIs (hepatitis A and 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. • Abstinence is also recommended if under the influence of drugs or alcohol. Adapted from Sex & U: https://www.sexandu.ca/ HIV, Human immunodeficiency virus; STI, sexually transmitted infection.

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 patient also can be severe. These conditions are discussed in Chapter 15.

Gynecological Conditions Patients are at risk throughout their reproductive years for pelvic inflammatory disease, endometriosis, STIs and other vaginal infections, uterine fibroids, uterine deformities such as bicornuate uterus, ovarian cysts, interstitial cystitis, and urinary incontinence related to pelvic relaxation. These gynecological conditions may contribute negatively to pregnancy by causing infertility, miscarriage, preterm labour (see Chapter 7), and fetal and newborn health challenges. Gynecological cancers also affect patients’ health, although risk factors depend on the type of cancer. The impact of developing a gynecological condition or cancer on patients and their families is shaped by a number of factors, including the specific type of condition or cancer, the implications of the diagnosis for the patient and their family, and the timing of the occurrence in the patient’s and family’s lives.

Female Genital Cutting Female genital mutilation, infibulation (surgical closure of the labia majora), 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, 2020). The SOGC recommends using the term female genital cutting (FGC) for this procedure as it is less judgmental and stigmatizing and more culturally sensitive (Perron et al., 2020). These procedures are attempts to control women through controlling their sexuality. FGC is supposed to remove sexual desire so that the girl will not become sexually active until married. FGC is practised in more than 45 countries, with most of these countries being in Africa. The increasing multicultural mosaic of Canada means that more practitioners are working with clients who have experienced FGC. FGC occurs in women of many different ethnic, cultural, and religious backgrounds. Although FGC is usually performed on girls between the ages of 5 and 12 years, infants and adult women are sometimes subjected to the procedure. 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.

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The extent of the FGC 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. It is illegal in Canada to perform or assist with FGC. An obstetrical care provider may incise the closed labia to assist in the birth of a baby or remove cysts but may not sew the labia back to its previous state, reinfibulation. FGC is internationally recognized as a harmful practice and a violation of girls’ and women’s rights to life, physical integrity, and health (Perron et al., 2020). It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. FGC is nearly always carried out on minors and it is a violation of the rights of children. Nurses in Canada are providing care to a growing number of women who have emigrated from the Middle East, Asia, and Africa, where FGC is more common, thus nurses need to increase their knowledge about FGC. 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. Health care providers must also be careful not to stigmatize women who have undergone FGC (Perron et al., 2020). As advocates for women’s health, nurses are in a position to promote initiatives that promote the elimination of FGC and should use interactions with patients as opportunities to educate women and their families about FGC and other aspects of women’s health and reproductive rights (Perron et al., 2020).

Human Trafficking Human trafficking is actually a form of slavery in which people are forced into becoming part of the unpaid labour force, usually in sweatshops or in domestic work, or to serve as sex slaves (Green, 2016). The majority of these trafficking slaves are women and children, and many of these women have some interaction with health care providers. Thus, the implications for nursing are that it is imperative that signs of trafficking be recognized so that appropriate care can be delivered. Similar to victims of IPV, these patients often have signs of physical abuse or neglect, such as scars, bruises, burns, unusual bald patches, or tattoos that may be a sign of branding. They may also demonstrate signs and symptoms of emotional distress and mental health issues. They are likely to be accompanied by someone who never leaves them alone and who speaks for them. They may not speak English and may lack identification documents or health care information. If the person is alone, they may have their cell phone on and in speaker mode so that the person on the other end can hear everything that is being said during the health care visit (Collins & Skarparis, 2020). The nurse needs to be creative in getting the patient alone for questioning. Strategies might include sending the accompanying person to the front desk to fill out paperwork, interviewing the patient in the restroom, or telling them they need to go for testing and cannot take their cell phone. With the consent of suspected or confirmed victims of human trafficking, intervention plans can be developed (Collins & Skarparis, 2020). Green (2016) recommended asking simple “yes” or “no” questions in order to screen for suspected trafficking (Box 5.8). Certain findings on history are also indicative of possible trafficking.

Intimate Partner Violence Intimate partner violence (IPV), also called gender-based violence, is violence perpetrated by a spouse, partner, or someone with whom the person has had an ongoing intimate relationship, and is the most common form of violence experienced by women worldwide, with a

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BOX 5.8

Women’s Health

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 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.

reported incidence of one out of every six women having been a victim of domestic violence. Common elements of IPV are physical abuse; psychological or emotional abuse; sexual assault; isolation; and controlling all aspects of the person’s life, including money, shelter, time, and food. In some cases, people do not recognize that they are being abused; they may not realize that psychological aggression exhibited as public humiliation, coercive control, threats of harm, or damage to personal property are forms of IPV (Breiding et al., 2015). Estimates of IPV are low primarily because many people may be afraid to disclose the abuse for fear of retaliation and escalation of violence. In Canada, IPV is a significant social concern that affects many individuals each year and costs millions of dollars in annual medical costs. In 2015, the rate at which women were killed by an intimate partner was five times that of men (Canadian Femicide Observatory for Justice and Accountability, 2020). Canadian Indigenous people are three times as likely to be victims of violence and at a significantly higher risk of being killed than non-Indigenous women (Canadian Femicide Observatory for Justice and Accountability, 2020; Scrim, 2017). Several factors present in Indigenous communities have been linked to this risk factor, including colonization, ongoing racism, and socioeconomic challenges (Varcoe et al., 2017). Violence is neither random nor constant; rather, it occurs in repeated cycles. Health care providers often refer to the “cycle of violence” (Figure 5.3). 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, punching, choking, pushing, breaking of bones, burns from irons, and mutilations from knives and guns (see Box 5.9 for signs of IPV). The honeymoon phase is characterized by a period of calm and remorse in which the partner displays kind, loving behaviour 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. Dating violence is also a growing concern among adolescents. Knowledge of the potential for violence among youth in dating relationships is an important consideration for nurses when completing assessments with youth.

Tension building

Abusive incident Cycle of violence

Honeymoon phase Fig. 5.3 Cycle of violence.

BOX 5.9 • • • • • • • •

Signs of Intimate Partner Violence

Overuse of health services Vague, nonspecific concerns Missed appointments Unexplainable injuries 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

Source: Krieger, C. L. (2008). Intimate partner violence: A review for nurses. Nursing & Women’s Health, 12(3), 224–234.

Because violence against women, as well as against LGBTQ2 persons, 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 (Table 5.2). Violence is also known to increase during and after conflict (WHO, 2017), which has a particular impact for immigrant patients coming from countries with war and conflict. It is important that immigrants to Canada know that they will not be deported if they leave their partner because of violence, even if the partner is their sponsor. Reporting rates may not reflect the magnitude of the issue, as many patients do not disclose violence because of fear, embarrassment, or not having been asked by those from whom they seek help. Poor and uneducated patients tend to be disproportionately represented because they are seen in emergency departments, they are financially more dependent, and they have fewer resources and support systems. They also may have fewer problem-solving skills. Although IPV is the preferred term, domestic or family violence are terms that may be applied to a pattern of assaultive and coercive behaviours inflicted by a partner in a marriage or other significant, intimate relationship. It is also important to note that not all violence is caused by an intimate partner; non-IPV also occurs. Violence in general has negative effects on people’s health. Because IPV is not uncommon, with many patients being abused frequently, routine assessment of violence against patients should be included in primary care histories.

CHAPTER 5

TABLE 5.2

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Myths and Facts About Intimate Partner Violence (IPV)

Myths

Facts

Violence occurs in a small percentage of the population.

One third of all Canadian patients have experienced violence in their life.

Being pregnant protects the patient from abuse.

From 4 to 8% of all patients suffer IPV during pregnancy. IPV often begins or escalates in frequency and intensity during pregnancy. Pregnancy may be the result of forced sex or of the partner’s control of contraception.

Violence occurs only in “problem” or lower-class families.

IPV can occur in any family. Although lower-income families have a higher reported incidence of violence, it also occurs in middle- and upper-income families. Incidence is not accurately known because of the tendency of middle- and upper-income families to hide the violence.

Individuals like to be beaten and deliberately provoke the attack. They are masochistic.

People are terrified of their assailants and go to great lengths to avoid a confrontation. In some cases, the person may provoke their partner to release tension that, if left unchecked, might lead to a more severe beating and possible death.

Only men or women with psychological problems are abusers.

Many offenders are successful professionals. Research indicates that only a small number of abusers have psychological problems.

Only people who come from abusive families end up in abusive relationships.

Most individuals report that their partners were the first person to subject them to violence.

Alcohol and drug use cause abuse.

Although alcohol may be involved in abusive incidents, it is not the cause. Many offenders use alcohol as an excuse for the violence and shift the blame to the alcohol.

Individuals would leave the relationship if the abuse were really that bad.

Individuals who stay in the relationship do so out of fear and financial dependence. Shelters have long waiting lists or may not be accessible in more remote communities.

Abusers and survivors of violence cannot change.

Counselling may effectively help both the offenders and victims of violence.

Some individuals stay in abusive relationships because it is part of their culture.

Many people stay because of social isolation, language barriers, and poverty or for a sense of family responsibility. Many immigrant patients may fear deportation.

Abuse does not happen in same-sex relationships.

Power dynamics can occur in any intimate relationship. Violence against a partner is a crime regardless of gender.

Sources: Canadian Women’s Foundation. (n.d.). The facts about gender-based violence. http://www.canadianwomen.org/facts-about-violence; Canadian Women’s Health Network. (2012). Domestic violence in the LGBT community. https://cwhn.ca/en/node/39623; Society of Obstetricians and Gynecologists of Canada. (2005). SOGC clinical practice guideline: Intimate partner violence consensus statement. Journal of Obstetrics and Gynaecology Canada, 27(4), 365–388.

All patients entering the health care system should be assessed for potential abuse. At least the following questions should be asked (Pellizzari et al., 2005): • “Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?” • “Do you feel safe in your current relationship?” • “Have you ever been forced to have sex or engage in sexual activities against your will?” These questions give a patient permission to disclose sensitive information. A therapeutic relationship and skillful interviewing can help patients disclose and describe their abuse (Box 5.10). Sensitive use of language is important when talking with patients. For example, the term victim connotes powerlessness and hopelessness; a more empowering term is survivor. Demonstrating concern for patients who are experiencing violence, showing respect, exercising confidentiality, and conveying a nonjudgemental attitude are important attributes of health care providers to facilitate disclosure of violence (Catallo et al., 2012). Many patients are concerned about health care providers discovering their IPV (Catallo et al., 2012). If a patient discloses IPV, the first step is to assess for immediate danger and to take action to protect the person and their children, if needed. A complete physical examination is needed to assess for injuries and to observe the patient’s behaviours and verbal responses when asked about the various injuries (Bianchi et al., 2016). The next step is to help the patient formulate a safety plan (Box 5.11). It is imperative that people are aware of resources available to them and have a plan of action if they stay with the violent partner. The nurse should provide telephone numbers of a hotline and a shelter or other

safe haven. The patient can be offered a telephone to call the shelter if this is an option they choose. If they choose 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 neighbour), money or a chequebook, 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 24 hours a day from the police department. Shelters also can be helpful with assistance in obtaining orders of protection. If the patient chooses not to act in the middle of a violent episode, they may use the hotline or shelter for some counselling when the threat of harm is no longer present. Of critical importance to addressing IPV on a wider scale is a coordinated approach to maintain the safety of patients, good access to health care, and nonjudgemental treatment from health providers. Collaborative efforts to teach youth about healthy relationships are also essential to preventing IPV (Exner-Cortens et al., 2019). Community involvement in developing a response to IPV is important to sustaining safe, resilient communities.

Violence During Pregnancy. Violence against pregnant patients is a significant public health concern (Tailleu et al., 2016). The greatest predictor of violence during pregnancy is IPV prior to pregnancy; violence tends to worsen during pregnancy. Risk factors for IPV during pregnancy include younger age (especially adolescents), unintended pregnancy, lower income, and lower level of education (Martin-de-lasHeras et al., 2015). Abuse also may happen for the first time during pregnancy.

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Women’s Health

BOX 5.10

What Not to Say to a Person Who Has Been Subjected to Violence and What You Can Say and Do What Not to Say 1. Do not ask “why.” This question “re-victimizes” and blames the victim. 2. Do not talk negatively about the abuser to the victim. The person 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.” 5. “You are not alone.” 6. “It is a crime.” 7. “I’m here for you.” What to Do 1. Empower the patient. 2. Sit down with them. 3. Assure the patient of total privacy and confidentiality (but only if you can). 4. Use your best listening and relational practice skills. 5. Call 911 or call local police and report any incident of imminent danger. 6. Give the patient the telephone number and/or email address of the nearest shelter or safe house. 7. For further assistance, refer to a victim services division in the city or province if available.

BOX 5.11

Safety Strategies

Survivors of intimate partner violence should try to maintain the following safety strategies: • Always be aware of surroundings. • Minimize time in kitchens, bathrooms, and closets when the abuser is near. • Shop and bank at different places. • Drive to work multiple ways. • Get a protection order. • Never lunch alone. • Cancel joint credit cards and old bank accounts with the abuser. • Provide a picture of the abuser to security at the workplace. • Be escorted by workplace security to the car or transportation. • When in danger, go to a place of safety and call 911 or local emergency response or police. • Change locks on the house if the abuser has moved out. • Get an unlisted telephone number. • Block caller ID. Source: Krieger, C. L. (2008). Intimate partner violence: A review for nurses. Nursing & Women’s Health, 12(3), 224–234.

During pregnancy the nurse should assess for abuse at each prenatal visit and on admission to labour. Violent episodes initiate or 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 partner may be jealous of the fetus, resenting intrusion into the couple’s relationship and the pregnant person’s displacement of attention; (3) the abuser may be angry at the unborn child or their partner; and (4) the violence may be the partner’s conscious or subconscious attempt to end the

pregnancy. A pregnant patient is often accompanied by their partner to the prenatal appointment, especially if the patient does not speak English and the partner does. Unless an interpreter is available, it is difficult to interview the patient alone. In addition, asking questions about abuse through an interpreter is more difficult unless the interpreter is patient and can communicate the nurse’s sensitivity and concern accurately. See more discussion of IPV during pregnancy in Chapter 11.

Prevention. Nurses can make a difference in stopping IPV and preventing further injury. Educating patients that abuse is a violation of their rights and facilitating their access to protective and legal services is an important first step. Other helpful measures for nurses to take to discourage the risk of abusive relationships are promoting assertiveness and self-defence courses; suggesting support and self-help groups that encourage positive self-regard, confidence, and empowerment; and recommending educational and skills development classes that will enhance independence and the ability to take care of oneself. Classes for English-language learners may be particularly helpful to immigrant patients. Nurses can offer information on local classes.

HEALTH PROMOTION AND ILLNESS PREVENTION Over the last several decades, women have made tremendous strides in education, careers, policy making, and overall participation in today’s complex society. There have been costs for these advances, however; although women are living longer, they may not be living better. As a result, the health care system needs to include greater attention to the health consequences for women. Women also must be active participants in their own health promotion and illness prevention. Nurses have a major opportunity and responsibility to help patients understand risk factors and motivate them to adopt healthy lifestyles that prevent disease. Lifestyle factors that affect health—and over which the patient has some control—include diet; use of tobacco, alcohol, and cannabis and substance use; exercise; sunlight exposure; stress management; and sexual practices. Other influences such as genetic and environmental factors may be beyond the patient’s control, although some opportunities for prevention exist (e.g., through environmental legislative activism or genetic counselling services). Knowledge alone is not enough to bring about healthy behaviours. The person must be convinced that they have some control over their life and that healthy life habits, including periodic health examinations, are a sound investment. They must believe in the efficacy of prevention, early detection, and therapy and in their ability to perform self-management practices. Many people believe that they have little control over their health, or they become so immobilized by fear and anxiety in the face of life-threatening illnesses such as cancer that they delay seeking treatment. The nurse must explore the reality of each person’s perceptions about health behaviours and individualize teaching if it is to be effective.

Health Screening for Women Across the Lifespan Periodic health screening includes history, physical examination, education, counselling, and selected diagnostic and laboratory tests. This regimen provides the basis for overall health promotion, prevention of illness, early diagnosis of health concerns, and referral for appropriate management. Such screening should be customized according to a patient’s age and risk factors. In most instances it is completed in health care offices, clinics, or hospitals; however, portions of the screening are now being carried out at events such as community health fairs. An overview of health screening recommendations for women over 18 years of age is provided in Table 5.3. Consistent with information provided earlier in this chapter, it is important for the nurse to continually educate and counsel on diet, exercise, smoking cessation, alcohol moderation, help for substance use, and stress management.

CHAPTER 5

TABLE 5.3

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Health Promotion

Health Screening Recommendations for Women Age 18 Years and Older

Intervention

Recommendation

Physical Examination Blood pressure

All primary care visits, but at least every 2 years

Height and weight and BMI∗

At appropriate primary care visits, but at least every 2 years

Pelvic examination

Recommended to be done with Pap test unless symptomatic

Skin examination†

Yearly examinations or more frequently if risk factors; regular self-examinations recommended of moles, birthmarks, healing skin

Oral cavity examination

Annually if history of mouth lesion or exposure to tobacco or excessive alcohol at least annually

Breast Examination Clinical examination∗

Laboratory and Diagnostic Tests Blood cholesterol (fasting lipoprotein analysis)‡

Not recommended in patients who have no risk factors Annually after age 18 if high risk with history of premenopausal breast cancer in first-degree relative Screening at age 50 or postmenopausal Repeat yearly if have abnormal levels or risk factors for coronary artery disease; if low risk repeat every 3– 5 years

Papanicolaou (Pap) test∗

26 if ongoing risk of exposure Male patients should also consider receiving vaccine

Hepatitis A

Primary series of two injections for all who are in risk categories

Hepatitis B††

Three doses: the second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose. Provinces and territories differ as to when the first dose is given. Continued

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TABLE 5.3

Women’s Health

Health Screening Recommendations for Women Age 18 Years and Older—cont’d

Intervention Influenza

Recommendation Annually

Pneumococcal

One dose after age 65; earlier if risk factors

Varicella (chickenpox)

Susceptible adults up to and including 49 years of age: 2 doses; if previously received 1 dose should receive a second dose Known seronegative adults 50 years of age and older: 2 doses; routine testing is not advised

Herpes zoster (shingles)

One dose at age 60 (can be given between 50 and 59 years of age)

∗

Canadian Taskforce on Preventative Care. (2013). CTFPHC published guidelines. https://canadiantaskforce.ca/guidelines/published-guidelines/ HealthLinkBC. (2018). Skin cancer screening. http://www.healthlinkbc.ca/healthtopics/content.asp?hwid¼skc1179 ‡ goire, J., Hegele, R. A., et al. (2012). Update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of Anderson, T. J., Gre dyslipidemia for the prevention of cardiovascular disease in the adult. Canadian Journal of Cardiology, 29, 151–167. § Papaioannou, A., Morin, S., Cheung, A. M., et al. (2010). 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. Canadian Medical Association Journal, 82(17), 1864–1873. doi:10.1503/cmaj.100771. ¶ Canadian Ophthalmological Society. (n.d.). When should you see an ophthalmologist? http://www.cos-sco.ca/vision-health-information/when-shouldyou-see-an-ophthalmologist/ ∗∗ Immunization schedules vary among provinces and territories. See local public health agency for specific schedules. †† Some provinces and territories start the first hepatitis B injection after the newborn is 24 hours old, some at 2 months, and some not until age 13. Check individual provincial and territorial immunization schedules. †

HEALTH TEACHING Health education is the process of providing information, encouraging a learner to use the resources they have, and teaching health promotion strategies or how to manage an existing condition. Nurses must have the knowledge to provide effective teaching to different groups of people. There are many factors to consider when planning teaching, including the domains of learning, factors that can enhance or inhibit learning, adult learning principles, and effective teaching strategies that can be used.

Domains of Learning Learning often occurs through one or a combination of the three domains of learning: cognitive (understanding), affective (attitudes), and psychomotor (motor skills). When teaching patients, it is important to understand which domain is involved in order to plan the appropriate teaching strategy. See Box 5.12 for a discussion of teaching methods based on the domains of learning.

Cognitive Learning. Cognitive learning involves the acquiring of knowledge and development of intellectual skills, including the recall of specific facts. Bloom’s taxonomy (knowledge, comprehension, application, analysis, synthesis, and evaluation) is frequently used to describe the increasing complexity of cognitive skills as learners move from beginner to more advanced in their knowledge of content. When considering which teaching strategies are appropriate to use for cognitive learning to occur, consult Box 5.12. An example of cognitive learning is when teaching a patient about the different types of birth control methods that are available. Affective Learning. Affective learning involves feelings, emotions, and values. Changing attitudes and values clarification are part of affective learning. This domain deals with attitudes, motivation, willingness to participate, valuing what is being learned, and ultimately incorporating values into one’s way of life. Discussing attitudes regarding the use of birth control is an example of incorporating affective learning in teaching. Psychomotor Learning. The acquisition of a new motor skill involves psychomotor learning. This type of learning involves using physical movement. An example of this would be learning how to insert a diaphragm or how to put on a condom. Psychomotor skills are often taught using demonstrations and return demonstrations (see Box 5.12).

Adult Learning Malcolm Knowles (1970) identified adult learning as an approach to learning that is problem based and collaborative. He focused on the equality between the learner and teacher. Knowles also identified six principles of adult learning: 1. Adults are internally motivated and self-directed—It is important to foster their internal motivation to learn and to facilitate learners’ attitude toward being self-directed and responsible for their own learning. Adults resist learning when they feel it is being imposed on them. 2. Adults bring life experiences and knowledge to learning experiences—It is important to consider and build on learners’ previous knowledge and experience; the ability to do this will enhance learning. Nurses should ask learners about their past experience and build on this information. 3. Adults are goal oriented—Learners will learn best when it is felt the information is important to them. 4. Adults are relevancy oriented—Adult learners like to know the relevance of what they are trying to achieve. 5. Adults are practical—It is important to ensure the learning applies to the specific situation. 6. Adult learners like to be respected—Nurses must convey respect and need to acknowledge the expertise and experience of the learner.

Learning Styles Everyone processes information differently, therefore, learners have different learning styles and preferences. Processing information involves seeing and hearing, reflecting and acting, reasoning logically and intuitively, and analyzing and visualizing (Edgecombe, 2019). Visual learners learn best by seeing what they are learning. Auditory learners want to hear the information, often in a lecture or through discussion. Kinesthetic learners want to be involved with the learning by doing hands-on practice. Nurses must first assess the learning style of the patient to ensure that the appropriate learning strategy is used. Assessing the type of environment the patient prefers to learn in is also necessary before providing teaching. Some people like to learn on their own and are very self-directed, whereas others like to learn in groups. Nurses also need to assess the preferred learning style of the learner and adapt strategies to meet the needs of the learner. When providing teaching in a group setting, it is often necessary to use several

CHAPTER 5

BOX 5.12

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Appropriate Teaching Methods Based on Domains of Learning

Cognitive Discussion (One-on-One or Group) May involve nurse and one patient or nurse with several patients Promotes active participation and focuses on topics of interest to patient Facilitates peer support Enhances application and analysis of new information Storytelling Can involve individual or group Facilitates cultural relevance and safety Enhances application of new information to a familiar context Lecture Is a more formal method of instruction because it is teacher controlled Helps learner acquire new knowledge and gain comprehension Question-and-Answer Session Is designed specifically to address patient’s concerns Assists patient in applying knowledge Role Play and Discovery Encourages patient to actively apply knowledge in a controlled situation Promotes synthesis of information and problem solving Independent Projects (e.g., Computer-Assisted Instruction) and Field Experience Assists patient to assume responsibility for learning at own pace Promotes analysis, synthesis, and evaluation of new information and skills

Affective Role Play Encourages expression of values, feelings, and attitudes Discussion (Group) Enables patient to acquire support from other people in group Encourages patient to learn from other people’s experiences Promotes responding, valuing, and organizing Discussion (One-on-One) Facilitates discussion of personal, sensitive topics of interest or concern Psychomotor Demonstration Provides presentation of procedures or skills by nurse Encourages patient to model nurse’s behaviour Allows nurse to control questioning during demonstration Practice Enables patient to perform skills by using equipment in a controlled setting Allows repetition Return Demonstrations Enables patient to perform skill as nurse observes Provides excellent source of feedback and reinforcement Independent Projects and Games Require teaching method that promotes adaptation and initiation of psychomotor learning Enable learner to use new skills

Source: Potter, P., Perry, A., Stockert, P., et al. (Eds.). (2019). Canadian fundamentals of nursing (6th ed.). Elsevier.

different teaching methods in order to ensure the needs of all the learners are met.

Teaching Methods Nurses need to consider the content being taught as well as how the patient learns best when deciding which method to use to provide the teaching. The nurse should assess the patient for their learning style and be prepared to modify the approach depending on how the patient responds. The most important factor when providing teaching is to provide an active learning environment; this is where the nurse and patient work together toward a common goal. See the Family-Centred Care box on teaching strategies for a guide to use when providing patient teaching.

One-on-One Discussion. Many times, nurses provide teaching in an individual session with a patient. Teaching one-on-one allows the learner to ask questions, and this should be encouraged. During the teaching session, the nurse can use pictures, written material, audiovisual aids, or models. The teaching aids that are used will depend on the learner’s needs and how the person learns best.

Group Teaching. Teaching groups is often done through the use of lectures, although lecturing is not always the most effective method to enhance learning. Lectures can be very structured and limit interaction. A better way to provide teaching to groups is through discussion and practice (Edgecombe, 2019). People can learn well within group settings, especially if they are able to learn from other people’s experiences. Nurses require practice and experience to feel comfortable facilitating group discussions rather than just lecturing.

Demonstration. Demonstration is an effective method to provide teaching about acquisition of a psychomotor skill. Showing the learner how to do something can be effective, although a more effective method is to have the learner return the demonstration to ensure that learning is acquired. Teaching new parents how to do a baby bath or a teenager how to apply a condom are examples of skills that are effectively taught using demonstration.

Factors That Influence Learning Environment. An environment that is quiet with few distractions will

Role Playing. Role playing is used to help a learner acquire new ideas and attitudes. The learner often takes the role of themselves or someone else in an unfamiliar situation and may practise a desired behaviour. An effective use for role playing is when a patient wants to feel more comfortable asking questions of a health care provider in an unfamiliar situation. The ability to practise the skill allows the learner to learn new skills and to feel more confident in situations when they are required.

enhance learning. The room should be well lit, well ventilated, and comfortable, as it is more difficult to learn in uncomfortable surroundings. It is important to determine whether the patient has pain or any other distractions, as these can affect learning. A new mother with a hungry, crying baby will find it difficult to concentrate on any teaching. The time of day may also have an impact on learning. People often learn better at different times of day. Nurses need to determine what is best for the patient when providing teaching.

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FAMILY-CENTRED CARE Teaching Strategies • Establish trust with the patient before beginning the teaching–learning session. • Limit teaching objectives. • Use simple terminology to enhance the patient’s understanding. • Schedule short teaching sessions at frequent intervals; minimize distractions during teaching sessions. • Begin and end each teaching session with the most important information. • Present information slowly, pacing to provide ample time for the patient to understand the material. • Repeat important information. • Provide many examples that have meaning to the patient; for example, relate new material to a previous life experience. • Build on existing knowledge. • Use visual cues and simple analogies when appropriate. • Ask the patient for frequent feedback to determine whether the patient comprehends information.

• Demonstrate procedures such as measuring dosages; ask for return demonstrations (which provide opportunities to clarify instructions and time to review procedures). • Provide teaching materials that reflect the reading level of the patient; use material written with short words and sentences, large type, and simple format (in general, information written on a Grade 5 reading level is recommended for adult learners). • Provide teaching materials that reflect health literacy of the patient; use material that avoids jargon, acronyms, and unnecessary medical terminology and defines medical terms that are necessary. • Model appropriate behaviour and use role playing to help the patient learn how to ask questions and ask for help effectively. • Pace the delivery of material so that patients can progress at their own speed. • Include family members or other caregivers in the education process.

Data from Bastable, S. (2008). Nurse as educator: Principles of teaching and learning for nursing practice. Jones & Bartlett; Lowenstein, A. J., Foord-May, L., & Romano, J. C. (Eds.). (2009). Teaching strategies for health education and health promotion: Working with patients, families and communities. Jones & Bartlett.

Ability to Learn. The ability to learn depends on emotional, intellectual, and physical capabilities. If a patient’s learning ability is impaired, the teaching may need to be postponed. For example, a patient who needs to learn to use a walker following hip surgery will not be able to learn this if their pain level is too high and they have not been out of bed postoperatively. It is important not to assume that everyone has the same intellectual ability to learn. Furthermore, it is important not to make the assumption that all people are literate.

Health Literacy. In Canada, 48% of adult Canadians have literacy skills that fall below a high school level, which negatively affects their ability to function at work and in their personal lives, and 60% of working-age adults in Canada are estimated to have less than adequate health literacy skills (ABC Life Literacy Canada, 2021). Health literacy is closely related to literacy, but focuses specifically on health information demands. Health literacy requires the ability to solve problems, evaluate information, and know when to take action. Individuals and groups for whom English is an additional language often lack the skills necessary to seek medical care and function adequately in the health care setting. Health literacy involves a spectrum of abilities, ranging from reading an appointment slip to interpreting medication instructions. Low health literacy may be an independent contributor to a disproportionate disease burden among disadvantaged populations. Nurses need to determine the level of reading ability before providing teaching and to ensure that written material is provided that meets the needs of the patient.

Motivation to Learn. The motivation to learn can be influenced by many factors, including a learner’s culture as well as the health beliefs of the learner. If a person does not have access to some of the determinants of health, it can be more difficult to teach preventive health strategies or ways to manage an existing illness. If someone does not see the value in quitting smoking, teaching on this topic is less likely to be effective. Health teaching must be provided in a culturally competent manner and in a way that meets the needs of the patient. Developmental level. The age and stage of development of a patient also can affect the ability to learn, as well as how the person learns best.

KEY POINTS • Many determinants of health, including culture and socioeconomic status, as well as personal circumstances, the uniqueness of the individual, and the stage of development, influence a person’s recognition of need for care, the degree to which they will or will not access care, and the response to the health care system and therapy. • People have many reasons for accessing the health care system: wellperson care, fertility prevention, infertility, and pregnancy. • Preconception counselling is important to improve the health of all people and to ensure healthy pregnancy outcomes. • There are many risk factors related to patients’ health that must be considered when providing care, including nutrition, lack of exercise, stress, and substance use. • IPV is a major social and health care issue in Canada and includes physical, sexual, emotional, psychological, and economic abuse. It affects all races and all socioeconomic, educational, and religious groups. • Periodic health screening provides the basis for overall health promotion, prevention of illness, early diagnosis of health conditions, and referral for management. • Health promotion and prevention of illness can help patients actualize their health potential by increasing motivation, providing information, and suggesting how to access specific resources. • Teaching should be timed to work with the patient’s readiness and ability to learn. • Teaching is most effective when it meets the needs of the learner. • The use of different types of teaching methods can improve the learner’s attentiveness and overall learning.

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Green, C. (2016). Human trafficking: Preparing for a unique patient population. American Nurse Today, 11(1), 9–12. Guttmann, A., Blackburn, R., Amartey, A., et al. (2019). Long-term mortality in mothers of infants with neonatal abstinence syndrome: A population-based parallel-cohort study in England and Ontario, Canada. PLoS Medicine, 16(11). https://doi.org/10.1371/journal.pmed.1002974. Health Canada. (2019). Canadian guidelines for body weight classification in adults. https://www.canada.ca/en/health-canada/services/food-nutrition/ healthy-eating/healthy-weights/canadian-guidelines-body-weightclassification-adults/questions-answers-public.html. Health Canada. (2020). Household food insecurity in Canada: Overview. https:// www.canada.ca/en/health-canada/services/food-nutrition/food-nutritionsurveillance/health-nutrition-surveys/canadian-community-health-surveycchs/household-food-insecurity-canada-overview.html. Heart and Stroke Foundation. (2020). How much physical activity do you need? https://www.heartandstroke.ca/get-healthy/stay-active/how-muchphysical-activity-do-you-need. Henderson, R., Montesanti, S., Crowshoe, L., et al. (2018). Advancing Indigenous primary health care policy in Alberta, Canada. Health Policy, 122(6), 638–644. Jarmasz, J. S., Basalah, D. A., Chudley, A. E., et al. (2017). Exposure and fetal alcohol spectrum disorder. Journal of Neuropathology & Experimental Neurology, 76(9), 813–833. https://doi.org/10.1093/jnen/nlx064. Kawakita, T., Wilson, K., Grantz, K. L., et al. (2016). Adverse maternal and neonatal outcomes in adolescent pregnancy. Journal of Pediatric and Adolescent Gynecology, 29(2), 130–136. Kingston, D., Austin, M., & Heaman, M. (2015). Barriers and facilitators of mental health screening in pregnancy. Journal of Affective Disorders, 186, 350–357. Knight, R. E., Shoveller, J. A., Carson, A. M., et al. (2014). Examining clinicians’ experiences providing sexual health services for LGBTQ youth: Considering social and structural determinants of health in clinical practice. Health Education Research, 29(4), 662–670. Knowles, M. S. (1970). The modern practice of adult education. Prentice Hall/Cambridge. Leemaqz, S. Y., Dekker, G. A., McCowan, L. M., et al. (2016). Maternal marijuana use has independent effects on risk for spontaneous preterm birth but not other common late pregnancy complications. Reproductive Toxicology, 62, 77–86. Liu, K., & Case, A. (2017). SOGC clinical practice guideline: Advanced reproductive age and fertility. Journal of Obstetrics and Gynaecology Canada, 39(8), 685–695. Manske, S. R., Rynard, V., & Minaker, L. (2014). Flavoured tobacco use among Canadian youth: Evidence from Canada’s 2010/2011 youth smoking survey. Propel Centre for Population Health Impact: University of Waterloo. https:// uwaterloo.ca/canadian-student-tobacco-alcohol-drugs-survey/sites/ ca.canadian-student-tobacco-alcohol-drugs-survey/files/uploads/files/ yss12_flavoured_tobacco_use_20140910.pdf. Martin-de-las-Heras, S., Velasco, C., Luna Jde, D., et al. (2015). Unintended pregnancy and intimate partner violence around pregnancy in a populationbased study. Women and Birth, 28(2), 101–105. McAlearney, A. S., Oliveri, J. M., Post, D. M., et al. (2011). Trust and distrust among Appalachian women regarding cervical cancer screening: A qualitative study. Patient Education & Counseling, 86(1), 120–126. McKay, A. (2013). Trends in Canadian national and provincial/territorial teen pregnancy rates: 2001–2010. The Canadian Journal of Human Sexuality, 21 (3/4), 160–175. MedlinePlus. (2021). Methamphetamine. National Institutes of Health: U.S. National Library of Medicine. https://www.nlm.nih.gov/medlineplus/ methamphetamine.html. 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. National Institute on Drug Abuse. (2019). Drug facts: Marijuana. https://www. drugabuse.gov/publications/drugfacts/marijuana. Nugent, C. N., & Black, L. I. (2016). Sleep duration, quality of sleep, and use of sleep medication, by sex and family type, 2013–2014. NCHS Data Brief, 230.

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Orr, S., Dachner, N., Frank, L., et al. (2018). Relation between household food insecurity and breastfeeding in Canada. Canadian Medical Association Journal, 190(11), E312–E319. https://doi.org/10.1503/cmaj.170880. Pellizzari, R., Mason, R., Grant, L., et al., & Society of Obstetricians and Gynaecologists of Canada. (2005). SOGC clinical practice guideline: Intimate partner violence consensus statement. Journal of Obstetrics and Gynaecology Canada, 27(4), 365–388. Perron, L., Senikas, V., Burnett, M., et al. (2020). SOGC clinical practice guideline No. 395-Female genital cutting. Journal of Obsterics and Gynaecology Canada, 42(2), 204–217. Popova, S., Lange, S., Burd, L., et al. (2016). The economic burden of fetal alcohol spectrum disorder in Canada in 2013. Alcohol, 51, 367–375. Public Health Agency of Canada (PHAC). (2016). Social determinants of health. https://cbpp-pcpe.phac-aspc.gc.ca/public-health-topics/socialdeterminants-of-health/. Public Health Agency of Canada (PHAC). (2019a). Chapter 2: Preconception care. In Family-centred maternity and newborn care: National guidelines. https://www.canada.ca/content/dam/phac-aspc/documents/services/ publications/healthy-living/maternity-newborn-care/maternity-newborncare-guidelines-chapter-2-eng.pdf. Public Health Agency of Canada (PHAC). (2019b). Fertility. https://www. canada.ca/en/public-health/services/fertility/fertility.html. Public Health Agency of Canada (PHAC). (2020). Caffeine and pregnancy. https://www.canada.ca/en/public-health/services/pregnancy/caffeine.html. Registered Nurses’ Association of Ontario (RNAO). (2015). Engaging clients who use substances. https://rnao.ca/sites/rnao-ca/files/Engaging_Clients_Who_ Use_Substances_13_WEB.pdf. Rezazadeh, M. S., & Hoover, M. L. (2018). Women’s experience of the immigration to Canada: A review of the literature. Canadian Psychology, 59(1), 76–88. Rotermann, M., Sammartin, C., Hennessy, D., et al. (2014). Prescription medication use by Canadians aged 6–79. Health Reports, 25(6), 39. Statistics Canada, Catalogue no. 82-003-X. Sammarco, A. (2016). Women’s health issues across the life cycle: A quality of life perspective. Jones & Bartlett. Scrim, K. (2017). Aboriginal victimization in Canada: A summary of the literature. Department of Justice Canada. http://www.justice.gc.ca/eng/ rp-pr/cj-jp/victim/rd3-rr3/p3.html. Shaver, J. L. F. (2015). Promoting healthy sleep. In E. F. Olshansky (Ed.), Women’s health and wellness across the lifespan. Wolters Kluwer. Smylie, J., Fell, D., Ohlsson, A., & The Joint Working Group on First Nations, Indian, Inuit, and Metis Infant Mortality of the Canadian Perinatal Surveillance System. (2010). Review of Aboriginal infant mortality rates in Canada: Striking and persistent Aboriginal/non-Aboriginal inequities. Canadian Journal of Public Health, 101, 143–148. Society of Obstetricians & Gynaecologists of Canada (SOGN). (2020). Your pregnancy. https://www.pregnancyinfo.ca/your-pregnancy/specialconsideration/unintended-pregnancy/. Statistics Canada. (2019a). Overweight and obese adults, 2018. https://www150. statcan.gc.ca/n1/pub/82-625-x/2019001/article/00005-eng.htm. Statistics Canada. (2019b). Smoking, 2018. https://www150.statcan.gc.ca/n1/ pub/82-625-x/2019001/article/00006-eng.htm. Statistics Canada. (2020a). Dimensions of poverty hub. https://www.statcan.gc. ca/eng/topics-start/poverty. Statistics Canada. (2020b). Report on sexually transmitted infections in Canada, 2017. https://www.canada.ca/en/public-health/services/publications/ diseases-conditions/report-sexually-transmitted-infections-canada-2017. html. Statistics Canada. (2021). Live births by age of mother in Canada. https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310041601. Stover, M. W., & Davis, J. M. (2015). Opioids in pregnancy and neonatal abstinence syndrome. Seminars in Perinatology, 39(7), 561–565. Taillieu, T. L., Brownridge, D. A., Tyler, K. A., et al. (2016). Pregnancy and intimate partner violence in Canada: A comparison of victims who were and were not abused during pregnancy. Journal of Family Violence, 31(5), 567–579. https://doi.org/10.1007/s10896-015-9789-4.

Truth and Reconciliation Commission of Canada. (2015). Executive summary. http://www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_the_ Future_July_23_2015.pdf. Varcoe, C., Browne, A. J., Ford-Gilboe, M., et al. (2017). Reclaiming our spirits: Development and pilot testing of a health promotion intervention for Indigenous women who have experienced intimate partner violence. Research in Nursing and Health, 40(3), 237–254. Woodley S.J., Boyle R., Cody J.D., et al. (2017). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews, (12): CD007471. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858. CD007471.pub3/full. World Health Organization. (2013). Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity: Feb 6–7 meeting report. Author. World Health Organization. (2017). Violence against women. https://www.who. int/news-room/fact-sheets/detail/violence-against-women. World Health Organization. (2020). Female genital mutilation. http://www.who. int/mediacentre/factsheets/fs241/en/.

ADDITIONAL RESOURCES Bridging Refugee Youth & Children’s Services: Female genital cutting (FGC). https://brycs.org/blog/female-genital-cutting-fgc/. Canadian Cancer Society: Smokers’ helpline. https://www.smokershelpline.ca/. Canadian Centre on Substance Abuse and Addiction. https://www.ccsa.ca/. Canadian Dietitians of Canada: UnlockFood.ca—Access to nutrition and healthy eating information: https://www.unlockfood.ca/en/default.aspx. Centre for Addiction and Mental Health: Canadian smoking cessation clinical practice guideline. https://www.nicotinedependenceclinic.com/en/canadaptt/ PublishingImages/Pages/CAN-ADAPTT-Guidelines/CAN-ADAPTT% 20Canadian%20Smoking%20Cessation%20Guideline_website.pdf. Centre for Effective Practice: Preconception Health Care Tool. https://cep. health/media/uploaded/CEP_Preconception_Health_Care_Tool_Updated_ 2018.pdf. Health Canada: Mental health—Coping with stress. https://www.canada.ca/en/ health-canada/services/healthy-living/your-health/lifestyles/your-healthmental-health-coping-stress-health-canada-2008.html. Health Canada: Protecting people at greater risk. https://www.canada.ca/en/ health-canada/services/environmental-workplace-health/environmentalcontaminants/vulnerable-populations.html. Heart and Stroke Foundation of Canada: Heart disease: Risk and prevention. https://www.heartandstroke.ca/heart/risk-and-prevention. The Lung Association: Smoking and tobacco: How to quit smoking. http://www. lung.ca/quit. Public Health Agency of Canada: Family-centred maternity and newborn care national guidelines. Chapter 2: Preconception care. https://www.canada.ca/ en/public-health/services/publications/healthy-living/maternity-newborncare-guidelines-chapter-2.html. Sex & U. https://www.sexandu.ca/. Ready or not Alberta—Preconception health resources: https:// readyornotalberta.ca/. Registered Nurses’ Association of Ontario. Best practice guideline: Integrating smoking cessation into daily nursing practice. http://www.rnao.ca/bpg/ guidelines/integrating-smoking-cessation-daily-nursing-practice. Registered Nurses’ Association of Ontario. Best Practice Guideline: Woman abuse: Screening, identification and initial response. http://rnao.ca/sites/ rnao-ca/files/Guideline__Supplement_PDF.pdf. Registered Nurses’ Association of Ontario elearning series: Tobacco Free—A resource for health care professionals working with clients who use tobacco or other substance use disorders. http://elearning.rnao.ca/. World Health Organization: High-quality health care for girls and women living with FGM: WHO launches new clinical handbook. https://www.who.int/ reproductivehealth/health-care-girls-women-living-with-FGM/en/.

UNIT 3 Women’s Health

6 Health Assessment Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe how to provide culturally competent care while completing a health assessment. 2. Describe components of taking a patient’s history and performing a physical examination.

3. Identify how the history and physical examination can be adapted for people with special needs. 4. Identify how to screen for intimate partner violence. 5. Identify the correct procedure for assisting with and collecting Papanicolaou test specimens.

The purpose of this chapter is to review gynecological health assessment. Although some people may have been female-assigned at birth but no longer identify as a woman, it is important to recognize that some of these assessments would be appropriate for these individuals as well.

private, comfortable, and relaxed setting (Figure 6.1). The nurse should be seated and make sure that the person is comfortable. The person should be addressed by their title and name (e.g., Mrs. Khan) and asked how they prefer to be addressed. Then the nurse can introduce themselves using name and title. It is important to phrase questions in a sensitive and nonjudgemental manner. Body language should match oral communication. The nurse needs to be aware of a patient’s vulnerability and assure them of strict confidentiality. For many patients fear, anxiety, and modesty make the examination a dreaded and stressful experience. Patients may feel that they do not have all the information a health provider has, may be misguided by myths, or be afraid that they will appear ignorant by asking questions about sexual or reproductive functioning. The person needs to be assured that no question is irrelevant. The history begins with an open-ended question, such as “What brings you into the office (or clinic or hospital) today?” and is furthered by other prompts, such as “Anything else?” and “Tell me about it.” Additional ways of encouraging patients to share information include the following: Facilitation—Using a word or posture that communicates interest, such as leaning forward, making eye contact, or saying “Mmhmmm” or “Go on” Reflection—Repeating a word or phrase that the person has used Clarification—Asking the person what is meant by a stated word or phrase Empathic responses—Acknowledging the feelings of a person through statements such as “That must have been frightening”

HEALTH ASSESSMENT Trends in women’s health have expanded its scope beyond a reproductive focus to include a holistic approach to health care across the lifespan and place women’s health within primary care. Women’s health assessment and screening focus on a systems evaluation that begins with a careful history and physical examination. Table 6.1 compares the variations in physical assessment related to age difference in women. During assessment and evaluation, the patient’s responsibility for shared decisionmaking, health promotion, and enhancement of wellness is emphasized. Often it is a nurse who takes the history, interprets test results, makes referrals, coordinates care, and directs attention to health issues requiring medical intervention. Advanced practice nurses who specialize in women’s health, such as nurse practitioners and clinical nurse specialists, order diagnostic tests and perform complete physical examinations, including gynecological examinations. On completion of the assessment, the nurse will discuss goals with the patient and how to achieve them, and plan for follow up and future steps.

History Contact with the patient usually begins with an interview, which is an integral part of the history. This interview should be conducted in a

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TABLE 6.1

Women’s Health

Female Reproductive Physical Assessment Across the Life Cycle

Adolescent

Adult

Postmenopausal

Breasts

Tender when developing; buds appear; small, firm; one side may grow faster; areola diameter increases; nipples more erect

Grow to full shape in early adulthood; nipples and areola become darker

Become stringy, irregular, pendulous, and nodular; borders are less well delineated; may shrink and become flatter, elongated, and less elastic; ligaments weaken; nipples are positioned lower

Vagina

Vagina lengthens; epithelial layers thicken; secretions become acidic

Growth complete by age 20

Introitus constricts; vagina narrows, shortens, loses rugation; mucosa is pale, thin, and dry; walls may lose structural integrity

Uterus

Musculature and vasculature increase; lining thickens

Growth complete by age 20

Size decreases; endometrial lining thins

Ovaries

Increase in size and weight; menarche occurs between 8 and 16 years of age; ovulation occurs monthly

Growth complete by age 20

Size decreases to 1–2 cm; follicles disappear; surface convolutes; ovarian function ceases between 40 and 55 years of age

Labia majora

Become more prominent; hair develops

Growth complete by age 20

Labia become smaller and flatter; pubic hair becomes sparse and grey

Labia minora

Become more vascular

Growth complete by age 20

Become shinier and drier

Uterine tubes

Increase in size

Growth complete by age 20

Decrease in size

Fig. 6.1 The nurse interviews a patient as part of a routine history and physical examination. (© Can Stock Photo Inc./JackF.)

BOX 6.1

Confrontation—Identifying something about the person’s behaviour or feelings not expressed verbally or apparently inconsistent with their history Interpretation—Putting into words what the nurse infers about the person’s feelings or about the meaning of their 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 history. Nurses should ask questions incrementally in order to build a comprehensive understanding, proceeding from the general to the specific. The nurse should also share insights with the patient by eliciting their concerns or thoughts as well as offering clarification to them. At a patient’s first visit, they are often expected to fill out a form with biographical and historical data before meeting with the examiner. This form aids the health care provider in completing the history during the interview. Box 6.1 describes the categories in a complete health history and assessment.

Health History and Review of Systems

Identifying data: Name, age, sex, marital status, occupation, and ethnicity Reason for seeking care: A response to the question, “What concern or symptom brought you here today?” Is there more than one reason? Focus on the one they think is most important. Present health: Current health status is described with attention to the following: • Use of safety measures: Seat belts, bicycle helmets, designated driver • Exercise and leisure activities: Regularity • Sleep patterns: Length and quality • Sexuality: Are they sexually active? With men, women, or both? Contraceptive use, 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 chronological narrative of the issue that includes a description of the following—location, quality or character, quantity or severity, timing (onset, duration, frequency), setting, factors that aggravate or relieve the issue, associated factors, and the patient’s perception of the meaning of the symptom Past health: • Infectious diseases: e.g., measles, mumps, rubella, tuberculosis (TB), hepatitis, sexually transmitted infections (STIs) • Chronic disease and system disorders: e.g., arthritis, cancer, diabetes, heart, lung, kidney, sickle cell anemia • Adult injuries, accidents • Hospitalizations, operations, blood transfusions • Obstetrical history • Mental health concerns: Previous history of depression, anxiety, bipolar disorder; has this been treated? Continued

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Health History and Review of Systems—cont’d

• Allergies: Medications, previous transfusion reactions, environmental allergies • Immunizations: e.g., diphtheria, pertussis, tetanus, measles, mumps, rubella, influenza, hepatitis B, human papillomavirus (HPV), pneumococcal vaccine, COVID-19 vaccine • Last date of screening tests: e.g., Pap test, mammogram, cholesterol test, colonoscopy • Current medications: Name, dose, frequency, duration, reason for taking, and adherence to prescription regimen; 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 the person ever been hit, kicked, slapped, or forced to have sex against their wishes? Verbally or emotionally abused? History of childhood sexual abuse? If yes, have they received counselling or do they need a referral? 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 patient gives a positive response to a question about an essential area, more detailed questions should be asked and further assessment completed. • General: Appearance, orientation, weight change, fatigue, weakness, fever, chills, or night sweats • Vital signs: Temperature, pulse respiration, blood pressure • Skin: Skin colour, integrity, texture, unusual odour; hair texture or 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 impairment • Ears: Hearing impairment, 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

Physical Examination In preparation for the physical examination, the patient should be asked to undress and given a gown to wear during the examination. They should be 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. Assessments are described in detail (see Box 6.1).

Cultural Considerations and Communication Variations in History and Physical A person’s recognizing signs and symptoms of disease and deciding to seek treatment may be influenced by cultural perceptions. Cultural competence is the ability of nurses to self-reflect on their own cultural values and how these impact the way they provide care (Canadian Nurses Association [CNA], 2018). Culture competence promotes cultural safety, and both are integral to providing high-quality, safe, and equitable nursing care (CNA, 2018) (see Chapter 2). Culture competence is more than simply acquiring knowledge about another ethnic group. It is essential that a nurse have respect for the rich and unique qualities that cultural diversity brings to individuals. In recognizing

• Mouth, throat, and neck: Hoarseness, voice changes, soreness, ulcers, bleeding gums, goitre, swelling, or enlarged nodes • Breasts: Masses, pain, lumps, dimpling, nipple discharge, fibrocystic changes, or implants • Respiratory: Chest symmetry with respirations, shortness of breath, wheezing, cough, sputum, hemoptysis • Cardiovascular: Rate, rhythm, murmurs, jugular vein distention, hypertension, rheumatic fever, murmurs, angina, palpitations, dyspnea, tachycardia, orthopnea, edema, chest pain, cough, cyanosis, cold extremities, ascites, phlebitis, or skin colour changes • Gastrointestinal: Bowel sounds, 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, or itching • 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 conditions, diabetes, or secondary sex characteristic changes • Hematological: 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 • Neurological: 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

the value of these differences, the nurse can respond appropriately in planning, implementing, and evaluating a plan of care to meet the needs of each person. Nurses must also be aware of the power differentials that may occur in a health care interaction. The patient needs to be trusted that they are the expert on their life, culture, and experiences. If the nurse asks with respect and a genuine desire to learn, the patient will tell the nurse how to care for them. Modifications may be necessary in conducting the physical examination. In many cultures, a female examiner is preferred. In some cultures, it may be considered inappropriate for the woman to disrobe completely for the physical examination. Culturally safe care is particularly important for improving the health care experience of Indigenous patients. Positive experiences involving patient–provider interactions that are based on respect, free of judgement, and holistic and that demonstrate an understanding of the cultural context are important aspects of this relationship (Kolahdooz et al., 2016). Communication may be hindered by different beliefs, even when the nurse and patient speak the same language. Examples of communication variations are listed in the Cultural Awareness box.

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CULTURAL AWARENESS Communication Variations Conversational style and pacing—Silence may show respect or acknowledgement that the listener has heard. In cultures in which a direct “no” is considered rude, silence may mean no. Repetition or loudness may mean emphasis or anger. Personal space—Cultural conceptions of personal space differ. For example, based on one’s culture, someone may be perceived as being distant for backing off when approached or aggressive for standing too close. Eye contact—Eye contact varies among cultures, from intense to fleeting. Consistent with the effort to refrain from invading personal space, avoiding direct eye contact may be a sign of respect. Touch—The norms about how people should touch each other vary among cultures. In some cultures, physical contact with the same sex (embracing, walking hand in hand) is more appropriate than that with an unrelated person of the opposite sex. Time orientation—In some cultures, involvement with people is more valued than being “on time.” In other cultures, life is scheduled and paced according to clock time, which is valued over personal time. Source: Srivastava, R. (2006). The healthcare professional’s guide to clinical cultural competence. Mosby.

Adolescents (Ages 13 to 19) As a young person matures, they should be asked the same questions that are included in any history. Particular attention should be paid to hints about risky behaviours, eating disorders, and depression. Sexual activity is addressed after rapport has been established. It is best to talk to a teen 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 nonjudgemental manner. Injury prevention should be a part of the counselling at routine health examinations, with special attention paid to use of seat belts and helmets, recreational hazards, and sports involvement. The use of drugs and alcohol and the non-use of seat belts increase the risk of motor vehicle injuries, which account for a great proportion of deaths in this age group. Information about contraceptives and sexually transmitted infection (STI) prevention may be needed for teens who are sexually active (see Chapter 7). Female athletes should have their weight assessed to ensure that they maintain an appropriate body mass index (BMI) (see Chapter 5). To provide developmentally appropriate care, it is important to review the major tasks for patients in this stage of life. Major tasks for teens 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 teen is egocentric as they progress rapidly through emotional and physical change. Their feelings of invulnerability may lead to misconceptions, such as the belief that unprotected sexual intercourse will not lead to pregnancy.

Women With Disabilities Patients with emotional or physical disorders have special needs. Those with vision, hearing, emotional, or physical impairment or 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 person, while maintaining eye contact. Family and significant others should be relied on only when absolutely necessary. The assessment and physical examination can be adapted to each person’s individual needs.

Communication with a person who is hearing impaired can be accomplished without difficulty. Many people can read lips, write, or both. The interviewer who speaks and enunciates each word slowly and in full view may be easily understood. It is important that the interviewer not stand in front of a light source, as this can make it more difficult for the person to lip read. If a person is not comfortable with lip reading, they may use an interpreter. In this case, it is important to continue to address the person directly, avoiding the temptation to speak directly with the interpreter (see Chapter 2, Use of Interpreters). The visually impaired person needs to be oriented toward the examination room and may have their guide dog with them. As with all patients, the visually impaired person needs a full explanation of what the examination entails before proceeding. Before touching them, the nurse should explain, “Now I am going to take your blood pressure. I am going to place the cuff on your right arm.” The patient can be asked if they would like to touch each of the items that will be used in the examination, to reduce their anxiety.

Women at Risk for Abuse Nurses should screen all patients for potential abuse who are entering the health care system. Abuse is a life-threatening public health concern that affects many patients and their children. Prior to asking about abuse, all patients should understand the reason for the questions being asked. A good way to present this is, “Because abuse happens to many people, we ask all patients if they have ever been in a situation that involved violence.” The risk for intimate partner violence (IPV) increases during pregnancy and after separation or divorce. Most patients will not spontaneously provide information about family violence because of fear, guilt, and embarrassment; however, many patients will often disclose if asked. Help for the person 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 governing abuse in the province or territory in which they practise. Pocket cards listing emergency numbers (abuse counselling, legal protection, and emergency shelter) may 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. An abuse assessment screen (Box 6.2) can be used as part of the interview or written history. If a partner is present, they should be encouraged to leave the room because the patient may not disclose experiences of abuse in their presence, or the partner may try to answer questions for the patient to protect themselves. The same procedure applies for adult children of older women. Not all patients will disclose abuse, but clues in the history and evidence of injuries on physical examination should elicit a high index of suspicion. The areas most commonly injured are the head, neck, chest, abdomen, breasts, and upper extremities. Burns and bruises in patterns resembling hands, belts, cords, or other weapons may be seen, as well as multiple traumatic injuries. Attention should be given to patients who repeatedly seek treatment for somatic concerns such as headaches, insomnia, choking sensations, hyperventilation, gastrointestinal symptoms, and pain in the chest, back, or pelvis. During pregnancy, the nurse should assess for injuries to the breasts, abdomen, and genitalia. See Chapter 5 for further discussion of IPV. Abusive relationships are often about power and control of the abuser over the person (see Figure 5.3). It is important to be aware of this when doing any physical examination, as any perception of power and control over the person by a health care provider may exacerbate an abused patient’s anxiety, discomfort, or fear. All patients need to be shown respect and allowed control during the physical examination. All people should always be addressed using eye contact first, and they should always be asked for permission prior to any physical contact.

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BOX 6.2

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Screening for Intimate Partner Violence

Sample Screening Questions While providing privacy, screen for intimate partner violence during new patient visits, annual examinations, initial prenatal visits, each trimester of pregnancy, and the postpartum checkup. Framing Statement “We’ve started talking to all of our patients about safe and healthy relationships because it can have such a large impact on your health.” Confidentiality “Before we get started, I want you to know that everything here is confidential, meaning that I won’t talk to anyone else about what is said unless you tell me that (insert the laws in your province or territory about what is necessary to disclose).” Sample Questions “Has your current partner ever threatened you or made you feel afraid?” (Threatened to hurt you or your children if you did or did not do something, controlled who you talked to or where you went, or gone into rages)

“Has your partner ever hit, choked, or physically hurt you?” (“Hurt” includes being hit, slapped, kicked, bitten, pushed, or shoved.) For patients of reproductive age: “Has your partner ever forced you to do something sexually that you did not want to do, or refused your request to use condoms?” “Does your partner support your decision about when or if you want to become pregnant?” “Has your partner ever tampered with your birth control or tried to get you pregnant when you didn’t want to be?” For patients with disabilities: “Has your partner prevented you from using a wheelchair, cane, respirator, or other assistive device?” “Has your partner refused to help you with an important personal need, such as taking your medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting food or drink, or threatened not to help you with these personal needs?”

Source: American College of Obstetricians and Gynecologists. (2012). Committee opinion: Intimate partner violence. Reaffirmed 2019. https://www. acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence

Transsexuality There is an increasing number of individuals who transition from male to female or female to male. Health care providers need to provide respectful and sensitive care to transsexual men and women. A transsexual man who is in the process of transitioning may still have female reproductive organs and thus continues to need Pap tests, internal exams, and possibly mammograms. Transgender men with a cervix should be screened with Pap smears following the guidelines for all women. This examination may be emotionally difficult or painful for trans men. Several strategies may be employed to minimize the discomfort or trauma associated with this examination for some men. Some strategies include asking the person what they call the body parts that are being examined, having a partner or support person with them, listening to music, or asking whether they want the procedure to be explained to them as it is happening. Mammograms should be considered for trans women every 2 years if they are older than 50 years and on estrogen for more than 5 years. Initiation of screening may need to be considered at a younger age if additional risk factors are present (Canadian Cancer Society, 2020). See Additional Resources at the end of this chapter for further information on this topic.

Breast Assessment Routine monthly breast self-examination (BSE), which is the systematic palpation of breasts to detect signs of breast cancer or other changes, is no longer recommended for women aged 40 to 74 years who do not have a high risk of developing breast cancer. Research has shown that BSE has not led to a decrease in mortality from breast cancer and has been linked to an increase in the number of unnecessary biopsies and other procedures (Klarenbach et al., 2018). Patients do need to know how their breasts feel and to look and watch for changes, but not on a regular schedule. There is no specific way to perform a BSE; it is just important to know what is normal for all the breast tissue so that changes can be noticed. Patients may hear conflicting information regarding BSE, and some patients may still choose to perform BSE.

Clinical breast examination (CBE) is also not effective in screening for breast cancer so is not recommended for patients with a low risk of developing breast cancer (Klarenbach et al., 2018). A routine mammogram every 2 to 3 years is the best screening tool; all provinces and territories have breast screening programs for patients aged 50 to 69 (see Chapter 7 for further discussion).

Pelvic Examination Many people fear the gynecological portion of the physical examination. The nurse can be instrumental in allaying these fears by providing information and assisting the patient to express their feelings to the examiner. The patient should be assisted into the lithotomy position for the pelvic examination. If the person is not comfortable in this position, alternative positions may be used (Figure 6.2). When the patient is in the lithotomy position, their hips and knees are flexed, with buttocks at the edge of the table, and their feet are supported by heel or knee stirrups. Many patients, especially those with physical disabilities, cannot comfortably lie in the lithotomy position for the pelvic examination. Several alternative positions may be used, including a lateral (sidelying) position, a V-shaped position, a diamond-shaped position, or an M-shaped position (see Figure 6.2). The patient can be asked what has worked best for them previously. If they have never had a pelvic examination or have never had a comfortable pelvic examination, the nurse should proceed slowly by showing them a picture of various positions and asking them which one they would prefer. The nurse’s support and reassurance can help the patient to relax, which will make the examination go more smoothly. Some patients prefer to keep their shoes or socks on, especially if the stirrups are not padded. Patients may express feelings of vulnerability and strangeness when in the lithotomy position. During the procedure, the nurse can assist the patient with relaxation techniques. Breathing techniques can be particularly helpful for the adolescent and for the person whose introitus may be especially tight or for whom the experience is new or may provoke tension. Some patients relax when they are encouraged to become involved with the examination by having a

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A

C

B

D E

Fig. 6.2 Lithotomy, and variable positions for pelvic examination. A: Lithotomy position. B: M-shaped position. C: Side-lying position. D: Diamond-shaped position. E: V-shaped position.

BOX 6.3

Procedure: Assisting With Pelvic Examination

1. Perform hand hygiene. Assemble equipment (see illustration on right). 2. Ask patient to empty their bladder before the examination (obtain cleancatch urine specimen as needed). 3. Assist with relaxation techniques. Have patient place their hands on their chest at about the level of the diaphragm, breathe deeply and slowly (in through their nose and out through their O-shaped mouth), concentrate on the rhythm of breathing, and relax all body muscles with each exhalation. 4. Encourage patient to become involved with the examination if they show interest. For example, a mirror can be placed so that they can see the area being examined. 5. Assess for and treat signs of health concerns, such as supine hypotension. 6. Warm the speculum in warm water if a prewarmed one is not available. 7. Instruct patient to bear down when the speculum is being inserted. 8. Apply gloves and assist the examiner with collection of specimens for cytological 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.

mirror placed so that they can view the area being examined. This type of participation helps with health teaching as well. Distraction is another technique that can be used effectively (e.g., placing interesting pictures on the ceiling over the head of the table). Box 6.3 discusses the nurse’s role in pelvic examinations. Some patients find it distressing to attempt to converse in the lithotomy position. Most will appreciate an explanation of the procedure as it unfolds, as well as coaching for the type of sensations they may expect.

10. Assist the patient to a sitting position upon completion of the examination. 11. Provide tissues to wipe lubricant from perineum. 12. Provide privacy for the patient while they are dressing.

Equipment used for pelvic examination. (Courtesy Michael S. Clement.)

Generally, however, patients 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 some patients tense. A teenager’s first speculum examination is the most important one because they will develop perceptions that will remain with them for future examinations. What the examination entails should be discussed with the teen while they are dressed. Models or illustrations can be used

CHAPTER 6 to show exactly what will happen. All of the necessary equipment should be assembled so that there are no interruptions. Pediatric specula that are 1 to 1.5 cm wide can be inserted with minimal discomfort. If the teen is sexually active, a small adult speculum may be used.

External Inspection. The examiner wears gloves and sits at the foot of the table for inspection of the external genitals and the speculum examination. In good lighting, external genitals are inspected for sexual maturity, including the clitoris, labia, and perineum, and for lesions indicative of STIs. After childbirth or other trauma there may be healed scars. This is a good time to discuss with a patient the benefits of knowing their body and what is normal for them. If abnormalities are detected by the patient these should be discussed further with a health care provider. Many lesions, including malignancy, condyloma acuminatum (wartlike growth), and Bartholin cysts, can be seen or palpated and are easily treated if diagnosed early. External Palpation. Before touching the patient, the examiner should explain what is going to be done and what the patient should expect to feel (e.g., pressure). The examiner may touch the patient in a less sensitive area such as the inner thigh to alert them that the genital examination is beginning. This gesture may put the patient more at ease. The labia are spread apart to expose the structures in the vestibule: urinary meatus, Skene glands, vaginal orifice, and Bartholin glands (Figure 6.3). To assess the 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 needs to keep in mind the data from the review of systems, such as history of burning on urination. The vaginal orifice is then 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 also assessed. The examiner spreads the labia with the index and middle fingers and then asks the patient to strain down. Any bulge from the

Fig. 6.3 External examination. Separation of the labia. (From Wilson, S. F., & Giddens, J. F. [2013]. Health assessment for nursing practice [5th ed.]. Mosby.)

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anterior wall (urethrocele or cystocele) or posterior wall (rectocele) should be noted and compared with the history, such as difficulty starting the stream of urine or with 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 tumours. 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 should note any odour, which may indicate infection or poor hygiene.

Internal Examination. A vaginal speculum consists of two blades and a handle, and 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: colour, lesions, bleeding, and discharge (Figure 6.4, A to 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 daughters), or polyps should be noted. Collection of specimens. The collection of specimens for cytological examination is an important part of the gynecological 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, and herpes simplex virus. Once the diagnoses have been made, treatment can be instituted (see discussion in Chapter 7). 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 6.4). 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 colour, 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 (Figure 6.5). The vagina is palpated for distensibility, lesions, and tenderness. The cervix is examined for position, shape, consistency, motility, 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 patient’s left side. Just before the intravaginal fingers are withdrawn, the patient is asked to tighten their vagina around the fingers as much as they can.

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A

B

D

C

Fig. 6.4 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.]. Mosby.)

BOX 6.4

Procedure: Papanicolaou Test

1. In preparation, make sure that the patient has not douched, used vaginal medications, or had sexual intercourse for at least 24 hours before the procedure. Reschedule the test if the patient is menstruating. Midcycle is the best time to test. 2. Explain to the patient the purpose of the test and what sensations they will feel as the specimen is obtained (e.g., for some patients this may feel uncomfortable, others may just feel pressure). 3. Assist the patient into a position that is most comfortable for them (usually lithotomy). A speculum is then inserted into the vagina. 4. The cytological specimen is obtained before any digital examination of the vagina is made or endocervical bacteriological specimens are taken. A cotton swab may be used to remove excess cervical discharge before the specimen is collected.

5. The specimen is obtained by using an endocervical sampling device (Cytobrush, Cervex-Brush, papette, or broom) (see Figures A and B). If the twosample 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 using a spatula. Broom devices are inserted and rotated 360 degrees five times. They are used to 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 require colposcopy and biopsy. If using a one-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; the slide is then sprayed with preservative within 5 seconds. The ThinPrep Pap test is a liquid-based method Continued

CHAPTER 6

BOX 6.4

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Procedure: Papanicolaou Test—cont’d

A

B Pap test. A: Collecting cells from the endocervix using a cytobrush. B: Obtaining cells from the transformation zone using a wooden spatula. (From Lentz, G. M., et al. [2012]. Comprehensive gynecology [6th ed.]. Mosby.)

Fig. 6.5 Bimanual palpation of the uterus. (From Seidel, H. M., et al. [2011]. Mosby’s guide to physical examination [7th ed., p. 566]. Mosby.)

If the muscle response is weak, the patient is assessed for their knowledge about Kegel exercises.

Rectovaginal Palpation. To prevent contamination of the rectum from organisms in the vagina, it is necessary to change gloves, add

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 Papnet test is 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. 6. Label the slides or vial with the patient’s name and site. Include on the form to accompany the slides the patient’s name, age, last menstrual period, and parity and the reason for taking the cytological specimens. 7. Send specimens to the pathology laboratory promptly for staining, evaluation, and a written report, with special reference to abnormal elements, including cancer cells. 8. Advise the patient that repeat tests may be necessary if the specimen is not adequate. 9. Instruct the patient about routine checkups for cervical and vaginal cancer. It is recommended that Pap tests be initiated by age 25 and done every 3 years for patients with no risk factors, although different provinces and territories may have different guidelines. Patients with abnormal Pap results need more frequent testing. Pap screening can be discontinued in a patient who is 70 years old and has had three negative smears in the past 10 years (Canadian Task Force on Preventative Health, 2013). 10. Record the examination date on the patient’s record.

Fig. 6.6 Rectovaginal examination. (From Seidel, H. M., et al. [2011]. Mosby’s guide to physical examination [7th ed., p. 568]. Mosby.)

fresh lubricant, and then reinsert the index finger into the vagina and the middle finger into the rectum (Figure 6.6). Insertion is facilitated if the patient strains down. The manoeuvres of the abdominovaginal examination are repeated. The rectovaginal examination enables assessment of the rectovaginal septum, the posterior surface

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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. After the rectal examination is completed, the patient should be assisted into a sitting position, given tissues or wipes to cleanse themselves, and given privacy to dress. The examiner returns after the patient 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 during a routine examination on a nonpregnant person. Pelvic measurements are completed, and uterine size is estimated. A Pap test may be done initially and cytological specimens collected to test for gonorrhea, chlamydia, human papillomavirus, and herpes simplex virus. While the pregnant patient is in lithotomy position, the nurse must watch 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 sweating. The patient should be positioned on their side until symptoms resolve and vital signs stabilize. The vaginal examination can be done with the patient in lateral position.

Pelvic Examination After Hysterectomy. The pelvic examination after hysterectomy is done in much the same way as on a person with a uterus. Vaginal screening using the Pap test is not recommended in patients who have had a total hysterectomy with removal of the cervix for benign disease.

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, glycated hemoglobin (HgbA1C), 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 radiograph, 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, through a secure online patient data system, or by letter. Tests for HIV, hepatitis B, and drug screening may be offered with informed consent in high-risk populations. These test results are usually reported in person.

KEY POINTS • Periodic health screening, including history, physical examination, and diagnostic and laboratory tests, provides the basis for overall health promotion, prevention of illness, early diagnosis of health issues, and referral for management. • Health screening needs to be performed in a culturally safe manner. • Nurses have a role in screening patients for intimate partner violence. • Routine screening mammography is recommended for early detection of breast cancer. • The role of the nurse is to assist patients to feel more comfortable during pelvic examinations.

REFERENCES Canadian Cancer Society. (2020). Trans women and breast cancer screening. https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/ find-cancer-early/screening-in-lgbtq-communities/trans-women-andbreast-cancer-screening/?region¼on. Canadian Nurses Association. (2018). Position statement: Promoting cultural competence in nursing. https://www.cna-aiic.ca/-/media/cna/page-content/ pdf-en/position_statement_promoting_cultural_competence_in_nursing. pdf?la¼en&hash¼4B394DAE5C2138E7F6134D59E505DCB059754BA9. Canadian Task Force on Preventative Health. (2013). Recommendations on screening for cervical cancer. Canadian Medical Association Journal, 185(1), 35–45. http://www.cmaj.ca/content/185/1/35.full. Klarenbach, S., Sims-Jones, N., Lewin, G., et al., & Canadian Task Force on Preventative Health Care (CTFPHC). (2018). Recommendations on screening for breast cancer in women aged 40–74 years who are not at increased risk for breast cancer. Canadian Medical Association Journal, 190(49), E1441–E1451. https://doi.org/10.1503/cmaj.180463. Kolahdooz, F., Launier, K., Nader, F., et al. (2016). Canadian Indigenous women’s perspectives of maternal health and health care services: A systematic review. Diversity and Equality in Health and Care, 13(5), 334–348. https://diversityhealthcare.imedpub.com/canadian-indigenouswomens-perspectives-ofmaternal-health-and-health-care-servicesasystematic-review.php?aid¼11328.

ADDITIONAL RESOURCES Rainbow Health Ontario. https://www.rainbowhealthontario.ca/. Rainbow Health Ontario—Tips for providing Paps to trans men. https://www. rainbowhealthontario.ca/resource-library/tips-for-providing-paps-totrans-men/.

UNIT 3 Women’s Health

7 Reproductive Health Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify the structures and functions of the female reproductive system. 2. Differentiate the menstrual cycle in relation to endometrial, hormonal, and ovarian responses. 3. Differentiate among the signs and symptoms of common menstrual disorders. 4. Develop a nursing care plan for the patient with primary dysmenorrhea. 5. Outline patient teaching about premenstrual syndrome. 6. Relate the pathophysiology of endometriosis to associated symptoms.

7. Describe the etiology, significance, and management of abnormal uterine bleeding. 8. Describe treatment for menopause symptoms. 9. Describe prevention and treatment of sexually transmitted infections in patients. 10. Summarize the care of patients with selected viral infections (i.e., human immunodeficiency virus and hepatitis B virus). 11. Differentiate the signs, symptoms, and management of selected vaginal infections. 12. Discuss the pathophysiology and emotional effects of selected benign breast conditions and malignant neoplasms of the breasts.

Health issues may occur at any point in a patient’s life, especially during the reproductive years. Many factors, including anatomical abnormalities, physiological imbalances, and lifestyle, can affect the menstrual cycle. The average person may have some concerns related to their menstrual and gynecological health at some point in their life and may experience bleeding, pain, discharge, or infections associated with their reproductive organs or functions. This chapter provides information on the female reproductive system, menstrual cycle, common menstrual problems, sexually transmitted infections, and selected other infections that can affect reproductive functions. Benign breast conditions as well as breast cancer are also discussed.

genitalia varies greatly among women. Heredity, age, race, and the number of children a patient has borne influence the size, shape, and colour of their external organs.

FEMALE REPRODUCTIVE SYSTEM The female reproductive system consists of external structures and internal structures located in the pelvic cavity as well as the breasts. 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

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 genitalia are illustrated in Figure 7.1. 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 composed 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

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Mons pubis (without pubic hair) Prepuce

Clitoris Orifice of urethra

Labia minora Hymen

Labia majora (without pubic hair)

Orifice of vagina Vestibule

Opening of Bartholin’s gland

Fourchette Anus

Perineal body

Fig. 7.1 External female genitalia.

clitoris). The labia minora join to form a thin, flat tissue, called the fourchette, underneath the vaginal opening at midline. The clitoris, located underneath the prepuce, 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 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 openings usually are 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, and ovaries. 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 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 childbirth. The uterine cervix projects into a blind vault at the upper end of

the vagina. There are anterior, posterior, and lateral pockets called fornices (singular: fornix) that surround the cervix. The internal pelvic organs can 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 cylindrical portion called the cervix (Figure 7.2). 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. 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. 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) (Figure 7.3). Longitudinal fibres of the outer myometrial layer are found mostly in the fundus, and this arrangement assists in the expelling of the fetus during the birth process. The middle layer contains fibres from all three directions, which form a figure-eight pattern encircling large blood vessels. These fibres assist in ligating blood vessels after childbirth and controlling blood loss. Most of the circular fibres of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibres help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation. The cervix is made up of mostly fibrous connective tissues and elastic tissue, making it possible for the cervix to stretch during vaginal childbirth. The opening between the uterine cavity and the canal that connects the uterine cavity to the vagina (endocervical canal) is the

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Ovary

Uterine tube

Round ligament

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Corpus of uterus

Symphysis pubis Urogenital diaphragm Bladder

External iliac vessels

Glans clitoris Urethra

Infundibulopelvic ligament

Labium minora Labium majora Vaginal orifice Urogenital diaphragm

Ureter Sacral promontory

Vagina

Uterosacral ligament

Anus External anal sphincter

Posterior cul-de-sac of Douglas

Levator ani muscle Fornix of vagina Rectum Cervix Fig. 7.2 Midsagittal view of female pelvic organs.

Uterine tube

Ovarian ligament

Round ligament Uterosacral ligament Cardinal ligament Anterior ligament Fig. 7.3 Schematic arrangement of directions of muscle fibres. Note that uterine muscle fibres are continuous with supportive ligaments of the uterus.

internal os. The narrowed opening between the endocervix and the vagina is the external os, a small circular opening in patients who have never been pregnant. The cervix feels firm (like the end of a nose) with a dimple in the centre 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 cervical os. This junction also is called the transformation zone and is the most common site for neoplastic changes. Cells from this site are scraped for the Papanicolaou (Pap) test.

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 (Figure 7.4). The uterine tubes provide a passage between the ovaries and the uterus for 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.

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Interstitial portion Fundus of uterine tube Isthmus of of uterus uterine tube Perimetrium

Ampulla of uterine tube Ovarian Epoophoron ligament

Infundibulum of uterine tube

Corpus of uterus Endometrium

Fimbriae Broad Ovary Hydatid of Morgagni ligament Uterine vessels Cardinal (Mackenrodt) ligament

Myometrium Internal os of cervix External os of vaginal cervix

Fornix of vagina

Vagina

Endocervical canal

Fig. 7.4 Cross section of uterus, fallopian tubes, ovaries, and upper vagina.

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 hormones produced by the ovaries.

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) Iliac crest

bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis (Figure 7.5). Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis (Figure 7.6). 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 (see Figure 7.5). 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.

Sacroiliac joint

Ilium Sacrosciatic notch

Sacral promontory

Iliac spines (posterior)

Sacrum

Acetabulum

Acetabulum Pubis Obturator foramen

Ischial spine

Ischial tuberosity

Coccyx

A

Subpubic arch under symphysis pubis

Ischium

B

Obturator foramen

Fig. 7.5 Adult female pelvis. A: Anterior view. B: External view of innominate bone (fused).

CHAPTER 7

False pelvis

Inlet

True pelvis

A

Inlet Midpelvis

Outlet

B Fig. 7.6 Female pelvis. A: The cavity of false pelvis is shallow. B: The cavity of true pelvis is an irregularly curved canal (arrows).

Breasts The breasts are paired mammary glands located between the second and sixth ribs (Figure 7.7). About two-thirds of the breast overlies the pectoralis major muscle, between the sternum and midaxillary line, with an extension to the axilla referred to as 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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The breasts of the healthy, mature patient are approximately equal in size and shape but often are not absolutely symmetrical. The size and shape vary with the patient’s age, heredity, and nutrition. However, the contour should be smooth with no retractions, dimpling, or masses. Estrogen stimulates growth of the breast 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 made of a number of lobes that are 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. 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 Figure 7.7). The round nipple is usually slightly elevated above the breast. On each breast the nipple projects slightly upward and laterally. It contains 4 to 20 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.

Clavicle Intercostal muscle Pectoralis major muscle Alveolus Ductule Duct Lactiferous duct

Nipple pore Cooper's ligaments

Fig. 7.7 Anatomy of the breast, showing position and major structures. (Adapted from Seidel, H. M., Stewart, R. W., Ball, J. W., et al. [2011]. Mosby’s guide to physical examination [7th ed.]. Mosby.)

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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, Montgomery tubercles, directly beneath the skin. These glands secrete a fatty substance thought to lubricate the nipple. Smooth muscle fibres 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 lymphatic vessels of the neck and abdomen. The lymphatic vessels 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 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 physiological change must be remembered when breast tissue is examined. Nodules may develop just before and during menstruation, when the breast is most active. The physiological alterations in breast size and activity reach their minimum level about 5 to 7 days after menstruation stops.

MENSTRUATION Menarche and Puberty Young girls secrete small, rather constant amounts of estrogen, but a marked increase in secretion 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 childhood and sexual maturity. Increasing amounts and variations in gonadotropin and estrogen secretion develop into a cyclic pattern at least a year before menarche. In North America this occurs in most females at about 13 years of age. 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 patients occur after the normally timed menarche. It is important that young adolescents of both sexes are informed 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 (Figure 7.8). 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. 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 pituitary glands, and the ovaries. The menstrual cycle prepares the uterus for pregnancy. When pregnancy does not occur, menstruation follows. A patient’s age, general health and emotional status, and environment influence the regularity of their 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 Figure 7.8). 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 8-fold to 10-fold thickening occurs, with a levelling 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, larger 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 layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Figure 7.8). 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 to release luteinizing hormone (LH). A marked surge of LH and a smaller peak of estrogen (day 12) (see Figure 7.8) 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,

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Hypothalamus GnRH

Pituitary gland

HYPOTHALAMICPITUITARY CYCLE

Posterior

Anterior

Follicle-stimulating hormone (FSH)

Pituitary hormones

Luteinizing hormone (LH)

Follicular phase

91

Luteal phase

LH

FSH

Ovulation

OVARIAN CYCLE Primary follicle

Degenerating corpus luteum

Egg Graafian follicle

Corpus luteum

Ovarian hormones

Progesterone Some estrogen

Estrogen

Estrogen Progesterone

Menstruation

Proliferative phase

Secretory phase

Ischemic phase Menstruation

ENDOMETRIAL CYCLE

Functional layer

Basal layer Day

1

5

10

14

28 1

5

Fig. 7.8 Menstrual cycle: hypothalamic–pituitary, ovarian, and endometrial. GnRH, Gonadotropin-releasing hormone.

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, from 1 to 30 follicles begin

to mature in each ovary under the influence of FSH and estrogen. The preovulatory 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 (preovulatory phase) (see Figure 7.8) of the ovarian cycle varies in length from person to person.

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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 people only a small amount of withdrawal bleeding occurs and it goes unnoticed. In 10% of people 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; 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 prostaglandins 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, urogenital, and nervous systems. They also exert a marked effect on metabolism, particularly on glycolysis. PGs play an important role in many physiological, pathological, and pharmacological reactions. 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 labour (term and preterm). After exerting their biological 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 patient 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 labour, the maintenance of labour, or both. They may also be involved in dysmenorrhea (see discussion later in chapter) and pre-eclampsia (see Chapter 14).

CONCERNS RELATED TO THE MENSTRUAL CYCLE Generally, a person’s menstrual frequency stabilizes at 28 days within 1 to 2 years after puberty, with a range of 26 to 34 days. Although no person’s cycle is exactly the same length every month, the typical month-to-month variation in an individual’s cycle is usually plus or minus 2 days. However, greater but still normal variations are commonly noted. People typically have menstrual cycles for about 40 years. Once a cyclic, predictable pattern of monthly bleeding is established, patients may worry about any deviation from that pattern or from what they have been told is normal for all menstruating people. A patient may be concerned about their ability to conceive and bear children or believe that they are not really a woman without monthly menstruation. Amenorrhea or excess menstrual bleeding can be a source of severe distress and concern for a person.

Amenorrhea Amenorrhea, the absence of menstrual flow, is a clinical sign of a variety of conditions. 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). Someone who is moderately obese (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). People who exercise strenuously before menarche can have delayed onset of menstruation, until about age 18 (Lobo, 2017). Although amenorrhea is not a disease, it is often a sign of disease. It may occur from any defect or interruption in the hypothalamic– pituitary–ovarian–uterine axis (see Figure 7.8). It may also result from anatomical abnormalities such as outflow tract obstruction, anterior pituitary disorders, other endocrine disorders such as polycystic ovary syndrome (PCOS), hypothyroidism or hyperthyroidism, chronic diseases such as type 1 diabetes, medications such as phenytoin (Dilantin), substance use (opiates, marijuana, cocaine), eating disorders, strenuous exercise, emotional stress, or oral contraceptive use. Secondary amenorrhea is commonly the result of pregnancy.

Hypogonadotropic Amenorrhea. Hypogonadotropic amenorrhea reflects a problem in the central hypothalamic–pituitary axis. In rare instances a pituitary lesion or genetic inability to produce FSH and LH is at fault. However, Lobo (2017) has noted that patients without a lesion who had a low level of gonadotropins were believed to have primary pituitary failure, referred to as hypogonadotropic hypogonadism, but it has been noted that 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 central nervous system (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. Research on the interaction between nervous system or neurotransmitter functions and hormone regulation throughout the

CHAPTER 7 body has demonstrated a biological basis for the relation of stress to physiological processes. Patients who are more than 20% underweight for height or who have had rapid weight loss, and patients with eating disorders such as anorexia nervosa may report amenorrhea. Amenorrhea is one of the classic signs of anorexia nervosa. The interrelation of disordered eating, amenorrhea, and premature osteoporosis has been described as the female athlete triad (Mielke et al., 2015). A loss of calcium from the bone, comparable to that seen in postmenopausal patients, may occur with this type of amenorrhea. Exercise-associated amenorrhea can occur in patients 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. People who participate in sports emphasizing low body weight are at greatest risk. Such sports include the following (Lobo, 2017): • Sports in which performance is subjectively scored (e.g., dance, gymnastics) • Endurance sports favouring participants with low body weight (e.g., distance running, cycling) • Sports in which body contour–revealing clothing is worn (e.g., swimming, diving, volleyball) • Sports with weight categories for participation (e.g., rowing, martial arts) • Sports in which prepubertal body shape favours 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 they have menstruated previously. An important initial step, often overlooked, is to be sure that the patient is not pregnant. Once pregnancy has been ruled out by a βhuman 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). Collaborative care. For patients with amenorrhea caused by hypothalamic disturbances, the nurse is an ideal health professional to assist with this condition. Many of the causes are potentially reversible (e.g., stress, weight loss for nonorganic reasons). Counselling and education are primary interventions and appropriate nursing roles. When a stressor known to predispose a patient to hypothalamic amenorrhea is identified, initial management involves addressing the stressor. Together, the patient and nurse plan how the patient can decrease or discontinue medications known to affect menstruation, correct weight loss, deal more effectively with psychological stress, address emotional distress, and alter exercise routine. The nurse can work with the patient to help them identify, cope with, and eliminate sources of stress in their life. Deep-breathing exercises and relaxation techniques are simple yet effective stressreduction measures. Referral for biofeedback or massage therapy also may be useful. In some instances, referrals for psychotherapy may be indicated. If a person’s exercise program is thought to contribute to their amenorrhea, several options exist for management. They may decide to decrease the intensity or duration of their training or to modify their diet to include the appropriate nutrition for their age. Accepting the former alternative may be difficult for a person who is committed to a strenuous exercise regimen. The patient and nurse may have several sessions before the patient elects to try exercise reduction. Many young

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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 patient 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 patients experiencing amenorrhea associated with the female athlete triad. Oral contraceptives may be helpful in amenorrheic patients but are usually not used in young patients with amenorrhea associated with the female athlete triad unless there are specific issues that warrant such treatment, which are best discussed with the patient’s health care provider (Drakh, 2016).

Dysmenorrhea Dysmenorrhea, or pain during or shortly before menstruation, is one of the most common gynecological concerns in patients of all ages. Symptoms usually begin with menstruation, although some patients have discomfort several hours before onset of flow. The range and severity of symptoms are different from person to person and from cycle to cycle in the same person. Symptoms of dysmenorrhea may last several hours or several days. Many adolescents have dysmenorrhea in the first 3 years after menarche. Young adult patients ages 17 to 24 are most likely to report painful menses. Approximately 75% of patients report some level of discomfort associated with menses, and approximately 15% report severe dysmenorrhea (Mendiratta, 2017); however, the amount of disruption in patients’ lives is difficult to determine. Menstrual issues, including dysmenorrhea, are relatively more common in patients who smoke and are obese. Severe dysmenorrhea is also associated with early menarche, nulliparity, and lack of physical exercise (Mendiratta, 2017). Traditionally, dysmenorrhea is differentiated as primary or secondary.

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 CNS symptoms (dizziness, syncope, headache, and poor concentration). Pain usually begins at the onset of menstruation and lasts 12 to 72 hours (Mendiratta, 2017). Primary dysmenorrhea is not caused by underlying pathology. Rather, it is the occurrence of a physiological alteration in some patients. Primary dysmenorrhea usually appears within 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 is the most common menstrual symptom in patients in their late teens and early 20s; 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. Risk factors for dysmenorrhea include smoking or exposure to environmental tobacco smoke, frequent life changes, decreased social supports, stressful close relationships, and mood disorders, and there may be an increased prevalence of dysmenorrhea in lower socioeconomic groups (Burnett & Lemyre, 2017).

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Collaborative care. Management of primary dysmenorrhea depends on the severity of the issue and an individual patient’s response to various treatments. Patients with symptoms of primary dysmenorrhea may not seek medical assistance and frequently do not make use of the prescription therapies that are available, for a variety of reasons, including the belief that the pain is inevitable or lack of or limited accessibility to a health care provider. Education and support are important components of nursing care. Because menstruation is so closely linked to reproduction and sexuality, menstrual concerns such as dysmenorrhea can have a negative influence on a person’s sense of sexuality and self-worth. Nurses can correct myths and misinformation about menstruation and dysmenorrhea by providing facts about what is normal. Patients 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, giving patients options for deciding which works best for them. Several of these alternatives are discussed in the following paragraphs (see Clinical Reasoning Case Study).

suppresses prostaglandins, and shunts blood flow away from the viscera, resulting in reduced pelvic congestion. Research shows a reduction in dysmenorrhea with exercise, although the evidence is not strong. Assuming that exercise is unlikely to result in harm, it is reasonable to recommend it to patients, even without strong supportive evidence from randomized trials (Burnett & Lemyre, 2017). In addition to maintaining good nutrition at all times, specific dietary changes may be helpful in decreasing some of the systemic symptoms associated with dysmenorrhea. Ginger supplementation taken during the first 3 to 4 days of menstruation may be comparable to the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Although goodquality research is lacking, there is some evidence for the use of fenugreek, fish oil, fish oil plus vitamin B1, valerian, vitamin B1 alone, zataria, and zinc sulphate (Burnett & Lemyre, 2017). Herbal preparations, including Chinese herbal medicine, have long been used for management of menstrual issues, including dysmenorrhea (Table 7.1). However, it is essential that patients understand that these therapies are not without potential toxicity and may cause medication interactions.

NURSING ALERT ?

CLINICAL REASONING CASE STUDY

Nurses must routinely ask patients about the use of herbal and other alternative therapies and document their use. Nurses need to be aware of the potential for medication interactions with some herbal therapies.

Management of Dysmenorrhea Cheri, 16, has come to the adolescent health clinic for a checkup. She reports that she has “really bad cramps” for the first 2 days of her period. She has been taking Advil 200 mg every once in a while, but says that it does not help “a lot.” She wants to know if anything else can be done to relieve her pain. How should the nurse respond?

TABLE 7.1

Herbal Medicinals Taken Orally for Menstrual Disorders

Questions 1. Evidence—Is evidence sufficient to draw conclusions about what advice the nurse should give? 2. Assumptions—Describe underlying assumptions about the following issues: a. Causes and symptoms of primary dysmenorrhea b. Self-help strategies (e.g., comfort measures, medications) 3. What implications and priorities for nursing care can be drawn at this time?

Complementary and alternative health modalities (CAM) have become increasingly popular as a therapy for dysmenorrhea. The use of heat (heating pad or hot bath) minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia. Massaging the lower back can reduce pain by relaxing paravertebral muscles and increasing the pelvic blood supply. Soft, rhythmic rubbing of the abdomen (effleurage) is useful because it provides a distraction and an alternative focal point. High-frequency transcutaneous electrical nerve stimulation (TENS) in combination with heat therapy has been shown to be helpful in alleviating pain (Burnett & Lemyre, 2017). Behavioural interventions such as biofeedback, desensitization, breathing, hypnotherapy, and relaxation training can also be used to decrease menstrual discomfort, although evidence is inconclusive regarding their effectiveness (Barnett & Lemyre, 2017). Acupuncture and acupressure may also provide benefit, although research trials have not been well done. Behavioural therapies and acupuncture/acupressure are probably most useful as an adjunct to pharmacological therapy or in patients who prefer an alternative to medication (Burnett & Lemyre, 2017). Aerobic exercise has also been found to help alleviate pain (Mendiratta, 2017). Exercise may help relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia. It also releases endogenous opiates (specifically beta-endorphins),

Symptoms or Indications

Herbal Therapy*

Menstrual cramping, dysmenorrhea

Black haw

Uterine antispasmodic

Fennel

Uterotonic

Premenstrual discomfort, tension Breast pain

Menorrhea, metrorrhagia

*

Action

Catnip

Uterine antispasmodic

Dong quai

Uterotonic; anti-inflammatory

Ginger

Anti-inflammatory

Motherwort

Uterotonic

Wild yam

Uterine antispasmodic

Valerian

Uterine antispasmodic

Potentilla

Anti-inflammatory

Black cohosh root

Estrogen-like luteinizing hormone suppressant; binds to estrogen receptors

Chamomile

Antispasmodic

Chaste tree fruit

Decreases prolactin levels

Bugleweed

Antigonadotropic; decreases prolactin levels

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 Health Canada. Data from Annie’s Remedy. (2018). Dysmenorrhea—Herbs for painful periods. http://www.anniesremedy.com/chart_remedy_dysmenorrhea. php; National Center for Complementary and Alternative Medicine. (2019). Herbs at a glance. https://nccih.nih.gov/health/herbsataglance.htm

CHAPTER 7

TABLE 7.2

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Medications Used to Treat Dysmenorrhea

Medication

Recommended Dosage (Oral)

Common Adverse Effects

Comments

diclofenac (Voltaren)

50 mg tid or 100 mg initially, then 50 mg tid up to 150 mg/day

Nausea, diarrhea, constipation, abdominal distress, dyspepsia, heartburn, flatulence, dizziness, tinnitus, itching, rash

Enteric coated; immediate release

ibuprofen (Motrin, Advil)

400 mg q6–8h, 200 mg q4–6h up to max 1 200 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 health care provider if rash occurs

naproxen

500 mg initially, then 250 mg q6–8 h or 500 mg q12h; not to exceed 1 250 mg/day on day 1; subsequent doses should not exceed 1 000 mg/day

See diclofenac

See ibuprofen

mefenamic acid

500 mg initially, then 150 mg q6h/day

See diclofenac

Very potent and effective prostaglandin-synthesis inhibitor; antagonizes already formed prostaglandins; increased incidence of adverse GI effects

acetaminophen

325–650 mg q4–6h; to maximum 4 g/day

Good GI tolerance Can cause liver damage with 3 or more alcoholic drinks/day

Does not have antiprostaglandin property of NSAIDs

Note: Risk with all NSAIDs is gastrointestinal ulceration, possible bleeding, and prolonged bleeding time. Incidence of adverse effects is dose related. Reported incidence, 1 to 10%. Do not give if patient has hemophilia or bleeding ulcers; do not give if patient has had an allergic or anaphylactic reaction to Aspirin or another NSAID; do not give if patient is taking anticoagulant medication. GI, Gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; tid, three times daily. Data from Calis, K. A. (2016). Dysmenorrhea medication. Medscape. http://emedicine.medscape.com/article/253812-medication#2; Mendiratta, V. (2017). Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: Etiology, diagnosis, and management. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Elsevier.

Medications used to treat primary dysmenorrhea in patients not desiring contraception include prostaglandin synthesis inhibitors, primarily NSAIDs (Table 7.2). NSAIDs are most effective if started with the onset of bleeding or associated symptoms and are usually not required for more than 2 or 3 days (Barnett & Lemyre, 2017). All NSAIDs have potential gastrointestinal adverse effects, including nausea, vomiting, and indigestion. All patients taking NSAIDs should be warned to report dark-coloured stools, which may be an indication of gastrointestinal bleeding. Approximately 80% of dysmenorrheic patients obtain relief with prostaglandin inhibitors. Over-the-counter (OTC) preparations indicated for primary dysmenorrhea contain the same active ingredients (e.g., ibuprofen or naproxen sodium) as those in prescription preparations. However, the labelled recommended dose may be subtherapeutic. Acetaminophen may also be used, although it is probably less effective than NSAIDs because acetaminophen does not have the antiprostaglandin properties of NSAIDs. Acetaminophen causes fewer gastrointestinal symptoms.

NURSING ALERT If one NSAID is ineffective, often a different one may be effective. If the second medication is unsuccessful after a 6-month trial, combined oral contraceptive pills may be used. Patients with a history of Aspirin sensitivity or allergy should avoid using all NSAIDs.

Combined oral contraceptives (COCs), which contain both progesterone and estrogen, are a reasonable choice for patients who may want to use contraception. COCs are effective in relieving

symptoms of primary and secondary dysmenorrhea. The benefit of a COC is that it suppresses ovulation and endometrial tissue growth, attributing to decreased prostaglandin synthesis and decreased menstrual blood flow and uterine cramping (Burnett & Lemyre, 2017). Extended-cycle or continuous hormonal contraception (CHC) has been found to be superior to cyclical regimens for pain relief in dysmenorrhea (Burnett & Lemyre, 2017). Since COCs have adverse effects, patients may not wish to use them for dysmenorrhea, and they may be contraindicated for some patients. (See Chapter 8 for a complete discussion of oral contraceptives.) Depot medroxyprogesterone acetate (DMPA) works by suppressing ovulation, which results in relief of dysmenorrhea symptoms. Continuous oral progestin may also be a useful alternative to CHC with comparable pain relief and fewer adverse effects (Burnett & Lemyre, 2017). Levonorgestrel intrauterine system (LNG-IUS) is an intrauterine system that releases progestin inside the uterine cavity, causing a local effect on the endometrium, and can be considered for use with primary or secondary dysmenorrhea. If dysmenorrhea is not relieved by one of the NSAIDs or COCs, further investigation into the cause of the symptoms is necessary.

Secondary Dysmenorrhea. Secondary dysmenorrhea is menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25. It is associated with an underlying pelvic pathology such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, or submucous or interstitial myomas (fibroids). Patients 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

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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 patients 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 patients with secondary dysmenorrhea. Surgical options may be used to decrease the pain when other medical alternatives have been refused or were unsuccessful, and hysterectomy can be considered when all other options have not worked and fertility is no longer a consideration (see the Nursing Process box on Evolve).

Premenstrual Syndrome Approximately 75% of people 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). A diagnosis of PMS is made when a specific group of symptoms consistent with PMS occurs in the luteal phase, to such a degree that lifestyle or work is affected, and is followed by a symptom-free week leading up to ovulation at midcycle (Reid & Soares, 2018). PMS symptoms include fluid retention (abdominal bloating, pelvic fullness, edema of the lower extremities, breast tenderness, and weight gain); behavioural or emotional changes (depression, crying spells, 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 patients in their 20s and 30s most frequently reporting symptoms. Ovarian function is necessary for the condition to occur. PMS does not occur before puberty, after menopause, or during pregnancy. The condition is not dependent on the presence of monthly menses; patients 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 3 to 8% of people 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. Box 7.1 lists the criteria that must be met for a diagnosis of PMDD. While the etiology of PMS and PMDD is not clear, 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 biological and neuroendocrine etiologies have been suggested; however, none have been substantiated conclusively as the causative factor. Reproductive hormones, genetic predisposition, and psychological stress may all contribute to the expression of premenstrual symptoms (Reid & Soares, 2018).

Collaborative Care. There is little agreement on management of PMS. A careful, detailed history and daily log of symptoms and mood fluctuations spanning several cycles may give direction to a plan of management. When a single symptom is distressing, a symptom-based approach to therapy may be sufficient (Reid & Soares, 2018). Any changes that assist a patient with PMS to exert control over their life have a positive impact. For this reason, lifestyle changes may be effective in its treatment.

BOX 7.1 Diagnosis of Premenstrual Dysphoric Disorder (PMDD) At least 5 of the following 11 symptoms should be experienced during most cycles over the previous 12 months. Of note, at least one of the symptoms listed in bold (numbers 1–4) should be present. 1. Depressed mood 2. Anxiety, tension 3. Affective lability 4. Anger, irritability 5. Decreased interest in usual activities 6. Difficulty in concentrating 7. Lack of energy, fatigue 8. Change in appetite, food cravings 9. Changes in sleep (hypersomnia, insomnia) 10. Feeling overwhelmed, “out of control” 11. Physical discomforts such as breast tenderness, joint pains, headaches, bloating, weight gain Also: PMDD interferes markedly with usual activities (work, school, social, relationships). PMDD is NOT a mere exacerbation of an underlying condition (e.g., depression, anxiety). PMDD should be confirmed by prospective daily ratings for two consecutive cycles. Source: Reid, R., & Soares, C. (2018). Premenstrual dysphoric disorder: Contemporary diagnosis and management. Journal of Obstetrics & Gynaecology Canada, 40(2), 215–223.

Education is an important component of the management of PMS. Nurses can advise patients that self-help modalities often result in significant symptom improvement. Patients have found a number of complementary and alternative therapies to be useful in managing the symptoms of PMS. Diet and exercise changes are a useful way to begin and may provide symptom relief for some people. Nurses can suggest that patients not smoke and limit their consumption of refined sugar, salt, red meat, alcohol, and caffeinated beverages. Patients can be encouraged to include whole grains, legumes, seeds, nuts, vegetables, fruits, and vegetable oils in their diets; reduce the 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). Patients who exercise regularly seem to have less premenstrual anxiety than do nonathletic patients. Researchers believe aerobic exercise increases beta-endorphin levels to offset symptoms of depression and to elevate mood. The use of natural diuretics may help reduce fluid retention. Nutritional supplements may assist in symptom relief. Calcium and vitamin B6 have been shown to be moderately effective in relieving symptoms, to have few adverse 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, although research on their effectiveness and safety is not conclusive; specific suggestions are found in Table 7.1. Nurses can explain to patients 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, and there are different management strategies available to help maintain serotonin levels. Support groups or individual or couple counselling may also be helpful in managing PMS. Stressreduction techniques may assist with symptom management.

CHAPTER 7 If these and other nonpharmacological strategies do not provide significant symptom relief in 1 to 2 months, medication is often added. Many medications have been used in the treatment of PMS, but no single medication alleviates all PMS symptoms. Medications often used in the PMS treatment include diuretics, prostaglandin inhibitors (NSAIDs), and COCs. These have been used mainly for the physical symptoms. Studies of progesterone have not shown it to be an effective treatment (Mendiratta, 2017). Serotonergic-activating agents, including the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), are used as first-line pharmacological therapy. Use of these medications during the luteal phase of the menstrual cycle has been shown to result in a decrease in emotional premenstrual symptoms, especially depression (Mendiratta, 2017; Reid & Soares, 2018). Common adverse effects of these medications 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 (Figure 7.9). Endometrial lesions have been found in the vagina and in surgical scars, as well as on the vulva, perineum, and bladder. Lesions 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 colouring of the contents of the cyst, caused by the presence of old blood. Endometrial tissue responds to cyclic hormone stimulation in the same way that the uterine endometrium does, but often out of phase with it. The endometrial tissue grows during the proliferative and secretory phases of the cycle. During or immediately after menstruation, the

Fig. 7.9 Common sites of endometriosis (identified in blue). (From Lentz, G. M., Lobo, D. M., Gershenson, D. M., et al. [2017]. Comprehensive gynecology [7th ed.]. Elsevier.)

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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 reproductiveage patients, 30 to 45% in infertile patients, and 33% in patients with chronic pelvic pain (Advincula et al., 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. Currently it is estimated that approximately 50% of teens with pelvic pain have endometriosis (Advincula et al., 2017). 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 patients receiving menopausal hormone therapy. Symptoms ranging from nonexistent to incapacitating vary among patients. The severity of symptoms can change over time and may not reflect the extent of the disease. The major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia (painful intercourse). Patients may also have chronic noncyclic pelvic pain, pelvic heaviness, or pain radiating into the thighs. Many people 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., 2017). 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.

Collaborative Care. Treatment is based on the severity of symptoms and the goals of the person or couple. Patients with endometriosis must be assessed for the level of pain they experience, their pain coping strategies, and the impact of the pain on their life. Patients without pain who do not want to become pregnant need no treatment. In patients 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). Patients who have early symptomatic disease and who can postpone pregnancy may be treated with COCs that have a low estrogen-toprogestin ratio to shrink endometrial tissue. The CHCs are taken continuously for 6 to 12 months, without any withdrawal time of the CHC. This approach is believed to lead to a more complete suppression, thus decreasing the endometriosis (Advincula et al., 2017). Any low-dose CHCs can be used if taken for 15 weeks, followed by 1 week of withdrawal. This therapy is associated with minimal adverse effects and can be taken for extended periods. Limited data exist on the effectiveness of progestogen-only medications for treating pain related to endometriosis. CHCs, the estrogen/progestin patch, or estrogen/progestin vaginal ring for menstrual suppression and administration of NSAIDs are the usual treatment for adolescents under the age of 16 who have endometriosis. Suppression of endogenous estrogen production and subsequent endometrial lesion growth is another method of disease management. Two main classes of medications are used to suppress endogenous estrogen levels: GnRH agonists and androgen derivatives. GnRH agonist therapy (leuprolide [Lupron, Eligard], nafarelin [Synarel], and 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 patients. Trabecular

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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), nafarelin (200 mg administered twice daily by nasal spray), and goserelin (3.6 mg every 28 days by subcutaneous implant) are effective and well tolerated. These medications reduce endometrial lesions and pelvic pain associated with endometriosis and have post-treatment pregnancy rates similar to those of danazol (Cyclomen) therapy ( Jarrell et al., 2018). Common adverse effects of these medications are those of natural menopause—hot flashes and vaginal dryness. Occasionally, patients report headaches and muscle aches. Treatment is usually limited to 6 months, to minimize bone loss. Although unlikely, it is possible for a patient to become pregnant while taking a GnRH agonist. Because the potential teratogenicity of this medication is unclear, patients should use a barrier contraceptive during treatment. GnRH agonist therapy for severe symptoms may have possible adverse effects on bone mineralization in adolescents, thus bone mineral density should be carefully monitored. 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 produce adverse effects severe enough to cause discontinuation of the medication. Adverse effects include masculinizing traits in the patient (weight gain, edema, decreased breast size, oily skin, hirsutism, and deepening of the voice), all of which often disappear when treatment is discontinued. Other adverse effects are amenorrhea, hot flashes, vaginal dryness, insomnia, and decreased libido. 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 patients with liver disease and should be used with caution in patients with cardiac and renal disease. Danazol should be given for a minimum of 3 months before other medical options are considered ( Jarrell et al., 2018). Surgical intervention is often needed for severe, acute, or incapacitating symptoms. Decisions regarding the extent and type of surgery are influenced by a patient’s age, their desire for children, and location of the disease. For patients who do not want to preserve their ability to have children, the only definite cure is total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH with BSO). In patients who are in their childbearing years and want children, reproductive capacity should be retained through the use of laparoscopic surgery, which may help decrease pain and subfertility associated with mild to moderate endometriosis. Laparoscopic excision and ablation treats the causes of pain and subfertility by destroying or removing all visible endometriotic lesions and repairing damaged organs and other sites (Duffy et al., 2014). Regardless of the type of treatment (short of TAH with BSO), endometriosis recurs in approximately 40% of patients. Thus, for many people, endometriosis is a chronic illness with conditions such as persistent pain or infertility. Counselling and education are critical components of nursing care for patients with endometriosis. Patients need an honest discussion of treatment options, with potential risks and benefits of each option reviewed. Because pelvic pain is a subjective, personal experience that can be frightening, support is important. Listening to patients, understanding their concerns, avoiding disease labelling, explaining plainly what is known and what is unknown, and giving constant reassurance and encouragement may be exceedingly important for the successful management of endometriosis and may change the patient’s perception of the clinical condition. Providing empathy may help a person to successfully cope with the disease (Vercellini

et al., 2017). Sexual dysfunction resulting from dyspareunia is common and may necessitate referral for counselling. Support groups for people with endometriosis may be found in some locations. The nursing care discussed in the previous section on dysmenorrhea is appropriate for managing persistent pelvic pain and dysmenorrhea experienced by patients with endometriosis (see Evolve resources for Nursing Care Plan for Patient With Endometriosis).

Alterations in Cyclic Bleeding Some patients experience changes in amount, duration, interval, or regularity of menstrual cycle bleeding. Commonly, patients worry 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, nurses should explain to patients that oral contraceptive pills (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 tumours of the smooth muscle of the uterus with an unknown cause. Fibroids occur in approximately 70% of patients, 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 person considers the amount or duration of bleeding to be excessive, the concern should be investigated.

Treatment for menorrhagia depends on the cause of the bleeding. If the bleeding is related to contraceptive method (e.g., an intrauterine device [IUD]), provide factual information and reassurance and discuss other contraceptive options. Tranexamic acid (an antifibrolytic agent) has also been shown to be effective in reducing menstrual blood loss between 40 and 59% from baseline (Singh et al., 2018). If there is no known cause for the bleeding and anatomical causes have been ruled out, therapy is aimed at reducing the amount of heavy bleeding. Current options for treatment include OCPs, NSAIDs, and other therapies: the levonorgestrel-releasing IUD, danazol, and antifibrinolytic agents (e.g., tranexamic acid) (Ryntz & Lobo, 2017; Singh et al., 2018). If bleeding is related to the presence of fibroids, the degree of disability and discomfort associated with the fibroids and the person’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. Patients with metrorrhagia should be warned 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 (Ryntz & Lobo, 2017; Singh et al., 2018). This reduction is often accomplished with the use of a GnRH agonist. However, usually after cessation of this treatment, the myomas return to their pretreatment size (Singh et al., 2018). If the person wishes to retain childbearing potential, a

CHAPTER 7 myomectomy may be performed. Myomectomy, or removal of the tumours only by laparoscopic or hysteroscopic resection or laser surgery, is particularly difficult if multiple myomas must be removed. One in four patients will have a hysterectomy performed within 20 years of having a myomectomy. If the person does not want to preserve their childbearing function or if they have severe symptoms (severe anemia, severe pain, considerable disruption of lifestyle), uterine artery embolization (UAE; a procedure that blocks blood supply to fibroid) or hysterectomy (removal of uterus) may be performed. After UAE, 20 to 30% of women will undergo a hysterectomy within 5 years (Ryntz & Lobo, 2017). Nursing roles include informing patients of their options, counselling and education as indicated, and referring patients to the appropriate specialists and health care services.

Abnormal Uterine Bleeding Abnormal uterine bleeding (AUB) may be defined as any variation from the normal menstrual cycle and includes changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss, as well as bleeding that is not related to menses. AUB is a common condition affecting patients of reproductive age that has significant social and economic impact due to loss of work time and possible decreased social interactions (Singh et al., 2018). Box 7.2 lists possible causes of AUB. Inherited bleeding disorders may be an underlying cause of AUB, with von Willebrand’s disease present in the majority of cases (Singh et al., 2018), and should be considered when other causes cannot be determined.

BOX 7.2

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Collaborative Care. The selection of a treatment for AUB will depend on the impact of the bleeding on the patient’s overall health (Singh et al., 2018). Acute bleeding episode. The most effective medical treatment of acute bleeding episodes of AUB is administration of high-dose estrogen and tranexamic acid. Surgery would only be done as a last resort because of the high morbidity associated with operating on patients with acute anemia and the resulting impaired healing, further bleeding, and infection. Surgical options in the acute setting include uterine curettage and hysteroscopic ablation, hysterectomy, and uterine artery embolization (Singh et al., 2018). Once the acute phase has passed, the patient is maintained on an oral conjugated estrogen and progestin regimen for at least 3 months. Such long-term treatment will help prevent recurrence of the pattern of AUB and hemorrhage. If the person wants contraception, they should continue to take OCPs. If the person has no need for contraception, the treatment may be stopped to assess their bleeding pattern. If their menses do not resume, a progestin regimen 10 days before the expected date of their menstrual period may be prescribed. This is done to prevent persistent anovulation with chronic unopposed endogenous estrogen hyperstimulation of the endometrium, which can result in eventual atypical tissue changes (Singh et al., 2018).

PERIMENOPAUSE 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

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 Anatomical Abnormalities Adenomyosis Ovarian cyst Leiomyomata Polyps of the cervix or endometrium Neoplasms Endometrial hyperplasia Cancer of the cervix and endometrium Hormonally active tumours (rare) Vaginal tumours (rare) Malignant Lesions Cervical squamous cell carcinoma Endometrial adenocarcinoma

Estrogen-producing ovarian tumours Testosterone-producing ovarian tumours Leiomyosarcoma Trauma Genital injury (accidental, coital trauma, sexual abuse) Foreign body Lacerations Systemic Conditions Adrenal hyperplasia and Cushing’s disease Blood dyscrasias Coagulopathies (e.g., von Willebrand’s disease) Hypothalamic suppression (from stress, weight loss, excessive exercise) Polycystic ovary disease Thyroid disease Pituitary adenoma or hyperprolactinemia 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 (e.g., ginseng)

Modified from 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.). Elsevier; Singh, S., Best, C., Dunn, S., et al. (2018). SOGC clinical practice guideline: Abnormal uterine bleeding in pre-menopausal women. Journal of Obstetrics and Gynaecology Canada, 40(5), e391–e415.

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when symptoms stop. A natural part of aging, menopause is considered the point at which a person has not had a menstrual period for 12 months. The average age for menopause to occur is 51.4 years, with an age range of 35 to 60 years. Perimenopause is the period of time prior to this when a person experiences physical and emotional changes; this lasts an average of 5 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. Any patient with postmenopausal bleeding always needs to be investigated for cancer. Menopause symptoms may vary from mild to intense. The common symptoms that patients report include vasomotor instability (hot flashes, night sweats), depression, anxiety, irritability, vaginal dryness, atrophic vaginitis, decreased libido, fatigue, aches and pains, and insomnia. Some patients will find that vasomotor symptoms decrease when they make lifestyle modifications, which include eating well, maintaining a healthy weight, regular exercise, reducing core body temperature (dressing in layers, use of a fan, and drinking cold fluids), smoking cessation, and limiting consumption of triggers (such as hot drinks and alcohol) (Reid et al., 2014). Stress management (relaxation, yoga, meditation) may also help with some psychological symptoms. Hormonal therapy (HT) is used to decrease menopausal symptoms. Estrogen alone or combined with a progestin is the most effective therapy for the medical management of menopausal symptoms. There has been some increased risk of breast cancer, ovarian cancer, thromboembolism, and heart disease identified with estrogen/progesterone therapy, and estrogen-only therapy has been associated with an increased rate of stroke (Reid et al., 2014). Patients for whom HT is contraindicated or not desired may use nonhormonal therapies. These include certain antidepressant medications, gabapentin, clonidine, and bellergal, which may provide some relief from hot flashes. These medications have their own adverse effects (Reid et al., 2014). The use of black cohosh and foods that contain phytoestrogens may improve mild menopausal symptoms, including hot flashes. Isoflavone (found in soy) and St. John’s wort may also be used (Reid et al., 2014). Patients should be asked about the use of any complementary therapies in order to decrease the risk of interactions with any medications. At present, the use of these therapies may be useful for some people, although research on the use of CAM is limited, and patients should be advised that alternative measures should be used with caution (Reid et al., 2014). Every person will go through the transition of menopause differently. Patients need an understanding health care provider who can explain what is considered normal and provide support. An excellent resource for information for patients is found at http://www. menopauseandu.ca.

INFECTIONS Infections of the reproductive tract can occur throughout a person’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 infection, such as infertility, last a lifetime. The emotional costs may include damaged relationships and lowered self-esteem.

Sexually Transmitted Infections Sexually transmitted infections (STIs) comprise more than 25 infectious diseases that are transmitted through sexual activity and the dozens of clinical syndromes that they cause (Box 7.3). STIs continue

BOX 7.3

Sexually Transmitted Infections

Bacteria Chlamydia (reportable to local health authority) Gonorrhea (reportable to local health authority) Syphilis (nationally reportable if infectious) Chancroid Lymphogranuloma venereum Genital mycoplasmas Viruses Human immunodeficiency virus (reportable to local health authority) Herpes simplex virus, types 1 and 2 Cytomegalovirus Viral hepatitis A and B (hepatitis B is reportable to local health authority) Human papillomavirus Protozoa Trichomoniasis Parasites Pediculosis (may or may not be sexually transmitted) Scabies (may or may not be sexually transmitted)

to be a significant and increasing public health concern in Canada, with rates of the three nationally reportable bacterial STIs (chlamydia, gonorrhea, and syphilis) increasing, especially among persons aged 15 to 24. The World Health Organization (WHO) has developed a global strategy for the prevention and control of STIs, because of the health and economic burden of STIs (WHO, 2016) (see Community Focus box). The most common STIs in women are chlamydia, human papillomavirus (HPV), gonorrhea, herpes simplex virus (HSV) type 2, syphilis, and human immunodeficiency virus (HIV) infection. Neonatal effects of STIs are discussed in Chapter 28.

COMMUNITY FOCUS Sexually Transmitted Infections While working in a clinic, interview a nurse about sexually transmitted infections commonly seen in the clinic. • What are the most common infections seen in the clinic? • Has the incidence of infections changed over the last 5 years? Which infections have increased and which have decreased in incidence during that time? • Are adolescents seen in the clinic? Is there a special clinic for adolescents? • How are patients diagnosed and treated for sexually transmitted infections? • What patient teaching guidelines are available in the clinic? Are the guidelines available in languages other than English?

Prevention. Preventing infection (primary prevention) is the most effective way of reducing the adverse consequences of STIs for people and for society. Prompt diagnosis and treatment of current infections (secondary prevention) can prevent personal complications and transmission to others. Preventing the spread of STIs requires that people at risk for transmitting or acquiring infections change their behaviour related to sexual activity (Box 7.4). A critical first step is for the nurse to include questions about a person’s sexual history, sexual risk behaviours, and drug-related risky behaviours as a part of the patient’s assessment (Box 7.5). Effective techniques in providing prevention counselling include using open-ended questions, using understandable

CHAPTER 7

BOX 7.4

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Risk Factors for Sexually Transmitted Infections (STIs)

The following STI risk factors are associated with increased incidence of STIs: • Sexual contact with person(s) with a known STI • Sexually active youth under 25 years of age • A new sexual partner or more than two sexual partners in the past year • Serially monogamous individuals who have one partner at present but who have had a series of one-partner relationships over time • No contraception or sole use of nonbarrier methods of contraception (i.e., oral contraceptives, Depo Provera, intrauterine device) • Injection drug use • Other substance use, such as alcohol or chemicals (marijuana, cocaine, ecstasy, crystal meth), especially if associated with having sex

• Any individual who is engaging in unsafe sexual practices (i.e., unprotected sex, oral, genital or anal; sex with blood exchange, including sadomasochism; sharing sex toys) • Sex workers and their clients • “Survival sex”: exchanging sex for money, drugs, shelter or food • Street involvement, homelessness • Anonymous sexual partnering (i.e., Internet, bathhouse, rave party) • Victims of sexual assault or abuse • Previous STI

Source: Public Health Agency of Canada. (2013). Section 2: Canadian guidelines on sexually transmitted infections—Primary care and sexually transmitted infections. https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadianguidelines/sexually-transmitted-infections/canadian-guidelines-sexually-transmitted-infections-17.html#a2

BOX 7.5

Focused Risk Assessment for Sexually Transmitted Infections

Information should be requested in a nonjudgemental manner, using language that is understandable. Relationship Do you have a regular sexual partner? If yes, how long have you been with this person? Do you have any concerns about your relationship? If yes, what are they? (e.g., violence, abuse, coercion) Sexual Risk Behaviour When was your last sexual contact? Was that contact with your regular partner or with a different partner? How many different sexual partners have you had in the past 2 months? In the past year? Are your partners men, women, or both? Do you perform oral sex (i.e., Do you kiss your partner on the genitals or anus)? Do you receive oral sex? Do you have intercourse (i.e., Do you penetrate your partner in the vagina or anus [bum]? Or does your partner penetrate your vagina or anus [bum])? Personal Risk Evaluation Have any of your sexual encounters been with people from a country other than Canada? If yes, where and when? How do you meet your sexual partners (when travelling, in a bathhouse, on the Internet)? Do you use condoms? All the time, some of the time, never? What influences your choice to use protection or not? If you had to rate your risk for STI, would you say that you are no risk, low risk, medium risk, or high risk? Why? STI History Have you ever been tested for an STI or HIV? If yes, what was your last screening date? Have you ever had an STI in the past? If yes, what and when?

Current Concern When was your last sexual contact of concern? If symptomatic, how long have you had the symptoms you are experiencing? Reproductive Health History Do you and/or your partner use contraception? If yes, what? Any problems? If no, is there a reason? Have you ever had any reproductive health problems? If yes, when? What? Have you ever had an abnormal Pap test? If yes, when? Result, if known? Have you ever been pregnant? If yes, how many times? What was the outcome (number of live births, abortions, miscarriages)? Substance Use Do you use alcohol? Drugs? If yes, frequency and type? If you use injection drugs, have you ever shared equipment? If yes, what was your last sharing date? Have you ever had sex while intoxicated? If yes, how often? Have you had sex while under the influence of alcohol or other substances? What were the consequences? Do you feel that you need help because of your substance use? Do you have tattoos or piercings? If yes, were they done using sterile equipment (i.e., professionally)? Psychosocial History Have you ever • traded sex for money, drugs, or shelter? • paid for sex? If yes, what is the frequency, duration, and last event? • been forced to have sex? If yes, when and by whom? • been sexually abused? • been physically or mentally abused? If yes, when and by whom? Do you have a home? If no, where do you sleep? Do you live with anyone?

HIV, Human immunodeficiency virus; STI, sexually transmitted infection. © All rights reserved. Canadian guidelines on sexually transmitted infections. Public Health Agency of Canada, 2016. Adapted and reproduced with permission from the Minister of Health, 2016.

language, and reassuring the patient that treatment will be provided regardless of ability to pay, language spoken, or lifestyle (Public Health Agency of Canada [PHAC], 2013a). Before considering any risk reduction strategy for preventing STIs, the person must first accept the fact that they are or might be sexually

active. Nurses need to show understanding of a person’s sexuality by initiating a nonjudgemental, two-way dialogue to help them examine the choices they make related to their sexuality. Examining these choices can be useful in helping patients to proactively plan risk reduction measures appropriate to their specific situation (PHAC, 2013a).

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Prevention messages should include descriptions of specific actions to be taken to avoid acquiring or transmitting STIs (e.g., refraining from sexual activity if STI-related symptoms are present) and should be individualized for each person, giving attention to the specific risk factors. To be motivated to take preventive actions, a person must believe that acquiring a disease will be serious for them and that they are at risk for infection. Nurses have a responsibility to ensure that their patients have accurate, complete knowledge about transmission and symptoms of STIs and the behaviours that place people at risk for contracting an infection. Primary preventive measures are individual activities aimed at avoiding infection. These practices include attaining knowledge of the partner, reducing the number of sexual partners, practising low-risk sex, avoiding the exchange of body fluids, and pre-exposure vaccinations. Nurses need to be aware that some patient do not have the ability or agency to take preventive action and may engage in high-risk behaviour because they have little choice or lack the confidence to take preventive measures. For these patients, nurses need to provide individualized and respectful care. Patients should be helped to plan for prevention by openly discussing safer sex, using a continuum approach (i.e., masturbation/mutual masturbation, low risk; oral sex, moderate risk for STIs and low risk for HIV; unprotected vaginal or anal intercourse, high risk for STIs and HIV). This can be useful in helping patients understand the risks associated with various activities, make informed choices about the initiation and maintenance of STI preventive actions, and deal with possible partner resistance (PHAC, 2013a). Specific self-management measures to prevent contracting and transmitting STIs are listed in Box 7.6. All patients need to be encouraged to think about the risk of STIs and to consider pre-sex testing before they become sexually active with a new partner so they can be proactive in preventing the risk of transmission. It is important to reinforce that it is not possible to assess the chances that a partner has an STI on the basis of knowing the partner’s sexual history, being in a close relationship with a partner, or being monogamous with a partner who has a sexual history and who has not been tested (PHAC, 2013a). Individuals also need to be aware that it is not possible to test for all STIs (e.g., HPV, HSV), so even if they or their partner’s tests are all negative, they may still have an asymptomatic STI. Nurses also need to discuss with patients the need to limit

BOX 7.6

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. • Pre-exposure vaccination is one of the most effective methods for preventing transmission of some STIs (hepatitis A and 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. • Abstinence is also recommended if under the influence of drugs or alcohol. HIV, Human immunodeficiency virus; STI, sexually transmitted infection. Adapted from Sex & U: https://www.sexandu.ca/

alcohol or drug intake prior to sexual activity, as these substances can impact decision-making and negotiation skills (PHAC, 2013a). The physical barrier promoted for the prevention of sexual transmission of HIV and other STIs is the condom. The nurse should teach the patient the importance of using 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 in order to avoid damaging it with fingernails, teeth, or other sharp objects. Condoms should be stored away from high heat. Although it is not ideal, people may choose to carry condoms in wallets, shoes, or inside a bra. Patients 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 provided in Box 8.8. The female condom (a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina) may be an effective mechanical barrier to viruses, including HIV. The consistent use of condoms for every act of sexual intimacy when there is the possibility of transmission of disease is ideal but not always possible in some situations. Patients should be encouraged to discuss concerns with their partner (Box 7.7). 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. Use of condoms lubricated with nonoxynol-9 is not recommended (PHAC, 2013a). Vaccination is an effective method for the prevention of some STIs such as hepatitis B and HPV. Hepatitis B vaccine is recommended for all people at high risk for STIs. A vaccine is available for HPV types 6, 11, 16, and 18 for females aged 9 to 45 and for males aged 9 to 26 (Salvadori & Canadian Paediatric Society [CPS], Infectious Diseases and Immunization Committee, 2018) (see later discussion). Patients should be counselled to watch out for situations that make it hard to talk about and practise risk reduction. These situations include romantic times when condoms are not available and when use of alcohol or drugs makes it difficult to make wise decisions.

BOX 7.7 Strategies to Enhance A Person’s Negotiation and Communication Skills Regarding Condom Use • Suggest that the patient talk with their partner about condom use at a time not during sexual activity. • Role play possible partner reactions with the patient and their alternative responses. • For a patient who appears particularly uncomfortable, ask them to rehearse how they might approach the topic of condom use with their partner. • Patients may feel more comfortable and in control of the situation if they sort out their feelings and fears before talking with their partners. Reassure the patient that it is natural to be uncomfortable and that the hardest part is getting started. • Suggest that the patient clarify for themselves what they will and will not do sexually. • Suggest that the patient begin the conversation by saying, “I need to talk with you about something that is important to both of us. It’s hard for me, and I feel embarrassed, but I think we need to talk about ways to reduce risk when we have sex.” • The partner may need time to think about what they have heard. • If the partner resists risk-reducing sexual behaviours, the patient may wish to reconsider the relationship.

CHAPTER 7

Sexually Transmitted Bacterial Infections Chlamydia. Chlamydia trachomatis is a reportable STI in Canada. Rates of chlamydia in Canada and elsewhere have been steadily increasing; between 2005 and 2014 the rate of chlamydia in females increased by 49% (PHAC, 2017a). Among males, the rates increased by 64.6%. Persons aged 15 to 29 comprised nearly 80% of chlamydia cases reported in 2014 (PHAC, 2017a). It is important to note that chlamydia is often underdiagnosed because the majority of infected individuals are asymptomatic (PHAC, 2017b). Risk factors are those listed in Box 7.4. While these infections are often silent, they are highly destructive, and their sequelae and complications can be very serious. Chlamydial infections are difficult to diagnose; the symptoms, if present, are nonspecific. Acute salpingitis, or pelvic inflammatory disease, is the most serious complication of chlamydial infections. Past chlamydial infections are associated with an increased risk of ectopic pregnancy and tubal factor infertility. Furthermore, chlamydial infection of the cervix causes inflammation, resulting in microscopic cervical ulcerations that may increase risk of acquiring HIV infection. More than half of infants born to a parent with chlamydia will develop conjunctivitis or pneumonia after perinatal exposure to the parent’s infected cervix. C. trachomatis is the most common infectious cause of ophthalmia neonatorum. Screening and diagnosis. In addition to obtaining information about the presence of risk factors (see Box 7.4), the nurse should inquire about the presence of any symptoms. All pregnant patients should have cervical cultures done for chlamydia at the first prenatal visit. Screening

TABLE 7.3

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late in the third trimester (36 weeks) may be carried out if the patient was positive previously or is younger than 25 years, has a new sex partner, or has multiple sex partners. Although chlamydia infections are 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. Diagnosis of chlamydia is best done using nucleic acid amplification testing (NAAT), which is more sensitive and specific than culture, enzyme immunoassay (EIA), and direct fluorescent antibody assay (DFA). NAAT should be used whenever possible for urine, urethral, or cervical specimens. Results are highly dependent on the type of test available, specimen collection and transport, and laboratory expertise. Not all local laboratories will have the ability to provide all types of testing, so it is important to know what is available in the particular region (PHAC, 2017b). Collaborative care. The Public Health Agency of Canada (PHAC) (2017b) recommendations for the treatment of chlamydial infections include doxycycline or azithromycin (Table 7.3). Azithromycin is often prescribed when adherence may be an issue, because only one dose is needed. Because chlamydia is often asymptomatic, the patient should be cautioned to take all medication prescribed. Patients treated with recommended or alternative regimens do not need to be retested unless symptoms continue (PHAC, 2017b). All sexual partners who have had contact with the index case within 60 days before symptom onset must

Sexually Transmitted Infections and Medication Therapies*

Disease

Nonpregnant Patient (>18 yr)

Pregnant/Lactating Patient

Chlamydia

doxycycline, 100 mg orally bid for 7 days or azithromycin, 1 g orally once (if poor adherence is suspected) For children 18 yr)

Pregnant/Lactating Patient

Human papillomavirus

For external genital warts: Patient-applied: podophyllotoxin/podofilox 0.5% solution to wart with a cotton swab q12h for 3 days (followed by 4 days without treatment) for up to 4 weeks or imiquimod 3.75% cream, daily at hs for 8 weeks or imiquimod, 5% cream, at hs 3 times a week for
16 weeks or sinecatechins 10% ointment tid for up to 16 weeks Provider-applied: Cryotherapy with liquid nitrogen or cryoprobe or podophyllin resin, 25%, 1–2 mL weekly (wash off in 1–4 hr). Repeat weekly for up to 6 weeks as necessary or TCA 50–90% in 70% alcohol weekly for 6–8 weeks Surgical treatment: CO2 laser vaporization; electrosurgical treatments; surgical excision

For external genital warts: Provider applied: Cryotherapy with liquid nitrogen or cryoprobe or trichloracetic acid (TCA) 50–90% solution in 70% alcohol weekly for 6–8 weeks. Imiquimod, podophyllin, podofilox/podophyllotoxin, and sinecatechins should not be used in pregnancy or during lactation.

Genital herpes simplex virus (HSV-1 or HSV-2)

Primary infection: acyclovir, 200 mg orally 5 times a day for 5–10 days or famciclovir, 250 mg orally tid for 5 days or valacyclovir, 1 g orally bid for 10 days For severe primary disease, IV acyclovir 5 mg/per kg infused over 60 minutes q8h with conversion to oral therapy when substantial improvement has occurred Recurrent infection: valacyclovir, 500 mg orally bid or 1 g daily for 3 days or famciclovir, 125 mg orally bid for 5 days or ayclovir, 200 mg orally 5 times/day for 5 days Suppression therapy: Take daily for up to 1 year: acyclovir, 200 mg orally 3 to 5 times/day or 400 mg orally bid or famciclovir, 250 mg orally bid or valacyclovir, 500 mg orally once a day (for patients with
9 recurrences/year) or valacyclovir, 1 g orally once a day (if >9 recurrences/year)

No increase in birth defects beyond the general population has been found with acyclovir use in pregnancy or while breastfeeding. Suppression therapy: 4 weeks before birth for women with recurrent infections can reduce the need for a Caesarean birth. acyclovir 200 mg orally qid or acyclovir 400 mg orally tid or valacyclovir 500 mg orally bid

bid, Twice daily; hs, bedtime; HSV, herpes simplex virus; IM, intramuscularly; IV, intravenously; qid, four times daily; tid, three times daily. * List is not inclusive of all medications that may be used as alternatives. Data from Public Health Agency of Canada. (2019). Canadian guidelines on sexually transmitted infections. http://www.phac-aspc.gc.ca/std-mts/sti-its/ cgsti-ldcits/index-eng.php#toc

be tested and treated (PHAC, 2017b). Chlamydia is a reportable disease to the local health authority in all provinces and territories. Local public health authorities are able to help notify contacts.

Gonorrhea. Gonorrhea is the second most common reported STI in Canada. The number of cases reported in 2016 was more than double the number reported in 2010 (rising from 33.5 to 65.4 per 100 000 population), corresponding to a 95% increase in rates. Males accounted for at least 56% of all cases diagnosed. The most commonly affected age group was 15- to 39-year-olds; they comprised 82% of reported cases

of gonorrhea, although they represented only 33% of the total population (Bodie et al., 2019). The incidence of medication-resistant cases of gonorrhea, in particular penicillinase-producing Neisseria gonorrhoeae, is increasing dramatically in Canada and worldwide. Gonorrhea is caused by the aerobic, Gram-negative diplococci N. gonorrhoeae. It is transmitted almost exclusively 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.

CHAPTER 7 Patients are often asymptomatic; but when they are symptomatic, they may have a greenish-yellow purulent endocervical discharge or may experience menstrual irregularities. Patients may also have pain: chronic or acute severe pelvic or lower abdominal pain, or menses that last longer or are more painful than normal. Infrequently, dysuria, vague abdominal pain, or low backache prompts a person to seek care. Gonococcal rectal infection may occur in patients after anal intercourse. Individuals with rectal gonorrhea may be completely asymptomatic or, conversely, have 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 females. Signs of infection may include vaginal discharge, dysuria, or swollen, reddened labia. Gonococcal infections in pregnancy potentially affect both the pregnant parent and their fetus. Patients with cervical gonorrhea may develop salpingitis in the first trimester. Perinatal complications of gonococcal infection include postpartum endometritis or sepsis in the patient and ophthalmia neonatorum or systemic neonatal infection in the newborn (PHAC, 2017c). Screening and diagnosis. Because gonococcal infections are often asymptomatic, all pregnant patients should be screened at the first prenatal visit, and infected patients and those identified with risky behaviours rescreened at 36 weeks of gestation (PHAC, 2017d). 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, when indicated, the pharynx. Cultures are critical for improved public health monitoring of antimicrobial resistance patterns and trends (PHAC, 2017c). Depending on the clinical situation, consideration should be given for collection of samples using both culture and NAAT, especially in symptomatic patients. Because coinfection is common, any person suspected of having gonorrhea should have a chlamydial culture and serological test for syphilis as well as HIV counselling and testing. Collaborative care. Management of gonorrhea is becoming more challenging as medication-resistant strains are increasing. Treatment should optimally be combination gonorrhea infection therapy in response to increasing antimicrobial resistance (PHAC, 2017c). Combination therapy using medications with two different mechanisms of action is thought to improve treatment efficacy as well as to potentially delay the emergence of cephalosporin-resistant gonorrhea (PHAC, 2017c). Patients should also receive concomitant treatment for chlamydia because coinfection is common (PHAC, 2017c) (see Table 7.3). Gonorrhea is highly communicable. Recent (past 60 days) sexual partners must be notified and should be examined, cultured, and treated with appropriate regimens. Most treatment failures result from reinfection. The patient needs to be informed of this, as well as of the consequences of reinfection in terms of chronicity, complications, and potential infertility. Patients should be counselled to use condoms. Repeat screening for individuals with a gonococcal infection is recommended 6 months post-treatment (PHAC, 2017c). LEGAL TIP Gonorrhea, chlamydia, infectious syphilis, and HIV are reportable communicable diseases in all provinces and territories. Health care providers are legally responsible for reporting all cases of these STIs to local public health authorities. All patients should be informed that the case will be reported, told why it will be reported, and informed of the possibility of being contacted by a health department epidemiologist.

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Syphilis. Syphilis, one of the earliest described STIs, is caused by Treponema pallidum, a motile spirochete. Transmission is thought to occur by entry through microscopic abrasions in the subcutaneous tissue, which can happen during vaginal, anal, or oral sexual contact. Transplacental transmission may occur at any time during pregnancy; the degree of risk is related to the quantity of spirochetes in the maternal bloodstream. The risk of transmission to the fetus in untreated pregnant patients is 70 to 100% with primary or secondary syphilis, 40% with early latent syphilis, and 10% in late latent stages in pregnancy. About 40% of pregnancies in patients with infectious syphilis result in fetal demise (PHAC, 2020). Infectious syphilis (primary, secondary and early latent stages) is the least common of the three nationally reportable bacterial STIs, although the rate of infectious syphilis in Canada has been increasing since 2001. From 2010 to 2015, the rate of infectious syphilis in Canada increased by 85.6%, from 5.0 to 9.3 cases per 100 000 population. In 2015, a total of 3 321 cases of infectious syphilis were reported, mainly in males (93.7%), and most of these increases were in men having sex with men (Choudhri et al., 2018). Syphilis is a complex disease that can lead to serious systemic disease and even death when untreated. Infection occurs in distinct stages with different symptoms and clinical manifestations. Primary syphilis is characterized by a primary lesion, the chancre, which appears 3 to 90 days after infection. This lesion often begins as a painless papule at the site of inoculation and then erodes to form a nontender, shallow, indurated, clean ulcer several millimetres to centimetres in size (Figure 7.10, A). Secondary syphilis occurs 2 weeks to 6 months after the appearance of the chancre. It is characterized by a widespread, symmetrical, maculopapular rash on the palms and soles and generalized

A

B Fig. 7.10 Syphilis. A: Primary stage: chancre with inguinal adenopathy. B: Secondary stage: condylomata lata.

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lymphadenopathy. The infected individual also may experience fever, headache, and malaise. Condylomata lata (broad, painless, pink-grey, wartlike infectious lesions) may develop on the vulva, perineum, or anus (see Figure 7.10, B). If the person remains untreated, they enter a latent phase that is asymptomatic for most individuals. Left untreated, about one third of these patients will develop tertiary syphilis. Neurological, cardiovascular, musculoskeletal, or multiorgan system complications can develop in the third stage. Screening and diagnosis. All individuals who are diagnosed with another STI or with HIV should be screened for syphilis. Universal screening of all pregnant patients is important and remains the standard of care in most jurisdictions. The screening test should be repeated at 28 to 32 weeks and again during labour in patients at high risk of acquiring syphilis (PHAC, 2020). 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 body’s immune system to develop antibodies to any antigens. Up to one third of people with early primary syphilis may have nonreactive serological tests. Two types of serological tests are used: nontreponemal and treponemal. Nontreponemal antibody tests such as VDRL (Venereal Disease Research Laboratories) and RPR (rapid plasma reagin) are used as screening tests. False-positive results are not unusual, particularly when conditions such as acute infection, autoimmune disorders, malignancy, pregnancy, and substance use disorder 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. Screening for concomitant STIs (e.g., chlamydia and gonorrhea) as well as HIV should also be considered. Collaborative care. Penicillin is the preferred medication for treating patients with all stages of syphilis, including pregnant patients (see Table 7.3). 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 patients should receive skin testing and be treated with penicillin or be desensitized (PHAC, 2020).

perinatal contacts must be notified and treated, and preventive measures should be discussed (PHAC, 2020).

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; most cases are associated with more than one organism. The pathogenic organisms can be categorized as sexually transmitted or endogenous (PHAC, 2013b). In the past, the most common causative agent was thought to be N. gonorrhoeae; however, C. trachomatis is now estimated to cause one half of all cases of PID. In addition to gonorrhea and chlamydia, a wide variety of anaerobic and aerobic bacteria cause PID. Most PID results from the ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. This spread most commonly happens at the end of or just after menses following reception of an infectious agent. During the menstrual period, several factors facilitate development of an infection: the cervical os is slightly open, the cervical mucous 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 of contracting an STI, including young age, multiple partners, high rate of new partners, and a history of STIs. PID tends to recur and is a significant public health concern in Canada. There are approximately 100 000 cases of PID annually in Canada, although up to two thirds of cases go unrecognized, and underreporting is common (PHAC, 2013b). Patients who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. The incidence of long-term sequelae of PID is directly related to the number of episodes of PID. Other conditions 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 clinical presentations. It may be dull, cramping, and intermittent (subacute) or severe, persistent, and incapacitating (acute). Patients 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 (PHAC, 2013b).

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, patients are at risk for preterm labour and birth. They should be advised to contact their health care provider if they notice any change in fetal movement or have any contractions.

Screening and diagnosis. PID is difficult to diagnose because of the accompanying wide variety of symptoms. A complete abdominal and pelvic examination should be performed in any patient with lower abdominal pain. PID should be treated in all sexually active young individuals 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 or 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 (PHAC, 2013b).

Monthly follow-up is important so that repeated treatment may be given, if needed. The nurse should emphasize the necessity of long-term serological testing even in the absence of symptoms. The patient should be advised to practise sexual abstinence until treatment is completed, all evidence of primary and secondary syphilis is gone, and serological evidence of a cure is demonstrated. Infectious syphilis is reportable in all provinces and territories to the PHAC. Noninfectious syphilis is reportable at the provincial/territorial level but not to the PHAC. All sexual or

Collaborative care. The most important nursing intervention is prevention counselling (see earlier discussion). Early diagnosis and treatment are crucial in order to maintain fertility, particularly the detection of asymptomatic gonorrheal or chlamydial infections. 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 individuals in self-protective measures such as practices to avoid contracting STIs and using barrier methods is critical. Patients using hormonal

NURSING ALERT

CHAPTER 7 contraception or an IUD and those who have chosen tubal ligation must be reminded to use a condom with intercourse when indicated. Although treatment regimens vary with the infecting organism, generally a broad-spectrum antibiotic is used (PHAC, 2013b). Treatment for PID may be intramuscular ceftriaxone plus oral doxycycline with or without metronidazole; or cefoxitin parenterally plus oral probenecid in a single dose concurrently once with doxycycline; or other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) with doxycycline. Regimens can be administered in inpatient or outpatient settings. PID can be difficult to treat if due to an antibiotic-resistant organism (specifically gonorrhea), and this needs to be determined. Also, management of patients with PID is considered inadequate unless their sexual partners are also clinically evaluated (PHAC, 2013b). All outpatients treated for PID should undergo evaluation 2 to 3 days after the initiation of treatment (PHAC, 2013b). When and if patients with PID are hospitalized varies according to their particular circumstances. The PHAC recommends hospitalization for parenteral antibiotic treatment in the following situations (PHAC, 2013b): • Surgical emergencies such as appendicitis cannot be excluded. • The person has a tubo-ovarian abscess. • The person is pregnant. • The person does not respond clinically to oral antimicrobial therapy. • The person is unable to follow or tolerate an outpatient oral regimen. • The person has severe illness, nausea and vomiting, or high fever. The patient 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 patient should restrict their 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 affected patients and encourage them to continue with all therapy and prevention recommendations, emphasizing the need to take all medication, even if symptoms disappear. Any potential issues (such as lack of money for prescriptions or lack of transportation to return for follow-up appointments) that would prevent a person from completing a course of treatment should be identified, referrals made for assistance as needed, and the importance of follow-up visits stressed. Patients should be counselled to refrain from sexual intercourse until their treatment is completed. Contraceptive counselling, 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 a person’s self-concept. Part of the nurse’s role is to help the person adjust their self-concept to fit reality and to accept alterations in a way that promotes health. Because PID is so closely tied to sexuality, body image, and self-concept, the patient diagnosed with it will need supportive care. The patient’s feelings should be discussed and the partner(s) included in the discussion, when appropriate.

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genital HPV infection over their lifetime, and prevalence among females is usually highest in those aged less than 25 years (Zimmermann et al., 2018). HPV prevalence is highest in socially disadvantaged females, such as those living in low-income housing, innercity settings, and Indigenous communities (PHAC, 2015). HPV, a double-stranded DNA virus, has more than 40 serotypes that can be transmitted sexually, 5 of which are known to cause genital wart formation and 8 of which are currently thought to have oncogenic (tumour-causing) potential (PHAC, 2015). HPV is the primary cause of cervical neoplasia. In patients, 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 (Figure 7.11). Typically the lesions are small (2 to 3 mm in diameter and 10 to 15 mm in height), soft, papillary 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 coloured or slightly darker on White people, black on Black people, and brownish on Asian people. 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. During pregnancy, pre-existing HPV lesions may enlarge, 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 Caesarean is rarely necessary. Caesarean birth should be reserved for patients with obstructions that do not allow the fetus to pass through. Initial observation of large growths can be 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 fetus to pass through. Screening and diagnosis. A person with HPV lesions may have symptoms such as profuse, irritating vaginal discharge, itching, dyspareunia, or postcoital bleeding. The person also may report “bumps” on the 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.

Sexually Transmitted Viral Infections Human Papillomavirus. Human papillomavirus (HPV) infection, also known as condylomatata acuminate, or genital warts, is the most common viral STI seen in ambulatory health care settings. It is estimated that 70 to 80% of the adult population will have at least one

Fig. 7.11 Human papillomavirus (HPV) infection. Genital warts or condylomata acuminata.

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Physical inspection of the vulva, perineum, anus, vagina, and 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 is available but not standard practice. History, evaluation of signs and symptoms, Pap test, and physical examination are used in making a diagnosis. Some research shows that combining an HPV test with a Pap test may extend the time between cervical cancer screenings. HPV testing is most useful in screening for cervical cancer in individuals 30 years of age or older (Canadian Cancer Society [CCS], 2021a). Collaborative care. Untreated warts may resolve on their own in young patients since their immune systems may be strong enough to fight the HPV infection. Treatment of genital warts, if needed, is often difficult. No therapy has been shown to eradicate HPV. Therefore, the goal of treatment is removal of warts and symptom relief (PHAC, 2015). The patient often must make multiple office visits; frequently many different treatment modalities will be used. Treatment of genital warts may be patient- (self) or clinicianapplied and should be guided by preference of the patient; availability of resources; cost, size, shape, number, and site of lesions; convenience; potential adverse effects; and experience of the health care provider (PHAC, 2015). No one of the treatments is superior to all other treatments, and no one treatment is ideal for all warts (PHAC, 2015) (see Table 7.3). Imiquimod, polophyllin, and podofilox are common treatments but should not be used during pregnancy. Because the lesions can proliferate and become friable during pregnancy, many experts recommend their removal using cryotherapy or various surgical techniques (PHAC, 2015). Individuals 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 growth of the warts. Cotton underwear and loosefitting clothes that decrease friction and irritation may lessen discomfort. Individuals should be advised to maintain a healthy lifestyle to aid the immune system and be counselled regarding diet, rest, stress reduction, and exercise. Patient education is essential. Patients must understand the virus, how it is transmitted, that no immunity is conferred with infection, and that reinfection is likely with repeated contact (PHAC, 2015). All sexually active people with multiple partners or a history of HPV should be encouraged 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 to screen for cervical cancer. The provinces and territories have different cervical cancer screening guidelines for follow-up for patients who have been treated for HPV infections and these should be referred to. People with HPV infection may radically alter their sexual practices both from fear of transmission to and from a partner and from genital discomfort associated with treatment, which may have a negative impact on their sexual relationships. Unless the partner accepts and understands the necessary precautions, it may be difficult for the patient to follow the treatment regimen. The nurse can offer to discuss feelings that the person may have. When indicated, joint counselling can be suggested.

Prevention. The two most important preventive strategies are the use of condoms and prophylactic vaccination (PHAC, 2015). A vaccine against HPV was approved by Health Canada in 2006 and is recommended for females ages 9 to 45 and males aged 9 to 26. There are three approved HPV vaccines in Canada. The vaccine approved most recently is Gardasil 9 (HPV-9), the nonavalent vaccine against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The quadrivalent vaccine (Gardasil or HPV-4) targets HPV 6, 11, 16, and 18. The bivalent (HPV-2) vaccine (Cervarix) targets HPV 16 and 18. HPV-4 and HPV-9 are approved for use in females aged 9 to 45 and males aged 9 to 26; Carvarix is only approved for use in females (Salvadori & CPS, Infectious Diseases and Immunization Committee, 2018). The HPV vaccine is highly effective and is given in two or three doses depending on the vaccine used over a 6-month period. All provinces and territories in Canada have implemented publicly funded HPV vaccine programs for females and eight provinces fund vaccine administration to males, with the goal of reducing the risk of cervical cancer (Salvadori & CPS, Infectious Diseases and Immunization Committee, 2018). For provincial/territorial guidelines for immunizations see Additional Resources at the end of this chapter.

Herpes Simplex Virus. Unknown until the middle of the twentieth century, herpes simplex virus (HSV) infection is now widespread in Canada, especially in females. HSV infection 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. HSV infection is not a reportable disease in Canada, therefore the number of cases is unknown, although it is known that the incidence and prevalence of HSV-1 genital infection is increasing globally (PHAC, 2013d). Recurrent HSV infections are much more common. Most persons infected with HSV-2 have not been diagnosed, and most infections are transmitted by persons unaware that they are infected. Genital herpes increases the risk of acquisition of HIV twofold (PHAC, 2013d). 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 men do. 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 (Figure 7.12). These ulcers are extremely tender, and primary infections may be bilateral. Patients also may have itching, inguinal tenderness, and

Fig. 7.12 Herpes genitalis.

CHAPTER 7 lymphadenopathy. Severe vulvar edema may develop, and individuals may have difficulty sitting. HSV cervicitis is common with initial HSV2 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. People 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 9 to 11 days. Lesions begin as vesicles and progress rapidly to ulcers. Few patients with recurrent disease have cervicitis. During pregnancy infection with HSV-2 can have adverse effects on both the pregnant patient and fetus. Viremia occurs during the primary infection, and congenital infection is possible, although rare. The risk for newborn infection is greatest when the primary infection occurs in the third trimester in the pregnant patient. Primary infections during the first trimester have been associated with increased miscarriage rates (Money et al., 2017). Screening and diagnosis. Although a diagnosis of herpes infection may be suspected from the history and physical examination, it is confirmed by laboratory studies. A viral culture is obtained by swabbing exudate during the vesicular stage of the disease. A primary infection can be confirmed by demonstrating an absence of HSV antibody in an acute-phase blood sample and the presence of antibody in the convalescent sample (i.e., seroconversion). Most individuals seroconvert within 3 to 6 weeks; by 12 weeks, more than 70% will have seroconverted (PHAC, 2013d). Collaborative care. 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 psychological 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 patients with severe disease (PHAC, 2013d) (see Table 7.3). Acyclovir and valacyclovir may be used during pregnancy to reduce the symptoms of HSV and to suppress HSV close to the time of birth. 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 individuals when lesions are active include warm sitz baths with baking soda; keeping lesions dry by using cool air from a hair dryer or by patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydrogen peroxide, Burow solution, or oatmeal baths; and applying cool, wet, black tea bags to lesions. Patients 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. Counselling and education are critical components of the nursing care of patients with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. The nurse should explain that each patient is unique in their response to herpes and emphasize the variability of symptoms. Patients should

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be helped to understand when viral shedding and thus transmission to a partner are most likely. They should be counselled to refrain from sexual contact from the onset of prodrome until the 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. Individuals can be encouraged to maintain close contact with their partners while avoiding contact with lesions. Patients 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 individuals understand that when lesions are active, they should not share intimate articles (e.g., washcloths or wet towels) that come into contact with the lesions. 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. Individuals may wish to keep a diary to identify stressors that seem to be associated with recurrent herpes attacks so that they can then 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 may also be helpful. Individuals in their childbearing years should be counselled about the risk of herpes infection during pregnancy. They should be instructed to use condoms if there is any risk of contracting an STI from a sexual partner. If they become pregnant while taking acyclovir, the risk of birth defects does not appear to be higher than that for the general population; however, continued use should be based on whether the benefits for the patient outweigh the possible risks to the fetus. Acyclovir does enter breast milk, but the amount of medication ingested during breastfeeding is very low and is usually not a health concern (Centers for Disease Control and Prevention [CDC], 2015). Because newborn HSV infection is such a devastating disease, prevention is critical. Patients 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 labour and birth. This could prevent the need for Caesarean birth and also decrease the risk of newborn infection (PHAC, 2013d). Patients should be questioned regarding the presence of HSV at the onset of labour. If visible lesions are not present when labour begins, vaginal birth is acceptable. Caesarean birth within 4 hours after labour 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. The emotional impact of contracting an incurable STI such as herpes can be considerable. The most common psychological patient concerns include the following: • Fear of transmission • Fear of being judged or rejected by a partner • Loneliness, depression, and low self-esteem • Anxiety concerning potential effect on childbearing Patients need the opportunity to discuss their feelings and may need help in learning to live with the disease. A patient can be encouraged to think of themselves as someone who is healthy and merely inconvenienced from time to time. Herpes can affect a person’s sexuality, their sexual practices, and their current and future relationships. They may need help in discussing their HSV status with their partner or with future partners.

Hepatitis. Five different viruses (hepatitis viruses A, B, C, D, and E) account for almost all cases of viral hepatitis in humans. While only

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hepatitis B is considered an STI, hepatitis A 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 a fecal–oral route by ingestion of contaminated food, particularly milk, shellfish, or polluted water, or person-to-person contact. People who are at risk for developing HAV include travellers to or immigrants from HAV-endemic areas, drug users (injectable and noninjectable), household contacts of adopted children from countries with endemic HAV, and individuals living in some Indigenous communities (Government of Canada, 2021a). HAV infection is characterized by flulike symptoms with malaise, fatigue, anorexia, nausea, pruritus, fever, and upper right quadrant pain. Serological testing to detect the immunoglobulin M (IgM) antibody is done to confirm acute infections. Because HAV infection is self-limited and does not result in chronic infection or chronic liver disease, treatment is usually supportive and includes bed rest, balanced nutrition, and avoidance of alcohol or other medications that cause liver damage (e.g., acetaminophen ethyl alcohol) (Government of Canada, 2021a). Patients who become dehydrated from nausea and vomiting or who have fulminating hepatitis A may need to be hospitalized. Hepatitis A vaccine is effective in preventing most HAV infections and is recommended for persons travelling to areas with high levels of HAV or with other increased risks of developing HAV. Hepatitis B. Hepatitis B virus (HBV) infection is an STI and is the virus most threatening to the fetus and newborn. 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). HBsAg has been found in blood, saliva, sweat, tears, vaginal secretions, and semen. Screening for active or chronic disease or disease immunity is based on testing for these antigens and their antibodies. Populations at greatest risk for HBV are listed in Box 7.8. Perinatal transmission most often occurs in infants of a pregnant parent who has 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, or breast milk. HBsAg has also been transmitted by artificial insemination. Although HBV can be transmitted via blood transfusion, the incidence of such infections has decreased significantly since the testing of blood for HBsAg became routine. The prevalence of HBV in Canada is estimated to be 0.5 to 1.0%, with an increased rate among immigrants and Indigenous populations (PHAC, 2014). 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 person may have clay-coloured stools, dark urine, increased abdominal pain, and jaundice. Approximately 5% of individuals with HBV have persistent HBsAg and become chronic hepatitis B carriers. Screening and diagnosis. All people at high risk for contracting HBV should be screened on a regular basis. Screening should also be done routinely in the following situations: pregnancy, HIV or HCV infection, planned therapy with immunosuppressive/immunoregulatory agents, or a compromised immune system. Screening for the presence of HBsAg is recommended in all pregnant patients at the first prenatal visit or on admission for labour and birth if prenatal test results are not available (PHAC, 2014). It is important to maintain a

BOX 7.8

High-Risk Groups for Hepatitis B

• Birth in a region with intermediate or high endemicity • Infants born to hepatitis B surface antigen (HBsAg)-positive mothers • Exposure before 7 years of age (e.g., child’s immediate and/or extended family immigrated from a region of intermediate or high endemicity and/ or child visited such a region) • Family history of hepatitis B or hepatoma • Exposure to HBsAg-positive person (e.g., percutaneous, sexual/household contact) • High-risk sexual activities (e.g., unprotected sex, multiple sexual partners) • Substance use with sharing of equipment (e.g., injection or inhalation drug use) • Exposure to blood or blood products in endemic regions without routine precautions or screening • Transfusion recipient or medical procedure in Canada before 1970 • Use of shared or contaminated materials or equipment (e.g., instruments or tools used for personal services procedures such as tattooing or piercing and body modifications, or any alternative health care that has the potential to break the skin) • Use of shared or contaminated medical devices (e.g., glucometers) • Occupational exposure to blood or body fluids • Travel to or residence in a region of intermediate or high endemicity • Incarceration • Institutionalization (particularly in institutions for developmentally challenged persons) HBV, Hepatitis B virus; HBsAg, hepatitis B surface antigen. Government of Canada. (2014). Primary care management of hepatitis B—Quick reference (HBV-QR). https://www.canada.ca/en/public-health/ services/reports-publications/primary-care-management-hepatitis-bquick-reference.html#intro. Reproduced with permission from the Minister of Health, 2016.

high index of suspicion for HBV, as infection is frequently asymptomatic; 30% of infections have no identified risk factors (PHAC, 2014). 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 person is identified as a carrier. If the HBsAg test result is positive, further laboratory studies may be ordered: anti-HBe, anti-HBc, serum glutamicoxaloacetic transaminase (SGOT), alkaline phosphatase, and liver panel. HBV is a notifiable disease in all provinces and territories in Canada and must be reported to the regional/local Medical Officer of Health. Collaborative care. There is no specific treatment for hepatitis B. Recovery is usually spontaneous in 3 to 16 weeks for 95% of people with the infection. Pregnancies complicated by acute viral hepatitis are managed on an outpatient basis. Patients should be advised to increase bed rest; eat a high-protein, low-fat diet; and increase their fluid intake. They should avoid using alcohol and medications metabolized in the liver. Pregnant patients with a definite exposure to HBV should be given hepatitis B immunoglobulin (HBIG) and begin the hepatitis B vaccine series within 14 days of the most recent contact to prevent infection (Castillo et al., 2017). Pregnant patients who are not immune to HBV may be vaccinated, and those who are at risk of HBV infection should be vaccinated during pregnancy, as vaccination during pregnancy is not thought to pose risks to the fetus (Castillo, et al., 2017: Government of Canada, 2020). Patient education includes explanation of the meaning of hepatitis B infection, including transmission, state of infectivity, and sequelae. The nurse should also explain the need for immunoprophylaxis for

CHAPTER 7 household members and sexual contacts. To decrease transmission of the virus, patients with hepatitis B or 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; not share razor blades, toothbrushes, needles, or manicure implements; have a male partner use a condom if he is unvaccinated and without hepatitis; avoid sharing saliva through kissing or through sharing of silverware or dishes; and wipe up blood spills immediately with soap and water). Patients should inform all health care providers of their carrier state. Postpartum patients should be reassured that breastfeeding is not contraindicated and patients with chronic HBV infection who wish to breastfeed should be encouraged to do so (Castillo et al., 2017). Prevention. Primary prevention of HBV should be the focus for treatment. Primary prevention includes counselling and education regarding risky behaviours, harm reduction strategies (needle exchange programs), and hepatitis B vaccination (pre-exposure). All provinces and territories have either a universal school-based hepatitis B vaccination program aimed at children aged 9 to 13 or a newborn vaccination program, although the Canadian Paediatric Society (CPS) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) are advocating for the harmonization of immunization schedules in Canada and for universal HBV immunization for newborns (Castillo et al., 2017). Hepatitis B vaccine should also be offered to high-risk groups (see Box 7.8). The vaccine is given in a series of three (four if rapid protection is needed) doses over a 7-month period, with the first two doses given at least 1 month apart. Secondary prevention is the administration of HBIG. This should be offered to affected individuals, including pregnant patients who have percutaneous (needlestick) or mucosal exposure, up to 7 days after exposure and to sexual contacts within 14 days of exposure (ideally within 48 hours), followed by hepatitis B vaccine. For infants born to an HBV-infected parent, the first dose of hepatitis B vaccine and HBIG should be administered within 12 hours of birth (Castillo et al., 2017). Hepatitis C. Hepatitis C virus (HCV) is an important cause of chronic liver disease and is becoming a major public health concern worldwide. It is estimated that there are approximately 220 000 people with chronic hepatitis C, and many people are unaware of their infection (Ha et al., 2016). The most common risk factor is sharing drug use equipment (injection, intranasal, or inhalation), even once. Other risk factors include exposure to nonsterile equipment during hemodialysis, needle stick injury, tattooing or body piercing, sharing of personal care items, or during surgical procedures; receipt of blood, blood product, or organ transplant prior to 1992 in Canada; invasive medical procedures in countries where infection prevention and control practices are not standardized; engaging in high-risk sexual behaviour; and being born to a mother who is HCV-positive (Government of Canada, 2021b). Most patients with HCV are asymptomatic or have general flu-like symptoms similar to those of hepatitis A. HCV infection is confirmed by the presence of anti-C antibody during laboratory testing. Routine HCV testing is recommended for people with risk factors (Boucher & Gruslin, 2017). The treatment of hepatitis C involves direct-acting antivirals for nearly all patients. The treatment of infected patients should be individualized to maximize chance of success, especially for difficult-to-cure populations, including patients with renal failure, decompensated cirrhosis, and active substance use disorders (Shah et al., 2018). Harm reduction strategies for drug use is an important adjunct for many persons with HCV. Currently, there is no vaccine to prevent hepatitis C. Transmission of HCV through breastfeeding has not been reported, although

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individuals with cracked, bleeding nipples are advised to stop breastfeeding until the nipples heal. Hepatitis C is reportable to local public health authorities in all provinces and territories.

Human Immunodeficiency Virus (HIV). The number of people living with HIV (including acquired immunodeficiency syndrome [AIDS]) continues to rise, with an estimated 62 050 Canadians living with HIV at the end of 2018 (CATIE, 2021). One reason for the increase in the number of people living with HIV is that new infections continue to increase at a greater number than HIV-related deaths, as new treatments have improved survival. An estimated 23% of cases of HIV are among women, and 10% of all people with HIV are Indigenous (CATIE, 2021). Behaviours that place people at risk have been well documented; nonetheless, all patients should be assessed for the possibility of HIV exposure. Severe depression of the cellular immune system associated with HIV infection characterizes AIDS. The most commonly reported opportunistic diseases are Pneumocystis carinii pneumonia, 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 patients with PID who are also HIV-positive, but antibiotics are often as effective in HIV-positive patients with PID as they are in HIVnegative patients with PID (Gardella et al., 2017). The clinical course of HPV infection in women with HIV infection is accelerated and recurrence is more frequent. 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 epidemiological 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 for HIV, as well as teaching and counselling on risk factors, indications for being tested, and testing, are important roles for nurses. A number of behaviours place people at risk for HIV infection, including intravenous drug use, high-risk sex practices, multiple sex partners, and a previous history of multiple STIs. In Canada, HIV infection is screened for by using fourth-generation HIV tests, which can detect both the p24 antigen and anti-HIV antibodies. These HIV tests are sometimes referred to as antigen–antibody combination tests. Fourth-generation HIV tests can detect HIV infection in 50% of people by 18 days after infection, 95% of people by 34 days after infection, and 99% of people by one and a half months after infection (CATIE, 2020). An alternative method of rapid testing for HIV is available, which involves using a blood sample obtained by fingerstick or venipuncture, serum, or plasma. The tests have accuracy rates of 98 to 99%. Currently, there are two rapid HIV screening tests that have been approved in Canada. These rapid tests are the point-of-care test and the self-test, both of which can provide results within minutes (CATIE, 2020). If results to this test are reactive, this must be confirmed with an additional blood test. Transmission of the virus from pregnant patient to fetus can occur throughout the perinatal period. Exposure may occur to the fetus through parental circulation as early as the first trimester of pregnancy, to the newborn during labour and birth by inoculation or ingestion of

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parental blood and other infected fluids, or to the newborn through breast milk (Bitnum et al., 2014). Thus all pregnant patients should have HIV screening with appropriate counselling. This testing must be voluntary; no one should be tested without their knowledge (Keenan-Lindsay & Yudin, 2017). Because the HIV antibody crosses the placenta, a definite diagnosis of HIV in children younger than 18 months is based on laboratory evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection (Bitnum et al., 2014). Counselling about HIV testing. Counselling before and after HIV testing is standard practice. It is a nurse’s responsibility to assess a person’s understanding of the information that such a test would provide and to ensure that they thoroughly understand the emotional, legal, and medical implications of a positive or negative test, before taking an HIV test. Given the strong social stigma attached to HIV infection, nurses must consider the issue of confidentiality and documentation before providing counselling and offering HIV testing to patients. Unless rapid testing is done, there is generally a 1- to 3-week waiting period for results after testing for HIV; this can be a very anxious time for the patient. The nurse should inform them that this time period between blood drawing and test results is routine. Test results must always be communicated in person, and patients should be told in advance that this is the procedure. Whenever possible, the person who provided the pretest counselling should also be the one to give the patient the test results. The person’s reaction to a negative test should be explored by asking, “How do you feel?” Counselling sessions for patients with an HIVnegative result are another opportunity to provide education. Emphasis can be placed on ways in which a person can remain HIV-free. Patients should be encouraged to have ongoing testing if high-risk behaviours continue. In post-test counselling of an HIV-positive patient, privacy with no interruptions is essential. Adequate time for the counselling sessions should also be provided. The nurse should make sure that the person understands what a positive test means and review the reliability of the test results. Risk-reduction practices should be re-emphasized. Referral for appropriate medical evaluation and follow-up should be made, and the need or desire for psychosocial or psychiatric referrals assessed. The public health unit needs to be notified regarding the positive status, as HIV is a reportable disease in Canada. Disclosure issues should be discussed with the patient, including the medicolegal requirement to disclose the HIV status to a potential sexual or drug-injecting partner. In general, persons with HIV infection should inform their primary health care provider and consider informing other health care providers (e.g., dentist). Disclosure in the workplace is usually not mandatory but should be individualized (e.g., where the person with HIV infection has direct patient-care responsibilities). The nurse should also discuss disclosing the diagnosis to friends or family; while not essential, this might be considered if there is potential for a positive outcome (e.g., positive family support). The importance of early medical evaluation (to determine baseline health status) and the benefits of treatment and follow-up need to be stressed. If possible, the nurse should make a referral or appointment for the patient at the post-test counselling session. Collaborative care. During the initial contact with an HIV-infected person, the nurse should establish what the person knows about HIV infection and determine whether they are being cared for by a medical practitioner or facility with expertise in caring for persons with HIV infections, including AIDS. Psychological referral also may be indicated. Resources such as counselling for financial assistance and legal advocacy may be appropriate. Patients who are drug users should be offered referral to a substance-use cessation program. A major focus of counselling is prevention of transmission of HIV to partners.

Nurses counselling seropositive persons wishing for contraceptive information can recommend oral contraceptives and latex condoms, or tubal sterilization or vasectomy and latex condoms. Female condoms or abstinence should be suggested to patients whose male partners will not wear condoms. No cure is available for HIV infections at this time, although proper treatment and care have slowed disease progression to such a degree that HIV infection is now considered a chronic, manageable condition. Opportunistic infections and concurrent diseases caused by HIV can be managed vigorously with treatment specific to the infection or disease. Routine gynecological care for HIV-positive patients should include a pelvic examination with thorough Pap screening every 6 months, twice and then at least annually depending on the results (PHAC, 2016). Thorough Pap screening is essential because of the greatly increased incidence of abnormal findings on examination. In addition, HIVpositive patients should be screened for syphilis, gonorrhea, chlamydia, and other vaginal infections and treated if infections are present. General health promotion strategies are an important part of care (e.g., smoking cessation, sound nutrition), as is antiretroviral therapy (ART). Discussion of the medical care of HIV-positive patients or patients with AIDS is beyond the scope of this chapter because of the rapidly changing recommendations. The reader is referred to the Centers for Disease and Prevention (CDC) (https://www.cdc.gov/hiv/ default.html) and to Internet websites such as the Canadian Aids Treatment Information Exchange (http://www.catie.ca) for current information and recommendations. For care of the pregnant patient with HIV see Chapter 15.

NURSING ALERT Counselling associated with HIV testing has two components: pretest and posttest. During pretest counselling, a personalized risk assessment is conducted, the meaning of positive and negative test results is explained, informed consent for HIV testing is obtained, and the patient is helped to develop a realistic plan for reducing risk and preventing infection. Post-test counselling includes informing the patient of the test results, reviewing the meaning of the results, and reinforcing prevention messages. All pretest and post-test counselling should be documented.

Zika Virus. The Zika virus is spread by bites from the Aedes mosquito. It is also spread via sexual contact through semen. Patients 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-Barre syndrome, a neurological condition that can lead to muscle weakness and possibly paralysis (Government of Canada, 2019). The Aedes mosquito has been found predominantly in Africa, Southeast Asia, the Caribbean, Central America, South America, and the Pacific Islands. Currently, the mosquitoes that transmit Zika virus are not established in Canada because of the colder climate, so there is a very low probability of mosquito transmission in Canada (Government of Canada, 2019). Pregnant individuals and those considering becoming pregnant should avoid travelling to areas that are known to have the Aedes mosquito. Male travellers who may have been exposed to the Zika virus should use a condom for 3 months after exposure. Male travellers with a pregnant partner should refrain from unprotected sex for the duration of the pregnancy (Government of Canada, 2019).

Vaginal Infections Vaginal discharge and itching of the vulva and vagina are among the most common reasons an individual seeks help from a health care provider. Patients cite discomfort from vaginal discharge more than any

CHAPTER 7 other gynecological symptom. 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 odour. 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, candidiasis, and trichomoniasis. Vulvovaginitis (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 vaginitis. The exact etiology of BV is unknown and it is not usually considered an STI. It is a syndrome in which normal hydrogen peroxide–producing lactobacilli are replaced with high concentrations of anaerobic bacteria (Gardnerella and Mobiluncus). With the proliferation 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 odour of BV occurs. Screening and diagnosis. A careful history may help distinguish BV from other vaginal infections if the person is symptomatic. Most patients with BV notice a characteristic “fishy odour” in the vaginal area, although not all note it. The odour may be noticed by the patient or their partner after intercourse when semen is present, because semen releases the vaginal amines. When present, the BV discharge is usually profuse; thin; and white, grey, or milky in appearance. Some patients also may experience mild irritation or pruritus. Patients with previous occurrence of similar symptoms, diagnosis, and treatment should be queried because patients with BV often have been treated incorrectly due to misdiagnosis. Microscopic examination of vaginal secretions is always done (Table 7.4). Both normal saline and 10% potassium hydroxide (KOH) smears should be made. The presence of clue cells confirmed by wet smear is highly diagnostic because the phenomenon is specific TABLE 7.4

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) prep (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 odour

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to BV (PHAC, 2013c). Vaginal secretions should be tested for pH and amine odour. Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. The fishy odour of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum. Collaborative care. Treatment of BV with oral metronidazole (Flagyl) is most effective (PHAC, 2013c), although vaginal preparations (e.g., metronidazole gel, clindamycin cream) are also used. The decision of which treatment to use should be based on the preference of the patient. Adverse effects of metronidazole are numerous and include a sharp, unpleasant metallic taste in the mouth; furry tongue; CNS reactions; and urinary tract disturbances. When oral metronidazole is taken, the patient is advised not to drink alcoholic beverages, as severe adverse effects of abdominal distress, nausea, vomiting, and headache may occur. Gastrointestinal symptoms are common whether alcohol is consumed or not. Treatment of sexual partners is not recommended because sexual transmission of BV has not been proven. BV during pregnancy is associated with premature rupture of the membranes, chorioamnionitis, preterm labour, preterm birth, and post-Caesarean endometritis (PHAC, 2013c). Therefore, pregnant patients should be treated to relieve vaginal symptoms and the signs of infection.

Candidiasis. Vulvovaginal candidiasis (VVC), or yeast infection, is a common type of vaginal infection in Canada. It is estimated that approximately 75% of women will have at least one episode of VVC in their lifetime, and 5% of patients of reproductive age will have recurrent VVC (four or more episodes of VVC a year) (PHAC, 2013c). Although vaginal candidiasis infections are common in healthy patients, those seen in patients 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 infecting organism is Candida albicans. It is estimated that 90% of yeast infections in patients are caused by this organism. In recent years, the incidence of non–C. albicans infections has increased steadily. Patients with chronic or recurrent infections often are infected with a higher percentage of non–C. albicans species than are patients with their first infection or those who have few recurrences (PHAC, 2013c). Numerous factors have been identified as predisposing a person to yeast infections. These include antibiotic therapy, particularly broadspectrum 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 grow. The most common symptom of yeast infection is vulvar and possibly vaginal pruritus. The itching may be mild or intense, may interfere with rest and activities, and may occur during or after intercourse. Some patients report a feeling of dryness. Others may have painful urination as the urine flows over the vulva. The latter usually occurs in patients 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 odour characteristic of yeast infections, sometimes a yeasty or musty smell is noted. Screening and diagnosis. In addition to noting the person’s symptoms, their onset, and their course, 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

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smear and vaginal pH are obtained (see Table 7.4). 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. Collaborative care. A number of antifungal preparations are available for the treatment of C. albicans. Fluconazole in a single dose can be prescribed, and other medications (e.g., miconazole [Monistat] and clotrimazole [Canesten]) are available as OTC agents. Fluconazole is contraindicated in pregnancy. 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 person suspects that they have a yeast infection they should see a health care provider for confirmation of the diagnosis and for treatment recommendation. If they have another infection, they may wish to purchase an OTC preparation and self-treat. Treatments should begin to work in 2 to 3 days. If the person elects to do this, they should always be counselled 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. Patients 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 person’s comfort. Not wearing underpants to bed may help decrease symptoms and prevent recurrences. Completion of the full course of treatment prescribed is essential to removing the pathogen. Medication should be continued even during menstruation. Patients should be counselled not to use tampons during menstruation because the medication will be absorbed by the tampon. If possible, intercourse should be avoided during treatment; if this is not feasible, the patient’s partner should be encouraged to use a condom if appropriate, to prevent introduction of more organisms. Suggested measures to prevent genital tract infections are in the Patient Teaching Box, Prevention of Genital Tract Infections.

PATIENT TEACHING Prevention of Genital Tract Infections • • • • • • • • • • • • •

Practise genital hygiene. 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. Avoid coloured 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 yogourt (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 Trichomonas vaginalis, an anaerobic, one-celled protozoan with characteristic flagella. Although trichomoniasis may be asymptomatic, commonly patients have yellowish-to-greenish, frothy, mucopurulent,

copious, and malodourous discharge. Inflammation of the vulva, vagina, or both may be present, and the patient may report irritation and pruritus. Dysuria and dyspareunia are often present. Typically the discharge worsens during and after menstruation. The cervix and vaginal walls demonstrate the characteristic “strawberry spots” or tiny petechiae in less than 10% of patients, and the cervix may bleed on contact. In severe infections the vaginal walls, cervix, and, occasionally, the vulva may be acutely inflamed. Screening and diagnosis. In addition to obtaining a history of current symptoms, a thorough sexual history should be taken. The nurse should note any history of similar symptoms in the past and treatment used. The nurse also needs to determine whether the patient’s partner or partners were treated and if they have had subsequent relations with new partners. A speculum examination is always done, even though it may be uncomfortable for the person; relaxation techniques and breathing exercises may help the patient with the procedure. 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 prep (see Table 7.4). The pH of the discharge is greater than 5.0. Because trichomoniasis is an STI, once diagnosis is confirmed, appropriate laboratory studies for other STIs should be carried out. Collaborative care. The recommended treatment is metronidazole (Flagyl), 2 g orally in a single dose, or an alternative treatment is 500 mg orally bid for 7 days (PHAC, 2013c). Although a male partner is usually asymptomatic, he should receive treatment also because he often harbours 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. Patients should be taught that they should not drink alcohol during and for 24 hours after therapy as there is a risk of a disulfiram (Antabuse) reaction. Symptoms of this reaction include dizziness, headache, shortness of breath, palpitation, and nausea and vomiting. In pregnant patients trichomoniasis may be associated with premature rupture of the membranes, preterm birth, and low birth weight. Symptomatic pregnant patients should be treated with metronidazole (PHAC, 2013c). Patients with trichomoniasis need to understand the sexual transmission of this disease. Patients must know that the organism may be present without observable symptoms, perhaps for several months, and that determining when they became infected is impossible. Trichomoniasis is a reportable disease in some jurisdictions.

CONCERNS OF THE BREAST Benign Problems Fibrocystic Changes. Approximately 50% of patients have a breast concern at some point in their adult lives. The most common benign breast issue is fibrocystic change (Sandadi et al., 2017). Fibrocystic changes occur to varying degrees in breasts of healthy individuals. The etiological 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 usually develop approximately a week before menstruation begins and subside approximately a 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 feels like peas (Sandadi et al., 2017). Larger cysts are often described as feeling like water-filled balloons.

CHAPTER 7 Patients in their 20s report the most severe pain. Patients in their 30s have premenstrual pain and tenderness; small, multiple nodules are usually present. Patients in their 40s usually do not report severe pain, but cysts are tender and often regress in size (Sandadi et al., 2017). Steps in the workup of a breast lump may begin with an ultrasound to determine whether it is fluid filled or solid. Fluid-filled cysts are aspirated, and the patient is monitored on a routine basis for the development of other cysts. If the lump is solid, a mammogram may be obtained if the patient is older than age 50 years. A fine-needle aspiration (FNA) is performed, regardless of the patient’s age, to determine the nature of the lump (Sandadi et al., 2017). A low-fat, nutrient-dense diet with decreased saturated fat is recommended, and sometimes, despite lack of clear evidence, eliminating methylxanthines (colas, coffee, tea, chocolate) is also advised. Some practitioners suggest that patients 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 people, although more research on these treatments is needed. Oral contraceptives, danazol, bromocriptine, and tamoxifen have also been used with varying degrees of success.

Fibroadenomas. The next most common benign neoplasm of the

breast is a fibroadenoma. It is the single most common type of tumour seen in the adolescent population, although it can also occur in people in their 30s. Fibroadenomas are discrete, usually solitary lumps averaging 2.5 cm in diameter (Sandadi et al., 2017). Occasionally the person with a fibroadenoma experiences tenderness in the tumour 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 patient ages. The cause of fibroadenomas is unknown. Diagnosis is made by reviewing the patient history and physical examination. Mammography, ultrasound, or magnetic resonance imaging (MRI) helps determine the type of lesion. FNA may be used to determine underlying pathological conditions. Surgical excision may be necessary if the lump is suspicious for malignancy 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). Individuals need to recognize changes in their breasts and seek further evaluation from a clinician.

Lipomas. A lipoma is a tumour composed of fat that is soft and has discrete borders. The cause of lipoma is unknown. Lipomas are often found in individuals over 45 years of age, usually on the chest wall and breast. They are characterized as palpable soft masses that are mobile and nontender. Mammograms can be used to make a diagnosis; biopsy usually is not needed. Lipomas can be surgically excised if removal is desired. Nipple Discharge. Nipple discharge is a common occurrence that affects many patients. Although most nipple discharge is physiological, each patient who has this problem must be evaluated thoroughly, as a small percentage of patients are 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 patient 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

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levels, caused by a thyroid disorder, pituitary tumour, or chest wall surgery or trauma. Obtaining a complete medication history for each patient is essential, as some medications can precipitate galactorrhea in some people (Sandadi et al., 2017). Diagnostic tests that may be indicated include a physical examination, mammography, ultrasound or MRI, as well as ductoscopy to microscopically evaluate the discharge (Sandadi et al., 2017).

Mammary Duct Ectasia. Mammary duct ectasia is an inflammation of the ducts behind the nipple. It occurs most often in perimenopausal patients and is characterized by a nipple discharge that is thick, sticky, and white, brown, green, or purple. The patient frequently experiences a burning pain, an itching, or a palpable mass behind the nipple. The diagnostic 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 individuals between 30 and 50 years of age. The papilloma is usually too small to be palpated (less than 0.5 cm), and the characteristic sign is 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). Nursing Care. Assessment should include a careful history and physical examination. Table 7.5 compares common manifestations of benign breast masses. 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 nurse should document the following patient information: pain, whether symptoms increase with menses, dietary habits, smoking habits, and the use of oral contraceptives. The patient’s emotional status, including stress level, fears, and concerns, should also be assessed. Physical examination may include assessment of the breasts for symmetry, masses (size, number, consistency, and mobility), and nipple discharge. Nursing actions might include the following: • Discuss the intervals for and facets of breast screening mammography (see Table 7.5). Patients with breast implants may require special views of the breast and precautions taken to avoid rupture of the implant during mammography. • Provide written educational materials in the patient’s primary language. • Encourage expression of fears and concerns about treatment and prognosis. • Provide specific information regarding the patient’s condition and treatment, including dietary changes, medication therapy, comfort measures, stress management, and surgery. • 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.

Cancer of the Breast After skin cancer, breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer deaths in women in Canada.

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TABLE 7.5

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Comparison of Common Manifestations of Benign Breast Masses

Fibrocystic Changes

Fibroadenoma

Lipoma

Intraductal Papilloma

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

Mortality rates from breast cancer have declined slightly since 1990. Nonetheless, 1 in 8 Canadian women will develop breast cancer in their lifetime, and 1 out of every 33 is expected to die from it. The prognosis for and survival of the patient are improved with early detection. Therefore, patients 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 the risk for developing a malignancy. These factors are listed in Box 7.9. Although most breast cancers are not related to genetic factors, the identification of the BRCA1 and BRCA2 genes demonstrated the role of heredity and genetic mutations in this disease. Only 5 to 10% of breast cancers are attributed to heredity. Individuals who have abnormalities in the BRCA1 and BRCA2 genes have up to an 85% chance of developing breast cancer (CCS, 2021b). During breast cancer risk counselling, facts should be presented to patients by their health care provider in a supportive, nondirective way, without personal opinions or preferences. Discussion should also include treatment options and prognosis of breast cancer, as well as risks and benefits of alternative methods of prevention and early diagnosis. A patient’s recognition of having increased breast cancer risk can carry psychological consequences such as anxiety, guilt, depression, and reduced self-esteem. Enormous guilt may be experienced by highrisk patients who pass specific genetic mutations on to their children.

BOX 7.9

Psychological intervention may be offered to assist individuals in coping with these significant adverse sequelae.

Genetic Testing for Breast Cancer Risk. Although knowing whether one is hereditarily predisposed to breast cancer may have benefits, the extent to which an individual can benefit from this information remains unclear. Confirming one’s mutation status may provide a sense of control in life plans or it may create high levels of anxiety and distress. Genetic testing can alter decisions regarding family and intimate relationships, childbearing, body image, and quality of life. Regardless of whether results are positive or negative for BRCA1 and BRCA2 mutations, the results can have a highly negative impact on individual’s lives. Patients at increased risk for breast cancer need comprehensive information about the benefits and limitations of genetic testing to ensure that informed decisions about genetic testing can be made. Because decisions regarding genetic testing, genetic counselling, and breast cancer risk assessment are highly individualized, health care providers should be careful in making any generalizations about individuals at risk for breast cancer. Prevention. Patients who are at high risk for breast cancer have options to consider that can reduce the risk of developing cancer. Chemoprevention includes the use of tamoxifen, which is an antiestrogen medication. It block the effects of estrogen in some tissues,

Risk Factors for Breast Cancer

There is convincing evidence that the following factors increase the risk for breast cancer: • Previous history of breast cancer • Family history of breast cancer and other cancers, especially if a first-degree relative had breast cancer diagnosed before menopause • Inherited genetic mutations in BRCA1 and BRCA2 genes • Dense breasts • Certain rare genetic conditions (e.g., Li-Fraumeni syndrome, ataxia telangiectasia [AT], Cowden syndrome, or Peutz-Jeghers syndrome) • Other gene mutations (e.g., CHEK2 or PALB2) • Ashkenazi Jewish ancestry • Reproductive history: early menarche (11 years or younger); Late menopause (after age 55); nulliparity or first pregnancy after age 30; not breastfeeding • Exposure to ionizing radiation • Use of hormone replacement therapy

• • • • • • •

Use of oral contraceptives Atypical hyperplasia (in breasts) Alcohol consumption Obesity Physical inactivity Higher socioeconomic status Tall adult height

Possible Risk Factors • Increased adult weight gain • Smoking or exposure to secondhand smoke • Night shift worker • Some noncancerous breast conditions • Never having breastfed

Source: Canadian Cancer Society. (2021). Risk factors for breast cancer. https://www.cancer.ca/en/cancer-information/cancer-type/breast/risks/? region¼on

CHAPTER 7 such as breast tissue, and acts like estrogen in other tissues. Tamoxifen reduces the risk of breast cancer, especially in patients with BRCA2 gene mutations, although it increases the risk of uterine (endometrial) cancer. Patients need information in order to weigh the risks and benefits of taking these medications. Surgical prophylaxis (bilateral mastectomy, oophorectomy) can reduce the risk of breast cancer, but it should be considered only for people at very high risk (CCS, 2021b).

Screening and Diagnosis. Breast cancer in its earliest form can be detected by a mammogram before it is felt by a patient. More than half of all lumps are 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. In Canada, screening mammography (X-ray filming of the breast) (Figure 7.13) is recommended as the only method used to detect early breast cancers. Individuals at low risk for developing breast cancer who are between the ages of 50 and 69 should have screening mammograms done every 2 to 3 years. Individuals aged 40 to 49 are not recommended to have regular mammography, but some individuals may wish to be screened on the basis of their values and preferences; in this circumstance, care providers should engage in shared decision making with patients who express an interest in being screened (Canadian Task Force on Preventative Health Care [CTFPHC], 2018). Patients over 70 years of age should discuss with their health care provider how often mammograms should be done (CTFPHC, 2018). From an early age, patients should be familiar with how their breasts look and feel; however, routine breast self-examination (BSE) is no

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longer recommended, as BSE does not save lives and leads to more unnecessary biopsies. Individuals who wish to continue to perform BSE need to be given appropriate information that includes performing an examination of the breasts when they are not tender or swollen. Clinical breast examination (CBE) by a qualified health care provider is also not recommended in patients with a low risk for breast cancer (CTFPHC, 2018). All provinces and territories have organized breast cancer screening programs for patients 50 to 69 years of age. Individuals are automatically invited to take part in the breast screening program and are sent letters reminding them of their next screening mammogram. Cultural factors may influence a patient’s decision to participate in breast cancer screening. Knowledge of these factors and use of culturally sensitive tailored messages and materials that appeal to the unique concerns, beliefs, and reading abilities of identified groups of patients who do not participate in breast screening may assist the nurse in helping patients overcome barriers to seeking care (see Cultural Awareness box).

CULTURAL AWARENESS Breast Screening Practices Some individuals do not take part in breast cancer screening. More than half of recent immigrants (less than 10 years) have not had a screening mammogram, compared to 25% of Canadian-born patients. Many factors play a role in influencing the screening practices of patients, including lack of awareness of mammography screening, gender and modesty concerns unique to cultural beliefs, and fear resulting from a sense of vulnerability to breast cancer. Income, marital status, education, and language difficulties also influence rates of screening. Interventions that encourage all patients to participate in early breast cancer screening practices require patients’ input to improve our understanding of the barriers that individuals have to getting screened. This information could contribute to the design of community-driven interventions to enhance accessibility of breast cancer screening services. Existing research has suggested various strategies that place an emphasis on the need to develop tailored and culturally appropriate interventions for patients to overcome knowledge and structural barriers, address misconceptions, and promote screening practices. Mobile breast cancer screening units may help patients overcome these various obstacles to accessing this preventive care. Interventions that encourage individuals to participate in early breast cancer screening practices begin with the development of culturally sensitive community education programs designed to help patients deal with barriers to reaching optimal levels of health. Source: Mahamoud, A. (2014). Breast cancer screening in racialized women: Implications for health equity. Wellesley Institute. http://www. wellesleyinstitute.com/publications/breast-cancer-screening-inracialized-women/

Fig. 7.13 Mammography. (Courtesy Shannon Perry.)

When a suspicious finding on a mammogram is noted or when a lump is detected, diagnosis is confirmed by means of diagnostic mammogram, FNA, core needle biopsy, or surgical excision (Figure 7.14). Ultrasound may also be used to assess a specific area of abnormality found during a mammogram procedure (CCS, 2021b). Patients need specific information regarding advantages and disadvantages of these procedures to make a decision about which one is most appropriate for them. 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 chest X-ray film examination, bone scan, CT, MRI, and positron emission tomography (PET) scan (CCS, 2021b). An important step in evaluating a breast cancer is to test for the presence of estrogen and progesterone receptors in the biopsied

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A

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Women’s Health

B

Fig. 7.14 Diagnosis of breast abnormality. A, Needle aspiration. B, Open biopsy. (Redrawn from National Women’s Health Resource. [1995]. National Women’s Health Report, 13[5], 3.)

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. Patients with hormone-positive tumours tend to respond better to treatment and have higher survival rates than individuals with hormone-negative results (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).

Breast Cancer During Pregnancy. Although breast cancer is the most common cancer diagnosed during pregnancy, it is rare. About 1 out of every 3 000 pregnant patients is diagnosed with breast cancer. Treatment decisions for breast cancer in pregnancy are based on the stage of breast cancer and the age of the fetus. Ending a pregnancy (therapeutic abortion) is not considered a necessary part of treatment because it does not improve a patient’s prognosis or survival. Treatment for breast cancer during pregnancy often begins immediately and may include the following: • Surgery to remove the lump or the affected breast. Surgery can be carried out at any stage in pregnancy. • Chemotherapy—not given during the first 13 weeks of pregnancy as it may cause abnormalities in the fetus • Radiation—not usually offered as a treatment option until after the birth • Tamoxifen—not recommended during pregnancy as there seems to be an increased risk of fetal abnormalities when taken during pregnancy. The evidence is limited, so patients require counselling regarding its use (Schurman et al., 2019). Many individuals who are diagnosed with breast cancer during pregnancy are concerned that they can pass the breast cancer cells to their baby. There is no evidence that a fetus can get cancer from the parent with cancer while in the womb. Patients also cannot pass cancer cells to the baby through breastfeeding. Patients need correct information regarding how breast cancer treatment may affect fertility. The medical team should take into account any plans for future pregnancies and offer chemotherapy medications that are less likely to affect fertility.

Collaborative Care. Controversy continues regarding the best treatment for breast cancer. Nodal involvement, tumour size, receptor status, and aggressiveness are important variables for treatment selection.

Medical management of breast cancer includes surgery, breast reconstruction, radiation therapy, adjuvant hormone therapy, biological targeted therapy, and chemotherapy. Many patients face difficult decisions about the various treatment options. Treatment plans are designed to meet the unique needs of each person with cancer and are based on the following: stage of the breast cancer; if the person has reached menopause; hormone receptor status of the cancer; HER2 status of the cancer; risk for recurrence (with early-stage breast cancer); the overall health of the patient; and the patient’s personal decision about certain treatments (CCS, 2021b). For further information on the medical treatment and nursing care of breast cancer, refer to a medical surgical nursing text book as well as the Canadian Cancer Society.

KEY POINTS • The female’s reproductive tract structures and breasts respond predictably to changing levels of sex steroids across her lifespan. • The myometrium of the uterus is uniquely designed to expel the fetus and promote hemostasis after birth. • Normal feedback regulation of the menstrual cycle depends on an intact hypothalamic–pituitary–gonadal mechanism. • Menstrual disorders may diminish the quality of life for affected patients and their families. • Primary dysmenorrhea is a condition associated with ovulatory cycles and is related to the release of prostaglandins with menses. • PMS is a disorder with both physiological and psychological characteristics. • Endometriosis is characterized by dysmenorrhea, infertility, and, less often, alterations in menstrual cycle bleeding and dyspareunia. • Abnormal uterine bleeding has many causes; the treatment chosen is based on managing the cause of the bleeding. • Menopause is a healthy transition that has different symptoms and may require different treatments. • Key strategies for preventing STIs are the practice of and education in safer sex behaviours. • STIs are responsible for substantial mortality and morbidity, personal suffering, and a heavy economic burden in Canada. • HIV is transmitted through body fluids—primarily blood, semen, and vaginal secretions. • HPV is the most common viral STI. • Syphilis has re-emerged as a common STI. • Rates of chlamydia are increasing, and it is the most common cause of PID. • The development of breast neoplasms, whether benign or malignant, can have a significant physical and emotional effect on an individual and their family. • Approximately 50% of individuals experience a breast issue at some point in their adult lives; the risk of a Canadian woman developing breast cancer is 1 in 8.

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CHAPTER 7 Boucher, M., & Gruslin, A. (2017). SOGC clinical practice guideline: No. 96— The reproductive care of women living with hepatitis C infection. Journal of Obstetrics and Gynaecology Canada, 39(7), e1–e25. Burnett, M., & Lemyre, M. (2017). SOGC clinical practice guideline. No. 345— Primary dysmenorrhea consensus guideline. Journal of Obstetrics and Gynaecology Canada, 39(7), 585–595. Canadian Cancer Society (CCS). (2021a). Human papillomavirus (HPV) test. https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/ tests-and-procedures/hpv-test/?region¼on. Canadian Cancer Society (CCS). (2021b). What is breast cancer. http://www. cancer.ca/en/cancer-information/cancer-type/breast/breast-cancer/? region¼on. Canadian Task Force on Preventative Health Care (CTFPHC). (2018). Breast cancer update (2018). https://canadiantaskforce.ca/guidelines/publishedguidelines/breast-cancer-update/. Castillo, E., Murphy, K., van Schalkwyk, J., et al. (2017). No. 342—Hepatitis B and pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(3), 181–190. CATIE. (2020). HIV testing technologies. https://www.catie.ca/en/fact-sheets/ testing/hiv-testing-technologies. CATIE. (2021). The epidemiology of HIV in Canada. https://www.catie.ca/en/ fact-sheets/epidemiology/epidemiology-hiv-canada. Centers for Disease Control and Prevention (CDC). (2015). Sexually transmitted diseases treatment guidelines: Special populations. https://www.cdc.gov/std/ tg2015/specialpops.htm. Choudhri, Y., Miller, J., Sandhu, J., et al. (2018). Infectious and congenital syphilis in Canada, 2010–2015. Canada Communicable Disease Report, 44(2), 43–48. Drakh, A. (2016). Low energy availability in female athletes: Oral contraceptives in athletes. Medscape News and Perspective. http://emedicine.medscape.com/ article/312312-overview#a10. Duffy, J., Arambage, K., Correa, F., et al. (2014). Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews, 2014(Issue 3). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011031/ epdf/full. Art. No.: CD011031. 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. (Eds.), Comprehensive gynecology (7th ed.). Elsevier. Government of Canada. (2019). Zika virus: For health professionals. https:// www.canada.ca/en/public-health/services/diseases/zika-virus/healthprofessionals.html. Government of Canada. (2020). Immunization in pregnancy and breastfeeding: Canadian immunization guide. https://www.canada.ca/en/public-health/ services/publications/healthy-living/canadian-immunization-guide-part-3vaccination-specific-populations/page-4-immunization-pregnancybreastfeeding.html. Government of Canada. (2021a). For health professionals: Hepatitis A. https:// www.canada.ca/en/public-health/services/diseases/hepatitis-a/for-healthprofessionals.html. Government of Canada. (2021b). For health professionals: Hepatitis C. https:// www.canada.ca/en/public-health/services/diseases/hepatitis-c/healthprofessionals-hepatitis-c.html. Ha, S., Totten, S., Potagny, L., et al. (2016). Hepatitis C in Canada and the importance of risk-based screening. Canadian Communicable Disease Report, 42, 57–62. https://www.canada.ca/content/dam/phac-aspc/ migration/phac-aspc/publicat/ccdr-rmtc/16vol42/dr-rm42-3/assets/pdf/ 16vol42_3-ar-02-eng.pdf. Jafari, M., & Orenstein, G. (2015). Women and herbal medicine. In E. F. Olshansky (Ed.), Women’s health and wellness across the lifespan. Wolters Kluwer. Jarrell, J. F., Vilos, G. A., Allaire, C., et al. (2018). SOGC clinical practice guideline: No. 164—Consensus guidelines for the management of chronic pelvic pain. Journal of Obstetrics and Gynaecology Canada, 40(11), e747–e787. Lobo, R. A. (2017). Primary and secondary amenorrhea and precocious puberty. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Elsevier. Keenan-Lindsay, L., & Yudin, M. (2017). HIV screening in pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(7), e54–e58.

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Mendiratta, V. (2017). Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Elsevier. Mielke, R., Parsons, K., & Greenberg, C. S. (2015). Puberty through early adulthood. In E. F. Olshansky (Ed.), Women’s health and wellness across the lifespan. Wolters Kluwer. Money, D., Steben, M., & Infectious Disease Committee. (2017). SOGC clinical practice guideline: No. 208—Guidelines for the management of herpes simplex virus in pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(8), e199–e205. Public Health Agency of Canada (PHAC). (2013a). Section 2: Canadian guidelines on sexually transmitted infections—Primary care and sexually transmitted infections. http://www.phac-aspc.gc.ca/std-mts/sti-its/cgstildcits/section-2-eng.php#a4. Public Health Agency of Canada (PHAC). (2013b). Section 4-5: Canadian guidelines on sexually transmitted infections—Management and treatment of specific syndromes—Pelvic inflammatory disease (PID). http://www.phacaspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-4-eng.php. Public Health Agency of Canada (PHAC). (2013c). Section 4-9: Canadian guidelines on sexually transmitted infections. Management and treatment of specific syndromes: Vaginal discharge (bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis). http://www.phac-aspc.gc.ca/std-mts/sti-its/ cgsti-ldcits/section-4-8-eng.php. Public Health Agency of Canada (PHAC). (2013d). Section 5-4: Canadian guidelines on sexually transmitted infections. Management and treatment of specific syndromes: Genital herpes simplex virus (HSV) infections. http:// www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-4-eng.php. Public Health Agency of Canada (PHAC). (2014). Primary care management of Hepatitis B – Quick reference (HBV-QR). https://www.canada.ca/en/publichealth/services/reports-publications/primary-care-management-hepatitisb-quick-reference.html. Public Health Agency of Canada (PHAC). (2015). Section 5-5: Canadian guidelines on sexually transmitted infections. Management and treatment of specific infections: Human papillomavirus (HPV) infections. http://www. phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-5-eng.php. Public Health Agency of Canada (PHAC). (2016). Section 5-8: Canadian guidelines on sexually transmitted infections. Management and treatment of specific syndromes: Human immunodeficiency virus infections. http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/ section-5-8-eng.php. Public Health Agency of Canada (PHAC). (2017a). Report on sexually transmitted infections in Canada: 2013–2014. https://www.canada.ca/en/ public-health/services/publications/diseases-conditions/report-sexuallytransmitted-infections-canada-2013-14.html#a2. Public Health Agency of Canada (PHAC). (2017b). Section 5-2: Canadian guidelines on sexually transmitted infections—Management and treatment of specific infections – Chlamydial infections. https://www.canada.ca/en/publichealth/services/infectious-diseases/sexual-health-sexually-transmittedinfections/canadian-guidelines/sexually-transmitted-infections/canadianguidelines-sexually-transmitted-infections-30.html. Public Health Agency of Canada (PHAC). (2017c). Section 5-6: Canadian guidelines on sexually transmitted infections—Management and treatment of specific infections—Gonococcal infections. https://www.canada.ca/en/publichealth/services/infectious-diseases/sexual-health-sexually-transmittedinfections/canadian-guidelines/sexually-transmitted-infections/canadianguidelines-sexually-transmitted-infections-34.html. Public Health Agency of Canada (PHAC). (2017d). Section 6-4: Canadian guidelines on sexually transmitted infections—Specific populations— Pregnancy. https://www.canada.ca/en/public-health/services/infectiousdiseases/sexual-health-sexually-transmitted-infections/canadianguidelines/sexually-transmitted-infections/canadian-guidelines-sexuallytransmitted-infections-41.html. Public Health Agency of Canada (PHAC). (2020). Syphilis: Key information and resources. https://www.canada.ca/en/public-health/services/infectiousdiseases/sexual-health-sexually-transmitted-infections/canadianguidelines/sexually-transmitted-infections/canadian-guidelines-sexuallytransmitted-infections-27.html.

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Reid, R., Abramson, B. L., Blake, J., et al. (2014). SOGC clinical practice guideline: Managing menopause. Journal of Obstetrics and Gynaecology Canada, 36(9 eSuppl A), S1–S80. Reid, R., & Soares, C. (2018). Premenstrual dysphoric disorder: Contemporary diagnosis and management. Journal of Obstetrics and Gynaecology Canada, 40(2), 215–223. 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.). Elsevier. Salvadori, M. I., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2018). Human papillomavirus vaccine for children and adolescents. Paediatrics & Child Health, 23(4), 262–265. Sandadi, S., Rock, D. T., Orr, J. W., et al. (2017). Breast diseases: Detection, management, and surveillance of breast disease. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Elsevier. Schurman, T. N., Witteveen, P. O., van der Wall, E., et al. (2019). Tamoxifen and pregnancy: An absolute contraindication? Breast Cancer Research and Treatment, 175(1), 17–25. https://doi.org/10.1007/s10549-019-05154-7. Shah, H., Bilodeau, M., Burak, K., et al. (2018). The management of chronic hepatitis C: 2018 guideline update from the Canadian Association for the Study of the Liver. Canadian Medical Association Journal, 190, E677–E687. https://doi.org/10.1503/cmaj.170453. Singh, S., Best, C., Dunn, S., et al. (2018). SOGC clinical practice guideline: Abnormal uterine bleeding in pre-menopausal women. Journal of Obstetrics and Gynaecology Canada, 40(5), e391–e415.

Vercellini, P., Facchin, F., Buggio, L., et al. (2017). Management of endometriosis: Toward value-based, cost-effective, affordable care. Journal of Obstetrics and Gynaecology Canada, 40(6), 726–749. World Health Organization. (2016). Global health sector strategy on sexually transmitted infections 2016–2021: Towards ending STIs. https://apps.who. int/iris/bitstream/handle/10665/246296/WHO-RHR-16.09-eng.pdf? sequence¼1. Zimmermann, M., Kohut, T., & Fisher, W. (2018). HPV unvaccinated status and HPV sexual risk behaviour are common among Canadian young adult women and men. Journal of Obstetrics and Gynaecology Canada, 40(4), 410–414.

ADDITIONAL RESOURCES Bodysense—Promoting positive body image in sport. http://www.bodysense.ca/. Breast cancer risk assessment tool. http://www.cancer.gov/bcrisktool/. Canadian Cancer Society. http://www.cancer.ca/. Centers for Disease Control and Prevention—Sexually transmitted diseases (STDs): https://www.cdc.gov/std/default.htm. Fertility Matters. http://fertilitymatters.ca/. Government of Canada—Provincial and territorial immunization information: https://www.canada.ca/en/public-health/services/provincial-territorialimmunization-information.html. Menopauseandu.ca. http://www.menopauseandu.ca. Public Health Agency of Canada: Canadian guidelines on sexually transmitted infections: http://www.phac-aspc.gc.ca/std-mts/sti-its/index-eng.php. Sex & U. http://www.sexandu.ca.

UNIT 3 Women’s Health

8 Infertility, Contraception, and Abortion Lisa Keenan-Lindsay Originating US Chapter by Ellen F. Olshansky http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. List common causes of infertility. 2. Discuss the psychological impact of infertility. 3. Describe common diagnoses and treatments for infertility. 4. Compare reproductive alternatives for couples experiencing infertility. 5. State the advantages and disadvantages of the following methods of contraception: fertility awareness–based methods, barrier methods, hormonal methods, intrauterine contraception, and sterilization.

6. Explain common nursing interventions that facilitate contraceptive use. 7. Describe the techniques used for medical and surgical interruption of pregnancy. 8. Recognize ethical, legal, cultural, and religious considerations related to infertility, contraception, and elective abortion.

INFERTILITY

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.

Incidence Infertility is a serious concern that affects the quality of life of approximately 16% of reproductive-age couples in Canada (Public Health Agency of Canada [PHAC], 2019). Commonly, infertility is considered 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. 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 difficulties. The incidence of infertility has increased in Canada. A probable cause of infertility includes 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 (Liu & Case, 2017). Infertility increases with the age of the woman, with fertility rates in women ages 40 to 45 being 95% lower than that for women ages 20 to 24. It is unknown whether there has been an actual 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 require considerable physical, emotional, and financial investments

Factors Associated With Infertility Although exact percentages vary somewhat with populations, approximately 80% of couples have an identifiable cause of infertility, with about 40% of these causes being related to factors in the female partner, 30% related to factors in the male partner, and 20% related to factors in both partners. About 10% or more couples will experience unexplained, or idiopathic, causes of infertility (PHAC, 2019). Nevertheless, 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 lifespan. Assisted human reproduction (AHR) has 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:

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• Sperm that has the capacity to fertilize an egg must be deposited close to the cervix at the time of ovulation. The sperm must be able to ascend through the uterus and fallopian tubes (sperm factor). • The cervix must be sufficiently open to allow semen to enter the uterus and provide a nurturing environment for sperm (cervical factor). • The fallopian 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).

BOX 8.1

Factors Affecting Female Fertility

Ovarian Factors • Developmental anomalies • Anovulation—primary • Pituitary or hypothalamic hormone disorder • Adrenal gland disorders (rare) • Congenital adrenal hyperplasia (rare) • Anovulation—secondary • Disruption of hypothalamic–pituitary–ovarian axis • Anorexia • Insufficient fat in athletic women • Increased prolactin levels • Thyroid disorders • Premature ovarian failure • Polycystic ovarian syndrome Tubal/Peritoneal Factors • Developmental anomalies of the tubes • Reduced tubal motility • Inflammation within the tube

BOX 8.2

An alteration in one or more of these structures, functions, or processes results in some degree of impaired fertility. Boxes 8.1 and 8.2 list factors affecting female and 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 7 days. The oocyte can only be successfully fertilized for up to 24 hours after ovulation (Blackburn, 2018). The couple seeking pregnancy should be taught about the menstrual cycle and ways to detect ovulation (see discussion later in the chapter). They should be counselled to have intercourse two to three 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.

• Tubal adhesions • Disruption caused by tubal pregnancy • Endometriosis Uterine Factors • Developmental anomalies of the uterus (see Figure 8.1) • Endometrial and myometrial tumours • Asherman syndrome (uterine adhesions or scar tissue) Vaginal–Cervical Factors • Vaginal–cervical infections • Cervical mucus inadequate • Isoimmunization (development of sperm antibodies) Other Factors • Nutritional deficiencies • Thyroid dysfunction • Obesity • Idiopathic conditions

Factors Affecting Male Fertility

Hormonal Disorders • Congenital disorders • Tumours of the pituitary and hypothalamus • Trauma to the pituitary or hypothalamus • Hyperprolactinemia • Excess of androgens, estrogen, cortisol • Drugs and substance use (recreational and prescribed medications) • 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 (gonorrhea, chlamydial infection) • Obstructive lesions of the epididymis and vas deferens

Factors Associated With Sperm Transport • Medications • Sexually transmitted infections of the epididymis • Ejaculatory dysfunction • Premature ejaculation

Environmental toxins Trauma Torsion Castration Systemic illnesses Changes in sperm from cigarette smoking or use of heroin, marijuana, amylnitrate, butyl nitrate, ethyl chloride, or methaqualone • Decrease in libido from use of heroin, methadone, selective serotonin reuptake inhibitors, or barbiturates • Impotence from use of alcohol or antihypertensive medications • Antisperm antibodies

Idiopathic Male Infertility

CHAPTER 8 Infertility, Contraception, and Abortion

Nursing Care Nurses who care for infertile couples should consider the following four goals: • 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, counselling, and support group meetings, either faceto-face or online. Fertility Matters and RESOLVE are organizations that provide support, advocacy, and education about infertility for those experiencing infertility as well as for health care providers (see Additional Resources at the end of the chapter). • Guide and educate those who fail to conceive biologically as a couple 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. Nurses should also remember that among healthy women and men, promotion of normal reproduction and prevention of infertility may be assisted if both partners maintain a normal body mass index (BMI), avoid contracting sexually transmitted infections (STIs), and avoid exposures to substances or habits (such as smoking) that impair reproductive ability. As they make plans for their future family, adults should also know that, realistically, fertility decreases with age. Infertility care management includes a team of health care providers, including an obstetrical care provider, fertility specialist, embryologist, genetic counsellor, and mental health provider or counsellor. 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, the nurse obtains information from the couple through interview and physical examination, regardless of whether 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. Care providers should seek to understand the patient’s religious views and how beliefs affect their perception of health care, especially in relation to infertility. Patients may wish to seek infertility treatment but have questions about proposed diagnostic and therapeutic procedures because of religious proscriptions. These individuals should be encouraged to consult their minister, rabbi, priest, or other spiritual leader for advice. The Cultural Awareness box notes some cultural rituals and beliefs regarding fertility. See Nursing Process: Infertility, on Evolve. In addition, the nurse will obtain and monitor 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 frayed 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 8.3 describes the status of insurance coverage in Canada for infertility treatment.

BOX 8.3

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Insurance Coverage for Infertility

The cost for in vitro fertilization (IVF) treatment can be very high and unaffordable for many people. All provinces in Canada cover the cost of diagnostic testing and some medical and surgical treatment of infertility through provincial insurance plans. Presently, four provinces will provide some coverage for IVF treatment. Ontario will pay for one IVF cycle with only one embryo to be transferred, for women who are less than 43 years of age. Quebec and Manitoba currently provide a tax credit, and New Brunswick pays a one-time grant for infertility treatment. The Canadian Fertility and Andrology Society strongly advocates for both regulation and public funding of IVF across the country. Private insurance plans may pay for some aspects of treatment. Patients need information about what they can expect from their private insurers and are encouraged to contact companies to obtain more complete information.

CULTURAL AWARENESS Fertility and Infertility In some cultures, women are not considered to be socially acceptable if they cannot have their own biological child. The social stigma of childlessness still leads to isolation and abandonment in many developing countries. Differences between the developed and developing world in ability to bear children are emerging because of the differing availability for infertility care. In many cultures the responsibility for infertility is usually attributed to the woman and it may not be acceptable for the man to seek fertility assessment. In many developing countries, infertile women live without hope as access to infertility treatment is not available. Nurses need to be aware of cultural influences on fertility (Gerrits et al., 2012; World Health Organization, 2010).

Assessment of Female Infertility. Evaluation for infertility should be offered to couples who have failed to become pregnant after 1 year of regular intercourse or after 6 months if the woman is over 35. 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 polycystic ovarian syndrome (PCOS), which can be caused by high levels of androgens or insulin, should be noted, such as excess body hair, pigmentation changes, weight gain, or difficulty losing weight. The general physical examination is followed by a specific assessment of the reproductive tract. A history of infection of the genitourinary system 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 adnexa. A woman may have an abnormal uterus and tubes (Figure 8.1) 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 preconception 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 8.1. Previous status regarding ovulation can be evaluated through menstrual history, serum hormone studies, and use of an ovulation predictor kit. If the patient is over

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A

B

C

D

Fig. 8.1 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.

TABLE 8.1

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 antibodies (tubal patency)

Variable

Negative antibody test may indicate tubal patency assessment (HSG); not needed in low-risk patients

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, high spinnbarkeit (ability to stretch) during ovulation

Basal body temperature (ovulation)

Chart entire cycle

Elevation occurs in response to progesterone; documents ovulation

Urinary or salivary ovulation predictor kit (ovulation)

Variable, ovulation

Detects timing of lutein hormone surge before ovulation

Semen analysis (sperm factor)

2–7 days after abstinence

Detects ability of sperm to fertilize egg

Sperm penetration assay (sperm factor)

After 2 days but
1 week of abstinence

Evaluation of 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 patient’s own eggs; value 20) indicate that pregnancy will not occur with patient’s own eggs; FSH 30% (normal oval) Motility: At least 50% of sperm exhibit normal forward movement after 1 hour • Liquefaction: 20–30 minutes after collection

Source: MyHealth.Alberta.ca. (2018). Semen analysis. https://myhealth. alberta.ca/health/Pages/conditions.aspx?hwid¼hw5612#hw5641 NOTE: These values are not absolute but are only relative to final evaluation of the couple as a single reproductive unit. Normal values vary from lab to lab.

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. Hormone analyses are done for testosterone, gonadotropin, FSH, and luteinizing hormone (LH). The sperm penetration assay and other alternative tests can be used to evaluate the ability of sperm to penetrate an egg. Testicular biopsy may be warranted. Scrotal ultrasound is used to examine the testes for presence of varicoceles and to identify abnormalities in the scrotum and spermatic cord. Transrectal ultrasound is used to evaluate the ejaculatory ducts, seminal vesicles, and vas deferens.

Assessment of the Couple. The postcoital test (PCT) is one method used to test for adequacy of coital technique, cervical mucus, sperm, and degree of sperm penetration through cervical mucus. The test is performed within several hours after ejaculation of semen into the vagina. A specimen of cervical mucus is obtained from the cervical os and examined under a microscope. The quality of mucus and the number of forward-moving sperm are noted. A PCT with good mucus and motile sperm is associated with fertility. Intercourse is synchronized with the expected time of ovulation (as determined from evaluation of basal body temperature [BBT], cervical mucus changes, and usual length of menstrual cycle or use of LH

Psychosocial Considerations. Infertility is recognized as a major life stressor that can affect self-esteem; relations with the partner, family, and friends; and careers. Psychological responses to the diagnosis of infertility may tax a couple’s capacity for giving and receiving physical and sexual closeness. The prescriptions and proscriptions for achieving conception may add tension to a couple’s sexual functioning. Couples may report decreased desire for intercourse, orgasmic dysfunction, or midcycle erectile disorders. Treatment for infertility is complex and stressful, and many couples quit treatment before becoming pregnant, due to the stress. Couples need support and encouragement to express their concerns about infertility treatment. In order to deal comfortably with a couple’s sexuality, nurses must be comfortable with their own sexuality so that they can better help couples understand why the private act of lovemaking needs to be shared with health care providers. Nurses need current factual knowledge about human sexual practices and must be accepting of the preferences and activities of others without being judgemental. They must be skilled in interviewing and in therapeutic use of self, sensitive to the nonverbal cues of others, and knowledgeable about 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 and has two children from a previous marriage. Diane has a history of amenorrhea when she was in college and a member of the track team.

Continued

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?

CLINICAL REASONING CASE STUDY— CONT’D 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 a year. They have come to the fertility clinic today for an evaluation. Diane tells the nurse that she has heard a lot 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? 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? e. Costs of infertility treatment: What are the different costs (financial, physical, and psychological) that must be considered when undergoing infertility treatment? 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 Diane and Charles.

Either member of the couple facing infertility may exhibit behaviours of the grieving process that are associated with other types of loss. The loss of one’s genetic continuity with the generations to come can lead to a loss of self-esteem, a sense of inadequacy as a woman or a man, a loss of control over one’s destiny, and a reduced sense of self. Infertile individuals can perceive greater dissatisfaction with their partner relationships. Not all people will have all of these reactions, nor can it be predicted how long any reaction will last for any one individual. Often a mental health counsellor with experience and expertise dealing with infertility can be very helpful to an individual or couple. If the couple conceives, their concerns and difficulties with infertility may not be over. Many couples are overjoyed with the pregnancy; however, some are not. Some couples rearrange their lives, sense of self, and personal goals based on accepting their infertile state. The couple may think that those who worked with them to identify and treat impaired fertility expect them to be happy with the pregnancy. They may be shocked to find that they feel resentment because the pregnancy, once a cherished dream, now necessitates another change in goals, aspirations, and identities. The normal ambivalence toward pregnancy may be perceived as reneging on the original choice to become parents. 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 to not have a child. The couple may find helpful a list of agencies, support groups, and other resources in their community.

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 PCOS, losing just 5 to 10% of body weight can restore ovulation within 6 months. Anovulatory women

with a BMI 35 kg/m2) Decreased maternal oxygen-carrying capability • Significant anemia (e.g., iron deficiency, hemoglobinopathies) • Carboxyhemoglobin (smokers) Decreased uterine blood flow • Hypotension (e.g., blood loss, sepsis) • Regional anaesthesia • Maternal positioning Chronic maternal conditions • Vasculopathies (e.g., systemic lupus erythematosus, type I diabetes, chronic hypertension) • Antiphospholipid syndrome • Cyanotic heart disease • Chronic obstructive pulmonary disease Uteroplacental Factors Excessive uterine activity

• Tachysystole secondary to oxytocin, prostaglandins (PGE2), or spontaneous labour • Placental abruption Uteroplacental dysfunction • Placental abruption • Placental infarction—dysfunction marked by IUGR, oligohydramnios, or abnormal Doppler studies • Chorioamnionitis • Uterine rupture Fetal Factors Malpresentation (e.g., breech) Polyhydramnios Oligohydramnios Cord compression, prolapse or entanglement •
3 nuchal loops Umbilical cord knots Single umbilical artery Decreased fetal oxygen carrying capability • Significant anemia (e.g., isoimmunization, maternal–fetal bleed, ruptured vasa previa) • Carboxyhemoglobin (if mother is a smoker)

BMI, Body mass index; IUGR, intrauterine growth restriction. Adapted from Dore, S. & Ehman, W. (2020). SOGC clinical practice guideline: No. 396-Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics & Gynaecology Canada, 42(3), 316348. https://doi.org/10.1016/j.jogc.2019.05.007.

been established for how frequently the FHR should be assessed, based on the clinical picture and the stage of labour. The SOGC recommends that the FHR be assessed and interpreted hourly in the latent stage of labour (if the patient is admitted to hospital) or when a significant change occurs (e.g., spontaneous rupture of the amniotic membrane or a change in clinical status). In active labour, the FHR should be assessed and interpreted every 15 to 30 minutes; the same is true for the passive phase of the second stage (when the labouring person is not pushing despite being fully dilated). During the active phase of the second stage of labour (when pushing), assessments are required every 5 to 15 minutes, depending on the method of fetal surveillance being used (Dore & Ehman, 2020). In addition, the FHR should be assessed before and after artificial rupture of membranes as well as with the administration of medications and anaesthesia. The FHR should be assessed more frequently when atypical or abnormal FHR patterns are identified (Dore & Ehman, 2020). The SOGC recommends that each facility have written guidelines regarding the appropriate use of each method of fetal surveillance, including clinically appropriate responses to atypical and abnormal FHS findings (Dore & Ehman, 2020). In clinical practice, FHS patterns (when monitored via EFM) are described as normal, requiring no interventions; as atypical, requiring vigilance and ongoing monitoring; or as abnormal, which requires various interventions, potentially including expediting birth. Interventions for both atypical and abnormal FHS findings are based on the total clinical picture (Dore & Ehman, 2020). The perinatal nurse should document all aspects of FHS, including the method of monitoring used (IA or EFM), the UA pattern, and the associated FHR features that can be documented (based on the method of monitoring) as well as the interpretation of the FHS findings. Documentation should be completed according to institutional policies and guidelines.

Uterine Activity UA is assessed by palpation; additional assessment methods used include an external tocotransducer or an internal intrauterine pressure catheter (IUPC) (both are used in conjunction with the EFM) (see discussion later in chapter). The following components should be included in a complete assessment of UA: frequency, duration, intensity, and resting tone (Figure 19.1). The type of information obtained depends on the type of monitoring method selected. • Frequency is measured by determining the number of contractions in a 10-minute period averaged out over a 30-minute window (Dore & Ehman, 2020). • Duration is measured in seconds, from the beginning to the end of the contraction. Contraction duration remains fairly stable throughout the first and second stages of labour, ranging from 45 to 80 seconds. A contraction should last no longer than 90 seconds (Miller et al., 2017). Duration of contractions is always expressed as a range in seconds, from the shortest to the longest contraction that occurred in the time being documented. • Intensity is determined by palpation or by IUPC. If palpation is the method of assessment, the contractions are described as mild, moderate, or strong. If an IUPC is in place, intensity is measured in mm Hg. To understand how intensity is measured via palpation see Table 19.1. • Resting tone is the degree of muscular tension when the uterus is relaxed. It is assessed between contractions and should last at least 30 seconds. When assessed through palpation, the relaxed uterus is described as soft; if assessed using an IUPC, the average resting tone during labour is less than 25 mm Hg (Dore & Ehman, 2020). A normal UA pattern in labour is characterized by five or less contractions occurring in a 10-minute window (averaged over a 30-minute time period); these contractions last less than 90 seconds, with a

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Fig. 19.1 Components of uterine activity during labour. (From Murray, S. S., & McKinney, E. S. [2010]. Foundations of maternal-newborn nursing [5th ed.]. Saunders).

TABLE 19.1

Comparison Model for Palpation of Uterine Activity Palpation of Uterus

Feels Like . . .

TABLE 19.2

Normal Intrapartum Fetal Surveillance Findings

Contraction Intensity

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Intrapartum Conditions Maternal Vaginal bleeding in labour Intrauterine infection/chorioamnionitis Previous Caesarean birth/attempted VBAC Prolonged ROM at term (>24 hours) Combined spinal-epidural analgesia Oxytocin induction or augmentation of labour Post-term pregnancy (>42 weeks’ gestation) Labour dystocia Tachysystole Difficulties in reliably determining UA and/or FHR with IA Fetal

Abnormal FHR on auscultation Prematurity (2 min but 3 min but 80 min • Erratic baseline

bpm, Beats per minute; FHR, fetal heart rate. Source: Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics & Gynaecology Canada, 42(3), 316348. https://doi.org/10.1016/j.jogc.2019.05.007.

rate should be recorded as a single number to lessen confusion and to allow for clarity in identifying baseline variability. However, recording practices may be determined on an individual organization level. Organizations that choose to accept a range for the FHR baseline rate (e.g., 130–140) should clearly communicate with staff and have this preference written in organizational policies and procedures. The normal FHR range at term is 110 to 160 bpm. In the preterm fetus, the baseline rate is slightly higher.

Tachycardia. Fetal tachycardia is a baseline FHR greater than 160 bpm that lasts for more than 10 minutes (Figure 19.8) (Dore & FHR 240 bpm

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Fig. 19.8 Fetal tachycardia: Fetal heart rate (FHR) greater than 160 beats per minute (bpm). UA, Uterine activity.

Ehman, 2020). Tachycardia is labelled as either “atypical” or “abnormal,” depending on the length of time it occurs (see Table 19.5). It can be considered an early warning sign of potential fetal hypoxemia, especially when associated with decreasing variability and decelerations. Fetal tachycardia most commonly occurs as a result of maternal fever. Other causes of fetal tachycardia include maternal or fetal infection, maternal hyperthyroidism, fetal anemia, and maternal administration of medications (e.g., atropine, hydroxyzine) or illicit drug use (e.g., cocaine, methamphetamines). Table 19.6 lists causes, clinical significance of, and nursing interventions for fetal tachycardia.

Bradycardia. Fetal bradycardia is a baseline FHR less than 110 bpm for more than 10 minutes (Figure 19.9) (Dore & Ehman, 2020). In the presence of possible fetal bradycardia, it is essential to confirm the maternal pulse to differentiate it from the FHR. True bradycardia occurs rarely and is not specifically related to fetal oxygenation. It is critical to distinguish true bradycardia from a prolonged deceleration, since the causes and management of these two conditions are very different. Bradycardia is often caused by some type of fetal cardiac problem, such as structural defects involving the pacemakers or conduction system or fetal heart failure. Other causes of bradycardia include viral infections (e.g., cytomegalovirus), maternal hypoglycemia, and maternal hypothermia. The clinical significance of the bradycardia depends on the underlying cause and accompanying FHR patterns, including variability and the presence of accelerations or decelerations (Miller et al., 2017). Table 19.6 lists causes and clinical significance of and nursing interventions for bradycardia.

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Fetal Tachycardia and Bradycardia and Nursing Implications Tachycardia Definition FHR >160 bpm lasting >10 min Possible Causes • Early fetal hypoxemia • Fetal cardiac arrhythmias or congenital anomalies • Maternal fever • Infection (including chorioamnionitis) • Parasympatholytic medications (atropine, hydroxyzine) • Maternal hyperthyroidism • Fetal anemia • Drugs (caffeine, cocaine, methamphetamines)

Clinical Significance Persistent tachycardia in the absence of periodic changes does not appear to be serious in terms of newborn outcomes (especially true if tachycardia is associated with maternal fever); tachycardia is abnormal when associated with decelerations (variable or late decelerations) or absent variability. Nursing Interventions • Confirm maternal vital signs • Notify the primary health care provider and carry out health care provider’s orders based on alleviating cause—this may include antipyretics, antibiotics, and cooling measures; fluid bolus; and scalp pH or lactate sampling • Intrauterine resuscitation if thought due to hypoxia (see Box 19.8)

FHR 10 min

Baseline bradycardia alone is not specifically related to fetal oxygenation. Clinical significance of bradycardia depends on the underlying cause and accompanying FHR patterns, including variability, and the presence of accelerations or decelerations. • Confirm maternal pulse as different from FHR • Consider vaginal examination to rule out cord prolapse • May consider scalp stimulation or scalp pH or lactate sampling • Other interventions, depending on cause

AV, Atrioventricular; bpm, beats per minute; FHR, fetal heart rate.

Fetal Heart Rate Variability Baseline variability of the FHR refers to fluctuations in the baseline FHR that are irregular in amplitude and frequency and are visually quantified as the amplitude of the peak to trough in bpm. Variability is determined over a 10-minute segment of baseline, excluding accelerations and decelerations (AWHONN, 2009; Dore & Ehman, 2020; Miller et al., 2017). Distinctions are no longer made between short-term (beat-to-beat) or long-term variability because in actual practice they are visually determined as a unit (Miller et al., 2017). Variability is classified as follows: • Absent: Amplitude range is undetectable (0 to 2 bpm). • Minimal: Amplitude range is detectable but less than or equal to 5 bpm. • Moderate: Amplitude range is 6 to 25 bpm. • Marked: Amplitude range is greater than 25 bpm.

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TABLE 19.6

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Fig. 19.9 Fetal bradycardia: Fetal heart rate (FHR) less than 110 beats per minute (bpm). UA, Uterine activity.

Minimal or absent FHR variability (Figure 19.10, A and B) can result from fetal hypoxemia and metabolic acidemia. Other conditions potentially associated with minimal or absent variability include fetal sleep, fetal tachycardia, medications, prematurity, congenital anomalies, fetal anemia, cardiac arrhythmias, infection, and pre-existing neurological injury (Miller et al., 2017). Table 19.7 contrasts key differences between increased and decreased variability and the clinical implications of each. Moderate variability is considered normal (see Figure 19.10, C). Its presence is highly predictive of a normal fetal acid–base balance (absence of fetal metabolic acidemia) at the time of its presence (Dore & Ehman, 2020). Moderate variability indicates that FHR regulation is not affected significantly by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, pre-existing neurological injury, or CNS depressant medications (Macones et al., 2008; Miller et al., 2017). The significance of marked variability (see Figure 19.10, D) is unclear. Possible explanations include a normal variant or an exaggerated autonomic response to interruption of fetal oxygenation (Macones et al., 2008; Miller et al., 2017). A sinusoidal FHR pattern is not included in the definition of FHR variability. A sinusoidal FHR pattern is a smooth, wavelike undulating pattern of the FHR with a cycle frequency of 3 to 5 waves/min that persists for 20 minutes or more (Figure 19.11). Although the pathophysiological mechanisms are unclear, this uncommon pattern classically occurs with severe fetal anemia (Dore & Ehman, 2020; Miller et al., 2017). Variations of the sinusoidal pattern (pseudosinusoidal FHR patterns) have been described in association with chorioamnionitis, fetal sepsis, and administration of opioids (Miller et al., 2017).

Periodic and Episodic Changes in Fetal Heart Rate Changes in FHR from baseline are categorized as periodic or episodic. Periodic changes are those that occur with uterine contractions. Episodic changes are those that are not associated with uterine contractions. These patterns include accelerations and decelerations (Macones et al., 2008).

Accelerations. An acceleration of the FHR is defined as a visually apparent, abrupt (onset to peak less than 30 seconds) increase in FHR above the baseline rate (Dore & Ehman, 2020) (Figure 19.12). The peak is at least 15 bpm above the baseline and the acceleration lasts 15 seconds or longer, with the return to baseline in less than 2 minutes. Before 32 weeks of gestation, the definition of an acceleration is a peak of 10 bpm or more above the baseline and duration of at least 10 seconds. An acceleration that lasts longer than 2 minutes but less than 10 minutes in length is considered a prolonged acceleration. An

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Marked: amplitude range ⱖ25 bpm Fig. 19.10 Classification of fetal heart rate (FHR) variability. A: Absent: amplitude range undetectable. B: Minimal: amplitude range detectable 5 beats/min. C: Moderate: amplitude range 6–25 beats/min. D: Marked: amplitude range
25 beats/min. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

acceleration of the FHR that lasts more than 10 minutes is considered a change in baseline rate (Miller et al., 2017). Accelerations can be either periodic or episodic. They may occur in association with fetal movement or spontaneously. If accelerations do not occur spontaneously, they can be elicited by fetal scalp stimulation (Dore & Ehman, 2020). Accelerations are considered an indication of fetal well-being. Their presence is highly predictive of a normal fetus with an intact oxygenated sympathetic nervous system (Canadian Perinatal Programs Coalition [CPPC], 2020). However, the lack of an acceleration with digital fetal scalp stimulation does not predict fetal

compromise (Dore & Ehman, 2020). To perform digital fetal scalp stimulation, gently stroke the fetal scalp for 15 seconds during a vaginal examination when the FHR is at baseline. It is important to note that digital fetal scalp stimulation should not be used as a resuscitative intervention and should therefore be avoided during a FHR deceleration. Box 19.3 lists causes and clinical significance of and nursing interventions for accelerations.

Decelerations. A deceleration (caused by dominance of a parasympathetic response) may be benign or abnormal. FHR decelerations are

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TABLE 19.7

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Increased and Decreased Variability and Clinical Significance

Increased Variability

Decreased Variability

Potential Causes • Hypoxic events (e.g., uterine tachysystole) • Hyperoxygenation • Fetal cardiac dysrhythmias • Normal maturation • Increased parasympathetic activity • Illicit drug use • Fetal stimulation

• • • • • • • • •

Clinical Significance Significance of marked variability not known; rule out artifact; if thought to be due to hypoxia, maximize fetal oxygenation. Marked variability persisting for 10 minutes or more is abnormal and requires urgent action, such as fetal scalp pH or lactate sampling or emergent delivery. Nursing Intervention If birth is not indicated, continuously observe FHR tracing for other abnormal characteristics that may develop, including increasing baseline, prolonged decelerations, changes in variability to minimal or absent, and development of complicated variable decelerations or late decelerations.

Hypoxia/acidosis Severe fetal anemia CNS depressants Maternal smoking Fetal sleep cycles Congenital abnormalities Fetal cardiac dysrhythmias Maternal temperature elevation Hypovolemia

Benign when associated with periodic fetal sleep states, which last approximately 40 minutes; if caused by drugs, variability usually increases as drugs are excreted; minimal or absent variability for >80 minutes is considered a sign of potential fetal acidemia. Rule out nonhypoxic etiologies; intervention is not warranted if associated with fetal sleep states or temporarily associated with CNS depressants; if thought to be due to hypoxia, maximize fetal oxygenation, consider performing fetal scalp stimulation to elicit an acceleration of the FHR, determine duration of time FHR has experienced absent or minimal variability, notify primary health care provider, prepare for birth if indicated by primary health care provider.

CNS, Central nervous system; FHR, fetal heart rate.

Fig. 19.11 Sinusoidal pattern. FHR, Fetal heart rate. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.) 240

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Fig. 19.12 Accelerations of fetal heart rate in a term pregnancy. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

categorized as early, late, variable, or prolonged (Figure 19.13 and further discussion below). They are described by their visual relation to the onset and end of a contraction and by the nature of their descent, either gradual or abrupt. Clinically, decelerations are also characterized by their general shape. In the SOGC guideline, “repetitive” decelerations

BOX 19.3

Accelerations

Cause Spontaneous fetal movement Fetal stimulation from: • Vaginal examination • Electrode application • Fetal scalp stimulation Fetal reaction to external sounds Uterine activity Fundal pressure Abdominal palpation Brief occlusion of umbilical vein only Clinical Significance Normal pattern: Acceleration with fetal movement signifies fetal well-being, representing fetal alertness or arousal states. Nursing Interventions None required

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437

Fig. 19.13 Differentiating fetal heart rate (FHR) decelerations. (From Dore, S., & Ehman, W. [2020]. SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 42[3], 316348. https://doi.org/10.1016/j.jogc.2019.05.007.)

are defined as greater than three decelerations in a row (Dore & Ehman, 2020). In the 2008 (NICHD) Workshop on EFM documentation, decelerations are defined as “recurrent” if they occur with greater than or equal to 50% of uterine contractions in any 20-minute window (Dore & Ehman, 2020; Macones et al., 2008). Early decelerations. An early deceleration of the FHR is a visually apparent, usually symmetrical, gradual decrease (onset to lowest point [nadir] greater than or equal to 30 seconds) in the FHR and return to baseline associated with a uterine contraction (Figures 19.14 and 19.15) (CPPC, 2020). Usually occurring in the context of moderate variability, early decelerations are thought to be caused by transient fetal head compression, which leads to a slowing of the FHR due to vagal reflex (Dore & Ehman, 2020). Early decelerations are considered normal and generally benign (Dore & Ehman, 2020; Miller et al., 2017). The onset, nadir, and recovery of the deceleration usually correspond to the beginning, peak, and end of the contraction, respectively. For this reason, an

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Fig. 19.14 Electronic fetal monitor tracing showing early decelerations. FHR, Fetal heart rate; UA, uterine activity. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

early deceleration is sometimes referred to as the “mirror image” of a contraction. Although uncommon, when early decelerations are present, they usually occur during the first stage of labour when the cervix is dilated 4 to 7 cm. However, they are sometimes seen during the second stage when the patient is pushing. Early decelerations are thought to be benign, thus interventions are not necessary. Identification of early decelerations enables the health care provider to distinguish them from late or variable decelerations, which may lead to atypical or abnormal FHR patterns and for which interventions are appropriate. Box 19.4 lists causes, clinical significance of, and nursing interventions for early decelerations. Late decelerations. A late deceleration of the FHR is a visually apparent gradual (onset to nadir greater than or equal to 30 seconds) decrease in and return to baseline FHR associated with uterine contractions (Dore & Ehman, 2020; Macones et al., 2008). In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively. The deceleration begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction. The deceleration usually does not return to baseline until after the contraction is over (Figures 19.16 and 19.17). Traditionally, late decelerations have been attributed to uteroplacental insufficiency. However, in reality a number of factors can disrupt oxygen transfer to the fetus, even with mild uterine contractions and a normally functioning placenta (Miller et al., 2017). Potential causes and clinical significance of and nursing interventions for late decelerations are described in Box 19.5. Rarely, fetal oxygenation can be interrupted sufficiently to result in metabolic acidemia. For this reason, persistent and repetitive late decelerations should be considered an ominous sign when they are uncorrectable, especially if they are associated with absent or minimal variability and tachycardia (Dore & Ehman, 2020; Miller et al., 2017). Episodic gradual decelerations. Episodic gradual deceleration is a term new in the SOGC’s 2020 Fetal Health Surveillance: Intrapartum Consensus Guideline (Dore & Ehman, 2020). These decelerations are similar in shape to both early and late decelerations where the onset

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Fig. 19.15 Line drawing illustrating early decelerations. FHR, Fetal heart rate. (From Tucker, S. M. [2004]. Pocket guide to fetal monitoring and assessment [5th ed.]. Mosby.)

BOX 19.4

Early Decelerations

Cause Head compression resulting from the following: • Uterine contractions • Malposition • Unengaged presenting part • Vaginal examination • Fundal pressure • Placement of internal spiral electrode • Cephalopelvic disproportion (CPD); usually seen early in labour Clinical Significance Normal pattern: not associated with fetal hypoxemia, acidemia, or low Apgar scores. If thought to be due to CPD, monitor labour progress. If seen in association with atypical or abnormal baseline features, early decelerations may have acid–base implications for the fetus. Nursing Interventions None required

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Fig. 19.16 Electronic fetal monitor tracing showing late decelerations. FHR, Fetal heart rate; UA, uterine activity. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

and return to the baseline FHR is gradual (greater than or equal to 30 seconds from onset to nadir). This term is used to describe gradual decelerations when they are occurring without identifiable UA either by palpation or with IUPC. Variable decelerations. Variable decelerations are the most common type of deceleration seen in labour. They are defined as a visually abrupt (onset to nadir less than 30 seconds) decrease in the FHR below baseline. The FHR decreases at least 15 bpm below baseline and the deceleration lasts for at least 15 seconds but less than 2 minutes from the time of onset (Figures 19.18 and 19.19). They can occur during or between contractions (CPPC, 2020; Macones et al., 2008). Variable decelerations are thought to reflect an autonomic reflex response to umbilical cord compression, which interrupts oxygen transfer to the fetus (Dore & Ehman, 2020, Miller et al., 2017). Box 19.6 lists causes and clinical significance of and nursing interventions for variable decelerations. The appearance of variable decelerations differs from those of early and late decelerations, which closely approximate the shape of the corresponding uterine contraction. Instead, variable decelerations often have a U, V, or W shape, are characterized by an abrupt (less than 30 seconds) descent to the nadir of the deceleration, and return to the FHR baseline (see Figure 19.19). Variable decelerations are further classified as uncomplicated or complicated variable decelerations. Uncomplicated variable decelerations are characterized by their abrupt decrease in the FHR and the sudden (abrupt) return to baseline. These variables may or may not be accompanied by an acceleratory response of the FHR prior to and immediately following the deceleration of the FHR—these accelerated portions of the fetal heart are part of the deceleration and are commonly called “shoulders.” The accelerations or “shoulders” are a compensatory response to compression of the umbilical vein. Despite the appearance of an acceleration, this physiological response to compression of the umbilical vein does not in and of itself indicate the presence of fetal well-being as the presence of spontaneous accelerations would. Uncomplicated variable decelerations rarely alter the fetal pH and have little clinical significance. When uncomplicated variable decelerations are present in the FHR tracing, they may be classified as either normal, atypical, or abnormal depending on the frequency of the decelerations and other characteristics of the FHR baseline. Complicated variables are more likely to affect fetal well-being. The FHR tracing is classified as abnormal if complicated variable

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Fig. 19.17 Line drawing illustrating late decelerations. FHR, Fetal heart rate. (Modified from Tucker, S. M. [2004]. Pocket guide to fetal monitoring and assessment [5th ed.]. Mosby.)

BOX 19.5

Late Decelerations

Variable decelerations

Cause Uteroplacental insufficiency caused by the following: Acute Conditions

Chronic Conditions

• Uterine tachysystole • Maternal hypotension related to epidural or spinal anaesthesia • Maternal supine positioning • Reduced maternal PO2 • Acute placental disruption (i.e., abruption, previa) • Intra-amniotic infection • Vasoconstriction • Maternal hypo/hyperventilation

• Maternal comorbidities (e.g., diabetes, collagen disease, hypertensive disorders) • Post-term (>42 weeks’ gestation) pregnancy • Reduced maternal PO2 • Poor placental development/ malformation • Premature placental aging (i.e., intrauterine growth restriction)

Clinical Significance An FHR tracing is classified as atypical if the late decelerations are seen occasionally and as abnormal if the late decelerations are occurring with greater than 50% of contractions in any 20 minute window. Late decelerations are associated with fetal hypoxemia, acidemia, and low Apgar scores; they are considered ominous if persistent and uncorrectable with intrauterine resuscitation, especially when associated with fetal tachycardia and loss of variability. Nursing Interventions When occasional late decelerations are detected, change maternal position (lateral), check maternal vital signs, communicate with the team, document and continue to observe closely. When late decelerations are repetitive, intrauterine resuscitation should be initiated (see Box 19.8).

decelerations are repetitive (three or more in a row) (Dore & Ehman, 2020). These decelerations can deplete the fetal reserve and lead to fetal hypoxemia. Complicated variable decelerations include the following: • Failure to return to baseline by the end of the contraction • Deceleration lasting greater than or equal to 60 seconds AND down to less than or equal to 60 bpm OR decreased by greater than or equal to 60 bpm below baseline • Overshoot of 20 bpm for 20 seconds after deceleration

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6 4 2 0 kPa

Fig. 19.18 Electronic fetal monitor tracing showing variable decelerations. FHR, Fetal heart rate; FECG, fetal electrocardiogram; UA, uterine activity. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

• Variable deceleration in the presence of minimal or absent baseline variability • Baseline tachycardia or bradycardia (Dore & Ehman, 2020) Prolonged decelerations. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) of at least 15 bpm below the baseline and lasting more than 2 minutes but less than 10 minutes from onset to return to baseline (Figure 19.20). A deceleration lasting more than 10 minutes is considered a baseline change (Macones et al., 2008) and requires immediate intrauterine resuscitative measures and a teamwork approach to management, communication, and documentation of the situation. Prolonged decelerations occur when the mechanisms responsible for late or variable decelerations last for an extended period (more than 2 minutes). Examples of conditions that can cause an interruption in the fetal oxygen supply long enough to produce a prolonged deceleration include maternal hypotension, cervical examination, uterine tachysystole or rupture, extreme placental insufficiency, cord entanglement, and prolonged cord compression or prolapse (Miller, 2017; Miller et al., 2017).

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61180

240 210 180 150

FHR Variable shape

120 90 Rapid return

60

Sudden drop 30 Variable time relationship to contractions 100 Umbilical cord compression (CC) Variable deceleration

75 50 25 0

Fig. 19.19 Line drawing illustrating variable decelerations. FHR, Fetal heart rate. (From Tucker, S. M. [2004]. Pocket guide to fetal monitoring and assessment [5th ed.]. Mosby.)

BOX 19.6

Variable Decelerations

HR 240 bpm

FHR 240 bpm

FHR 240 bpm

FHR 240 bpm

210

210

210

180

180

180

150

150

150

150

120

120

120

120

90

90

90

90

60

60

60

60

30

30

30

210 180

Cause Umbilical cord compression caused by the following: • Oligohydramnios • Maternal position with cord between fetus and maternal pelvis (occult umbilical cord prolapse) • Cord around fetal neck (nuchal cord), arm, leg, or other body part • Short cord • Knot in cord • Prolapsed umbilical cord • Decreased amniotic fluid Clinical Significance Variable decelerations occur in most labours and are usually correctable. Complicated variable decelerations require critical analysis and timely decision making, including intrauterine resuscitation and confirmation of fetal wellbeing, either directly or indirectly (fetal scalp stimulation or fetal scalp blood sampling for pH or lactate) (Dore & Ehman, 2020). Preparation for an expeditious birth may be necessary. Nursing Interventions • Change patient position (side to side, knee chest). • Consider need for intrauterine resuscitation (particularly if variables are complicated) (see Box 19.8). • Notify primary care provider. • Assess for possible cord prolapse. • Assist with scalp stimulation, scalp pH or lactate, or amnioinfusion (see discussion later in chapter), if ordered. • Alter pushing technique (e.g., open glottis, shorter pushes). • Assist with birth (vaginal assisted or Caesarean) if pattern cannot be corrected.

The presence and severity of hypoxia are thought to correlate with the depth and duration of the prolonged deceleration, how long it takes for the FHR to return to baseline, how much variability is lost during the deceleration, and whether or not rebound tachycardia and decreased variability are seen following the deceleration (Miller, 2017).

Prolonged decelerations

100 75 50 25 UA 0 mmHg

12 10 8 6 4 2 0 kPa

100 75 50 25 UA 0 mmHg

12 10 8 6 4 2 0 kPa

30 100 75 50 25 UA 0 mmHg

12 10 8 6 4 2 0 kPa

Fig. 19.20 Prolonged decelerations. FHR, Fetal heart rate; UA, uterine activity. (From Miller, L., Miller, D., & Cypher, R. [2017]. Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach [8th ed.]. Mosby.)

NURSING ALERT Nurses should notify the primary care provider immediately and initiate appropriate intrauterine resuscitation when they identify a prolonged deceleration.

Nursing Care The primary goals of obstetrical nursing care are to have healthy fetal and maternal outcomes. Knowledge of fetal status and standards for care determine the interventions implemented. All planning and interventions must take into account the total clinical picture. The planning process includes meeting the needs of the patient and family, answering questions, and explaining nursing interventions. Although the use of EFM can be comforting to many parents, it can be a source of anxiety to others. The nurse needs to be particularly sensitive to the emotional, informational, and physical comfort needs of the labouring person and their family and respond appropriately (Figure 19.21 and Box 19.7). See the Nursing Care Plan, Fetal Monitoring during Labour on the Evolve site.

Electronic Fetal Monitoring Pattern Recognition. Nurses take into consideration the total clinical picture to determine whether an FHR pattern is normal, atypical, or abnormal. They evaluate these factors on the basis of the presence of other obstetrical complications, progress in labour, and use of analgesia or anaesthesia. Further consideration of the estimated time to birth is also important.

CHAPTER 19

Fetal Health Surveillance During Labour

441

intrauterine resuscitation and call for help. Determine the duration of the effect and reserve tolerance of the fetus, consider FBS, mobilize additional teams, including pediatrics and anaesthesiology, and consider expediting birth (vaginal or Caesarean birth) unless there is evidence of normal oxygenation by FBS assessment for either pH or lactate.

LEGAL TIP: Fetal Monitoring Standards

Fig. 19.21 Nurse explains electronic fetal monitoring as ultrasound transducer monitors the fetal heart rate. (Courtesy Julie Perry Nelson.)

BOX 19.7

Patient and Family Teaching When Intermittent Auscultation or Electronic Fetal Monitor Is Used The following guidelines relate to patient teaching: • Explain the purpose of monitoring is to identify fetal well-being in labour. • Explain each procedure. • Provide the rationale for labouring patient’s positions other than supine. • Explain that fetal status can be assessed safely using intermittent auscultation (IA) or explain the need for electronic fetal monitoring (EFM) if there are risk factors for adverse perinatal outcomes. The patient should be encouraged to decide what type of monitoring they prefer. • If using EFM, explain that the lower tracing on the monitor strip paper shows uterine activity (UA); the upper tracing shows the fetal heart rate (FHR). • Reassure the labouring patient and their partner that prepared childbirth techniques can be implemented without difficulty. • Using palpation, note peak of contraction; knowing that contraction will not get stronger and is half over is usually helpful. Note diminishing intensity. • Reassure the labouring patient and partner that the use of internal monitoring does not restrict movement unless medically indicated. Portable telemetry monitors allow the FHR and uterine contraction patterns to be monitored and may increase ambulation during labour. • Reassure the labouring patient and partner that the use of monitoring does not imply fetal jeopardy.

Considering these factors, the nurse must determine which interventions are appropriate, based on sound clinical judgement of a complex, integrated process. • Normal—Characteristics are within normal parameters. • Atypical—Further vigilant assessment is required, especially when combined features are present. The nurse must determine the significance and cause of the FHR features and correct any reversible causes, initiate intrauterine resuscitation, call for help, determine the duration of the effect and reserve tolerance of the fetus, and consider whether further fetal evaluation (scalp stimulation and/or fetal blood sampling [FBS] for pH or lactate) is indicated or may be of value. The nurse must also consider the need to expedite birth if the FHR tracing abnormalities persist or the fetus continues to deteriorate further (Dore & Ehman, 2020). • Abnormal—Action is required. Review the overall clinical situation, assessing for potential causes that are reversible. Initiate appropriate

Nurses who care for patients who require EFM during childbirth are legally responsible for maintaining an interpretable monitor strip, correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, documenting the outcomes of those interventions, and communication with the primary health care provider. Perinatal nurses are responsible for the timely notification of the primary health care provider in the event of atypical or abnormal FHR patterns or contraction patterns (i.e., patterns that indicate the need for intervention or expedited birth). Perinatal nurses also are responsible for initiating collaborative resolution (the institutional chain of command) should differences in opinion arise among health care providers about the interpretation of the FHS findings and the interventions required.

Nursing management of atypical or abnormal patterns. The six essential components of the FHR tracing that must be evaluated regularly are UA, the baseline FHR, baseline variability, accelerations, decelerations, and changes or trends in the FHR over time. Whenever one of these essential components of the FHS findings is assessed as atypical or abnormal, corrective measures must be taken immediately. The purpose of these actions is to improve fetal oxygenation (Miller et al., 2017). The term intrauterine resuscitation is sometimes used to refer to specific interventions initiated when an atypical or abnormal FHS patterns is noted. Basic corrective measures include instituting maternal position changes, stopping or decreasing oxytocin if it is infusing, and checking maternal vital signs to differentiate FHR from maternal heart rate and to determine if the labouring person is hypotensive or hypovolemic. If the person is pushing, the nurse may need to modify or pause pushing efforts. The nurse may also need to improve hydration with an intravenous bolus, if appropriate and indicated (e.g. maternal hypotension, hypovolemia or hypoxia), maintaining awareness of overall fluid balance of the pregnant person. The nurse must also rule out cord prolapse, consider tocolysis in the event of tachysystole with FHR changes, consider amnioinfusion in the presence of repetitive (three or more in a row) complicated decelerations, and provide supportive care to reduce the pregnant person’s anxiety. Administration of oxygen by mask should be reserved for situations of hypoxia and hypovolemia of the pregnant person (Dore & Ehman, 2020). These interventions are implemented to improve uterine and intervillous space blood flow and increase oxygenation and cardiac output of the pregnant person (Miller et al., 2017). Box 19.8 lists basic interventions to improve maternal and fetal oxygenation status. Nurses must assign priorities to interventions in order to maximize the efficacy of the intrauterine resuscitation. The purpose of intrauterine resuscitation is to improve uterine blood flow, improve umbilical blood flow, optimize maternal–fetal oxygenation, and decrease UA (Dore & Ehman, 2020). Decisions regarding which intrauterine resuscitation measure should be undertaken first are based on the clinical situation, gestational age, resources available, the stage of labour, and additional risk factors that are present (Dore & Ehman, 2020). Some interventions are specific to the FHR pattern. Nursing interventions appropriate for the management of tachycardia and bradycardia are given in Table 19.6, and those appropriate for the management of increased or decreased variability are given in Table 19.7. No specific nursing interventions are required for the

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BOX 19.8

Management of Atypical or Abnormal Fetal Heart Rate Pattern Intrauterine resuscitation: • Stop or decrease oxytocin. • Change patient position (to left or right lateral). • Check labouring patient’s vital signs, including differentiation of the pulse from the FHR. Modify breathing or pushing techniques during second stage: • Use open-glottis rather than Valsalva-style pushing. • Use fewer pushing efforts during each contraction or make individual pushing efforts shorter. • Push only with every second or third contraction. • Push only with contractions (with use of regional anaesthesia) or the urge to push. If indicated—Improve patient hydration with an IV fluid bolus (e.g., maternal hypovolemia and/or hypoxia); be aware of patient’s fluid balance. Perform vaginal examination to rule out cord prolapse and assess progress. Consider IV tocolysis in the presence of tachysystole with atypical or abnormal FHS findings. Consider amnioinfusion (see discussion later in chapter) in the presence of complicated variable decelerations. Provide supportive care to the labouring patient and family to reduce anxiety and lessen catecholamine impact. Consider administration of oxygen (8 to 10 L/min) by mask, only when maternal hypoxia and/or hypovolemia is suspected or confirmed. Oxygen administration is reserved for maternal resuscitation, not fetal resuscitation. Notify primary health care provider.

FHR, Fetal heart rate; FHS, fetal health surveillance; IV, intravenous. From Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 42(3), 316348. https://doi.org/ 10.1016/j.jogc.2019.05.007.

management of FHR accelerations or early decelerations (see Boxes 19.3 and 19.4). However, late and complicated variable decelerations require aggressive intervention (see Boxes 19.5 and 19.6). Based on the FHR response to these interventions, the primary health care provider decides whether additional interventions should be instituted or whether immediate vaginal or Caesarean birth should be performed.

Patient and Family Teaching. Part of the perinatal nurse’s role includes acting as a partner with the labouring patient and their family to achieve a high-quality birthing experience (see Community Focus box). In addition to providing teaching and support for the patient and family or support people regarding the labour and birth process, breathing techniques, use of equipment, and pain management techniques, the nurse can help with two factors that have an effect on fetal status: pushing and positioning.

COMMUNITY FOCUS Education About Electronic Fetal Monitoring Interview childbirth educators from two different types of childbirth preparation classes regarding what they teach expectant parents about electronic fetal monitoring. Do the educators regard it to be “normal”? Do they discuss its advantages and disadvantages, or do they just describe it as a routine intervention? Do they discuss choice in labour (i.e., are parents able to select auscultation rather than electronic monitoring)? Intermittent rather than continuous monitoring? What implications does this information have for your practice as a labour and birth nurse?

Positioning during labour. Supine hypotension is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the pregnant patient is in a supine position. The supine position decreases venous return to the heart and cardiac output and subsequently reduces blood pressure. If the labouring person’s blood pressure is low, it decreases intervillous space blood flow during uterine contractions and results in fetal hypoxemia. This is reflected on the fetal monitor as an atypical or abnormal FHS pattern; usually this begins with variable decelerations, followed by decreasing variability, and ultimately may result in late decelerations or complicated variable decelerations. The nurse should instruct the labouring patient to avoid using the supine position, if possible. The patient should be encouraged to maintain an upright, side-lying, or semi-Fowler position with a lateral tilt to the uterus. Either the right or left lateral position effectively enhances uteroplacental blood flow. Discouraging the Valsalva manoeuvre. The Valsalva manoeuvre can be described as the process of making a forceful bearing-down attempt while holding one’s breath with a closed glottis and tightening the abdominal muscles. This process stimulates the parasympathetic division of the autonomic nervous system, producing a vagal response that results in a decrease of the labouring person’s heart rate and blood pressure. Prolonged pushing in this manner can decrease placental blood flow, alter the labouring patient’s and fetus’s oxygenation, decrease the fetal pH and PO2, increase the fetal PCO2, and increase the likelihood of fetal hypoxemia, as reflected in FHR pattern changes. During the second stage of labour, when the patient needs to push, an alternative to breath holding with a closed glottis is to perform the open-mouth and open-glottis breathing-pushing technique. The nurse can instruct the patient to keep their mouth and glottis open and let air escape from the lungs during the pushing process. This may result in an audible grunting sound and will prevent doing the Valsalva manoeuvre (see Chapter 17).

ADDITIONAL METHODS OF ASSESSMENT AND INTERVENTION A major shortcoming of EFM is its high rate of false-positive results. Even the most abnormal patterns are poorly predictive of newborn morbidity. Therefore, EFM assessment of the FHR should be viewed as a screening test that signals when atypical or abnormal features are present, warranting the use of other diagnostic tests (when available) to evaluate fetal status and intervene as needed. Fetal scalp blood sampling (for lactate or pH) is sometimes employed to evaluate the fetus further; amnioinfusion is sometimes used to decrease the physiological stress of UA that has resulted in an atypical or abnormal FHR pattern. Umbilical cord blood acid–base determination is a postpartum assessment technique that is useful as an adjunct to the Apgar score in assessing the immediate condition of the newborn.

Fetal Scalp Blood Sampling Fetal scalp blood sampling involves obtaining a capillary fetal blood sample in a fetus more than 34 weeks of gestation. It is obtained through a small incision in the fetal scalp, taken through the dilated cervix after the membranes have ruptured. It is an adjunct to EFM when the pattern is difficult to interpret or is atypical or abnormal and birth is not imminent. The capillary sample is tested for pH or lactate. Results will guide the primary health care provider on whether to expedite birth, reassess within 30 minutes, or allow labour to continue (Table 19.8). Fetal scalp blood sampling is limited by many factors, including the requirement for cervical dilation and ruptured membranes, technical difficulty of the procedure, and the need for repetitive pH or lactate determinations. Fetal scalp lactate blood sampling may be easier to

CHAPTER 19

TABLE 19.8

Fetal Blood Sampling

FETAL SCALP BLOOD SAMPLING—PH AND LACTATE VALUES pH Value

Lactate Value*


7.25

4.8

Interpretation

Abnormal—birth indicated

*Lactate values are applicable only to the Nova Biomedical Stat Strip lactate meter—currently the only lactate meter available in Canada. Source: Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 42(3), 316348. https:// doi.org/10.1016/j.jogc.2019.05.007.

obtain than the sample required for pH testing, as only a very small sample is required. The guideline for determination of fetal status is determined by the type of meter used. Values included in Table 19.8 are applicable to the Nova Biomedical Stat Strip Lactate meter, which is available for clinical use in Canada.

Umbilical Cord Acid–Base Determination In assessing the immediate condition of the newborn after birth, a sample of cord blood is a useful adjunct to the Apgar score. The SOGC strongly recommends that both umbilical arterial and venous cord gases be measured after all births, as they may help in providing appropriate care to the newborn and in planning subsequent management (Dore & Ehman, 2020). Umbilical arterial values reflect fetal condition and thus are considered by some as most relevant; umbilical venous blood values reflect placental function (Miller et al., 2017). Umbilical cord gas measurements reflect the acid–base status of the newborn at birth, a measurement not reflected in the Apgar score (Table 19.9). If only one sample is possible, it should be arterial, since arterial samples are the best indicator of fetal oxygenation at birth. If acidemia is present, the type—respiratory, metabolic, or mixed—is determined by analyzing the blood gas values (Table 19.10).

Amnioinfusion Amnioinfusion is infusion of room- or body-temperature isotonic fluid (usually normal saline or lactated Ringer’s solution) into the uterine cavity when the volume of amniotic fluid is low (Miller et al., 2017). Without the buffer of amniotic fluid, the umbilical cord can easily become compressed during contractions or with fetal movement,

TABLE 19.9

Approximate Normal Values for

Cord Blood

pH

PCO2 (mm Hg)

HCO3 (MMOL/L)

Base Excess (MMOL/L)

Artery

7.20–7.34

39.2–61.4

18.4–25.6

5.5–0.1

Vein

7.28–7.40

32.8–48.6

18.9–23.9

4.4–0.4

Cord Blood

Adapted from Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics & Gynaecology Canada, 42(3), 316 348. https://doi.org/10.1016/j.jogc.2019.05.007.

Fetal Health Surveillance During Labour

TABLE 19.10

443

Types of Acidemia

Respiratory

Metabolic

Mixed

pH

38 weeks • Diabetes mellitus (glucose control may dictate urgency) • Alloimmune disease at or near term • Intrauterine growth restriction • Oligohydramnios • Gestational hypertension >38 weeks • Intrauterine fetal death • PROM near or at term (GBS negative) • Logistical issues (history of fast labour, distance from the hospital) • Intrauterine demise in previous pregnancy (to allay anxiety)

Action • PGE2 ripens the cervix, making it softer and causing it to begin to dilate and efface; it stimulates uterine contractions.

or inducible. Cervical ripeness is the most important predictor of successful induction. A rating system such as the Bishop score (Table 20.2) can be used to evaluate inducibility. For example, a score of 8 or more on this 13-point scale indicates that the cervix is soft, anterior, 50% or more effaced, and dilated 2 cm or more and that the presenting part is engaged. When the Bishop score totals 7 or more, induction of labour is usually successful (Leduc et al., 2013; Sheibani & Wing, 2017). The Bishop score should be documented before the use of methods to ripen the cervix or induce labour.

Cervical Ripening Agents Chemical agents. Preparations of prostaglandins E1 (PGE1) and E2 (PGE2) have been shown to be effective when used before induction to “ripen” (soften and thin) the cervix (see Medication Guides: Prostaglandin E1; Misoprostol and Prostaglandin E2: Dinoprostone).

Bishop Score SCORE 1

2

3

Dilation (cm)

Closed

1–2

3–4


5

Effacement (%)

0–30

40–50

60–70


80 +1, +2

Station (cm)

3

2

1, 0

Cervical consistency

Firm

Medium

Soft

Cervix position

Posterior

Midposition

Anterior

In some cases, patients spontaneously begin labouring after the administration of prostaglandin, thereby eliminating the need to administer oxytocin to induce labour. Additional advantages of prostaglandin use for cervical ripening include decreased oxytocin induction time and a decrease in the amount of oxytocin required for successful induction (Sheibani & Wing, 2017). PGE1 is associated with a higher risk for uterine tachysystole with abnormal fetal heart rate and pattern changes and passage of meconium into the amniotic fluid. Most of these adverse outcomes are associated with higher-dose protocols (ACOG, 2009/ 2019; Sheibani & Wing, 2017). The benefits of PGE1 include its stability at room temperature, rapid onset of action, multiple potential routes of administration, and low cost. These potential benefits make it an attractive alternative to PGE2. However, updated guidelines are needed to promote the safe and effective use of PGE1 for induction of labour (Chatsis & Frey, 2018). PGE2 in the form of a vaginal insert (dinoprostone [Cervidil]), although more expensive than PGE1, has the major advantage of easy removal should adverse reactions, including uterine tachysystole, occur.

MEDICATION GUIDE

Source: Leduc, D., Biringer, A., Lee, L., et al. (2013). SOGC clinical practice guideline: Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), S1–S20.

0

463

Prostaglandin E2 (PGE2): Dinoprostone (Cervidil Insert; Prepidil Gel)

Unacceptable Indications • Suspected fetal macrosomia • Absence of fetal or maternal indication • Caregiver or patient convenience

TABLE 20.2

Labour and Birth at Risk

Indications • PGE2 is used for preinduction cervical ripening (to ripen the cervix before oxytocin induction of labour when the Bishop score is 6 or less) and to induce labour or abortion (abortifacient agent). • It is not recommended for use if the patient has a history of previous Caesarean birth or other major uterine surgery. Dosage and Route Cervidil Insert • Dosage is 10 mg of dinoprostone, designed to be gradually released (approximately 0.3 mg/hour) over 12 hours. Insert is placed transvaginally into the posterior fornix of the vagina. The insert is removed after 12 hours or at the onset of active labour or earlier if tachysystole or abnormal fetal heart rate and patterns occur. Prepidil Gel • Dosage is 0.5 mg of dinoprostone in a 2.5-mL syringe. Gel is administered through a syringe into the vaginal canal just below the internal cervical os. Dose may be repeated every 6 hours as needed for cervical ripening up to a maximum cumulative dose of 1.5 mg (3 doses) in a 24-hour period. Adverse Effects • Potential adverse reactions include headache, nausea and vomiting, diarrhea, fever, hypotension, tachysystole (greater than five contractions in 10 minutes, averaged over a 30-minute window with or without alteration of fetal heart rate or pattern), and fetal passage of meconium. Nursing Considerations • Explain the procedure to the patient and family. Ensure that informed consent has been obtained per agency policy. • Assess the patient and fetus before each insertion and during treatment, following agency protocol for frequency. Assess vital signs and health status of patient being induced, fetal heart rate and pattern, and status of pregnancy, including indications for cervical ripening or induction of labour, signs of labour or impending labour, and the Bishop score. Recognize that an

464

• • •

• • •

• •

•

•

UNIT 5

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abnormal fetal heart rate and pattern; fever, infection, vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of dinoprostone. Avoid use in patients with asthma, glaucoma, and hypotension or hypertension. Use with caution if the patient has cardiac, renal, or hepatic disease, anemia, jaundice, diabetes, epilepsy, or genitourinary infections. Bring the Prepidil gel to room temperature just before administration. Do not force the warming process by using a warm-water bath or other source of external heat such as microwave because heat may cause inactivation. Keep the Cervidil insert frozen until just before insertion. No warming is needed. Have the patient void before insertion. Assist the patient in maintaining a supine position with lateral tilt or a sidelying position for at least 30 minutes after insertion of gel or for 2 hours after placement of insert. Allow the patient to ambulate after a recommended period of bed rest and observation. Prepare to pull the string to remove the insert if significant adverse effects occur. There is no effective way to remove the gel from the vagina if uterine tachysystole occurs. Delay initiation of oxytocin for induction of labour for 6 hours after last instillation of gel or at least 30 to 60 minutes after removal of the insert. Follow agency protocol for induction if ripening has occurred and labour has not begun. Document all assessment findings and administration procedures.

Data from Hill, W., & Harvey, C. (2013). Induction of labor. In N. Troiano, C. Harvey, & B. Chez (Eds.), AWHONN’s high risk & critical care obstetrics (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins; Leduc, D., Biringer, A., Lee, L., et al. (2013). SOGC clinical practice guideline: Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), S1–S18.

MEDICATION GUIDE Prostaglandin E1 (PGE1): Misoprostol Action • PGE1 ripens the cervix, making it softer and causing it to begin to dilate and efface; it stimulates uterine contractions. Indications • PGE1 is used for preinduction cervical ripening (ripen the cervix before oxytocin induction of labour when the Bishop score is 4 or less) and for inducement of labour or abortion (abortifacient agent); it has not yet been approved by Health Canada for cervical ripening or labour induction (i.e., this is an unlabelled use for obstetrics). • It should not be used if the patient has a history of previous Caesarean birth or other major uterine surgery. Dosage and Administration • Misoprostol is available either as a 100-mcg or 200-mcg tablet. Therefore, tablets must be broken to prepare the correct dose. This preparation should take place in the pharmacy to ensure accurate doses. • Initial dose is 50 mcg orally with a drink of water (ensure that it is swallowed quickly to avoid sublingual absorption) or 25 mcg vaginally. Insert intravaginally into the posterior vaginal fornix using the tips of index and middle fingers, without the use of a lubricant. Repeat every 4 hours up for to 6 doses in a 24-hour period or until an effective contraction pattern is established (three or more uterine contractions in 10 minutes), the cervix ripens (Bishop score of 8 or greater), or significant adverse effects occur.

Adverse Effects • Higher doses (e.g., 50 mcg every 6 hours) are more likely to result in adverse reactions such as nausea and vomiting, diarrhea, fever, uterine tachysystole with or without an abnormal fetal heart rate and pattern, or fetal passage of meconium. The risk for adverse reactions is reduced with lower dosages and longer intervals between doses. Nursing Considerations • Explain the procedure to the patient and family; ensure that informed consent has been obtained per agency policy. • Assess the patient and fetus before each insertion and during treatment, following agency protocol for frequency. Assess vital signs and health status of labouring patient, fetal heart rate and pattern, and status of pregnancy, including indications for cervical ripening or induction of labour, signs of labour or impending labour, and the Bishop score. Recognize that an atypical or abnormal fetal heart rate and pattern; maternal fever, infection, vaginal bleeding, or hypersensitivity; and regular, progressive uterine contractions contraindicate the use of misoprostol. • Avoid giving aluminum hydroxide and magnesium-containing antacids along with misoprostol. • Use with caution in patients with renal failure because the medication is eliminated through the kidneys. • Misoprostol is contraindicated in patients with previous Caesarean birth because of an increased risk of uterine rupture. • Have the patient void before insertion. • Assist the patient in maintaining a supine position with a lateral tilt or a side-lying position for 30 to 40 minutes after vaginal insertion. • Prepare to swab the vagina to remove unabsorbed vaginal medication using a saline-soaked gauze wrapped around fingers if significant adverse effects occur. • Initiate oxytocin for induction of labour no sooner than 4 hours after the last dose of misoprostol was administered, following agency protocol, if ripening has occurred and labour has not begun. • Document all assessment findings and administration procedures. Data from Hill, W., & Harvey, C. (2013). Induction of labor. In N. Troiano, C. Harvey, & B. Chez (Eds.), AWHONN’s high risk & critical care obstetrics (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins; Leduc, D., Biringer, A., Lee, L., et al. (2013). SOGC clinical practice guideline: Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), S1–S18; Thorp, J. M., & Laughon, K. (2018). Clinical aspects of normal and abnormal labor. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s Maternal-fetal medicine: Principles and practice (8th ed.). Elsevier.

Mechanical and physical methods. Mechanical dilators ripen the cervix by stimulating the release of endogenous prostaglandins. Balloon catheters (e.g., Foley catheter) can be inserted through the intracervical canal to ripen and dilate the cervix and are often used in patients attempting a trial of labour following a previous Caesarean birth. The catheter balloon is inflated above the internal cervical os with 30 to 50 mL of sterile water. This process results in pressure and stretching of the lower uterine segment and the cervix, as well as the release of endogenous prostaglandins. It is especially helpful for patients who cannot receive exogenous prostaglandins for cervical ripening. The balloon will fall out when cervical dilation reaches approximately 3 cm or is removed after 24 hours have elapsed. Simplicity of use, potential for reversibility, reduction in certain adverse effects such as excessive uterine activity, and low cost are advantages to using a mechanical dilator (Leduc et al., 2013). Evidence supports the insertion of a balloon catheter as a cervical ripening method because of its low cost compared with

CHAPTER 20 that of prostaglandins, stability at room temperature, and reduced risk for uterine tachysystole with or without FHR changes (ACOG, 2009/ 2019; Leduc et al., 2013). Low-lying placenta is an absolute contraindication to the use of a Foley catheter. Relative contraindications include antepartum hemorrhage, rupture of membranes, and evidence of lower tract genital infection (Leduc et al., 2013). Hydroscopic dilators (substances that absorb fluid from surrounding tissues and enlarge) also can be used for cervical ripening. Laminaria tents (natural cervical dilators made from desiccated seaweed) and synthetic dilators containing magnesium sulphate (Lamicel) are inserted into the endocervix without rupturing the membranes. As they absorb fluid, they expand and cause cervical dilation and the release of endogenous prostaglandins. These dilators are left in place for 6 to 12 hours before being removed to assess cervical dilation. Fresh dilators are inserted if further cervical dilation is necessary. Synthetic dilators swell faster than natural dilators and become larger with less discomfort. When compared with prostaglandins, these mechanical methods achieved a lower rate of birth within 24 hours but resulted in no change in the Caesarean birth rate. Also, they were less likely to cause uterine tachysystole with or without changes in the FHR (ACOG, 2009/2016; Thorp & Laughon, 2018). Hydroscopic dilators compare favourably with prostaglandins in terms of their effectiveness in ripening the cervix but are associated with increased discomfort at insertion and during expansion and with a higher incidence of postpartum infections in patients as well as newborns. They are a reliable alternative when prostaglandins are contraindicated or are unavailable. Nursing responsibilities for patients who have dilators inserted include the following: • Documenting the number of dilators and sponges inserted during the procedure, as well as the number removed • Assessing for urinary retention, rupture of membranes, uterine tenderness or pain, contractions, vaginal bleeding, infection, and atypical or abnormal FHR Amniotic membrane stripping or sweeping is a method of inducing labour through the release of prostaglandins and oxytocin. The procedure involves separation of the membrane from the wall of the cervix and lower uterine segment by inserting a finger into the internal cervical os and rotating it 360 degrees. The results of two studies suggested that membrane stripping increased the rate of spontaneous vaginal birth and shortened the induction to birth interval. Neither study reported harmful adverse effects that could be attributed to the procedure. Research has not demonstrated an increase in infections in either patients or newborns associated with membrane stripping. However, because there are limited data available on the risk for infection in patients who are known to be group B streptococci positive, potential risks and benefits of the procedure should be carefully considered before performing membrane stripping on this group of patients (Sheibani & Wing, 2017). Physical methods such as sexual intercourse (prostaglandins in the semen and stimulation of contractions with orgasm), nipple stimulation (release of endogenous oxytocin from the pituitary gland), and walking (gravity applies pressure to the cervix, which stimulates the secretion of endogenous oxytocin) may be used by patients to “selfinduce” labour in an effort to “get it over with.” Breast (nipple) stimulation has been shown to initiate or enhance labour, especially the latent phase of labour. Although orgasm does stimulate uterine contractions, it is unclear whether sexual intercourse enhances cervical ripening (Leduc et al., 2013). Ambulation may be an effective measure to augment labour.

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Alternative methods. A variety of alternative methods have been used by patients to stimulate cervical ripening and the onset of labour. For example, some patients may take blue cohosh and castor oil for labour-stimulation effects and black cohosh and evening primrose oil to ripen the cervix. Although the effects of these alternative methods are not well researched, nurses must be knowledgeable about these preparations and ask about their use when assessing patients during prenatal visits and on admission during labour. Patients may accidentally take too much of the preparation or use it incorrectly. Also, these preparations may potentiate the effect of pharmacological methods to stimulate cervical ripening and uterine contractions, thereby increasing the potential for tachysystole and precipitous labour and birth. Acupuncture has been used effectively to induce labour and has been found in several studies to reduce the duration of labour, the use of oxytocin, and the rate of Caesarean birth. Specific points have been identified to stimulate uterine contractions or to facilitate cervical dilation. More than one treatment may be required to establish labour.

Amniotomy. Amniotomy (i.e., artificial rupture of membranes [AROM]) can be used to induce labour when the condition of the cervix is favourable (ripe) or to augment labour if progress begins to slow. Labour usually begins within 12 hours of the rupture. Amniotomy can decrease the duration of labour by up to 2 hours, even without oxytocin administration. However, if amniotomy does not stimulate labour, the resulting prolonged rupture may lead to chorioamnionitis. Variable FHR deceleration patterns can occur as a result of cord compression associated with umbilical cord prolapse or decreased amniotic fluid. Once an amniotomy is performed, the patient is committed to giving birth with an unknown outcome for how and when birth will occur. For this reason, amniotomy often is used in combination with oxytocin induction. Evidence from controlled trials clearly demonstrates that amniotomy combined with oxytocin for induction is more effective than either amniotomy or oxytocin alone (Leduc et al., 2013). Before the procedure, the patient should be told what to expect; they should also be assured that the actual rupture of membranes is painless for both themselves and the fetus, although they may experience some discomfort when the Amnihook is inserted through the vagina and cervix (Box 20.9). The presenting part of the fetus should be engaged and well applied to the cervix to reduce the risk of cord prolapse. The patient should be free of active infection of the genital tract (e.g., herpes) and should be human immunodeficiency virus (HIV) negative or have a viral load low enough that vaginal birth is acceptable. After rupture the amniotic fluid is allowed to drain slowly. The fluid is assessed for colour, odour, amount, and consistency (i.e., for the presence or absence of meconium or blood). The time of rupture and characteristics of the fluid are recorded.

NURSING ALERT The FHR is assessed before and immediately after the amniotomy to detect any changes (transient tachycardia is common, but bradycardia and variable decelerations are not), which may indicate cord compression or prolapse.

The patient’s temperature should be checked at least every 2 hours after rupture of membranes and more frequently if signs or symptoms of infection are noted. If the temperature is 38°C (100.4°F) or greater, the obstetrical health care provider should be notified. The nurse needs to assess for other signs and symptoms of infection, such as chills in the patient, fetal tachycardia, uterine tenderness on palpation, and foul-smelling vaginal drainage. Comfort measures such as frequently changing the patient’s underpads and perineal cleansing need to be implemented.

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BOX 20.9

Childbirth

Procedure: Assisting With

Amniotomy Procedure Explain to the patient what will be done. Assess fetal heart rate and pattern before procedure begins, to obtain a baseline reading. Place several underpads under the patient’s buttocks to absorb fluid. Position the patient on a padded bed pan, fracture pan, or rolled-up towel to elevate the hips as needed. Assist the health care provider who is performing the procedure by providing sterile gloves and lubricant for the vaginal examination. Unwrap sterile package containing Amnihook or Allis clamp and pass instrument to the primary health care provider, who inserts it alongside the fingers and then hooks and tears the membranes. Reassess fetal heart rate and pattern. Assess colour, consistency, amount, and odour of fluid. Assess the patient’s temperature every 2 hours or per protocol. Evaluate the patient for signs and symptoms of infection. Documentation Record the following: • Indication for amniotomy • Time of rupture • Colour, odour, amount, consistency, and clarity of fluid • Fetal heart rate and pattern before and after procedure • Labouring patient’s status and how well procedure was tolerated

LEGAL TIP

BOX 20.10 Indications and Contraindications for Use of Oxytocin for Induction or Augmentation of Labour The indications for oxytocin induction or augmentation of labour may include but are not limited to the following: • Suspected fetal jeopardy (e.g., intrauterine growth restriction) • Inadequate uterine contractions; dystocia • Prelabour rupture of membranes • Post-term pregnancy • Chorioamnionitis • Medical concerns in pregnant patient (e.g., severe Rh isoimmunization, inadequately controlled diabetes, chronic renal disease, or chronic pulmonary disease) • Gestational hypertension (e.g., pre-eclampsia, eclampsia) • Fetal death The management of stimulation of labour is the same, regardless of indication. Because of the potential dangers associated with the injection of oxytocin in the prenatal and perinatal periods, there are contraindications to its use. Contraindications to oxytocic stimulation of labour include but are not limited to the following: • Cephalopelvic disproportion, prolapsed cord, transverse lie • Abnormal fetal heart rate • Placenta previa or vasa previa • Prior classic uterine incision or other uterine surgery • Active genital herpes infection • Invasive cancer of the cervix • Previous uterine rupture

SAFETY ALERT

Performing an amniotomy is outside the scope of practice of nurses. A policy that is consistent with professional standards of care and clearly explains the nurse’s role in amniotomy should be in place in all labour and birth areas.

Oxytocin is listed on the Institute for Safe Medication Practices’ list of highalert medications because it has the potential to cause significant harm when used inappropriately (Institute for Safe Medication Practices, 2018).

Oxytocin. Oxytocin is a hormone normally produced by the posterior

Oxytocin use can present hazards to the labouring patient and fetus. Hazards in the labouring patient include placental abruption, uterine rupture, unnecessary Caesarean birth because of abnormal fetal heart rate and patterns, postpartum hemorrhage, and infection. When placental perfusion is diminished by contractions that are too frequent or prolonged, the fetus can experience hypoxemia and acidemia, which eventually results in late decelerations and minimal or absent baseline variability. The goal of oxytocin use is to produce contractions of normal intensity, duration, and frequency while using the lowest dose of medication possible (Lee et al., 2016). The obstetrical health care provider writes the order for the induction or augmentation of labour with oxytocin. The nurse implements the order by initiating the primary IV infusion and administering the oxytocin solution through a secondary line. The nurse’s actions related to assessment and care of a patient whose labour is being induced are guided by hospital protocol and professional standards. The ideal dosing regimen of oxytocin is not known, and there are both low-dose and highdose protocols (see Medication Guide: Oxytocin). EFM is required for oxytocin induction of labour, although once the infusion rate is stable and provided the FHR tracing is normal, it is reasonable to allow periods of up to 30 minutes without EFM for ambulation, personal care, and hydrotherapy (Dore & Ehman, 2020) (Figure 20.4).

pituitary gland. It stimulates uterine contractions and aids in milk letdown. A synthetic version of this hormone may be used to either induce labour or augment (speed up) a labour that is progressing slowly because of inadequate uterine contractions. See Box 20.10 for indications and contraindications for oxytocin induction or augmentation. Although certain maternal and fetal conditions are not contraindications to the use of oxytocin to stimulate labour, they do require special caution during its administration. These conditions include the following: • Multifetal presentation • Breech presentation • Presenting part above the pelvic inlet • Atypical fetal heart rate and pattern not requiring emergency birth • Polyhydramnios • Grand multiparity • Previous Caesarean birth • Maternal cardiac disease; hypertension Oxytocin is the medication most commonly associated with adverse events during childbirth. A standard approach to oxytocin administration should be implemented in each obstetrical unit (Lee et al., 2016).

Fig. 20.4 Woman in side-lying position receiving oxytocin. (Courtesy Cheryl Briggs, RNC, Annapolis, MD.)

MEDICATION GUIDE Oxytocin Action • Oxytocin is a hormone produced in the posterior pituitary gland that stimulates uterine contractions and aids in milk let-down. Syntocinon is a synthetic form of this hormone. Indications • Oxytocin is used primarily for labour induction and augmentation. It is also used to control postpartum bleeding. Dosage • The IV solution containing oxytocin should be mixed in a standard concentration. Concentrations often used are 10 units in 1 000 mL of fluid, 20 units in 1 000 mL of fluid, or 30 units in 500 mL of fluid. • Isotonic IV solutions (e.g., 0.9% sodium chloride, lactated Ringer’s) are used to avoid electrolyte imbalance. • Oxytocin is administered intravenously through a secondary line connected to the main line at the proximal port (connection closest to the IV insertion site). Oxytocin is always administered by pump. • Oxytocin administration is started at a low-dose or high-dose regimen (see below). Dosage is increased per protocol until an adequate contraction pattern is established. • The goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by a consistent pattern of three to five contractions every 10 minutes. • Once labour is established, oxytocin is maintained at or decreased to a rate adequate for continued labour progress. Adverse Effects • Possible adverse effects in the labouring patient include uterine tachysystole with or without FHR changes, placental abruption, uterine rupture, unnecessary Caesarean birth caused by abnormal fetal heart rate and patterns, postpartum hemorrhage, infection, and death from water intoxication (e.g., severe hyponatremia). • Possible fetal adverse effects include hypoxemia and acidosis, eventually resulting in abnormal fetal heart rate and patterns. Nursing Considerations • Oxytocin is considered a high-alert medication because it has the potential to cause significant harm when used inappropriately.

• Patient and family teaching and support: • Reasons for use of oxytocin (e.g., to start or improve labour) • Reactions to expect concerning the nature of contractions: the intensity of the contraction increases more rapidly, holds the peak longer, and ends more quickly; contractions will come regularly and more often • Continue to keep patient and their family informed regarding progress. • Remember that patients vary greatly in their response to oxytocin; some require only very small amounts of medication to produce adequate contractions, whereas others need larger doses. • Continue to provide labour support techniques, such as use of the birth ball or a rocking chair. • Encourage change in position every 20 to 30 minutes; encourage walking or standing, especially after the oxytocin dose is stable. Assessment • Assess level of the labouring patient’s discomfort and pain and the effectiveness of pain management. • Fetal status using electronic fetal monitoring: Evaluate tracing every 15 minutes and with every change in dose during the first stage of labour and every 5 minutes during the active pushing phase of the second stage of labour. • Monitor the contraction pattern and uterine resting tone every 15 minutes and with every change in dose during the first stage of labour and every 5 minutes during the second stage of labour. • Monitor blood pressure, pulse, and respirations every 30 to 60 minutes and with every change in dose. • Assess intake and output; limit IV intake to 1 000 mL in 8 hours; urine output should be 120 mL or more every 4 hours. • Perform vaginal examination as indicated. • Monitor for adverse effects, including nausea, vomiting, headache, and hypotension. • Observe emotional responses of labouring patient and their partner. • The rate of oxytocin infusion should be continually titrated to the lowest dose that achieves acceptable labour progress. Usually the oxytocin dose can be decreased or discontinued after rupture of membranes and in the active phase of first-stage labour.

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Reportable Conditions • Uterine tachysystole (with or without FHR changes) • Abnormal fetal heart rate and pattern (absent baseline variability and any of the following: [1] recurrent late decelerations, [2] recurrent variable decelerations, [3] bradycardia, or [4] prolonged decelerations) • Suspected uterine rupture • Inadequate uterine response at 30 mU/min Emergency Measures Discontinue use of oxytocin per hospital protocol and notify primary care provider immediately: • Turn patient onto lateral position. • Give IV bolus if patient is hypovolemic or hypotensive. • If there is evidence of hypoxia or hypovolemia in the patient, administer oxygen by nonrebreather face mask at 8 to 10 units/min or per protocol or primary health care provider’s order. Oxygen is reserved for maternal resuscitation in the presence of maternal hypoxia or hypovolemia, NOT for fetal resuscitation. • Prepare to administer nitroglycerine, if ordered, to decrease uterine activity. • Continue monitoring fetal heart rate and pattern and uterine activity. Documentation • The time the oxytocin infusion is begun, and each time the infusion is increased, decreased, or discontinued • Assessment data as described above

• Interventions for uterine tachysystole and abnormal fetal heart rate and patterns and the response to the interventions • Notification of the obstetrical health care provider and that person’s response Low-Dose Protocol Initial dose: 1–2 mU/min Increase interval: 30 minutes Dosage increment: 1–2 mU/min Usual dose for adequate labour: 8–12 mU/min Maximum dose before reassessment: 30 mU/min Benefits: Less risk of tachysystole; overall use of a smaller dose High-Dose Protocol Initial dose: 4–6 mU/min Increase interval: 15–30 minutes Dosage increment: 4–6 mU/min Usual dose for adequate labour: 8–12 mU/min Maximum dose before reassessment: 30 mU/min Benefits: Reduced length of labour with no appreciable increase in newborn morbidity Risks: Associated with an increase in uterine tachysystole with associated FHR changes ALERT: Because mixing methods may vary, the rate of infusion should always be documented in mU/min rather than mL/hr.

Data from American College of Obstetricians and Gynecologists (ACOG). (2009/2019). Induction of labor (ACOG Practice Bulletin No. 107). Author; Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 42(3), 316 348. https://doi.org/10.1016/j.jogc.2019.05.007; Hill, W., & Harvey, C. (2013). Induction of labor. In N. Troiano, C. Harvey, & B. Chez (Eds.), AWHONN’s high risk & critical care obstetrics (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins; Leduc, D., Biringer, A., Lee, L., et al. (2013). SOGC clinical practice guideline: Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), S1–S18; Lee, L., Dy, J., Azzon, H., et al. (2016). SOGC clinical practice guideline: Management of spontaneous labour at term in healthy women. Journal of Obstetrics and Gynaecology Canada, 38(9), 843–865. doi:10.1016/j.jogc.2016.04.093; Simpson, K., & O’Brien-Abel, N. (2014). Labor and birth. In K. Simpson & P. Creehan (Eds.), AWHONN’s perinatal nursing (4th ed.). Lippincott. FHR, Fetal heart rate; IV, intravenous.

Nursing care. An evidence-informed written protocol for the preparation and administration of oxytocin should be established by the obstetrical department (physicians, midwives, nurses) in each institution. Oxytocin is decreased or discontinued and the obstetrical health care provider notified if tachysystole resulting in an abnormal fetal heart rate or pattern occurs. Other nursing interventions, such as administering 8 to 10 L oxygen by nonrebreather mask, positioning the patient on their side, and administering an IV fluid bolus, are independent nursing interventions and are implemented immediately as necessitated by the clinical picture (see Emergency Measures in Medication Guide). Based on the status of the maternal–fetal unit, the obstetrical health care provider may order the infusion to be restarted once the FHR and uterine activity return to acceptable levels. Depending on the fetal heart rate and pattern assessment and the length of time the infusion was discontinued, the oxytocin may be restarted at half the rate that resulted in tachysystole (e.g., discontinued for 10 to 20 minutes) or at the same rate as the initial rate (e.g., discontinued for more than 30 to 40 minutes) (Simpson & O’Brien-Abel, 2014).

Augmentation of Labour Augmentation of labour is the stimulation of uterine contractions after labour has started spontaneously but progress has been unsatisfactory. Augmentation is usually implemented for the management of hypotonic uterine dysfunction resulting in a slowing of labour (protracted active phase). Common augmentation methods include oxytocin infusion and amniotomy. Noninvasive methods such as emptying

the bladder, ambulation, position changes, relaxation measures, nourishment, hydration, and hydrotherapy can be attempted before invasive interventions are initiated. The procedures and nursing assessments are similar to those used for oxytocin induction of labour (see Medication Guide). See Evolve for Nursing Care Plan on Patient with Hypotonic Uterine Dysfunction. Some physicians advocate active management of labour, that is, augmentation of labour to establish efficient labour with the aggressive use of oxytocin so that the patient gives birth within 12 hours of admission to the labour unit. Advocates of active management believe that intervening early (as soon as a nulliparous labour is not progressing at least 1 cm/hour) with use of higher (pharmacological) oxytocin doses administered at frequent increment intervals shortens labour (Simpson & O’Brien-Abel, 2014). Additional components of the active management of labour include the following: • Strict criteria to diagnose that the patient is indeed in active labour with 100% effacement • Amniotomy within 1 hour of admission of a patient in labour if spontaneous rupture of the membranes has not occurred • Continuous presence of a nurse who provides one-on-one care for the patient while they are in labour Many health care providers emphasize using high-dose oxytocin protocols but do not implement all the other components of active management. At least one review of published studies on the effectiveness of active management of labour protocols concluded that the presence of a nurse who provides constant emotional and

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physical one-on-one support is the only component associated with shorter labours and lower rates of Caesarean birth (Simpson & O’Brien-Abel, 2014).

Operative Vaginal Births Forceps-Assisted Birth. A forceps-assisted vaginal birth is one in which an instrument with two curved blades is used to assist in the birth of the fetal head. The cephalic-like curve of the forceps commonly used is similar to the shape of the fetal head, with a pelvic curve to the blades conforming to the curve of the pelvic axis. The blades are joined by a pin, screw, or groove arrangement. These locks prevent the forceps from compressing the fetal skull (Figure 20.5). There are several types of forceps-assisted births, defined primarily by the station and position of the fetal head in relationship to the pelvis of the labouring patient (Table 20.3). Indications for forceps-assisted birth include a prolonged second stage of labour and the need to shorten the second stage of labour for patient reasons (e.g., exhaustion or cardiopulmonary or cerebrovascular disease) (Hobson et al., 2019; Nielsen et al., 2017). Fetal indications include an abnormal FHR tracing or certain abnormal presentations, arrest of rotation, or extraction of the head in a breech presentation (Hobson et al., 2019). The use of forceps during childbirth has been decreasing; in 2015–2016, the forceps-assisted birth rate was 3.4% (PHAC, 2020).

Fenestrated blades Simpson

Fig. 20.6 Outlet forceps-assisted extraction of the head.

Certain conditions are required for a forceps-assisted birth to be successful. The patient’s cervix must be fully dilated to prevent lacerations and hemorrhage, and the bladder should be empty. The presenting part must be engaged—vertex presentation is desired. Membranes must be ruptured so the position of the fetal head can be determined precisely and the forceps can grasp the head firmly during birth (Figure 20.6). The size of the labouring patient’s pelvis must be assessed as adequate for the estimated fetal head circumference and weight. Management. Both blades are positioned by the physician, and the handles are locked. Traction is usually applied during contractions. The patient may or may not be instructed to push during contractions, depending on physician preference. If a decrease in the FHR occurs, the forceps are removed and reapplied.

NURSING ALERT Piper

Kielland Solid blades Tucker-McLean Fig. 20.5 Types of forceps. Piper forceps are used to assist birth of the head in a breech birth.

TABLE 20.3

Definitions for Forceps- and Vacuum-Assisted Births Outlet

Fetal scalp is visible on the perineum without manually separating the labia

Low

Fetal head is at least at the +2 station

Midpelvis

Fetal head is engaged (no higher than 0 station) but above the +2 station

Source: Hobson, S., Cassell, K., Windrim, R., & Cargill, Y. (2019). SOGC clinical practice guideline: Assisted vaginal birth. Journal of Obstetrics and Gynaecology Canada, 41(6), 870–882. https://doi.org/10.1016/j.jogc. 2018.10.020.

Because compression of the cord between the fetal head and the forceps will cause a decrease in FHR, the FHR is assessed, reported, and recorded before and after application of the forceps.

Nursing care. When a forceps-assisted birth is deemed necessary, the nurse obtains the type of forceps requested by the physician (see Figure 20.5). The nurse can explain to the patient that the forceps blades fit like two tablespoons around an egg, with the blades coming over the baby’s ears. After the birth, the postpartum patient should be assessed for vaginal and cervical lacerations (e.g., bleeding that occurs even with a contracted uterus); urinary retention, which may result from bladder injuries or urethral injuries; and hematoma formation in the pelvic soft tissues, which may result from blood vessel damage. The newborn should be assessed for bruising or abrasions at the site of the blade applications, facial palsy resulting from pressure of the blades on the facial nerve (cranial nerve VII), and subdural hematoma. Newborn and postpartum caregivers should be told that the birth was forceps assisted.

Vacuum-Assisted Birth. Vacuum-assisted birth, or vacuum extraction, is a birth method involving the attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head (Figure 20.7). It is generally not used to assist birth before 34 weeks of gestation. Indications for use are similar to those for outlet forceps. Prerequisites for use include a completely dilated cervix, ruptured membranes, engaged head, vertex presentation, and no suspicion of CPD (Cunningham et al., 2018). The types of vacuum-assisted births are defined the same as for forceps-assisted births—by the station

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A B Fig. 20.7 Use of vacuum extraction to rotate fetal head and assist with descent. A: Arrow indicates direction of traction on the vacuum cup. B: Caput succedaneum formed by the vacuum cup.

and position of the fetal head in relation to the maternal pelvis (see Table 20.3). The rate of vacuum-assisted birth in Canada in 2015–2016 was 9.2% (PHAC, 2020). Advantages of vacuum-assisted birth over forceps-assisted birth are the ease with which the vacuum can be placed and the need for less anaesthesia. Also, it is far easier to learn the skills necessary to safely use the vacuum than to gain a similar level of skill with forceps (Thorp & Laughon, 2018). Management. The vacuum cup is applied to the fetal head by the physician. Basically, two types of vacuum devices are in use. One is a self-contained unit, which allows the physician to both position the cup on the baby’s head and generate the desired amount of negative pressure to create a vacuum. With another type of vacuum device, the physician applies the cup to the baby’s head, then the nurse connects the suction tubing attached to the cup to wall suction or a separate hand pump and generates the amount of pressure requested by the physician. With both devices, a caput develops inside the cup as the pressure is initiated (see Figure 20.7, B). The patient is encouraged to push as traction is applied by the physician. The vacuum cup is released and removed after birth of the head. If vacuum extraction is not successful, a forceps-assisted or Caesarean birth is performed. Risks to the newborn include cephalhematoma, scalp lacerations, and subdural hematoma. Fetal complications can be reduced by adhering strictly to the manufacturer’s recommendations for method of application, degree of suction, and duration of application. Complications in the labouring patient are uncommon but can include perineal, vaginal, and cervical lacerations and soft tissue hematomas. Nursing care. The nurse needs to provide education and support for the patient who has a vacuum-assisted birth. The nurse can prepare the patient for birth and encourage them to remain active in the birth process through the pushing during contractions. The FHR should be assessed frequently during the procedure. After birth, the newborn should be observed for signs of trauma at the application site and for cerebral irritation (e.g., poor sucking or listlessness). Documentation includes the time and number of applications, any “pop-offs,” the number of pulls, and the maximum amount of suction used. Newborn caregivers should be told that the birth was vacuum assisted. After birth, the newborn must be observed for signs of trauma and infection at the application site and for cerebral irritation (e.g., seizures, lethargy, increased irritability or poor feeding) (Simpson & O’Brien-Abel, 2014). The newborn may also be at risk for hyperbilirubinemia and jaundice as bruising resolves. The parents may need to be reassured that the caput succedaneum usually disappears in 3 to 5 days (see Figure 20.7, B).

Caesarean Birth Caesarean birth is the birth of a fetus through a transabdominal incision of the uterus. Whether Caesarean birth is planned (scheduled) or unplanned, the loss of the experience of giving birth to a child in the traditional manner may have a negative effect on a patient’s self-esteem. Thus it is important to maintain the focus on the birth of the baby rather than on the operative procedure. The purpose of Caesarean birth is to preserve the life or health of the labouring patient, the fetus, or both; it may be the best choice when there is evidence of complications in either the labouring patient or fetus. Since the advent of modern surgical methods and care and the use of antibiotics, morbidity and mortality rates have decreased in both the labouring patient and the fetus. In addition, incisions are made into the lower uterine segment rather than into the muscular body of the uterus and thus promote more effective healing. However, despite these advances, Caesarean birth still poses threats to the health of both the labouring patient and the newborn. The incidence of Caesarean births has increased, from 17.6% in 1993 to 28.8% in 2017–2018 (Canadian Institute for Health Information [CIHI], 2020). Part of the reason for this increase is that a number of common risk factors for Caesarean birth are increasing, such as fetal macrosomia, advanced maternal age, obesity, gestational diabetes, multifetal pregnancy, and labour dystocia in first pregnancies (Thorp & Laughon, 2018). Other factors cited include the increase in primary elective Caesarean births and a decline in the rate of trial of labour after Caesarean (TOLAC). This decline may be the result of perceived risks of TOLAC (e.g., uterine rupture), legal pressures, conservative practice guidelines, and debate over the relative benefits and risks of Caesarean versus vaginal route for births. Although some patients desire elective Caesarean birth, fewer than 10% of all North American patients prefer a Caesarean birth, based solely on their request (Berghella et al., 2017). Approaches for the management of labour and birth in order to reduce the rate of Caesarean births are presented in Box 20.11. These approaches involve the combined efforts of health care providers and pregnant patients and their families. The labour management approach that most consistently reduces the risk for a Caesarean birth outcome is continuous, early support of the labouring patient that is provided by another person (e.g., doula, relative, friend, nurse, or midwife). When this person is not a member of the labour unit staff and is thus able to spend all of their time providing physical and emotional support, the risk for Caesarean birth is further reduced (Bohren et al., 2017).

CHAPTER 20

BOX 20.11 Recommended Measures to Safely Reduce the Primary Caesarean Birth Rate • Encourage more expectant management of second-stage labour, considering current definitions of “normal” labour. • Use standardized fetal heart rate interpretation and management. • Increase access to nonmedical interventions during labour, such as continuous labour support. • Offer external cephalic version for breech presentation. • Offer the option of labour for patients with twin gestations when the first twin is in cephalic presentation. • Avoid Caesarean birth for suspected fetal macrosomia unless the estimated fetal weight is at least 5 000 g in patients without diabetes and at least 4500 g in patients with diabetes. • Offer operative (forceps- or vacuum-assisted) vaginal birth, performed by an experienced, well-trained physician. • Conduct research to provide a better knowledge base to guide decisions regarding Caesarean birth. • Encourage policy changes that safely lower the rate of primary Caesarean birth. Data from American College of Obstetricians and Gynecologists & Society for Maternal-Fetal Medicine. (2014). Safe prevention of the primary cesarean delivery. Obstetrics & Gynecology, 123, 693–711.

The type of nursing care given also may influence the rate of Caesarean births. A labour management approach that uses one-to-one support and emphasizes ambulation, position changes in the labouring patient, relaxation measures, oral fluids and nutrition, hydrotherapy, and nonpharmacological pain relief can facilitate the progress of labour and reduce the incidence of dystocia.

Indications. Few absolute indications exist for Caesarean birth. Currently, most are performed for conditions that might pose a threat to both the labouring patient and the fetus if vaginal birth occurred, such as placenta previa or placental abruption (Berghella et al., 2017). Box 20.12 lists common indications for Caesarean birth. Elective Caesarean birth. Elective Caesarean birth, sometimes referred to as Caesarean on request or Caesarean on demand, refers to a primary Caesarean birth without medical or obstetrical indication. Reasons given for elective Caesarean birth include fear of the pain of childbirth and the mistaken belief that the surgery will prevent future issues with pelvic support, bladder and bowel incontinence, or sexual dysfunction (Alsayegh et al., 2018). Although some nulliparous patients may fear the pain of labour because of no firsthand experience, multiparous patients may request a Caesarean birth after a previous traumatic vaginal birth. Other pregnant patients desire an elective Caesarean birth because of the convenience of planning a date or having control and choice about when to give birth. At this time, evidence is insufficient to recommend elective Caesarean birth to prevent urinary or fecal incontinence later in life (Berghella et al., 2017; Thorp & Laughon, 2018). Potential risks of Caesarean birth on request include the following: • Higher rates of endometritis, blood transfusion, and venous thrombosis • A longer hospital stay and recovery time for the postpartum patient • An increased risk for respiratory issues for the baby • Greater complications in subsequent pregnancies, including uterine rupture and placental implantation difficulties Caesarean birth on request should not be performed unless a gestational age of 39 weeks has been accurately determined. Also, the procedure is not recommended for patients who desire several

BOX 20.12

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Indications for Caesarean Birth

Pregnant Patient • Specific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease) • Specific respiratory disease (e.g., Guillain-Barre syndrome) • Conditions associated with increased intracranial pressure • Mechanical obstruction of the lower uterine segment (tumours, fibroids) • Mechanical vulvar obstruction (e.g., extensive condylomata) • History of two or more previous Caesarean births • Elective Caesarean birth (Caesarean on patient request) Fetal • Abnormal fetal heart rate or pattern • Malpresentation (e.g., breech or transverse lie) • Active herpes lesions in labouring patient • Maternal human immunodeficiency virus (HIV) with a viral load of more than 1 000 copies/mL • Congenital anomalies Labouring Patient–Fetal Conditions • Dysfunctional labour (e.g., cephalopelvic disproportion, “failure to progress” in labour) • Placental abruption • Placenta previa Data from Berghella, V., Mackeen, A. D., & Jauniaux, E. R. M. (2017). Cesarean delivery. In S. Gabbe, J. Niebyl, J. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier.

additional children, because the risks for placenta previa, placenta accreta, and Caesarean hysterectomy increase with each Caesarean birth (Berghella et al., 2017). The SOGC does not promote Caesarean on demand and promotes vaginal childbirth but believes that the final decision as to the safest route for childbirth rests with the patient and their health care provider (Alsayegh et al., 2018). It is essential that patients be fully informed about the risks and benefits of Caesarean birth when they consider requesting elective Caesarean birth. Following discussion of the risks and benefits of Caesarean birth versus vaginal birth, if the patient should choose Caesarean birth, the physician may agree and perform the operation no earlier than 39 weeks of gestation (Alsayegh et al., 2018). Scheduled Caesarean birth. Caesarean birth is scheduled or planned if: • Labour and vaginal birth are contraindicated (e.g., complete placenta previa, active genital herpes, positive HIV status with a high viral load) • Birth is necessary but labour is not inducible (e.g., hypertensive states that cause an intrauterine environment that threatens the health of the fetus) • This course of action has been chosen by the obstetrical health care provider and the patient (e.g., a repeat or elective Caesarean birth). Patients who are scheduled for a Caesarean birth have time to prepare for it psychologically. However, the psychological responses of these patients may vary. Those having a repeat Caesarean birth can have disturbing memories of the conditions preceding the initial (primary) Caesarean birth and their experiences in the postoperative recovery period. They may be concerned about the added burden of caring for a newborn and perhaps other children while recovering from a surgery. Others may feel glad to have been relieved of the uncertainty about the date and time of birth and to be free from the pain of labour. Unplanned Caesarean birth. The psychosocial outcomes of unplanned or emergency Caesarean birth are usually more pronounced

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and negative in nature than the outcomes associated with a scheduled or planned Caesarean birth. Patients and their families experience abrupt changes in their expectations for birth, postpartum care, and the care of the new baby at home. This may be a traumatic experience for all involved. The labouring patient may approach the procedure tired and discouraged after a difficult labour. They may worry about their own safety and well-being and that of their fetus. The patient may be dehydrated, with low glycogen reserves. Because preoperative procedures must be done quickly and competently, the time available for explanation of the procedures and operation is often short. Patient and family anxiety levels tend to run high at this time, so much of what is said may be forgotten or misunderstood. The patient may experience feelings of anger or guilt in the postpartum period. Fatigue is often noticeable in these patients, and they need much supportive care. After surgery, it is important for the nurse to spend time with the patient reviewing the events preceding the operation and the operation itself to ensure that they understand what has happened and that gaps in their recollections are filled. This approach will help create more realistic memories of the childbirth experience and can leave a more positive impression for future pregnancies and labours. Forced Caesarean birth. Health care providers are ethically obliged to protect the well-being of both the labouring patient and the fetus; a decision for one affects the other. If a patient refuses a Caesarean birth that is recommended because of fetal jeopardy, health care providers must make every effort to find out why they are refusing and provide clear information to ensure that they are making an informed decision. If the patient continues to refuse surgery, the health care provider must decide if it is ethical to get a court order for the surgery; however, every effort should be made to avoid this legal step.

Surgical Techniques. The skin incision used is vertical, extending from near the umbilicus to the mons pubis, or transverse (Pfannenstiel) in the lower abdomen (Figure 20.8). The transverse incision, sometimes referred to as the “bikini” incision, is performed more often. The type of skin incision is generally determined by the urgency of the surgery and the presence of any prior skin incisions (Berghella et al., 2017). The type of skin incision does not necessarily indicate the type of uterine incision. The two main types of uterine incision are the low transverse incision (Figure 20.9, A) and the vertical incision, which may be either low or classic (see Figure 20.9, B and C). Ideally, the vertical incision is contained entirely within the lower uterine segment, but extension into the contractile portion of the uterus (e.g., a classic incision) can occur (Berghella et al., 2017). Indications for a vertical incision include an underdeveloped lower uterine segment, a transverse lie presentation, an anterior placenta previa or accreta, or if uterine leiomyomas (fibroids) obstruct the lower uterine segment (Berghella et al., 2017). Because it is associated with a higher incidence of uterine rupture in subsequent pregnancies than is a lower-segment incision, vaginal birth after a classic uterine incision is contraindicated.

Vertical through skin

B

C Fig. 20.9 Uterine incisions for Caesarean birth. A: Low transverse incision. B: Low vertical incision. C: Classic incision. (From Gabbe, S. G., Niebyl, J. R., Simpson, J. L., et al. [2017]. Obstetrics: Normal and problem pregnancies [7th ed.]. Elsevier.)

The low transverse uterine incision is performed in most Caesarean births (see Figure 20.9, A). The transverse incision is preferred over the vertical incision because it does not compromise the upper uterine segment, is easier to perform and repair, and is associated with less blood loss. It also provides for the option of TOLAC in subsequent pregnancies (Berghella et al., 2017).

Complications and Risks. Possible complications related to Caesarean birth include anaesthesia events (difficulty with intubation, medication reactions, aspiration pneumonia), hemorrhage, bowel or bladder injury, amniotic fluid embolism, and air embolism. Possible postpartum complications include atelectasis; endometritis; urinary tract infection; abdominal wound hematoma formation, dehiscence, infection, or necrotizing fasciitis; thromboembolic disease; and bowel dysfunction (Thorp & Laughon, 2018). In addition to these risks, the patient will also have a longer recovery period and additional time in the hospital. Caesarean birth is associated with uncommon but significant dangers to the newborn. The fetus may be born prematurely if the gestational age has not been accurately determined (iatrogenic prematurity). Fetal asphyxia can occur if the uterus and placenta are poorly perfused as a result of hypotension in the labouring patient caused by regional anaesthesia (epidural or spinal) or positioning. Fetal injuries (e.g., injuries caused by scalpel lacerations) can also occur during the surgery. The newborn is more likely to require resuscitation efforts and develop respiratory complications (Thorp & Laughon, 2018). Anaesthesia. Spinal, epidural, and general anaesthetics are used for

Horizontal through skin (first skin crease under hairline)

A

A

B

Fig. 20.8 Skin incisions for Caesarean birth. A: Vertical. B: Horizontal (Pfannenstiel).

Caesarean births. Regional blocks (epidural and spinal) are used most often because of their safety, and most patients want to be awake for and aware of the birth experience. However, the choice of anaesthetic depends on several factors. The patient’s medical history or present condition, such as a spinal injury, hemorrhage, or coagulopathy, may rule out the use of regional anaesthesia. In the case of an emergency and the patient’s or newborn’s life being at risk, general anaesthesia will most likely be used unless an epidural is already in place. The patient is

CHAPTER 20 also a factor. The person may not know all the options or may have fears about “a needle in the back” or of being awake and feeling pain. They need to be fully informed about the risks and benefits of the different types of anaesthesia so that they can participate in the decision whenever there is a choice to be made. See Chapter 18 for further discussion.

Prenatal Preparation. A discussion of Caesarean birth should be included in all childbirth preparation classes. No patient can be guaranteed a vaginal birth, even if they are in good health and no indication of danger to the fetus exists before the onset of labour. Therefore, every pregnant patient needs to be aware of and prepared for the possibility of having a Caesarean birth. Childbirth educators should emphasize the similarities and differences between a Caesarean and a vaginal birth. Most hospitals permit partners and family members to share in these births as they do in vaginal births. Patients who have undergone Caesarean birth agree that the continued presence and support of their partners helped them respond more positively to the entire experience. In addition, hospitals are moving toward practices in the operating room, such as skin-to-skin, that help normalize the birth process for the patient and the baby. Along with preparing pregnant patients for the possibility of Caesarean birth, more importantly, childbirth educators should empower clients to believe in their ability to give birth vaginally and to seek care measures during labour that will enhance the progress of their labour and reduce their risk for Caesarean birth. Nursing Care Preoperative care. The preparation of the patient for a Caesarean birth is the same as that for other elective or emergency surgery. The obstetrical health care provider discusses with the patient and their family the need for the Caesarean birth. The anaesthesiologist assesses the patient’s cardiopulmonary system and describes the options for anaesthesia. Patients who are scheduled for an elective Caesarean are often told to remain NPO (nothing by mouth) for at least 8 hours before the surgery. Informed consent is obtained for the procedure. Blood and urine tests are usually done within a week before a planned Caesarean birth or on admission to the hospital. Laboratory tests, most commonly ordered to establish baseline data, include a complete blood cell count, blood type and Rh status, and possibly a urinalysis. Vital signs, blood pressure, and fetal heart rate and pattern continue to be assessed per hospital routine until the operation begins. IV fluids are started to maintain hydration and to provide an open line for the administration of medications and for blood, if needed. Other physical preoperative preparation usually includes inserting a retention (Foley) catheter to keep the bladder empty (this should be done after administration of anaesthetic, if possible) and administering prescribed preoperative medications. In the rare instance that an abdominal-mons shave or a clipping of pubic hair is ordered by the obstetrical health care provider, this is performed in the operating room just before making the incision because shaving can result in injury of the integument, thereby increasing the risk for infection. Often TED hose and SCD boots will be placed on the patient’s legs to prevent blood clot formation, especially if it is determined that there is increased risk for development of thrombophlebitis. An antacid is often administered orally to neutralize gastric secretions in case of aspiration. Removal of contact lenses, dentures, nail polish, and jewellery may be optional, depending on hospital policies and type of anaesthesia used. If the patient wears glasses and is going to be awake, the nurse should make sure that their glasses accompany them to the operating room so they can see the newborn. During preoperative preparation, the support person is encouraged to remain with the patient as much as possible to provide

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continuing emotional support (if this is culturally acceptable to the patient and support person). The nurse needs to provide essential information about the preoperative procedures during this time. Although nursing actions may have to be carried out quickly if a Caesarean birth is unplanned, verbal communication, particularly explanations, is important. Silence and lack of information can be frightening to the patient and their support person. The nurse’s use of touch (if culturally appropriate) can communicate feelings of care and concern for the patient. The nurse can assess the patient’s and partner’s perceptions about Caesarean birth. As the patient expresses their feelings, the nurse may identify possible self-concept concerns that may need to be addressed during the postpartum period. If there is time before the birth, the nurse can teach the patient about postoperative expectations and pain relief, turning, coughing, and deep-breathing measures. Intraoperative care. Family-centred care is the goal for the patient who is undergoing Caesarean birth and for their family. Some options that can be offered to improve the Caesarean birth experience include playing music chosen by the parents, softening the overhead lighting, using a surgical drape with a window if desired by the patient, and limiting extraneous conversation in the operating room. Implementing skin-to-skin care and breastfeeding in the operating room for any newborn who is healthy are other interventions that are often desired by patients and their families. Even seemingly “small” interventions, such as inserting the IV line into the patient’s nondominant arm or hand, can enhance the birth experience (Schorn et al., 2015). Caesarean births occur in operating rooms in the surgical suite or in the labour and birth unit. Once the patient has been taken to the operating room, the care becomes the responsibility of the obstetrical team, surgeon, anaesthesiologist, and nursing staff (Figure 20.10). If possible, the partner or another person, dressed appropriately for the operating room, accompanies the patient to the surgical unit and remains close to them so that continued support and comfort can be provided. In an unplanned Caesarean birth, the nurse who cared for the patient during labour should be part of the interprofessional care team in the operating room, if possible. The nurse who is circulating can assist with positioning the patient on the surgical table. Positioning is important so that the uterus is displaced laterally, to prevent compressing the inferior vena cava, which causes decreased placental perfusion. This is usually accomplished by placing a wedge under the hip. The patient’s legs should be secured to the table to ensure proper positioning during the surgery. A Foley catheter is inserted into the bladder at this time if one is not already in place. If the patient has general anaesthesia, the partner may not be permitted in the operating room. If the partner or another person is not allowed or chooses not to be present, the nurse can stay in communication with them and give progress reports whenever possible. If the patient is awake during the birth, the nurse or anaesthetist can tell the patient what is happening and provide support. The patient may be anxious about the sensations they are experiencing, such as the coldness of solutions used to prepare the abdomen and pressure or pulling during the actual birth of the infant. They may also be apprehensive because of the bright lights or the presence of unfamiliar equipment and masked and gowned personnel in the room. Explanations by the nurse can help decrease the patient’s anxiety. Care of the newborn usually is delegated to a nurse or other care provider skilled in newborn resuscitation. If risk factors are present, a pediatrician may also be present. An infant warmer with resuscitation equipment is readied before surgery. Those responsible for care are expert not only in resuscitative techniques but also in the ability to detect normal and abnormal newborn responses. After birth, if the

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A

A

B B Fig. 20.11 A: Parents and their newborn. While the physician manually removes the placenta; suctions the remaining amniotic fluid and blood from the uterine cavity; and closes the uterine incision, peritoneum, muscle layer, fatty tissue, and, finally, the skin while the new family shares some private time. B: Parents become better acquainted with their newborn while mother rests after surgery. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

LEGAL TIP: Disclosure of Patient Information

C Fig. 20.10 Caesarean birth. A: “Bikini” incision has been made, the muscle layer is separated, the abdomen is entered, the uterus has been exposed and incised. Note small amount of bleeding. B: The newborn’s birth through the uterine incision is nearly complete. C: A quick assessment is performed; note significant moulding of head resulting from cephalopelvic disproportion. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

newborn’s condition permits and the mother is awake, the baby may be placed skin-to-skin on the birthing parent or partner or can be given to the partner to hold (Figure 20.11). The newborn whose condition is compromised is transported after initial stabilization to the nursery for observation and the implementation of appropriate interventions. Usually the partner may accompany the newborn; if not, personnel should keep the family informed of the newborn’s progress, and parent–infant contacts are initiated as soon as possible.

Some parents want the privilege of informing family and friends of the gender of the newborn (if it was not known before the birth) or other information about the birth. Before responding to requests for such information from people waiting outside the birthing area, the nurse should check to see if the parents have given consent for such information to be released and to whom.

Immediate postoperative care. Once surgery is completed, the patient is transferred to a postanaesthesia recovery area. Patients who undergo a Caesarean birth have both postoperative and postpartum needs that must be addressed. They are surgical patients, as well as new parents. Nursing assessments in this immediate postbirth period follow agency protocol and include degree of recovery from the effects of anaesthesia, postoperative and postbirth status, and degree of pain. If general anaesthesia was administered, it is essential that a patent airway be maintained and that the patient be positioned to prevent possible aspiration until they are fully alert and responsive

CHAPTER 20 (see Chapter 18, General Anaesthesia). Vital signs should be taken every 15 minutes for 1 to 2 hours or until stable. The condition of the incisional dressing, the fundus, and the amount of lochia need to be assessed, as well as IV intake and urine output through the Foley catheter. Oxytocin is usually added to at least the first litre of the IV infusion to ensure that the fundus remains firmly contracted, thereby reducing blood loss unless the medication carbetocin has been administered in the operating room. The patient should be helped to turn and do coughing, deep-breathing, and leg exercises. Medications for pain relief should be administered before postoperative pain becomes severe. Routine postpartum care is organized to facilitate parent–infant interaction as soon as possible and to answer the family’s questions. When appropriate, the nurse should assess the new parent’s readiness to see the baby, as well as their response to the anaesthesia and to the event that may have necessitated general anaesthesia (e.g., emergency Caesarean birth when vaginal birth was anticipated). If the baby is present, the parents should be given some time alone with the baby to facilitate bonding and attachment. Newborns should be placed skin-to-skin with a parent as soon as possible, and breastfeeding can be initiated when the postpartum patient feels like trying to breastfeed, preferably within the first 30 to 60 minutes after birth. The patient is usually transferred to the postpartum unit after 1 to 2 hours or once their condition is stable and the effects of anaesthesia have decreased (i.e., patient is alert, oriented, and able to feel and move extremities). Postpartum care. The attitude of the nurse and other health team members can influence the patient’s perception of themselves after a Caesarean birth. The caregivers should stress that the patient is a new parent first and a surgical patient second. This attitude helps the patient perceive themselves as having the same concerns and needs as those of other new parents while at the same time requiring supportive postoperative care. The patient’s physiological concerns for the first few days may be dominated by pain at the incision site and pain resulting from intestinal gas, thus the need for pain relief. For the first 24 hours after surgery, pain relief can be provided by epidural opioids, patientcontrolled analgesia (PCA), or IV or intramuscular injections. The most commonly used analgesics include opioids (e.g., hydromorphone or morphine sulphate) and NSAIDs (e.g., naproxen). If opioids are used, an antiemetic (e.g., dimenhydrinate [Gravol], promethazine [Phenergan], ondansetron [Zofran]) is often ordered to be administered either as needed by the patient or around the clock as long as the opioid is used. Palpation of the fundus with the possibility of massage should be performed after an analgesic is given to decrease pain. By 24 hours after surgery, patients are generally given oral analgesics. Other comfort measures such as position changes, splinting the incision with pillows, and relaxation and breathing techniques may be implemented. Patients are often the best judge of what their bodies need and can tolerate, including the postoperative ingestion of foods and fluids. Because most patients have an epidural or spinal anaesthetic for surgery, most health care providers allow the early introduction of solid food if desired and tolerated. Some health care providers may order clear fluids until bowel sounds return, but research does not support this practice for gynecological surgery (Charoenkwan & Matovinovic, 2014). IV fluids are usually continued until the patient is tolerating fluids orally. Patients should be taught methods to help limit gas formation and thereby minimize the severity of gas pains (see Patient Teaching box: Postpartum Pain Relief After Caesarean Birth).

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PATIENT TEACHING Postpartum Pain Relief After Caesarean Birth Incisional Pain • Splint incision with a pillow when moving or coughing. • Use relaxation techniques such as listening to music, deep breathing, and dimming lights. Intestinal Gas • Get out of bed as quickly as possible and walk as often as you can. • Do not eat or drink gas-forming foods, carbonated beverages, or whole milk. • Do not use straws for drinking fluids. • Take antiflatulence medication if prescribed. • Lie on your left side to expel gas. • Rock in a rocking chair.

Nurses must be alert to the patient’s physiological needs, managing care to ensure adequate rest and pain relief. Couplet care for a Caesarean birth patient can be modified according to their physiological limitations as a surgical patient. Daily care includes perineal care and routine hygienic care, including showering after the dressing has been removed (if showering is acceptable according to the patient’s cultural beliefs and practices). The indwelling (Foley) catheter is also usually removed on the first postpartum day (usually within 8 to 12 hours). The patient is encouraged to be out of bed and ambulating several times each day as soon as possible. Use of TED hose or SCD boots should continue as long as the patient remains in bed. They may be removed when they begin ambulating. The nurse assesses the patient’s vital signs, incision, fundus, and lochia according to hospital policies, procedures, or protocols. Breath sounds, bowel sounds, circulatory status of lower extremities, and urinary and bowel elimination also are assessed. It is also important to note parental emotional status and progress of attachment to their baby.

SAFETY ALERT The patient should be taught to seek assistance initially when getting out of bed, especially when an IV line and catheter are still in place. Thereafter, when rising from a supine position, they should sit on the side of the bed first to determine if dizziness will occur, then stand at the bedside, and finally ambulate.

During the postpartum period, the nurse can provide care that meets the psychological and learning needs of patients who have had Caesarean births. The nurse should explain postpartum procedures to help the patient participate in the recovery from surgery. Also, the nurse can help the patient plan care and visits from family and friends that allow for adequate rest periods. Information and assistance with newborn care can facilitate adjustment to the role as a parent. The patient needs to be supported as they breastfeed the baby, receiving individualized assistance to comfortably hold and position the baby at the breast. The side-lying position or football hold and the use of pillows to support the newborn can enhance comfort and facilitate successful breastfeeding (see Chapter 27). The partner and other family members can be included in teaching sessions about newborn care and the postpartum patient’s recovery.

SAFETY ALERT When holding the baby or breastfeeding, a patient may become drowsy and even fall asleep because of the sedation that occurs with the use of analgesics. It is important that someone be with them during these times.

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The couple also should be encouraged to express their feelings about the birth experience. Some parents are angry, frustrated, or disappointed that a vaginal birth was not possible. Some patients may express feelings of low self-esteem or a negative self-image. Others express relief and gratitude that the baby is healthy and safely born. It may be helpful for them to have the nurse who was present during the birth visit help fill in “gaps” about the experience. Discharge after Caesarean birth is usually by the second or third postoperative day. The patient’s predominant needs at home are for rest and sleep; relief of pain and discomfort; and assistance with household chores, newborn care and feeding, and self-care. The nurse must provide discharge teaching in the limited time the patient is in the hospital, while also ensuring that they are comfortable and able to rest. The nurse should assess the patient’s information needs and coordinate the health care team’s efforts to meet them. Discharge teaching and planning should include information about the following: • Nutrition • Measures to relieve pain and discomfort • Exercise and specific activity restrictions • Time management that includes periods of uninterrupted rest and sleep • Hygiene, breast, and incision care • Timing for resumption of sexual activity and contraception • Signs of complications (see Patient Teaching box: Signs of Postoperative Complications After Discharge Following Caesarean Birth) • Newborn care The patient’s family and friends should be educated about their needs during the recovery process, and their assistance should be coordinated before discharge. Referrals to community agencies may be indicated to further promote the recovery process. A postdischarge program of telephone follow-up and home visits can facilitate the patient’s full recovery after Caesarean birth.

PATIENT TEACHING Signs of Postoperative Complications After Discharge Following Caesarean Birth Report the following signs to your health care provider: • Temperature exceeding 38°C (100.4°F) • Urination; painful urination, urgency, cloudy urine • Lochia: A heavier than normal menstrual period, clots, odour • Caesarean incision: Redness, swelling, bruising, foul-smelling discharge or bleeding, wound separation • Severe, increasing abdominal pain

Trial of Labour After Caesarean (TOLAC) A patient who has had a previous low-segment Caesarean birth may be a candidate for a TOLAC. Indications for primary Caesarean birth such as dystocia, breech presentation, or abnormal FHR pattern often are nonrecurring. Therefore, a patient who has had a Caesarean birth with a low transverse uterine incision and subsequently becomes pregnant may not have any contraindications to labour and vaginal birth in that pregnancy and may be offered a TOLAC. Box 20.13 lists contraindications suggested by the SOGC for a TOLAC. The major risk associated with TOLAC is uterine rupture, although the absolute risk for this is low (Dy et al., 2019). Other risks include operative injury, blood transfusion, hysterectomy, endometritis, and patient death (Dy et al., 2019; Thorp & Laughon, 2018) (see Clinical Reasoning Case Study: Trial of Labour After Caesarean [TOLAC]).

BOX 20.13 Contraindications for a Trial of Labour After Caesarean (TOLAC) • • • • • •

Previous or suspected classical uterine incision Previous inverted T or low vertical uterine incision Previous uterine rupture Previous major uterine surgery Patient requests repeat Caesarean birth Inability to perform an emergency Caesarean birth if necessary

Data from Dy, J., DeMeester, S., Lipworth, H., & Barrett, J. (2019). SOGC clinical practice guideline: No. 382—Trial of labour after Caesarean. Journal of Obstetrics and Gynaecology Canada, 41(7), 992–1011. https:// doi.org/10.1016/j.jogc.2018.11.008.

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CLINICAL REASONING CASE STUDY

Trial of Labour After Caesarean (TOLAC) Heather, a 28-year-old G2 T1 P0 A0 L1, had a Caesarean birth in her previous pregnancy because of breech position of the fetus. During her routine prenatal visit at 32 weeks of gestation, Heather tells the nurse that she really wants to have a vaginal birth this time. Heather asks, “What do you think? Can I try for a TOLAC?” Questions 1. Evidence—Is there sufficient evidence to advise Heather about the safety and feasibility of a TOLAC? 2. Assumptions—Describe an underlying assumption about each of the following issues: a. Risks that Heather faces if she chooses a TOLAC b. Criteria that must be met for Heather to attempt a TOLAC c. Labour management practices that facilitate a successful TOLAC 3. What implications and priorities for nursing care can be drawn at this time? 4. Interprofessional care—Describe the roles and responsibilities of health care providers who might be involved in Heather’s care.

The overall vaginal birth after Caesarean (VBAC) success rate is approximately 60 to 80%. The strongest predictors for a successful VBAC are a prior vaginal birth and spontaneous (rather than induced or augmented) labour (Dy et al., 2019). Patients whose first Caesarean birth was performed because of a nonrecurring indication (e.g., breech presentation) also are likely to have a successful VBAC (Dy et al., 2019). Patients with the following characteristics are less likely to have a successful VBAC (Dy et al., 2019): • Recurrent indication (e.g., labour dystocia) for initial Caesarean birth • Increased age in labouring person • Non-White race or ethnicity • Gestational age greater than 40 weeks • Obesity in labouring person • Pre-eclampsia • Short interpregnancy interval (less than 18-month interval) • Induction and/or augmentation of labour • Increased newborn birth weight Patients are the primary decision makers with regard to choice of birth method. During the antepartum period, the patient should be given information about TOLAC and encouraged to choose it as an alternative to a repeat Caesarean, as long as no contraindications exist.

CHAPTER 20 VBAC support groups (see Additional Resources at end of the chapter) and prenatal classes can help prepare the patient psychologically for labour and vaginal birth. Patients need to believe not only that their efforts during a TOLAC will be successful but also that they are fully capable of doing what is necessary to give birth vaginally. They must be given the opportunity to discuss their previous labour experience, including feelings of failure and loss of control, and to express any concern they may have about how they will manage during their upcoming labour and birth. Not everyone is enthusiastic about TOLAC and VBAC. After being fully informed about the benefits and risks, more than 25% of potential candidates choose to have a repeat Caesarean birth instead (Thorp & Laughon, 2018). There is conflicting evidence that administering oxytocin to induce or augment labour increases the risk of uterine rupture. If oxytocin is used for the TOLAC, caution and close monitoring of the labouring patient are urged. However, use of prostaglandins to ripen the cervix or induce labour is not recommended because they have been associated with an increased risk for uterine rupture (Dy et al., 2019). If a patient chooses TOLAC, attention should be given to their psychological as well as physical needs. Anxiety increases the release of catecholamines and can inhibit the release of oxytocin, delaying the progress of labour and possibly leading to a repeat Caesarean birth. To alleviate anxiety, the nurse can encourage the patient to use breathing and relaxation techniques and change position to promote labour progress. The patient’s partner can be encouraged to provide comfort measures and emotional support. Collaboration among the labouring patient, their partner, the nurse, and other health care providers often results in a successful VBAC. If a TOLAC does not proceed to vaginal birth, the patient will need support and encouragement to express their feelings about having another Caesarean birth. It is important that this outcome not be labelled a “failed” VBAC. The nurse needs to assess the patient’s vital signs and the fetus’ heart rate and pattern and should be alert for signs of potential complications. If complications develop, the nurse is responsible for initiating appropriate actions, including notifying the obstetrical health care provider, and for evaluating and documenting the patient’s and fetal responses to the interventions. Supporting and encouraging the patient and their partner and providing information on progress can reduce stress, enhance the labour process, and facilitate a successful outcome. Many patients who are appropriate candidates for TOLAC lack access to health care providers and health care facilities that are able and willing to offer this option. Because resources for immediate Caesarean birth may not be available in all birthing facilities, the best alternative in some situations may be to refer interested patients to other facilities that have the obstetrical, anaesthetic, pediatric, and surgical staff necessary to offer TOLAC (Dy et al., 2019).

OBSTETRICAL EMERGENCIES Meconium-Stained Amniotic Fluid Meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth. Meconium-stained amniotic fluid is green. The consistency of the amniotic fluid is often described as either thin (light) or thick (heavy), depending on the amount of meconium present. Three possible reasons for the passage of meconium are as follows: • It is a normal physiological function that occurs with maturity (meconium passage being infrequent before weeks 23 or 24, with

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an increased incidence after 38 weeks) or with a breech presentation. • It is the result of hypoxia-induced peristalsis and sphincter relaxation. • It may be a sequel to umbilical cord compression–induced vagal stimulation in mature fetuses. The major risk associated with meconium-stained amniotic fluid is the development of meconium aspiration syndrome (MAS) in the newborn. MAS causes a severe form of aspiration pneumonia that occurs most often in term or post-term infants who have passed meconium in utero (see Chapter 28, Meconium Aspiration Syndrome). MAS most likely results from a long-standing intrauterine process rather than from aspiration immediately after birth as respirations are initiated (Rozance & Rosenberg, 2017).

Collaborative Care. The presence of an interprofessional team skilled in newborn resuscitation is required at the birth of any infant with meconium-stained amniotic fluid. To address occurrence of meconium-stained amniotic fluid, the Canadian Paediatric Society along with the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) Neonatal Resuscitation Program no longer recommend routine suctioning of the newborn’s mouth and nose followed by endotracheal suctioning after birth. Instead, management of a newborn with meconium-stained amniotic fluid is based only on assessment of the baby’s condition at birth. No clinical studies warrant basing tracheal suctioning guidelines simply on meconium consistency (AAP & AHA, 2016). See the Emergency box: Immediate Management of the Newborn With Meconium-Stained Amniotic Fluid for specific interventions.

EMERGENCY Immediate Management of the Newborn With Meconium-Stained Amniotic Fluid Before Birth • Assess the amniotic fluid for the presence of meconium after rupture of membranes. • If the amniotic fluid is meconium stained, gather equipment and supplies that might be necessary for neonatal resuscitation. • Have at least one person capable of performing endotracheal intubation on the baby present at the birth. Immediately After Birth • Assess whether the baby appears term, has good muscle tone, and is breathing or crying. • If the baby meets these three criteria, the baby should remain skin-to-skin with the parent and routine care should be provided. • If the baby does not meet any of these three criteria, the baby should be moved to a warmer for further assessment. If secretions are present, clear the airway with a bulb syringe. Do not vigorously suction the baby because this may cause bradycardia or apnea. Data from American Academy of Pediatrics (AAP) and American Heart Association (AHA). (2016). Textbook of neonatal resuscitation (7th ed.). AAP.

SAFETY ALERT Every birth should be attended by at least one person whose only responsibility is the baby and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation.

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Shoulder Dystocia Shoulder dystocia is an uncommon obstetrical emergency that increases the risk for morbidity and mortality in the fetus, newborn, or labouring patient during the attempt to accomplish birth vaginally. Shoulder dystocia is a condition in which the head is born but the anterior shoulder cannot pass under the pubic arch. It is difficult to estimate the incidence of shoulder dystocia because of a lack of consensus related to the definition; however, 1% has been identified as a useful average (Cunningham et al., 2018). The incidence of shoulder dystocia has increased in recent years, perhaps because of larger birth weights or simply because more attention is now paid to documenting the condition (Cunningham et al., 2018). Fetopelvic disproportion caused by excessive fetal size (greater than 4 000 g) or pelvic abnormalities in the labouring patient may be a cause of shoulder dystocia, although up to half of all cases of shoulder dystocia occur with smaller fetuses (Lanni et al., 2017; Thorp & Laughon, 2018). Other risk factors for shoulder dystocia include diabetes during pregnancy (risk for macrosomia), a prolonged second stage of labour, and a history of shoulder dystocia with a previous birth. In half of all cases of shoulder dystocia, however, no risk factors are identified (Thorp & Laughon, 2018). Shoulder dystocia cannot be accurately predicted or prevented (Cunningham et al., 2018). Retraction of the fetal head against the perineum immediately after its emergence (turtle sign), however, is an early warning that birth of the shoulders may be difficult (Thorp & Laughon, 2018). Fetal injuries are usually caused either by asphyxia related to the delay in completing the birth or by trauma from the manoeuvres used to accomplish the birth. Complications related to trauma include brachial plexus and phrenic nerve injuries and fracture of the humerus or clavicle. The most serious complication is brachial plexus injury (Erb palsy), which occurs in 10 to 20% of infants born following shoulder dystocia (Thorp & Laughon, 2018). Evidence now exists that brachial plexus injuries may result from intrauterine forces during the second stage of labour rather than from the manoeuvres used to accomplish birth (Lanni et al., 2017). If brachial plexus injuries are recognized early and treated properly, 80 to 90% heal completely. Therefore, permanent neurological injury is rare. The major complications in postpartum patients associated with shoulder dystocia are postpartum hemorrhage and rectal injuries (Lanni et al., 2017).

Fig. 20.12 McRoberts manoeuvre. (From Gabbe, S. G., Niebyl, J. R., Simpson, J. L., et al. [2017]. Obstetrics: Normal and problem pregnancies [7th ed.]. Elsevier.)

Collaborative Care. Many manoeuvres, such as suprapubic pressure and position changes in the labouring patient, have been suggested and tried to free the anterior shoulder. The McRoberts manoeuvre and suprapubic pressure are usually the first-line interventions for shoulder dystocia, because they are noninvasive and easily learned and they can be performed quickly. The specific interventions used are less important than is being prepared at every vaginal birth to manage shoulder dystocia using a planned sequence of interventions if the need arises (Lanni et al., 2017). In the McRoberts manoeuvre (Figure 20.12), the patient’s legs are hyperflexed on the abdomen. This manoeuvre causes the sacrum to straighten, and the symphysis pubis rotates toward the patient’s head; the angle of pelvic inclination is decreased, freeing the shoulder. Suprapubic pressure can then be applied over the anterior shoulder (Figure 20.13) in an attempt to dislodge the shoulder. Use of the McRoberts manoeuvre and suprapubic pressure may relieve more than one half of all cases of shoulder dystocia. Fundal pressure as a method of relieving shoulder dystocia should be avoided because it will only further impact the anterior shoulder behind the symphysis pubis (Lanni et al., 2017). The Gaskin manoeuvre (having the patient move to a hands-and-knees position) has also been highly effective in resolving cases of shoulder dystocia. However, the Gaskin manoeuvre may be

Fig. 20.13 Application of suprapubic pressure. (From Gabbe, S. G., Niebyl, J. R., Simpson, J. L., et al. [2017]. Obstetrics: Normal and problem pregnancies [7th ed.]. Elsevier.)

difficult to accomplish if the patient has significant loss of motor function caused by regional anaesthesia. When shoulder dystocia is diagnosed, the nurse should stay calm and immediately call for additional assistance. The nurse can then help the patient assume the position(s) that may facilitate birth of the shoulders, assist the obstetrical health care provider with these manoeuvres, and monitor the fetal response. The nurse should also provide encouragement and support to reduce anxiety and fear. Newborn assessment should include examination for fracture of the clavicle or humerus, brachial plexus injuries, and asphyxia. Postpartum patient assessment should focus on early detection of hemorrhage and trauma to the soft tissue of the birth canal.

CHAPTER 20

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Fig. 20.14 Prolapse of umbilical cord. Note pressure of presenting part on umbilical cord, which endangers fetal circulation. A: Occult (hidden) prolapse of cord. B: Complete prolapse of cord. Note that membranes are intact. C: Cord presenting in front of fetal head may be seen in vagina. D: Frank breech presentation with prolapsed cord.

Prolapsed Umbilical Cord Prolapse of the umbilical cord occurs when the cord lies below the presenting part of the fetus. Umbilical cord prolapse may be occult (hidden, not visible) at any time during labour, regardless of whether or not membranes are ruptured (Figure 20.14, A and B). It is most common to see frank (visible) prolapse directly after rupture of membranes, when gravity washes the cord in front of the presenting part (see Figure 20.14, C and D). Contributing factors are a long cord (longer than 100 cm), malpresentation (breech or transverse lie), or unengaged presenting part. If the presenting part does not fit snugly into the lower uterine segment, as in polyhydramnios, when the membranes rupture, a sudden gush of amniotic fluid may cause the cord to be displaced downward. Similarly, the cord may prolapse during amniotomy if the presenting part is high. A small or preterm fetus may not fit snugly into the lower uterine segment; as a result, cord prolapse is more likely to occur.

Collaborative Care. Prompt recognition of a prolapsed cord is important because fetal hypoxia resulting from prolonged cord compression (i.e., occlusion of blood flow to and from the fetus for more than 5 minutes) can occur and potentially lead to fetal hypoxia, newborn asphyxia, neurological brain injury, or death of the fetus. Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off of the umbilical cord (Figure 20.15, A and B). The patient should be assisted into a position such as lateral recumbent (see Figure 20.15, C), Trendelenburg, or knee–chest (see Figure 20.15, D) position, in which gravity keeps the presenting part off the cord. If the cervix is fully dilated, a forceps- or vacuum-assisted birth can be performed for the fetus in a cephalic presentation; otherwise, emergent Caesarean surgery is likely to be performed. Abnormal fetal heart rate and pattern (e.g., bradycardia, absent or minimal variability, and variable or prolonged decelerations), inadequate uterine relaxation, and bleeding also can occur as a result of a prolapsed umbilical cord. Indications for immediate interventions are presented in the Emergency box: Prolapsed Umbilical Cord. Ongoing assessment of the patient and the fetus is critical to determine the effectiveness of each action taken. The patient and the family are often aware of the seriousness of the situation; therefore, the nurse must provide support by giving explanations for the interventions being implemented and their effect on the status of the fetus.

EMERGENCY Prolapsed Umbilical Cord Signs • Variable or prolonged deceleration during uterine contraction • Patient reports feeling the cord after membranes rupture • Cord is seen or felt in or protruding from the vagina Interventions • Call for assistance. Do not leave the patient alone. • Have someone notify the obstetrical health care provider immediately. • Glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord (see Figure 20.15, A and B). Do not move your hand. Another person may place a rolled towel under the patient’s right or left hip. • Place patient into the extreme Trendelenburg or a lateral recumbent position (see Figure 20.15, C), or a knee–chest position (see Figure 20.15, D). • If the cord is protruding from the vagina, wrap it loosely in a sterile towel saturated with warm, sterile, normal saline solution. Do not attempt to replace the cord into the cervix. • Administer oxygen to the patient by mask at 8 to 10 L/min until birth is accomplished. • Start intravenous fluids or increase existing drip rate. • Continue to monitor fetal heart rate continuously. • Explain to the patient and support person what is happening and the management plan. • Prepare for immediate vaginal birth if the cervix is fully dilated or for Caesarean birth if it is not.

Rupture of the Uterus Uterine rupture is defined as the symptomatic disruption and separation of the layers of the uterus or previous scar. Uterine rupture can result in the ejection of fetal parts or the entire fetus into the peritoneal cavity. It is a rare but very serious obstetrical injury that occurs in 1 in 2 000 births (Francois & Foley, 2017). During labour and birth, the major risk factor for uterine rupture is a scarred uterus as a result of previous Caesarean birth or other uterine surgery. Rupture usually

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D Fig. 20.15 Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by examiner’s fingers in A: vertex presentation and B: breech presentation. C: Gravity relieves pressure when woman is in a lateral position with hips elevated as high as possible with pillows. D: Knee–chest position.

occurs during a TOLAC; symptomatic rupture is rarely observed in planned, repeat Caesarean births. The likelihood of uterine rupture varies, depending on the type and location of the previous uterine incision. Uterine rupture occurs most often with a previous classic incision. Other factors that increase the risk for uterine rupture include multiple prior Caesarean births, no previous vaginal births, induced or augmented labour, term gestation, thin uterine scar identified by ultrasound, multifetal gestation, fetal macrosomia, post–Caesarean birth infection, and short interpregnancy interval (Francois & Foley, 2017; Landon & Grobman, 2017). Uterine dehiscence, sometimes called incomplete uterine rupture, is separation of a prior scar. It may go unnoticed unless the patient undergoes a subsequent Caesarean birth or other uterine surgery. The potential for maternal or fetal complications as a result of uterine dehiscence is negligible because separation of a prior scar does not result in hemorrhage (Landon & Grobman, 2017). Signs and symptoms vary with the extent of the uterine rupture. The most common finding is an abnormal FHR tracing, particularly prolonged decelerations or bradycardia sometimes preceded by variable or late decelerations. A loss of fetal station may also occur.

The patient may experience vaginal bleeding, constant abdominal pain, uterine tenderness, a change in uterine shape, blood in the urine, and cessation of contractions (Francois & Foley, 2017; Landon & Grobman, 2017). The patient may also exhibit signs of hypovolemic shock caused by hemorrhage (i.e., hypotension, tachypnea, pallor, and cool, clammy skin). If the placenta separates, the FHR will be absent. Fetal parts may be palpable through the abdomen.

Collaborative Care. Prevention is the best treatment. Patients at risk for uterine rupture should be assessed closely during labour. Labouring patients who are induced with oxytocin or prostaglandin (especially if the previous birth was Caesarean) should be monitored for signs of uterine tachysystole with or without FHR changes because this can precipitate uterine rupture. If tachysystole occurs, the oxytocin infusion is discontinued or decreased, and a tocolytic medication may be given to decrease the intensity of uterine contractions. After giving birth, patients should be assessed for excessive bleeding, especially if the fundus is firm and signs of hemorrhagic shock are present.

CHAPTER 20 If rupture occurs, the type of medical management depends on its severity. A small rupture may be managed with a laparotomy and birth of the newborn, repair of the laceration, and blood transfusions, if needed. Hysterectomy and blood replacement are the usual treatments for a complete rupture. The nurse’s role may include starting IV fluids, transfusing blood products, administering oxygen, and assisting with preparation for immediate surgery. Supporting the patient’s family and providing information about the treatment are important during this emergency. The associated fetal mortality rate is high (approximately 50 to 75%). Maternal morbidity and mortality can also be substantial (Cunningham et al., 2018). Providing information about spiritual support services or suggesting that the family contact their own support system may be warranted.

Amniotic Fluid Embolism Amniotic fluid embolism (AFE), also known as anaphylactoid syndrome of pregnancy, is a rare but devastating complication of pregnancy characterized by the sudden, acute onset of hypoxia, hypotension, cardiovascular collapse, and coagulopathy. The incidence is estimated at 1.7 to 7.7 in 100 000 births. The true incidence is unknown because of the difficulty in confirming the diagnosis and inconsistent reporting of nonfatal cases (Drummond & Yeomans, 2019). AFE occurs during labour, during birth, or within 30 minutes after birth. This combination of sudden respiratory and cardiovascular collapse, along with coagulopathy, is similar to that observed in patients with anaphylactic or septic shock. In both conditions, a foreign substance is introduced into the circulation, resulting in disseminated intravascular coagulation, hypotension, and hypoxia (Drummond & Yeomans, 2019). In AFE, the foreign substance that initiates the condition is presumed to be present in amniotic fluid that is introduced into the circulation of the labouring patient. However, the exact factor that initiates AFE has not been identified. In the past, particles of fetal debris (e.g., vernix, hair, skin cells, or meconium) found in amniotic fluid were thought to be responsible for initiating the syndrome; however, fetal debris can be found in the pulmonary circulation of most normal labouring patients. Also, fetal debris is identified in only 78% of patients diagnosed with AFE. Therefore, AFE is diagnosed clinically (Drummond & Yeomans, 2019). Although AFE is rare, the mortality rate is 61% or higher (Drummond & Yeomans, 2019). Outcome for newborns in cases of AFE is poor. The newborn survival rate is between 20 and 60%. However, only half of these fetuses survive neurologically intact (Drummond & Yeomans, 2019). Risk factors for AFE include advanced age, non-White race, placenta previa, pre-eclampsia, and forceps-assisted or Caesarean birth. Other factors commonly associated with the development of AFE are rapid labour and meconium staining (Cunningham et al., 2018). Previously it was thought that the hypertonic uterine contractions that often accompany AFE actually caused the event. Instead, it appears that the physiological response to AFE produces the hypertonic contractions (Drummond & Yeomans, 2019).

Collaborative Care. The immediate interventions for AFE are summarized in the Emergency box: Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy). Care must be instituted immediately. Cardiopulmonary resuscitation is often necessary. If cardiopulmonary arrest occurs, for optimal fetal survival, a perimortem Caesarean birth should be accomplished within 5 minutes (Drummond & Yeomans, 2019). The nurse’s immediate responsibility is to assist with the resuscitation efforts.

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EMERGENCY Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy) Signs • Respiratory distress • Restlessness • Dyspnea • Cyanosis • Pulmonary edema • Respiratory arrest • Circulatory collapse • Hypotension • Tachycardia • Shock • Cardiac arrest • Hemorrhage • Coagulation failure: bleeding from incisions, venipuncture sites, trauma (lacerations); petechiae, ecchymoses, purpura • Uterine atony Interventions Oxygenate. • Administer oxygen by nonrebreather face mask (10 L/min) or resuscitation bag delivering 100% oxygen. • Prepare for intubation and mechanical ventilation. • Initiate or assist with cardiopulmonary resuscitation. Tilt pregnant patient 30 degrees to side to displace uterus. Maintain cardiac output and replace fluid losses. • Position patient on their side. • Administer IV fluids. • Administer blood: packed cells, fresh frozen plasma. • Insert in-dwelling catheter and measure hourly urine output. Correct coagulation failure. Monitor fetal and maternal status. Prepare for emergency birth once patient’s condition has stabilized. Provide emotional support to the patient, partner, and family.

Additional interventions will likely include replacing blood and clotting factors and maintaining adequate hydration and blood pressure. The patient is usually placed on mechanical ventilation. Invasive hemodynamic monitoring may also be required (Drummond & Yeomans, 2019). Support of the patient’s partner and family is needed; they will be anxious and distressed. Brief explanations of what is happening are important during the emergency and can be reinforced after the immediate crisis is over. If the patient dies and the infant survives, grieving, anger, and blame may interfere with parent–infant attachment. When both the parent and infant die, it is important that the family has the opportunity to spend time with them. Emotional support and involvement of the perinatal loss support team or other resource for grief counselling, including the spiritual care team, are needed (see Box 24.7). Referral to grief and loss support groups is appropriate. The nursing staff also may need help in coping with emotions that result from a patient’s death.

KEY POINTS • Preterm labour is defined as uterine contractions leading to cervical change occurring between 20 and 37 completed weeks of pregnancy; preterm birth is any birth that occurs before the completion of 37 weeks of pregnancy.

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• The cause of preterm labour is unknown and is assumed to be multifactorial. • Bed rest, a commonly prescribed intervention for preterm labour, has many deleterious adverse effects and has never been shown to decrease preterm birth rates. • Preterm birth that occurs in a tertiary care centre leads to better outcomes for the labouring patient and the newborn. • Vigilance for signs of infection is a major part of the care for patients with PPROM. • Dystocia results from differences in the normal relationships among any of the five factors affecting labour. • Dystocia due to uterine contractions occurs as a result of hypertonic uterine dysfunction, hypotonic uterine dysfunction, or inadequate voluntary expulsive forces. • The functional relationships among the uterine contractions, the fetus, and the pelvis of the labouring patient are altered by changing positions of the labouring patient. • Uterine contractility is increased by oxytocin and prostaglandin and decreased by tocolytic medications. • Cervical ripening using chemical or mechanical measures can increase the success of labour induction. • Expectant parents benefit from learning about operative obstetrics (e.g., forceps- or vacuum-assisted birth, Caesarean birth) during the prenatal period. • The basic purpose of Caesarean birth is to preserve the life and health of the labouring patient and the fetus. • Unless contraindicated, a vaginal birth may be possible after a previous Caesarean birth. • Labour management that emphasizes one-to-one support of the labouring patient by another person (doula, nurse, or midwife) can reduce the rate of Caesarean births and increase the rate of trial of labour after Caesarean (TOLAC). • Obstetrical emergencies (e.g., shoulder dystocia, prolapsed cord, rupture of the uterus, and amniotic fluid embolism) occur rarely but require immediate intervention. • The perinatal loss support team or other resource for grief counselling, including the spiritual care team, can provide support for families experiencing death of the perinatal patient, the infant, or both.

REFERENCES Alsayegh, E., Bos, H., Campbell, K., et al. (2018). SOGC committee opinion: Caesarean delivery on maternal request. Journal of Obstetrics and Gynaecology Canada, 40(7), 967–971. American Academy of Pediatrics (AAP) & American Heart Association (AHA). (2016). Textbook of neonatal resuscitation (7th ed.). AAP. American College of Obstetricians and Gynaecologists (ACOG). (2009). ACOG practice bulletin No. 107: Induction of labor. Obstetrics & Gynecology, 114, 386–397. Reaffirmed 2019. American College of Obstetricians and Gynecologists (ACOG). (2013). Obesity in pregnancy. ACOG Committee opinion No. 549. Obstetrics & Gynecology, 121(1), 213–217. American College of Obstetricians and Gynecologists (ACOG). (2016). Practice bulletin no. 171: Management of preterm labor. Obstetrics & Gynecology, 128 (4), e155–e164. Baird, S. M., Kennedy, B. B., & Dalton, J. (2017). Special considerations for individualized care of the laboring woman. In B. B. Kennedy, & S. M. Baird (Eds.), Intrapartum management modules: A perinatal education program (5th ed.). Wolters Kluwer. Berghella, V., Mackeen, A. D., & Jauniaux, E. R. M. (2017). Cesarean delivery. In S. Gabbe, J. Niebyl, J. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Bohren, M. A., Hofmeyer, G. J., Sakala, C., et al. (2017). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 7. https://doi.org/10.1002/14651858.CD003766.pub6.

Brizot, M. L., Hernandez, W., Liao, A. W., et al. (2015). Vaginal progesterone for the prevention of preterm birth in twin gestations: A randomized placebocontrolled double-blind study. American Journal of Obstetrics & Gynecology, 213(1), e81–e89. https://doi.org/10.1080/14767058.2017.1403577. Buhimschi, C. S., Mesiano, S., & Muglia, L. J. (2018). Pathogenesis of spontaneous preterm birth. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s Maternal-fetal medicine: Principles and practice (8th ed.). Elsevier. Butt, K., & Lim, K. (2019). SOGC clinical practice guideline: Determination of gestational age by ultrasound. Journal of Obstetrics and Gynecology Canada, 41(10), 1497–1507. https://doi.org/10.1016/j.jogc.2019.04.010. Canadian Institute for Health Information (CIHI). (2020). Health system performance, 2018: Caesarean section. https://yourhealthsystem.cihi.ca/ epub/?language=en&_ga=2.8282934.548875796.1634078735-1811595331. 1634078735. Chan, W.-S., Rey, E., & Kent, N. (2014). Venous thromboembolism and antithrombotic therapy in pregnancy. Journal of Obstetrics and Gynaecology Canada, 36(6), 527–553. Charoenkwan, K., & Matovinovic, E. (2014). Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database of Systematic Reviews, 12. https://doi.org/ 10.1002/14651858.CD004508.pub4, CD004508. Chatsis, V., & Frey, N. (2018). CADTH rapid response report: Summary with critical appraisal. Misoprostol for cervical ripening and induction of labour: A review of clinical effectiveness, cost-effectiveness and guidelines. CADTH. https://www.cadth.ca/sites/default/files/pdf/htis/2018/RC1047% 20Misoprostol%20for%20Labour%20Final.pdf. Cunningham, F., Leveno, K., Bloom, S., et al. (2018). Williams obstetrics (25th ed.). McGraw Hill. DeFranco, E. A., Lewis, D. F., & Odibo, A. O. (2013). Improving the screening accuracy for preterm labor: Is the combination of fetal fibronectin and cervical length in symptomatic patients a useful predictor of preterm birth? A systematic review. American Journal of Obstetrics and Gynecology, 208(1), 233.e1–233.e6. Delaney, M., & Roggensack, A. (2017). SOGC clinical practice guideline: Guidelines for the management of pregnancy at 41+ 0 to 42+0 weeks. Journal of Obstetrics and Gynaecology Canada, 39(8), e164–e174. https://doi. org/10.1016/j.jogc.2017.04.020. Denison F., Aedla N., Keag O., et al., on behalf of the Royal College of Obstetricians and Gynaecologists. (2018). Care of women with obesity in pregnancy. Green-top Guideline No. 72. British Journal of Obstetrics and Gynecology, November. https://www.rcog.org.uk/en/guidelines-researchservices/guidelines/gtg72/. Dore, S., & Ehman, W. (2020). SOGC clinical practice guideline: No. 396—Fetal health surveillance: Intrapartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 42(3), 316–348. https://doi.org/10.1016/j.jogc. 2019.05.007. Drummond, S., & Yeomans, E. R. (2019). Amniotic fluid embolism. In N. H. Troiano, P. M. Witcher, & S. McMurtry Baird (Eds.), AWHONN’s high risk and critical care obstetrics (4th ed.). Lippincott Williams & Wilkins. Duff, P. (2018). Maternal and fetal infections. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy and Resnik’s maternal-fetal medicine: Principles and practice (8th ed.). Elsevier. Duff, P., & Birsner, M. (2017). Maternal and perinatal infection in pregnancy: Bacterial. In S. Gabbe, J. Niebyl, J. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Dy, J., DeMeester, S., Lipworth, H., et al. (2019). SOGC clinical practice guideline: No. 382—Trial of labour after Caesarean. Journal of Obstetrics and Gynaecology Canada, 41(7), 992–1011. https://doi.org/10.1016/j. jogc.2018.11.008. Fell, D. B., Sprague, A. E., Grimshaw, J. M., et al. (2014). Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: A multiple baseline time-series design. British Journal of Obstetrics & Gynecology, 121(4), 438–446. https://doi.org/10.1111/14710528.12511. Feng, Y. Y., Jarde, A. J., Seo, Y. R., et al. (2018). What interventions are being used to prevent preterm birth and when? Journal of Obstetrics and Gynaecology Canada, 40(5), 547–554. https://doi.org/10.1016/j.jogc.2017.08.036 (web archive link).

CHAPTER 20 Francois, K. E., & Foley, M. R. (2017). Antepartum and postpartum hemorrhage. In S. Gabbe, J. Niebyl, J. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Friedman, E. (1989). Normal and dysfunctional labour. In W. Cohen, D. B. Acker, E. A. Friedman, et al. (Eds.), Management of labour (2nd ed.). Aspen. Grobman, W., Rice, M., Reddy, U., et al. (2018). Labor induction versus expectant management in low-risk nulliparous women. New England Journal of Medicine, 379, 513–523. https://doi.org/10.1056/ NEJMoa1800566. Gupta, J. K., Sood, A., Hofmeyr, G. T., et al. (2017). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, 5. https://doi.org/10.1002/14651858.CD002006.pub4. Heavey, E. (2011). Obesity in pregnancy: Deliver sensitive care. Nursing, 41(10), 42–50. https://doi.org/10.1097/01.NURSE.0000405101.68864.19. Hobson, S., Cassell, K., Windrim, R., et al. (2019). SOGC clinical practice guideline: Assisted vaginal birth. Journal of Obstetrics and Gynaecology Canada, 41(6), 870–882. https://doi.org/10.1016/j.jogc.2018.10.020. Hofmeyr, G. J. (2021). External cephalic version. UptoDate. http://www. uptodate.com/contents/external-cephalic-version. Institute for Safe Medications. (2018). High-alert medications in acute care settings. https://www.ismp.org/recommendations/high-alert-medicationsacute-list. Kotaska, A., & Menticoglou, S. (2019). SOGC clinical practice guideline: Management of breech presentation at term. Journal of Obstetrics and Gynaecology Canada, 41(8), 1193–1205. https://doi.org/10.1016/j. jogc.2018.12.018. Landon, M. B., & Grobman, W. A. (2017). Vaginal birth after Cesarean delivery. In S. Gabbe, R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Lanni, S., Gherman, R., & Gonik, B. (2017). Malpresentations. In S. Gabbe, R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Lawrence, A., Lewis, L., Hofmeyr, G. J., et al. (2013). Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 10. https://doi.org/10.1002/14651858.CD003934.pub4. Leduc, D., Biringer, A., Lee, L., et al. (2013). SOGC clinical practice guideline: Induction of labour. Journal of Obstetrics and Gynaecology Canada, 35(9), S1–S18. Lee, L., Dy, J., Azzon, H., et al. (2016). SOGC clinical practice guideline: Management of spontaneous labour at term in healthy women. Journal of Obstetrics and Gynaecology Canada, 38(9), 843–865. https://doi.org/ 10.1016/j.jogc.2016.04.093. Lim, K., Butt, K., & Crane, J. M. (2018). SOGC clinical practice guideline: Ultrasonographic cervical length assessment in predicting preterm birth in singleton pregnancies. Journal of Obstetrics and Gynaecology Canada, 40(2), e151–e164. https://doi.org/10.1016/j.jogc.2017.11.016. Liston, R., Sawchuck, D., Young, D., et al. (2018). Fetal health surveillance: Antepartum consensus guideline. Journal of Obstetrics and Gynaecology Canada, 40(4), e251–e271. https://doi.org/10.1016/j.jogc.2018.02.007. Magee, L. A., Silva, D. A., Sawchuck, D., et al. (2019). SOGC clinical practice guideline: Magnesium sulphate for fetal neuroprotection. Journal of Obstetrics and Gynaecology Canada, 41(4), 505–522. https://doi.org/ 10.1016/j.jogc.2018.09.018. Mahomed, K., Anwar, S., Geer, J. E., et al. (2019). Evaluation of fetal fibronectin for threatened preterm labour in reducing inappropriate interventions. Australian and New Zealand Journal of Obstetrics and Gynaecology, 59(4), 523–527. https://doi.org/10.1111/ajo.12914. Malone, F. D., & D’Alton, M. E. (2018). Multiple gestation. Clinical characteristics and management. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s maternal–fetal medicine: Principles and practice (8th ed.). Elsevier. Maxwell, C., Gaudet, L., Cassir, G., et al. (2019). SOGC clinical practice guideline: No. 392 Pregnancy and maternal obesity Part 2: Team planning for delivery and postpartum care. Journal of Obstetrics and Gynaecology Canada, 41(11), 1660–1675. Mercer, B. M. (2017). Premature rupture of membranes. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Mercer, B., & Chien, E. (2018). Premature rupture of the membranes. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s maternal–fetal medicine: Principles and practice (8th ed.). Elsevier.

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Newman, R., & Unal, E. (2017). Multiple gestations. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Newnham, J. P., Dickinson, J. E., Hart, R. J., et al. (2014). Strategies to prevent preterm birth. Frontiers in Immunology, 5, Article 584. https://doi.org/10. 3389/fimmu.2014.00584. Nielsen, P., Deering, S. H., & Galan, H. (2017). Operative vaginal delivery. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Picklesimer, A., & Dorman, K. (2013). Maternal obesity: Effects on pregnancy. In N. Troiano, C. Harvey, & B. Chez (Eds.), AWHONN’s high risk and critical care obstetrics (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins. Public Health Agency of Canada (PHAC). (2017). Perinatal health indicators for Canada 2017: A report from the Canadian perinatal surveillance system (Cat. No. HP7-1E-PDF). http://publications.gc.ca/collections/collection_ 2018/aspc-phac/HP7-1-2017-eng.pdf. Public Health Agency of Canada (PHAC). (2020). Family centred maternity and newborn care: National guidelines. https://www.canada.ca/en/public-health/ services/maternity-newborn-care-guidelines.html. Rampersad, R., & Macones, G. (2017). Prolonged and postterm pregnancy. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Rozance, P., & Rosenberg, A. (2017). The neonate. In S. Gabbe, J. Niebyl, J. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Schorn, M. N., Moore, E., Spetalnick, B. M., et al. (2015). Implementing familycentered cesarean birth. Journal of Midwifery & Women’s Health, 60(6), 682–690. Shah, P. S., McDonald, S. D., Barrett, J., et al. (2018). The Canadian Preterm Birth Network: A study protocol for improving outcomes for preterm infants and their families. CMAJ Open, 6(1), E44–E49. https://doi.org/10.9778/ cmajo.20170128. Sheibani, L., & Wing, D. A. (2017). Abnormal labor and induction of labor. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Simhan, H. H., Berghella, V., & Iams, J. D. (2018). Prevention and management of preterm parturition. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s Maternal-fetal medicine: Principles and practice (8th ed.). Elsevier. Simhan, H., Iams, J., & Romero, R. (2017). Preterm labor and birth. In S. Gabbe, R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Simpson, K. R., & O’Brien-Abel, N. (2014). Labor and birth. In K. Rice Simpson, & P. A. Creehan (Eds.), AWHONN’s perinatal nursing (4th ed.). Williams & Wilkins: Lippincott. Skoll, A., Boutin, B., Bujold, E., et al. (2018). SOGC clinical practice guideline: Antenatal corticosteroid therapy for improving neonatal outcomes. Journal of Obstetrics and Gynaecology Canada, 40(9), 1219–1239. https://doi.org/ 10.1016/j.jogc.2018.04.018. Statistics Canada. (2021). Live births and fetal deaths (stillbirths), by type of birth (single or multiple). https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid¼1310042801. Thorp, J. M., & Laughon, K. (2018). Clinical aspects of normal and abnormal labour. In R. Resnik, C. J. Lockwood, T. R. Moore, et al. (Eds.), Creasy & Resnik’s Maternal-fetal medicine: Principles and practice (8th ed.). Elsevier. Yudin, M., van Schalwyk, J., Van Eyk, N., et al. (2017). SOGC clinical practice guideline: Antibiotic therapy in preterm premature rupture of the membranes. Journal of Obstetrics and Gynecology Canada, 39(9), e207–e212. https://doi.org/10.1016/j.jogc.2017.06.003. Zhang, J., Bricker, L., Wray, S., et al. (2007). Poor uterine contractility in obese women. British Journal of Obstetrics and Gynaecology, 114, 343–348.

ADDITIONAL RESOURCES Multiple-birth resources for parents. https://www.multiplebirths.ca/. Trillium Health Partners—Breastfeeding Your Baby After a Caesarean Birth: http://trilliumhealthpartners.ca/patientservices/womens/Pages/ breastfeeding-after-caesarean-birth.aspx. Vaginal birth after Caesarean (VBAC) support groups: https://www.vbac.com and https://www.ican-online.org.

UNIT 6 Postpartum Period

21 Physiological Changes in the Postpartum Patient Lisa Keenan-Lindsay Originating US Chapter by Kathryn R. Alden http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the anatomical and physiological changes that occur during the postpartum period. 2. Apply assessment techniques for uterine involution and lochial flow.

3. List expected values for vital signs and blood pressure, deviations from normal findings, and probable causes of the deviations.

The postpartum period is the interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state. This period is sometimes referred to as the puerperium, or fourth trimester of pregnancy, and is considered to last 6 to 12 weeks. The physiological changes that occur during the reversal of the processes of pregnancy are distinctive, but they are normal. To provide care during the recovery period that is beneficial to the postpartum patient, their newborn, and their family, the nurse needs to synthesize knowledge of anatomy and physiology of the postpartum patient during the recovery period, the newborn’s physical and behavioural characteristics, newborn care activities, and the family’s response to the birth of the newborn. This chapter focuses on anatomical and physiological changes that occur in the postpartum patient during the postpartum period.

sixth postpartum day, the fundus is normally located halfway between the umbilicus and the symphysis pubis. The uterus should not be palpable abdominally after 2 weeks. The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. The size of the uterus gradually decreases over the next month so that by 6 weeks the uterus has nearly returned to its nonpregnant location and size (Blackburn, 2018). Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and hypertrophy, an enlargement of the existing cells. After birth, the decrease in these hormones causes autolysis, the selfdestruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy. Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection (see Chapter 24).

REPRODUCTIVE SYSTEM AND ASSOCIATED STRUCTURES Uterus Involution Process. The return of the uterus to a nonpregnant state following birth is called involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. During the first 12 hours postpartum, the fundus of the uterus is located approximately at the level of the umbilicus. At this time, the uterus weighs approximately 1 000 g (Blackburn, 2018). By 24 hours after birth, the uterus is about the same size as it was at 20 weeks of gestation. Involution progresses rapidly during the next few days. The fundus descends 1 to 2 cm every 24 hours (Figure 21.1). By the 484

Contractions. Postpartum hemostasis is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts rather than by platelet aggregation and clot formation. The hormone oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions, which compress blood vessels and promote hemostasis. During the first 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated. Because it is vital that the uterus remain firm and well contracted, exogenous oxytocin is usually administered intravenously or intramuscularly

CHAPTER 21

Physiological Changes in the Postpartum Patient

485

Full bladder? Day postpartum 1 2 3 4 5 6 7 8 9

A

B

C

D Fig. 21.1 Assessment of involution of uterus after childbirth. A: Normal progress, days 1 through 9. B: Size and position of uterus 12 hours after childbirth. C: Two days after childbirth. D: Four days after childbirth. (B through D, courtesy Marjorie Pyle, RNC, Lifecircle.)

immediately after expulsion of the placenta. Patients who are at risk of increased bleeding may have an intravenous infusion of oxytocin for the first several hours after birth (e.g., long labour, grand multiparity). The uterus is very sensitive to oxytocin during the first week or so after birth. Breastfeeding immediately after birth and in the early days postpartum increases the release of oxytocin, which decreases blood loss and reduces the risk for postpartum hemorrhage. Afterpains. In first-time mothers uterine tone is good, the fundus generally remains firm, and the patient usually perceives only mild uterine cramping. Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and may cause uncomfortable cramping called afterpains (afterbirth pains), which typically resolve in 3 to 7 days. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.

Placental Site. Immediately after the placenta and membranes are expelled, vascular constriction and thromboses reduce the placental site to an irregular nodular and elevated area. Upward growth of the endometrium causes sloughing of necrotic tissue and prevents the scar formation characteristic of normal wound healing. This unique healing process enables the endometrium to resume its usual cycle of changes and permit implantation and placentation in future pregnancies. Endometrial regeneration is completed by postpartum day 16, except at the

placental site. Regeneration at the placental site usually is not complete until 6 weeks after birth (Blackburn, 2018).

Lochia. Postbirth uterine discharge, commonly called lochia, initially is bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth, the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochia flow should steadily decrease. Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. Lochia serosa is a pinkish-brown discharge lasting approximately 2 to 4 weeks (Blackburn, 2018). Lochia alba is whitish-yellow in colour because it contains primarily leukocytes and decidual cells; it may continue for another few weeks, although not all patients experience lochia alba. Overall lochia duration may last 4 to 6 weeks postpartum (Blackburn, 2018). If the patient receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a Caesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation. Lochia tends to pool in the vagina when the patient is lying in bed; the patient then may experience a gush of blood when they stand. This gush should not be confused with hemorrhage.

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Postpartum Period

Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for patients to experience a sudden, but brief, increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the patient needs to be evaluated for possible retained placental fragments (Isley & Katz, 2017). About 10 to 15% of patients still have normal lochia serosa discharge at their 6-week postpartum examination (Isley & Katz, 2017). However, in some patients, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate endometritis, particularly if the patient has fever, pain, or abdominal tenderness. Lochia should smell like normal menstrual flow; an offensive odour usually indicates infection. Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth may be caused by unrepaired vaginal or cervical lacerations. Box 21.1 lists factors used to distinguish between lochial and nonlochial bleeding.

Cervix The cervix is soft immediately after birth. The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. The cervical os, which dilated to 10 cm during labour, closes gradually. The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth. By the second or third postpartum day, the cervix is dilated 2 to 3 cm, and by 1 week after birth, it is approximately 1 cm dilated (Blackburn, 2018). The external cervical os never regains its prepregnancy appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a “fish mouth” (see Figure 10.2, B). Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.

Vagina and Perineum Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae. The greatly distended, smooth-walled vagina gradually decreases in size and regains tone, although it never completely returns to its prepregnancy state. Rugae reappear within 3 weeks, but they are never as prominent as they are in the nulliparous person. Most rugae are permanently flattened. The mucosa remains atrophic in the lactating patient, at least until menstruation resumes. Thickening of the vaginal mucosa occurs with the return of ovarian function. Estrogen deficiency is responsible for a decreased amount of vaginal lubrication; vaginal dryness is more prevalent among breastfeeding patients. Localized dryness and coital discomfort

BOX 21.1

Lochial and Nonlochial Bleeding

Lochial Bleeding • Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts. • A gush of lochia may result as the uterus is massaged. If it is dark in colour, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium). Nonlochial Bleeding • If the bloody discharge spurts from the vagina, and the uterus is firmly contracted, there may be cervical or vaginal tears in addition to the normal lochia. • If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

(dyspareunia) may persist until ovarian function returns and menstruation resumes. The use of a water-soluble lubricant to reduce discomfort during sexual intercourse is usually recommended. Immediately after vaginal birth, the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. Within 2 weeks, it is barely distinguishable from that of a nulliparous patient if lacerations and an episiotomy have been carefully repaired, hematomas are prevented or treated early, and the patient practises good hygiene. Most episiotomy or laceration repairs are visible only if the patient is lying on their side with their upper buttock raised or if they are placed in the lithotomy position. A good light source is essential for visualization of some repairs. Healing of an episiotomy or laceration is the same as that of any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or loss of approximation (separation of the edges of the incision) may occur. Initial healing occurs within 2 to 3 weeks, but 4 to 6 months can be required for the repair to heal completely (Blackburn, 2018). If forceps were used for the birth, the patient may have experienced vaginal or cervical lacerations; hematomas of the pelvic soft tissues can also occur with forceps-assisted birth (see Chapter 20). Hemorrhoids (anal varicosities) are commonly seen (see Figure 10.15). Internal hemorrhoids may evert while the patient is pushing during birth. Patients often experience associated symptoms such as itching, discomfort, and bright red bleeding upon defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

Pelvic Muscular Support. The supporting structure of the uterus and vagina can be injured during childbirth and can contribute to later gynecological problems. Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone. Kegel exercises, which help strengthen perineal muscles and encourage healing, are recommended after childbirth (see Patient Teaching box: Kegel Exercise in Chapter 5). Later in life, patients can experience pelvic relaxation—the lengthening and weakening of the fascial supports of pelvic structures. These structures include the uterus, upper posterior vaginal wall, urethra, bladder, and rectum. Although relaxation can occur in any patient, it is commonly a direct but delayed complication of childbirth.

Abdomen When the postpartum patient stands during the first days after birth, their abdomen protrudes and gives them a still-pregnant appearance. During the first 2 weeks after birth, the abdominal wall is relaxed. It takes about 6 weeks for the abdominal wall to return almost to its prepregnancy state (Figure 21.2). The skin regains most of its previous elasticity, but some striae may persist. The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue. Occasionally, with or without overdistension because of a large fetus or multiple fetuses, the abdominal wall muscles separate, a condition termed diastasis recti abdominis (see Figure 10.14, B). Persistence of this separation may be disturbing to the patient, but surgical correction rarely is necessary. With time, the separation becomes less apparent.

ENDOCRINE SYSTEM Placental Hormones Significant hormonal changes occur during the postpartum period. Expulsion of the placenta results in dramatic decreases of the hormones produced by that organ. Estrogen and progesterone levels drop

CHAPTER 21

Fig. 21.2 Abdominal wall 7 weeks after Caesarean birth is almost back to prepregnancy appearance. Note that the linea nigra is still visible. (Azoreg. This file is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license, https://creativecommons.org/licenses/by-sa/3.0/ deed.en.)

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increase more. In patients who breastfeed, prolactin levels are highest during the first month after birth and remain elevated above nonpregnant levels as long as the patient is breastfeeding. Serum prolactin levels are influenced by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. Individual differences in the strength of an infant’s sucking stimulus probably also affect prolactin levels. In nonlactating patients, prolactin levels decline after birth and reach the prepregnant range by the third postpartum week (Isley & Katz, 2017). Lactating and nonlactating patients differ considerably in the timing of their first ovulation and when menstruation resumes. Ovulation occurs as early as 27 days after birth in nonlactating patients, with a mean time of about 7 to 9 weeks. About 70% of nonbreastfeeding patients resume menstruating by 12 weeks after birth. The mean time to ovulation in patients who breastfeed is about 6 months (Isley & Katz, 2017). The persistence of elevated serum prolactin levels in breastfeeding patients appears to be responsible for suppressing ovulation. In someone who is lactating, both the resumption of ovulation and the return of menses are determined in large part by breastfeeding patterns. For example, ovulation is delayed longer in patients who breastfeed exclusively than in patients who breastfeed and offer supplemental infant formula to their infants. Because of the uncertainty about the return of ovulation and menstruation, the patient who is not exclusively breastfeeding needs to consider contraceptive options early in the postpartum period. The first menstrual flow after childbirth is usually heavier than normal. Within three or four cycles the amount of menstrual flow returns to the person’s prepregnancy volume.

URINARY SYSTEM markedly after expulsion of the placenta and reach their lowest levels 1 week after birth. Decreased estrogen levels are associated with diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating patients, estrogen levels begin to increase by 2 weeks after birth and by postpartum day 17 are higher than in patients who breastfeed (Isley & Katz, 2017). Human chorionic gonadotropin (hCG) disappears fairly quickly from the circulation of the postpartum patient. However, because removing hCG from the extravascular and intracellular spaces takes additional time, the hormone can be detected in the maternal system for 3 to 4 weeks after birth (Blackburn, 2018).

Metabolic Changes Decreases in human placental lactogen, estrogens, cortisol, and the placental enzyme insulinase reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood glucose levels in the immediate puerperium. Patients with type 1 diabetes will likely require much less insulin for several days after birth, especially if they are breastfeeding. Because these normal hormonal changes make the puerperium a transitional period for carbohydrate metabolism, it is more difficult to interpret results of glucose tolerance tests at this time. Thyroid volume gradually returns to normal by 3 months after birth. Levels of thyroxine and triiodothyronine decrease to prepregnant levels within 4 weeks. There is an increased risk for transient autoimmune thyroiditis in the postpartum period (Isley & Katz, 2017). The basal metabolic rate remains elevated for the first 1 to 2 weeks after birth (James, 2014). It gradually returns to prepregnancy levels.

Pituitary Hormones and Ovarian Function Prolactin levels in blood rise progressively throughout pregnancy. After birth, as levels of estrogen and progesterone decrease, prolactin levels

The hormonal changes of pregnancy (i.e., high steroid levels) contribute to an increase in renal function; diminishing steroid levels after childbirth may partly explain the reduced renal function that occurs during the puerperium. Kidney function returns to normal within 1 month after birth. About 6 weeks are required for the pregnancyinduced hypotonia and dilation of the ureters and renal pelves to return to the nonpregnant state. In a small percentage of patients, dilation of the urinary tract may persist for 3 months or longer, increasing the chances of developing a urinary tract infection (Isley & Katz, 2017).

Urine Components The renal glycosuria induced by pregnancy disappears by 1 week postpartum, but lactosuria may occur in lactating patients. The blood urea nitrogen increases during the puerperium as autolysis of the involuting uterus occurs. Plasma creatinine levels return to normal by 6 weeks postpartum. Pregnancy-associated proteinuria resolves by 6 weeks after birth (Blackburn, 2018). Ketonuria may occur in patients with an uncomplicated birth or after a prolonged labour with dehydration.

Fluid Loss Within 12 hours of birth, patients begin to lose excess tissue fluid accumulated during pregnancy. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body in ridding itself of excess fluid. Urine output of 3 000 mL or more each day during the first 2 to 3 days is common. Profuse diaphoresis often occurs, especially at night, for the first 2 to 3 days after birth. Fluid loss through perspiration and increased urinary output accounts for a weight loss of 2 to 3 kg during the early puerperium (Cunningham et al., 2018). Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.

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Urethra and Bladder Birth-induced trauma, increased bladder capacity following childbirth, and the effects of conduction anaesthesia (epidural or spinal) combine to cause a decreased urge to void. In addition, pelvic soreness caused by the forces of labour, vaginal lacerations, or the episiotomy reduces or alters the voiding reflex. Decreased voiding combined with postpartal diuresis may result in bladder distension. Immediately after birth, excessive bleeding can occur if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. Later in the puerperium, overdistension can make the bladder more susceptible to infection and impede the resumption of normal voiding (Cunningham et al., 2018). With adequate emptying of the bladder, bladder tone is usually restored by 5 to 7 days after childbirth. Some patients experience stress incontinence during the postpartum period. This is more likely to occur after vaginal than Caesarean birth. Stress incontinence can be related to tissue trauma to the pelvic floor occurring with maternal expulsive efforts and increased size of the newborn. Coached pushing versus uncoached (non-Valsalva) pushing can increase the risk for damage to the pelvic floor and subsequent stress incontinence (James, 2014).

GASTROINTESTINAL SYSTEM Most new mothers are very hungry shortly after birth and usually can tolerate a regular diet. Requests for extra portions of food and frequent snacks are not uncommon. A spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth. This delay can be explained by decreased muscle tone in the intestines during labour and the immediate puerperium, prelabour diarrhea, and lack of food or dehydration during labour. The postpartum patient often anticipates discomfort during the bowel movement because of perineal tenderness as a result of episiotomy, lacerations, or hemorrhoids and may resist the urge to defecate. Patients need to be encouraged to increase fluid and fibre intake to prevent constipation and discomfort. Regular bowel habits should be reestablished when bowel tone returns. Occasionally stool softeners may be required. Operative vaginal birth (forceps or vacuum use) and anal sphincter lacerations are associated with an increased risk of postpartum anal incontinence. Patients with this problem are more often incontinent of flatus than of stool. If anal incontinence lasts more than 6 months, studies should be conducted to determine the specific cause and appropriate treatment (Isley & Katz, 2017). Patients who have had a Caesarean birth may have abdominal pain due to a buildup of flatus. Patients need to be encouraged to move as much as possible to enhance movement of the intestinal system.

BREASTS Promptly after birth there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds their infant.

Breastfeeding Mothers During the first 24 hours after birth, there is little, if any, change in the breast tissue. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts. The breasts initially feel soft and then

gradually become fuller and heavier as the colostrum transitions to milk by about 72 to 96 hours after birth; this is often referred to as the “milk coming in” or lactogenesis II. The breasts may feel warm, firm, and somewhat tender. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. As milk glands and milk ducts fill with milk, breast tissue may feel somewhat nodular or lumpy. Unlike the lumps associated with fibrocystic breast disease or cancer (which can be palpated consistently in the same location), the nodularity associated with milk production tends to shift in position. Some patients experience engorgement at this time due to an increase in blood and lymphatic fluid as milk production increases. Engorged breasts are hard and uncomfortable; the fullness of the nipple tissue can make it difficult for the newborn to latch on and feed. With frequent breastfeeding and proper care, engorgement is a temporary condition that typically lasts only 24 to 48 hours (see Chapter 27).

Nonbreastfeeding Mothers The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant patients. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day as milk production begins may indicate tissue tenderness in some patients. On the third or fourth postpartum day engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch. Breast distension is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line can be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A well-fitted supportive bra, ice packs, fresh cabbage leaves, or mild analgesics may be used to relieve discomfort. Nipple stimulation should be avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

CARDIOVASCULAR SYSTEM Blood Volume Changes in blood volume after birth depend on several factors, such as blood loss during childbirth and the amount of extravascular water (physiological edema) mobilized and excreted. Pregnancy-induced hypervolemia (an increase in blood volume of 40 to 45% over prepregnancy values near term) allows most patients to tolerate considerable blood loss during childbirth. The average blood loss for a vaginal birth of a single fetus ranges from 300 mL to 500 mL (10% of blood volume). The typical blood loss for patients who give birth by Caesarean is 500 mL to 1 000 mL (15 to 30% of blood volume). During the first few days after birth, the plasma volume decreases further as a result of diuresis (Blackburn, 2018). The patient’s response to blood loss during the early puerperium differs from that in a nonpregnant patient. Three postpartum physiological changes protect the patient by increasing the circulating blood volume: (1) elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10 to 15%; (2) loss of placental endocrine function removes the stimulus for vasodilation; and (3) mobilization of extravascular water stored during pregnancy occurs. By the third postpartum day, the plasma volume has been replenished as extravascular fluid returns to the intravascular space (Isley & Katz, 2017) (see Clinical Reasoning Case Study).

CHAPTER 21

?

CLINICAL REASONING CASE STUDY

Physiological Changes in the Postpartum Patient

TABLE 21.1

Postpartum Blood Loss and Fatigue You are caring for four patients on the postpartum unit, two of whom had vaginal births and two of whom had Caesarean births. Each of the patients has stated they are feeling tired and has expressed concern about the amount of blood they lost during birth. Before providing patient education related to fatigue after birth and blood loss, you review the patient records with attention to estimated blood loss, hemoglobin and hematocrit values, intake and output, and nursing notes. Questions 1. Evidence—Is there sufficient evidence to draw conclusions about the relation between tiredness (fatigue) after birth and blood loss? What other information would be important to know about each patient? 2. Assumptions—What assumptions can be made about the following factors? a. Comparison of amount of blood loss between patients who give birth vaginally and by Caesarean b. Postpartum norms for hematocrit and hemoglobin for patients who give birth vaginally and by Caesarean c. Causes of fatigue after birth d. Interventions to alleviate fatigue and replace blood lost at birth 3. What implications and priorities for nursing care can be drawn at this time?

Cardiac Output Pulse rate, stroke volume, and cardiac output increase throughout pregnancy. Dramatic changes in maternal hemodynamic status occur with birth of the newborn and delivery of the placenta. The immediate blood loss reduces plasma volume without reducing cardiac output. This is due to the compensatory influx of nearly 500 mL of blood into the maternal system from the uteroplacental bed, a rapid decrease in uterine blood flow, and mobilization of extracellular fluid. Typically, cardiac output is increased immediately after birth by 60 to 80% over prelabour values; it returns to prelabour values within 1 hour. Stroke volume, cardiac output, end-diastolic volume, and systemic vascular resistance remain elevated over nonpregnant values for 12 weeks after birth and may not stabilize until 24 weeks after birth (Blackburn, 2018).

Vital Signs. Few alterations in vital signs are seen under normal circumstances. Heart rate and blood pressure return to nonpregnant levels within a few days (Isley & Katz, 2017) (Table 21.1). Respiratory function rapidly returns to nonpregnant levels after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized. As many as 50% of patients experience shivering episodes during the first few minutes up to the first hour after birth. The exact cause is unknown, and usually no treatment is needed; if the shivering is related to the effects of anaesthesia, pharmacological treatment may be needed (Berens, 2021).

Blood Components. Hematocrit and hemoglobin. In patients with an average blood loss during birth, the hematocrit level drops moderately for 3 to 4 days, then begins to increase, and reaches nonpregnant levels by 8 weeks postpartum (Isley & Katz, 2017). A postpartum hematocrit can be lower than normal if the blood loss was increased or if the hypervolemia of pregnancy was less than normal.

Normal Findings

489

Vital Signs After Childbirth Deviations From Normal Findings and Probable Causes

Temperature During the first 24 hours temperature A diagnosis of puerperal sepsis is may increase to 38°C as a result of suggested if an increase in maternal dehydrating effects of labour. After temperature to 38°C is noted after 24 hours the patient should be the first 24 hours after childbirth and afebrile. recurs or persists for 2 days. Other possibilities are mastitis, endometritis, urinary tract infections, and other systemic infections. Pulse Pulse, along with stroke volume and A rapid pulse rate or one that is cardiac output, remains elevated for increasing may indicate the first hour or so after childbirth. It hypovolemia as a result of gradually decreases over the first hemorrhage or an increased 48 hours postpartum. Puerperal temperature. bradycardia (40–50 beats/min) is common. Respirations The respiratory rate, which was Hypoventilation (respiratory unchanged or slightly increased depression) may occur after an during pregnancy, should be within unusually high subarachnoid (spinal) the patient’s normal prepregnancy block or epidural opioid after a range soon after birth. Caesarean birth. Blood Pressure Blood pressure shows a transient A low or decreasing blood pressure increase of approximately 5% over may indicate the existence of the first few days after birth, hypovolemia secondary to returning to prepregnancy levels hemorrhage; however, it is a late over weeks or months. Orthostatic sign, and other symptoms of hypotension, as indicated by hemorrhage are usually seen first. feelings of faintness or dizziness An increased reading may result immediately after standing up, can from excessive use of vasopressor develop in the first 48 hours as a or oxytocic medications. Because result of the splanchnic gestational hypertension can persist engorgement that may occur after into or occur first in the postpartum birth. period, routine evaluation of blood pressure is needed. If a patient states they have a headache, hypertension must be ruled out as a cause before analgesics are administered.

White blood cell count. Normal leukocytosis of pregnancy ranges from 5 to 15  109/L. During and after labour the white blood cell may rise to 30  109/L. Leukocytosis, coupled with the increase in erythrocyte sedimentation rate that normally occurs, can obscure the diagnosis of acute infections at this time (Antony et al., 2017). Coagulation factors. Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism,

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especially after a Caesarean birth. Patients need to be encouraged to move around as soon as possible after birth to prevent thromboembolism, and some patients may require anticoagulants. Fibrinolytic activity also increases during the first few days after childbirth (Isley & Katz, 2017). Factors I, II, VIII, IX, and X decrease to nonpregnant levels within a few days. Fibrin split products, probably released from the placental site, can also be found in maternal blood.

Varicosities Varicosities (varices) of the legs and around the anus (hemorrhoids) are common during pregnancy (Figure 21.3). All varices, even the less common vulvar varices, regress (empty) rapidly immediately after childbirth. Total or nearly total regression of varicosities is expected after childbirth.

RESPIRATORY SYSTEM

the median nerve. The periodic numbness and tingling of fingers usually disappear after the birth, unless lifting and carrying the baby aggravates the condition. Headaches are not uncommon in the first few weeks postpartum. The most common form of headache occurs in breastfeeding patients and are those caused by muscular contraction or tension and migraines without aura. Tension headaches are characterized by a persistent bandlike or viselike pain extending from the base of the neck to the forehead (Blackburn 2018). Headaches do require careful assessment as they may be due to postpartum-onset pre-eclampsia, or leakage of cerebrospinal fluid into the extradural space during placement of the needle for administration of epidural or spinal anaesthesia (see Chapter 18, Postdural puncture headache [PDPH]).

MUSCULOSKELETAL SYSTEM

When birth occurs, there is an immediate decrease in intra-abdominal pressure, which allows for greater excursion of the diaphragm. With decreased pressure on the diaphragm and reduced pulmonary blood flow, chest wall compliance increases. Rib cage elasticity can take months to return to a prepregnancy state. The costal angle that was increased during pregnancy may not completely return to the prepregnancy level. The decline in progesterone that occurs with loss of the placenta causes PaCO2 levels to rise (Blackburn, 2018).

Adaptations of the mother’s musculoskeletal system that occur during pregnancy are reversed in the puerperium. These adaptations include the relaxation and subsequent hypermobility of the joints and the change in the mother’s centre of gravity in response to the enlarging uterus. The joints are completely stabilized by 6 to 8 weeks after birth. Although all other joints return to their normal prepregnancy state, those in the parous patient’s feet do not. The new mother may notice a permanent increase in shoe size. Back pain usually resolves in a few weeks or months following birth.

NEUROLOGICAL SYSTEM

INTEGUMENTARY SYSTEM

Neurological changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labour and childbirth. Pregnancy-induced neurological discomforts disappear after birth. Elimination of physiological edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of

Melasma (chloasma or “mask of pregnancy”) usually disappears in the postpartum period but can persist in about 30% of patients (Wang & Kroumpouzos, 2017). Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth. Some patients will have permanent darker pigmentation of those areas. Striae gravidarum (stretch marks) (Figure 10.12) on the breasts, abdomen, and thighs may fade but usually do not disappear. Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress in response to the rapid decline in estrogen after the end of pregnancy. For some patients, spider nevi persist indefinitely. Hair growth slows during the postpartum period. Some patients may experience hair loss because the amount of hair lost is temporarily more than the amount regrown. The abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.

IMMUNE SYSTEM In the postpartum period, the patient’s immune system, which was mildly suppressed during pregnancy, gradually returns to its prepregnant state, although the exact timeline is unclear (Blackburn, 2018). This rebound of the immune system can trigger flare-ups of autoimmune conditions such as multiple sclerosis or lupus erythematosus (Isley & Katz, 2017).

KEY POINTS

Fig. 21.3 Varicosities in legs. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

• The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks and resumes normal size and position by 6 weeks. • The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomical and physiological changes in the puerperium.

CHAPTER 21 • Assessment of lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems. • The return of ovulation and menses is determined in part by whether the patient breastfeeds their infant. • Marked diuresis, decreased bladder sensitivity, and overdistension of the bladder can lead to problems with urinary elimination. • Pregnancy-induced hypervolemia, combined with several postpartum physiological changes, allows the patient to tolerate considerable blood loss at birth. • Few alterations in vital signs are seen after birth under normal circumstances. • Hypercoagulability, vessel damage, and immobility predispose the patient to thromboembolism.

REFERENCES Antony, K. M., Racusin, D. A., Aagaard, K., et al. (2017). Maternal physiology. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier.

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Berens, P. (2021). Overview of postpartum care: Normal physiology and routine maternal care. UpToDate. https://www.uptodate.com/contents/overview-ofthe-postpartum-period-normal-physiology-and-routine-maternalcare#H50. Blackburn, S. T. (2018). Maternal, fetal, and neonatal physiology (5th ed.). Elsevier. Cunningham, F., Leveno, K. J., Bloom, S. L., et al. (2018). Williams obstetrics (25th ed.). McGraw Hill. Isley, M. M., & Katz, V. (2017). Postpartum care. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. James, D. C. (2014). Postpartum care. In K. R. Simpson, & P. A. Creehan (Eds.), Perinatal nursing (4th ed.). Lippincott Williams & Wilkins. Wang, A. R., & Kroumpouzos, G. (2017). Skin disease and pregnancy. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier.

UNIT 6 Postpartum Period

22 Nursing Care of the Family During the Postpartum Period Keri-Ann Berga Originating US Chapter by Kathryn R. Alden http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe components of a systematic postpartum assessment. 2. Recognize signs of potential complications in the postpartum patient. 3. Identify criteria for postpartum discharge. 4. Develop a plan to provide care for a postpartum patient. 5. Explain the influence of cultural beliefs and practices on postpartum care.

6. Identify psychosocial needs of the patient in the early postpartum period. 7. Prepare a plan for teaching for a new postpartum parent’s selfmanagement. 8. Describe the nurse’s role in these postpartum follow-up strategies: home visits, telephone follow-up, warm lines and help lines, support groups, and referrals to community resources.

At no other time is family-centred maternity and newborn care more important than in the postpartum period. Nursing care is provided in the context of the family unit and focuses on assessment and support of the postpartum patient’s physiological and emotional adaptation after birth. During the early postpartum period, components of nursing care include assisting the new parent with rest and recovery from the process of labour and birth, assessing their physiological and psychological adaptation after birth, preventing complications, educating them about self-care and newborn care, and supporting the postpartum parent and partner during the initial transition to parenthood. In addition, the nurse considers the needs of other family members and includes strategies when providing nursing care to help the family adjust to the new baby. The approach to the care of patients after birth is wellness oriented. In Canada most patients remain hospitalized no more than 1 or 2 days after vaginal birth and 2 to 4 days for a Caesarean birth. Because so much important information needs to be shared with these patients in a very short time, their care and follow-up in the community must be thoughtfully planned and provided. This chapter discusses nursing care of the childbearing person and their family in the postpartum period, extending into the fourth trimester.

nursing unit. In facilities with labour, birth, recovery, and postpartum (LBRP) rooms, the patient labours, gives birth, recovers, and spends the postpartum period in the same room, and the nurse who provides care during the recovery period may continue to care for the patient in the same space. In some settings patients who have received general or regional anaesthesia must be cleared for transfer from the recovery area by a member of the anaesthesia care team. In other settings a nurse makes this determination. In preparing the transfer report, the nurse caring for the patient during the recovery period uses information from the records of admission, birth record, and recovery. Information communicated to the postpartum nurse includes obstetrical history; age; anaesthetic used; any medications given; duration of labour and time of rupture of membranes; whether labour was induced or augmented; type of birth and repair; blood type and Rh status; group B streptococcus status; status of rubella immunity; hepatitis serology test results; intravenous infusion of any fluids; physiological status since birth; description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of the care provider for both newborn and postpartum patient; chosen method of feeding; any abnormalities noted; and assessment of initial parent–infant interactions. In addition, specific information should be provided regarding the infant’s Apgar scores (see Chapter 26), voiding, and stooling and whether the infant has been fed since birth. Nursing interventions that have been completed (e.g., eye prophylaxis and vitamin K injection) also must be recorded. Table 22.1 gives examples for documenting this information before the transfer of the patient from the recovery area.

TRANSFER FROM THE RECOVERY AREA After the initial recovery period of about 1 to 2 hours has been completed (see Chapter 17: The Fourth Stage of Labour), the patient may be transferred to a postpartum room in the same or another

492

CHAPTER 22

TABLE 22.1

Nursing Care of the Family During the Postpartum Period

493

Recovery Nurse’s Report

Item

Example of Documentation of Mother

Example of Documentation of Newborn

Type of labour and birth; unusual observations, if any, of the placenta

Spontaneous or assisted (forceps, vacuum extraction) vaginal birth; vertex presentation; time of ROM

Spontaneous or assisted (forceps) vaginal birth; vertex presentation; time of ROM

GTPAL, age

G1 T0 P0 A0 L0, age 22 yr; 39 wk of gestation

G1 T0 P0 A0 L0, age 22 yr; 39 wk of gestation

Anaesthesia and analgesia used

None; epidural, spinal, local

None; epidural, spinal, local

Condition of perineum

Episiotomy; lacerations; repaired; intact

Events since birth

Vital signs, BP, fundus, lochia, intake and output, medications (dosage, time of administration, and results); length of time newborn was skin-to-skin and with whom; response to newborn; observation of family interactions, including siblings, if present

Vital signs, blood glucose level (if assessed), nursed at breast for ____ min Voided
1; meconium stool
1 Eye prophylaxis given Vitamin K injection given Skin-to-skin for ____ min Held by siblings who are happy (or have other response to newborn)

Condition and sex of newborn; other information

Time of birth; weight; whether breastfeeding or bottle-feeding; sex of the baby

Time of birth; Apgar at 1 and 5 min; sex; weight; name of health care provider; breastfeeding or bottle-feeding

Relevant information from prenatal record

Need for rubella vaccination; presence of infections; hepatitis B status; HIV status; blood type; Rh status; GBS status and treatment if positive

Unremarkable pregnancy; mother’s hepatitis B status and GBS status; whether mother received adequate antibiotic prophylaxis for GBS

Miscellaneous information: IV drip

If IV drip is infusing, rate of infusion, medications added (e.g., oxytocin), whether to keep open or discontinue after completion of bag that is hung

Whether mother received magnesium sulphate; time of last systemic analgesia; IV solution and rate

Social factors

If patient is releasing baby for adoption, whether they want to see baby, breastfeed, or allow visitors, or other preferences they may have

Baby up for adoption

BP, Blood pressure; GBS, group B streptococcus; HIV, human immunodeficiency virus; IV, intravenous; ROM, rupture of membranes.

In recent years, many inpatient nursing units, including perinatal care areas, have used a bedside report. Bedside reporting is increasingly being used instead of the traditional report given at the nurses’ station. Bedside reporting has been shown to improve patient safety and patient satisfaction. Patients feel more involved in their plan of care, which increases their satisfaction. Additionally, completing the report at the bedside has enabled many nurses to both visualize and communicate with the patient at the time of report, which improves patient safety (Agency for Healthcare Research and Quality [AHRQ], 2013/2017).

PLANNING FOR DISCHARGE From their initial contact with the labouring patient, nurses prepare the new parent for the time when they will return home. Planning for discharge begins with the first interaction between the nurse, the childbearing person, and their family and continues until they leave the hospital or birthing facility. The length of stay after giving birth depends on many factors, including the physical condition of the mother and the newborn, emotional status of the mother, social support at home, and patient education needs for self-care and newborn care. Those who give birth in birthing centres and in the hospital may be discharged within a few hours, after the mother’s and newborn’s conditions are stable, although most mothers and newborns with no complications are discharged from the hospital within 24 to 36 hours after vaginal birth. Before discharge the nurse needs to ensure that the health of the mother and newborn is stable and that the new parent is able and confident to provide care for their newborn; there should be adequate

support systems in place and access to follow-up care. It is essential that the nurse consider the individual needs of the patient and their newborn and provide care that is coordinated to meet these needs. Timely physiological interventions and treatment can help prevent morbidity and hospital readmission. Hospital-based maternity nurses continue to play invaluable roles as caregivers, teachers, and advocates for parents, newborns, and families in developing and implementing effective home-care strategies. With predetermined criteria for identifying low risk in mothers and newborns (Box 22.1), the length of hospitalization can be based on medical need for care in an acute care setting or in consideration of ongoing care needed in the home. Postpartum order sets and maternal teaching checklists (Figure 22.1) can be used to accomplish patient care tasks and educational outcomes. Nurses must also provide discharge teaching related to the newborn. With coordination, clinical care and education can be planned and provided throughout the pregnancy, during the hospital stay, and in the home after discharge to promote and support the family’s continued well-being. To optimize the health of mothers and infants, postpartum care should be an ongoing process, rather than a single encounter, with services and supports tailored to each individual’s needs (McKinney et al., 2018). In addition, education programs should include information for both at-risk and healthy postpartum patients, because complications may not be clearly identified or apparent before a patient’s discharge after birth (Suplee et al., 2017). Community-based postpartum care programs are also key to reducing readmission of newborns. Mothers should be contacted and, if needed, seen by a skilled caregiver within 24 to 48 hours after discharge to ensure that newborn health issues are identified (e.g., jaundice, dehydration).

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BOX 22.1

Postpartum Period

Criteria for Discharge

Mother Perineum is healing with appropriate care provided. There are no intrapartum or postpartum complications that require ongoing treatment or observation. The mother is mobile with adequate pain control. Bladder and bowel functions are adequate (although patient will probably not have had a bowel movement). The mother has received Rh immune globulin, if appropriate. The mother has demonstrated ability to feed the infant—i.e., the infant has demonstrated adequate latch. Contraception advice has been provided. The care provider for ongoing care has been identified and notified of discharge. The community liaison nurse is aware of discharge and has access to the patient’s contact information for postdischarge follow-up (if appropriate). Appointments are made for follow-up and the mother understands the necessity for and timing of newborn health checks. If the home environment is not adequate, community resources are in place to support the new mother and newborn. The mother is aware of community resources and how and when to access these resources. The mother has received rubella immunization if not immune. Infant The newborn is a full-term (37 to 42 weeks) with weight appropriate for gestational age.

LEGAL TIP: Early Discharge Regardless of whether or not the postpartum patient and their family have chosen early discharge, the nurse and the primary health care provider are responsible for ensuring that they are not discharged before their condition has stabilized within normal limits.

NURSING CARE The nursing plan of care includes both the postpartum person and their newborn. It is also family centred, considering the needs and concerns of the family and focusing on family unity (Waller-Wise, 2012). In most hospitals in Canada, combined care (also called single-room maternity care) is practised. Nurses in these settings have been educated in both mother and newborn care and function as primary nurses for the mother and newborn.

Ongoing Physical Assessment Ongoing assessments are performed throughout hospitalization. In addition to vital signs, physical assessment of the postpartum patient focuses on evaluation of the breasts, uterine fundus, lochia, perineum, bladder and bowel function, vital signs, and legs, using the acronym BUBBLLEE. See Table 22.2 for normal findings. B 5 Breasts (firmness) and nipples U 5 Uterine fundus (location; consistency) B 5 Bladder function (amount; frequency) B 5 Bowel function (passing gas or bowel movements) L 5 Lochia (amount; colour) L 5 Legs (peripheral edema) E 5 Episiotomy/Laceration or Caesarean birth incision (perineum: discomfort; condition of repair, if done) E 5 Emotional status (mood, fatigue)

There is normal cardiorespiratory adaptation to extrauterine life. Temperature, respirations, and heart rate are within normal limits and stable. At least two successful feedings have been completed (normal sucking and swallowing). Urination and stooling have occurred at least once. There is no evidence of significant jaundice in the first 24 hours after the birth. There is no evidence of sepsis. There is no evidence of bleeding from circumcision for 2 hours (if procedure is performed prior to discharge). Metabolic screening tests have been performed according to provincial policies; tests should be repeated at the follow-up visit if done before the infant is 24 hours old. Newborn hearing screening test is completed before discharge; if not, alternative arrangements have been made for testing. The mother is able to provide newborn care and recognizes signs of illness or concerns related to their newborn. Arrangements have been made for assessment and evaluation of the newborn within 48 hours of discharge, i.e., with a community health nurse, physician, or midwife. Initial hepatitis B vaccine has been given or scheduled for the first follow-up visit if required by provincial guidelines. Postpartum follow-up screening has been completed, based on jurisdiction. Some provinces offer telephone calls, clinic or home visits, depending on risk factors.

Routine Laboratory Tests. Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit values may be evaluated on the first postpartum day to assess blood loss during birth, especially after Caesarean birth, although it is important to remember that hematocrit can be lower than normal if the blood loss was increased or if the hypervolemia of pregnancy was less than normal. In addition, if the patient’s rubella and Rh status are unknown, tests to determine their status and need for possible treatment should be performed at this time.

Nursing Interventions Based on the available data (e.g., medical record) and assessment findings, the nurse plans with the patient which nursing measures are appropriate and which are to be given priority. The nursing plan of care includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain, safety measures to prevent injury or infection, and teaching and counselling measures designed to promote the postpartum patient’s feelings of competence in self-care and newborn care. The partner as well as other family members who are present can be included in the teaching. The nurse needs to evaluate continuously and be ready to change the plan, if indicated. Almost all hospitals use standardized care plans or care maps as a base. Nurses individualize care of the postpartum patient and newborn according to their specific needs (see Nursing Care Plan: Postpartum Care— Vaginal Birth, available on Evolve). Signs of potential complications that may be identified during the assessment process are listed in Table 22.2. Nurses assume many roles while implementing the plan of care. They provide direct physical care, teach mother and baby care, and provide anticipatory guidance and counselling. Perhaps most important of all, they nurture the postpartum patient by providing encouragement and support as they begin to assume the many tasks of motherhood. Nurses who take the time to “mother the mother” do much to increase feelings of self-confidence in new mothers. Nurses need to be careful to

CHAPTER 22

Nursing Care of the Family During the Postpartum Period

Summary, Education/Anticipatory Guidance Interpretation req’d

Language

EDUCATION/ANTICIPATORY GUIDANCE

INITIALS INITIALS N/A

COMMENTS

1. Breast, nipple care, management of engorgement 2. Knows how to hand express milk 3. Recognizes and responds to newborn feeding cues, behaviours 4. Recognizes effective feeding and milk transfer 5. For newborns fed breastmilk substitute: appropriate formula, preparation, and storage 6. Normal physiological change/care, fundus & flow, incision 7. Voiding & bowel patterns 8. Self-care hygiene, pericare 9. Pain management/options 10. S &S for follow-up (e.g., fever, infection, overly drowsy) 11. Community and Admission medications reviewed. Discharge prescription written and given to patient. Patient teaching complete. Discharge prescription given to patient and patient teaching complete. 12. Activity and rest 13. Healthy eating 14. Postpartum blues/perinatal depression 15. Family planning/sexuality 16. Support systems in place 17. Access to Baby’s Best Chance Parents’ Handbook 18. Tests and procedures Rubella status MMR given: Date Rh immune globulin given: Date Time

Initials Initials

Other:

19. Tobacco cessation/exposure to second-hand smoke 20. Review of communicable diseases 21. Knows who primary health care provider (PHCP) is, how to access & when to contact 22. Aware of PHN contact/role/community resources 23. Ready for hospital discharge, discharge order Variances - Plan(s) including referrals

5 Discharge

Postpartum hours/days at discharge:

Hospital discharge: Date

Time

Home with Baby

Liaison completed

RN Signature

PSBC 1592 – JANUARY 2011 V2 ©Perinatal Services BC

Fig. 22.1 Maternal teaching and discharge plan. MMR, Measles, mumps, and rubella; N/A, not applicable; PHN, public health nurse; RN, registered nurse; S&S, signs and symptoms. (Printed with permission from Perinatal Services BC.)

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TABLE 22.2

Postpartum Assessment and Signs of Potential Complications

Assessment

Normal Findings

Signs of Potential Complications

Blood pressure (BP)

Consistent with BP baseline during pregnancy; can have orthostatic hypotension for 48 hours

Hypertension: anxiety, pre-eclampsia, essential hypertension Hypotension: hemorrhage

Temperature

36.2°–38° C (97.2°–100.4° F)

>38° C (100.4° F) after 24 hours: infection

Pulse

60–100 beats/min

Tachycardia: pain, fever, dehydration, hemorrhage

Respirations

12–24 breaths/min

Bradypnea: effects of opioid medications Tachypnea: anxiety; may be sign of respiratory disease

Breath sounds

Clear to auscultation

Crackles: possible fluid overload

Breasts

Days 1–2: soft

Firmness, heat, pain: engorgement

Days 2–3: filling Days 3–5: full, soften with breastfeeding (milk is “in”)

Redness of breast tissue, heat, pain, fever, body aches: mastitis

Nipples

Skin intact; no soreness reported

Redness, bruising, cracks, fissures, abrasions, blisters: usually associated with latching difficulties

Uterus (fundus)

Firm, midline; first 24 hours at level of umbilicus; involutes  1–2 cm/day

Soft, boggy, higher than expected level: uterine atony Lateral deviation: distended bladder

Bladder

Able to void spontaneously by 8 hours; no distension; able to empty completely; no dysuria

Overdistended bladder possibly causing uterine atony, excessive lochia

Diuresis begins  12 hours after birth; can void 3 000 mL/day

Dysuria, frequency, urgency: infection

Bowels and abdomen

Passing flatus soon after vaginal birth Bowel movement by day 2 or 3 after birth Abdomen soft, active bowel sounds in all quadrants (assessed if Caesarean birth)

No bowel movement by day 3 or 4: constipation; diarrhea

Lochia

Birth to 3-4 days: rubra (dark red) Day 4–to 2–4 weeks: serosa (brownish red or pink) After 10–14 days: alba (yellowish white) Amount: scant to moderate Few clots Fleshy odour

Large amount of lochia: uterine atony, vaginal or cervical laceration Foul odour: infection

Swelling (legs)

Peripheral edema possibly present

Redness, tenderness, pain, venous thromboembolism (VTE)

Perineum/Incision

Minimal edema

Pronounced edema, bruising, hematoma

Laceration or episiotomy: edges approximated

Redness, warmth, drainage: infection

Caesarean: incision dressing clean and dry; suture line intact

Abdominal incision—redness, edema, warmth, drainage: infection

Rectal area

No hemorrhoids; if hemorrhoids are present, soft and pink

Discoloured hemorrhoidal tissue, severe pain: thrombosed hemorrhoid

Emotional status/ Energy level

Able to care for self and newborn; able to sleep Excited, happy, interested or involved in newborn care Sad and tearful on day 3–14: postpartum blues

Lethargy, extreme fatigue, difficulty sleeping: postpartum depression Sad, tearful, disinterested in newborn care: postpartum mood disorder

include the patient’s partner and other primary support persons in education and counselling. The childbearing person and their family need to be oriented to their surroundings. Familiarity with the postpartum unit, routines, resources, and personnel reduces one potential source of anxiety—the unknown. The mother can be reassured through knowing whom and how they can call for assistance and what they can expect in the way of supplies and services. If the mother’s usual daily routine before admission differs from the routine of the facility, the nurse should work with them to develop a mutually acceptable routine. The nurse must also confirm the patient’s identity by checking their wristband. At the same time, the newborn’s identification number is matched with the corresponding band on the mother’s wrist and, in some instances, the partner’s wrist. The nurse should determine how the mother wishes to be addressed and note their preference in the health care record.

Promoting Safety. While newborn abduction from hospitals in Canada is rare, hospital staff should be alert and prepared for such an event. The mother should be taught to check the identity of any person who

comes to remove the baby from their room; for instance, hospital personnel wear picture identification badges. On some units all staff members wear matching scrubs or special badges. Other units use closedcircuit television, computer monitoring systems, or fingerprint identification pads. Many hospitals have systems to prevent newborn abduction that involve attaching a security tag to the newborn’s ankle. This will cause an alarm to sound or doors to lock when the newborn is close to a unit exit. Patients and nurses must work together to ensure the safety of newborns in the hospital environment.

SAFETY ALERT Nurses play a critical role in educating parents about measures to prevent newborn abduction. Parents should be instructed how to identify legitimate hospital personnel, to never leave the newborn in the hospital room without direct supervision, and to request a second staff member to verify the identity of any questionable person who wants to take the baby from the mother’s room. Parents should be instructed to use caution when posting photos of the new baby on the Internet and publishing public notices about the birth.

CHAPTER 22

Nursing Care of the Family During the Postpartum Period

Preventing Excessive Bleeding. The most frequent cause of excessive bleeding after childbirth is uterine atony (i.e., failure of the uterine muscle to contract firmly). The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distension. If uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results. Although the cause of uterine atony is not always clear, it often results from retained placental fragments. Excessive blood loss after childbirth can also be caused by vaginal or vulvar hematomas or by unrepaired lacerations of the vagina or cervix. These potential sources might be suspected if excessive vaginal bleeding occurs in the presence of a firmly contracted uterine fundus. See discussion of postpartum hemorrhage (PPH) in Chapter 24 for more information on reasons for excessive bleeding.

NURSING ALERT A perineal pad saturated in 15 minutes or less or pooling of blood under the buttocks is an indication of excessive blood loss requiring immediate assessment, intervention, and notification of the primary health care provider.

Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy (profuse). Figure 22.2 shows examples of perineal pad saturation corresponding to each of these descriptions. Although postpartal blood loss may be estimated by observing the amount of staining on a perineal pad, it is difficult to judge the amount of lochial flow based only on observation of perineal pads. Quantification of blood loss by weighing clots and items saturated with blood (1 g equals 1 mL) is recommended as the most accurate way to objectively determine blood loss. Any estimation of lochial flow is inaccurate and incomplete without consideration of the time factor. The patient who saturates a perineal pad in 1 hour or less is bleeding much more heavily than someone who saturates a perineal pad in 8 hours. When assessing blood loss, the nurse needs to ask the patient how long it has been since they changed their perineal pad.

Scant: 5 cm

Light: 10 cm

Moderate: 15 cm

Heavy: >15 cm Fig. 22.2 Blood loss after birth is assessed by the extent of perineal pad saturation as (from top to bottom) scant, light, moderate, or heavy (one pad saturated within 2 hours). (From Leifer, G. [2015]. Introduction to maternity and pediatric nursing [7th ed.]. Saunders.)

497

Nurses in general tend to overestimate rather than underestimate blood loss. Also, different brands of perineal pads vary in their saturation volume and soaking appearance. For example, blood placed on some brands tends to soak down into the pad, whereas on other brands it tends to spread outward. Nurses should determine saturation volume and soaking appearance for the perineal pad brands used in their institution to improve accuracy of blood loss estimation.

NURSING ALERT The nurse should always check under the mother’s buttocks. Although the amount on the perineal pad may be slight, blood may flow between the buttocks onto the linens under the patient. When this happens, excessive bleeding goes undetected.

When excessive bleeding occurs, vital signs need to be monitored closely. Blood pressure is not a reliable indicator of impending shock from early hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the person has lost 30 to 40% of their blood volume. Respirations, pulse, skin condition, urinary output, and level of consciousness are more sensitive means of identifying hypovolemic shock. The frequent physical assessments performed during the fourth stage of labour (see Box 17.17) are designed to provide prompt identification of excessive bleeding (see Emergency box: Hypovolemic Shock).

EMERGENCY Hypovolemic Shock Signs and Symptoms Persistent significant bleeding: Perineal pad is soaked within 15 minutes; initially it may not be accompanied by a change in the patient’s vital signs, colour or behaviour. Patient states that they feel weak, light-headed, “funny,” or “nauseated” or “see stars.” Patient does not want to hold their baby. Patient appears anxious or exhibits air hunger. Skin colour turns ashen or greyish. Skin feels cool and clammy. Pulse rate increases. Blood pressure declines. Interventions Notify primary health care provider. If uterus is atonic, massage gently and expel clots to cause uterus to contract. Administer uterotonic medications (e.g., oxytocin, prostaglandins) as ordered to increase uterine tone. Give oxygen by nonrebreather face mask or nasal prongs at 8 to 10 L/min. Tilt patient to their side or elevate the right hip; elevate the legs to at least a 30degree angle. Provide additional or maintain existing IV infusion of lactated Ringer’s solution or normal saline solution to restore circulatory volume (the patient should have two patent IV lines: insert second IV infusion using 16- to 18-gauge IV catheter). Administer blood or blood products as ordered. Monitor vital signs. Insert an in-dwelling urinary catheter to monitor perfusion of kidneys. Administer emergency medications as ordered. Prepare for possible surgery or other emergency treatments or procedures. Record incident, medical and nursing interventions instituted, and person’s response to interventions. IV, Intravenous.

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Maintaining uterine tone. A major intervention to restore good uterine tone is stimulation, by gently massaging the fundus until firm (Figure 22.3). Fundal massage can cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots can be expelled. The uterus may remain boggy even after massage and expulsion of clots. Fundal massage can be a very uncomfortable procedure. Communicating the causes and dangers of uterine atony and the purpose of fundal massage to the patient can help facilitate understanding for the reasons for the procedure and may help the patient tolerate it better, based on its importance. Teaching the patient to massage their own fundus enables the patient to maintain some control and can decrease their anxiety. When uterine atony and excessive bleeding occur, additional interventions likely to be used are administration of intravenous fluids and uterotonic medications (medications that stimulate contraction of the uterine smooth muscle). See the Medication Guide: Uterotonic Medications Used to Manage Postpartum Hemorrhage, in Chapter 24 for information about common uterotonic medications. Preventing bladder distension. Uterine atony and excessive bleeding after birth can be the result of bladder distension. A full bladder causes the uterus to be displaced above the umbilicus and well to one side of the midline in the abdomen. It also prevents the uterus from contracting normally. Postpartum patients can be at risk of bladder distension resulting from urinary retention, based on intrapartum factors. These risk factors include epidural anaesthesia, extensive vaginal or perineal lacerations, episiotomy, instrument-assisted birth, or prolonged labour. Patients who have had in-dwelling catheters can experience some difficulty as they initially attempt to void after the catheter is removed. Nurses aware of these risk factors can be proactive in preventing complications. Nursing interventions focus on helping the patient empty their bladder spontaneously as soon as possible. The first priority is to assist the patient to the bathroom or onto a bedpan if they are unable to

ambulate. Having the patient listen to running water, placing the patient’s hands in warm water, or pouring water from a squeeze bottle over the perineum may stimulate voiding. Assisting the patient into the shower or sitz bath and encouraging the patient to void can be effective. Administering analgesics, if ordered, may be indicated because some people anticipate pain and thus fear voiding. If these measures are unsuccessful, a sterile catheter can be inserted to drain the urine.

Preventing Infection. Nurses in the postpartum setting are acutely aware of the importance of preventing infection in their patients. One important means of preventing infection is maintaining a clean environment. Bed linens should be changed as needed. Disposable pads should be changed frequently. Patients should wear shoes when walking about to avoid picking up bacteria from the floor and contaminating the linens when they return to bed. Personnel must be conscientious about their hand hygiene to prevent cross-infection. Routine precautions must be practised. Staff members with colds, coughs, or skin infections (e.g., a cold sore on the lips [herpes simplex virus type I]) must follow hospital protocol when in contact with postpartum patients. In many hospitals, staff with open herpetic lesions, strep throat, conjunctivitis, upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers and newborns by staying home until the condition is no longer contagious. Visitors with signs of illness should not be permitted to enter the postpartum unit. Perineal lacerations and episiotomies can increase the risk of infection through interruption in skin integrity. Proper perineal care helps prevent infection in the genitourinary area and aids the healing process. Nurses should teach the patient to wipe from front to back (urethra to anus) after voiding or defecating in order to prevent infection. In many hospitals, a squeeze bottle (peri-bottle) filled with warm water is used after each voiding to cleanse the perineal area. The postpartum patient should change their perineal pad from front to back each time they void or defecate and wash their hands thoroughly before and after doing so (Box 22.2). Promoting Comfort. Most patients experience some degree of discomfort during the postpartum period. Common causes of discomfort include afterpains, perineal laceration or episiotomy, hemorrhoids, sore nipples, and breast engorgement. The patient’s description of the type and severity of pain is the best guide in choosing an appropriate intervention. To confirm the location and extent of discomfort, the nurse needs to inspect and palpate areas of pain, as appropriate, for redness, swelling, discharge, and heat and observe for body tension, guarded movements, and facial tension. Blood pressure, pulse, and respirations may be elevated in response to acute pain. Diaphoresis may accompany severe pain. A lack of objective signs does not necessarily mean there is no pain because there may also be a cultural component to the expression of pain. Nursing interventions are intended to eliminate the pain sensation entirely or reduce it to a tolerable level that allows the postpartum patient to care for themselves and their baby. Nurses may use both nonpharmacological and pharmacological interventions to promote comfort. Pain relief is generally enhanced by using more than one method or route.

SAFETY ALERT

Fig. 22.3 Palpating and massaging fundus of uterus. Note that upper hand is cupped over fundus; lower hand dips in above symphysis pubis and supports uterus while it is massaged gently.

If a postpartum patient states they have extreme perineal pain, especially after having received pain medication, the first action by the nurse should be to assess the perineum. There may be a hematoma or perineal infection that is causing the pain. Although rare, an inordinate degree of pain can be a sign of serious complications including perineal cellulitis, necrotizing fasciitis, or angioedema (Isley & Katz, 2017).

CHAPTER 22

BOX 22.2

Nursing Care of the Family During the Postpartum Period

499

Interventions for Episiotomy, Lacerations, and Hemorrhoids

Explain both the procedure and rationale before implementation. Cleansing Teach the patient to do the following: • Wash hands before and after cleansing perineum and changing pads. • Wash perineum with mild soap and warm water at least once daily. • Cleanse from symphysis pubis to anal area. • Apply peripad from front to back, protecting inner surface of pad from contamination. • Wrap soiled pad and place in covered waste container. • Change pad with each void or defecation or at least four times per day. • Assess amount and character of lochia with each pad change. Ice Pack (for First 24 Hours) Apply a covered ice pack to perineum from front to back: • During first 2 hours to decrease edema formation and to increase comfort • After the first 2 hours following the birth to provide anaesthetic effect

Sitz Bath: Disposable Encourage patient to use at least twice a day for 20 minutes, if required. Place call bell within easy reach. Clamp tubing and fill bag with warm water. Raise toilet seat and place bath in bowl with overflow opening directed toward back of toilet. Place container above toilet bowl. Attach tube into groove at front of bath. Loosen tube clamp to regulate rate of flow; fill bath to about one-half full. Teach patient to sit on sitz bath by first tightening gluteal muscles and keeping them tightened and then relaxing them after they are on the sitz bath. Place dry towels within reach. Ensure privacy. Check patient in 15 minutes.

Squeeze Bottle (Peri-Bottle) Demonstrate use and assist patient. Fill bottle with tap water warmed to approximately 38°C (comfortably warm on the wrist). Instruct patient to position nozzle between their legs so that squirts of water reach perineum as they sit on toilet seat. Explain that it will take the whole bottle of water to cleanse the perineum. Teach patient to blot dry with toilet paper or clean wipes. Remind patient to avoid contamination from anal area. Apply clean pad.

Sitz bath (Leifer, G. [2015]. Introduction to maternity and pediatric nursing [7th ed.]. Saunders.)

Topical Applications Apply anaesthetic cream or spray: use sparingly three to four times per day, if required. Offer witch hazel pads (Tucks) for after voiding or defecating; patient pats perineum dry from front to back and then applies witch hazel pads. Apply hemorrhoidal cream as ordered to anal area after cleansing. Peri-bottle. (Courtesy Lunapads.)

Nonpharmacological interventions. A variety of nonpharmacological measures are used to reduce postpartum discomfort. These include distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, and music therapy. Many of these measures are similar to those used during labour, discussed in Chapter 18. For patients who are experiencing discomfort associated with uterine contractions, applying warmth (e.g., heating pad) or lying prone

may be helpful. Interaction with the newborn may also provide distraction and decrease this discomfort. Because afterpains are more severe during and after breastfeeding, interventions are planned to provide the most timely and effective relief. Administering pain medication about 30 minutes before breastfeeding can help minimize afterpains that are caused by breastfeeding. A simple intervention that can decrease the discomfort associated with an episiotomy or perineal lacerations is to encourage the patient

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to lie on their side whenever possible. Other interventions include application of an ice pack (for first 24 hours); topical medication (if ordered); heat (usually after 24 hours); cleansing with a squeeze bottle; and a cleansing shower, tub bath, or sitz bath. Many of these interventions, especially ice packs, sitz baths, and topical applications (e.g., witch hazel pads), are also effective for hemorrhoids (see Box 22.2). Sore nipples in breastfeeding mothers are most likely related to ineffective latch technique. Assessment of and assistance with feeding are most important in helping the mother establish an effective technique. To ease discomfort associated with sore nipples, the mother may apply expressed colostrum or breastmilk, topical preparations such as purified lanolin, or hydrogel pads (see Chapter 27). Breast engorgement can occur whether the postpartum patient is breastfeeding or formula-feeding. The discomfort associated with engorged breasts may be reduced by applying ice packs or cabbage leaves (or both) (see further discussion below) to the breasts and wearing a well-fitted support bra. Anti-inflammatory medications can also help relieve some of the discomfort. Decisions about specific interventions for engorgement are based on whether the person chooses breastfeeding, chestfeeding, or bottle-feeding (Wolfe-Roubatis & Spatz, 2015). Pharmacological interventions. Pharmacological interventions are commonly used to relieve or reduce postpartum discomfort. Most health care providers routinely order a variety of analgesics to be administered as needed, including both opioid and nonopioid (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) medications. NSAIDs commonly used are ibuprofen or naproxen. These medications provide better relief from uterine cramping and perineal pain than acetaminophen. Ibuprofen is preferred for breastfeeding patients because it has a low milk/maternal plasma drug concentration ratio and a short-half life (Isley & Katz, 2017). In some hospitals, NSAIDs are administered on a scheduled basis, especially if the patient had perineal repair. Topical application of antiseptic or anaesthetic ointments or spray can be used for perineal pain. Patient-controlled analgesia (PCA) pumps and epidural analgesia are commonly used to provide pain relief after Caesarean birth.

NURSING ALERT The nurse should monitor all patients receiving opioids carefully because respiratory depression and decreased intestinal motility are adverse effects.

Most patients want to participate in decisions about using analgesia. If an analgesic is to be given, the nurse must, in conjunction with the mother, make a clinical judgement of the type, dosage, and frequency from the medications ordered. Patients and their support people should be informed of the prescribed analgesic and its common adverse effects; this teaching should be documented. Many hospitals offer selfmedication packages for postpartum patients. These packages have the medications that a patient might require in the immediate postpartum period. Clear instructions are given regarding the medications and how to take them when necessary, while also remembering to document the date, time, and dose each time they take the medication. If acceptable pain relief has not been obtained within 1 hour and there has been no change in the initial assessment, the nurse should contact the primary care provider for additional pain-relief orders or further directions. Unrelieved pain results in fatigue, anxiety, and a worsening perception of the pain. It can also indicate the presence of a previously unidentified or untreated condition. Breastfeeding mothers often have concerns about the effects of an analgesic on the newborn. Although nearly all medications present in maternal circulation are also found in breast milk, many analgesics commonly used during the postpartum period are considered relatively

safe for breastfeeding patients and their newborns. Nonopioid analgesics are preferred for pain management in postpartum breastfeeding women because they do not alter maternal or newborn alertness (Lawrence & Lawrence, 2016). Timing of medication administration can be adjusted to minimize newborn exposure. A mother may be given pain medication immediately after breastfeeding so that the interval between medication administration and the next nursing period is as long as possible, although some patients may require medication prior to breastfeeding if they are having significant afterpains. The decision to administer medications of any type to a breastfeeding mother must always be made by carefully weighing the patient’s need against actual or potential risks to the newborn. Resources are readily accessible for nurses and health care providers to examine the safety of medications for breastfeeding mothers (see Additional Resources at the end of the chapter).

Promoting Rest. Fatigue is common in the early postpartum period and involves both physiological and psychological components. Sleep loss, feeling stressed, and physical exhaustion have been reported as the top three conditions patients experience within the first 2 months after birth (Declercq et al., 2014). The early postpartum period is the time that new parents experience the greatest disruption to their lives as they try to adjust to the nearly constant demands of a newborn (Aber et al., 2013). Other factors can contribute to physical fatigue or exhaustion, such as long labour or Caesarean birth, hospital routines that interrupt periods of sleep and rest, and physical discomfort. Fatigue can also be associated with anemia, infection, or thyroid dysfunction. The excitement and exhilaration experienced after the birth of the newborn makes resting difficult. Physical discomfort can interfere with sleep. Well-intentioned visitors may interrupt periods of rest in the hospital and at home. Postpartum fatigue. Postpartum fatigue (PPF) is more than just feeling tired; it is a complex phenomenon affected by a combination of physiological, psychological, and situational variables (Volrathongchai et al., 2013). Disrupted sleep and fatigue in the postpartum patient may contribute to the development of a perinatal mood disorder (PMD) (Bhati & Richards, 2015; Okun, 2015; Park et al., 2013). Symptoms of PPF and depressive symptoms are interrelated. Depressive symptoms can affect fatigue, whereas fatigue can lead to depressive symptoms. Fatigue is likely to worsen over the first 6 weeks after birth, often because of situational factors. After discharge from the hospital, fatigue increases as the patient provides care and feeding for the newborn in combination with other family and household responsibilities, such as caring for other children, preparing meals, and doing laundry. Many patients have partners, family members, or friends to provide muchneeded assistance, whereas others may be without any help at all. The nurse needs to inquire about resources available to the patient after discharge and help them to plan accordingly. Interventions are planned to meet the patient’s individual needs for sleep and rest while they are in the hospital. Back rubs and other comfort measures may be necessary. For instance, the side-lying position for breastfeeding helps minimize fatigue in nursing mothers. Support and encouragement of mothering behaviours can help reduce anxiety. Hospital and nursing routines can be adjusted to meet the needs of individual mothers. In addition, the nurse can help the family limit visitors and provide a comfortable chair or bed for the partner or other family member staying with the new mother. Because PPF can be very debilitating, follow-up after hospital discharge is important. Screening for PPF can be done at the routine 6-week postpartum visit with the health care provider. Nurses in the pediatric care provider’s office or clinic should also be alert for signs

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of PPF, as they often see the mother before the mother sees an obstetrical care provider. Physiological factors contributing to PPF are amenable to intervention and may be identified even before birth. People with sleeping disorders during pregnancy, anemia, infection or inflammation, or thyroid dysfunction can be identified as having increased risk for PPF. Other physical conditions and psychological or situational factors that might contribute to PPF should be identified during the prenatal period. The medical records of patients with known risk factors should be flagged to alert hospital staff to their special needs (see Clinical Reasoning Case Study). ?

CLINICAL REASONING CASE STUDY

Fatigue and Rest After Childbirth Patricia gave birth to her third baby; she has two children at home, ages 3 years and 18 months. Her partner travels frequently with his job. She is breastfeeding the baby without difficulty but is concerned about how she will care for all three of her children, stating, “I remember how tired I was after my last baby. I’m not sure I can manage with three children since my partner is gone so much. Do you have any suggestions to help me?” Questions 1. Evidence—Is there sufficient evidence to draw conclusions about whether support would be helpful for Patricia? 2. Assumptions—What assumptions can be made about the following factors? a. The relation between breastfeeding and fatigue b. Support in the postpartum period c. The role of sleep and rest in relation to fatigue and depression d. Spacing of pregnancies and fatigue 3. What implications and priorities for nursing care can be drawn at this time? 4. Interprofessional care—Describe the roles and responsibilities of health care providers who might be involved in Patricia’s care.

Promoting Ambulation. Early ambulation promotes the return of strength. Free movement should be encouraged once anaesthesia wears off, unless an opioid analgesic has been administered. After the initial recovery period is over, the mother should be encouraged to ambulate frequently. In the early postpartum period some patients can feel light-headed or dizzy upon standing. The rapid decrease in intra-abdominal pressure after birth results in a dilation of blood vessels supplying the intestines (splanchnic engorgement) and causes blood to pool in the viscera. This condition contributes to the development of orthostatic hypotension and can occur when the patient who has recently given birth sits or stands, first ambulates, or takes a warm shower or sitz bath. The nurse must consider the baseline blood pressure; amount of blood loss; and type, amount, and timing of analgesic or anaesthetic medications administered when assisting a patient to ambulate. Patients who have had epidural or spinal anaesthesia may have slow return of sensory and motor function in their lower extremities, increasing the risk of falls with early ambulation. Careful assessment by the postpartum nurse can prevent falls. Factors that the nurse should consider are the time lapse since the medication was given; the patient’s ability to bend both knees, place both feet flat on the bed, and lift buttocks off the bed without assistance; medications since birth; vital signs; and estimated blood loss with birth. Before allowing the patient to ambulate the nurse should assess the patient’s ability to stand unassisted beside the bed: they should simultaneously bend both knees

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slightly and then stand with knees locked. If the patient is unable to balance themselves they should be eased back into bed safely (Lockwood & Anderson, 2013).

NURSING ALERT To promote patient safety and prevent injury, it is important to have hospital personnel present at least the first time the patient gets out of bed after birth because the patient can feel weak, dizzy, faint, or light-headed. The patient should be instructed to call for assistance before getting out of bed the first time and any time thereafter if they feel dizzy or weak. The partner or family members who are present should be instructed to call for help as well.

Early ambulation is also successful in reducing the incidence of venous thromboembolism (VTE). Blood is hypercoagulable in the postpartum period, especially during the first 48 hours after birth (Isley & Katz, 2017). Patients who must remain in bed after giving birth are at increased risk for this complication. For patients who are immobilized, antiembolic stockings (TED hose) or sequential compression device (SCD) boots may be ordered prophylactically, especially after Caesarean birth. If a patient remains in bed longer than 8 hours (e.g., for postpartum magnesium sulphate therapy for pre-eclampsia), exercise to promote circulation in the legs is indicated, using the following routine: • Alternate flexion and extension of feet. • Rotate ankles in circular motion. • Alternate flexion and extension of legs. • Press back of knee to bed surface; relax. If the patient is susceptible to VTE, they should be encouraged to walk about actively and discouraged from sitting immobile in a chair. Patients with increased risk for thromboembolism include those with morbid obesity (body mass index [BMI] >40), and those who had an unexpected Caesarean birth, are over 35 years of age, and had VTE during pregnancy. These patients should be offered low-molecularweight heparin during the postpartum period. The length of time required for the prophylaxis ranges from 10 days to 6 weeks and depends on the number of risk factors (Royal College of Obstetricians and Gynaecologists [RCOG], 2015). In addition, it is important to note that the higher-molecular-weight anticoagulants, or warfarin, are considered safe for breastfeeding mothers. The dose is based on maternal weight (RCOG, 2015). (See further discussion in Chapter 24). Patients with varicosities are advised to wear support hose. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the suspected leg, the primary health care provider should be notified immediately; meanwhile the patient should be confined to bed with the affected limb elevated on pillows.

Promoting Exercise. Some people who have just given birth are interested in regaining their nonpregnant figures and previous level of exercising. Postpartum exercise can usually begin soon after birth, although the patient should be encouraged to start with simple exercises and gradually progress to more strenuous ones. Figure 22.4 illustrates a number of exercises appropriate for the new mother. Abdominal exercises are postponed until about 4 weeks after Caesarean birth. It often takes several months for the body to return to prepregnancy weight and shape, and nurses should provide new mothers with realistic information regarding this.

Promoting Nutrition. During the hospital stay, most postpartum patients have a good appetite and eat well; nutritious snacks are usually welcomed. Patients may request that family members bring to the hospital favourite or culturally appropriate foods. Cultural dietary preferences must be respected. An example is that some Asian mothers may only eat hot

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Abdominal Breathing. Lie on back with knees bent. Inhale deeply through nose. Keep ribs stationary and allow abdomen to expand upward. Exhale slowly but forcefully while contracting the abdominal muscles; hold for 3 to 5 seconds while exhaling. Relax. Combined Abdominal Breathing and Supine Pelvic Tilt (Pelvic Rock). Lie on back with knees bent. While inhaling deeply, roll pelvis back by flattening lower back on floor or bed. Exhale slowly but forcefully while contracting abdominal muscles and tightening buttocks. Hold for 3 to 5 seconds while exhaling. Relax.

Reach for the Knees. Lie on back with knees bent. While inhaling, deeply lower chin onto chest. While exhaling, raise head and shoulders slowly and smoothly and reach for knees with arms outstretched. The body should rise only as far as the back will naturally bend while waist remains on floor or bed (about 6 to 8 inches). Slowly and smoothly lower head and shoulders back to starting position. Relax.

Double Knee Roll. Lie on back with knees bent. Keeping shoulders flat and feet stationary, slowly and smoothly roll knees over to the left to touch floor or bed. Maintaining a smooth motion, roll knees back over to the right until they touch floor or bed. Return to starting position and relax.

Leg Roll. Lie on back with legs straight. Keeping shoulders flat and legs straight, slowly and smoothly lift left leg and roll it over to touch the right side of floor or bed and return to starting position. Repeat, rolling right leg over to touch left side of floor or bed. Relax.

Buttocks Lift. Lie on back with arms at sides, knees bent, and feet flat. Slowly raise buttocks and arch back. Return slowly to starting position.

Single Knee Roll. Lie on back with right leg straight and left leg bent at the knee. Keeping shoulders flat, slowly and smoothly roll left knee over to the right to touch floor or bed and then back to starting position. Reverse position of legs. Roll right knee over to the left to touch floor or bed and return to starting position. Relax.

Arm Raises. Lie on back with arms extended at 90-degree angle from body. Raise arms so they are perpendicular and hands touch. Lower slowly.

Fig. 22.4 Postpartum exercise should begin as soon as possible. The patient should start with simple exercises and gradually progress to more strenuous ones.

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food after birth and will avoid anything cold. This interest in food presents an ideal opportunity for nutrition counselling on dietary needs after pregnancy, such as for breastfeeding, preventing constipation and anemia, promoting weight loss, and promoting healing and well-being. Prenatal vitamins and iron supplements should be continued until 6 weeks after birth, and some patients may require supplements for the entire time they breastfeed. The recommended caloric intake for the moderately active, nonlactating postpartum female is 1 800 to 2 200 kcal/day. According to the Government of Canada (2010), the estimated energy requirement for a breastfeeding person is an extra 350 to 400 kcal/day, which is usually an extra snack or a small meal. Higher-than-normal caloric intake is recommended for patients who are underweight or who exercise vigorously and those who are breastfeeding more than one newborn.

Promoting Bladder Function. The postpartum patient should void spontaneously within 6 to 8 hours after giving birth. The first several voidings should be measured to document adequate emptying of the bladder. A volume of at least 150 mL is expected for each voiding. Some patients experience difficulty in emptying the bladder, possibly as a result of diminished bladder tone, edema from trauma, use of epidural or spinal anaesthetic, or fear of discomfort. Nursing interventions for inability to void and bladder distension are discussed in the Preventing Bladder Distention section earlier in the chapter. Urinary incontinence is not uncommon, especially if there was significant perineal trauma with birth. Pelvic floor muscle training, also known as Kegel exercises, helps to strengthen muscle tone, particularly after vaginal birth. Kegel exercises help in regaining the muscle tone often lost as pelvic tissues are stretched and torn during pregnancy and birth. Patients who maintain muscle strength may benefit years later by maintaining urinary continence. It is essential that patients learn to perform Kegel exercises correctly (see Patient Teaching box: Kegel Exercise, in Chapter 5). Some people perform them incorrectly and can increase their risk of incontinence, which can occur when inadvertently bearing down on the pelvic floor muscles, thrusting the perineum outward. The technique can be assessed during the pelvic examination at the patient’s checkup by inserting two fingers intravaginally and checking whether the pelvic floor muscles correctly contract and relax.

Promoting Bowel Function. After birth, patients can be at risk for constipation related to the adverse effects of medications (e.g., opioid analgesics, iron supplements, magnesium sulphate), dehydration, immobility, perineal lacerations or episiotomy, or hemorrhoids. Some patients fear discomfort with straining to have a bowel movement. Nursing interventions to promote normal bowel elimination include educating the patient about measures to avoid constipation. These interventions include ambulating and increasing the intake of fluids and fibre. Alerting the postpartum patient to adverse effects of medications such as opioid analgesics (decreased gastrointestinal tract motility) may encourage them to implement measures to reduce the risk of constipation. It is normal to not have a bowel movement for 2 to 3 days after birth, so many new mothers may be home before having a bowel movement. Occasionally, stool softeners or laxatives may be necessary during the early postpartum period, especially if the patient has extensive perineal repairs. Some mothers experience gas pains; this is more common following Caesarean birth. Ambulation or rocking in a rocking chair may stimulate passage of flatus and relieve discomfort. Anti-gas medications may be ordered. Patients who have had a Caesarean birth should avoid drinking carbonated beverages and the use of straws, as well as eating

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foods that tend to produce gas (e.g., legumes, beans, broccoli), as this promotes gas formation.

NURSING ALERT Rectal suppositories and enemas should not be administered to patients with third- or fourth-degree perineal lacerations. These measures to treat constipation can be very uncomfortable and can cause hemorrhage or damage to the suture line.

Promoting Breastfeeding. The ideal time to initiate breastfeeding is as soon as possible after birth (Breastfeeding Committee for Canada [BCC], 2021). The Baby-Friendly Initiative (BFI) recommends placing the newborn in uninterrupted skin-to-skin contact for at least 1 to 2 hours after birth (BCC, 2021). At this time, the newborn is in an alert state and ready to nurse. Breastfeeding promotes contraction and involution of the uterus and thus can help decrease the risk of PPH. With the first feeding, the nurse can assess the appearance of the breasts and nipples, assess the patient’s basic understanding of breastfeeding technique, and provide assistance and basic instructions to facilitate breastfeeding as well as provide information about responsive, cue-based feeding (see Community Focus box: Breastfeeding Support). Optimal positioning and latching will help the baby to suck effectively. It is recommended that positioning and latching be assessed before discharge from the hospital and when any breastfeeding issues occur (BFI Strategy for Ontario and Toronto Public Health, 2019). Maternal confidence, also referred to as breastfeeding self-efficacy, is highly correlated with positive breastfeeding outcomes, including initiation, duration, and exclusivity (McQueen et al., 2011). Patients will need continuous support throughout their hospitalization and prompt follow-up after discharge to ensure successful breastfeeding. (See Chapter 27 for further information on assisting the breastfeeding patient.)

COMMUNITY FOCUS Breastfeeding Support Studies have shown that people breastfeed longer if they have support in their breastfeeding efforts. Both nurses and International Board Certified Lactation Consultants (IBCLCs) can provide such support after childbirth. Some hospitals and birthing centres offer IBCLC support during the inpatient stay after birth. Often IBCLCs are nurses or have other allied health backgrounds. IBCLCs are an important part of the health care team and remain a significant means for reaching population-level breastfeeding goals (Chetwynd et al., 2019). It is recommended that families have a plan for support after discharge, including a follow-up visit with their primary health care provider, as well as for support with breastfeeding. In discharge planning, nurses should refer breastfeeding mothers to community groups for support. It is vital that nurses facilitate a seamless transition between the services provided by the hospital, community health services, and peer support programs. Social support interventions that include peer support have been shown to be successful in increasing the duration of exclusive breastfeeding and satisfaction with breastfeeding. Community health nurses can facilitate breastfeeding efforts through organizing or facilitating support groups. Mothers experienced in breastfeeding can also facilitate these efforts as an evidence-informed peer support intervention. Identify sources of breastfeeding support in your community. Are these resources free of charge and available in various parts of the community? What form does the support take? Are there group classes? Individual consultation? Who provides the consultation? Make a list of the resources you identified and share the list with your clinical group.

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Suppression of Lactation. Suppression of lactation is necessary when the person has decided not to breastfeed or in the case of newborn death. Wearing a well-fitted support bra continuously for at least the first 72 hours after giving birth aids in this process. These patients should avoid breast stimulation, including running warm water over the breasts, newborn suckling, or expressing milk. Some nonbreastfeeding mothers experience severe breast engorgement (swelling of breast tissue caused by increased blood and lymph supply to the breasts as the body produces milk, which occurs at about 72 to 96 hours after birth). If breast engorgement occurs, it usually can be managed satisfactorily with nonpharmacological interventions. Periodic application of ice packs to the breasts can help decrease the discomfort associated with engorgement. The patient should use a 15minutes-on, 45-minutes-off schedule (to prevent the rebound swelling that can occur if ice is used continuously). Although there is lack of scientific evidence to support effectiveness, cabbage leaves are often recommended to help relieve engorgement; formula-feeding mothers may be told to place fresh green cabbage leaves over their breasts and to replace the leaves when they are wilted. A mild analgesic or anti-inflammatory medication can reduce discomfort associated with engorgement. Medications that were once prescribed for lactation suppression (e.g., estrogen, estrogen and testosterone, and bromocriptine) are no longer used.

Health Promotion for Future Pregnancies Rubella vaccination. For postpartum patients who have not had rubella or for those who are serologically not immune (titre of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies; this is given as the measles, mumps, rubella (MMR) vaccine. Seroconversion occurs in approximately 90% of people vaccinated after birth. The live attenuated rubella virus is not communicable; therefore, breastfeeding mothers can be vaccinated (Government of Canada, 2019). However, because the virus is shed in urine and other body fluids, the vaccine should not be given if the mother or other household members are immunocompromised. A transient arthralgia or rash is common after administration of the rubella vaccine. Canadian guidelines recommend immunizing new mothers immediately postpartum, and they should delay pregnancy for at least 4 weeks following MMR vaccination (Government of Canada, 2019).

LEGAL TIP: Rubella Vaccination Informed consent for rubella vaccination in the postpartum period includes information about possible adverse effects and the risk of teratogenic effects. Patients and their families need to understand that they must practise contraception for 1 month after being vaccinated to avoid pregnancy, given the theoretical risk of disease transmission to the fetus. There is no evidence demonstrating a teratogenic risk from the vaccine. Termination of pregnancy should not be recommended following inadvertent immunization with either of these vaccines on the basis of fetal risks following maternal immunization.

Prevention of Rh isoimmunization. Injection of Rh immune globulin (a solution of gamma-globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) (see Medication Guide: Rh Immune Globulin). Rh immune globulin promotes lysis of fetal Rh-positive blood cells before the mother forms their own antibodies against them. Administration of

Rh immune globulin is intended to prevent complications in future pregnancies should the Rh-negative patient have an Rh-positive fetus.

MEDICATION GUIDE Rh Immune Globulin Action Suppression of immune response in nonsensitized people with Rh-negative blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion, or accident Indications Routine antepartum prevention at 26 to 28 weeks of gestation in people with Rh-negative blood; suppress antibody formation after birth, miscarriage, pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villus sampling Dosage/Route Standard dose: 1 vial (300 mcg) IM in deltoid or ventrogluteal muscle Microdose: 1 vial (50 mcg) IM in deltoid or ventrogluteal muscle Rho(D) immune globulin can be given IM or IV Adverse Effects • Myalgia, lethargy, localized tenderness and stiffness at injection site, mild and transient fever, malaise, headache; rarely nausea, vomiting, hypotension, tachycardia, and allergic response can occur Nursing Considerations • Give standard dose to the mother at 28 weeks of gestation as prophylaxis or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g., amniocentesis, second-trimester miscarriage or abortion, after external version) • Give standard dose within 72 hours after birth if the baby is Rh positive. • Give microdose for first-trimester miscarriage or abortion, ectopic pregnancy, or chorionic villus sampling. • Verify that the woman is Rh negative and has not been sensitized; if postpartum that Coombs’ test is negative; and that baby is Rh positive. Provide a thorough explanation to the patient and support person(s) about the procedure, including the purpose, possible adverse effects, and the effect on future pregnancies. Have patient sign a consent form if required by the agency. Verify correct dosage and confirm the lot number and patient’s identity before giving the injection (verify with another nurse or by other procedure per agency policy); document administration per agency policy. Observe patient for at least 20 minutes after administration for allergic response. • Document lot number and expiration date in the patient record. • The medication is made from human plasma (a consideration if the patient is a Jehovah’s Witness). Patients receiving this medication must be informed about the risks and benefits, and the nurse needs to document this discussion and the patient’s understanding before administering the medication. The risk of transmitting infectious agents, including viruses, cannot be completely eliminated. IM, Intramuscularly; IV, intravenously.

NURSING ALERT After birth, Rh immune globulin is administered to all Rh-negative, antibody (Coombs’ test)–negative patients who give birth to Rh-positive newborns. Rh immune globulin is administered to the mother intramuscularly or intravenously. It should never be given to an newborn.

The administration of 300 mcg of Rh immune globulin is usually sufficient to prevent maternal sensitization. However, if a large

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fetomaternal transfusion is suspected, the dosage needed should be determined by performing a Kleihauer-Betke test, which detects the amount of fetal blood in the maternal circulation. If more than 15 mL of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased. Because Rh immune globulin is considered a blood product, precautions similar to those used for transfusing blood are necessary when it is given. The identification number on the patient’s hospital wristband should correspond to the identification number found on the laboratory slip. The nurse must also check to see that the lot number of the laboratory slip corresponds to the lot number on the vial. Finally, the expiration date on the vial should be checked to ensure that it is a usable product.

SAFETY ALERT Rh immune globulin suppresses the immune response. Therefore, the patient who receives both Rh immune globulin and a live virus immunization such as rubella must be tested in 3 months to see if they have developed rubella immunity. If not, they will need another dose of the vaccine.

Psychosocial Assessment and Care Meeting the psychosocial needs of new parents involves assessing their reactions to the birth experience, their feelings about themselves, and their interactions with the new baby (Figure 22.5) and other family members. Specific interventions are then planned in order to increase the parents’ knowledge and self-confidence as they assume the care and responsibility of the new baby and integrate this new member into their existing family structure in a way that meets their cultural expectations. Taking time to assess maternal emotional needs and concerns before discharge can promote better psychological health and adjustment to parenting. Ongoing support for patients during the postpartum period is also needed. Issues such as fatigue that often appear during the hospital stay tend to continue after discharge and can intensify. Postpartum support is especially beneficial to at-risk populations, such as low-income primiparas, people who lack adequate support because of isolation (e.g., physical or language), those at risk for family dysfunction and child abuse, and those at risk for PMD (see Chapter 24). Sometimes the findings of the psychosocial assessment indicate serious actual or potential difficulties that must be addressed. Box 22.3 identifies psychosocial characteristics and behaviours that may warrant

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BOX 22.3

Signs of Potential Psychosocial Complications The following signs in the mother can suggest potentially serious complications and should be reported to the health care provider or clinic (these may be noticed by the partner or other family members): • Unable or unwilling to discuss labour and birth experience • Refers to self as ugly and useless • Excessively preoccupied with self (body image) • Markedly depressed • Lacks a support system • Partner or other family members react negatively to baby • Refuses to interact with or care for baby (e.g., does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or dirty diapers) (cultural appropriateness of actions must be considered) • Expresses disappointment over baby’s sex • Sees baby as messy or unattractive • Baby reminds mother of family member or friend they do not like • Has difficulty sleeping • Experiences loss of appetite It is key to discuss and plan how symptoms will be monitored (for example, by using validated self-report questionnaires, such as the Edinburgh Postnatal Depression Scale [EPDS], Patient Health Questionnaire [PHQ-9], or the 7-item Generalized Anxiety Disorder scale [GAD-7]). Refer to Chapter 24 for more details.

Source: National Institute for Health and Care Excellence. (2014). Antenatal and postnatal mental health: Clinical management and service guidance. Updated 2020. https://www.nice.org.uk/guidance/ cg192.

ongoing evaluation after hospital discharge. Patients exhibiting these needs should be referred to appropriate community resources for assessment and management. Cultural issues must be considered when planning care, as childbirth occurs within a sociocultural context. The nurse must take time to interact with the patient and their extended family in order to learn and understand which practices need to be followed for the new mother and their newborn newborn. Recognizing the importance of family and community in relation to the patient and the newborn is integral to providing culturally appropriate care.

Impact of the Birth Experience. Many patients indicate a need to examine retrospectively the birth process itself and their own behaviour during labour. Their partners may express similar desires. If their birth experience was quite different from the one they had planned (e.g., induction, epidural anaesthesia, Caesarean birth), both partners may need to mourn the loss of their expectations before they can adjust to the reality of their actual birth experience. Inviting them to review the events and describe how they feel can help the nurse assess how well they understand what happened and how well they have been able to put their childbirth experience into perspective.

Maternal Self-Image. An important assessment concerns the patient’s self-concept, body image, and sexuality. How this new mother feels about their own body during the postpartum period may affect the new parent’s behaviour and adaptation to parenting. The patient’s self-concept and body image may also affect their sexuality. Fig. 22.5 Parents getting acquainted with their newborn. (iStock.com/ FatCamera)

Adaptation to Parenthood and Parent–Infant Interactions. The psychosocial assessment includes evaluating adaptation to parenthood

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as evidenced by the parents’ reactions to and interactions with the new baby. Clues indicating successful adaptation begin to appear early in the postbirth period as parents react positively to the newborn and continue the process of establishing a relationship with their child. Parents are adapting well to their new roles when they exhibit a realistic perception and acceptance of their newborn’s needs and limited abilities, immature social responses, and helplessness. Examples of positive parent–newborn interactions include taking pleasure in the newborn and in providing care, responding appropriately to newborn cues, and providing comfort (see Chapter 23). If these indicators are missing, the nurse must investigate further in an attempt to identify what is hindering the normal adaptation process. The nurse can ask several questions, such as “Tell me how you are feeling?” or “What are your concerns about being a parent?” These will help determine if the mother is experiencing the normal “baby blues” or if there is a more serious underlying condition (i.e., PMD) (see Clinical Reasoning Case Study: Risk for Perinatal Mood Disorder). ?

CLINICAL REASONING CASE STUDY

Risk for Perinatal Mood Disorder Elisabeth, a 38-year-old multipara, has just given birth to her fourth baby. The ages of her other children are 8, 4, and 2. During the morning nursing assessment, Elisabeth was noted to be tearful and stated that she was feeling “overwhelmed” and “very unsure” of herself and how to take care of the new baby, even though she has successfully taken care of her three previous children. She shared that her mother was diagnosed with cancer 2 months ago and is undergoing treatment. Her partner will be starting a much-needed new job next week and will not be able to get any time off for a while. Other family members do not live close by except for her sister, who is out of town often because of her job responsibilities. Elisabeth is concerned about how she will manage taking care of a newborn and three other children with a seemingly depleted support system. 1. Evidence—Is there sufficient evidence to support counselling women with psychosocial concerns in the immediate postpartum period? 2. Assumptions—What assumptions can be made about the following issues? a. Elisabeth’s risk for a perinatal mood disorder b. Elisabeth’s support system c. Elisabeth’s ability to connect with community resources after discharge 3. What implications and priorities for nursing care can be drawn at this time? 4. Interprofessional care: Describe roles and responsibilities of other health care providers who should be involved in planning and implementing care for Elisabeth and her family.

Postpartum Blues. The period surrounding the first day or two after birth is characterized by heightened joy and feelings of well-being. This is often followed by a “blue” period. Approximately 50 to 80% of new mothers experience the postpartum blues or “baby blues.” During this period, new mothers are emotionally labile and often cry easily for no apparent reason. This lability seems to peak around the fifth day and subside by the tenth day. Other symptoms of postpartum blues include depression, a let-down feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and anger. Postpartum blues are transient, mild, and time limited and do not require treatment other than reassurance. Biochemical, psychological, social, and cultural factors have been explored as possible causes of the postpartum blues; however, the etiology remains unknown. Because the postpartum blues occur in up to 80% of postpartum patients, all postpartum patients and their support person(s) must be taught about the symptoms of the blues and that this is a normal postpartum occurrence (Registered Nurses’ Association of Ontario, 2018).

Whatever the cause, the early postpartum period appears to be one of emotional and physical vulnerability for new mothers who may be already psychologically overwhelmed by the reality of parental responsibilities. The mother may feel deprived of the supportive care she received from family members and friends during pregnancy. Some mothers regret the loss of the mother–unborn child relationship and mourn its passing. Still others have a let-down feeling when labour and birth are complete. Most postpartum patients experience fatigue after childbirth, which is compounded by the around-the-clock demands of the new baby and can accentuate the feelings of depression. Symptoms of depression can have a negative effect on the development of a maternal role. To help mothers cope with postpartum blues, nurses can suggest various strategies (see Patient Teaching box: Coping with Postpartum Blues).

PATIENT TEACHING Coping With Postpartum Blues It is important to teach this information to all new mothers. • Remember that the blues are normal. • Get plenty of rest; nap when the baby does, if possible. Go to bed early and let friends know when to visit. • Use relaxation techniques learned in childbirth classes (or ask the nurse to teach you and your partner some techniques). • Do something for yourself. Take advantage of the time when your partner or family members care for the baby—soak in the tub or go for a walk. • Plan a day out of the house—go to the mall or a park with the baby, being sure to take a stroller or carriage, or go out to eat with friends without the baby. Many communities have churches or other agencies that provide child care programs, such as Mothers’ Morning Out. • Share your feelings with your partner. For example, talk about feeling tied down, if applicable; how the birth met your expectations; and things that will help you. • If you are breastfeeding, give yourself and your baby time to learn to do this together. • Monitor yourself for signs of depression and anxiety. • Seek out and use community resources, such as peer support programs to meet other new mothers, La Leche League, local public health agencies, or community health centres.

Although the postpartum blues are usually mild and short-lived, approximately 15% of women experience a PMD (see Chapter 24). PMD symptoms can range from mild to severe, with postpartum mothers having good and bad days. It can go undetected because new parents generally do not voluntarily admit to this kind of emotional distress out of embarrassment, guilt, or fear. Nurses must include teaching about the normalcy of the blues as well as how to differentiate symptoms of the blues from those of PMD and urge parents to report depressive symptoms promptly if they do occur (see Box 24.4). For further discussion of PMD and how to screen for it, see Chapter 24.

Family Structure and Functioning. A mother’s adjustment to this new role is affected greatly by relationships with their partner, their mother and other relatives, and any other children (Figure 22.6). Nurses can help ease the new mother’s return home by identifying possible conflicts among family members and helping them to plan strategies for dealing with these concerns before discharge. Such a conflict could arise when couples have very different ideas about parenting. Dealing with the stresses of sibling rivalry and unsolicited grandparent advice can also affect the person’s transition to motherhood. Only by asking about other nuclear and extended family members can the nurse

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Fig. 22.6 Older sibling cuddles with mother and new baby. (Courtesy Jennifer Hobgood.)

discover potential conflicts in such relationships and help plan workable solutions for them.

Impact of Cultural Diversity. The final component of a complete postpartum psychosocial assessment is the patient’s cultural beliefs, values, and practices. Much of a person’s behaviour during the postpartum period may be strongly influenced by their cultural background. Nurses are likely to come into contact with people from many different countries and cultures. All cultures have developed safe and satisfying methods of caring for new mothers and babies. The nurse can identify some cultural beliefs and practices through observation and interaction with the mother and the family. Asking questions of the mother and the family about their cultural practices can provide useful information to help the nurse provide optimal care. Only by understanding and respecting the values and beliefs of each individual can the nurse design a plan of care to meet individual needs. Many traditional health beliefs and practices exist among the various cultures within the North American population. Traditional health practices used to maintain health or avoid illnesses often involve the whole person (body, mind, and spirit) and may be culturally based. While it is vital that the nurse spend time assessing and listening to the individual and their family and what they value, the nurse should not assume from their cultural background what may or may not be relevant for them. This is an important aspect of the family assessment and promotes patient- and family-centred care. For Indigenous people the importance of traditional birth keepers, midwives, and/or birth attendants (such as aunties, grandmothers, sisters, and mothers) must be considered when providing nursing care. Ceremony and cultural practices are used to honour and ground women in two-spirit wellness, which is the backbone of the health of communities. Many effective medicines have been developed through traditional practices and have kept people strong, providing health for the community. Knowledge of traditional medicine is passed down from generation to generation. Beliefs supporting such practices involve a balance between physical, emotional, mental, and spiritual elements. The importance of balance also extends beyond the individual to include the family, the community, and the environment. Close linkages and balanced relationships with land, water, and ice and with their communities and their societies govern the sense of well-being and may be expressed among Indigenous women through distinct

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cultural practices in relation to labour, birth, and postpartum periods (Best Start Resource Centre, 2013; Wilson et al., 2013). Other traditional practices among cultures may include the observance of certain dietary restrictions, wearing certain clothing, or taboos for balancing the body; participation in certain activities such as sports and art for maintaining mental health; and the use of silence, prayer, or meditation for spiritual development. Some practices (e.g., using religious objects or eating garlic) are used to protect the person from illness and may involve avoiding people who are believed to create hexes and spells or who have an “evil eye.” Restoration of health may involve a person accessing alternative and complementary health models (e.g., herbs, animal substances) or using a traditional healer. It is thus vital that nurses bring a relational and nonjudgemental approach to all settings and remember that birth occurs within a sociocultural context. Supporting each person’s choice is important to family-centred care. Rest, seclusion, dietary restraints, and ceremonies honouring the mother may be other traditional practices that are followed for the promotion of the health and well-being of the mother and baby. Other postpartum traditional health practices and beliefs are those of new mothers and their families in Southeast Asia, where some families believe that pregnancy is considered to be a “hot” state and childbirth results in a sudden loss of this state. Therefore, balance needs to be restored by increasing the return of the hot state, which is present physically or symbolically in hot food, hot water, and warm air. Mothers may wish to stay warm and avoid bathing, exercising, and hair washing for 7 to 30 days after childbirth. Another belief is that the mother and baby are in a weak and vulnerable state for a period of several weeks following birth. During this time, the mother may remain in a passive role, take no baths or showers, and stay in bed to prevent cold air from entering their body. This practice is considered “doing-the-month,” and while some postpartum Chinese practices might seem unusual and even unhealthy to those in Western civilizations, doing-the-month practices have a positive effect on patients; most Chinese patients believe that doing-the-month practices will help restore their health and protect them from future disease, because they have been taught to believe so from childhood. In addition, failure to follow the practices might increase maternal stress and stimulate family discord (Qun Liu et al., 2015). Thus nurses must consider all cultural aspects when planning care and not use their own cultural beliefs as the framework for that care. In order to provide family- and patient-centred, relational care, patients’ rituals and traditions should be encouraged as long as the mother and the baby experience no ill effects. The nurse must also determine whether a person is using complementary and alternative medical therapy during the postpartum period, as active ingredients in some herbal remedies can have adverse physiological effects on the patient when ingested with prescribed medicines. Also, people who have immigrated to Western nations without their extended families may not have much help at home, making it difficult for them to observe these activity restrictions. Many young people who are first- or second-generation Canadians may feel conflicted about following their cultural traditions and need to be supported in the decisions they make regarding postpartum care.

Discharge Teaching Discharge planning begins at the time of admission to the unit and should be individualized for each patient. The nurse functions primarily as teacher, encourager, and supporter rather than doer, while implementing the plan of care for a postpartum patient. The goal is for all postpartum patients to be capable of providing basic care for themselves and their newborns at the time of discharge. Topics that should be included are promotion of parenting skills and adjustment

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of family members to the newborn, self-care, and sexual activity and contraception. Because of the limited time available for teaching, nurses must focus their teaching on the patient’s expressed needs. Giving the patient a list of topics and asking them to indicate their teaching needs can help the nurse maximize teaching efforts and increase the patient’s retention of information. Using “teachable moments” (i.e., when the topic arises during the daily routine) enhances the mother’s learning. It is also important that teaching be provided when the mother is ready to learn and not distracted by pain, visitors, or a crying baby. Providing written materials on postpartum self-care, breastfeeding, and newborn care that the patient can consult after discharge may be helpful. See Chapter 5 for more information on health teaching. Just before the time of discharge, the nurse should review the patient’s chart to check that laboratory reports, medications, signatures, and other items are in order. Some hospitals use a checklist to be completed before the patient’s discharge. The nurse should also verify that the newborn is ready to be discharged.

Self-Care and Signs of Complications. Every postpartum patient must be taught to recognize physical and psychological signs and symptoms that might indicate health concerns and how to obtain advice and assistance quickly if these signs appear. Table 22.2 and Box 22.3, respectively, list several common indications of maternal physical and psychosocial issues in the postpartum period. (See Chapter 24 for more information on postpartum complications.) Before discharge, postpartum patients need basic instruction in a variety of self-care topics, such as nutrition, exercise, family planning, the resumption of sexual intercourse, prescribed medications, and routine mother–baby follow-up care. No medication that would make the mother sleepy should be administered if they are the one who will be holding the baby on the way out of the hospital. In some instances, the mother is seated in a wheelchair and given the baby to hold. Some families leave unescorted and ambulatory, depending on hospital protocol. The mother’s and the baby’s identification bands should be carefully checked. In most hospitals, nurses must ensure that the parents are able to properly secure the baby in a car seat for the drive home (see Figure 26.25). Sexual Activity and Contraception. Feelings related to sexual adjustment after childbirth are often a cause of concern for new parents. Postpartum patients who have recently given birth may be reluctant to resume sexual intercourse for fear of pain, or worry that coitus could damage healing perineal tissue. Because many new parents are anxious for information but reluctant to bring up the subject, postpartum nurses should matter-of-factly include the topic of postpartum sexuality during their routine physical assessment. For example, while examining a perineal laceration or episiotomy site the nurse can say, “I know you’re sore right now, but it probably won’t be long until you (or you and your partner) are ready to make love again. Do you have any questions about resuming sex?” This approach assures the patient and their partner that resuming sexual activity is a legitimate concern for new parents and indicates the nurse’s willingness to answer questions and share information. Discussing sexual activity with the patient and their partner is important before they leave the hospital, because many couples resume sexual activity before the traditional postpartum checkup 6 weeks after childbirth. For most postpartum patients the risk of hemorrhage or infection is minimal by approximately 2 weeks after birth. The nurse needs to discuss the physical and psychological effects that giving birth can have on sexual activity (see Patient Teaching box: Resuming Sexual Activity After Birth).

Many factors can influence the timing and quality of sexual activity after birth. Postpartum perineal pain and dyspareunia (painful intercourse) are common among patients with perineal lacerations or episiotomy. Some patients who had an episiotomy report discomfort with intercourse for months after birth. Perineal lacerations that reach the anal sphincter (third degree) and the rectal wall (fourth degree) are called obstetrical anal sphincter injuries (OASIS) (see Chapter 17, Evidence-Informed Practice Box: When an OASIS Is Not a Scenic Travel Destination: Minimizing Anal Sphincter Injury in Childbirth). These injuries may cause long-term postpartum anal incontinence and urgency, pelvic pain, and dyspareunia. Patients may be deeply embarrassed discussing dyspareunia and incontinence with their partners and with their health care team. Prior to hospital discharge, the nurse can initiate discussions with the patient and their partner regarding pain, dyspareunia, resumption of intercourse, and contraception. At postpartum visits, the nurse assesses bladder, bowel, and sexual function; inspects the perineum; and assesses and discusses mood and intimacy challenges such as fatigue and timing issues. Alternate positions that may help increase comfort during intercourse can be suggested. Breastfeeding parents often experience vaginal dryness related to high prolactin levels and low estrogen levels; they need to know that they may require additional vaginal lubrication. Changes in family

PATIENT TEACHING Resuming Sexual Activity After Birth • Unless your health care provider indicates otherwise, you can safely resume sexual activity (intercourse) by the second to fourth week after birth, when bleeding has stopped and the perineum is healed. Many people resume sexual activity by 5 to 6 weeks after birth, although this varies and is often related to perineal discomfort. Perineal lacerations or episiotomy increases the chances of discomfort with intercourse. For the first 6 weeks to 6 months, vaginal lubrication can be decreased, especially among breastfeeding or chestfeeding people. • Your physiological reactions to sexual stimulation for the first 3 months after birth will be slower and less intense. The strength of the orgasm is reduced. • A water-soluble gel, or contraceptive cream or jelly might be recommended for lubrication. If some vaginal tenderness is present, your partner can be instructed to insert one or more clean, lubricated fingers into the vagina and rotate them to help the vagina relax and identify possible areas of discomfort. A position in which you have control of the depth of the insertion of the penis also is useful. The side-by-side or female-on-top position may be more comfortable than other positions. • The presence of the baby can influence postbirth lovemaking. Parents hear every sound made by the baby; conversely, you may be concerned that the baby hears every sound you make. In either case, any phase of the sexual response cycle may be interrupted by hearing the baby cry or move, leaving both of you frustrated and unsatisfied. In addition, the amount of psychological energy you expend in child care activities may lead to fatigue. Newborns require a great deal of attention and time. • Some people have reported feeling sexual stimulation and orgasms when breastfeeding their babies. Some breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers are, although some breastfeeding mothers may find their interest in sexual relations is decreased, as they may feel their breasts are for feeding the baby and may not find sexual stimulation desirable. • You should be instructed to correctly perform the Kegel exercises to strengthen your pubococcygeal muscle. This muscle is associated with bowel and bladder function and with vaginal feeling during intercourse.

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structure and altered sleep patterns can make it difficult for a couple to find time for privacy and intimacy. PMDs are associated with decreased sexual desire; medication used to treat depression can also reduce sexual desire and inhibit orgasm. Contraceptive options should be discussed with postpartum patients (and their partners, if present) before discharge so that they can make informed decisions about fertility management before resuming sexual activity. Waiting to discuss contraception at the 6-week checkup may be too late. Ovulation can occur as soon as 1 month after birth, particularly in people who formula-feed. Breastfeeding mothers should be taught about appropriate birth control methods that include the lactational amenorrhea method or condoms. Hormonal methods of birth control (e.g., oral contraceptives) may be used once breastfeeding is well established. Contraceptive options are discussed in detail in Chapter 8.

Prescribed Medications. Postpartum patients should continue to take their prenatal vitamins for the first 6 weeks after birth. Breastfeeding mothers may be instructed to continue prenatal vitamins for the duration of breastfeeding. Supplemental iron can be prescribed for mothers with lower-than-normal hemoglobin levels. Postpartum patients with extensive episiotomies or perineal lacerations (third or fourth degree) are usually prescribed stool softeners to take at home. Pain medications (analgesics or NSAIDs) may be prescribed, especially for patients who had Caesarean birth. The nurse should make certain that the patient knows the route, dosage, frequency, and common adverse effects of all ordered medications. Written information about the medications is usually included in the discharge instructions.

Coping With Visitors. A newborn in the family or neighbourhood draws visitors. The nurse can help the parents explore ways in which they can assert their needs in such situations. When family or friends ask what they can do to help, the family can respond with “Please bring us a casserole or a meal” or “Could you please pick up some items at the grocery store?” The couple can work out a signal for alerting the partner that the new mother is becoming tired or uncomfortable and needs to have the partner invite the visitors into another part of the house. Some new mothers have found that if they remain in their robes and do not appear ready for company, visitors stay for a shorter time. A “Please Do Not Disturb” sign on the front door may be useful when the mother is resting.

Follow-up After Discharge Routine Mother and Baby Checkups. Follow-up with the obstetrical health care provider is important to the health of the postpartum patient. It is a time for comprehensive evaluation of the new parent’s physical, emotional, mental, and social well-being. Important components of the postpartum visit are review of the patient’s postpartum concerns; routine screening for a PMD; review of the labour and birth experience and any complications that occurred; counselling for patients with ongoing health concerns such as diabetes; contraceptive planning; and health teaching related to weight loss. Postpartum patients who have experienced uncomplicated vaginal births are commonly scheduled for the traditional 6-week postpartum examination. Those patients who have had a Caesarean birth are often seen in the health care provider’s office or clinic within 2 weeks after hospital discharge. Early follow-up is warranted for women who experienced complications such as hypertensive disorders of pregnancy, those with chronic health conditions, patients at high risk for depression, and breastfeeding mothers who are experiencing lactation difficulties. The date and time for the follow-up appointment should be

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included in the discharge instructions. If an appointment is not made before the patient leaves the hospital, they should be encouraged to call the health care provider’s office or clinic to schedule one. Parents who have not already done so need to make plans for newborn follow-up at the time of discharge. Most health care providers like to see newborns for an initial examination within 3 to 5 days after birth or 48 to 72 hours after hospital discharge. If an appointment for a specific date and time was not made for the newborn before leaving the hospital, the parents should be encouraged to call the office or clinic right away.

Home Visits. Community health nurse visits to new mothers and babies can help bridge the gap between hospital care and routine visits to health care providers. Nurses are able to assess the mother, newborn, and home environment; answer questions and provide education; and make referrals to community resources, if necessary. Home visits reduce the need for more expensive health care, such as emergency department visits and rehospitalization. They can also help to improve the overall quality of care provided to newborns and their parents. Ideally, immediate follow-up contact and home visits should be available 7 days a week. The support provided by nurses and other trained community health care workers such as peer counselors can help support parent–newborn interaction and parenting skills; home visits also help to promote mutual support between the mother and their partner. Breastfeeding outcomes can be enhanced through home visitation programs. Community nursing care may not be available, even if needed, because of funding issues, but in some provinces mothers receive a phone call within the first week after discharge. Patients who are assessed to be high risk may then receive a home visit from a community health nurse to assist with the new mother’s concerns, depending on the practice of the local health department. During the home visit, the nurse conducts an assessment of the mother and newborn to determine physiological adjustment, identify any existing complications, and answer any questions the mother has about herself or newborn care. Conducting the assessment in a separate room provides private time for the mother to ask questions on topics such as breast care, family planning, and constipation. The assessment should also include the mother’s emotional adjustment and their knowledge of self-care and newborn care. During the newborn assessment, the nurse can demonstrate and explain normal newborn behaviour and capabilities and encourage the mother and family to ask questions or express concerns they may have. See Chapter 3 for more information on home visiting.

Telephone Follow-up. Many local health departments have implemented postpartum telephone follow-up calls to women for assessment, health teaching, and identification of complications to effect timely intervention and referrals. Telephonic nursing assessments may also be used after a postpartum home care visit to reassess a patient’s knowledge about the signs and symptoms of adequate intake by the breastfeeding newborn or, after initiating home phototherapy, to assess the caregiver’s knowledge regarding equipment complications. There is evidence that phone support for new mothers during the postpartum period is beneficial; it can contribute to improved breastfeeding outcomes, reduced depression scores, and increased patient satisfaction (Lavender et al., 2013; Miller et al., 2014).

Warm Lines. The warm line is another type of telephone link between the new family and concerned caregivers or experienced parent volunteers. A warm line is a helpline or consultation service, not a crisis intervention line. The warm line is appropriately used for dealing

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with less extreme concerns that can seem urgent at the time the call is placed but are not actual emergencies. Calls to warm lines commonly relate to newborn feeding, prolonged crying, sibling rivalry, or perinatal mood disorder concerns. Families are encouraged to call when concerns arise. Telephone numbers for warm lines should be given to parents before hospital discharge.

Support Groups. The person adjusting to motherhood sometimes seeks a special group experience. Postpartum patients who have met earlier in prenatal clinics or on the hospital unit can begin to associate for mutual support. Members of childbirth preparation classes may decide to extend their relationship during the postpartum period. A postpartum support group enables mothers and partners to share with and support each other as they adjust to parenting. Many new parents find it reassuring to discover that they are not alone in their feelings of confusion and uncertainty. An experienced parent can often impart concrete information to other members. Inexperienced parents can find themselves imitating the behaviour of others in the group whom they perceive to be particularly capable. There are local support groups for a variety of postpartum topics and concerns. For example, women can find breastfeeding support through local meetings of La Leche League. Postpartum mothers can connect with support groups via the Internet and can also find support through groups on social media. They can participate in virtual meetings while in the comfort of their own homes, and they can participate in forums on specific topics. Referral to Community Resources. In order to develop an effective referral system, it is important that the nurse have a clear understanding of the needs of the postpartum person and family and of the organization and community resources available for meeting those needs. Locating and compiling information about available community services contributes to the development of a referral system. It is important for the nurse to develop their own resource file of local and national services that are frequently useful to postpartum families.

KEY POINTS • Postpartum care is modelled on the concept of health. • Postpartum nursing care is influenced by knowledge of antepartum and intrapartum care. • Cultural beliefs and practices affect the patient’s response to the puerperium. • Nursing care includes assessments to detect deviations from normal comfort measures for relieving discomfort or pain and safety measures for preventing infection. • A postpartum assessment includes a review of breasts, uterus, bladder elimination, bowel elimination, amount and colour of lochia, swelling of legs, condition of episiotomy or laceration, and emotional status. • Teaching and counselling measures are designed to promote the person’s feelings of competence in self-management and baby care. • Common nursing interventions in the postpartum period include evaluating and treating the boggy uterus and the full urinary bladder; providing for nonpharmacological and pharmacological relief of pain and discomfort associated with the episiotomy, lacerations, afterbirth pains, or breastfeeding; and instituting measures to promote or suppress lactation. • Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family as well as an understanding of different cultural beliefs and practices.

• Many mothers may exhibit signs of postpartum blues (baby blues). • Postpartum teaching includes self-care needs, warning signs, exercise, and sexuality and resumption of sexual relations. • Telephone follow-up, home visits, warm lines, and support groups are effective means of facilitating physiological and psychological adjustments in the postpartum period.

REFERENCES Aber, C., Weiss, M., & Fawcett, J. (2013). Contemporary women’s adaptation to motherhood: The first 3 to 6 weeks postpartum. Nursing Science Quarterly, 26(4), 344–351. Agency for Healthcare Research and Quality. (2013). Strategy 3: Nurse bedside shift report. Updated 2017. http://www.ahrq.gov/professionals/systems/ hospital/engagingfamilies/strategy3/index.html. Best Start Resource Centre. (2013). Pimotisiwin: A good path for pregnant and parenting Aboriginal teens. http://www.beststart.org/resources/rep_health/ pimotosiwin_oct.pdf. BFI Strategy for Ontario and Toronto Public Health. (2019). Breastfeeding protocols for health care providers. https://breastfeedingresourcesontario.ca/ resource/breastfeeding-protocols-health-care-providers. Bhati, S., & Richards, K. (2015). A systematic review of the relationship between postpartum sleep disturbance and postpartum depression. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(3), 350–357. Breastfeeding Committee for Canada [BCC]. (2021). Baby friendly implementation guideline. https://breastfeedingcanada.ca/wp-content/ uploads/2021/02/BFI-Implementation-Guideline-final-draft-Feb-8-2021. pdf. Chetwynd, E. M., Wasser, H. M., & Poole, C. (2019). Breastfeeding support interventions by International Board Certified Lactation Consultants: A systemic review and meta-analysis. Journal of Human Lactation, 35(3), 424–440. Declercq, R., Sakala, C., Corry, M. P., et al. (2014). Major survey findings of Listening to Mothers III: New mothers speak out. Journal of Perinatal Education, 23(1), 17–24. Government of Canada. (2010). Prenatal nutrition guidelines for health professionals—Background on Canada’s food guide. http://www.hc-sc.gc.ca/ fn-an/pubs/nutrition/guide-prenatal-eng.php. Government of Canada. (2019). Rubella immunization: Canadian immunization guide. https://www.canada.ca/en/public-health/services/ publications/healthy-living/canadian-immunization-guide-part-4-activevaccines/page-20-rubella-vaccine.html#p4c19a6. Isley, M. M., & Katz, V. L. (2017). Postpartum care and long-term health considerations. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Lavender, T., Richens, Y., Milan, S. J., et al. (2013). Telephone support for women during pregnancy and the first six weeks postpartum. Cochrane Database of Systematic Reviews, 7. https://doi.org/10.1002/14651858. CD009338.pub2, CD009338. Lawrence, R. A., & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. Lockwood, S., & Anderson, K. (2013). Postpartum safety: A patient-centered approach to fall prevention. American Journal of Maternal Child Nursing, 38(1), 15–18. McKinney, J., Keyser, L., Clinton, S., et al. (2018). ACOG committee opinion no. 736: Optimizing postpartum care. Obstetrics and Gynecology, 132(3), 784–785. https://doi.org/10.1097/AOG.0000000000002849. McQueen, K. A., Dennis, C., Stremler, R., et al. (2011). A pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40(1), 35–46. https://doi.org/10.1111/j.1552-6909.2010.01210.x. Miller, Y. D., Dane, A. C., & Thompson, R. (2014). A call for better care: The impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland, Australia. BMC Health Services Research, 14(1), 1–13.

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Okun, M. L. (2015). Sleep and postpartum depression. Current Opinion in Psychiatry, 28(6), 490–496. Park, E. M., Meltzer-Brody, S., & Stickgold, R. (2013). Poor sleep maintenance and subjective sleep quality are associated with postpartum maternal depression symptom severity. Archives of Women’s Mental Health, 16(6), 539–547. Qun Liu, Y., Petrini, M., & Maloni, J. A. (2015). “Doing the month”: Postpartum practices in Chinese women. Nursing and Health Sciences, 17, 5–14. https:// doi.org/10.1111/nhs.12146. Registered Nurses’ Association of Ontario. (2018). Assessments and interventions for perinatal depression (2nd ed.). https://rnao.ca/sites/rnao-ca/files/bpg/ Perinatal_Depression_FINAL_web_0.pdf. Royal College of Obstetricians and Gynaecologists (RCOG). (2015). Reducing the risk of thrombosis and embolism during pregnancy and the puerperium (Green-top guideline No. 37a). https://www.rcog.org.uk/globalassets/ documents/guidelines/gtg-37a.pdf. Suplee, P. D., Kleppel, L., Santa-Donato, A., et al. (2017). Improving postpartum education about warning signs of maternal morbidity and mortality. Nursing for Women’s Health, 20(6), 552–567. https://doi.org/10.1016/j.nwh. 2016.10.009. Volrathongchai, K., Neelasmith, S., & Thinkhamrop, J. (2013). Nonpharmacological interventions for women with postpartum fatigue. Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/ 14651858.CD010444. Waller-Wise, R. (2012). Mother-baby care: The best for patients, nurses, and hospitals. Nursing for Women’s Health, 16(4), 273–278.

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Wilson, D., de la Ronde, S., Brascoupe, S., et al. (2013). Health professionals working with First Nations, Inuit, and Metis consensus guideline. Journal of Obstetrics and Gynaecology Canada, 35(6S2), S1–S4. https://doi.org/10.1016/ S1701-2163(15)30699-X. Wolfe-Roubatis, E., & Spatz, D. L. (2015). Transgender men and lactation: What nurses need to know. MCN: The American Journal of Maternal Child Nursing, 40(1), 32–38. https://doi.org/10.1097/NMC. 0000000000000097.

ADDITIONAL RESOURCES Association of Women, Obstetrical and Neonatal Nurses (AWHONN)—Video on estimation of postpartum blood loss: https://www.youtube.com/watch? v¼F_ac-aCbEn0&list¼UUPrOhL3Od7ZeFDq27ycS00g. Best Start—A Child Becomes Strong: Journeying Through Each Stage of Life Resource: https://resources.beststart.org/wp-content/uploads/2019/01/K12A-child-becomes-strong-2020.pdf. First Nations Health Authority—Maternal Child and Family Health: https:// www.fnha.ca/what-we-do/maternal-child-and-family-health. LactMed—Provides information about medication use while breastfeeding: https://www.ncbi.nlm.nih.gov/books/NBK501922/. Perinatal Services BC—Postpartum Nursing Care Pathway: http://www. perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/ PostpartumNursingCarePathway.pdf.

UNIT 6 Postpartum Period

23 Transition to Parenthood Keri-Ann Berga http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify parental and newborn behaviours that facilitate and those that inhibit parental attachment to the newborn. 2. Describe sensual responses that strengthen attachment. 3. Examine the process of becoming a mother. 4. Compare maternal and paternal adjustments to parenthood. 5. Describe ways in which the nurse can facilitate parent–infant adjustment.

6. Examine the effects of the following on parenting responses and behaviour: parental age (i.e., adolescence and older than 35 years), same-sex parenting, social support, culture, socioeconomic conditions, personal aspirations, and sensory impairment. 7. Describe sibling adjustment. 8. Describe grandparent adaptation.

Becoming a parent creates a period of change and instability for all people who decide to have children. This period occurs whether parenthood is biological or adoptive and whether the parents are husband-and-wife couples, single mothers, single fathers, lesbian couples with one woman as biological mother, gay male couples who adopt a child, or couples who are transgender and give birth to or adopt a child. Parenting is a process of role attainment and role transition. The transition is an ongoing process as the parent(s) and infant develop and change. A thorough understanding of the process parents go through during their transition to parenthood guides the nurse in helping family members adapt. Family-centred care supports the family as the primary source of knowledge about what is best for them as they work in collaboration with health care providers to plan care. This chapter reviews the transition to parenthood, including the parenting process and the adjustment of all family members in this transition.

of parents, stating that it took longer than minutes or hours for parents to form an emotional relationship with their infants. The terms attachment and bonding continue to be used interchangeably. Attachment is an emotional bond to another person and is described as a lasting, psychological connectedness between human beings (Bowlby, 1969). The earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. Attachment is developed and maintained through proximity and interaction with the newborn as the parent becomes acquainted with the infant, identifies the infant as an individual, and claims the infant as a member of the family. Attachment is facilitated by positive feedback (i.e., social, verbal, and nonverbal responses, whether real or perceived, that indicate acceptance of one partner by the other). Attachment occurs through a mutually satisfying experience. One mother commented on her daughter’s grasp reflex, noting, “I put my finger in her hand, and she grabbed right on. It’s just a reflex, I know, but it felt good anyway” (Figure 23.1). The concept of attachment includes mutuality (i.e., the infant’s behaviours and characteristics elicit a corresponding set of parental behaviours and characteristics). The infant displays signalling behaviours such as crying, smiling, and cooing that initiate the contact and bring the caregiver to the child. These behaviours are followed by behaviours such as rooting, grasping, and postural adjustments that maintain the contact. Most caregivers are attracted to an alert, responsive, cuddly infant and repelled by an irritable, apparently disinterested infant. Attachment occurs more readily with the infant whose temperament, social capabilities, appearance, and sex fit the parent’s expectations. If the child does not meet these expectations, the parent’s disappointment can delay the attachment process. Table 23.1 presents a comprehensive list of classic infant behaviours affecting parental

PARENTAL ATTACHMENT, BONDING, AND ACQUAINTANCE The process by which a parent comes to love and accept a child and a child comes to love and accept a parent is known as attachment. Using the terms attachment and bonding, Klaus and Kennell (1976) originally proposed that there is a sensitive period during the first few minutes or hours after birth when mothers and fathers must have close contact with their newborns to optimize the child’s later development. Klaus and Kennel (1982) later revised their theory of parent–infant bonding, modifying their claim of the critical nature of immediate contact with the newborn after birth. They acknowledged the adaptability

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Fig. 23.1 Grasping. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

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finally in terms of “uniqueness.” The unique newcomer is thus incorporated into the family. Parents examine their newborn carefully and point out characteristics that the child shares with other family members and that are indicative of a relationship between them. The claiming process is revealed by comments such as the following: “David held him close and said, ‘He’s the image of his father,’ but I found one part like me—his toes are shaped like mine.” Conversely, some mothers react negatively. They “claim” the newborn in terms of the discomfort or pain the baby causes. The mother interprets the newborn’s normal responses as being negative toward them and reacts to their child with dislike or indifference. They do not hold the child close or touch the child to be comforting; for example, “The nurse put the baby into Marie’s arms. She promptly laid him across her knees and glanced up at the television. ‘Stay still until I finish watching—you’ve been enough trouble already.’” Nurses play an important role in facilitating parental attachment. They can enhance positive parent–infant contacts by heightening parental awareness of an infant’s responses and ability to communicate. As the parent attempts to become competent and loving in that role, nurses can bolster the parent’s self-confidence and ego. Nurses are in prime positions to identify actual and potential parenting issues and to collaborate with other health care providers who will care for the parents after discharge. Nursing interventions related to the promotion of parent–infant attachment are numerous and varied (Table 23.3).

Assessment of Attachment Behaviours attachment. Table 23.2 presents a corresponding list of parental behaviours that affect infant attachment. An important part of attachment is acquaintance. Parents use eye contact (Figure 23.2), touching, talking, and exploring to become acquainted with their newborn during the immediate postpartum period. Adoptive parents undergo the same process when they first meet their new child. During this period, families engage in the claiming process, which is the identification of the new baby. The child is first identified in terms of likeness to other family members, then in terms of differences, and

TABLE 23.1

One of the most important areas of assessment is careful observation of behaviours thought to indicate the formation of emotional bonds between the newborn and family, especially the mother. Unlike physical assessment of the newborn, which has concrete guidelines to follow, assessment of parent–infant attachment relies more on skillful observation and interviewing. Rooming-in of mother and newborn and liberal visiting privileges for the partner, siblings, and grandparents can help nurses identify behaviours that demonstrate positive or negative attachment. An excellent opportunity exists during newborn feeding sessions. Box 23.1 presents guidelines for assessment of attachment behaviours.

Infant Behaviours Affecting Parental Attachment

Facilitating Behaviours

Inhibiting Behaviours

Visually alert; eye-to-eye contact; tracking or following of parent’s face

Sleepy; eyes closed most of the time; gaze averted

Appealing facial appearance; randomness of body movements reflecting helplessness

Resemblance to person parent dislikes; hyperirritability or jerky body movements when touched

Smiles

Bland facial expression; infrequent smiles

Vocalization; crying only when hungry or wet

Crying for hours on end; colicky

Grasp reflex

Exaggerated motor reflex

Anticipatory approach behaviours for feedings; sucks well; feeds easily

Feeds poorly; regurgitates; vomits often

Enjoys being cuddled, held

Resists being held and cuddling by crying, stiffening body

Easily consolable

Inconsolable; unresponsive to parenting, caretaking tasks

Activity and regularity somewhat predictable

Unpredictable feeding and sleeping schedule

Attention span sufficient to focus on parents

Inability to attend to parent’s face or offered stimulation

Differential crying, smiling, and vocalizing; recognizes and prefers parents

Shows no preference for parents over others

Approaches through locomotion

Unresponsive to parent’s approaches

Clings to parent; puts arms around parent’s neck

Seeks attention from any adult in room

Lifts arms to parents in greeting

Ignores parents

Date from Gerson, E. (1973). Infant behavior in the first year of life. Raven Press.

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TABLE 23.2

Postpartum Period

Parental Behaviours Affecting Infant Attachment

Facilitating Behaviours

Inhibiting Behaviours

Looks; gazes; takes in physical characteristics of infant; assumes en face position; eye contact

Turns away from infant; ignores infant’s presence

Hovers; maintains proximity; directs attention to and points to infant

Avoids infant; does not seek proximity; refuses to hold infant when given opportunity

Identifies infant as unique individual

Identifies infant with someone parent dislikes; fails to discern any of infant’s unique features

Claims infant as family member; names infant

Fails to place infant in family context or identify infant with family member; has difficulty naming

Touches; progresses from fingertip to fingers to palms to encompassing contact

Fails to move from fingertip touch to palmar contact and holding

Smiles at infant

Maintains bland countenance or frowns at infant

Talks, coos, or sings to infant

Wakes infant when infant is sleeping; handles roughly; hurries feeding by moving nipple continuously

Expresses pride in infant

Expresses disappointment, displeasure in infant

Relates infant’s behaviour to familiar events

Does not incorporate infant into daily life

Assigns meaning to infant’s actions and sensitively interprets infant’s needs

Makes no effort to interpret infant’s actions or needs

Views infant’s behaviours and appearance in positive light

Views infant’s behaviour as exploiting, deliberately uncooperative; views appearance as distasteful, ugly

Data from Mercer, R. (1983). Parent–infant attachment. In L. Sonstegard, K. Kowalski, & B. Jennings (Eds.), Women’s health (Vol. 2). Grune & Stratton.

Fig. 23.2 Eye-to-eye contact. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

TABLE 23.3

During pregnancy and often even before conception, parents develop an image of the “ideal” or “fantasy” newborn. At birth, the fantasy newborn becomes the real newborn. How closely the dream child resembles the real child influences the bonding process. Assessing such expectations during pregnancy and at the time of the newborn’s birth enables identification of discrepancies in the parents’ view of the fantasy child and the real child. The labour process significantly affects the immediate attachment of mothers to their newborn. Factors such as a long labour, feeling tired or “drugged” after birth, difficulties with breastfeeding (Tharner et al., 2012), premature birth, and being separated from the newborn at birth (Flacking et al., 2012; Hoffenkamp et al., 2012) can delay the development of initial positive feelings toward the newborn. Nurses can provide breastfeeding support and referrals to groups such as La Leche League Canada or Postpartum Support International (see Additional Resources at the end of the chapter), which may be useful to some mothers.

Examples of Parent–Infant Attachment Interventions

Intervention Label and Definition

Activities

Attachment Promotion Facilitating development of an affective, enduring relationship between infant and parent

Discuss with patient culture-based expressions of attachment before and after birth. Place newborn skin-to-skin with parent immediately after birth (if mother wishes this). Provide opportunity for parent or parents to see, hold, and examine newborn immediately after birth (i.e., delay unnecessary procedures and provide privacy). Discuss infant behavioural characteristics with parent. Assist parent of multiples in recognizing individuality of each infant. Instruct parent on attachment development, emphasizing its complexity, ongoing nature, and opportunities. Continued

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Examples of Parent–Infant Attachment Interventions—cont’d

Intervention Label and Definition

Activities

Family Integrity Promotion: Childbearing Family Facilitation of the growth of individuals or families who are adding an infant to family unit

Respect and support family’s cultural value system. Assist family in developing adaptive coping mechanisms to assist with the transition to parenthood. Prepare parent(s) for expected role changes involved in becoming a parent. Prepare parent(s) for responsibilities of parenthood. Reinforce positive parenting behaviours. Identify effect of newborn on family dynamics and equilibrium.

Lactation Counselling Assisting in the establishment and maintenance of successful breastfeeding Correct misconceptions, misinformation, and inaccuracies about breastfeeding. Provide mother the opportunity to breastfeed after birth, when possible. Instruct on newborn feeding cues (e.g., rooting, sucking, and quiet alertness). Determine frequency of normal feeding patterns, including cluster feedings and growth spurts. Discuss strategies aimed at optimizing milk supply (e.g., breast massage, frequent milk expression, complete emptying of breasts, kangaroo care, and medications). Instruct on signs and symptoms warranting reporting to a health care provider or lactation consultant. Parent Education: Infant Instruction on nurturing and physical care needed during the first year of life

Determine parent’s (or both parents’) knowledge and readiness and ability to learn about infant care. Provide anticipatory guidance about developmental changes during first year of life. Teach parent(s) skills to care for newborn. Demonstrate ways in which parent(s) can stimulate infant’s development. Discuss infant’s capabilities for interaction. Demonstrate quieting techniques.

Risk Identification: Childbearing Family Identification of individual or family likely to experience difficulties in parenting, and prioritization of strategies to prevent parenting issues

Ascertain understanding of English or other language used in community. Determine developmental stage of parent or parents. Review prenatal history for factors that predispose patient to complications. Monitor parent–infant interactions, noting behaviours thought to indicate attachment. Plan for risk-reduction activities, in collaboration with the individual or family. Refer to the appropriate community agency for follow-up if risk for parent concerns or a lag in attachment has been identified.

Data from Bulechek, G., Butcher, H., Dochterman, J., et al. (2013). Nursing interventions classification (NIC) (6th ed.). Mosby.

BOX 23.1

Assessing Attachment Behaviours

• When the newborn is brought to the parents, do they reach out for the newborn and call the child by name? (Recognize that in some cultures parents may not name the baby in the early newborn period.) • Do the parents speak about the newborn in terms of identification—whom the newborn resembles, and what appears special about their newborn over other newborns? • When parents are holding the newborn, what kind of body contact is seen—do parents feel at ease in changing the newborn’s position, are fingertips or whole hands used, and does the newborn have parts of the body they avoid touching or parts of the body they investigate and scrutinize?

• When the newborn is awake, what kinds of stimulation do the parents provide—Do they talk to the newborn, to each other, or to no one? How do they look at the newborn—using direct visual contact, avoiding eye contact, or looking at other people or objects? • How comfortable do the parents appear in terms of caring for the newborn? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers? • What types of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking? • If the newborn is fussy, what kinds of comforting techniques do the parents use, such as rocking, talking, or stroking?

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PARENT–INFANT CONTACT Early Contact Early close contact may facilitate the attachment process between parent and child. Although a delay in contact does not necessarily mean that attachment will be inhibited, additional psychological energy may be necessary to achieve the same effect. To date, no scientific evidence has demonstrated that immediate contact after birth is essential for the parent–child relationship. Early skin-to-skin contact between the mother and newborn immediately after birth and during the first hour facilitates maternal affection and attachment behaviours and is recommended as a standard of care because of its many benefits and lack of adverse effects (Kilpatrick & Garrison, 2017; King & Pinger, 2014; Stewart & Rodgers, 2017). The newborn is placed in the prone position on the parent’s bare chest; the baby and the parent’s chest are covered with a warm, dry blanket (Figure 23.3). This practice promotes early and effective breastfeeding and increases breastfeeding duration. It is also associated with less newborn crying, improved thermoregulation (especially in low–birth weight infants), and improved cardiorespiratory stability in late preterm infants (Kilpatrick & Garrison, 2017; Stewart & Rodgers, 2017). Parents who cannot have early contact with their newborn (i.e., the newborn was transferred to the intensive care nursery) can be reassured that such contact is not essential for optimal parent–infant interactions. Otherwise, adopted infants would not form ties of affection with their parents. Nurses need to stress that the parent–infant relationship is a process that develops over time. Nurses can facilitate skin-to-skin contact in most birth settings, whether the newborn is preterm or term or birthed vaginally or by Caesarean, and with fathers or partners and mothers.

Extended Contact Rooming-in ensures that the newborn stays in the room with the mother and is the norm in Canadian hospitals. In most facilities, the newborn never leaves the parent’s presence; nurses should perform the initial and ongoing assessments and care in the room with the parents whenever possible. Nurses should encourage the partner to participate in caring for the newborn in as active a role as desired

Fig. 23.4 Father changes diaper of his newborn son. (Courtesy Darren Nelson.)

(Figure 23.4). They can also encourage siblings and grandparents to visit and become acquainted with the newborn. Extended contact with the newborn should be available for all parents but especially for those at risk for parenting difficulties, such as adolescents and those with minimal social and financial support. Perinatal nurses need to consider and encourage activities that optimize family-centred care (Public Health Agency of Canada [PHAC], 2017). Baby Friendly status for a hospital is one means to promote family-centred care (Breastfeeding Committee of Canada, 2021; Jaafar et al., 2016). See more discussion on the Baby Friendly Hospital Initiative in Chapter 27.

COMMUNICATION BETWEEN PARENT AND INFANT The parent–infant relationship is strengthened through the use of sensual responses and abilities by both partners in the interaction. The nurse should keep in mind that there may be cultural variations in these interactive behaviours.

The Senses Touch. Touch, or the tactile sense, is used extensively by parents as

Fig. 23.3 Placing the naked infant on the bare chest of the mother encourages both breastfeeding and bonding. (Leifer, G. [2015]. Introduction to maternity and pediatric nursing [7th ed.]. Saunders.)

a means of becoming acquainted with the newborn. Many parents reach out for their newborns as soon as they are born. Mothers lift their newborn to their breasts, enfold them in their arms, and cradle them. Once the newborn is close, the mother begins the exploration process with their fingertips, one of the most touch-sensitive areas of the body (Figure 23.5). Within a short period of time, they use their palm to caress the baby’s trunk and eventually enfold the newborn. Gentle, stroking motions are used to soothe and quiet the newborn. Patting or gently rubbing the newborn’s back is a comfort after feedings. Infants also pat the parent’s breast as they nurse. Both seem to enjoy sharing each other’s body warmth. Parents seem to have an innate desire to touch, pick up, and hold the newborn. They comment on the softness of the baby’s skin and note details of the baby’s appearance. As parents become increasingly sensitive to the infant’s like or dislike of different types of touch, they draw closer to their baby.

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toward them. Newborns respond to higher-pitched voices and can distinguish the mother’s voice from others soon after birth.

Odour. Another behaviour shared by parents and infants is a response to each other’s odour. Mothers comment on the smell of their babies when first born and have noted that each newborn has a unique odour. Newborns learn rapidly to distinguish the odour of their mother’s breast milk.

Entrainment Newborns move in time with the structure of adult speech, which is termed entrainment. They wave their arms, lift their heads, and kick their legs, seemingly “dancing in tune” to a parent’s voice. Culturally determined rhythms of speech are ingrained in the infant long before the child uses spoken language to communicate. This shared rhythm also gives the parent positive feedback and establishes a positive setting for effective communication. Fig. 23.5 Mother uses fingertip to explore infant. (Courtesy Rebekah Vogel.)

Variations in touching behaviours have been noted in parents from different cultural groups. For example, minimal touching and cuddling can be a traditional Southeast Asian practice, thought to protect the newborn from evil spirits. Because of tradition and spiritual beliefs, some new mothers in India and Bali have practised infant massage since ancient times. The benefits of infant massage include enhanced weight gain in preterm infants.

Biorhythmicity The fetus is in tune with the mother’s natural rhythms, or biorhythmicity, such as their heartbeat. After birth, the mother’s heartbeat or a recording of a heartbeat can soothe a crying newborn. One task of the newborn is to establish a personal biorhythm. Parents can help in this process by giving consistent loving care and using their newborn’s alert state to develop responsive behaviour and increase social interactions and opportunities for learning (Figure 23.6). The more quickly parents become competent in child care activities, the more quickly their psychological energy can be directed toward observing the communication cues that the infant gives them.

Eye Contact. Parents repeatedly demonstrate interest in having eye contact with the baby. Some mothers remark that, once their babies have looked at them, they feel much closer to them. Parents spend much time getting their babies to open their eyes and look at them. In North American culture, eye contact appears to reinforce the development of a trusting relationship and is an important factor in human relationships at all ages (see Figure 23.2). In other cultures, eye-to-eye contact may be perceived differently. For example, in Mexican culture, sustained direct eye contact is considered to be rude and immodest and even dangerous for some individuals. This danger may arise from the mal ojo (evil eye), resulting from excessive admiration. Women and children are thought to be more susceptible to the mal ojo (Berger, 2012). As newborns become functionally able to sustain eye contact with their parents, time is spent in mutual gazing, often in the en face position. In this position, the parent’s face and the newborn’s face are approximately 20 cm apart and on the same plane (see Figure 23.2). Nurses and other obstetrical health care providers can facilitate eye contact immediately after birth by positioning the newborn on the mother’s abdomen or breasts with the mother’s and the newborn’s faces on the same plane. Dimming the lights encourages the newborn’s eyes to open. To promote eye contact, instillation of prophylactic antibiotic ointment in the newborn’s eyes can be delayed until the newborn and parents have had some time together after birth. This intervention should be provided while maintaining skin-to-skin contact between mother and newborn whenever possible.

Voice. The shared response of parents and infants to each other’s voices is also remarkable. Parents wait tensely for the first cry. Once that cry has reassured them of the baby’s health, they begin comforting behaviours. As the parents speak, the newborn is alerted and turns

Fig. 23.6 Newborn in alert state. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

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Fig. 23.7 Sharing a smile; an example of synchrony. (iStock.com/Monica Ninker).

Reciprocity and Synchrony When they are noticing and responding appropriately to infant cues, mothers and caregivers can be regulators of their infants’ states. The terms reciprocity and synchrony are used to describe these interactions as they relate to newborn cues. One of the most essential experiences in shaping the architecture of the developing brain is “serve and return” interaction between children and significant adults in their lives. Young children naturally reach out for interaction through babbling, facial expressions, and gestures, and adults respond with the same kind of vocalizing and gesturing back at them. This back-and-forth process is fundamental to the wiring of the brain, especially in the earliest years (Center on the Developing Child, Harvard University, 2020) (see Additional Resources). Reciprocity often takes several weeks to develop with a new baby. For example, when the newborn fusses and cries, the mother responds by picking up and cradling the newborn; the baby becomes quiet and alert and establishes eye contact; and the mother verbalizes, sings, and coos while the baby maintains eye contact. As the baby habituates to the stimulus, the infant’s responses stop; the baby then averts the eyes and yawns; and the mother decreases their active response. If the parent continues to stimulate the infant, the baby may become fussy. Synchrony refers to the fit between the infant’s cues and the parent’s response. When parent and infant have a synchronous interaction, it is mutually rewarding (Figure 23.7). Parents need time to learn to interpret the infant’s cues correctly. For example, the infant develops a specific cry in response to different situations, such as boredom, loneliness, hunger, and discomfort. The parent may need assistance in interpreting these cries, along with trial-and-error interventions, before synchrony develops.

of coping may seem ineffective during this time. Some parents can be so distressed that they are unable to be supportive of each other. Because men often identify their spouses as their primary or only source of support, the transition can be harder for fathers or partners. They often feel deprived when the mothers, who are also experiencing stress, cannot provide their usual level of support. Many parents are unprepared for the strong emotions that can develop, such as the helplessness, inadequacy, and anger that arise when dealing with a crying newborn. However, parenthood allows adults to develop and display a selfless, warm, and caring side that may not be expressed in other adult roles. For most mothers and their partners, the transition to parenthood is an opportunity rather than a time of danger. Parents try new coping strategies as they work to master their new roles and reach new developmental levels. As they work through the transition, they often find personal strength and resourcefulness. Some parents have limited knowledge of what being a parent entails. These parents can benefit from more information on child care, changes in relationships, and differing views of parenting held by partners. Women tend to have more support from female relatives and postpartum groups, whereas men often lack support mechanisms and may only have health care providers and work colleagues for information and support. There is a need for more public health messaging about parenting programs and the importance of father participation, as fathers are underrepresented in parenting interventions (PanterBrick et al., 2014; Tully et al., 2017). In the Canadian Maternity Experience Survey, women reported that they had received enough information on breastfeeding, basic newborn and self-care, and community resources; however, they did not have enough information on the transition to parenthood. The topics of particular interest were sexual changes, physical demands of newborn care, and the effects of the transition period on the relationship with their partner (PHAC, 2009). The period after birth is often referred to as the “fourth trimester.”

Parental Tasks and Responsibilities Parents may need to reconcile the actual child with the fantasy and dream child. This means coming to terms with the newborn’s physical appearance, sex, innate temperament, and physical status. If the real child differs greatly from the fantasy child, parents may delay acceptance of the child. In some instances, they may never accept the child. Many parents know the sex of the newborn before birth because of the results of prenatal testing. For those who do not have this information, disappointment over the sex can take time to resolve. The parents can provide adequate physical care but find it difficult to be sincerely involved with the newborn until this internal conflict has been resolved. See the Cultural Awareness box.

CULTURAL AWARENESS Birth Story: It’s a Girl (Again)!

PARENTAL ROLE AFTER BIRTH Adaptation involves stabilizing tasks and coming to terms with commitments. Parents demonstrate growing competence in child care activities and become increasingly attuned to their newborn’s behaviour. The period from the decision to conceive through the first months of having a child is termed the transition to parenthood.

Transition to Parenthood Historically, the transition to parenthood was viewed as a crisis; however, the current perspective is that for most families parenthood is a developmental transition rather than a major life crisis. The transition to parenthood is described as a time of disorder and disequilibrium, as well as satisfaction, for mothers and their partners. Usual methods

Faduma is a midwife from Saudi Arabia who faced a difficult situation while assisting a woman who desperately wanted her baby to be a boy because she already had several little girls. When the patient gave birth to yet another baby girl, Faduma says, she set the newborn aside for as long as she could and kept telling the woman she had given birth to a “beautiful, healthy baby.” She shared that the baby was a girl only when the patient pressed her for the information. Her reasons for doing this were to give the mother time to stabilize physically before she received what she would consider disappointing news. Faduma reported that this was common practice among midwives in her country. From Watts, N., & McDonald, C. (2007). The beginning of life (the perinatal period). In R. Srivastava (Ed.). The healthcare professional’s guide to clinical cultural competence. Elsevier.

CHAPTER 23 The normal appearance of the newborn—size, colour, moulding of the head, or bowed appearance of the legs—is startling for some parents. Nurses can encourage parents to examine their babies and to ask questions about newborn characteristics. Parents need to become adept in the care of the newborn, including caregiving activities, noting the communication cues the newborn gives to indicate needs and responding appropriately to those needs. Selfesteem tends to grow with competence. Breastfeeding can help mothers feel they are contributing in a unique way to the welfare of the newborn. The parent may interpret the newborn’s response to parental care and attention as a comment on the quality of that care. Newborn behaviours that parents interpret as positive responses to their care include being consoled easily, enjoying being cuddled, and making eye contact. Spitting up frequently after feedings, crying, and being unpredictable may be perceived as negative responses to parental care. Continuation of these infant responses that are viewed as negative can result in alienation of parent and infant, to the detriment of the infant. Some people view assistance—including advice from partners, mothers, mothers-in-law, and health care providers—as supportive. Others view advice as criticism or an indication of how inept these others judge the new parents to be. Criticism, real or imagined, of the new parents’ ability to provide adequate physical care, nutrition, or social stimulation for the newborn can prove to be discouraging. By providing encouragement and praise for parenting efforts, nurses can bolster the new parents’ confidence. Parents must establish a place for the newborn within the family group. Whether the baby is the firstborn or the last born, all family members need to adjust their roles to accommodate the newcomer.

Becoming a Mother Rubin (1961) identified three phases as the mother adjusts to a parental role. These phases extend over the first several weeks and are characterized by dependent behaviour, dependent–independent behaviour, and interdependent behaviour (Table 23.4). Rubin’s research was conducted when the length of stay in the hospital was for a longer period of time (3 to 5 or more days). With today’s early discharge, mothers seem to move through the phases faster. Mercer (2004) has suggested that the concept of maternal-role attainment introduced by Rubin in 1967 be replaced with becoming a mother, to signify the transformation and growth of the mother identity. Becoming a mother implies more than attaining a role; it includes learning new skills and increasing one’s confidence as the mother meets new challenges in caring for their child or children. Mercer identified four stages in the process of becoming a mother (Mercer & Walker, 2006): 1. Commitment, attachment to the unborn baby, and preparation for birth and motherhood during pregnancy 2. Acquaintance/attachment to the newborn, learning to care for the newborn, and physical restoration during the first 2 to 6 weeks following birth 3. Moving toward a new normal 4. Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months) The time of achievement of the stages varies, and the stages may overlap. Achievement is influenced by mother and infant variables and the social environment. Maternal sensitivity or maternal responsiveness is an important determinant of the maternal–infant relationship. It can be defined as the quality of a mother’s sensitive behaviours that are based on the mother’s awareness, perception, and responsiveness to newborn cues and behaviours. Maternal sensitivity significantly influences the newborn’s physical, psychological, and cognitive development. Maternal

TABLE 23.4

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Phases of Maternal Postpartum

Adjustment Phase

Characteristics

Dependent: taking-in phase

First 24 hours (range of 1–2 days) Focus: self and meeting of basic needs • Reliance on others to meet needs for comfort, rest, closeness, and nourishment • Excited and talkative • Desire to review birth experience

Dependent–independent: taking-hold phase

Starts second or third day; lasts 10 days to several weeks Focus: care of newborn and competent mothering • Desire to take charge • Nurturing and acceptance by others still important • Eagerness to learn and practise—optimal period for teaching by nurses • Handling of physical discomforts and emotional changes • Possible experience with postpartum blues (see Chapter 22)

Interdependent: letting-go phase

Focus: forward movement of family as unit with interacting members • Reassertion of relationship with partner • Resumption of sexual intimacy • Resolution of individual roles

From Rubin, R. (1961). Basic maternal behavior. Nursing Outlook, 9, 683–686.

qualities inherent to this sensitivity include awareness and responsiveness to infant cues, affect, timing, flexibility, acceptance, and conflict negotiation and develop over time. Not all mothers experience the transition to motherhood in the same way. For some people, becoming a mother entails multiple losses. For example, for some single people there may be a loss of the family of origin when they do not accept the person’s decision to have the child. There may be loss of a relationship with the father of the baby, with friends, and with their own sense of self. Some mothers describe a loss of dreams, including loss of job, financial security, and a future profession. More reality-based perinatal education programs are needed, to better prepare mothers and to decrease their anxiety. Classes allow time for questions to be answered and for mothers to lend support to one another. These classes can be provided in person or online, through Skype, Zoom, or video chat. Mothers need to know during the first months of parenthood that it is common to feel overwhelmed and insecure and to experience physical and mental fatigue. They need to be assured that this situation is temporary and that 3 to 6 months may be needed to become comfortable in caregiving and in being a mother. Maternal support by professionals should not end with hospital discharge but extend over the next 4 to 6 months; long-term interventions tend to be more successful than one-time encounters. Nurses can advocate for the extension of such support services well into the postpartum period. Nurses can also advocate the use of doulas, who are laypersons who provide ongoing support to pregnant and postpartum patients. During pregnancy and after birth, nurses can discuss the usual postpartum concerns that mothers experience. They can provide anticipatory

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guidance on coping strategies, such as resting when the newborn sleeps and planning with an extended family member or friend to do the housework for the first week or two after the baby is born. In some provinces, once a mother is home, she will receive a phone call and, if needed, a visit from a community health nurse. Nurses should plan additional supportive counselling for first-time mothers inexperienced in child care, people whose careers had provided outside stimulation, mothers who lack friends or family members with whom to share delights and concerns, and adolescent mothers. Whenever possible, postpartum home visits should be included in the plan of care.

Becoming a Father The realities of the first few weeks at home with a newborn may cause fathers to change their expectations, set new priorities, and redefine their role. They develop strategies for balancing work, their own needs, and the needs of their partner and infant. Men usually become increasingly more comfortable with infant care. During this time, they may struggle for recognition and positive feedback from their partner, the infant, and others. They may feel excluded from support and attention by health care providers. The final phase of becoming an involved father is one of reaping rewards, the most significant being reciprocity from the infant, such as a smile. This phase typically occurs at around 6 weeks to 2 months. Increased sociability of the infant enhances the father–infant relationship (Table 23.5). First-time fathers tend to perceive the first 4 to 10 weeks of parenthood in much the same way that mothers do. It is a period characterized by uncertainty, increased responsibility, disruption of sleep, and inability to control the time needed to care for the infant and reestablish the relationship with their partner (Yu et al., 2012). Fathers express concerns about decreased attention from their partners relative to their personal relationship, the mother’s lack of recognition of the father’s desire to participate in decision making for the infant, and limited time for establishing a relationship with their infant (de Montigny et al., 2012). These concerns can precipitate feelings of jealousy of the infant. The father should discuss their individual concerns and needs with their partner and become more involved with the infant. This can help alleviate feelings of jealousy. Concerns of fathers are often not addressed adequately in prenatal or postnatal education. The father’s relationship with the child is fostered by time alone with the child. Health professionals need to address the father’s needs to assist in infant care in the father’s transition to

parenthood. An excellent resource for fathers is The New Fathers Guide, as well the Region of Peel Health Department’s website. The First Nations Health Authority (FNHA) in British Columbia provides another excellent option for fathers, called “Fatherhood is Forever.” FNHA also provides various information for women, men, children, and families (see Additional Resources).

Father–Infant Relationship. As in many other cultures, in North American culture, newborns have a powerful impact on their fathers, who can become intensely involved with their babies. More and more young mothers are in the workforce, and although mothers still provide the bulk of care for their young children, fathers are playing an expanded role, with 11% of stay-at-home parents being fathers (PHAC, 2017). The term used for the father’s absorption, preoccupation, and interest in the infant is engrossment. Characteristics of engrossment include some of the sensual responses relating to touch and eye-to-eye contact that were discussed earlier (see section The Senses) and the father’s keen awareness of features both unique and similar to himself that validate his claim to the newborn. An outstanding response is one of strong attraction to the newborn. Fathers spend considerable time “communicating” with the newborn and taking delight in the newborn’s responses to them (Figure 23.8). Fathers often experience increased self-esteem and a sense of pride and of being more mature after seeing their baby for the first time. Fathers receive less interpersonal and professional support than do mothers and can feel excluded from antenatal appointments and prenatal classes (Steen et al., 2012). They need information and encouragement during pregnancy and in the postnatal period related to infant care, parenting, and relationship changes. During the postpartum hospital stay, nurses can arrange to teach newborn care when the father is present and provide anticipatory guidance for fathers about the transition to parenthood. Mothers need to be made aware that fathers may take more time to learn certain skills and that this is normal; the father needs support and encouragement from the mother, not criticism. Separate prenatal and parenting classes and parenting support groups for fathers can provide them with an opportunity to discuss their concerns and have some of their needs met. To prepare fathers for the transition to parenthood, perinatal education should include information on role changes associated with parenting, the importance of parenting “teamwork,” the increased risk for mental distress and depression, the mother’s

TABLE 23.5

Early Development of the Involved Father Role Phase

Characteristics

Expectations and intentions

Desire for emotional involvement and deep connection with infant

Confronting reality

Dealing with unrealistic expectations, frustration, disappointment, feelings of guilt, helplessness, and inadequacy

Creating the role of involved father

Altering expectations, establishing new priorities, redefining role, negotiating changes with partner, learning to care for infant, increasing interaction with infant, struggling for recognition

Reaping rewards

Infant smile, sense of meaning, completeness and immortality

Data from Goodman, J. (2005). Becoming an involved father of an infant. Journal of Obstetrics, Gynecology, & Neonatal Nursing, 34(2), 190–200.

Fig. 23.8 Father interacts with his newborn son. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

CHAPTER 23 experience and how to provide support, how to interpret and respond to infant behaviours, and how to cope with infant crying (May & Fletcher, 2013). Postpartum phone calls and home visits by a nurse should include time for assessment of the father’s adjustment and needs.

Adjustment for the Couple The transition to parenthood brings about changes in the relationship between the mother and their partner. A strong, healthy couple relationship is the best foundation for parenthood, although even the best relationships are often shaken with the addition of a baby. During the first few weeks after birth, parents experience a plethora of emotions. Even though they may feel an overwhelming love and a sense of amazement toward their newborn, they also feel a great responsibility. Even if the mother and their partner have attended prenatal classes, read books, or sought advice from family or friends, they are usually surprised by the realities of life with a new baby and the changes in their relationship. Because men and women experience pregnancy and birth differently, the expectation is that they will also vary in their adjustment to parenthood. Common issues that couples face as they become parents include changes in their relationship with one another, division of household and infant care responsibilities, financial concerns, balancing work and parental responsibilities, and social activities. To assist new parents in their transition, nurses can encourage them during pregnancy and in the postpartum period to share personal expectations with each other and to assess their relationship periodically. Couples need to schedule time into their busy lives for one-on-one conversation and try to have regular “dates” or time apart from the infant. The mother and partner need to express appreciation for one another as well as for their baby. Support from family, friends, and community health professionals should be identified early and used as needed during pregnancy and in the postpartum period and beyond. The couple who is willing to experiment with new approaches to their lifestyle and habits may find the transition to parenthood less difficult. Nurses can provide opportunities for parents to discuss concerns and ask questions about resuming sexual intimacy. Sexual intimacy

A

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enhances the adult aspect of the family, and the adult pair share a closeness denied to other family members. Changes in a woman’s sexuality after childbirth are related to hormonal shifts, increased breast size, uneasiness with a body that has yet to return to a prepregnant size, fatigue related to sleep deprivation, and physical exhaustion. The resumption of sexual intimacy seems to bring the parents’ relationship back into focus (see Patient Teaching box: Resuming Sexual Activity After Birth, in Chapter 22). Before and after birth, nurses should review with new parents their plans for other pregnancies and their preferences for contraception.

INFANT–PARENT ADJUSTMENT Newborns participate actively in shaping their parents’ reaction to them. Behavioural characteristics of the infant influence parenting behaviours. The newborn and parent each have unique rhythms, behaviours, and response styles that are brought to every interaction. Infant–parent interactions can be facilitated in at least three ways: (1) modulation of rhythm, (2) modification of behavioural repertoires, and (3) mutual responsivity. Nurses can teach parents about these three aspects of infant–parent interaction through discussions, written materials, and video recordings describing infant capabilities. A creative approach is to record the parent–infant pair during an interaction and then use the individualized recording to discuss the pair’s rhythm, behavioural repertoire, and responsivity.

Rhythm To modulate rhythm, both parent and newborn must be able to interact. Therefore, the newborn must be in the quiet alert state, one of the most difficult of the sleep–wake states to maintain. The alert state (Figure 23.9) occurs most often during a feeding or in face-to-face play. The parent must make an effort to help the newborn maintain the alert state long enough and often enough for interactions to take place. The en face position is usually assumed (see Figure 23.9, B–E). Multiparous mothers in particular are very sensitive and responsive to the newborn’s

C

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F

Fig. 23.9 Holding newborn in en face position, a mother works to alert her daughter, 6 hours old. A: Infant is quiet and alert. B: Mother begins talking to daughter. C: Infant responds, opens mouth like her mother. D: Infant gazes at her mother. E: Infant waves hand. F: Infant glances away, resting. Hand relaxes. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

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feeding rhythms. Mothers learn to reserve stimulation for pauses in sucking activity and not to talk or smile excessively while the newborn is sucking because the baby will stop feeding to interact with the mother. With maturity, the infant can sustain longer interactions by modulating activity rhythms (i.e., limb movement, sucking, gaze alternation, and habituation). Meanwhile, the parent becomes more attuned to the infant’s rhythms and learns to modulate the rhythms, facilitating a rhythmic turn-taking interaction.

Behavioural Repertoires Both the newborn and the parent have a repertoire of behaviours they can use to facilitate interactions. Fathers and mothers engage in these behaviours, depending on the extent of their contact and caregiving with the newborn. Nurses can teach parents to recognize, interpret, and respond to newborn behaviours. An innovative program called HUG Your Baby (Help, Understanding and Guidance for Young Families) is designed to prepare health care providers to teach parents how to understand their newborns and prevent issues related to crying, sleeping, eating, attachment, and bonding (see Additional Resources and Chapter 26: Family-Centred Care box: Helping Parents Recognize, Interpret, and Respond to Newborn Behaviours). The infant’s behavioural repertoire includes gazing, vocalizing, and facial expressions. The newborn is able to focus and follow the human face from birth and to alternate the gaze voluntarily, looking away from the parent’s face when understimulated or overstimulated (see Figure 23.9, F). Parents need to learn to be sensitive to the newborn’s capacity for attention and inattention and to recognize the states and signs of overstimulation. Developing this sensitivity is especially important when interacting with preterm infants. Body gestures form a part of the infant’s early language. Babies greet parents with waving hands (see Figure 23.9, E) or a reaching out of hands. They can raise an eyebrow or soften their expression to elicit loving attention. Game playing can stimulate them to smile or laugh. Pouting or crying, arching of the back, and general squirming usually signal the end of an interaction. The parents’ repertoire includes various types of interactive behaviours, such as constantly looking at the infant and noting the infant’s response. New parents often remark that they are exhausted from looking at the baby and smiling. Adults also “infantilize” their speech to help the infant listen. They do this by slowing the tempo, speaking loudly and rhythmically, and emphasizing key words. Phrases are repeated frequently. Infantilizing does not mean using baby talk, which involves distortion of sounds. To communicate emotions to the infant, parents often use facial expressions such as slow and exaggerated looks of surprise, happiness, and confusion. Games such as “peek-a-boo” and imitation of the infant’s behaviours are other means of interaction. For example, if the baby smiles, so does the parent; if the baby frowns, the parent responds in kind.

Responsivity Contingent responses (responsivity) are those that occur within a specific time and are similar in form to a stimulus behaviour. The adult has the feeling of having an influence on the interaction. Infant behaviours such as smiling, cooing, and sustained eye contact, usually in en face position, are viewed as contingent responses. The infant’s responses act as rewards to the initiator and encourage the adult to continue with the game when the infant responds positively. When the adult imitates the infant, the infant appears to enjoy it. A progression occurs in the types of behaviours that parents present for the baby to imitate; for example, in early interactions the parent will grimace rather than laugh, which is in keeping with the infant’s developmental level. Such behaviours sustain interactions and promote harmony in the relationship.

SIBLING ADAPTATION Because the family is an interactive, open unit, the addition of a new family member affects everyone in the family. Siblings have to assume new positions within the family hierarchy. Parents often face the task of caring for a new child while not neglecting the others and need to distribute their attention equitably. When the newborn was born prematurely or has special needs, this can be difficult. Reactions of siblings result from temporary separation from the mother, changes in the mother’s or father’s behaviour, or the newborn coming home. Positive behavioural changes of siblings include interest in and concern for the baby and increased independence. Regression in toileting and sleep habits, aggression toward the baby, and increased seeking of attention and whining are examples of behaviours that are normal. Parents should be taught that punishing the child for these behaviours is not the best strategy, rather, diverting the child’s attention is often more effective. The parents’ attitudes toward the arrival of the baby can set the stage for the other children’s reactions. Because the baby absorbs the time and attention of the important people in the other children’s lives, jealousy (sibling rivalry) is to be expected once the initial excitement of having a new baby in the home is over. Parents, especially mothers, spend much time and energy promoting sibling acceptance of a new baby. If sibling preparation classes are available, participation in these classes can help prepare older children to understand what life may be like with a new baby and may make a difference in the ability of parents to cope with their behaviour. Older children are actively involved in preparing for the infant, and this involvement intensifies after the birth of the child. Parents have to manage their feelings of guilt that the older children are being deprived of parental time and attention. They have to monitor the behaviour of older children toward the more vulnerable infant and divert aggressive behaviour. Strategies that parents have used to facilitate siblings’ acceptance of a new baby are presented in the Patient Teaching box: Strategies for Facilitating Sibling Acceptance of a New Baby.

PATIENT TEACHING Strategies for Facilitating Sibling Acceptance of a New Baby Prenatal • Take your child on a prenatal visit. Let the child listen to the fetal heartbeat and feel the baby move. • Involve the child in preparations for the baby, such as helping decorate the baby’s room. • Move the child to a bed (if still sleeping in a crib) at least 2 months before the baby is due. • Read books, show videos or DVDs, and/or take your child to sibling preparation classes, including a hospital tour. • Answer your child’s questions about the coming birth, what babies are like, and any other questions. • Take your child to the homes of friends who have newborns so that the child has realistic expectations of what babies are like. During the Hospital Stay • Have someone bring the child to the hospital to visit you and the baby (unless you plan to have the child attend the birth). • When the child arrives, make sure your arms are open to embrace the child. • Do not force interactions between the child and the baby. Often the child will be more interested in seeing you and being reassured of your love.

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PATIENT TEACHING—CONT’D • Help the child explore the newborn by showing how and where to touch the baby. • Give the child a gift (from you or from you, the father or your partner, and baby). Going Home • Leave the child at home with a relative or babysitter or have someone such as the grandmother available to focus on the child during hospital discharge and on the trip home. • Have someone else carry the baby from the car so that you can hug the child first. Adjustment After the Baby Is Home • Arrange for a special time for the child to be alone with each parent. • Do not exclude the child during infant feeding times. The child can sit with you and the baby and feed a doll or drink juice or milk or sit quietly with a game. You can read aloud to the child while you are feeding the infant. • Prepare small gifts for the child so that when the baby gets gifts, the sibling will not feel left out. The child can also help open the baby gifts. • Praise the child for acting age appropriately (so that being a baby does not seem better than being older).

Siblings demonstrate acquaintance behaviours with the newborn. The acquaintance process depends on the information given to the child before the baby is born and on the child’s cognitive development level. The initial behaviours of siblings with the newborn include looking at the infant and touching the head. The adjustment of older children to a newborn takes time, and children should be allowed to interact at their own pace rather than being forced to interact. To expect a young child to accept and love a rival for the parents’ affection assumes an unrealistic level of maturity. The bond between siblings involves a secure base in which one child provides support for the other, is missed when absent, and is looked to for comfort and security.

GRANDPARENT ADAPTATION Becoming a grandparent is usually associated with great joy and happiness. Yet it is also a time of transition as roles and relationships are changing and new opportunities arise. Emotions are varied and can change from day to day; feelings of joy, anticipation, and excitement are often intermingled with some degree of anxiety and uncertainty. Circumstances surrounding the pregnancy and birth influence the feelings, reactions, and responses of grandparents. Pregnancy and birth necessitate redefining intergenerational roles and relationships within the family. A primary role of the grandparents is to support, nurture, and empower their child in their parenting role. Grandparents must acknowledge that things have changed since they first became parents as they deal with changes in practices and attitudes toward childbirth and child-rearing. The degree to which grandparents understand and accept current practices can influence how supportive they are to their adult children. At the same time that they are adjusting to grandparenthood, the majority of grandparents are experiencing normative middle- and old-age life transitions, such as retirement and a move to smaller housing, and they may need support from their adult children. Some may feel regret about their limited involvement because of poor health or geographic distance.

Fig. 23.10 Grandfather and new grandson get acquainted. (Courtesy William Perry.)

The extent of involvement of grandparents in the care of the newborn depends on many factors—for example, the willingness of the grandparents to become involved, the proximity of the grandparents, and ethnic and cultural expectations of their role (Figure 23.10). If the new parents live in Canada and the grandparents do not, they may be asked to come to Canada to care for the baby and mother after birth. Many Canadian-born paternal grandparents, in contrast to those in other cultures, consider themselves secondary to the maternal grandparents. Less seems expected of them and they are initially less involved. Nevertheless, these grandparents are often eager to help and express great pleasure in their son’s fatherhood and his involvement with the baby. Relationships between grandparents and parents may change with the birth of a new baby. For first-time parents, pregnancy and parenthood can reawaken old issues related to dependence versus independence. Couples often do not plan on their parents’ help immediately after the baby arrives. They want time “to be a family,” implying a couple–baby unit, not the intergenerational family network. Intergenerational help may be perceived as interference. Contrary to their expectations, however, most new parents do call on their parents for help, especially the maternal grandmother. Many grandparents are aware of their adult children’s wishes for autonomy, respect these wishes, and remain available to help, when asked. Grandparents’ classes can be used to bridge the generation gap and to help the grandparents understand their adult children’s parenting concepts. The classes include information on up-to-date childbearing practices; family-centred care; infant care, feeding, and safety (car seats); and exploration of roles that grandparents can play in the family unit (see Community Focus box: Helping Grandparents Bridge the Generation Gap). Increasing numbers of grandparents are providing permanent care to their grandchildren as a result of divorce, substance use, child abuse or neglect, abandonment, teenage pregnancy, death, incarceration, and mental health challenges. Educational and financial considerations must be addressed and available support systems identified for these families.

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COMMUNITY FOCUS Helping Grandparents Bridge the Generation Gap Interview a grandfather and grandmother about their experiences with childbirth and infant care. The purpose is to understand grandparents’ experiences and perspectives. Ask them how they feel about their new roles; their description of their involvement in helping their son or daughter with a new baby; their description of how they view rewards and challenges of being a grandparent; and what they would like their grandchild to call them. Students can discuss findings in clinical conference and learn from one another about the various perspectives of being a grandparent.

DIVERSITY IN TRANSITIONS TO PARENTHOOD Various factors, including age, social networks, socioeconomic conditions, and personal aspirations for the future, influence how parents respond to the birth of a child. Cultural beliefs and practices also affect parenting behaviours. Factors that influence the risk for various parenting issues include age (adolescent or older than 35 years of age), samesex parenting, social support, culture, socioeconomic conditions, and personal aspirations.

Age Maternal age has a definite effect on the outcome of pregnancy. The mother and fetus are at highest risk when the mother is an adolescent or is more than 35 years old (see Clinical Reasoning Case Study: Postpartum Adjustment for the Adolescent and the Older Mother). ?

CLINICAL REASONING CASE STUDY

Postpartum Adjustment for the Adolescent and the Older Mother You are a community health nurse and have had two patients referred to you. Carol is a 15-year-old first-time mother of a 5-day-old girl; she lives with her mother. The father of the baby, Robert, is 17 years old and attended childbirth education classes with Carol. She is breastfeeding the baby but says that the baby sucks too slowly and takes too much time to eat. She says she thinks the baby should know enough to sleep longer at night. Robert would like to feed the baby some cereal since he heard that solid food will make a baby sleep longer at night. Audrey is a 36-year-old lawyer who has been practising law for 7 years. She just gave birth to her first baby; she and her husband delayed parenting by choice until their careers were well established. She had an uneventful pregnancy, labour, and birth. During a telephone call 48 hours after discharge, when she was asked how things were going, Audrey burst into tears and said, “I didn’t expect it to be like this! Nothing is going right.” Questions 1. Evidence—Is there sufficient evidence to draw conclusions about both Carol’s condition and Audrey’s condition? 2. Assumptions—What assumptions can be made about the following? a. The relationship of maternal age and postpartum adjustment b. The need for social support in the postnatal period c. The need for perinatal education d. Long-term prognosis for positive outcomes 3. What is the nursing priority in these two situations? 4. Interprofessional care—Describe roles and responsibilities of other health care providers who would potentially be involved in the care of both of these patients.

The Adolescent Mother. Although becoming a parent is biologically possible for the adolescent, their egocentricity and concrete thinking may interfere with their ability to parent effectively. In a study of Ontario adolescent births it was shown that, compared with adults, adolescents have improved outcomes such as lower rates of gestational hypertension, gestational diabetes, antepartum hemorrhage, and operative births. However, adolescents also have higher sociodemographic risk factors and seek prenatal care later than adults. These risk factors, in combination with young age, lead to other important maternal, obstetrical, and newborn adverse outcomes (Fleming et al., 2013). These outcomes can be influenced by the mother’s inexperience, lack of knowledge, and immaturity. Nevertheless, in most instances, with adequate support and developmentally appropriate teaching, adolescents can learn effective parenting skills. Strong social and functional support promotes positive outcomes for adolescent mothers. Contrary to popular beliefs regarding the detrimental effects of adolescent pregnancy, research evidence suggests that the life course for adolescent mothers is similar to that of their socioeconomic peers. In some families or communities, adolescent parenthood is considered a normal or positive life event. Even so, adolescent pregnancy and parenting are important public health concerns. The transition to parenthood can be difficult for adolescent parents. Because many adolescents have their own unmet developmental needs, coping with the developmental tasks of parenthood is often difficult. Some young parents experience difficulty accepting a changing selfimage and adjusting to new roles related to the responsibilities of infant care. Adolescent mothers are at increased risk for postpartum mood disorders; this is often associated with a lack of social support and poor relations with their partner (Jeha et al., 2015). As adolescent parents move through the transition to parenthood, they may feel “different” from their peers, excluded from “fun” activities, and prematurely forced to enter an adult social role. The conflict between their own desires and the infant’s demands, in addition to the low tolerance for frustration that is typical of adolescence, further contribute to the normal psychosocial stress of childbirth and parenting. Maintaining a relationship with the baby’s father is beneficial for the teen mother and their infant, although adolescent pregnancy often heralds the departure of the young father from the relationship. Adolescent mothers provide warm and attentive physical care; however, they use less verbal interaction than older parents, and adolescents tend to be less responsive to and interact less positively with their infants than older mothers. Interventions emphasizing verbal and nonverbal communication skills between mother and infant are important. Such strategies must be concrete and specific to match the cognitive level of adolescents. In comparison with adult mothers, teenage mothers have a limited knowledge of child development. They tend to expect too much of their children too soon and often characterize their infants as being fussy. This limited knowledge may cause teenagers to respond to their infants inappropriately. Many young mothers pattern their maternal role on what they themselves experienced. Therefore, nurses need to determine the kind of support that people close to the young mother are able and prepared to give, as well as the kinds of community assistance available to supplement this support. Many teen mothers can identify a source of social support, the predominant source being their own mothers. Continued assessment of the new mother’s parenting abilities during this postbirth period is essential. Continued support should be provided by involving grandparents and other family members and through home visits and group sessions for discussion of infant care and parenting concerns. Community-based programs for pregnant adolescents and adolescent parents improve access to health care, education, and other support services. Outreach programs addressing

CHAPTER 23 self-management, parent–child interactions, and child injuries, in addition to programs that provide prompt and effective community intervention, can prevent serious issues from occurring. As the adolescent performs their mothering role within the framework of the family, they may need to address dependence and independence issues. The adolescent’s family members also may need help adapting to their new roles.

The Adolescent Father. The adolescent father and mother face immediate developmental crises, which include completing the developmental tasks of adolescence, making a transition to parenthood, and sometimes adapting to marriage. These transitions can be stressful. The nurse can initiate interaction with the adolescent father if he is present during prenatal visits or if he is with his partner during labour and birth. The nurse can assess the relationship between the two adolescents and encourage them to discuss their plans for the father’s involvement with the mother and infant after birth (Fagan, 2013). During the hospital stay, the nurse can include the adolescent father in teaching sessions about newborn care and parenting. The nurse can ask him to be present during postpartum home visits and to accompany the mother and baby to well-baby checkups at the clinic or health care provider’s office. With the adolescent mother’s agreement, the nurse may contact the father directly. Adolescent fathers need support to discuss their emotional responses to the pregnancy, birth, and fatherhood. The nurse needs to be aware of the father’s feelings of guilt, powerlessness, or bravado because these feelings may have negative consequences for both the parents and the child. Counselling of adolescent fathers needs to be reality oriented and should include topics such as finances, child care, parenting skills, and the father’s role in the birth experience. Teenage fathers also need to know about reproductive physiology, birth control options, as well as sex practices that lower the risk for pregnancy and sexually transmitted infections. The adolescent father may or may not continue to be involved in an ongoing relationship with the young mother and his baby. If he does, he can play an important role in the decisions about child care and raising the child. He may need help in developing realistic perceptions of his role as “father to a child” and should be encouraged to use coping mechanisms that are not harmful to his own, his partner’s, or his child’s well-being. The nurse can enlist support systems, parents, and professional agencies on his behalf. Maternal Age Greater Than 35 Years. Women older than 35 years of age continue their childbearing either by choice or because of a lack or failure of contraception during the perimenopausal years. Added to this group are women who have postponed pregnancy because of careers or for other reasons, as well as women of infertile couples who finally become pregnant with the aid of reproductive technology. Support from partners aids in the adjustment of older mothers to changes involved in becoming a parent and seeing themselves as competent. Support from other family members and friends is also important for positive self-evaluation of parenting, a sense of well-being and satisfaction, and help in dealing with stress. Women who are older can experience social isolation. Older mothers may have less family and social support than that of younger mothers. They are less likely to live near family, and their own parents, if still living, may be unable to provide assistance or support because of age or health issues. These mothers are often caught in the “sandwich generation,” taking on responsibility for care of aging parents while parenting young children. Social support may be lacking because their peers are busy with their careers and have limited time to help. Their friends are likely to have older children and have less in common with the new mother.

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Changes in the sexual aspect of a relationship can create a stressor for new midlife parents. Mothers report that it is difficult to find time and energy for any romance. They attribute much of this difficulty to the reality of caring for an infant, but the decreasing libido that normally accompanies getting older is also a factor. Work and career issues tend to be sources of conflict for older mothers. Conflicts emerge over being disinterested in work, worrying about giving enough attention to work with the distractions of a baby, and anticipating what it will be like to return to work. Child care is a major factor in causing stress about work. Another major issue for older mothers with careers is the perception of loss of control. Mothers older than 35 are at a different stage in their careers than younger mothers, often having attained high levels of education, career, and income. The loss of control experienced when going from the consistency of a work role to the inconsistency of the parent role comes as a surprise to many. Helping the older mother have realistic expectations of herself and parenthood is essential. New mothers who are also perimenopausal may have difficulty understanding that fatigue, loss of sleep, decreased libido, or other physiological symptoms are the causes of the change in their sex drive. Although many women view menopause as a natural stage of life, for midlife mothers this cessation of menstruation coincides with the state of parenthood. The changes of midlife and menopause can add more emotional and physical stress to older mothers’ lives because of the time- and energy-consuming aspects of raising a young child.

Paternal Age Greater Than 35 Years. Although many older fathers describe their experience of midlife parenting as wonderful, they also recognize the drawbacks. Positive aspects of parenthood in older years include increased love and commitment between the two parents, a reinforcement of why one committed to a relationship in the first place, a feeling of being complete, experiencing “the child” in oneself again, more financial stability than in younger years, and more freedom to focus on parenting rather than on career. Drawbacks of midlife parenting include having a young child and not being physically fit to participate in activities, being much older than other fathers, and the change it makes in the relationship with their partner.

Parenting Among LGBTQ2 Couples Although same-sex marriage has been legal in Canada since 2003, the transition to parenting for same-sex couples can still present unique challenges. Whether the couple consists of two women (Figure 23.11), two men, or a parent who is transgender, issues such as lack of family acceptance and support, public ignorance, and social invisibility can influence their ability to adapt as new parents. The health care environment is heteronormative; for example, most educational materials for new parents include information for mothers and fathers, and photos depict the traditional heterosexual couple. Attitudes of health care providers can affect the care provided to same-sex couples either positively or negatively. The decision for lesbian couples to conceive is intentional. Factors that influence the decision include the age, health, infertility, and career considerations of each partner. Several pathways are available for two women in a lesbian relationship who wish to become parents. The couple may decide for one of the women to conceive a child who is genetically related to her; this is usually done through donor insemination. Alternatively, the fertilized egg of one partner can be implanted into the uterus of the other partner, who carries the pregnancy. In some cases, a woman is implanted with the fertilized egg from a donor so the child is not biologically related to either partner. Another option is for a lesbian couple to adopt an infant born to a surrogate mother. They can also

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Fig. 23.11 Lesbian couple welcoming a new member of the family. (Courtesy Elliana Gilbert Photography.)

choose to adopt an infant through an adoption agency or by private arrangement. Health care providers have demonstrated a variety of reactions to lesbian couples, ranging from rejection and exclusion to complete acceptance and inclusion. Some couples attempt to hide their relationship because they fear a homophobic response. Judgemental attitudes, confusion, or lack of understanding can affect the quality of care provided to these families (Dahl et al., 2013). Although the traditional roles of the mother and father in heterosexual relationships are well recognized, the role of the lesbian non-birth parent can be questioned, misunderstood, and ignored by society and by health care providers. Intentionally or accidentally, health care providers may exclude partners or fail to acknowledge their roles in pregnancy, birth, and parenting. Integration of the non-birth parent into care includes offering opportunities afforded male partners of heterosexual women, such as cutting the cord and rooming in with the mother and baby during hospitalization. An option not available to male partners is to actually breastfeed the infant. The non-birth female partner can stimulate milk production through induced lactation using medications and regular pumping. A supplemental feeding device containing expressed breast milk or formula can be used to provide additional milk to the breastfeeding infant. Women who choose not to induce lactation yet desire to have the breastfeeding experience can put the baby to breast using a supplemental feeding device containing formula or expressed breast milk (Wambach & Spencer, 2021). Similar to heterosexual parents, lesbian couples face challenges in adjusting to life with a new baby. After birth, the birth mother tends to be the one most responsible for child care because she is likely to be working fewer hours than her partner. As in heterosexual relationships, tensions can arise between the partners in relation to their roles. This can be compounded by the lack of a formal, recognized relationship between the non-birth parent and the infant and issues surrounding her legal rights in relation to her partner and the infant (Abelsohn et al., 2013). Men in same-sex relationships, or gay couples, can become parents by adoption or by impregnating a surrogate by artificial insemination or sexual intercourse. Same-sex male couples face the same social sanctions regarding pregnancy and parenting that lesbian couples

encounter. Both lesbian and gay couples may have children from previous heterosexual relationships. Nurses are likely to encounter gay couples in the hospital setting if they are present for birth by a surrogate or if they are adopting a newborn and visit the hospital to spend time with the newborn and learn about newborn care. Nurses can help these men locate support groups that will address their needs. They need to ensure that these families receive effective health care. Data on gay and lesbian parenting are limited and focus more on developmental outcomes of the children than on parenting styles or parental caregiving. Research is needed to identify the needs of gay and lesbian parents and ways to support them in their parenting. People who are transgender may also decide to become pregnant. Transmasculine individuals are people who were assigned as female at birth, but identify on the male side of the gender spectrum and as such may choose to use and engage their bodies to become pregnant, birth a baby, and chestfeed (MacDonald et al., 2016). Gendering has the potential to impact caregiving and infant feeding practices for lesbian, gay, bisexual, transgender, queer, intersex, or two-spirited (LGBTQ2) parents; all families require respectful, supportive care and the appropriate space to feel comfortable (Wambach & Spencer, 2021). A recent case report describes a transgender woman who was able to breastfeed their baby along with supplementation after taking feminizing hormone for several years, followed by a lactation-inducing medication regimen (Reisman & Goldstein, 2018). Non-birth parents deserve to have their unique experiences validated and celebrated in their personal relationships and social networks, through accessible and appropriate resources that address their health and wellness needs, and through policies that respect the creation of their families and facilitate a supportive legal environment in which to do so (Abelsohn et al., 2013). In situations in which family support is limited or absent, the nurse can help LGBTQ2S couples locate supportive social groups.

Social Support Social support is strongly related to positive adaptation by new parents, especially adolescent parents, during the transition to parenthood. Social support is multidimensional and includes the number of members in a person’s social network, the types of support, perceived general support, actual support received, and satisfaction with support available and received. Partner support in pregnancy can decrease emotional distress in the postpartum period (Stapleton et al., 2012). The type and satisfaction of support appear to be more important than the total number of support network members. Across cultural groups, families and friends of new parents form an important dimension of the parents’ social network. Through seeking help within the social network, new mothers learn culturally valued practices and develop competency in their role as mother. While social networks provide a support system on which parents can rely for assistance, they also can be a source of conflict. Sometimes a large network can cause difficulties because it results in conflicting advice coming from numerous people. Grandparents or inlaws are most appreciated when they assist with household responsibilities and do not intrude on the parents’ privacy or judge them critically. Because of the extent of restructuring and reorganization that occurs in a family with the birth of a child, the mother’s moods and fatigue in the postpartum period can be helped more by situation-specific support from family and friends than by general support. General support addresses feeling loved, respected, and

CHAPTER 23 valued. Situation-specific support relates to practical concerns, such as physical needs and child care. For example, the practical support of a grandparent bathing the infant can help lessen a second-time mother’s feelings of loss by providing her time to be with her firstborn child.

Culture Cultural beliefs and practices are important determinants of health for the mother and infant and also influence parenting behaviours. Culture influences interactions with the baby and the parents’ or family’s caregiving style. For example, providing for a period of rest and recuperation for the mother after birth is prominent in several cultures. Asian mothers are encouraged to remain at home with the baby up to 30 days after birth and are not supposed to engage in household chores, including care of the baby. Often, the grandmother takes over the newborn’s care immediately, even before discharge from the hospital. Jordanian mothers may have a 40-day lying-in after birth, during which their mothers or sisters care for the newborn. Japanese mothers rest for the first 2 months after childbirth. Latin Americans may practise an intergenerational family ritual, la cuarentena: for 40 days after birth, the mother is expected to recuperate and get acquainted with their newborn. Traditionally, this involves many restrictions concerning food, exercise, and activities, including sexual intercourse. All cultures place importance on desiring and valuing children. In many families, children are a source of family strength and stability, are perceived as wealth, and are objects of parental love and affection. Knowledge of cultural beliefs can help the nurse make more accurate assessments and diagnoses of observed parenting behaviours. For example, nurses may become concerned when they observe cultural practices that appear to reflect poor maternal–infant bonding. Algerian mothers may not unwrap and explore their newborns as part of the acquaintance process because in Algeria babies are wrapped tightly in swaddling clothes to protect them physically and psychologically (D’Avanzo, 2008). A Vietnamese woman may give minimal care to her newborn and refuse to cuddle or further interact with her baby. This apparent lack of interest in the newborn is this cultural group’s attempt to ward off evil spirits and actually reflects an intense love and concern for the child (Galanti, 2015). An Asian mother might be criticized for almost immediately relinquishing the care of the newborn to the grandmother and not attempting to hold her baby when it is brought to her room; in Asian extended families, members show their support for a new mother’s need for rest and recuperation by assisting with the care of the baby. Contrary to the guidance given to new mothers in Canada to watch for breastfeeding difficulties when using a mix of breastfeeding and bottle-feeding initially, this mix of feeding is standard practice for Japanese mothers. This tradition is related to concern for the mother’s rest during the first 2 to 3 months and does not usually lead to any issues with lactation; breastfeeding is widespread and successful among Japanese women. Cultural beliefs and values give perspective to the meaning of childbirth for a new mother. Nurses can provide an opportunity for a new mother to talk about their perception of the meaning of childbearing. In helping new families adjust to parenthood, nurses must provide culturally competent care by following principles that facilitate nursing practice within transcultural situations. At the same time, because not all members of a cultural group adhere to traditional practices, nurses need to validate which cultural practices are important to individual parents.

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CULTURAL AWARENESS Fostering Bonding: Women of Varying Ethnic and Cultural Groups Canadian women, families, and health care workers are influenced by their various cultures, socioeconomic backgrounds, and ethnicities. Childbearing practices and rituals may be incongruent with Anglo-Canadian standards but that does not mean they are incorrect and should not be used. New mothers from China as well as from India and Thailand may practice a 40-day “confinement” period after giving birth, often called “doing the month.” During this time, extended family members help provide care for the newborn so the mother can rest and recover. Some Asian and Latin American women do not initiate breastfeeding until their breast milk comes in. Indigenous persons may consciously place long silences in conversation for reflection and engage in minimal eye contact. It would be easy for Anglo-Canadian health care workers to perceive this behaviour as disrespect and indifference. Nurses must become knowledgeable about childbearing beliefs and practices of diverse cultural and ethnic groups. They must also develop cultural sensitivity and use relevant cultural resources to promote cultural safety (see Chapter 2). Because individual cultural variations exist within groups, nurses need to clarify with the patient and family members or friends the cultural norms that the patient follows. Incorrect judgements may be made about mother–infant bonding if nurses do not practise culturally sensitive care. Adapted from D’Avanzo, C. (2008). Mosby’s pocket guide to cultural health assessment (4th ed.). Mosby; Registered Nurses’ Association of Ontario. (2007). Embracing cultural diversity in health care: Developing cultural competence. http://rnao.ca/bpg/guidelines/embracing-culturaldiversity-health-care-developing-cultural-competence; Srivastava, R. H. (2007). The healthcare professional’s guide to cultural competence. Elsevier Canada.

Indigenous Families Given the legacy of residential schools in the Indigenous community, there continue to be parents who have difficulty being effective parents to their children (see Chapter 1, Indigenous People). One of the greatest impacts of residential schools is the breakdown of family relationships, as families were separated for months or years. Children were deprived of the positive family environment necessary for the transmission of parenting knowledge and skills. Survivors describe being removed from loving families into situations that were deplorable and “loveless” (Truth and Reconciliation Commission, 2012). The impact of this institutionalization and separation continues to be seen to this day and is evidenced in high rates of child apprehensions by social services and Indigenous youth involvement in crime. The Truth and Reconciliation Commission (TRC) (2015) has recommended that families not be separated, if possible, and that adequate housing, addiction resources, and educational supports for parents be provided to help overcome some of the negative impact of residential schools. Nurses should be aware of the potential impact of residential schools on any Indigenous family and be able to incorporate this knowledge into the care provided. Nurses can also work with partner groups to develop culturally appropriate early childhood and parent programs that assist young parents and families affected by the impact of residential schools and historical policies of cultural oppression in the development of parental understanding and skills (TRC, 2015). See Additional Resources at the end of the chapter for resources for caring Indigenous families.

Socioeconomic Conditions Socioeconomic conditions, a key determinant of health, often determine access to available resources. Parents who have low socioeconomic status

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may find childbirth complicated by concern for their own health and a sense of helplessness. Serious financial concerns may override any desire for mothering the infant. Similarly, fathers who are overwhelmed with financial stresses may lack effective parenting skills and behaviours. Families who have limited access to social support and financial resources may require extra education and support to access necessary supports.

Personal Aspirations For some people, parenthood may interfere with their plans for personal freedom or advancement in their careers. Unresolved resentment can affect caregiving activities and adjustment to parenting. This situation may result in indifference and neglect of the infant or in excessive concerns; the mother may set impossibly high standards for their own behaviour or the child’s performance. Nursing interventions include providing opportunities for mothers to express their feelings freely to an objective listener, discuss measures to enable personal growth, and learn about the care of their infant. Referring the woman to a support group of other mothers who are in similar circumstances may also be helpful. Nurses also can be proactive in influencing changes in work policies related to work sharing and to promoting family-friendly work environments. Some corporations already structure their workplace to support new mothers (e.g., by providing on-site day care facilities and lactation rooms).

PARENTAL SENSORY IMPAIRMENT In the early interactions between parent and newborn, each uses all senses—sight, hearing, touch, taste, and smell—to initiate and sustain the attachment process. A parent who has an impairment of one of the senses needs to maximize use of the remaining senses. Parents with disabilities tend to value performing parenting tasks in a way perceived as culturally normative. It is important for nurses and other health care providers to remember that these individuals are parents living with a disability; they are not disabled parents. Most provinces now have legislation to ensure that people with disabilities have access to required resources.

Visually Impaired Parent Visual impairment alone does not appear to have a negative effect on parents’ early parenting experiences. These parents, just as sighted parents, express the wonders of parenthood, and they encourage other visually impaired persons to become parents. Although visually impaired mothers initially feel pressure to conform to traditional, sighted ways of parenting, they soon adapt these ways and develop methods better suited to themselves. For example, visually impaired parents may prepare the infant’s nursery, clothes, and supplies in a way that is different from a sighted person’s routine.

BOX 23.2

Some parents put an entire clothing outfit together and hang it in the closet rather than keeping the items separate in drawers. Some develop a labelling system for the infant’s clothing and put diapering, bathing, and other care supplies where these will be easy to locate. A strength that visually impaired parents have is a heightened sensitivity to other sensory outputs. A visually impaired parent can tell when their infant is facing them because they can feel the baby’s breath on the face. One of the major difficulties that visually impaired parents experience is the skepticism, open or hidden, of health care providers. Visually impaired people may sense reluctance on the part of others to acknowledge that they have a right to be parents. All too often, health care providers lack the experience to deal with the childbearing and child-rearing needs of visually impaired parents and those of parents with other disabilities (such as the hearing impaired, physically impaired, and mentally challenged). The nurse’s best approach here is to assess the parent’s capabilities. From that basis the nurse can make plans to assist the parent, often in much the same way as for a parent with sight. Visually impaired mothers have made suggestions for providing care to persons such as themselves during childbearing (Box 23.2). The nurse can use such approaches to help a parent avoid feeling increased vulnerability. Eye contact with others is considered important in North American culture. With a parent who is visually impaired, this critical factor in the parent–child attachment process is obviously missing. However, the visually impaired parent who may never have experienced this method of strengthening relationships does not miss it. The infant will need other sensory input from that parent. An infant looking into the eyes of a mother who is visually impaired may not be aware that the eyes are unseeing. Other people in the newborn’s environment can participate in active eye-to-eye contact to supply this need. A difficulty may arise, however, if the visually impaired parent has an impassive facial expression. The infant, making repeated unsuccessful attempts to engage in face play with the mother, will abandon the behaviour with them and intensify it with the father or other persons in the household. Nurses can provide anticipatory guidance regarding this situation and help the mother learn to nod and smile while talking and cooing to the infant.

Hearing-Impaired Parent A parent with a hearing impairment faces challenges in caregiving and parenting, particularly if the deafness dates from birth or early childhood. Whether one or both parents are hearing impaired, they are likely to have established an independent household. Devices that transform sound into light flashes can be fitted into the infant’s room to enable immediate detection of crying. Even if the parent is not speech trained, vocalizing can serve as both a stimulus and a response to the infant’s early vocalizing. Deaf parents can provide additional

Nursing Approaches for Working With Parents With a Visual Impairment

• Parents who are visually impaired need oral teaching by health care providers because pregnancy and childbirth information is usually not accessible to visually impaired people. • A visually impaired parent needs an orientation to the hospital room that enables the parent to move about the room independently; for example, “Go to the left of the bed and trail the wall until you feel the first door. That is the bathroom.” • Parents who are visually impaired need explanations of routines.

• Parents who are visually impaired need to feel devices (e.g., portable sitz bath equipment, breast pump) and to hear descriptions of the devices. • Visually impaired parents need a chance to ask questions. • Visually impaired parents need the opportunity to hold and touch the newborn after birth. • Nurses need to demonstrate newborn care by touch and to follow with “Now show me how you would do it.” • Nurses need to give instructions, such as “I’m going to give you the baby. The head is to your left side.”

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BOX 23.3

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Nursing Approaches for Working With Parents with a Hearing Impairment

• Before initiating communication, be aware of the parents’ preferences and capabilities: Do they wear a hearing aid? Do they read lips? Do they wish to have an interpreter? • Make certain that the parent(s) sees you approaching to avoid startling the parent. • Before speaking, be directly in front of the parent and have that person’s full attention. • When speaking, face the parent directly and be at the same level. • Avoid standing in front of a light or a window while speaking to the parent. • Keep your hands away from your face while speaking, to minimize distractions. • If the parent relies on lip-reading, sit close enough so that the parent can easily see your lip movements. • Speak clearly with a regular voice volume and lip movements, while maintaining eye contact. • Speak in short, simple sentences to facilitate understanding.

vocal training by use of recordings and television so that from birth the child is aware of the full range of the human voice. Young children acquire sign language readily, and the first sign used is as varied as the first word. Hospitals and other institutions use various communication techniques and resources with the hearing-impaired, including having staff members or certified interpreters who are proficient in sign language. For example, providing written materials with demonstrations and having nurses stand where the parent can read their lips (if the parent practises lip-reading) are two techniques that can be used. A creative approach is for the nursing unit to develop movies in which information on postpartum care, newborn care, and parenting issues is signed by an interpreter and spoken by a nurse or that has closed-captioning. Many resources are available to the deaf parent via the Internet (see Additional Resources at the end of the chapter). Box 23.3 lists suggestions for working with hearingimpaired parents.

NURSING CARE Numerous changes occur during the first weeks of parenthood. Nursing care should be directed toward helping parents cope with newborn care, role changes, altered lifestyle, and change in family structure resulting from the addition of a new baby. Developing skill and confidence in caring for a newborn can be anxiety provoking. Anticipatory guidance can help prevent or minimize parents’ shock of reality in the transition from the hospital or birthing centre to home that might negate the parents’ joy or cause them undue stress. Key messages for families should be individualized, family-centred information that is relevant for each unique family situation and context. All children deserve the best possible start in life, and a child’s early years from before birth to age 6 years are very important to their healthy development and long-term health. This is a time in life when children’s brains and bodies are developing at a rapid pace. Healthy babies are more likely to continue to be healthy through their childhood, teen, and adult years (see Patient Teaching Box: Key Messages for Parents).

• If the parent does not understand something, it is better to find a different way to say what needs to be communicated rather than repeating the same words over and over. • Written messages aid in communication. A small white or black erasable board can be useful. • Give educational materials to parents with a hearing impairment and ask them to read the materials before doing parent teaching. They can refer to the materials after discharge. • Use visual aids such as pictures, diagrams, or other devices when doing parent teaching. • When doing parent teaching, it is helpful for a hearing person (partner or family member) to be present. • Allow ample time to communicate with the parent with a hearing impairment; being in a rush can evoke stress and create barriers to effective communication.

PATIENT TEACHING Key Messages for Parents Teach Parents About the Following Key Messages: Your baby is constantly learning about you and the world around them, and you are your baby’s best teacher. How you care for and talk and play with your infant will influence how your child learns and grows. Here are some suggestions to help you enjoy your time with your new baby in the first year: • Babies love to be held. Take time to cuddle and hold your child. • Comfort your baby when they cry. • Learn your baby’s cues—when they are hungry or sleepy or want to play with you. • Breast milk provides all the nutrition your baby needs for the first 6 months. Feeding can be a special way to feel close to your baby. • Speak in a soft, gentle voice to your baby. • Talk to your baby and tell them about the things that are around them. The way you talk to, play with, teach, and love your child will help them grow and learn. • Help your child explore safely. Share different textures, colours, sounds, and smells. • Share picture books and read simple stories, including in your first language. This is also an opportunity to cuddle with your child. • Babies learn naturally through play. Have fun and play with your child, sing to them, play music, and dance with your child. • Taking care of yourself is important too! Ask a trusted friend or family member to watch your baby so you can take a break. Source: Ontario Ministry of Children, Community and Social Services. (2014). Tips for new parents: Making the best of the early years. http:// www.children.gov.on.ca/htdocs/English/documents/earlychildhood/tips/ Tips-EN.pdf

Through education, support, and encouragement, nurses can be instrumental in assisting mothers and their partners in the transition to parenthood, whether they are first-time parents or parents of several other children. Early and ongoing assessment and intervention promote positive outcomes for parents, infants, and family members

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(see Community Focus box: Identifying Parenting Resources on the Web). (See also Nursing Care Plan: Home Care Follow-up: Transition to Parenthood, available on Evolve.)

COMMUNITY FOCUS Identifying Parenting Resources on the Web • Visit the website of a hospital that provides maternity services in your community. Does the hospital offer childbirth education, parenting, sibling, or infant/child cardiopulmonary resuscitation (CPR) classes? Are group tours of the birthing centre provided for expectant parents? • Visit a local health department website. Look for information for parents about pregnancy, parenting, and children’s health. Review the information about postpartum emotional health, causes and treatments of baby blues, and baby blues versus postpartum mood disorder. Is there adequate information there for new families? • Research the availability of support groups for parents in your community.

KEY POINTS • The birth of a child necessitates changes in the existing interactional structure of a family. • Attachment is the process by which the parent and infant come to love and accept each other. • Attachment is strengthened through the use of sensual responses or interactions by both partners in the parent–infant interaction. • A person goes through stages in becoming a mother. • Fathers and non-birth parents experience emotions and adjustments during the transition to parenthood that are similar to and also distinctly different from those of mothers. • Modulation of rhythm, modification of behavioural repertoires, and mutual responsivity facilitate infant–parent adjustment. • Sibling adjustments to a new baby require creative parental interventions. • Grandparents can have a positive influence on the postpartum family. • LGBTQ2 families require respectful support when becoming parents, as they may face different challenges, including legal aspects of parenting. • Many factors (e.g., age, culture, socioeconomic level, and expectations of what the child will be like) influence adaptation to parenthood.

REFERENCES Abelsohn, K. A., Epstein, R., & Ross, L. E. (2013). Celebrating the “other” parent: Mental health and wellness of expecting lesbian, bisexual, and queer nonbirth parents. Journal of Gay & Lesbian Mental Health, 17(4), 387–405. https://doi.org/10.1080/19359705.2013.771808. Berger, A. S. (2012). The evil eye—An ancient superstition. Journal of Religion and Health, 51(4), 1098–1103. Bowlby, J. (1969). Attachment and loss. (OKS Print.). Basic Books. Breastfeeding Committee for Canada (BCC). (2021). Baby friendly implementation guideline. https://breastfeedingcanada.ca/wp-content/ uploads/2021/02/BFI-Implementation-Guideline-final-draft-Feb-8-2021. pdf. Center on the Developing Child, Harvard University. (2020). Serve and return. https://developingchild.harvard.edu/science/key-concepts/serve-and-return/. Dahl, B., Fylkesnes, A. M., Sorlie, V., et al. (2013). Lesbian women’s experiences with healthcare providers in the birthing context: A meta-ethnography. Midwifery, 29(6), 674–681.

D’Avanzo, C. (2008). Mosby’s pocket guide to cultural health assessment (4th ed.). Mosby. de Montigny, F., Lacharite, C., & Devault, A. (2012). Transition to fatherhood: Modeling the experience of fathers of breastfed infants. Advances in Nursing Science, 35(3), E11–E22. Fagan, J. (2013). Adolescent parents’ partner conflict and parenting alliance, fathers’ prenatal involvement, and fathers’ engagement with infants. Journal of Family Issues, 35(11), 1415–1439. Flacking, R., Lehtonen, L., Thomson, G., et al. (2012). Closeness and separation in neonatal intensive care. Acta Paediatrica, 101(10), 1032–1037. Fleming, N., Ng, N., Osborne, C., et al. (2013). Adolescent pregnancy outcomes in the province of Ontario: A cohort study. Journal of Obstetrics and Gynaecology Canada, 35(3), 234–245. https://doi.org/10.1016/S1701-2163 (15)30995-6. Galanti, G. (2015). Caring for patients from different cultures (5th ed.). University of Pennsylvania Press. Hoffenkamp, H. N., Tooten, A., Hall, R. A., et al. (2012). The impact of premature childbirth on parental bonding. Evolutionary Psychology, 10(3), 542–561. Jaafar, S. H., Ho, J. J., & Lee, K. S. (2016). Rooming-in for new mother and infant versus separate care for increasing the duration of breastfeeding. Cochrane Database of Systematic Reviews, 8. https://doi.org/10.1002/14651858. CD006641.pub3. Jeha, D., Usta, I., Ghulmiyyah, L., et al. (2015). A review of the risks and consequences of adolescent pregnancy. Journal of Neonatal & Perinatal Medicine, 8(1), 1–8. Kilpatrick, S., & Garrison, E. (2017). Normal labor and delivery. In S. G. Gabbe, J. R. Neibyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. King, T. L., & Pinger, W. (2014). Evidence-based practice for intrapartum care: The pearls of midwifery. Journal of Midwifery and Women’s Health, 59, 572–585. Klaus, M., & Kennell, J. (1976). Maternal–infant bonding. Mosby. Klaus, M., & Kennell, J. (1982). Parent–infant bonding (2nd ed.). Mosby. MacDonald, T., Noel-Weiss, J., West, D., et al. (2016). Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: A qualitative study. BMC Pregnancy and Childbirth, 16(106), 1–17. https:// doi.org/10.1186/s12884-016-0907-y. May, C., & Fletcher, R. (2013). Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery, 29(5), 474–478. Mercer, R. T. (2004). Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship, 36(3), 226–232. Mercer, R. T., & Walker, L. O. (2006). A review of nursing interventions to foster becoming a mother. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(5), 568–582. Panter-Brick, C., Burgess, A., Eggerman, M., et al. (2014). Practitioner review: Engaging fathers—Recommendations for a game change in parenting interventions based on a systematic review of the global evidence. Journal of Child Psychology and Psychiatry, 55(11), 1187–1211. https://doi.org/10.1111/ jcpp.12280. Public Health Agency of Canada (PHAC). (2009). What mothers say: The Canadian maternity experiences survey (Cat. No. HP5-74/2-2009E-PDF). Author. Public Health Agency of Canada (PHAC). (2017). Chapter 1: Family-centred maternity and newborn care in Canada: Underlying philosophy and principles. In Family-centred maternity and newborn care: National guidelines. Author. https://www.canada.ca/en/public-health/services/ publications/healthy-living/maternity-newborn-care-guidelines-chapter-1. html. Reisman, T., & Goldstein, Z. (2018). Case report: Induced lactation in a transgender woman. Transgender Health, 1, 24. https://doi.org/10.1089/ TRGH.2017.0044. Rubin, R. (1961). Basic maternal behaviour. Nursing Outlook, 9, 683–686. Stapleton, L. R., Schetter, C. D., Westling, E., et al. (2012). Perceived partner support in pregnancy predicts lower maternal and infant distress. Journal of Family Psychology, 26(3), 453–463.

CHAPTER 23 Steen, M., Downe, S., Bamford, N., et al. (2012). Not-patient and not-visitor: A metasynthesis fathers’ encounters with pregnancy, birth and maternity care. Midwifery, 28(4), 362–371. Stewart, L. S., & Rodgers, E. (2017). Assessment and care of the term newborn transitioning to extrauterine life. In B. B. Kennedy, & S. M. Baird (Eds.), Intrapartum management modules: A perinatal education program (5th ed.). Wolters Kluwer. Tharner, A., Luijk, M. P., Raat, H., et al. (2012). Breastfeeding and its relation to maternal sensitivity and infant attachment. Journal of Developmental and Behavioral Pediatrics, 33(5), 396–404. Truth and Reconciliation Commission (TRC). (2012). Truth and Reconciliation Commission of Canada: Interim report. Government of Canada. https:// www.falconers.ca/wp-content/uploads/2015/07/TRC-Interim-Report.pdf. Truth and Reconciliation Commission (TRC). (2015). Truth and Reconciliation Commission of Canada: Calls to action. Government of Canada. https:// ehprnh2mwo3.exactdn.com/wp-content/uploads/2021/01/Calls_to_Action_ English2.pdf. Tully, L. A., Piotrowska, P. J., Collins, D., et al. (2017). Optimising child outcomes from parenting interventions: Fathers’ experiences, preferences and barriers to participation. BMC Public Health, 1(1). https://doi.org/ 10.1186/s12889-017-4426-1. Wambach, K., & Spencer, B. (2021). Breastfeeding and human lactation (6th ed.). Jones & Bartlett Learning. Yu, C. Y., Hung, C. H., Chan, T. F., et al. (2012). Prenatal predictors of father–infant attachment after childbirth. Journal of Clinical Nursing, 21(11–12), 1577–1583.

ADDITIONAL RESOURCES Alberta Family Wellness Initiative—Brain Story Certification Training. https:// www.albertafamilywellness.org/training. Best Start—Indigenous Child Development—Taking Care of Our Children. http://www.beststart.org/resources/aboriginal/TCoOC.pdf. Best Start—Waiting for Baby: Pregnancy After Age 35. http://www.beststart.org/ resources/rep_health/pdf/pregnancy35plus_12pg_book.pdf. Best Start—What to Expect in the First 3 Months. http://www.beststart.org/ resources/hlthy_chld_dev/K82-E-hospitalhandout.pdf.

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Best Start Resource Centre—A Child Becomes Strong: Journeying Through Each Stage of the Life Cycle. https://resources.beststart.org/wp-content/uploads/ 2019/01/K12-A-child-becomes-strong-2020.pdf. Center on the Developing Child, Harvard University—Build Resilience in the Community [game]. https://developingchild.harvard.edu/resilience-game/. Center on the Developing Child, Harvard University—Serve and Return Interaction Shapes Brain Circuitry. https://developingchild.harvard.edu/ resources/serve-return-interaction-shapes-brain-circuitry/. First Nations Health Authority—Women, Men, Children and Families. https:// www.fnha.ca/wellness/wellness-for-first-nations/women-men-childrenand-families. Government of Canada—Nobody’s Perfect Parenting Tip Sheets. https://www. canada.ca/en/public-health/services/health-promotion/childhoodadolescence/publications/nobody-perfect-parenting-sheets.html. Healing the Hurt - Caring for Indigenous Mothers and Infants. https://www. indigenousmomandbaby.org/. Hug Your Baby - Help, Understanding, Guidance, for Young Families. https:// www.hugyourbaby.org/. La Leche League Canada (breastfeeding support). http://www.lllc.ca. Parenting in Peel—Health After Pregnancy. https://www.peelregion.ca/health/ family-health/after-pregnancy/. Postpartum Support International. https://postpartum.net. Rainbow Health Ontario—Enhancing Health for LGBTQ2 Communities. https://www.rainbowhealthontario.ca/. Silent Voice—Parent Education Program. https://silentvoice.ca/pep/.

FATHERING RESOURCES Best Start—Father Resources—Daddy and Me on the Move. http:// www.beststart.org/resources/hlthy_chld_dev/BSRC_Daddy_and_Me_ EN.pdf. Dad Central—Connecting Dads Across Canada. https://www.dadcentral.ca. National Collaborating Centre for Aboriginal Health (NCCAH) and First Nations Health Authority—Fatherhood is Forever. http://www.fnha.ca/ Documents/fatherforever.pdf. Parent in Peel - Health After Pregnancy - Becoming a Dad. https://www.peelregion. ca/health/family-health/after-pregnancy/becoming-dad/index.htm.

UNIT 6 Postpartum Period

24 Postpartum Complications Janet Andrews Originating US Chapter by Kathryn R. Alden http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify causes, signs and symptoms, possible complications, and medical and nursing care of postpartum hemorrhage. 2. Describe hemorrhagic shock (hypovolemic shock) as a complication of postpartum hemorrhage, including the collaborative care necessary. 3. Identify causes, signs and symptoms, possible complications, and medical and nursing care of postpartum infection.

4. Describe thromboembolic disorders, including incidence, etiology, signs and symptoms, and related medical and nursing care. 5. Differentiate among perinatal mood disorders, including incidence, risk factors, signs and symptoms, severity, and collaborative care. 6. Describe the nurse’s role in assisting families who are grieving from perinatal loss.

The postpartum period is a time of change and transition for mothers and newborns. Mothers experience incredible physiological shifts and emotional adjustments in the hours and days following birth. Perinatal nurses provide education, care, and support for mothers and newborns during this important time. In addition, nurses have the responsibility to pay careful attention to signs and symptoms of complications. The nurse works collaboratively with the interprofessional health care team to provide safe and effective care to patients experiencing postpartum complications. In most instances, patients respond to treatment, and outcomes are positive. Whenever possible, the mother–baby dyad must be supported to remain together. Involvement of partners and families in caring for the postpartum parent and baby is important in the face of postpartum complications. This chapter focuses on the postpartum complications of hemorrhage, infection, thromboembolic disorders, psychological complications, and loss and grief.

is a life-threatening event that can occur with little warning and is often unrecognized until the patient has profound symptoms. With prevention and treatment interventions, most of the deaths could be avoided (World Health Organization [WHO], 2019). Definitions of PPH in the literature are varied. PPH is often defined as the loss of 500 mL or more of blood after vaginal birth and 1 000 mL or more after Caesarean birth, although normal blood loss for some patients approaches these amounts. PPH may be defined as a 10% decline in hemoglobin concentration and the need for a transfusion (Francois & Foley, 2017). Diagnosis is frequently based on subjective observations, with blood loss often being underestimated by as much as 50% (Cunningham et al., 2018). For clinical purposes, any blood loss that has the potential to produce hemodynamic instability should be considered PPH. The amount of blood loss required to cause hemodynamic instability will depend on the pre-existing condition of the patient (Leduc et al., 2018). PPH is classified as primary or secondary with respect to the birth. Primary PPH occurs within 24 hours of the birth. Secondary PPH occurs more than 24 hours but less than 12 weeks after the birth and is due to retained products, infection, or both (Francois & Foley, 2017) (see Clinical Reasoning Case Study: Postpartum Hemorrhage).

POSTPARTUM HEMORRHAGE Definition and Incidence Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. All patients who give birth are at risk for PPH. It

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CHAPTER 24 Postpartum Complications

?

CLINICAL REASONING CASE STUDY

Postpartum Hemorrhage A nurse on the mother–baby unit is assigned to Ms. Avery. She is a G4 T3 P0 A0 L3 who gave birth to a 4 080-g baby boy this morning. Ms. Avery had an uncomplicated but precipitous vaginal birth. Her perineum is intact. She is breastfeeding. All labs are normal. She is now 3 hours postpartum. A family member calls out from the patient’s room for assistance. When the nurse walk into the room Ms. Avery is standing up on her way to the bathroom with a large pool of blood on the floor. She states, “I don’t know what happened; it all just came when I stood up. I am so dizzy and lightheaded.” 1. Evidence—Is there sufficient evidence to draw conclusions about what the nurse should do next? 2. Assumptions—Describe underlying assumptions about each of the following: a. Risk factors for early postpartum hemorrhage (PPH) and specifically those described for Ms. Avery b. Need for frequent assessments in the early postpartum period c. Use of oxytocics for prevention and management of PPH 3. What implications and priorities for nursing care can be made at this time? 4. Interprofessional care: Describe roles and responsibilities of health care providers who would potentially be involved in care management for Ms. Avery.

Etiology and Risk Factors When excessive bleeding is observed, it is important to note the colour and consistency of the blood. For example, dark red blood is likely of venous origin, perhaps from varices or superficial lacerations of the birth canal. Bright red blood is arterial and can indicate deep lacerations of the cervix. Failure of blood to clot or remain clotted indicates a pathological condition or coagulopathy such as disseminated intravascular coagulation (DIC) (see discussion below; Thrombin). Excessive bleeding can occur during the period from the separation of the placenta to its expulsion or removal. This can result from incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or removed, persistent or excessive blood loss usually is the result of uterine atony or prolapse of the uterus into the vagina. Secondary postpartum bleeding may occur as a result of subinvolution of the uterus (delayed return of the enlarged uterus to normal size and function). Recognized causes of subinvolution include retained placental fragments (discussed below, in the section Tissue) and pelvic infection. Signs and symptoms include prolonged lochial discharge, foul odour, pain, fever, irregular or excessive bleeding, and sometimes hemorrhage. The patient is often at home when the symptoms occur. Discharge teaching should emphasize the signs of normal involution, potential complications, and the importance of prompt assessment by a health care provider in the event of PPH. Risk factors for and causes of PPH are listed in Box 24.1. It is common to look at the etiology of PPH within four categories: tone, tissue, trauma, and thrombin. These are referred to as the four T’s of PPH.

Tone (Uterine Atony). Uterine atony is marked hypotonia (relaxation) of the uterine muscle. Normally, placental separation and expulsion are facilitated by contraction of the uterus, which also prevents hemorrhage from the placental site. The uterine corpus is in essence a basket weave of strong, interlacing smooth-muscle bundles through

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BOX 24.1

Risk Factors and Causes of Postpartum Hemorrhage Tone: Uterine Atony • Overdistended uterus—large fetus, multiple fetuses, hydramnios, distension with clots • Anaesthesia and analgesia—conduction anaesthesia • Previous history of uterine atony • High parity • Prolonged labour, oxytocin-induced labour • Magnesium sulphate administration during labour or postpartum period • Chorioamnionitis • Uterine subinvolution • Obesity Trauma • Lacerations of the birth canal • Trauma during labour and birth—forceps-assisted birth, vacuum-assisted birth, Caesarean birth • Ruptured uterus • Inversion of the uterus • Manual removal of a retained placenta Tissue • Retained placental fragments • Placenta accreta, increta, percreta • Placental abruption • Placenta previa Thrombin • Coagulation disorders

which many large maternal blood vessels pass (see Figure 7.3). Bleeding is controlled by the contraction of smooth muscle in the uterus. If the uterus is flaccid after detachment of all or part of the placenta, brisk bleeding occurs, and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted. This marked hypotonia of the uterus is called uterine atony. Uterine atony is the leading cause of early PPH. It is associated with high parity, polyhydramnios, fetal macrosomia, and multiple gestation. In such conditions, the uterus is “overstretched” and contracts poorly after birth. Other causes of atony include traumatic birth, use of halogenated anaesthetic (e.g., halothane), use of magnesium sulphate, rapid or prolonged labour, chorioamnionitis, use of oxytocin for labour induction or augmentation, fibroids, and uterine atony in a previous pregnancy (Leduc et al., 2018).

Trauma. Any lacerations of the genital tract, extensions or lacerations during Caesarean birth, uterine rupture, and uterine inversion are all considered trauma and can cause PPH. Lacerations of the perineum are the most common of all injuries in the lower portion of the genital tract. These are classified as first, second, third, and fourth degree (see Chapter 17, Vaginal Lacerations). An episiotomy may extend to become either a third- or fourth-degree laceration. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetrical lacerations of the lower genital tract include operative birth, precipitous

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birth, congenital abnormalities of the maternal soft parts, and contracted pelvis. Size, abnormal presentation, and position of the fetus; relative size of the presenting part and the birth canal; and deep engagement in the pelvis prior to Caesarean birth may all lead to tissue trauma. Hematomas. Pelvic hematomas (i.e., a collection of blood in the connective tissue) can be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common type. Persistent perineal, vaginal, or rectal pain and pressure are the most common symptoms, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an episiotomy, or primigravidity (Francois & Foley, 2017). Retroperitoneal hematomas are least common but are lifethreatening. They are caused by laceration of one of the vessels attached to the hypogastric artery, usually associated with rupture of a Caesarean scar during labour. During the postpartum period, if the patient reports persistent perineal or rectal pain or a feeling of pressure in the vagina, a careful examination is made. A retroperitoneal hematoma can also cause minimal pain, and the initial symptoms can be signs of shock (Francois & Foley, 2017; Rafi & Khalil, 2018). Hematomas may self-absorb or they may require surgical evacuation. Once the bleeding has been controlled, usual postpartum care is provided with careful attention to pain relief, monitoring the amount of bleeding, replacing fluids, and reviewing laboratory results (hemoglobin and hematocrit). Inversion of the uterus. Uterine inversion (turning inside out) after birth is a rare but potentially life-threatening complication. The incidence of uterine inversion varies, from 1 in 1 200 to 1 in 57 000 births, and differs depending on whether the birth was vaginal or Caesarean (Francois & Foley, 2017). Uterine inversion can recur with a subsequent birth. Uterine inversion may be incomplete, complete, or prolapsed. Incomplete inversion cannot be seen; a smooth mass can be palpated through the dilated cervix. In complete inversion, the lining of the fundus crosses through the cervical os and forms a mass in the vagina. Prolapsed inversion of the uterus is obvious; a large, red, rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the introitus. Factors contributing to uterine inversion include short umbilical cord, adherent placental tissue, weakness of uterine wall or cervix, fundal implantation of the placenta, uterine tumours, uterine atony, sudden uterine emptying, manual removal of the placenta, inappropriate fundal pressure, excessive traction on the umbilical cord, and uterotonic medications prior to placenta removal (Gilmandyar & Thornburg, 2019). The primary presenting signs of uterine inversion are sudden and include hemorrhage, shock, and pain and the uterus is not palpable abdominally. (Gilmandyar & Thornburg, 2019). Prevention—always the easiest, cheapest, and most effective therapy — is especially appropriate for uterine inversion. The umbilical cord should not be pulled unless the placenta has definitely separated. Uterine inversion is an emergency situation requiring immediate interventions that include maternal fluid resuscitation, repositioning of the uterus within the pelvic cavity, and correction of associated clinical conditions. Tocolytics or halogenated anaesthetics may be given to relax the uterus before attempting replacement (Francois & Foley, 2017). Oxytocic agents are given after the uterus is repositioned to control bleeding and broad-spectrum antibiotics should be initiated to prevent infection. The patient requires further monitoring for recurrence of uterine inversion (Gilmandyar & Thornburg, 2019).

Tissue. Uterine involution and the prevention of PPH rely on expulsion of the entire placenta. Retained placental segments (tissue) may result from partial separation of a normal placenta, the existence of

an additional succenturiate lobe, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third stage of labour, or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall. Delivery of the placenta occurs in the third stage of labour. When the placenta has not been delivered within 30 to 60 minutes after birth despite gentle traction on the umbilical cord and uterine massage, it is described as “retained.” Initial management of a retained placenta consists of manual separation and removal by the obstetrical health care provider. This involves the provider reaching into the uterus and gently separating the placenta from the uterine wall and removing it manually. When the patient has regional anaesthesia for labour, supplementary anaesthesia is usually not needed. For other patients, administration of light nitrous oxide and oxygen inhalation anaesthesia or intravenous (IV) pain medications should be considered (Francois & Foley, 2017). After removal of a retained placenta, the postpartum patient is at continued risk for PPH and infection. In rare instances there is abnormal adherence of the placenta to the myometrium, which is beyond the endometrium. Attempts to remove the placenta in the usual manner are unsuccessful, and laceration or perforation of the uterine wall can result, putting the patient at great risk for severe PPH and infection (Booker & Moroz, 2019). PPH can be due to abnormally implanted, invasive, or adhered placenta; this is known as placenta accrete syndrome. Unusual placental adherence can be total, partial, or focal, depending on how much placental tissue is involved. The following degrees of abnormal placental attachment are recognized: • Placenta accreta—Slight penetration of myometrium • Placenta increta—Deep penetration of myometrium • Placenta percreta—Perforation of myometrium and uterine serosa, possibly involving adjacent organs (e.g., bladder) Placenta accrete syndrome has demonstrated an increased incidence in association with the rise in Caesarean birth rates (Cunningham et al., 2018). Other risk factors include placenta previa, prior uterine surgery, endometrial defects, submucosal fibroids, multiparity, and older maternal age (Francois & Foley, 2017). Placenta accrete syndrome can be diagnosed before the birth using ultrasonography and magnetic resonance imaging (MRI), but often it is not recognized until there is excessive bleeding after birth. Caesarean birth is recommended when the diagnosis is made prenatally. Bleeding may not occur unless manual removal of the placenta is attempted. With more extensive involvement, bleeding becomes profuse when removal of the placenta is attempted. Less blood is lost if the diagnosis is made antenatally and no attempt is made to manually remove the placenta. Treatment includes blood component replacement therapy. Hysterectomy can be indicated for all three types of placental adherence if bleeding is uncontrolled (Cunningham et al., 2018). Attempts to remove the placenta in the usual manner are unsuccessful, and laceration or perforation of the uterine wall can result, putting the patient at great risk for severe PPH and infection (Francois & Foley, 2017).

Thrombin (Coagulopathies). The final T in the etiology of PPH stands for thrombin, or coagulopathies. When bleeding is continuous and there is no identifiable source, a coagulopathy may be the cause. The patient’s coagulation status must be assessed quickly and continuously. Abnormal results depend on the cause and may include increased prothrombin time, increased partial thromboplastin time, decreased platelets, decreased fibrinogen level, increased fibrin degradation products, and prolonged bleeding time. Causes of

CHAPTER 24 Postpartum Complications coagulopathies may be pre-existing (von Willebrand disease, hemophilia A, immune thrombocytopenic purpura) or pregnancy related, such as thrombocytopenia with pre-eclampsia or DIC. Coagulopathies may also develop as a result of therapeutic anticoagulation, fetal demise, severe infection, placental abruption, or amniotic fluid embolus (Leduc et al., 2018). Immune thrombocytopenic purpura (ITP). Immune thrombocytopenic purpura (ITP) is an autoimmune disorder in which antiplatelet antibodies decrease the lifespan of the platelets. Thrombocytopenia, capillary fragility, and increased bleeding time are diagnostic findings. ITP may cause severe hemorrhage after Caesarean birth or from cervical or vaginal lacerations. The incidence of postpartum uterine bleeding and vaginal hematomas is also increased. Medical management focuses on control of platelet stability. If ITP was diagnosed during pregnancy, the pregnant patient likely was treated with corticosteroids or IV immune globulin. Platelet transfusions are usually given when there is significant bleeding. A splenectomy may be needed if the ITP does not respond to medical management (Cunningham et al., 2018). von Willebrand disease (vWD). von Willebrand disease (vWD), a type of hemophilia, is probably the most common of all hereditary bleeding disorders. Although vWD is rare, it is among the most common congenital clotting defects in North American patients of childbearing age. It results from a deficiency or defect in a blood-clotting protein called von Willebrand factor (vWF). There are as many as 20 variations of vWD, most of which are inherited as autosomal dominant traits—types I and II are the most common ones (Cunningham et al., 2018). Symptoms include recurrent bleeding episodes, such as nosebleeds or after tooth extraction, bruising easily, heavy menstrual bleeding, prolonged bleeding time (the most important test), factor VIII deficiency (mild to moderate), and bleeding from mucous membranes. Although factor VIII increases during pregnancy, a risk for PPH still exists as levels of vWF begin to decrease (Cunningham et al., 2018). The patient may be at risk for bleeding for up to 4 weeks after birth. The treatment of choice is administration of desmopressin, which promotes the release of vWF and factor VIII. It can be given nasally, intravenously, or orally. Transfusion therapy with plasma products that have been treated for viruses and contain factor VIII and vWF also may be used. Concentrates of antihemophiliac factor (Humate) may be used (Cunningham et al., 2018). Disseminated intravascular coagulation (DIC). Disseminated intravascular coagulation (DIC), also known as consumptive coagulopathy, is an imbalance between the body’s clotting and fibrinolytic systems. It is a pathological form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. Widespread external bleeding, internal bleeding, or both can result. DIC also causes vascular occlusion of small vessels that results from small clots forming in the microcirculation. In the obstetrical population, DIC may occur as a result of massive antepartum or postpartum hemorrhage; sepsis; severe pre-eclampsia; hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome; amniotic fluid embolism; fetal demise; placental abruption; septic abortion; or acute fatty liver of pregnancy (Erez et al., 2015; Francois & Foley, 2017). The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding; spontaneous bleeding from the patient’s gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on the patient’s arm. Excessive bleeding may occur from the site of a slight trauma (e.g., venipuncture sites, intramuscular or subcutaneous

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injection sites, nicks from shaving the abdomen, and injury from insertion of a urinary catheter). Hypotension is out of proportion to the observed blood loss. Other symptoms include tachycardia and diaphoresis. Laboratory tests reveal decreased levels of platelets, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin (the factors consumed during coagulation). Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads to the accumulation of fibrin split products in the blood; these have anticoagulant properties and prolong the prothrombin time. Bleeding time is normal, coagulation time shows no clot, clot-retraction time shows no clot, and partial thromboplastin time is increased. DIC must be distinguished from other clotting disorders before therapy is initiated. DIC may cause critical bleeding and multi-organ failure requiring admission to the critical care unit and may cause maternal death (Takeda & Takeda, 2019). Primary medical management in all cases of DIC involves correction of the underlying cause (e.g., removal of the dead fetus, treatment of existing infection or of pre-eclampsia or eclampsia, or removal of a placental abruption). If the fetus is alive, expedient birth is recommended. Volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters are the usual forms of treatment. Resolution of DIC usually begins with the birth of the newborn and as coagulation abnormalities resolve (Takeda & Takeda, 2019). Nursing interventions include frequent and accurate assessment of bleeding; frequent monitoring for uterine atony; timely communication with the interprofessional team; additional IV line insertion; administration of fluid, blood products, and coagulation factors as ordered; observing for signs of complications from the administration of blood and blood products; and protecting the patient from injury. Because multi-organ failure, specifically renal failure, may be a result of DIC, insertion of an in-dwelling urinary catheter for close monitoring of urine output is recommended. Urinary output of less than 30 mL/hr must be reported to the primary health care provider. The patient and their family will be extremely anxious or concerned about the patient’s condition and prognosis. The nurse should offer explanations about care and provide emotional support to them throughout this critical time.

Collaborative Care Care of patients experiencing PPH requires collaboration of an interprofessional health care team. Nurses and obstetrical care providers work closely with personnel from the transfusion services department (blood bank), pharmacy, and laboratory to manage the emergent situation that occurs when a patient begins to bleed excessively after birth.

Assessment. Early recognition and treatment of PPH are critical to care management. Risk assessment beginning during pregnancy and continuing during the intrapartum and postpartum periods is important in identifying patients who are at risk for PPH (see Box 24.1). This increases the awareness of the health care team in planning and implementing care and in preventing hemorrhage and its sequelae. Team members should be made aware when a patient with identified risk factors is admitted to the birthing facility (Fleischer & Meirowitz, 2016). Excessive blood loss is the clinical finding that warrants prompt action. In general, health care providers are highly inaccurate in estimating blood loss in terms of volume (Hancock et al., 2015). Nurses must be able to quantify blood loss accurately. The Association of

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Women, Obstetric and Neonatal Nurses (AWHONN) (2015b) states that visual estimation of blood loss can be inaccurate, with underestimates of 33 to 55%, which can delay life-saving treatment. Weighing perineal pads is a much more accurate method of determining blood loss and is recommended by AWHONN. Whenever blood loss appears to be excessive, the first step is to evaluate the contractility of the uterus and the amount of bleeding. If the uterus is hypotonic, management is directed toward increasing contractility, primarily with active uterine massage and uterotonic medication to minimize blood loss (Leduc et al., 2018). If the uterus is firmly contracted and bleeding continues, the source of bleeding must be identified and treated. Assessment may include visual or manual inspection of the perineum, vagina, uterus, cervix, or rectum and laboratory studies (e.g., hemoglobin, hematocrit, coagulation studies, platelet count). Treatment depends on the source of the bleeding.

Medical Management. The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends active management of the third stage of labour in order to prevent PPH, where possible (Leduc et al., 2018). This involves administering oxytocin intramuscularly or by IV push after delivery of the anterior shoulder, considering delayed cord clamping, gentle cord traction, and immediate fundal massage and

IV infusion of oxytocin after the complete birth. If it takes longer than 30 minutes to deliver the placenta, the risk of PPH increases (Leduc et al., 2018). The initial management of excessive postpartum bleeding due to uterine atony is firm massage of the uterine fundus. Expression of any clots in the uterus, elimination of bladder distension, and continuous IV infusion of 10 to 40 units of oxytocin in 1 000 mL of Ringer’s lactate or normal saline solution are also primary interventions. If the uterus fails to respond to oxytocin, other uterotonic medications are administered. Misoprostol (Cytotec), a synthetic prostaglandin E1 analogue, is often used as it can be given rectally, sublingually, or orally. Methylergonovine may be given intramuscularly to produce sustained uterine contractions. A derivative of prostaglandin F2α (carboprost tromethamine [Carboprost; Hemabate]) may be given intramuscularly. It can also be given intramyometrially at Caesarean birth or intra-abdominally after vaginal birth (see Medication Guide: Uterotonic Medications to Manage Postpartum Hemorrhage for a comparison of uterotonic medications and common dosages used to manage PPH). In addition to the medications used to contract the uterus, rapid administration of crystalloid solutions or blood or blood products, or both will be needed to restore the patient’s intravascular volume (Francois & Foley, 2017).

MEDICATION GUIDE Uterotonic Medications Used to Manage Postpartum Hemorrhage Medication

Action

Adverse Effects

Contradictions

Dosage and Route

Nursing Considerations

Oxytocin (Syntocinon)

Contraction of uterus; decreases bleeding Contraction of uterus

Infrequent: water intoxication, nausea and vomiting Headache, nausea, vomiting, diarrhea, fever, chills Hypertension, hypotension, nausea, vomiting, headache

None for PPH

20–40 units/L diluted in 1 000 mL lactated Ringer’s solution or normal saline at 150 mL/hour; or 10 units IM or 5 to 10 units IV push (over 1 to 2 minutes) 600 to 800 mcg rectal, sublingual, or PO

Continue to monitor vaginal bleeding and uterine tone

0.25 mg IM

Headache, nausea, vomiting, diarrhea, fever, chills, tachycardia, hypertension Nausea, vomiting, diarrhea, dizziness

Avoid with asthma or hypertension

250 mcg IM

Check blood pressure before giving, and do not give if >140/90 mm Hg; continue monitoring vaginal bleeding and uterine tone Continue to monitor vaginal bleeding and uterine tone

History of blood clots or taking any anticoagulant

1 g IV

Misoprostol (Cytotec)∗

Methylergonovine; Ergonovine Maleate

Contraction of uterus

Carboprost tromethamine (Hemabate)

Contraction of uterus

Tranexamic acid (Cyclokapron)

For blood clotting and to stop prolonged bleeding

Do not use if history of allergy to prostaglandins Hypertension, preeclampsia, cardiac disease

Continue to monitor vaginal bleeding and uterine tone

Often given to prevent PPH in someone with a bleeding disorder

IM, Intramuscular; IV, intravenous; PO, by mouth; PPH, postpartum hemorrhage. ∗ Off-label use; research reports vary in conclusions about dosage and efficacy of use in comparison to other medications used to manage postpartum hemorrhage. Source: Leduc, D., Senikas, V., & Lalonde, A. (2018). SOGC clinical practice guideline No. 235—Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology Canada, 40(12), e841–e855.

CHAPTER 24 Postpartum Complications Oxygen can be given by nonrebreather face mask to enhance oxygen delivery to the cells. Assessment of bladder status is also essential as a full bladder will impede contraction of the uterus. An in-dwelling urinary catheter is usually inserted to monitor urine output as a measure of intravascular volume and to keep the bladder empty. Laboratory studies usually include a complete blood count with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time. Blood type and antibody screen are done if not previously performed (Cunningham et al., 2018). If bleeding persists, bimanual compression may be performed by an obstetrical health care provider. One hand is placed over the uterus externally; the other is placed in the vagina to apply pressure on the lower segment. Consistent compression with the two hands results in external compression of the uterus to reduce blood flow (Leduc et al., 2018). If the uterus still does not become firm, the physician or midwife will perform manual exploration of the uterine cavity for retained placental fragments. If all of these procedures are ineffective, surgical management is needed. Surgical management options include uterine tamponade (uterine packing or an intrauterine tamponade balloon), bilateral ligation of the internal iliac artery, or uterine compression suturing (using, for example, B-Lynch or Hayman vertical sutures). If other treatment measures are ineffective, hysterectomy will likely be needed (Leduc et al., 2018).

NURSING ALERT Use of ergonovine or methylergonovine is contraindicated in the presence of hypertension or cardiovascular disease.

Nursing Care. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss (Figure 24.1). Astute assessment of circulatory status can be done with noninvasive monitoring (Box 24.2). Frequent monitoring of the patient’s vital signs and encouraging them to empty their bladder are important nursing interventions for treatment and prevention of PPH. Interventions are based on the cause of PPH, as previously discussed. The patient and their family may be anxious about what is happening. The nurse can intervene by calmly providing explanations about interventions being performed and the need to act quickly. Once the patient’s condition is stabilized, preparations for discharge can be made. Discharge instructions for a patient who has experienced PPH are similar to those for any postpartum patient. In addition, the patient should be told that they will probably feel fatigue, even exhaustion, and will need to limit their physical activities to conserve their strength. They may require instructions in increasing their dietary iron and protein intake as well as using iron supplementation to rebuild lost red blood cell (RBC) volume. They may need assistance with newborn care and household activities until they have regained strength. Some postpartum patients who have experienced a PPH may have difficulties involving delayed lactogenesis or insufficient milk production, or they may develop a perinatal mood disorder (PMD). Referrals for home care follow-up or to community resources may be needed (see Nursing Care Plan: Postpartum Hemorrhage, available on Evolve).

Hemorrhagic (Hypovolemic) Shock Hemorrhage may result in hemorrhagic (hypovolemic) shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised; death may occur. Physiological compensatory mechanisms are activated in response to hemorrhage. See

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Table 24.1 for severity of shock symptoms. The adrenal glands release catecholamines, causing arterioles and venules in the skin, lungs, gastrointestinal tract, liver, and kidneys to constrict. The available blood flow is diverted to the brain and heart and away from other organs, including the uterus. If shock is prolonged, the continued reduction in cellular oxygenation results in an accumulation of lactic acid and acidosis (from anaerobic glucose metabolism). Acidosis (lowered serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A circular pattern is established (i.e., decreased perfusion, increased tissue anoxia and acidosis, edema formation, and pooling of blood further decrease the perfusion). Cellular death occurs. See the Emergency box: Hemorrhagic Shock for assessment of and interventions for hemorrhagic shock.

EMERGENCY Hemorrhagic Shock Assessment

Characteristics

Respirations Pulse Blood pressure Skin Urinary output Level of consciousness Mental status Central venous pressure

Rapid and shallow Rapid, weak, irregular Decreasing (late sign) Cool, pale, clammy Decreasing Lethargy ! coma Anxiety ! coma Decreased

Interventions Summon assistance and equipment. Start intravenous infusion per standing orders. Ensure patent airway; administer oxygen. Continue to monitor status.

Collaborative Care. Interprofessional teamwork and collaboration are key to managing care of postpartum patients who experience hemorrhagic shock. The patient is likely to be transferred to a critical care unit for stabilization and ongoing care and monitoring. Vigorous treatment is necessary to prevent adverse outcomes. Management of hypovolemic shock involves restoring circulating blood volume and eliminating the cause of the hemorrhage (e.g., lacerations, uterine atony, or inversion). Venous access with a largebore IV catheter is critical to successful care management of the patient with a hemorrhagic complication. Establishing two IV lines facilitates fluid resuscitation, which includes the administration of crystalloids (lactated Ringer’s, normal saline solution), colloids (albumin), blood, and blood components. To restore circulating blood volume, a rapid IV infusion of crystalloid solution is given at a rate of 3 mL infused for every 1 mL of estimated blood loss (e.g., 3 000 mL infused for 1 000 mL of blood loss). Packed RBCs are usually infused if the patient is still actively bleeding and no improvement in their condition is noted after the initial crystalloid infusion. Infusion of fresh frozen plasma may be needed if clotting factors and platelet counts are below normal values (Francois & Foley, 2017; Leduc et al., 2018). Hemorrhagic shock can occur rapidly, but the classic signs of shock may not appear until the postpartum patient has lost 30 to 40% of their blood volume. By the time vital signs are abnormal, the patient may be in an advanced stage of shock. The nurse must continue to reassess the patient’s condition as evidenced by the degree of measurable and anticipated blood loss and mobilize appropriate resources.

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Postbirth hemorrhage Assessment to determine source of bleeding and signs of shock

Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation studies

Establish venous access/verify patency of venous access and start IV fluids

Placenta removed

Placenta retained

Suspected coagulopathy

Fundal massage

Anticipate need for anaesthetic

Assess for underlying cause and start supplemental oxygen

Fundus boggy

Uterus firm

Give tocolytic as ordered

Empty urinary bladder

Assess for cervical or vaginal lacerations/hematoma

Anticipate and assist with manual removal of placenta

Anticipate fluid/blood replacement therapy

Give uterotonics as ordered

Uterus firms

Anticipate and assist with repair

Atony persists

Continue assessments for maternal hemodynamic status

Continuous assessment of maternal hemodynamic status

Give uterotonics as ordered Anticipate pharmacological management: antibiotics, vasoactive drugs, uterotonic agents

Bleeding continues

Start supplemental oxygen

If bleeding continues or signs and symptoms of shock

Anticipate surgical intervention

Repeat laboratory studies

Anticipate fluid/blood replacement therapy

Anticipate surgical intervention Fig. 24.1 Nursing assessments and interventions for excessive postpartum bleeding. CBC, Complete blood count; IV, intravenous; tocolytics, medications to relax the uterus; uterotonics, medications to contract the uterus.

BOX 24.2 Noninvasive Assessments of Circulatory Status in Postpartum Patients Who Are Bleeding Palpation of Pulses (Rate, Quality, Equality) • Arterial Inspection • Skin colour, temperature, turgor • Level of consciousness • Capillary refill • Neck veins • Mucous membranes

Auscultation • Heart sounds/murmurs • Breath sounds Observation • Presence or absence of anxiety, apprehension, restlessness, disorientation Measurement • Blood pressure • Pulse oximetry • Urinary output

CHAPTER 24 Postpartum Complications

TABLE 24.1

Degree of Hypovolemic Shock

Degree of Shock

Blood Loss

Mild

40%

As above, as well as hypotension, agitation/confusion Hemodynamic instability

Signs and Symptoms

Source: Leduc, D., Senikas, V., & Lalonde, A. (2018). SOGC clinical practice guideline No. 235—Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology Canada, 40(12), e841–e855.

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although measurements may not always be accurate in a patient with hypovolemia or decreased perfusion. Level of consciousness is assessed frequently and provides additional indications of blood volume and oxygen saturation. In early stages of decreased blood flow, the patient may report “seeing stars” or feeling dizzy or nauseated. They may become restless and orthopneic. As cerebral hypoxia increases, the patient may become confused and react slowly to stimuli or not at all. Some patients state they have headaches. An improved sensorium is an indicator of improved perfusion. Continuous electrocardiographic monitoring may be indicated for the patient who is hypotensive or tachycardic, continues to bleed profusely, or is in shock. A Foley catheter with a urometer is inserted to allow hourly assessment of urine output. The most objective and least invasive assessment of adequate organ perfusion and oxygenation is a urine output of at least 30 mL/hr (Cunningham et al., 2018). Hemoglobin and hematocrit levels, platelet count, and coagulation studies need to be closely monitored.

VENOUS THROMBOEMBOLIC DISORDERS Major goals of care are to restore oxygen delivery to the tissues and maintain cardiac output. Fluid resuscitation must be monitored carefully because fluid overload can occur. Intravascular fluid overload occurs most often with colloid therapy. If the patient is actively bleeding and unstable despite fluid boluses, transfusion of blood products is needed. Protocols need to be in place for emergency release of blood products; these products may be universally compatible (e.g., O-negative RBCs or AB plasma) or type-specific if the patient’s blood type is known and the supply is available. A massive transfusion protocol facilitates timely access to and administration of blood products (Fleischer & Meirowitz, 2016). Transfusion reactions can follow administration of blood or blood components, including cryoprecipitates. Even in an emergency, each unit of blood or blood products should be carefully checked per hospital protocol. Complications of fluid or blood replacement therapy include hemolytic reactions, febrile reactions, allergic reactions, circulatory overloading, and air embolism.

Venous thromboembolism (VTE) results from the formation of a blood clot or clots inside a blood vessel and is caused by inflammation (thrombophlebitis) or partial obstruction of the vessel (Figure 24.2). Three thromboembolic conditions are of concern in the postpartum period: • Superficial venous thrombosis—Involvement of the superficial saphenous venous system • Deep venous thrombosis (DVT)—Involvement varies but can extend from the foot to the iliofemoral region • Pulmonary embolism (PE)—Complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs

LEGAL TIP: Standard of Care for Bleeding Emergencies The standard of care for obstetrical emergency situations such as PPH or hypovolemic shock is that provision should be made for the nurse to implement nursing actions independently. Policies, procedures, standing orders or protocols, and clinical guidelines should be established by each health care facility in which births occur and should be agreed on by health care providers involved in the care of obstetrical patients.

The nurse needs to continue to monitor the postpartum patient’s pulse and blood pressure. If invasive hemodynamic monitoring is ordered, the nurse may assist with placement of an arterial line or central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter. The nurse then monitors CVP, pulmonary artery pressure, or pulmonary artery wedge pressure as ordered. Additional assessments to be made include evaluation of skin temperature, colour, and turgor and assessment of the patient’s mucous membranes. Breath sounds should be auscultated before fluid volume replacement to provide a baseline for future assessment. Inspection for oozing at the sites of incisions or injections and assessment of the presence of petechiae or ecchymosis in areas not associated with surgery or trauma are critical in the evaluation for DIC. Oxygen is administered and titrated to maintain oxygen saturation. Oxygen saturation should be monitored with a pulse oximeter,

Fig. 24.2 Deep vein thrombophlebitis. (From Murphy, E. H., Davis, C. M., Journeycake, J. M., et al. [2009]. Symptomatic ileofemoral DVT after onset of oral contraceptive use in patients with previously undiagnosed May-Thurner syndrome. Journal of Vascular Surgery, 49[3], 697–703.)

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Incidence and Etiology Pregnant patients have a 15 times increased risk of thromboembolism (Bates et al., 2016; Cunningham et al., 2018). The incidence of VTE is approximately 1 in 1 500 pregnancies and is a leading cause of mortality and serious morbidity in pregnant patients (Pettker & Lockwood, 2017). This rate represents a nearly ten-fold increase compared with nonpregnant patients of comparable age. VTE can occur in any trimester of pregnancy or during the postpartum period. DVT occurs most often during pregnancy, although it can occur up to 12 weeks postpartum, and PE is more common in the postpartum period. The incidence of VTE in the postpartum period has declined in the last 30 years because early ambulation after childbirth, a preventive measure, has become standard practice (Cunningham et al., 2018). However, PE is a major cause of maternal death (Bates et al., 2018; Chan et al., 2014). The major causes of thromboembolic disease are venous stasis and hypercoagulation, both of which are present in pregnancy and continue into the postpartum period. Caesarean birth nearly doubles the risk for VTE; other risk factors include operative vaginal birth; history of venous thrombosis, PE, or varicosities; body mass index (BMI) greater than 30; prolonged immobility; and smoking (Bates et al., 2018; Pettker & Lockwood, 2017). Patients who experience complications such as pre-eclampsia, hemorrhage, or postpartum infection also have an increased risk for VTE (Tepper et al., 2014). The SOGC recommends that each patient be evaluated for risk, and consideration for thromboprophylaxis should be individualized (Chan et al., 2014). Patients who are at risk for VTE should consider wearing TED stockings shortly after birth. If compression stockings do not fit, then a sequential compression device (SCD) may be used. Because these stockings and pneumatic compression devices pose no hemorrhagic risk and do little harm, they should be strongly considered for thromboprophylaxis in all patients with risk factors, such as those patients who are hospitalized or immobilized, including pregnant or postoperative Caesarean patients (Chan et al., 2014).

Clinical Manifestations Superficial venous thrombosis is the most common form of postpartum thrombophlebitis. It is characterized by pain and tenderness in the lower extremity. Physical examination may reveal warmth, redness, and an enlarged, hardened vein over the site of the thrombosis. DVT is more common in pregnancy and is characterized by unilateral leg pain, calf tenderness, and swelling. Physical examination may reveal redness and warmth, but patients may also have a large clot with few symptoms. Acute PE usually results from dislodged deep vein thrombi. Presenting symptoms are dyspnea and tachypnea (more than 20 breaths/min). Other signs and symptoms frequently seen include tachycardia (more than 100 beats/min), apprehension, cough, hemoptysis, elevated temperature, and syncope (Cunningham et al., 2018). Physical examination is not a sensitive diagnostic indicator for DVT. D-dimer assays and diagnostic imaging are used for diagnosis. With PE, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated diagnostic tests (Lim et al., 2018).

They need to be taught how to put on the stockings before getting out of bed. IV heparin therapy continues for 3 to 5 days or until symptoms resolve. Oral anticoagulant therapy (warfarin [Coumadin]) is started during this time and is continued for about 3 months. If a breastfeeding mother is on long-term anticoagulant therapy, the infant’s prothrombin time should be monitored at least monthly and vitamin K given to the infant, if necessary (Lawrence & Lawrence, 2016). Acute PE is an emergent situation that requires prompt treatment. Massive pulmonary emboli can lead to pulmonary hypertension and hemodynamic instability; mortality is increased to 25% in these cases (Cunningham et al., 2018). Immediate treatment of PE is anticoagulant therapy. Continuous IV heparin therapy is used for PE until symptoms have resolved. Intermittent subcutaneous heparin or oral anticoagulant therapy is often continued for up to 6 months (Pettker & Lockwood, 2017). In the hospital, nursing care of the patient with a thrombosis consists of ongoing assessments: inspecting and palpating the affected area; palpating the peripheral pulses; and measuring and comparing leg circumferences. Signs of PE, including chest pain, coughing, dyspnea, and tachypnea, and respiratory status for presence of crackles are also assessed. Laboratory reports are monitored for prothrombin or partial thromboplastin times. The nurse needs to assess for unusual bleeding. Increased lochia, generalized petechiae, hematuria, or oozing from venipuncture sites should be immediately reported to the health care provider. In addition, the patient and their family are assessed for their level of understanding about the diagnosis and their ability to cope during the unexpected extended period of recovery. Interventions include explanations and education about the diagnosis and treatment. The patient will need assistance with personal care as long as they are on bed rest. The family should be encouraged to participate in the patient’s care if the patient and they wish. While the patient is on bed rest, they should be encouraged to change positions frequently but not to place the knees in a sharply flexed position that could cause pooling of blood in the lower extremities. They should also be cautioned not to rub the affected areas, because rubbing could cause the clot to dislodge. Heparin and warfarin are administered as ordered, and the health care provider is notified if clotting times are outside the therapeutic level. If the patient is breastfeeding, they should be informed that neither heparin nor warfarin is excreted in significant quantities in breast milk (Lawrence & Lawrence, 2016). If the newborn has been discharged, the family is encouraged to bring the newborn for feedings as permitted by hospital policy; the patient also can express breastmilk to be sent home. Pain can be managed with a variety of measures. Changing of positions, elevation of the leg, and application of moist heat may decrease discomfort. It may be necessary to administer analgesics and antiinflammatory medications.

NURSING ALERT Medications containing Aspirin are not given to patients on anticoagulant therapy because Aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk of bleeding.

Collaborative Care Superficial venous thrombosis is also treated with analgesia (nonsteroidal anti-inflammatory medications), rest with elevation of the affected leg, and elastic compression stockings and heat (Cunningham et al., 2018). DVT is initially treated with anticoagulant therapy (usually continuous IV heparin), bed rest with the affected leg elevated, and analgesia. After the symptoms have decreased, the patient may be fitted with elastic compression stockings to wear when they are allowed to ambulate.

The patient is usually discharged home on oral anticoagulants and will need an explanation of the treatment schedule and possible adverse effects. If subcutaneous injections are to be given, the patient and family need to be taught how to administer the medication and about site rotation. They should also be given information about dietary restrictions (e.g., limited intake of green, leafy vegetables) and safe care practices to prevent bleeding and injury while the patient is on anticoagulant

CHAPTER 24 Postpartum Complications therapy (e.g., using a soft toothbrush and an electric razor). They will need information about follow-up with their health care provider to monitor clotting times and regulate the correct dosage of anticoagulant therapy. The patient should also use a reliable form of contraception if taking warfarin because this medication is considered teratogenic. Oral contraceptives are contraindicated because of the increased risk for thrombosis (Cunningham et al., 2018).

POSTPARTUM INFECTIONS Postpartum infection or puerperal infection is any clinical infection that occurs within 42 days after miscarriage, induced abortion, or birth (WHO, 2015). The most common symptoms of postpartum infection are pyrexia (presence of fever of greater than 38°C), tachycardia, and subjective feelings of localized pain (Cunningham et al., 2018). Common postpartum infections include uterine, wound, breast, urinary tract, and respiratory infections (Cunningham et al., 2018). The most common infecting organisms are the numerous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria, and Clostridia are less common but serious pathogenic organisms that can cause puerperal infection. Postpartum infections are more common in patients with obesity, who have concurrent medical or immunosuppressive conditions, or who had a Caesarean or other operative birth. Intrapartal factors such as prolonged rupture of membranes, prolonged labour, and internal fetal monitoring also increase the risk of infection (Cunningham et al., 2018). Factors that predispose the patient to postpartum infection are listed in Box 24.3.

Endometritis Endometritis (infection of the lining of the uterus) usually begins as a localized infection at the placental site but can spread to the entire

BOX 24.3

Predisposing Factors for Postpartum Infection Preconception or Antepartal Factors • History of previous venous thrombosis, urinary tract infection, mastitis, pneumonia • Diabetes mellitus • Alcohol misuse • Substance misuse • Immunosuppression • Anemia • Malnutrition • Obesity • Pre-eclampsia Intrapartal Factors • Caesarean birth • Operative vaginal birth • Prolonged rupture of membranes • Chorioamnionitis • Prolonged labour • Bladder catheterization • Internal fetal or uterine pressure monitoring • Multiple vaginal examinations after rupture of membranes • Epidural anaesthesia • Retained placental fragments • Postpartum hemorrhage • Episiotomy or lacerations • Hematomas

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endometrium. It is the most common postpartum infection, occurring in up to 3% of vaginal births and 5 to 10% of Caesarean births (Duff & Birsner, 2017). The highest incidence occurs in patients who gave birth by Caesarean after prolonged labour and rupture of membranes. Prophylactic antibiotics administered during labour and during Caesarean surgery can help reduce the incidence and severity of endometritis. Signs of endometritis include fever (usually greater than 38°C [100.4°F]), increased pulse, chills, anorexia, nausea, fatigue and lethargy, pelvic pain, uterine tenderness, and foul-smelling, profuse lochia. Leukocytosis and a markedly increased RBC sedimentation rate are typical laboratory findings. Anemia can also be present. Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the offending pathogens within 36 to 48 hours. The most common cause of uterine infections is from organisms transmitted from hands to vagina to uterine placental site (Cunningham et al., 2018).

Management. Management of endometritis consists of IV broadspectrum antibiotic therapy (cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care, including hydration, rest, and pain relief. Most uterine infections respond to antibiotics, and the treatment continues until the patient has been afebrile for 48 hours. Assessments of lochia, vital signs, and changes in the patient’s condition continue during treatment. Comfort measures depend on the symptoms and may include cool compresses, warm blankets, perineal care, and sitz baths. Patient education should include adverse effects of therapy, prevention of spread of infection, signs and symptoms of worsening condition, importance of completing the treatment, and the need for follow-up care. Patients may need to be encouraged or assisted to maintain mother–infant interactions and breastfeeding.

Wound Infections Wound infections are common postpartum infections that often develop after the patient is at home. Sites of infection include the Caesarean incision and repaired laceration or episiotomy site. Predisposing factors are similar to those for endometritis (see Box 24.3). Signs of wound infection include fever, erythema, edema, warmth, tenderness, pain, seropurulent drainage, and wound separation. In order to decrease the risk of wound infections in patients who have a Caesarean birth, the SOGC recommends that all patients undergoing elective or emergency Caesarean birth receive antibiotic prophylaxis. The timing of the antibiotic should be 15 to 30 minutes before the skin incision (van Schalkwyk & Van Eyk, 2017). Prophylactic antibiotics may also be considered for patients who have third- and fourth-degree perineal injury, and the dose may be doubled for patients who have a BMI greater than 35 (van Schalkwyk & Van Eyk, 2017).

Management. Culture of wound exudate is performed to identify the causative organism. Wound infections are treated with IV antibiotic therapy. When pus is present in the incision, the wound is opened and drained. Wounds are irrigated with normal saline and re-dressed several times daily; healing occurs by secondary intention. In some cases, a wound vacuum device is used. Antibiotic treatment is continued until the base of the wound appears clear and there are no apparent signs of cellulitis (Duff & Birsner, 2017). Nursing care includes frequent assessments of temperature and vital signs; wound assessment and care; and comfort measures such as analgesics, sitz baths, warm compresses, and perineal care. Teaching includes hygienic care techniques (e.g., changing perineal pads front to back, hand hygiene before and after perineal care), self-care measures, and signs of worsening conditions to report to the obstetrical health care provider. Wound care and assessment will continue after

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discharge from the birthing facility. The patient and their family are instructed in how to perform wound care and dressing changes. Home visits by nurses may be provided to assess the wound, reinforce teaching, and offer support. If IV antibiotic therapy is continued in the home, it is likely to be administered by the family with regular monitoring by the visiting nurse.

Urinary Tract Infections Urinary tract infections (UTIs) occur in 2 to 4% of postpartum patients. Risk factors include urinary catheterization, frequent pelvic examinations, epidural anaesthesia, genital tract injury, history of UTI, and Caesarean birth (Simpson et al., 2020). Signs and symptoms include dysuria, frequency and urgency, low-grade fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank pain may indicate an upper UTI. The most common infecting organism is Escherichia coli, although other Gram-negative aerobic bacilli also may cause UTIs.

Management. Medical management for UTIs consists of antibiotic therapy, analgesia, and hydration. Postpartum patients are usually treated on an outpatient basis; therefore teaching should include instructions on how to monitor temperature, bladder function, and appearance of urine. The patient should also be taught about signs of potential complications and the importance of taking all antibiotics as prescribed. Other suggestions for prevention of UTIs include proper perineal care, wiping from front to back after urinating or having a bowel movement, and increasing fluid intake.

Mastitis Mastitis, or breast infection, affects 2 to 10% of patients after childbirth. Mastitis is almost always unilateral and develops well after the flow of milk has been established (Figure 24.3). The infecting organism generally is the hemolytic S. aureus. An infected nipple fissure usually is the initial lesion, followed by ductal system involvement. Inflammatory edema and engorgement of the breast obstruct the flow of milk in a lobe; regional, then generalized, mastitis follows. If treatment is not prompt, mastitis may progress to a breast abscess. Symptoms rarely appear before the end of the first postpartum week and are more common in the third to fourth weeks (Simpson et al., 2020). Chills, fever, malaise, and local breast tenderness are noted first. Localized breast tenderness, pain, swelling, redness, and axillary adenopathy may also occur. Antibiotics are prescribed for treatment. Lactation can be maintained by emptying the breasts every 2 to 4 hours by breastfeeding, manual expression, or a breast pump.

A

Because mastitis rarely occurs before the postpartum patient is discharged, they should be taught in the hospital about its warning signs and receive counselling about prevention of cracked nipples, incomplete breast emptying, and plugged milk ducts (Simpson et al., 2020). Management includes intensive antibiotic therapy (e.g., cephalosporins and vancomycin, which are particularly useful in staphylococcal infections), support of breasts, local heat or cold, adequate hydration, and analgesics. Almost all instances of acute mastitis can be avoided by using proper breastfeeding technique to prevent cracked nipples. Missed feedings, waiting too long between feedings, and abrupt weaning may lead to clogged nipples and mastitis. Cleanliness practised by all who have contact with the newborn and new mother also reduces the incidence of mastitis. See also Chapter 27.

Nursing Care Postpartum patients with factors predisposing to postpartum infection (see Box 24.3) should be assessed carefully. Signs and symptoms associated with postpartum infection were discussed earlier with each infection. Elevation of temperature, redness, and swelling are common signs. The mother may also have chills, fever, localized tenderness, pain, and foul-smelling lochia or urine. Depending on the type of infection, laboratory tests include a complete blood count, venous blood cultures, urine cultures, and uterine tissue cultures. Review of the patient’s history and the laboratory results should be included in the assessment. The nurse also needs to monitor for signs of sepsis, including hypotension, tachypnea, decreased urine output, and decreased level of consciousness (Cunningham et al., 2018). The most effective and least expensive treatment of postpartum infection is prevention. Preventive measures include good prenatal nutrition to reduce the risk for anemia. Good maternal perineal hygiene with thorough hand hygiene should be emphasized. Use of aseptic techniques by all health care personnel during childbirth and the postpartum period is essential. Postpartum patients are usually discharged home before 48 hours after birth, which is often before signs of infection are evident. Nurses in birth centres and hospital settings need to be able to identify patients at risk for postpartum infection and provide anticipatory teaching and counselling before the patient’s discharge. After discharge, telephone follow-up, hot lines, support groups, lactation consultants, home visits by a community health nurse, and teaching materials (movies, written materials, apps) are all interventions that can be implemented to decrease the risk of postpartum infections. Nurses working in the community must be able to recognize signs and symptoms of postpartum

B Fig. 24.3 Mastitis.

CHAPTER 24 Postpartum Complications infection and convey these to the patient so that they know when to contact their primary health care provider. Community nurses must also be able to provide the appropriate nursing care for patients who need follow-up home care.

PERINATAL MOOD DISORDERS For many postpartum patients the weeks after birth are a time of vulnerability to psychological complications, causing significant distress for the patient, disrupting family life, and, if prolonged, negatively affecting the couple’s relationship and the child’s emotional and social development. Perinatal mood disorders (PMDs) have traditionally been called postpartum mood disorders, but the terminology has been revised to perinatal mood disorders because these mental health issues may affect persons any time during pregnancy and in the first year after the birth of the baby, although they most commonly begin within the first 4 to 6 weeks following birth (Registered Nurses’ Association of Ontario [RNAO], 2018a). PMDs include anxiety, depression, and psychosis. It is important to identify the difference between mood changes and mood disorders. A common mood change in the postpartum period is postpartum blues. Within 3 to 5 days postpartum up to 75% of patients will experience episodes of tearfulness, agitation, mood swings, anxiety, sleep and appetite disturbances, and feelings of being overwhelmed (RNAO, 2018a). The distinguishing factor between this and a mood disorder is that it resolves within 2 weeks and does not disrupt the postpartum patient’s ability to care for themselves and their baby. Nursing care for patients with postpartum blues involves validation, reassurance, and education. See Chapter 22, Postpartum Blues, for further discussion of postpartum blues. Pregnant and postpartum patients with a mood disorder need to have their condition diagnosed because untreated perinatal depression and other mood disorders can have devastating effects on all members of the family (American College of Obstetricians and Gynecologists, Committee on Obstetric Practice [ACOG], 2015). Pre-existing mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Because birth is usually thought to be a happy event, a new parent’s emotional distress can puzzle and alienate family and friends. Nurses can offer anticipatory guidance, assess the mental health of new mothers, offer therapeutic interventions, and make referrals, when necessary. Failure to do so can result in tragic consequences. In 2018, in Canada, almost one-quarter (23%) of mothers who had recently given birth reported feelings consistent with either postpartum depression or an anxiety disorder. The proportion of mothers reporting these feelings varied across provinces, ranging from 16% in Saskatchewan to 31% in Nova Scotia (Statistics Canada, 2019b). PMD affects patients from all cultures, although the implications and manifestations of PMD and the barriers to obtaining treatment vary. Indigenous people have an 87% higher chance of developing postpartum depression than non-Indigenous patients (Black et al., 2019). This vulnerability could be due to history of colonization, intergenerational trauma, discrimination, racism, and marginalization (Black et al., 2019) (see Chapter 1, Indigenous People). Indigenous people may experience significant barriers to care, including geographic barriers, poverty, and lack of culturally safe care (Black et al., 2019). Negative social determinants of mental health can increase the risk for PMD with inequities such as poverty and intimate partner violence (RNAO, 2018b). The cause of a PMD can be biological, psychological, situational, or multifactorial. Estrogen fluctuations and postpartum hypogonadism (the change from the high levels of estrogen and progesterone at the end of pregnancy to the much lower levels of both hormones present after birth) are important etiological factors. Patients at greatest risk for

BOX 24.4

543

Risk Factors for Perinatal Mood

Disorders Strongest Risk Factors • A history of psychiatric illness, including depression or anxiety at any time, including, but not limited to, during the perinatal period • Prenatal symptoms of anxiety • Onset of depression during pregnancy or postpartum Moderate Risk Factors • Stressful life events (e.g., relationship breakdown or divorce, losing a job, incarceration, housing insecurity) • Refugee or immigrant status • Low social support or perception of low support • Unfavourable obstetrical outcome(s) • Low self-esteem • A history of physical or sexual abuse during childhood or adulthood • Intimate partner violence • A history of reproductive trauma (e.g., infertility) • Grief related to miscarriage, stillbirth, or infant loss • Substance use, including the use of tobacco Weak Risk Factors • Low socioeconomic status • Lack of significant other or partner; lone parent • Pregnancy, as defined by the person, as unplanned or unwanted • Breastfeeding challenges Source: Registered Nurses’ Association of Ontario. (2018). Assessments and interventions for perinatal depression (2nd ed.). https://rnao.ca/sites/ rnao-ca/files/bpg/Perinatal_Depression_FINAL_web_0.pdf.

PMD are those with a history of anxiety or depression and especially those who have had a previous episode of major depressive disorder whether during or after pregnancy (Cunningham et al., 2018; RNAO, 2018a). Box 24.4 lists risk factors for PMD. PMD affects parental infant attachment and the quality of parenting, and affected children are at increased risk of developing mental, social, and behavioural difficulties (Letourneau et al., 2017). The complications of having a PMD are listed in Box 24.5. Some patients have more serious mood disorders that can eventually incapacitate them to the point of being unable to care for themselves and their babies and may include thoughts of self-harm and suicide. Suicide is the leading cause of maternal death during the perinatal year (RNAO, 2018b).

BOX 24.5

Potential Complications of Having a Perinatal Mood Disorder • • • • • • •

Mother–infant attachment issues Depression in the partner Long-term emotional behavioural and cognitive issues in the child Relationship issues and family breakdown Social, financial, and occupational complications Self-harm and suicide Infant and sibling neglect and occasionally infanticide

From Lazarus, R., & Gutteridge, K. (2013). Post-natal psychiatric disorders. In S. E. Robson & J. Wough (Eds.), Medical disorders in pregnancy: A manual for midwives. Wiley Blackwell.

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Perinatal Anxiety Disorders One out of every five patients suffers from perinatal anxiety disorder (Fawcett et al., 2019). Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder (OCD), panic disorder and panic attacks, specific phobias, social anxiety disorder, and post-traumatic stress disorder (PTSD). Patients with a history of anxiety disorder are at greatest risk. Anxiety disorders and depression may occur at the same time (RNAO, 2018a). With generalized anxiety disorder, patients have a pervasive feeling of anxiety most of the time and worry excessively about multiple concerns. Anxiety symptoms can interfere with the mother’s ability to care for themselves, the infant, and their family. Patients with generalized anxiety disorder may experience chest tightness, shortness of breath, tachycardia, dizziness or lightheadedness, sweating, trembling, nausea, abdominal pain, fatigue, constant worry, a sense of doom, and difficulty concentrating (Wisner et al., 2017). Panic disorder consists of unpredictable, intermittent episodes (attacks) of symptoms similar to those of generalized anxiety disorder. Panic attacks are discrete periods of sudden onset of intense apprehension, fearfulness, or terror (Fawcett et al., 2019). During these attacks, symptoms such as shortness of breath, palpitations, chest pain, choking, smothering sensations, and fear of losing control are present. Patients with panic attacks have reported having intrusive thoughts about terrible injury done to the infant, such as stabbing or burns, sometimes by themselves. Rarely do these patients harm their baby. Patients with panic disorder may develop agoraphobia or fear of leaving home because they fear having another panic attack (Wisner et al., 2017). Nurses need only to listen to a mother with such attacks to hear symptoms of panic disorder. Usually these patients are so distraught that they will share their thoughts with whoever will listen. Often the family has tried to tell them that what they are experiencing is normal; however, they know that their symptoms are not normal. These patients need to have their feelings validated, and they need monitoring or treatment. Patients with OCD often find their symptoms increase during pregnancy and in the postpartum period (Fawcett et al., 2019). Onset of OCD can occur after birth. Patients with postpartum OCD tend to have obsessive, intrusive thoughts, and they perform compulsive actions that temporarily reduce or alleviate the distress caused by the intrusive thoughts. In the postpartum period, compulsive checking on the sleeping baby and repetitive ritualistic washing are common. Obsessions are usually focused and specific and associated with fear of consequences (Fawcett et al., 2019). The obsessive thoughts can be incapacitating. Patients fear they will lose control and act on their thoughts. Patients with OCD are afraid they will harm their infant but are unlikely to do so. Patients with postpartum psychosis who have the same thoughts are more apt to actually cause harm (Fawcett et al., 2019; Wisner et al., 2017). Postpartum PTSD is the result of exposure to trauma, either during the prenatal or intrapartum period, or it may be related to previous life experiences and events such as childhood sexual abuse or intimate partner violence. Risk factors for postpartum PTSD include history of pregnancy loss, high-risk pregnancy, preterm birth, having an infant in the neonatal intensive care unit (NICU), painful and/or difficult vaginal birth, instrument-assisted vaginal birth, and emergency Caesarean birth (Vesel & Nickasch, 2015–2016). Anxiety disorders in the prenatal period are strongly related to the development of postpartum depression. In addition, anxiety disorder in pregnancy is related to negative obstetrical outcomes and in the postpartum period. These can result in negative attachment as well as behavioural and emotional sequelae on the infant and siblings (Biaggi et al., 2016; Fawcett et al., 2019).

Collaborative Care. Effective treatments are available for anxiety disorders, and affected patients need to be given this information. Anxiety disorders may be treated with psychotherapy; cognitive behavioural therapy (CBT) and exposure response prevention (ERP) are often used. These therapies may be provided individually, in groups, or online and are recommended as the first line of treatment, as many patients prefer not to take medications (RNAO, 2018b). Pharmacological treatment includes selective serotonin reuptake inhibitors (SSRIs) and antianxiety medications, although it can take 2 weeks for these medications to be effective. Benzodiazepines provide short-term relief from anxiety symptoms but should be used judiciously as they can be addictive. Medications should be prescribed with careful consideration of safety for the fetus during pregnancy and for the breastfeeding infant postpartum. Each patient should be treated on an individualized basis: the severity of their symptoms needs to be assessed, their history and response to any previous treatments should be obtained, their preferences need to be acknowledged, and the potential benefits and risks of each treatment must be conveyed. Education is a crucial nursing intervention. New mothers should be provided with anticipatory guidance concerning the possibility of anxiety disorders during the perinatal period. Preparing for the attacks can help offset their unexpected, terrifying nature. Patients can be reassured that it is common to feel a sense of impending doom and fear of insanity during panic attacks. Nurses can help patients identify panic triggers that are particular to their own lives. Keeping a diary can help in identifying such triggers. Family and social supports are often helpful. The new mother needs to be encouraged to put usual chores on hold and to ask for and accept help when needed. Support groups can help these mothers experience some comfort in seeing others in similar circumstances.

Perinatal Depression Perinatal depression is the most common complication of childbirth, with approximately half of cases starting in the prenatal period (RNAO, 2018a). Rates of depression during the postpartum period are approximately 10 to 15% in Canadian patients (Lanes et al., 2011). It is likely that the actual occurrence of perinatal depression exceeds the reported estimates because it is often unrecognized and undiagnosed. Perinatal depression can be mild to severe. It is characterized by an intense and pervasive sadness with severe and labile mood swings. It is more serious and persistent than postpartum blues, lasting more than 2 weeks. Intense fears, anger, anxiety, and despondency that persist past the baby’s first few weeks are not a normal part of postpartum blues. The symptoms of perinatal depression do not differ from those of nonpostpartum depression except that the mother’s ruminations of guilt and inadequacy feed worries about being an incompetent and inadequate parent. New mothers report an increased yearning for sleep, sleeping heavily but awakening instantly with any infant noise, and an inability to go back to sleep after infant feedings. Determining difficulty falling asleep is a relevant screening question to ascertain risk for depression (see Clinical Reasoning Case Study: Perinatal Depression). A distinguishing feature of major depression is irritability. These episodes of irritability may flare up with little provocation and may sometimes escalate to violent outbursts or dissolve into uncontrollable sobbing. Many of these outbursts are directed against significant others. Postpartum patients with major depressive episodes often have spontaneous crying long after the usual duration of baby blues. Feelings of detachment toward the newborn and not feeling love for the newborn are common symptoms of perinatal depression. Patients feel guilt and shame for having these feelings at a time when they believe they should be happy. They can be reluctant to discuss their

CHAPTER 24 Postpartum Complications symptoms or their negative feelings toward the infant. A postpartum patient with depression may have obsessive thoughts about harming the infant, and this can be very frightening to them. Often they do not share these thoughts because of embarrassment; when they do, other family members become very frightened. On the other hand, some postpartum patients feel very emotionally attached and connected to their infants; this can prevent them from experiencing total despair (RNAO, 2018a). These symptoms rarely disappear without outside help. Many patients are reluctant to seek assistance. Loneliness, lack of social support, and language barriers also affect the ability to attain treatment. ?

CLINICAL REASONING CASE STUDY

Perinatal Depression Jennifer is a 35-year-old G1 T1 P0 A0 L1 who gave birth by emergency Caesarean 2 weeks ago, to a 3500-g baby. She has come to the OB clinic for her 2-week follow-up visit and is accompanied by her partner and her mother. Jennifer appears tired, her colour is pale, and she has dark circles under both eyes. Her affect is flat. Jennifer’s partner reports that she is not sleeping, she cries often, her appetite is poor, and she seems to be constantly worried about breastfeeding. Jennifer’s mother states that the baby cries much of the time and never seems satisfied after breastfeeding. She says that there have been times in the past when Jennifer was depressed and she took antidepressant medication, although she did not want to take any medication during pregnancy. 1. Evidence—Is there sufficient evidence to draw conclusions about Jennifer’s current condition? 2. Assumptions—What assumptions can be made about the following? a. Jennifer’s risk factors for perinatal depression b. Jennifer’s support system c. Jennifer’s concern with breastfeeding d. Jennifer’s reluctance to take antidepressant medication 3. Priority: What is the nursing priority in this situation? 4. Interprofessional care—Describe roles and responsibilities of health care providers who would potentially be involved in care management for Jennifer.

Collaborative Care. Treatment options for perinatal depression include psychotherapy and antidepressant and antianxiety medication. Psychotherapy without the use of medication can be effective for mild cases of perinatal depression. It is often used in combination with antidepressants for moderate to severe cases. Psychotherapy methods include general counselling (listening visits), interpersonal psychotherapy, CBT, and psychodynamic therapy (RNAO, 2018a). Peer support may be helpful; some patients find that postpartum support groups are very beneficial. Internet-based and telephone-based psychotherapy are increasing in use. For some patients with severe perinatal depression, hospitalization is necessary. The key to treatment of depression is to screen all patients to determine who may need treatment. All health care providers who come in contact with families in the perinatal period must be knowledgeable and prepared to screen all patients for PMDs (see discussion later in chapter).

Postpartum Psychosis The most severe of the PMDs, postpartum psychosis, is rare, affecting approximately 0.1% of postpartum patients (Holford et al., 2018). This disorder tends to show onset within 2 weeks postpartum, although a small number of patients may develop psychosis with a later onset (Brockington, 2017; Holford et al., 2018). Once a patient has had one episode of postpartum psychosis they are 50 to 80% more likely

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to develop a psychiatric disorder, often bipolar disorder (Tinkelman et al., 2017). There is also a 50% recurrence rate of postpartum psychosis. Postpartum psychosis is a psychiatric emergency and often requires hospitalization. Episodes of postpartum psychosis are characterized by rapid onset of bizarre behaviour, auditory or visual hallucinations, paranoid or grandiose delusions, elements of delirium or disorientation, and extreme deficits in judgement accompanied by high levels of impulsivity that can contribute to increased risk for suicide or infanticide (Tinkelman et al., 2017). Pre-existing bipolar disorder is a risk factor for postpartum psychosis (Holford, 2018). This mood disorder is defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood and one or more depressive episodes. The elevated moods are clinically referred to as mania. Clinical manifestations of a manic episode include at least three of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities without regard for negative consequences (American Psychiatric Association, 2017). While in a manic state, mothers need constant supervision when caring for their infant. Usually, however, they are too preoccupied to provide child care. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms or mixed episodes, in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of “normal” mood, but in some individuals, depression and mania may rapidly alternate. These rapid changes in mood are known as rapid cycling.

Collaborative Care. Postpartum psychosis carries a relatively good prognosis with early detection and aggressive treatment (Hardy & Reichenbacker, 2019). Postpartum psychosis is a psychiatric emergency, and the mother will probably need inpatient psychiatric care. Antipsychotics, mood stabilizers, and benzodiazepines are the treatments of choice. Other psychotropic medications such as antidepressants may be used on the basis of the underlying diagnosis (e.g., bipolar mania, bipolar depression). Electroshock therapy (ECT), especially when bilaterally administered, has also been shown to be highly effective in the treatment of postpartum psychosis. It is usually advantageous for the mother to have contact with their baby if they desire, but visits must be closely supervised. Psychotherapy is indicated after the period of acute psychosis has passed.

Interdisciplinary and Nursing Care An interprofessional team approach to care is needed for the patient who presents with signs and symptoms of a PMD. A nurse in the role of case manager can coordinate care management. The obstetrical health care provider assesses the patient’s physical condition in relation to postbirth recovery as well as their current symptoms. The provider may order pharmacological treatment (e.g., antidepressant medications) or may refer the patient to a psychiatric care provider for treatment of symptoms. A pharmacist may consult with the provider regarding the optimal medications and their safety during breastfeeding and may provide education to the patient about the medications (dose, schedule, adverse effects, when to expect improvement in symptoms). If the patient is experiencing a loss of appetite, a dietitian may be a part of care management. A lactation consultant and pediatric health care provider may need to be consulted if the patient is experiencing breastfeeding difficulties. The pediatric health care provider will monitor the infant’s weight and health status. Close follow-up and ongoing monitoring of the patient’s mental and physical status and the infant’s health, growth, and development are vital to optimizing outcomes. Even though the prevalence of PMD is fairly well established, patients may be unlikely to seek help from a mental health care

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provider. This reluctance can be related to social stigma of mental illness, cultural beliefs, lack of knowledge, or fear of child custody implications (Yonkers et al., 2011). Primary health care providers can usually recognize severe depression or postpartum psychosis but may miss milder forms; even if it is recognized, the patient may be treated inappropriately or subtherapeutically. Nurses are strategically positioned to offer anticipatory guidance, assess the mental health of new mothers, offer therapeutic interventions, and make referrals when necessary. Failure to do so may result in tragic consequences. In practice, it is the responsibility of all who are in contact with the patient to provide screening, assessment, and education to facilitate early detection and treatment. Identification and treatment of PMD must be continued beyond the immediate postbirth period to prevent negative effects of maternal mood disorders on the children of these mothers. To recognize symptoms of PMD as early as possible, the nurse should be an active listener and demonstrate a caring attitude. Nurses cannot depend on patients to volunteer unsolicited information about their mental health or ask for help. Examples of ways to initiate conversation include the following: “Now that you’ve had your baby, how are things going for you? Have you had to change many things in your life since having the baby?” and “How much time do you spend crying?” If the nurse assesses that the new mother is depressed, the nurse must ask if the mother has thought about hurting themselves or the baby. The patient may be more willing to answer honestly if the nurse says, “Many people feel depressed after having a baby, and some feel so bad that they think about hurting themselves or the baby. Have you had these thoughts?”

NURSING ALERT Because mothers with postpartum psychosis may harm their infants, extra precaution is needed in assessment and intervention. The nurse needs to ask specifically if the mother has had thoughts about harming their baby.

Screening for Perinatal Mood Disorders. When PMD is identified early, it is highly treatable. Screening for anxiety or depression during pregnancy and the postpartum period aids in prevention and early intervention for PMD. Patients at risk should be identified (see Box 24.4), although all patients should be screened during pregnancy and postpartum (ACOG, 2015; AWHONN, 2015a; RNAO, 2018a). Screening for PMD can be done before patients are discharged from the hospital, although this may be too early. While the screening may identify some who are at risk, it is important that follow-up screening also be done. PMD is most likely to occur around 4 weeks after birth but can occur any time within the perinatal period up to 1 year postpartum. Follow-up assessments for risks and signs of PMD can be done by primary care providers during pediatric care visits for the infant and during postpartum follow-up visits for the mother. Patients with a positive screen should be referred appropriately for evaluation and treatment. In perinatal populations the most widely used and validated tools are the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS). Both are brief, self-report questionnaires specifically developed for use with perinatal patients, which take between 5 and 10 minutes to complete (RNAO, 2018a). With the EPDS the person is asked to respond to 10 statements about the common symptoms of depression (Figure 24.4). It has been used and validated in studies in numerous cultures and is viewed as a valid screening tool throughout pregnancy and postpartum for PMD. The patient is asked to choose the response that is closest to describing how they have felt for the past week. A maximum score on the EPDS is 30; patients with scores of 12 or higher may possibly have depression

and need further assessment. One item on the tool addresses suicidal thoughts; responses to this item should be carefully examined (Cox et al., 2014). The effectiveness of screening for PMD is related to the follow-up for positive screening results. If PMD screening results are positive or if the patient’s self-report shows signs that they might be depressed, a formal screening is needed to determine the urgency of the referral and the type of provider. Also important is the need to assess the patient’s family because they may be able to offer valuable information, as well as need to express how they have been affected by the patient’s emotional disorder.

Nursing Considerations. Postpartum nurses need to carefully observe all new postpartum patients for signs of anxiety, depression, and disinterest in the newborn and conduct further assessments as necessary. Prior to discharge from the birthing facility, nurses educate the mother and their partner about signs of postpartum blues, PMD, as well as when and where to seek help (see Patient Teaching box: Signs of Postpartum Blues, Depression, and Psychosis). Nurses also need to provide information about how to prevent postpartum depression (see Patient Teaching box: Preventing a Perinatal Mood Disorder). Nurses can assist patients by teaching them self-care, especially the symptoms and risk factors for PMD; helping them to feel safe and empowered in discussing their mental and social health; and facilitating adequate social and partner support. Patients and their families should be given written resources in their native language and emergency numbers to call. Nurses should provide patients and their families with a current list of available community resources for treating postpartum depression. Nurses must also stress the importance of seeking help from a health care provider if PMD symptoms are present at any time within the year postpartum. The family must be able to recognize the symptoms and know where to go for help. Printed materials and online resources that explain what the patient can do to prevent a mood disorder can be used as part of discharge education. Pregnant persons need to be taught self-care strategies including exercise, relaxation, adequate sleep, and time for themselves as both a prevention and treatment strategy for depression and anxiety (RNAO, 2018a).

PATIENT TEACHING Signs of Postpartum Blues, Depression, and Psychosis Signs of baby blues (these should go away in a few days or 1 week): • Sad, anxious, or overwhelmed feelings • Crying spells • Loss of appetite • Difficulty sleeping Signs of postpartum depression (can begin any time in the first year): • Same signs as baby blues, but they last longer and are more severe • Thoughts of harming yourself or your baby • Not having any interest in the baby Signs of postpartum psychosis: • Seeing or hearing things that are not there • Feelings of confusion • Rapid mood swings • Trying to hurt yourself or your baby When to call your health care provider: • The baby blues continue for more than 2 weeks • Symptoms of depression get worse • Difficulty performing tasks at home or at work • Inability to care for yourself or your baby • Thoughts of harming yourself or your baby

Edinburgh Postnatal Depression Scale (EPDS) Name:

Address:

Your Date of Birth:

Baby’s Date of Birth:

Phone:

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed. I have felt happy:  Yes, all the time x Yes, most of the time   No, not very often  No, not at all (This would mean: “I have felt happy most of the time” during the past week.) Please complete the other questions in the same way. 1. I have been able to laugh and see the funny side of things.  As much as I always could  Not quite so much now  Definitely not so much now  Not at all 2. I have looked forward with enjoyment to things.  As much as I ever did  Rather less than I used to  Definitely less than I used to  Hardly at all

*6. Things have been getting on top of me.  Yes, most of the time I have not been able to cope at all  Yes, sometimes I have not been able to cope as well as usual  No, most of the time I have coped quite well  No, I have been coping as well as ever *7. I have been so unhappy that I have had difficulty sleeping.  Yes, most of the time  Yes, sometimes  Not very often

*3. I have blamed myself unnecessarily when things went wrong.

 No, not at all *8. I have felt sad or miserable.

 Yes, most of the time  Yes, some of the time  Not very often  No, never 4. I have been anxious or worried for no good reason.

 Yes, most of the time  Yes, quite often  Not very often  No, not at all *9. I have been so unhappy that I have been crying.  Yes, most of the time  Yes, quite often  Only occasionally  No, never *10. The thought of harming myself has occurred to me.  Yes, quite often  Sometimes  Hardly ever

 No, not at all  Hardly ever  Yes, sometimes  Yes, most of the time *5. I have felt scared or panicky for no good reason.  Yes, quite a lot  Yes, sometimes  No, not much  No, not at all

 Never

Administered/Reviewed by: SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 5–10 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts) Instructions for using the Edinburgh Postnatal Depression Scale: 1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days. 2. All the items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.) 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

Fig. 24.4 Edinburgh Postnatal Depression Scale (EPDS). (©1987 The Royal College of Psychiatrists. Cox, J. L., Holden, J. M., & Sagovsky, R. [1987]. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Translations of the scale, and guidance as to its use, may be found in Cox, J. L., Holden, J., & Henshaw, C. [2014]. Perinatal mental health: The Edinburgh Postnatal Depression Scale (EPDS) manual [2nd Ed.]. RCPsych Publications.

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NURSING ALERT Because the newborn may be scheduled for a checkup before the mother’s 6week checkup, nurses in well-baby clinics or physician offices should be alert for signs of PMD in new mothers and be knowledgeable about community referral resources.

PATIENT TEACHING Preventing a Perinatal Mood Disorder • Share knowledge about postpartum emotional issues with close family and friends. • At least once each day or every other day, purposely relax for 15 minutes, using deep breathing or meditating or by taking a hot bath. • Take care of yourself: eat a balanced diet. • Exercise on a regular basis, at least 30 minutes a day. • Sleep as much as possible; make a promise to yourself to try to sleep when the baby sleeps. • Get out of the house: try to leave home for 30 minutes a day; take a walk outdoors or walk at the mall. • Share your feelings with someone close to you; don’t isolate yourself at home with the TV. • Don’t overcommit yourself or feel like you need to be a supermom. Ask for help from family and friends. • Don’t place unrealistic expectations on yourself; you don’t need to be a perfect mother. • Be flexible with your daily activities. • Go to a new mothers’ support group: for example, take a postpartum exercise class or attend a breastfeeding support group. • Don’t be ashamed of having emotional challenges after your baby is born.

Patients who are at risk for PMD and those showing early signs of anxiety or depression may be followed after discharge from the birthing facility through home visits or telephone calls. Postpartum home visits can reduce the incidence of or complications from PMD. A brief home visit or phone call at least once a week until the new mother returns for their postpartum visit may save the life of a mother and their infant; however, home visits may not be feasible or available. Some provinces have mandatory telephone follow-up of all new mothers after the birth, and patients who are identified as high risk should receive more comprehensive followup. Supervision of the mother with emotional complications may become a prime concern. Because PMD can greatly interfere with mothering functions, family and friends may need to participate in the infant’s care. This is a time for extended family and friends to determine what they can do to help; the nurse can work with them to ensure adequate supervision and their understanding of the family member’s mental illness. When the postpartum patient has a PMD, a partner often reacts with confusion, shock, denial, and anger and feels neglected and blamed. The nurse can provide nonjudgemental opportunities for the partner to express feelings and concerns, help the partner identify positive coping strategies, and be a source of encouragement for the partner to continue supporting the patient. Suggestions for partners of patients with PMD include helping around the house, setting limits with family and friends, going with the patient to doctor’s appointments, educating themselves about PMD, writing down concerns and questions to take to the primary care provider or therapist, and just being with their partner—sitting quietly, hugging them, and demonstrating concern and compassion. Both the patient and their partner need an opportunity to express their needs, fears, thoughts, and feelings in a nonjudgemental environment. Even if the patient is severely depressed, hospitalization can be avoided if adequate resources can be mobilized to ensure safety for both

mother and infant. The community health nurse will need to make frequent phone calls or home visits for assessment and counselling. Community resources that may be helpful are temporary child care or foster care, homemaker service, meals on wheels, parenting guidance centres, mother’s-day-out programs, and telephone support groups.

Providing Safety. If delusional thinking about the baby is suspected, the nurse should ask the patient, “Have you thought about hurting your baby?” When PMD is suspected, the nurse asks, “Have you thought about hurting yourself?” Four criteria measure the seriousness of a suicidal plan: method, availability, specificity, and lethality. Has the patient specified a method? Is the method of choice available? How specific is the plan? If the method is concrete and detailed, with access to it right at hand, the suicide risk is increased. How lethal is the method? The most lethal method is shooting, with hanging being a close second. The least lethal method is slashing one’s wrists.

NURSING ALERT Suicidal thoughts or attempts are among the most serious symptoms of PMD. This is considered a psychiatric emergency and warrants immediate assessment, evaluation, and intervention by a mental health care provider.

Psychiatric Hospitalization. Patients with postpartum psychosis have a psychiatric emergency and must be referred immediately to a psychiatrist who is experienced in working with patients with psychosis, can prescribe medication and other forms of therapy, and can assess the need for hospitalization. LEGAL TIP: Commitment for Psychiatric Care If a patient with PMD is experiencing active suicidal ideation or harmful delusions about the baby and is unwilling to seek treatment, legal intervention may be necessary to commit the patient to an inpatient setting for treatment.

Within the hospital setting, the reintroduction of the baby to the mother can occur at the mother’s own pace. A schedule is set for increasing the number of hours during which the mother cares for the baby over several days, culminating in the infant staying overnight in the mother’s room. This enables the mother to experience meeting the infant’s needs and giving up sleep for the baby, a situation that is difficult for new mothers even under ideal conditions. The mother’s readiness for discharge and caring for the baby should be assessed. The mother’s interactions with the baby should also be carefully supervised and guided. A postpartum nurse may be asked to assist the psychiatric nursing staff in assessment of the mother–infant interactions. Nurses need to observe the mother for signs of bonding with the baby. Attachment behaviours are defined as eye-to-eye contact; physical contact that involves holding, touching, cuddling, and talking to the baby and calling the baby by name; and the initiation of appropriate care. A staff member should be assigned to keep the baby in sight at all times. Indirect teaching, praise, and encouragement are designed to bolster the mother’s self-esteem and self-confidence.

Psychotropic Medications. If a patient is diagnosed with depression, antidepressant medications will often be used. Antidepressant medications are the most widely used treatment for perinatal depression. Paroxetine, sertraline, fluoxetine, venlafaxine, nortriptyline, and nefazodone have been evaluated and are associated with improvement in depression symptoms over 2 to 3 months of treatment (O’Hara & Wisner, 2014) (Table 24.2). If the person with a PMD is not breastfeeding, in most cases antidepressants can be prescribed without special

TABLE 24.2

Medications for Perinatal Mood Disorders

Class

Medication

Indications

Maternal Adverse Effects

Infant Exposure Effects

Comments

SSRIs

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

Anxiety disorders, depression

Gastrointestinal distress, nervousness, headache, sexual dysfunction, sedation

All SSRIs are detectable in human milk. Paroxetine and sertraline are usually undetectable in infant serum; fluoxetine and citalopram >10% maternal level. Infant effects: irritability, uneasy sleep, drowsiness, colic, feeding difficulties. Fluoxetine is contraindicated during lactation.

Sertraline is most common; undetectable to low levels in human milk. Long-term effects of SSRI exposure on infants: more evidence is needed; recent evidence is reassuring.

SNRIs

Venlafaxine, duloxetine, desvenlafaxine

Depression

Galactorrhea

SNRIs are detectable in human milk and infant serum. No proven adverse effects; assess weight gain and sedation.

Lack of evidence on outcomes for breastfed infants

Other antidepressants (norepinephrine/ dopamine/ serotonin reuptake blockers)

Bupropion, mirtazapine

Depression

Drowsiness, increased appetite, weight gain, dizziness, dry mouth; dose-dependent

Limited data; concerns range from possible irritability to seizures.

Not a reason to stop breastfeeding; another medication may be preferable.

TCAs/ heterocyclics

Amitriptyline, amoxapine, clomipramine, desipramine, doxepin, maprotiline, nortriptyline, protriptyline, trimipramine

Anxiety disorders, depression

Hypotension, sedation, urinary retention, dry mouth, weight gain, sexual dysfunction, constipation; overdose can cause cardiac arrhythmias and death.

Lack of evidence on most medications; nortriptyline is undetectable in infant serum, no adverse effects are reported.

Older class of medications

Antipsychotic

Quetiapine

Bipolar disorder, schizophrenia

Sedation

Sedation

Mood stabilizer

Lithium

Postpartum psychosis

Diarrhea, vomiting

Elevated TSH

Dosage is based on maternal blood levels, which should be checked frequently.

Herbal/natural remedy

St. John’s wort

Depression

Poorly excreted into human milk; possible drowsiness, lethargy

Used in Europe for many years to treat depression; use in Canada is controversial.

SNRI, Serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; TSH, thyroid-stimulating hormone. Adapted from Sriraman N. K., Melvin K., Meltzer-Brody S., & Academy of Breastfeeding Medicine. (2015). ABM clinical protocol no. 18: Use of antidepressants in breastfeeding mothers. Breastfeeding Medicine, 10(6), 290–299.

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precautions. Patients who are breastfeeding need assessments to determine the risks and benefits of each medication, although there are several medications that can be taken (see further discussion below). Mood stabilizers are used in the treatment of severe psychiatric syndromes such as schizophrenia, bipolar disorder, or psychotic depression. Patients taking mood stabilizers must be taught about the many adverse effects; especially for those taking lithium, serum lithium levels need to be determined every 6 months. Most of the moodstabilizing medications can cause sedation and orthostatic hypotension—both of which can interfere with the mother being able to care safely for their baby. They also can cause peripheral nervous system effects such as constipation, dry mouth, blurred vision, tachycardia, urinary retention, weight gain, and agranulocytosis. Central nervous system effects may include akathisia, dystonias, parkinsonian-like symptoms, tardive dyskinesia (irreversible), and neuroleptic malignant syndrome (potentially fatal). Medication education is especially important when caring for patients who are taking antipsychotic medications. The nurse should use discretion in selecting the content to be shared because of the patient’s altered thought processes and the large number of adverse effects. The nurse may choose to provide more extensive education to a close family member. The newer, atypical antipsychotic medications such as aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone are usually safer and have fewer adverse effects than the older, more traditional antipsychotics. Their safety in breastfeeding patients, however, has not been established.

Psychotropic Medications and Lactation. Use of any psychotropic medication in a breastfeeding mother is done with consideration of risks and benefits. The risk of not treating the mother versus not breastfeeding the infant prompts providers to prescribe medications that reduce maternal symptoms without harming the infant. Concerns about many psychotropic drugs are related to the long-term use and potential effects on the infant (Hardy & Reichenbacker, 2019; Lawrence & Lawrence, 2016). SSRIs are the most common treatment for postpartum depression; they are also prescribed for anxiety disorders. Research has shown that the majority of the SSRIs taken by breastfeeding mothers pass through the milk to the infant in small amounts and have minimal effects on the infant (Hardy & Reichenbacker, 2019). Paroxetine, sertraline, and nortriptyline provide less infant exposure than fluoxetine and citalopram. All breastfeeding mothers who take SSRIs should be taught to monitor their infants for signs of irritability, poor feeding, and alterations in sleep pattern (Sriraman et al., 2015) (see Clinical Reasoning Case Study: Medications for Perinatal Depression). ?

CLINICAL REASONING CASE STUDY

Medications for Perinatal Depression Jenna, 31, gave birth to a 3400-g boy 4 weeks ago. She has been diagnosed with depression, and an SSRI (sertraline [Zoloft]) medication has been prescribed. Jenna is breastfeeding and has concerns about taking the medication. Questions 1. Evidence—Is there sufficient evidence regarding the safety of psychotropic medications and lactation? 2. Assumptions—What assumptions can be made about the following? a. Timing of feeding and medication administration b. Risks of discontinuing medications while breastfeeding 3. What is the nursing priority in this situation? 4. Does the evidence objectively support your conclusion? SSRI, Selective serotonin reuptake inhibitor.

Benzodiazepines, mood stabilizers, and antipsychotic medications are all used frequently in the treatment of postpartum psychiatric disorders despite the lack of research in this population. No long-term effects have been reported in exclusively breastfed infants whose mothers were taking benzodiazepines on a regular basis. The shorter-acting medications (alprazolam, lorazepam) are favoured over those with longer half-lives (clonazepam, diazepam) (Lawrence & Lawrence, 2016). Mood-stabilizing medications are present in the breast milk of patients who take these drugs. Lithium has been the most extensively studied. Lithium has been linked to several serious adverse effects in breastfeeding infants, including hypotonia, hypothermia, cyanosis, and electrocardiogram abnormalities. Therefore, its use is not recommended in breastfeeding mothers. Valproic acid and carbamazepine are considered reasonably safe for use while breastfeeding, although careful monitoring for infant hepatotoxicity is recommended. The benefits of breastfeeding and the potential risks must be carefully considered before using lithium or other mood stabilizers. In summary, all psychotropic medications studied to date are excreted in breast milk. The best psychotropic medications for breastfeeding patients are those with the greatest documentation of prior use, lower Hale risk category, few or no metabolites, and fewer adverse effects. The Hale risk category provides classification of medications used during lactation according to risk. The risk categories are L1 Safest, L2 Safer, L3 Moderately safe, L4 Possibly hazardous, and L5 Contraindicated. When breastfeeding patients have emotional complications and need psychotropic medications, referral to a mental health care provider who specializes in postpartum disorders is preferred. The patient should be informed of the risks and benefits to themselves and their infant of the medications to be taken. Depressed patients will need the nurse to reinforce the importance of taking antidepressants as ordered. Because antidepressants usually do not exert any significant effect for approximately 2 weeks and usually do not reach full effect for 4 to 6 weeks, many patients discontinue taking the medication on their own. Patient and family teaching should reinforce the schedule for taking medications until therapeutic effects are present and for as long as prescribed by the health care provider.

Other Treatments for Perinatal Mood Disorders. Other treatments for PMD include hormone therapy (often combined with antidepressant medication), complementary and alternative health modalities (e.g., yoga, massage, relaxation techniques), ECT, and psychotherapy. ECT may be used for patients with depression who have not improved with antidepressant therapy. Psychotherapy in the form of group therapy or individual (interpersonal) therapy has been used with positive results alone and in conjunction with antidepressant therapy; however, more studies are needed to determine what types of professional support are most effective. Fatigue may be associated with PMD, and development of interventions targeting stabilization of sleep and circadian rhythms in the perinatal period may improve outcomes (Krawczak et al., 2016). Alternative therapies may be used alone but often are used with other treatments for PMD. Safety and efficacy studies of these alternative therapies are needed to ensure that care and advice are based on evidence. Perinatal Depression in Male Partners. Often, postpartum patients are not alone in their experience of a mood disorder; partners may have depression or anxiety as well. The incidence is unclear, with reports varying from 10 to more than 25% (RNAO, 2018a). The best predictor of paternal perinatal depression (PPND) is having a partner with postpartum depression (Glasser & Lerner-Geva, 2019). Male partners who are underemployed, under financial stress, are older, and are

CHAPTER 24 Postpartum Complications experiencing a difference between parenting expectations and reality and those who feel excluded from the maternal infant bond are at higher risk of postpartum depression (RNAO, 2018a). Men may not exhibit classic symptoms of PMD but are likely to display fatigue, frustration, anger, irritability, and somatic symptoms (RNAO, 2018a) (see Evidence-Informed Practice: Paternal Perinatal Depression). Men are not routinely screened for perinatal depressive symptoms. There is no depression scale designed for this specific use. Some experts recommend using the EPDS in combination with the Gotland Male Depression Scale to identify men with signs of PPND (Habib, 2012). When both the father and the mother are depressed, life can be very difficult. Routine tasks of caring for the newborn and maintaining a household can present significant challenges. Interaction with the infant can be affected, and there can be negative effects on parenting. Nurses should include partners in discussions about postpartum depression, raising awareness that they can also suffer from depression, describing symptoms, and providing information about resources for help if the symptoms occur. During interactions with fathers, nurses can assess for signs of PPND, provide support and encouragement, and offer information about resources for further assessment and treatment (Letourneau et al., 2012; Stadtlander, 2015).

EVIDENCE-INFORMED PRACTICE Paternal Perinatal Depression Ask the Question For new fathers, what are the risks and protective factors for depression? What are the best ways to screen for depression? Search for the Evidence Search Strategies: English-language research-based publications on depression, fathers, anxiety, and paternal, perinatal, peripartum, and postpartum depression Databases Used: Cochrane Collaborative Database, National Guideline Clearinghouse (AHRQ), CINAHL, PubMed, and the professional website for ACOG Critical Appraisal of the Evidence When a mother develops perinatal depression, the evidence for poorer growth and cognitive and behavioural outcomes for their baby is indisputable. Much research continues our understanding of decreased maternal responsiveness to infant’s cues. Because family dynamics extend beyond the mother–baby dyad, new research is investigating the implications of paternal depression for the family system (Freitas et al., 2016): • Incidence of paternal depression (10%) is about half that of maternal depression (up to 20%), but about twice the male baseline rate of 5%. • Experts from many fields reached structured consensus about defining paternal depression markers as low mood, negative thoughts, feeling inadequate, weight loss, sleep deprivation, and “masked” male depressive symptoms of irritability, isolation or withdrawal, substance use, cheating, or gambling. • Risk factors for paternal depression include prior depression, poor social and relationship support, partner experiencing depression, and financial and work stress. Young paternal age, first child, and unrealistic expectations may also be risk factors. Massoud, Hwang, and Wickberg (2016) surveyed 885 Swedish couples at 3 months postpartum with the Edinburgh Postnatal Depression Scale (EPDS), which is also validated for fathers, and found the following: • Risk for depression doubled when the partner had depression, regardless which partner was the first to develop depression.

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• Other risk factors included prior depression, lower education level, lack of support from their partner, sleep deprivation, work stress, or conflicts. High EPDS scores for fathers were more likely to represent general distress, worry, anxiety, or unhappiness than actual depression. • Paternal depressive symptoms were associated with behavioural and relational issues in their offspring and increased conflict and violence in the home. Apply the Evidence: Nursing Implications Nurses who encounter new fathers, especially young and first-time fathers, in any setting should be alert to symptoms of distress and understand that depression may manifest differently in fathers than in mothers. • Reaching out to fathers should be a routine part of family-based care, beginning at pregnancy or before. Assessment begins with questions about physical issues such as sleep quality and diet changes and proceeds sensitively to questions about relational and life distress. Universal screening with validated screening tools and psychosocial interviews are recommended (Registered Nurses’ Association of Ontario [RNAO], 2018; Siu & US Preventive Services Task Force, 2016). • Starting with prenatal visits and continuing with well-child visits, nurses who reach out and include fathers may be in the best position to screen for depression in both parents and refer for early intervention (Vismara et al., 2016). • Discussing the transition to parenthood, life balance, and distress, and teaching about open communication, partner support, and self-care, especially adequate sleep, may be preventive for depression (RNAO, 2018). • Fathers do not like to be labelled. To avoid stigma, the health care team can call it whatever he wants (Freitas et al., 2016). • Spreading awareness of perinatal depression in society at large, and education for perinatal families in particular, can foster increased open communication and early identification of parents’ issues. Advocating for strong health care team relationships with parents and supportive employer, community, and government policies can also help, especially with unexpected stressors such as the special needs of a baby. References Freitas, C. J., Williams-Reade, J., Distelberg, B., et al. (2016). Paternal depression during pregnancy and postpartum: An international Delphi study. Journal of Affective Disorders, 202(15), 128–136. Massoud, P., Hwang, C. P., & Wickberg, B. (2016). Fathers’ depressive symptoms in the postnatal period: Prevalence and correlates in a population-based Swedish study. Scandinavian Journal of Public Health, 44(7), 688–694. https://doi.org/10.1177/ 1403494816661652. Registered Nurses’ Association of Ontario (RNAO). (2018). Assessments and interventions for perinatal depression (2nd ed.). https://rnao.ca/sites/rnao-ca/files/bpg/Perinatal_ Depression_FINAL_web_0.pdf. Siu, A. L., & US Preventive Services Task Force. (2016). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Journal of the American Medical Association, 315(4), 380–387. Vismara, L., Rolle, L., Agostini, F., et al. (2016). Perinatal parenting stress, anxiety, and depression outcomes in first-time mothers and fathers: A 3- to 6-months postpartum follow-up study. Frontiers in Psychology, 7, 938.

Pat Mahaffee Gingrich

LOSS AND GRIEF Situational life crises can be superimposed on the experiences of childbearing. Examples may include infertility, premature labour or premature birth, a Caesarean birth, any perception of loss of control during the birthing experience, the birth of a boy when the parents wanted a girl or vice versa, the birth of a child with a disability, a maternal death, or fetal or newborn death (see Community Focus box). All of these situations have a common denominator: they are losses of what was hoped for, dreamed about, and planned.

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COMMUNITY FOCUS Community Resources for Loss and Grief Investigate what resources and support groups exist in your community to assist parents who have experienced a maternal death; birth of a child with physical or intellectual challenges; a Caesarean birth if they hoped for a vaginal birth; or the death of a baby through miscarriage, stillbirth, or newborn death. Are resources available? Are there groups available for people who speak a language other than English? Are there enough of these resources to assist parents? How difficult was it for you to identify these resources? What could you do to make resources more known to bereaved parents and families?

These crises vary in degree, and every situation requires empathy, knowledge, and compassion from the health care provider. At the birth, the patient, partner, and family may be mourning instead of celebrating life. Newborn deaths within the first month of life have plateaued in Canada, with a rate of 3.3 deaths per 1 000 live births in 2019, and 4.4 per 1 000 within the first year of life (Statistics Canada, 2021). The leading cause of death is prematurity. Infants may die in the early postpartum period from prematurity, birth defects, birth trauma, or other acute illnesses. Thus, parents can experience grief before or during the childbearing experience. The focus of this section is to prepare the nurse to provide sensitive, supportive, and therapeutic interventions to parents and families experiencing perinatal loss in a variety of settings. An overview of the grief process is presented as a guide for assessing and understanding the responses of bereaved patients and their families. Guidelines for intervention are given, and specific intervention approaches are discussed.

Grief Responses Grief is the process of recovering from a loss, and in that process individuals experience many emotional, cognitive, behavioural, and physical responses. Grief is a normal process; however, complicated or prolonged grief responses including anxiety and depression are three times higher for the perinatal population than for other bereaved populations (Lundroff et al., 2017). Parental grief responses occur in four overlapping phases. According to Wilke and Limbo (2012) there is an early period of acute distress, shock, and numbness, which is most intense for the first 2 weeks. The second phase, from the second week to the fourth month, is characterized by searching and yearning. The fifth through the ninth month comprise the third phase, defined as disorientation. The final phase, reorganization or resolution, may be reached in the tenth through the twenty-fourth month, when parents return to their usual level of functioning in society, although the pain associated with the death remains. The duration of grief varies with the individual, but there is general agreement that grief is a long-term process that can extend for months and years. With a very close relationship such as with one’s baby, some aspects of grief never truly end.

Phase One: Shock and Numbness. The loss of a pregnancy or death of a newborn is an acute and distressing experience for families who planned for and expected a normal, healthy baby as the outcome. The loss encompasses a loss of their identity as parents and of their many dreams related to parenthood. The immediate reaction to news of a perinatal loss or newborn death is a period of acute distress. Parents generally are in a state of shock and numbness. They may feel a sense of unreality, loss of innocence, and powerlessness, as though they were in a bad dream or in a fog or trancelike state. Disbelief and denial can occur. Sadness, devastation, depression, and intense outbursts of

emotion and crying are common. Individuals describe feeling stunned, having a short attention span, and having an inability to concentrate or make decisions. In contrast, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or a personal way of coping with stress. Much of the attention during the time of a loss is on the birthing parent. The response of partners may vary more than that of mothers and depends on the level of identification with the pregnancy. Partners may be profoundly affected and grieve deeply for a perinatal loss, and it is important that they are supported in their grief as well as the mother. Partners are often distressed by the grief of the mother and may feel helpless in comforting them with the intense pain. Some partners may appear stoic and unemotional, to maintain the societal expectation that they be “strong” for the mother and other family members. Because many men do not easily share their feelings or ask for help, special efforts may be needed to help them acknowledge these feelings and realize that they, too, have a right to support from others in their pain. During this time of acute distress, parents face the first task of grief: accepting the reality of the loss. The pregnancy has ended, or the baby has died, and their lives have changed. Although parents are often required to make many decisions, such as having an autopsy, naming the newborn, and making funeral arrangements, normal functioning is impeded and decisions are difficult to make. Grandparents, friends, clergy, or other relatives may be available to help the couple cope. However, it is important that the parents ultimately make the decisions that are right for them.

Phase Two: Searching and Yearning. The phase of intense grief encompasses many difficult emotions as the parents work through their pain and adjust to life without the wished-for child. In the early months after the loss, parents often experience feelings of loneliness, emptiness, and yearning. The mother may report that their arms ache to hold or nurse their baby and that they wake to the sound of a baby crying. Both parents may be preoccupied with thoughts about the wished-for child. Some parents cope with these feelings by avoiding memories and not talking about the baby, whereas others want to reminisce and discuss their loss over and over. Deciding what to do about the nursery and baby clothes is particularly difficult during this period. Some parents may want the room taken down before they go home, whereas others want the room left intact until they have had time to grieve their loss. It is not unusual for a grandparent or other family member to want to rush home to take down the nursery, thinking that the parents would be spared additional grief. In fact, their actions might only complicate the grief if the parents were not involved in the decision. The bereaved parents must go through these types of experiences in their own time frame so that healing can take place. During this phase of intense grief, guilt may emerge from the deep feelings of helplessness in not somehow preventing the pregnancy loss or the death of the newborn. Mothers are particularly vulnerable to feeling guilt because of their sense of responsibility for the well-being of the fetus and baby. With many perinatal losses, there is no clear cause of the event, leaving the patient to speculate about what they might have done or not done to bring about the loss. Guilt may be intense if the parent thinks they are being punished for some unrelated event, such as having had a prior induced abortion. Many patients describe feeling tortured by “self-blame” and they need repeated emotional reassurance that they are not at fault. Other common responses during this phase are anger, resentment, bitterness, and irritability. Anger may be focused on the health care team who failed to save the pregnancy or newborn; toward a God who allowed the loss to occur; or toward family, friends, or peers when

CHAPTER 24 Postpartum Complications they do not provide the support that the bereaved parents need and want. Some parents focus their resentment on parents who do not appreciate their children or neglect and abuse them. A sense of bitterness or generalized irritability rather than frank anger may be another response. Physical symptoms of grief may include fatigue, headaches, palpitations, and lack of strength. During the grief process, fear and anxiety can occur as a profound worry that something else bad might happen to another pregnancy. Some parents, especially mothers, are almost obsessed with the desire to become pregnant again; others struggle with whether they can cope with the possibility of another loss.

Phase Three: Disorientation. Deep sadness and depression can arise when the parent has full awareness of the loss. This often occurs several months after a perinatal loss and can continue for some time. Sadness and depression can be accompanied by disorganization and difficulties with cognitive processing, memory, and organization. This, coupled with insomnia, social withdrawal, and lack of energy, can lead to behavioural changes, such as difficulty getting things done, an inability to concentrate, restlessness, confused thought processes, difficulty solving problems, and poor decision making. Disorganization, feelings of failure, and depression often cause difficulties in keeping up with work and family expectations. In addition, parents returning to work face issues such as handling well-meaning but painful comments or the silence of co-workers. Physical symptoms of grief include fatigue, headaches, dizziness, and altered appetite and exhaustion. Parents are at risk for developing health conditions and chronic undefined feelings of illness. It may be difficult to sleep; appetite may be depressed or voracious. Lack of sleep and inadequate nutrition and fluids can complicate other grief responses. Grief responses are very personal, ongoing, and difficult to handle. Some parents may suppress or deny their feelings because of perceived societal indifference toward pregnancy loss and infant death. On the surface, suppression of feelings may be more socially acceptable. However, denying the pain of grief may lead to eventual physical and emotional distress or illness. Although bereaved parents have many ups and downs for many months and even years after a child’s death, few

BOX 24.6

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parents actually become mentally ill or commit suicide. Knowing that these feelings are normal and that others have had similar feelings can be helpful to them. The grief process during this phase is often difficult for partners. Some may continue to have difficulty sharing their feelings. A rift can occur if one parent, usually the mother, wants to talk about the loss and pain, and the other parent—often, but not always, the partner—withdraws. Other signs of difficulties include reliance on alcohol and drugs, extramarital affairs, prolonged hours at work, and overinvolvement in activities outside the home as an escape.

Phase Four: Reorganization and Resolution. Reorganization and resolution continue beyond 24 months for many parents (Wilke & Limbo, 2012). From the time of the pregnancy loss or newborn death, parents attempt to understand why this happened. This leads to a long and intense search for meaning. At first the “why” is focused on the cause of death, which is often never determined. Finding few good answers, parents next focus on “why me, why mine?” These questions can lead some parents into an existential search about the meaning of life and death. This search continues into the phase of reorganization and may lead to profound changes in the parents’ view of the fragility of life. Time helps to slowly ease the painful feelings of grief. Reorganization occurs when parents are better able to function at home and work, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective. Reorganization begins to peak sometime after the first year, as parents begin to achieve the task of moving on with their lives as they feel renewed energy and a sense of release. Enjoying the simple pleasures of life without feeling guilty, nurturing self and others, developing new interests, and reestablishing relationships are all signs of moving on. For some families, another pregnancy and the birth of a subsequent child are important steps in moving on with their lives; however, the term recovery is used because the grief related to perinatal loss can continue to varying degrees throughout life. Parents who have suffered a pregnancy loss or newborn death have shared that they will never forget the baby who died and they are not the same people as before the loss (Box 24.6). The term bittersweet grief refers to the grief response that occurs with reminders of the loss. This

I Am Strong

I am strong. I am strong because at my 38 week OB appointment, I listened to a strong heartbeat and the doctor said everything was great. I am strong because she told me I was 3 cm dilated and labour could begin at any time. I am strong because I left the office, completely excited and happy and couldn’t wait to be able to meet my new love shortly! I am strong because the next day at 1130 pm labour and contractions began. They weren’t very strong or close together yet at that point. I am strong because the following morning at 9 am the contractions began to get closer together so I slipped into the tub to relax just a bit. I am strong because by 930 am contractions became so strong and frequent, I got out of the tub and called the hospital triage. I am strong because they told me to make my way over to the hospital. I am strong because, although I was in an amazing amount of pain, and contractions were now just under 2 minutes apart, I was so excited. I had arrived at labour and delivery around 10 am. I am strong because they took me into the triage room and began the routine.

I am strong because I immediately knew there was a problem when the nurse seemed to be having a hard time locating the heartbeat. I am strong because she called in the doctor on call who tried to locate a heartbeat also. I am strong because he gave us the news, news no parent should ever have to hear, “I’m so sorry, but the baby doesn’t have a heartbeat.” I am strong because I cried. I am strong because I then had to make a decision, to deliver my sleeping baby or proceed with a Caesarean section. I am strong because I choose to continue with the labour and contractions, I wanted to deliver this baby. I am strong because I was planning a VBAC and I wanted it to be that way. I am strong because I laboured for hours and at 6 pm I gave birth to my baby. I am strong because I had a son, a beautiful baby boy, 3500 g. I am strong because we named him Matteo. I am strong because the nurse cleaned up my baby and brought him over to me. I am strong because I had the opportunity to hold, cuddle and kiss my sleeping, stillborn son. Continued

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UNIT 6

BOX 24.6

Postpartum Period

I Am Strong—cont’d

I am strong because I cried. I am strong because my husband and my daughter were able to hold their baby son and baby brother. I am strong because my family was able to come and meet my new baby. I am strong because I knew he wouldn’t be coming home. I am strong because at midnight I had to let him go. I am strong because I cried. I am strong because the next day I was discharged and was able to go home. I sobbed as my husband wheeled me out of the room and down the hall. I am strong because I had to leave the hospital, after a day of labour, contractions, pains and sadness without my baby. I am strong because I cried. I am strong because we then had to go about and make arrangements for the baby boy I wasn’t able to take home. I am strong because we chose a spot for him among other sleeping babies, he could sleep with them, under a large green tree. I am strong because I chose a cozy little pajama with elephants for my baby to sleep in and a soft warm blanket for him to snuggle in. I am strong because I cried. I am strong because one week later, my husband, daughter, sleeping baby and myself, were allowed to be in a room together for one last time. I am strong because this is where I held his tiny hand in my fingers, I am strong because I was able to kiss his tiny nose, his perfect lips. I am strong because I spoke to him softly.

I am strong because this is where we had to say goodbye to baby Matteo. I am strong because I cried. I am strong because we proceeded to the cemetery where we had a simple, sweet ceremony for our baby. I am strong because we all cried. I am strong because I watched as he was buried. I am strong because my sweet baby, my son was buried. I am strong because I cried. I cried. We all cried. I am strong because I have the hope that we will see our baby Matteo again, soon. I am strong because I believe he now won’t have to live in a world of sin, pain and suffering, and I am strong because I know I will hold and cuddle him again, and he will be safe in my arms. I am strong because every day I think about him. I am strong because every day I want him back. I am strong because I am a mommy of two beautiful children. I am strong because I am only currently a parent to one of them. I am strong because of my daughter, although only 3 years old, she’s strong too. I am strong because, although every day I may be sad, I am also happy. I am strong because I am able to cry and I am strong because I am able to smile. I am strong because of all the blessings I have been given, including my beautiful sleeping baby.

(Used with permission of Author.) VBAC, Vaginal birth after Caesarean.

typically happens on birthdays, death days, and anniversaries; at school events; during changes in the seasons; and during the time of the year when the loss occurred. Grief feelings also can be triggered during subsequent pregnancies and after birth. Resumption of the couple’s sexual relationship is an important aspect of recovery but can be very complicated. Many parents are comforted by the belief that their babies were conceived in love, lived in love, and died in love. Their love and intimacy created this child, and parents may believe that they may never experience joy and closeness again. Some couples may have an increased need for sexual activity in an attempt for closeness and healing, whereas others have a decreased desire for sexual intimacy. Sexuality also brings with it decisions about a future pregnancy. Some couples are eager to have another child, although this child cannot replace the one who died and the grief will continue despite another pregnancy. Other parents have a deep fear of experiencing the pain of loss again, which can make the resumption of sexual activity difficult. These ambivalent feelings are normal, and couples can find themselves moving back and forth between the emotions of exhilaration and fear. The excitement that many other parents experience with a pregnancy is very different for previously bereaved parents. For some, this emotional distress can affect attachment to the new baby. Couples often mark the progress of the pregnancy in terms of fetal development, waiting anxiously until the number of weeks of the previous loss is passed. In some cases, the fear of repeated loss, especially after a stillbirth, is so great that induction of labour may be considered if the fetus is mature. Support groups are important in helping persons through pregnancies after loss of a fetus or newborn.

Some individuals experience complicated or prolonged grief in the form of depression. Unexplained death has been identified as a causal factor in complicated grief (Garstang et al., 2016). As well, it has been identified that patients who have other children show fewer cases of prolonged grief (Lundroff et al., 2017).

Family Aspects of Grief Grandparents and Siblings. It is extremely important for the nurse taking care of patients who have experienced a loss to keep in mind that they have an entire family to care for, including grandparents and siblings. Grandparents have hopes and dreams for a grandchild; these have been shattered. The grief of grandparents is often complicated by the fact that they are experiencing intense emotional pain by witnessing and feeling the immense grief of their own child. It is extremely difficult to watch their son or daughter experience unimaginable emotional trauma, with very few ways to comfort them and end their pain. As a result, the grief response may be complicated or delayed for grandparents. On occasion, some grandparents experience immense survivor guilt because they are alive and their grandchild has died. The siblings of the expected baby also experience a profound loss. Most children have been prepared for having another child in the family, once the pregnancy is confirmed. These children’s ages and stages of development must be considered in understanding how they view the event and experience the loss. Older siblings need to be included in grieving rituals, to the extent that the parents and the child feel comfortable. They may need to see

CHAPTER 24 Postpartum Complications the baby to realize the loss. Nurses need to have a basic understanding of how children view death and grief in order to reach out to siblings in an appropriate and sensitive manner. Nurses also need to help parents recognize and be sensitive to the grief of siblings, include them in family rituals, and keep the baby alive in the family memory.

Nursing Care Nursing care of parents experiencing a perinatal loss begins the first time they are faced with the potential loss of their pregnancy or death of their newborn. Assessment is as important for families experiencing a miscarriage or ectopic pregnancy as it is for those experiencing stillbirth or newborn loss. Supportive interventions are important at the time of the loss and after the parents have returned home. Parents often cannot recall details of their experiences at the time of the child’s death, but they may recall vividly a minor event that was perceived as particularly painful or particularly helpful. The interventions provided below are general ideas about what may be helpful to parents. However, care must be individualized for each parent and family. Cultural and spiritual beliefs and practices of individual parents and families must also be considered. Nurses and organizations are encouraged to facilitate perinatal bereavement training for all involved in perinatal loss (see Additional Resources at the end of the chapter). Nurses may experience compassion fatigue and are encouraged to seek assistance in the form of debriefs, support from colleagues, and seeking professional guidance when needed.

Communicating and Caring Techniques. Parents and extended families look to the interprofessional team for support and understanding during the time of loss. Therapeutic communication and counselling techniques help the mother, partners, and other family members express their feelings and emotions, understand their responses to the loss, and make decisions. The nurse should listen patiently while people tell their story of loss and grief. It may be necessary to ask questions that help people talk about their grief and the experiences surrounding the loss. However, grief responses in the initial days of crisis make it difficult for individuals to concentrate on what is being asked, think about what a question means, and respond to a question. The use of silence often gives the bereaved person the opportunity to collect their thoughts and respond to questions. The nurse should resist the temptation to give advice or use cliches in offering support. Nurses need to become comfortable with their own feelings of grief and loss to effectively support and care for the bereaved. It is appropriate to express feelings with the bereaved families and share the moment with them. The nurse might use some of the lines in Box 24.7 in helping the family share and express their grief. Helping Families Actualize the Loss. When a loss or death occurs, the nurse should be sure that parents have been honestly told about the situation by their primary health care provider or others on the health care team. It is important for their nurse to be with the parents during this time. With early pregnancy loss, it is recommended that the term miscarriage be used consistently. With newborn death, caregivers should use the words “dead” and “died,” rather than “lost” or “gone” to assist the bereaved in accepting this reality. Encouraging the family to choose a name helps make the baby a member of their family, so that the baby can be remembered in a special way.

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BOX 24.7

What to Say and What Not to Say to Bereaved Parents What to Say “I’m sad for you.” “How are you doing with all of this?” “This must be hard for you.” “What can I do for you?” “I’m sorry.” “I’m here, and I want to listen.” What Not to Say “God had a purpose for her.” “Be thankful you have another child.” “The living must go on.” “I know how you feel.” “It’s God’s will.” “You have to keep on going for her sake.” “You’re young; you can have others.” “We’ll see you back here next year, and you’ll be happier.” “Now you have an angel in heaven.” “This happened for the best.” “Better for this to happen now, before you knew the baby.” “There was something wrong with the baby anyway.”

Used with permission of Gundersen Lutheran Medical Foundation, Inc., La Crosse, WI.

NURSING ALERT A caution about naming is important to note. Naming is an individual decision that should never be imposed on parents. Beliefs and needs vary widely across individuals, cultures, and religions. Cultural taboos and rules in some religious faiths prohibit the naming of a newborn who has died.

On the basis of vast clinical experience with parents, many professionals believe that seeing the dead fetus or newborn helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for continued parenting. Many parents relish the memory of parenting their deceased baby by holding, bathing, and dressing the child. However, parents should never be made to feel that they should see or hold their newborn when this is something they do not want to do. It is good policy for the nurse to first tell them about this option and then give them time to think about it. The nurse can ask a question such as “Some parents have found it helpful to see their baby. Would you like time to consider this?” Later the nurse can return and ask each parent individually what each has decided. Because the need or willingness to see the newborn also may vary between the parents, it is important to determine what each parent really wants. In preparation for the visit with the baby, parents appreciate explanations about what to expect, so providing a description of how their baby looks is important. For example, babies may have red, peeling skin like a bad sunburn, dark discoloration similar to bruises, moulding of the head that makes the head look soft and swollen, or birth defects. The nurse should make the baby look as normal as possible and remember that parents see their baby with different eyes from those of health care providers. If the baby has been in the morgue, they can be placed

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underneath a warmer for 20 to 30 minutes and wrapped in a warm blanket before being brought to the parents. The use of powder and lotion stimulates the parents’ senses and can help provide pleasant memories of their baby. When bringing the newborn to the parents, it is important to treat the baby as one would a live baby. Holding the baby close, touching a hand or cheek, using the baby’s name, and talking with the parents about the special features of their baby convey that it is all right for them to do likewise. If a baby has a congenital anomaly, the nurse can focus on aspects of the baby that do not have an abnormality. Nurses can help parents explore the baby’s body as they desire. Parents often seek to identify family resemblance. A good question might be: “Who in your family does your baby resemble?” Some families may like to have the opportunity to bathe and dress their baby. Although the skin may be fragile, parents can still apply lotion with cotton balls; sprinkle powder; tie ribbons; fasten the diaper; and place amulets, medallions, rosaries, or special toys or mementos in their baby’s hands or next to their baby. Parents may want to perform other parenting activities, such as combing the baby’s hair, dressing the baby in a special outfit, wrapping the baby in a blanket, or placing the baby in a crib. Parents need to be offered time alone with their baby if they wish. They also need to know when the nurse will return and how to call if they should need anything. If at all possible, the family should be placed in a private room, and the room should have a rocking chair for the parents to sit in when holding their baby. This offers the mother and partner special time together with their baby and with other family members (Figure 24.5). Marking the door to the room with a special card can be helpful in reminding staff that this family has experienced a loss. Many hospitals use a specific picture (often a butterfly) to indicate that the family in the room has experienced a loss. This allows all staff in the hospital to be aware of the needs of the patient. Sensitivity to parental needs in actualizing the loss and coping with the reality of the death is essential for their healing. Grandparents should be offered the same opportunities to hold, rock, swaddle, and love their grandchildren so that their grief is started in a healthy way.

Helping Parents With Decision Making. At a time when parents are experiencing the great distress of a perinatal loss, and especially if the loss was of a newborn, these parents have many decisions to make. Mothers, partners, and extended families look to the medical and nursing staff for guidance in knowing what decisions they must and can make and in understanding the options related to those decisions. It is a primary responsibility of the nurse to help them and to advocate for them, because decisions made during the time of their loss will provide memories for a lifetime. One decision might be related to conducting an autopsy. An autopsy can be very important in answering the question “why” if there is a chance that the cause of death can be determined. This information can be helpful in processing grief and perhaps in preventing another loss. Some parents may believe that their baby has been through enough and prefer not to have further information about the cause of death. Some religions prohibit autopsy or limit the choice to instances in which autopsy may help prevent another loss. Parents may need time to make this decision. There is no need to rush them unless there was evidence of contagious disease or maternal infection at the time of death. Another important decision relates to spiritual rituals that may be helpful and important to parents. Support from clergy is an option that should be offered to all parents. Parents may wish to have their own

Fig. 24.5 Laura’s family members say a special goodbye. (Courtesy Amy and Ken Turner, Cary, NC.)

pastor, priest, rabbi, or spiritual leader contacted, or they may wish to see the hospital’s chaplain. They may choose to do neither. Clergy persons may offer the parents the opportunity for baptism, when appropriate. Other rituals that may be important include a blessing, a naming ceremony, anointing, ritual of the sick, memorial service, or prayer. One of the major decisions that parents must make is disposition of the body. Parents should be given information about the choices for the final disposition of their baby, regardless of gestational age. However, nurses must be aware of cultural and spiritual beliefs that may dictate the choices of parents, as well as the cost of burial, alternatives to burial, and provincial laws related to burial. In Canada, if a fetus is greater than or equal to 20 weeks of gestational age or is born alive, it is the parents’ responsibility to make the final arrangements for their baby, although some parents may want a burial for a fetus that is younger than 20 weeks and this should be facilitated.

CHAPTER 24 Postpartum Complications

LEGAL TIP: Laws Regarding Live Birth Laws in all provinces govern what constitutes a live birth. In most provinces, a live birth is considered to be any products of conception expelled that show any signs of life. Signs of life are considered to be any muscle irritability, respiratory effort, or heart rate, regardless of gestational age. All nurses should be knowledgeable about the provincial laws regarding what constitutes a live birth and the forms that must be completed and filed in the case of fetal death, stillbirth, or newborn death.

In making final arrangements for their baby, parents may want a special service. They may choose to have a service in the hospital chapel, visitation at a funeral home or their own home, a funeral service, or a graveside service. Parents can make any of these services as special, personal, and memorable as they like. The timing for actions such as naming the baby, seeing and holding the baby, creating mementos (e.g., pictures and footprint moulds), disposition of the body, and funeral arrangements should never be rushed. In some cases, the mother may be discharged home before these decisions are made. Then the family can think about them in the comfort of their home and contact the hospital in the following days to give their answers.

Helping Families to Acknowledge and Express Feelings. One of the most important goals of the nurse is to validate the experience and feelings of the parents, by encouraging them to tell their stories and by listening with care. Bereaved parents have many questions surrounding the event of their loss, and some questions can leave them feeling guilty. This is particularly true for mothers. Such questions include “What did I do?” “What caused this to happen?” “What do you think I should have, could have done?” Part of the grief process for bereaved parents is figuring out what happened, their role in the loss, why it happened to them, and why it happened to their baby. The nurse should recognize that these questions must be answered by the bereaved themselves; it is part of their healing. For example, a bereaved mother might ask, “Do you think that this was caused by painting the baby’s room?” An appropriate response might be, “I understand you need to find an answer for why your baby died, but we really don’t know why she died. What are some of the other things you have been thinking about?” Trying to give bereaved parents answers when there are no clear answers or trying to squelch their guilt feelings by telling them they should not feel guilty does not help them process their grief. In reality, many times there are no definite answers to the question of why this terrible thing has happened to them. However, factual information such as data about the frequency of miscarriages in pregnant patients or the fact that there usually is no clear cause of a stillbirth can be helpful. Feelings of anger, guilt, and sadness can occur immediately but often become more problematic in the early days and months after a loss. When a bereaved person expresses feelings of anger, it can be helpful to identify the feeling by simply saying, “You sound angry,” or “You look angry.” The nurse’s willingness to sit down and listen to these surface feelings of anger can help the bereaved person move past them into the underlying feelings of powerlessness and helplessness in not being able to control the many aspects of the situation. Normalizing the Grief Process and Facilitating Positive Coping. While helping parents share their feelings of pain, it is critical to help them understand their grief responses and know that they are not alone in these painful responses. Most parents are not prepared for the raw feelings they experience or the fact that these painful, complex

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feelings and related behavioural reactions continue for many weeks or months. Thus, reassuring them of the normality of their responses and preparing them for the length of their grief is important. The nurse can help the parent be prepared for the emptiness, loneliness, and yearning; for the feelings of helplessness that can lead to anger, guilt, and fear; and for the disorganization, difficulty making decisions, and sadness and depression that are part of the grief process. In the initial days after a loss, other useful nursing strategies include follow-up phone calls, referrals to a perinatal grief support group, or providing books, pamphlets, videos, or websites intended for helping parents who have experienced a perinatal loss (see Additional Resources at the end of the chapter). To help minimize relationship issues that can occur in grieving couples, it is particularly important to help them understand that they may respond and grieve in very different ways. This is called incongruent grief (Wilke & Limbo, 2012). For example, one partner may feel depressed and have no energy and be unable to work, while the other partner may cope by going back to work and working long hours. The differences in grieving can lead to serious relationship issues and be a risk factor for complicated bereavement. Remind the couple of the importance of being understanding and patient with each other and seeking professional help as needed. Nurses can reinforce positive coping efforts and encourage attempts to resume normal activities; reinforce and encourage positive ways to hold onto memories of the pregnancy or baby while letting go; and help the parents organize a plan for daily activities, if needed.

Meeting the Physical Needs of the Bereaved Postpartum Patient. Coping with loss and grief after childbirth can be an overwhelming experience for the patient and their family. One particularly difficult aspect of the loss is the sound of crying babies and the happiness of other families on the unit who have given birth to healthy newborns. The mother should be given the opportunity to decide if they want to remain on the maternity unit or be moved to another hospital unit. They also should be helped to understand the pluses and minuses of each choice. Postpartum care and grief support may not be as good on another hospital unit where the staff are not experienced in postpartum and bereavement care. The physical needs of a bereaved mother are the same as those of any patient who has given birth. The cruel reality for many bereaved mothers is that their milk can come in with no baby to feed, their afterpains remind them of their emptiness, and gas pains feel as though a fetus is still moving inside. The nurse should ensure that the mother receives appropriate medications to reduce these physical symptoms. Adequate rest, diet, and fluids must be offered to replenish their physical strength. Mothers need postpartum care instructions on discharge.

Creating Memories for Families to Take Home. Parents may want tangible mementos of their baby to help them actualize the loss. Some may want to bring in a previously purchased baby book. Special memory books, cards, and information on grief and mourning are often available to give to parents (Figure 24.6). The nurse can provide information about the baby’s weight, length, and head circumference to the family. Footprints and handprints can be taken and placed with the other information on a special card or in a memory or baby book. If the print does not turn out, the nurse can trace around the baby’s hands and feet, although this distorts the actual size. Moulds can also be used to make an imprint of the baby’s hand or foot. Parents often appreciate articles that were in contact with or used in caring for the baby. This might include the tape measure used to measure the baby, baby lotions, combs, clothing, hats, blankets, crib cards,

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Fig. 24.6 Memory kit assembled at John C. Lincoln Hospital, Phoenix, AZ. Memory kits may include pictures of the newborn, clothing, death certificate, footprints, ID bands, and ultrasound picture. (Courtesy Julie Perry Nelson.)

and identification bands. The identification band helps the parents remember the size of the baby and personalizes the mementos. The nurse should ask parents if they wish to have these articles. A lock of hair may be another important keepsake. Parents must be asked for permission before cutting a lock of hair, which can be removed from the nape of the neck where it is not noticeable. For some parents, pictures are the most important memento. Photographs are generally taken whenever there is an identifiable baby and when it is culturally acceptable to the family to take photos. It does not matter how tiny the baby is, what the baby looks like, or how long the baby has been dead. Pictures should include close-ups of the baby’s face, hands, and feet and photos of the baby clothed and wrapped in a blanket and unclothed. If there are any congenital anomalies, close-ups of these also should be taken. Flowers, blocks, stuffed animals, or toys can be placed in the background to make the picture more special. Parents may want their pictures taken holding the baby. Keeping a camera nearby and taking pictures when parents are spending special time with their baby can provide special memories. Some parents may have their own camera, video camera, or smartphone and ask the nurse to record them as they bathe, dress, hold, or diaper their baby. An organization called Now I Lay Me Down to Sleep provides a professional photographer to take pictures for families at no cost. Their website can be consulted to determine if there is a photographer within the geographical location.

Documentation. Many hospitals have a checklist that is used in providing care, mobilizing members of the interprofessional health care team, communicating options that the family has chosen, and keeping track of all the details in meeting the needs of bereaved parents. Documentation in the nursing notes of primary concerns, grief responses, health teaching, health care advice, and referrals of the mother or any other family members is essential to ensure continuity and consistency of care. Providing Sensitive Care at and After Discharge. Leaving the hospital can be a devastating experience for the patient who has had a pregnancy loss, as not carrying a baby in their arms is a very empty and painful experience. Giving the mother a special flower to carry in her arms can be a thoughtful gesture.

The grief of the mother and their family does not end with discharge; it really begins once they return home, attend the funeral, and start to live their lives without their baby. There are numerous models for providing follow-up care to parents after discharge. Such programs include hospital-based bereavement teams who provide support during hospitalization and follow-up contacts and memorial services. Phone calls from hospital staff after a loss may be helpful to some parents; however, it must be determined which parents do not want them. Follow-up calls let the parents know that someone still thinks and cares about them. The calls are made at predictably difficult times, such as the first week at home, 1 month to 6 weeks later, 4 to 6 months after the loss, and at the anniversary of the death. Families who have experienced a miscarriage, ectopic pregnancy, or death of a preterm baby may appreciate a phone call on the estimated due date. Such calls provide an opportunity for parents to ask questions, share their feelings, seek advice, and receive information to help them process their grief. A grief conference can be planned when parents return for an appointment with their doctor, nurses, and other health care providers. At the conference, the loss or death of the baby is discussed in detail, parents are given information about the baby’s autopsy report and genetic studies, and they have the opportunity to ask questions that have arisen since their baby’s death. This is an important time to help parents understand the cause of the loss or accept the fact that the cause will forever be unknown. This meeting also gives health care providers the opportunity to assess how the family is coping with their loss and to offer additional information and education on grief. Some parents are very interested in finding a perinatal or parent grief support group. Talking with others who have been through similar experiences, sharing memories of the pregnancy and the baby, and gaining an understanding of the normality of the grief process generally have been found to be supportive. Over time, it may be the only place where bereaved parents can talk about the wished-for child and their grief. However, not all parents find such groups helpful.

MATERNAL DEATH Maternal death can be caused by a variety of complications, including embolism, hypertension, hemorrhage, infection, and cardiomyopathy. In many cases, the death of a mother is sudden and unexpected. Any instance of maternal death is tragic for the family as well as for the nurses and other health professionals who were involved in her care. In Canada it is rare for a patient to die in childbirth; in 2018 the maternal death rate was 8.3 deaths per 100 000 (Statistics Canada, 2019a). When a patient dies of a complication related to childbearing, the partner and extended family are faced with mourning the death of a partner and mother. The loss and grief are greatly compounded when there is also the death of a fetus or newborn. When the newborn survives, the partner is faced with parenting a baby without a surviving mother. The responsibilities of newborn care can be overwhelming during this time of intense loss and grief. Because most maternal deaths are unexpected, the grief that follows a maternal death is sudden. This differs from anticipatory grief in which the loss is expected, such as with cancer. The shock and disbelief associated with unplanned grief can be engulfing and debilitating, overwhelming the normal coping abilities and creating difficulties with everyday functioning and decision making. Nurses and other health care providers working with families who experience maternal loss need to consider the context and the implications of the maternal death for the remaining family members. Young parents may never have experienced a significant personal loss or

CHAPTER 24 Postpartum Complications tragedy; in many cases, their parents and grandparents are still living. Cultural beliefs and customs surrounding death can influence a family’s response to maternal death. The grief response of each family member will vary; grief is an individual response, and the grieving process does not always proceed in a predictable manner. Families who experience maternal loss are at risk for developing complicated bereavement and altered parenting of the surviving newborn and other children in the family. A referral to social services to help the family mobilize support systems and for counselling can help prevent potential difficulties before they develop and can be beneficial not only at the time of the loss but also in the future. Follow-up care for grieving families is essential as they progress through the stages of grief and adjust to life without the mother. The emotional toll that a maternal death can take on the nursing and medical staff must also be addressed. Guilt, anger, fear, sadness, and depression are all common responses to a maternal death. The staff may want to participate in a debriefing session in which they can review the situation surrounding the events, their participation in caring for the mother, and their response to the death. Attending memorial or funeral services may benefit staff and family. Follow-up conferences with a social worker or grief counsellor can help staff members work through their grief.

KEY POINTS • PPH is the most common and most serious type of excessive obstetrical blood loss. • The etiology of PPH is related to one of the following categories: tone, tissue, trauma, and thrombin. • Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may ensue. • Postpartum infection is a major cause of maternal morbidity and mortality throughout the world. • Postpartum UTIs are common during the postpartum period. • Breast infection affects about 1% of patients soon after childbirth. • Perinatal mood disorders (PMDs) account for most mental health disorders in the postpartum period. • Suicidal thoughts or attempts are among the most serious symptoms of postpartum psychosis. • Treatment of PMD requires a combination of medication, education, supportive measures, and psychotherapy. • Antidepressant medications are the usual treatment for PMD; however, specific precautions are needed for breastfeeding patients. • An understanding of grief responses and the bereavement process is fundamental in implementation of the nursing process. • Therapeutic communication and counselling techniques can help families identify their feelings and feel comfortable in expressing their grief. • Follow-up after discharge is an essential component to providing care to families who have experienced a loss. • Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgemental environment of care and support for bereaved families.

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haemorrhage: An integrative review of the literature. BMC Pregnancy and Childbirth, 15, 1–9. Hardy, L. T., & Reichenbacker, O. L. (2019). A practical guide to the use of psychotropic medications during pregnancy and lactation. Archives of Psychiatric Nursing, 33(3), 254–266. http://doi.org/10.1016/j.apnu.2019. 04.001. Holford, N., Channon, S., Heron, J., et al. (2018). The impact of postpartum psychosis on partners. BMC Pregnancy and Childbirth, 18(414). https://doi. org/10.1186/s12884-018-2055-z. Krawczak, E., Minuzzi, L., Simpson, W., et al. (2016). Sleep, daily activity rhythms and postpartum mood: A longitudinal study across the perinatal period. Chronobiology International, 33(7), 791–801. https://doi.org/ 10.3109/07420528.2016.1167077. Lanes, A., Kuk, J. L., & Tamim, H. (2011). Prevalence and characteristics of postpartum depression symptomatology among Canadian women: A cross-sectional study. BMC Public Health, 11, 302. https://doi.org/10.1186/ 1471-2458-11-302. Lawrence, R. A., & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. Leduc, D., Senkas, V., & Lalonde, A. (2018). SOGC clinical practice guideline No. 235—Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology Canada, 40(12), e841–e855. https://doi.org/10.1016/j.jogc.2018.09.024. Letourneau, N., Dennis, C.-L., Cosic, N., et al. (2017). The effect of perinatal depression treatment for mothers on parenting and child development: A systematic review. Depression & Anxiety, 34(10), 928–966. https://doi.org/ 10.1002/da.22687. Letourneau, N., Tryphonopoulos, P. D., Duffett-Leger, L., et al. (2012). Support intervention needs and preferences of fathers affected by postpartum depression. Journal of Perinatal & Neonatal Nursing, 26(1), 69–80. Lim, A., Samarage, A., & Lim, B. H. (2018). Venous thromboembolism in pregnancy. Obstetrics, Gynaecology & Reproductive Medicine, 26(5), 133– 139. https://doi.org/10.1016/j.ogrm.2016.02.005. Lundroff, M., Holmgren, H., Zachariae, R., et al. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138–149. https://doi.org/10.1016/j. jad.2017.01.030. O’Hara, M. W., & Wisner, K. L. (2014). Perinatal mental illness: Definition, description, aetiology. Best Practice & Research: Clinical Obstetrics & Gynaecology, 28(1), 3–12. Pettker, C. M., & Lockwood, C. J. (2017). Thromboembolic disorders in pregnancy. In S. G. Gabbe, J. R. Niebyl, & J. L. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Rafi, J., & Khalil, H. (2018). Maternal morbidity associated with retroperitoneal hematomas in pregnancy. Journal of the Royal Society of Medicine, 9 (1). https://doi.org/10.1177/2054270417746059. Registered Nurses’ Association of Ontario (RNAO). (2018a). Assessments and interventions for perinatal depression (2nd ed.). https://rnao.ca/sites/rnaoca/files/bpg/Perinatal_Depression_FINAL_web_0.pdf. Registered Nurses’ Association of Ontario (RNAO). (2018b). Perinatal depression: Guideline release press conference. https://www.youtube.com/ watch?v¼7h4SC-qD_DM. Simpson, K., Creehan, P. A., O’Brien-Abel, N. J., et al. (2020). AWHONN’s perinatal nursing (5th ed.). Wolters Kluwer. Sriraman, N. K., Melvin, K., Meltzer-Brody, S., et al. (2015). ABM clinical protocol no. 18: Use of antidepressants in breastfeeding mothers. Breastfeeding Medicine, 10(6), 290–299. Stadtlander, L. (2015). Paternal postpartum depression. International Journal of Childbirth Education, 30(2), 11–13.

Statistics Canada. (2019a). Deaths, 2018. https://www150.statcan.gc.ca/n1/dailyquotidien/191126/dq191126c-eng.htm. Statistics Canada. (2019b). Maternal mental health in Canada. https://www150. statcan.gc.ca/n1/daily-quotidien/190624/dq190624b-eng.htm. Statistics Canada. (2021). Infant deaths and mortality rates by age group. https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid¼1310071301. Takeda, J., & Takeda, S. (2019). Management of disseminated intravascular coagulation associated with placental abruption and measures to improve outcomes. Obstetrics and Gynecology Science, 62(5), 299–306. https://doi. org/10.5468/ogs.2019.62.5.299. Tepper, N. K., Boulet, S. L., Whiteman, M. K., et al. (2014). Postpartum venous thrombosis: Incidence and risk factors. Obstetrics and Gynecology, 123(5), 987–996. Tinkelman, A., Hill, K. M., Deligiannidis, K. M., et al. (2017). Management of new onset psychosis in the postpartum period. Journal of Clinical Psychiatry, 78(9), 1423–1424. https://doi.org/10.4088/JCP.17ac11880. van Schalkwyk, J., & Van Eyk, N. (2017). SOGC clinical practice guideline: No. 247—Antibiotic prophylaxis in obstetric procedures. Journal of Obstetrics and Gynaecology Canada, 39(9), 293–299. https://doi.org/10.1016/j.jogc. 2017.06.007. Vesel, J., & Nickasch, B. (2015–2016). An evidence review and model for prevention and treatment of postpartum posttraumatic stress disorder. Nursing for Women’s Health, 19(6), 504–525. Wilke, J., & Limbo, R. (2012). Resolve through training: Gundersen Health System. Bereavement training in perinatal death (8th ed.). Gundersen Lutheran Medical Foundation. Wisner, K. L., Sit, D. K. T., Bogen, D. L., et al. (2017). Mental health and behavioral disorders in pregnancy. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. World Health Organization (WHO). (2015). WHO recommendations for prevention and treatment of maternal peripartum infections. https://apps. who.int/iris/bitstream/handle/10665/186171/9789241549363_eng.pdf; jsessionid¼2783174A09767D9AF2F77642D9116A35?sequence¼1. World Health Organization (WHO). (2019). Maternal mortality. https://www. who.int/news-room/fact-sheets/detail/maternal-mortality. Yonkers, K. A., Vigod, S., & Ross, L. E. (2011). Diagnosis, pathophysiology and management of mood disorders in pregnant and postpartum women. Obstetrics and Gynecology, 117(4), 961–977.

ADDITIONAL RESOURCES American College of Obstetricians and Gynecologists (ACOG)—Postpartum depression: Resource overview. http://www.acog.org/Womens-Health/ Depression-and-Postpartum-Depression. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)— Postpartum Hemorrhage (PPH). https://www.awhonn.org/postpartumhemorrhage-pph/. AWHONN—Quantification of Blood Loss. https://www.youtube.com/watch? v¼F_ac-aCbEn0&list¼UUPrOhL3Od7ZeFDq27ycS00g. Bereaved Families of Ontario. https://www.bereavedfamilies.net/. Edinburgh Postnatal Depression Scale in different languages: http://www. perinatalservicesbc.ca/health-professionals/professional-resources/healthpromo/edinburgh-postnatal-depression-scale-(epds). Pacific Post Partum Support Society. https://www.postpartum.org. Peel Postpartum Mood Disorder Program. https://www.pmdinpeel.ca.

UNIT 7 Newborn

25 Physiological Adaptations of the Newborn Jennifer Marandola Originating US Chapter by Kathryn R. Alden http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the physiological adaptations the newborn must make during the period of transition from intrauterine to extrauterine environment. 2. Describe the physiological and behavioural adaptations that are characteristic of the newborn during the transition period.

3. Explain the mechanisms of thermoregulation in the newborn and the potential consequences of hypothermia and hyperthermia. 4. Discuss the sensory and perceptual function of the newborn. 5. Identify signs that the newborn is at risk related to issues with each body system.

The newborn period includes the time from birth through day 28 of life. During this time, the newborn must make many physiological and behavioural adaptations to extrauterine life. Tasks of physiological adjustment are those that involve (1) establishing and maintaining respirations; (2) adjusting to circulatory changes; (3) regulating temperature; (4) ingesting, retaining, and digesting nutrients; (5) eliminating waste; and (6) regulating weight. Behavioural tasks include (1) establishing a regulated behavioural tempo independent of the mother, which involves self-regulating arousal, self-monitoring changes in state, and patterning sleep; (2) processing, storing, and organizing multiple stimuli; and (3) establishing a relationship with caregivers and the environment. The term newborn usually makes these adjustments with little or no difficulty. This chapter describes the physiological and behavioural adaptations required by the newborn for transition to extrauterine life.

increases rapidly to 160 to 180 beats per minute (bpm) but gradually falls by 30 minutes of age to a baseline rate between 100 and 160 bpm. Respirations may be irregular, with variation in the rate between 60 and 80 breaths/min. Fine crackles may be present on auscultation; audible grunting, nasal flaring, and retractions of the chest may also be noted, but these should resolve within the first hour of birth. The newborn is alert and may have spontaneous startles, tremors, crying, and movement of the head from side to side. Bowel sounds are audible, and meconium may be passed. After the first period of reactivity, the newborn either sleeps or has a marked decrease in motor activity. This period of decreased responsiveness usually lasts from 60 to 100 minutes. During this time the newborn is pink and respirations may be rapid and shallow (up to 60 breaths/ min) but not laboured. Bowel sounds are audible, and peristaltic waves may be noted over the rounded abdomen. The second period of reactivity occurs roughly between 2 and 8 hours after birth and lasts from 10 minutes to several hours. Brief periods of tachycardia and tachypnea occur, associated with increased muscle tone, skin colour changes, and mucus production. Meconium is commonly passed during this phase. Most healthy newborns experience this transition regardless of type of birth. Physiological immaturity prevents this in very preterm newborns.

TRANSITION TO EXTRAUTERINE LIFE The major adaptations associated with transition from intrauterine to extrauterine life occur during the first 6 to 8 hours after birth. The predictable series of events during transition are mediated by the sympathetic nervous system and result in changes that involve heart rate, respirations, temperature, and gastrointestinal function. This transition period represents a time of vulnerability for the newborn and warrants careful observation by nurses. To detect disorders in adaptation soon after birth, nurses must be aware of normal features of the transition period. In their classic work on newborn adaptation to extrauterine life, Desmond et al. (1966) proposed three stages, termed the transition period. The stages are still considered valid today. The first phase of the transition period lasts up to 30 minutes after birth and is called the first period of reactivity. The newborn’s heart rate

PHYSIOLOGICAL ADJUSTMENTS Respiratory System When the umbilical cord is clamped, the newborn undergoes rapid and complex physiological changes. The most critical and immediate adjustment is the establishment of respirations. Most newborns breathe spontaneously after birth and are able to maintain adequate

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oxygenation. Preterm infants often encounter respiratory difficulties related to immaturity of the lungs and gestational age.

Initiation of Breathing. During intrauterine life oxygenation of the fetus occurs through transplacental gas exchange. However, at birth the lungs must be established as the site of gas exchange. In utero, fetal blood was shunted away from the lungs, but when birth occurs the pulmonary vasculature must be fully perfused for this purpose. Clamping the umbilical cord causes a rise in blood pressure (BP), which increases circulation and lung perfusion. It has been recognized that there is no single trigger for newborn respiratory function. The initiation of respirations in the newborn is the result of a combination of chemical, mechanical, thermal, and sensory factors (Blackburn, 2018). Chemical factors. The activation of chemoreceptors in the carotid arteries and aorta results from the relative state of hypoxia associated with labour. With each labour contraction there is a temporary decrease in uterine blood flow and transplacental gas exchange, resulting in transient fetal hypoxia and hypercarbia. Although the fetus is able to recover between contractions, there appears to be a cumulative effect that results in progressive decline in PO2, increased PCO2, and lowered blood pH. Decreased levels of oxygen and increased levels of carbon dioxide are involved in initiating newborn breathing by stimulating the respiratory centre in the medulla. Another chemical factor may also play a role: it is thought that, as a result of clamping the cord, there is a drop in levels of a prostaglandin that can inhibit respirations. Mechanical factors. Respirations in the newborn can be stimulated by changes in intrathoracic pressure resulting from compression of the chest during vaginal birth. As the fetus passes through the birth canal, the chest is compressed. With birth this pressure on the chest is released, and the negative intrathoracic pressure helps draw air into the lungs. Crying increases the distribution of air in the lungs and promotes expansion of the alveoli. The positive pressure created by crying helps to keep the alveoli open. Thermal factors. With birth the newborn enters the extrauterine environment, in which the temperature is significantly lower. Exposure to the profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory centre in the medulla. Cold stress may be important for initializing breathing, but prolonged exposure should be avoided. Sensory factors. Sensory stimulation occurs in a variety of ways with birth, such as in handling or drying the newborn. The lights, sounds, and smells of the new environment can also be involved in stimulation of the respiratory centre. Pain associated with birth can also be a factor. At term the lungs hold approximately 20 mL of fluid per kilogram. Air must be substituted for the fluid that filled the fetal respiratory tract. Previously it had been thought that the thoracic squeeze occurring during normal vaginal birth resulted in significant clearance of lung fluid, but now it appears that this event plays a minor role. In the days preceding labour there is reduced production of fetal lung fluid and concomitant decreased alveolar fluid volume. Shortly before the onset of labour there is a catecholamine surge that appears to promote fluid clearance from the lungs, which continues during labour. The movement of lung fluid from the air spaces takes place through active transport into the interstitium, with drainage occurring through the pulmonary circulation and lymphatic system. Retention of lung fluid can interfere with the newborn’s ability to maintain adequate oxygenation, especially if other factors (e.g., meconium aspiration, congenital diaphragmatic hernia, esophageal atresia with fistula, choanal atresia, congenital cardiac defect, immature alveoli) that compromise respirations are present. Infants born by Caesarean birth when labour did not

occur before birth can experience some lung fluid retention, although it typically clears without deleterious effects on the newborn. These newborns are also more likely to develop transient tachypnea of the newborn (TTNB) caused by the lower levels of catecholamines (Fraser, 2015). The alveoli of the term newborn’s lungs are lined with two types of alveolar epithelium, named alveolar type I and type II cells. Type I alveolar cells comprise approximately 95% of the alveolar surface, with type II alveolar cells making up the remaining 5%. The type II cells make and produce surfactant, a group of phospholipids that reduce the alveolar surface tension. Subsequently, with lower surface tension the pressure required to keep the alveoli open with inspiration is reduced, which prevents total alveolar collapse on exhalation, thereby maintaining alveolar stability. The decreased surface tension results in increased lung compliance, helping to establish the functional residual capacity of the lungs (Blackburn, 2018). With absent or decreased surfactant, more pressure must be generated for inspiration, which can soon tire or exhaust preterm or sick term newborns. Breathing movements that began in utero as intermittent become continuous after birth, although the mechanism for this is not well understood. Once respirations are established, breaths are shallow and irregular, ranging from 30 to 60 breaths/min, with periods of breathing that include pauses in respirations lasting less than 20 seconds. These episodes of periodic breathing occur most often during the active (rapid eye movement [REM]) sleep cycle and decrease in frequency and duration with age. Apneic periods longer than 20 seconds indicate a pathological process and should be evaluated.

NURSING ALERT Newborns are by preference nose breathers. The reflex response to nasal obstruction is to open the mouth to maintain an airway. This response is not present in most newborns until 3 weeks after birth; therefore, cyanosis or asphyxia can occur with nasal blockage or stenosis and requires immediate intervention to support adequate ventilation and oxygenation.

In most newborns auscultation of the chest reveals loud, clear breath sounds that seem very near because there is very little chest tissue. Breath sounds should be clear and equal bilaterally. The ribs of the newborn articulate with the spine at a horizontal rather than a downward slope; consequently, the rib cage cannot expand with inspiration as readily as that of an adult. Because newborn respiratory function is largely a matter of diaphragmatic contraction, abdominal breathing is characteristic of newborns. The newborn’s chest and abdomen rise simultaneously with inspiration. Characteristics of the respiratory system of the newborn and the effects of these characteristics on respiratory function are listed in Table 25.1.

Signs of Respiratory Distress. Signs of respiratory distress may include nasal flaring, intercostal or subcostal retractions (i.e., drawing in of tissue between the ribs, or below the rib cage), or grunting with respirations. Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper airway obstruction. Seesaw or paradoxical respirations (exaggerated rise in abdomen, with respiration, as chest falls) instead of abdominal respirations are abnormal and should be reported. A respiratory rate less than 30 or greater than 60 breaths/min with the newborn at rest must be carefully evaluated. The respiratory rate can be negatively influenced (slowed, depressed, or absent) by analgesics or anaesthetics administered to the mother during birth. Apneic episodes can be related to events such as rapid increase in body temperature, hypothermia, hypoglycemia, or sepsis that require thorough evaluation. Tachypnea can result from

CHAPTER 25

TABLE 25.1

Physiological Adaptations of the Newborn

563

Characteristics of the Respiratory System of the Newborn

Characteristic

Effect on Function

Immature alveoli; decreased size and number of alveoli

Risk of respiratory insufficiency, inadequate oxygenation and ventilation

Thicker alveolar wall; decreased alveolar surface area

Less efficient gas transport and exchange; poor alveolar compliance

Continued development of alveoli until childhood

Possible opportunity to reduce effects of chronic lung disease

Decreased lung elastic tissue and recoil

Decreased lung compliance requiring higher pressures and more work to expand; increased risk of atelectasis

Reduced diaphragm movement and maximal force potential

Less effective respiratory movement; difficulty generating negative intrathoracic pressures; risk of atelectasis

Tendency to nose breathe; altered position of larynx and epiglottis

Enhanced ability to synchronize swallowing and breathing; risk of airway obstruction; possibly more difficult to intubate

Small compliant airway passages with higher airway resistance; immature reflexes

Risk of airway obstruction and apnea

Increased pulmonary vascular resistance with sensitive pulmonary arterioles

Risk of ductal shunting and hypoxemia with events such as hypoxia, acidosis, hypothermia, hypoglycemia, and hypercarbia

Increased oxygen consumption

Increased respiratory rate and work of breathing; risk of hypoxia; risk of retinopathy of prematurity

Increased intrapulmonary right–left shunting

Increased risk of atelectasis with ineffective ventilation; risk of persistent pulmonary hypertension; lower PCO2

Immaturity of pulmonary surfactant system in immature newborns

Increased risk of atelectasis and respiratory distress syndrome; increased work of breathing

Immature respiratory control

Irregular respirations with periodic breathing; risk of apnea; inability to rapidly alter depth of respirations

PCO2, Partial pressure of carbon dioxide. From Blackburn, S. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier, p. 333, Table 10–7, adapted from Blackburn, S. (1992). Alterations in the respiratory system in the neonate: Implications for practice. Journal of Perinatal & Neonatal Nursing, 6, 46.

inadequate clearance of lung fluid, or it can be an indication of newborn respiratory distress syndrome (RDS). Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses (Gardner et al., 2021). Changes in the newborn’s colour can indicate respiratory distress. Acrocyanosis, the bluish discoloration of hands and feet, is a normal finding in the first 7 to 10 days after birth (Figure 25.1). Transient

periods of duskiness while crying are not uncommon immediately after birth; however, central cyanosis is abnormal and signifies hypoxemia. With central cyanosis the lips and mucous membranes are bluish. It can be the result of inadequate delivery of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Newborns who experience mild TTNB often have signs of respiratory distress during the first 1 to 2 hours after birth as they transition to extrauterine life. Tachypnea with rates up to 100 breaths/min can be present along with intermittent grunting, nasal flaring, and mild retractions. Supplemental oxygen or noninvasive ventilator support may be needed. TTNB usually resolves in 24 to 48 hours (Soltau & Carol, 2014). In newborns with more serious respiratory complications, symptoms of distress are more pronounced and tend to last beyond the first 2 hours after birth. Respiratory rates can exceed 120 breaths/min. Moderate-to-severe retractions, grunting, pallor, and central cyanosis can occur. The respiratory symptoms can be accompanied by hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac concerns. Common respiratory complications affecting newborns include RDS, meconium aspiration, pneumonia, and persistent pulmonary hypertension of the newborn (PPHN). Congenital defects such as anomalies of the great vessels, diaphragmatic hernia, or chest wall defects can cause severe respiratory conditions. Blood incompatibilities such as hydrops fetalis can result in respiratory compromise (Gardner et al., 2021) (see Chapters 28 and 29).

Cardiovascular System Fig. 25.1 Newborn with acrocyanosis of upper and lower extremities. (Courtesy Barbara Wilson.)

The cardiovascular system changes significantly after birth. The newborn’s first breaths, combined with increased alveolar capillary distension, inflate the lungs and reduce pulmonary vascular resistance to pulmonary blood flow from the pulmonary arteries. Pulmonary artery

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pressure drops, and pressure in the right atrium declines. Increased pulmonary blood flow from the left side of the heart increases pressure in the left atrium, which causes a functional closure of the foramen ovale (see Chapter 47). During the first few days of life, crying may temporarily reverse the flow through the foramen ovale and lead to mild cyanosis. Soon after birth, cardiac output nearly doubles and blood flow increases to the lungs, heart, kidneys, and gastrointestinal tract. In utero, fetal PO2 is 20–30 mm Hg. After birth, when the PO2 level in the arterial blood approximates 50 mm Hg, the ductus arteriosus constricts in response to increased oxygenation. Circulating hormone prostaglandin (PGE2) levels also have an important role in closure of the ductus arteriosus. In term newborns it functionally closes within the first 24 hours after birth; permanent closure usually occurs within 3 to 4 weeks, and the ductus arteriosus becomes a ligament. The ductus arteriosus can open in response to low oxygen levels in association with

TABLE 25.2

hypoxia, asphyxia, or prematurity. With auscultation of the chest a patent ductus arteriosus can be detected as a heart murmur. The umbilical vein and arteries constrict rapidly within the first 2 minutes after birth. It is thought that this is related to exposure of the cord to the cooler extrauterine environment and to increased oxygenation as the newborn begins to breathe. With the clamping and severing of the cord, the umbilical arteries, the umbilical vein, and the ductus venosus are functionally closed; they are converted into ligaments within 2 to 3 months. The hypogastric arteries also occlude and become ligaments. Table 25.2 summarizes the cardiovascular changes at birth.

Heart Rate and Sounds. The newborn heart rate averages 110 to 160 bpm at birth, with variations noted during sleep and wake states. The range of the heart rate in the term newborn can be as low as

Cardiovascular Changes at Birth

Prenatal Status Primary Changes Pulmonary Circulation High pulmonary vascular resistance, increased pressure in right ventricle and pulmonary arteries Systemic Circulation Low pressures in left atrium, ventricle, and aorta Secondary Changes Umbilical Arteries Patent, carrying of blood from hypogastric arteries to placenta

Umbilical Vein Patent, carrying of blood from placenta to ductus venosus and liver

Ductus Venosus Patent, connection of umbilical vein to inferior vena cava Ductus Arteriosus Patent, shunting of blood from pulmonary artery to descending aorta

Foramen Ovale Formation of a valve opening that allows blood to flow directly to left atrium (shunting of blood from right to left atrium)

Postbirth Status

Associated Factors

Low pulmonary vascular resistance; decreased pressure in right atrium, ventricle, and pulmonary arteries

Expansion of collapsed fetal lung with air; assume responsibility for adequate gas exchange

High systemic vascular resistance; increased pressure in left atrium, ventricle, and aorta

Loss of placental blood flow

Functionally closed at birth; obliteration by fibrous proliferation possibly taking 2 to 3 months, distal portions becoming lateral vesicoumbilical ligaments, proximal portions remaining open as superior vesicle arteries

Closure preceding that of umbilical vein, probably accomplished by smooth muscle contraction in response to thermal and mechanical stimuli and alteration in oxygen tension Mechanically severed with cord at birth

Closed; becoming ligamentum teres hepatis after obliteration

Closure shortly after umbilical arteries; hence blood from placenta possibly entering newborn for short period after birth Mechanically severed with cord at birth

Closed; becoming ligamentum venosum after obliteration

Loss of blood flow from umbilical vein

Functionally closed almost immediately after birth; anatomical obliteration of lumen by fibrous proliferation requiring 1 to 3 months, becoming ligamentum arteriosum

Increased oxygen content of blood in ductus arteriosus creating vasospasm of its muscular wall High systemic resistance increasing aortic pressure; low pulmonary resistance reducing pulmonary arterial pressure

Functionally closed at birth; constant apposition gradually leading to fusion and permanent closure within a few months or years in most persons

Increased pressure in left atrium and decreased pressure in right atrium, causing closure of valve over foramen

Data from Blackburn, S. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier.

CHAPTER 25 80 to 100 bpm during deep sleep and can increase to 180 bpm or higher when the newborn cries. A heart rate that is either high (more than 160 bpm) or low (fewer than 110 bpm) should be re-evaluated within 30 minutes to 1 hour or when the activity of the newborn changes. Immediately after birth the heart rate can be palpated by grasping the base of the umbilical cord. The apical impulse (point of maximal impulse [PMI]) in the newborn is at the fourth intercostal space and to the left of the midclavicular line. The PMI is often visible and easily palpable because of the thin chest wall; this is also called precordial activity. Apical pulse rates should be obtained on all newborns. Auscultation should be for a full minute, preferably when asleep. An irregular heart rate in newborns is not uncommon in the first few hours of life. After this time, an irregular heart rate not attributed to changes in activity or respiratory pattern should be further evaluated. Heart sounds during the newborn period are of higher pitch, shorter duration, and greater intensity than during adult life. The first sound (S1) is typically louder and duller than the second sound (S2), which is sharp. The third and fourth heart sounds are not auscultated in newborns. Most heart murmurs heard during the newborn and infant periods have no pathological significance, and more than half of the murmurs disappear by 6 months. The presence of a murmur and accompanying signs such as poor feeding, apnea, cyanosis, or pallor is considered abnormal and should be further evaluated. There can be significant cardiac defects without symptoms in the early newborn period, thus ongoing assessment is essential (Sadowski, 2015).

Blood Pressure (BP). Values for newborn BP vary with gestational age and weight. The term newborn’s average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg. The number of weeks of gestation can be used as a guide for the mean arterial pressure (MAP). While not exact, it is a useful guide; for example, a newborn born at 40 weeks of gestation should have a MAP of at least 40. The BP increases by the second day of life, with minor variations noted during the first month of life. A drop in systolic BP (about 15 mm Hg) in the first hour of life is common. Crying and movement usually cause increases in the systolic BP. The measurement of BP is best accomplished with an oscillometric device while the newborn is at rest. A correctly sized cuff with proper placement must be used for accurate measurement of a newborn’s BP. Unless there is a specific indication, BP is not routinely measured in the healthy newborn. In the presence of cardiovascular symptoms such as tachycardia, murmur, abnormal pulses, poor perfusion, or abnormal precordial activity, four extremity BP and preductal and postductal oxygen saturation levels may be taken. If the systolic pressure is more than 10 mm Hg higher in the upper extremities than in the lower extremities, further diagnostic testing may be needed. Blood Volume. Blood volume in the newborn is about 80 to 100 mL/kg of body weight. Immediately after birth, the total blood volume averages 300 mL, but this volume can increase by as much as 100 mL, depending on the length of time to cord clamping and cutting. The infant born prematurely has a relatively greater blood volume than the term newborn because the preterm infant has a proportionately greater plasma volume, not a greater red blood cell (RBC) mass. Delayed clamping of the umbilical cord changes the circulatory dynamics of the newborn. Delayed cord clamping (DCC) expands the blood volume from the so-called placental transfusion of blood to the newborn by as much as 100 mL, depending on the length of time to cord clamping and cutting. DCC has been associated with increased blood volume and BP and reduced risk for intraventricular hemorrhage and necrotizing enterocolitis (Perlman et al., 2015). These benefits are

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most important for preterm infants. Polycythemia that occurs with delayed clamping is usually not harmful, although there can be an increased risk for hyperbilirubinemia that requires phototherapy. The Society of Obstetricians and Gynecologists of Canada (Leduc et al., 2018) and the World Health Organization (2014) recommend that DCC be practised whenever possible. DCC is reasonable for term and preterm newborns who do not need resuscitation.

Signs of Cardiovascular Concerns. Close monitoring of the newborn’s vital signs is important for early detection of impending complications. Persistent tachycardia (more than 160 bpm) can be associated with anemia, hypovolemia, hyperthermia, or sepsis. Persistent bradycardia (less than 100 bpm) can be a sign of a congenital heart block, hypoxemia, normal sinus bradycardia, or hypothermia. Unequal or absent pulses, bounding pulses, and decreased or elevated blood pressure can indicate cardiovascular concerns (Verklan, 2015). The newborn’s skin colour can reflect cardiovascular conditions. Pallor in the immediate postbirth period is often symptomatic of underlying issues such as anemia or marked peripheral vasoconstriction as a result of intrapartum asphyxia, difficult assisted birth, or sepsis. Any central or prolonged cyanosis can indicate respiratory or cardiac concerns and requires immediate investigation and evaluation. Congenital heart defects are the most common type of congenital malformations (see Chapter 47). Although the more serious defects of cyanotic heart defects, such as transposition of the great arteries, tricuspid atresia, and tetralogy of Fallot, are likely to have clinical manifestations such as cyanosis, dyspnea, and hypoxia, others, such as small ventricular septal defects, can be asymptomatic. The prenatal history can provide information regarding risk factors for congenital heart defects, alerting the nurse to watch for symptoms. Maternal illness such as rubella, metabolic disease such as diabetes, and drug ingestion are associated with an increased risk of cardiac defects.

Hematopoietic System The hematopoietic system of the newborn exhibits certain variations from that of the adult. Levels of RBCs and leukocytes differ, but platelet levels are relatively the same.

Red Blood Cells and Hemoglobin. Because fetal circulation is less efficient at oxygen exchange than the lungs, the fetus needs additional RBCs for transport of oxygen in utero. Therefore, at birth the average levels of RBCs and hemoglobin (fetal hemoglobin is predominant) are higher than those in the adult; these levels fall slowly over the first month. At birth the RBC count ranges from 4.8 to 7.1
1012/L (Blackburn, 2018). The term newborn can have a hemoglobin concentration of 140 to 240 g/L at birth, decreasing gradually to 120 to 200 g/L after the first month of life (Pagana et al., 2019). Hematocrit levels at birth range from 0.51 to 0.56, increase slightly in the first few hours or days as fluid shifts from intravascular to interstitial spaces (Blackburn, 2018), and by 8 weeks are between 0.31 and 0.39 (Pagana et al., 2019). Polycythemia (central venous hematocrit greater than 65%) can occur in term and preterm newborns as a result of DCC, maternal hypertension or diabetes, or intrauterine growth restriction. The source of the sample is a significant factor in levels of RBCs, hemoglobin, and hematocrit because capillary blood yields higher values than venous blood. The timing of blood sampling is also significant; the slight rise in RBCs after birth is followed by a substantial drop. At birth the newborn’s blood contains an average of 70% fetal hemoglobin; however, because of the shorter lifespan of the cells containing fetal hemoglobin the percentage falls rapidly, so that by the age of 6 to 12 months there is only a trace of fetal hemoglobin remaining (Christensen & Ohls, 2016). Iron stores generally are sufficient to

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sustain normal RBC production for approximately 4 to 6 months in the term infant, at which time a transient physiological anemia can occur.

Leukocytes. Leukocytosis, with a white blood cell (WBC) count of approximately 18
109/L (range 9 to 30
109/L), is normal at birth (Pagana et al., 2019). The number of WBCs increases to 23 to 24
109/L during the first day after birth. The initial high WBC count of the newborn decreases rapidly, and a stable level of 12
109/L is normally maintained during the newborn period. Serious infection is not well tolerated by the newborn; leukocytes are slow to recognize foreign protein and to localize and fight infection early in life. Sepsis may be accompanied by a concomitant rise in granulocytes (neutrophilia); however, some newborns may initially be seen with clinical signs of sepsis without a significant elevation in WBCs. In addition, events other than infection—prolonged crying, maternal hypertension, asymptomatic hypoglycemia, hemolytic disease, meconium aspiration syndrome, labour induction with oxytocin, surgery, difficult labour, high altitude, and maternal fever—may cause neutrophilia in the newborn. Platelets. Platelet count ranges between 150 and 300
109/L and is essentially the same in newborns as in adults (Pagana et al., 2019). Levels of vitamin K–dependent clotting factors II, VII, IX, and X increase slowly after birth and reach adult levels by 6 months of age (Monagle, 2017).

Blood Groups. The newborn’s blood group is genetically determined and established early in fetal life. However, during the newborn period, there is a gradual increase in the strength of the agglutinogens present in the RBC membrane. Cord blood samples may be used to identify the newborn’s blood type and Rh status.

Thermogenic System Next to establishing respiration and adequate circulation, heat regulation is most critical to the newborn’s survival. During the first 12 hours after birth the newborn attempts to achieve thermal balance in adjusting to the extrauterine environmental temperature. Thermoregulation is the maintenance of balance between heat loss and heat production. Newborns attempt to stabilize their core body temperatures within a narrow range. Hypothermia from excessive heat loss is a common and dangerous condition in newborns. Anatomical and physiological characteristics of newborns place them at risk for heat loss. Newborns have a thin layer of subcutaneous fat. The blood vessels are close to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centres in the hypothalamus. Newborns have larger body surface–to–body weight (mass) ratios than do children and adults (Blackburn, 2018).

Heat Loss. The body temperature of newborns depends on the heat transfer between the newborn and the external environment. Factors that influence heat loss to the environment include the temperature and humidity of the air, the flow and velocity of the air, and the temperature of surfaces in contact with and around the newborn. The goal of care is to maintain a neutral thermal environment for the newborn in which heat balance is maintained. The neutral thermal environment is the ideal environmental temperature that allows the newborn to maintain a normal body temperature to minimize oxygen and glucose consumption. Heat loss in the newborn occurs by four modes (Figure 25.2): 1. Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, the ambient temperature in the newborn care area should range between 22° and 26°C and

Evaporation Convection Radiation

Conduction Fig. 25.2 Heat loss in the newborn occurs in four ways: convection, radiation, evaporation, and conduction. (From WHO [1997]. Safe motherhood: Thermal protection of the newborn, a practical guide. http://apps. who.int/iris/bitstream/10665/63986/1/WHO_RHT_MSM_97.2.pdf.)

newborns in open bassinets are wrapped to protect them from the cold. A cap may be worn to decrease heat loss from the newborn’s head. 2. Radiation is the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity. To prevent this type of loss, cribs and examining tables are placed away from outside windows and care providers need to avoid exposing the newborn to direct air drafts. 3. Evaporation is the loss of heat that occurs when a liquid is converted to a vapour. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. This heat loss is intensified by failing to completely dry the newborn directly after birth or with bathing. The less mature the newborn, the more severe the evaporative heat loss. Evaporative heat loss, as a component of insensible water loss, is the most significant cause of heat loss in the first few days of life. 4. Conduction is the loss of heat from the body surface to cooler surfaces in direct contact. The scales used for weighing the newborn should have a protective cover to minimize conductive heat loss.

Skin-to-Skin Contact. Loss of heat must be controlled to protect the newborn. Control of such modes of heat loss is the basis of caregiving policies and techniques. One method for promoting maternal–newborn interaction is to place the naked, healthy dried newborn on a parent’s bare chest and covered with a warm blanket; a cap may be placed on the newborn’s head to help conserve heat. This skinto-skin contact reduces conductive and radiant heat loss and enhances newborn temperature control and parental–newborn interaction (Figure 25.3). Newborns who are placed skin-to-skin remain warmer than newborns held swaddled in their parent’s arms. If the birthing parent is unavailable, then the partner or other significant person in the room could hold the newborn skin-to-skin. Thermogenesis. In response to cold the newborn attempts to generate heat (thermogenesis) by increasing muscle activity. Cold newborns may cry and appear restless. Because of vasoconstriction the skin can feel cool to touch, and acrocyanosis can be present. There is an increase in cellular metabolic activity, primarily in the brain, heart, and liver; this also increases oxygen and glucose consumption. In an effort to conserve heat, term newborns assume a position of flexion that helps guard against heat loss because it diminishes the

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fat can warm the newborn by increasing heat production as much as 100%. Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. The amount of brown fat reserve increases with the weeks of gestation. A full-term newborn has greater stores than those of a preterm infant.

Fig. 25.3 Newborn in skin-to-skin contact with mother. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

amount of body surface exposed to the environment. Newborns also can reduce the loss of internal heat through the body surface by constricting peripheral blood vessels. Adults are able to produce heat through shivering; however, the shivering mechanism of heat production is rarely operable in the newborn unless there is prolonged cold exposure (Blackburn, 2018). Newborns produce heat through nonshivering thermogenesis. This is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and secondarily by increased metabolic activity in the brain, heart, and liver. Brown fat is located in superficial deposits in the interscapular region and axillae and in deep deposits at the thoracic inlet, along the vertebral column, and around the kidneys (Figure 25.4). Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown

Hypothermia and Cold Stress. When the newborn’s temperature drops, vasoconstriction occurs as a mechanism to conserve heat. The newborn can appear pale and mottled; the skin feels cool, especially on the extremities. If the hypothermia is not corrected, it will progress to cold stress, which imposes metabolic and physiological demands on all newborns, regardless of gestational age and condition. The respiratory rate increases in response to the increased need for oxygen. In the cold-stressed newborn oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival. If the newborn cannot maintain an adequate oxygen tension, vasoconstriction follows and jeopardizes pulmonary perfusion. As a consequence the PO2 is decreased, and the blood pH drops. These changes can prompt a transient respiratory distress or aggravate existing RDS. Moreover, decreased pulmonary perfusion and oxygen tension can maintain or reopen the right-to-left shunt across the ductus arteriosus. The basal metabolic rate increases with cold stress. If cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids. Metabolic acidosis develops, and, if an alteration in respiratory function is present, respiratory acidosis also develops (Figure 25.5). Excessive fatty acids can displace the bilirubin from the albumin-binding sites and exacerbate hyperbilirubinemia. Hypoglycemia is another metabolic consequence of cold stress. The process of anaerobic glycolysis uses approximately three to four times the amount of blood glucose, thereby depleting existing stores. If the newborn is sufficiently stressed and low glucose stores are not replaced, hypoglycemia can develop. Hypoglycemia is often asymptomatic in

Cold

O2 consumption

Respiratory rate

O2 uptake by lungs

Pulmonary vasoconstriction

O2 to tissues

Peripheral vasoconstriction

Anaerobic glycolysis

In PO2 and pH

Metabolic acidosis

Fig. 25.4 Distribution of brown fat in the newborn.

Fig. 25.5 Effects of cold stress. When a newborn is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in PO2 and pH, leading to metabolic acidosis.

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the newborn and typically resolves by 72 hours of life (Narvey et al., 2019).

Hyperthermia. Although occurring less frequently than hypothermia, hyperthermia can occur and must be corrected. A body temperature greater than 37.5°C (99.5°F) is considered to be abnormally high and is typically caused by excess heat production related to sepsis or a decrease in heat loss. Hyperthermia can result from the inappropriate use of external heat sources such as radiant warmers, phototherapy, sunlight, increased environmental temperature, and use of excessive clothing or blankets (Gardner & Cammack, 2021). The clinical appearance of the newborn who is hyperthermic often indicates the causative mechanism. Newborns who are overheated because of environmental factors such as being swaddled in too many blankets exhibit signs of heat-losing mechanisms: skin vessels dilate, the skin appears flushed, hands and feet are warm to touch, and the newborn assumes a posture of extension. The newborn who is hyperthermic because of sepsis appears stressed: vessels in the skin are constricted, colour is pale, and hands and feet are cool. Hyperthermia develops more rapidly in a newborn than in an adult because of the relatively larger surface area of a newborn. Sweat glands do not function well. Serious overheating of the newborn can cause cerebral damage from dehydration or even heat stroke and death (Gardner & Cammack, 2021).

Renal System At term, the kidneys occupy a large portion of the posterior abdominal wall. The bladder lies close to the anterior abdominal wall and is an abdominal as well as a pelvic organ. In the newborn, almost all palpable masses in the abdomen are renal in origin. At birth, a small quantity (approximately 40 mL) of urine is usually present in the bladder of a full-term newborn. Many newborns void at the time of birth, although this is easily missed and may not be recorded. During the first few days term newborns generally excrete 15 to 60 mL/kg; output gradually increases over the first month (Blackburn, 2018). The frequency increases with age of the newborn. At 1 day of age, a minimum of one void is expected. This increases one void per day for the first 5 days. At 1 week of age, about six to eight voidings per day of pale straw-coloured urine are indicative of adequate fluid intake.

NURSING ALERT Noting and recording the first voiding are important. A newborn who has not voided by 24 hours should be assessed for adequacy of fluid intake, bladder distension, restlessness, and symptoms of pain. The pediatric health care provider should be notified.

Full-term newborns have limited capacity to concentrate urine; therefore, the specific gravity ranges from 1.001 to 1.020 (Pagana et al., 2019). The ability to concentrate urine fully is attained by about 3 months of age. After the first voiding, the newborn’s urine may appear cloudy (because of mucus content) and have a much higher specific gravity. This decreases as fluid intake increases. Normal urine during early infancy is usually straw coloured and almost odourless. Sometimes pink-tinged uric acid crystal stains appear on the diaper; these stains are normal, although they can be misinterpreted as blood. Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake results in a 5 to 10% loss of the birth weight. See Chapter 27 for discussion on how to determine weight loss. This weight loss usually occurs over the first 3 to 5 days of life. Excessive weight loss can be related to feeding difficulties or other issues. The newborn should regain the birth weight within 10 to 14 days, depending on the feeding method (breastmilk or formula).

Fluid and Electrolyte Balance. In the term newborn approximately 75% of body weight consists of total body water (extracellular and intracellular). A reduction in extracellular fluid occurs with diuresis during the first few days after birth. The weight loss experienced by most newborns during the first few days after birth is caused primarily by extracellular water loss (Cadnapaphornchai et al., 2021). The daily fluid requirement for newborns weighing more than 1 500 g is 60 to 80 mL/kg/day during the first 2 days of life, and from 3 to 7 days the requirement is 100 to 150 mL/kg/day, and from 8 to 30 days it is 120 mL/kg/day to 180 mL/kg/day (Dell, 2015). At birth, the glomerular filtration rate (GFR) of a newborn is significantly lower than in the adult. This results in a decreased ability to remove nitrogenous and other waste products from the blood. The GFR rapidly increases during the 2 to 4 weeks after birth as a result of postnatal physiological changes, including decreased renal vascular resistance, increased renal blood flow, and increased filtration pressure. The GFR gradually rises to adult levels by 2 years of age (Blackburn, 2018; Vogt & Dell, 2015). Sodium reabsorption is decreased as a result of a lowered sodiumand potassium-activated adenosine triphosphate activity. The decreased ability to excrete excessive sodium results in hypotonic urine, leading to a higher concentration of sodium, phosphates, chloride, and organic acids and a lower concentration of bicarbonate ions. The newborn has a higher renal threshold for glucose than adults. Tubular reabsorption of glucose in the term newborn is similar to that of an adult. While the renal threshold for glucose is lower, newborns do not typically exhibit glycosuria. Because of a lower renal threshold for bicarbonate and a limited capacity for reabsorption, the newborn’s serum bicarbonate and plasma pH levels are lower. Buffering capacity is decreased. This reduces the newborn’s ability to cope with events (e.g., cold stress) that produce acidosis (Blackburn, 2018). Signs of Renal System Concerns. The renal system has a wide range of functions. Dysfunction resulting from physiological abnormalities can range from the lack of a steady stream of urine to anomalies such as hypospadias and exstrophy of the bladder, which can be identified at birth (see Chapter 49). Enlarged or cystic kidneys can be identified as masses during abdominal palpation. Some kidney anomalies also can be detected by ultrasound examination during pregnancy.

Gastrointestinal System The full-term newborn is capable of swallowing, digesting, metabolizing, and absorbing proteins and simple carbohydrates, and emulsifying fats. With the exception of pancreatic amylase, the characteristic enzymes and digestive juices are present even in low-birth-weight newborns. In the adequately hydrated newborn, the mucous membrane of the mouth is moist and pink; the hard and soft palates are intact. The presence of moderate to large amounts of mucus is common in the first few hours after birth. Small whitish areas (Epstein pearls) may be found on the gum margins and at the juncture of the hard and soft palates. The cheeks are full because of well-developed sucking pads. These, like the labial tubercles (sucking calluses) on the upper lip, disappear around the age of 12 months, when the sucking period is over. Feeding behaviour is related to gestational age and is influenced by neuromuscular maturity, maternal medications during labour and birth, and the type of initial feeding. Feeding requires that the newborn be able to coordinate sucking, swallowing, and breathing. Sucking is a reflex behaviour that begins in utero as early as 15 to 16 weeks. By 28 weeks, some infants can coordinate sucking and swallowing. By 32 to 34 weeks most are able to coordinate sucking, swallowing, and

CHAPTER 25 breathing; this is well developed by 36 to 38 weeks (Blackburn, 2018). Sucking takes place in small bursts of 3 or 4 and up to 8 to 10 sucks at a time, with a brief pause between bursts. The newborn is unable to move food from the lips to the pharynx; therefore, placing the nipple (breast or bottle) well inside the baby’s mouth is necessary. Peristaltic activity in the esophagus is uncoordinated in the first few days of life. It quickly becomes a coordinated pattern in healthy full-term newborns, and they swallow easily. Teeth begin developing in utero, with enamel formation continuing until about 10 years of age. Tooth development is influenced by newborn illnesses and medications, and by illnesses of or medications taken by the mother during pregnancy. The fluoride level in the water supply also influences tooth development. Occasionally a newborn may be born with one or more teeth. These natal teeth have poorly formed roots, and as they loosen they place the newborn at risk of aspiration. Therefore, they are usually extracted. Intestinal flora, or gut microbiota, are established within the first week after birth; normal intestinal flora help synthesize vitamin K, folate, and biotin. Traditionally it was thought that the fetus grows and develops in a sterile environment. Research on the human microbiome suggests that the pregnant patient and their developing fetus coexist with a variety of commensal and symbiotic microbes that have important influences on the health of both the mother and their infant. Research evidence of microbial presence in amniotic fluid, placenta, and meconium indicates that the fetus is exposed to microbes during pregnancy. The mode of birth (vaginal or Caesarean) seems to play a major role in the microbial colonization of the newborn. Infants born vaginally appear to be initially colonized by the maternal vaginal microbes, whereas infants born by Caesarean are first colonized by maternal skin microbes. This initial colonization plays a major role in establishing intestinal flora; research is ongoing to identify the implications for the child’s future health. The microbiome of the newborn is also influenced by diet, antibiotics, and environmental factors (B€ackhed et al., 2015; Mueller et al., 2015; Neu, 2017). Breastfeeding is important in establishing the intestinal microbiome of the newborn. Human milk contains a variety of microbes that appear to originate in the mother’s gastrointestinal tract. Oligosaccharides in human milk may have a prebiotic function that facilitates the growth of beneficial bacteria in the newborn gastrointestinal tract (Neu, 2017). The capacity of the newborn stomach varies widely, depending on the size of the infant, from less than 10 mL on day 1 to nearly 30 mL on day 3 and expanding to 60 mL on day 7. After birth, the newborn stomach becomes increasingly more compliant and relaxed to accommodate larger volumes. Several factors such as time and volume of feedings or type and temperature of food can affect the emptying time. The normal intermittent relaxation of the lower esophageal sphincter results in involuntary backflow of stomach contents into the esophagus, known as gastroesophageal reflux (GER). As a result, newborns are prone to regurgitation, “spitting,” and vomiting, especially during the first 3 months. GER can be minimized by avoiding overfeeding, burping, and positioning the newborn with the head slightly elevated. In some infants, GER is severe enough to cause dysphagia, esophagitis, and aspiration. This is known as gastroesophageal reflux disease (GERD). Treatment may include medications to reduce gastric acidity, such as antacids, histamine-blocking agents, or proton-pump inhibitors, and medication to increase gastric motility. In severe cases, surgical treatment may be considered (Hibbs, 2015).

Digestion. The newborn’s ability to digest carbohydrates, fats, and proteins is regulated by the presence of certain enzymes. Most of these are functional at birth except for pancreatic amylase and lipase. Amylase is produced by the salivary glands after about 3 months and by the

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pancreas at about 6 months of age. This enzyme is necessary to convert starch into maltose and occurs in high amounts in colostrum. The other exception is lipase, which is also secreted by the pancreas; it is necessary for the digestion of fat. Thus, the normal newborn is capable of digesting simple carbohydrates and proteins but has a limited ability to digest fats. Mammary lipase in human milk aids in digestion of fats by the newborn. Lactase levels in newborns are higher than in older infants. This enzyme is necessary for digestion of lactose, the major carbohydrate in human milk and commercial infant formula.

Stools. At birth, the lower intestine is filled with meconium. Meconium is formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa). Meconium is greenish black and viscous and contains occult blood. The first meconium passed is usually sterile, but within hours all meconium passed contains bacteria. Most healthy term newborns pass meconium within 12 to 24 hours of life, and almost all do so by 48 hours. The number of stools passed varies during the first week, being most numerous between the third and sixth days. Progressive changes in the stool pattern indicate a properly functioning gastrointestinal tract (Box 25.1 and Figure 25.6). Signs of Gastrointestinal Concerns. The time, colour, and character of the newborn’s first stool should be noted. Failure to pass meconium can indicate bowel obstruction related to conditions such as malrotation, small or large bowel atresia, an inborn error of metabolism (e.g., cystic fibrosis), or a congenital disorder (e.g., Hirschsprung disease or an imperforate anus). An active rectal “wink” reflex (contraction of the anal sphincter muscle in response to touch) is a sign of good sphincter tone. Fullness of the abdomen above the umbilicus can be caused by conditions such as hepatomegaly, duodenal atresia, or distension. Abdominal distension at birth usually indicates a serious disorder, such as a ruptured viscus (from abdominal wall defects). Distension that occurs later can be the result of overfeeding or failure to pass stool or signal gastrointestinal disorders. A scaphoid (sunken) abdomen, with bowel

BOX 25.1

Changes in Stooling Patterns of Newborns Meconium • Meconium is the newborn’s first stool, composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels) (see Figure 25.6, A). • Passage of meconium should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very-low-birth-weight newborns. Transitional Stools • Transitional stools usually appear by the third day after initiation of feeding. • They are greenish brown to yellowish brown, are thin and less sticky than meconium, and may contain some milk curds (see Figure 25.6, B). Milk Stool • Milk stool usually appears by the fourth day. • Breastfed newborns: Stools are yellow to golden, pasty in consistency, resemble a mixture of mustard and cottage cheese, with an odour similar to sour milk (see Figure 25.6, C). • Formula-fed newborns: Stools are pale yellow to light brown, have firmer consistency, with an odour more characteristic of a normal adult stool.

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A

B

C Fig. 25.6 Breastfed newborn stools. A: Meconium. B: Transition stool. C: Milk stool. (A, Courtesy Janet Andrews. B, C, Courtesy Connie Livingstone.)

sounds heard in the chest and signs of respiratory distress, indicate a diaphragmatic hernia. Fullness below the umbilicus can indicate a distended bladder. Passage of meconium from the vagina or urinary meatus is a sign of a possible fistulous tract from the rectum. Some newborns are intolerant of certain commercial formulas. If a newborn is allergic or unable to digest a formula, the stools can become very soft with a high water content that is signalled by a distinct water ring around the stool on the diaper. Forceful ejection of stool and a water ring around the stool are signs of diarrhea. Care must be taken to avoid misinterpreting transitional stools for diarrhea. The loss of fluid in diarrhea can rapidly lead to fluid and electrolyte imbalance. The amount and frequency of regurgitation (“spitting up”) after feedings should be documented. Colour change, gagging, and projectile (very forceful) vomiting occur in association with esophageal and tracheoesophageal anomalies (see Chapter 46). Bilious emesis is always considered a serious condition until proven otherwise (volvulus, malrotation).

Hepatic System The liver and gallbladder are formed by the fourth week of gestation. In the newborn, the liver can be palpated about 1 to 2 cm below the right costal margin because it is enlarged and occupies about 40% of the abdominal cavity. The newborn’s liver plays an important role in iron storage, carbohydrate metabolism, conjugation of bilirubin, and coagulation. Although the liver is relatively immature at birth, healthy term newborns do not typically experience complications.

Iron Storage. The fetal liver, which serves as the site for production of hemoglobin after birth, begins storing iron in utero. The newborn’s iron store is proportional to total body hemoglobin content and length of gestation. At birth, the term newborn has an iron store sufficient to

last 4 to 6 months. Iron stores of preterm and small-for-gestational-age newborns are often lower and are depleted sooner than in healthy term newborns. Although both breast milk and cow’s milk contain iron, the bioavailability of iron in breast milk is far superior. Exclusive breastfeeding during the first 6 months is accepted as the nutrition standard for infants as promoted by the World Health Organization as a global public health recommendation. Current opinion suggests that iron supplements are not generally needed for breastfed infants during the first 6 months. Newborns with lower iron stores are at higher risk of iron deficiency, and supplementation with oral iron drops should be prescribed when appropriate. Formula-fed newborns should receive a formula that contains supplemental iron (Health Canada et al., 2015).

Glucose Homeostasis. The liver is responsible for regulation of blood glucose levels. In utero the glucose concentration in the umbilical vein is approximately 70% of the maternal level. At birth the newborn is cut off from its maternal glucose supply and as a result experiences an initial decrease in serum glucose levels. Glucose levels reach a low point between 30 and 90 minutes after birth and then rise gradually. In most healthy term newborns blood glucose levels stabilize at 2.5 to 3.0 mmol/L during the first several hours after birth; by the third day of life, the blood glucose levels should be approximately 4.0 to 6.0 mmol/L. The initiation of feedings helps to stabilize the newborn’s blood glucose levels. Colostrum contains high amounts of glucose, thus also assisting in the stabilization of blood glucose levels in breastfed newborns. In general, blood glucose levels less than 2.2 mmol/L are considered abnormal and may require intervention (see further discussion in Chapter 26, Hypoglycemia). Glucose levels are not routinely assessed in newborns unless there are risk factors or symptoms of hypoglycemia. Risk factors include small or large for gestational

CHAPTER 25 age, preterm, and infant of a diabetic mother. The hypoglycemic newborn can display the classic symptoms of jitteriness, lethargy, apnea, feeding difficulties, or seizures, or the newborn can be asymptomatic. Hypoglycemia in the initial newborn period is most often transient and easily corrected through feeding. Persistent or recurrent hypoglycemia necessitates intravenous glucose therapy and possible pharmacological intervention.

Bilirubin Synthesis and Newborn Jaundice. The liver is responsible for the conjugation of bilirubin, which results from the breakdown of RBCs. When RBCs reach the end of their lifespan, their membranes rupture and hemoglobin is released. The hemoglobin is phagocytosed by macrophages; it then splits into heme and globin. The heme is broken down by the reticuloendothelial cells, converted to bilirubin, and released in an unconjugated form. The unconjugated (indirect) bilirubin is relatively insoluble and almost entirely bound to circulating albumin, a plasma protein. The unbound bilirubin can leave the vascular system and permeate other extravascular tissues (e.g., skin, sclera, and oral mucous membranes). It can also cross the blood–brain barrier and cause neurotoxicity (acute bilirubin encephalopathy or kernicterus). The unconjugated bilirubin must be conjugated so it becomes soluble and excretable. In the liver the unbound bilirubin is conjugated with glucuronic acid in the presence of the enzyme glucuronyl transferase. The conjugated form of bilirubin (direct bilirubin) is soluble and excreted from liver cells as a constituent of bile. Along with other components of bile, direct bilirubin is excreted into the biliary tract system that carries the bile into the duodenum. Bilirubin is converted to urobilinogen and stercobilinogen within the duodenum through the action of the bacterial flora. Urobilinogen is excreted in urine and feces; stercobilinogen is excreted in the feces (Figure 25.7). The effectiveness

Red blood cell

Hemoglobin

Heme

Iron

Globin

Unconjugated bilirubin Glucuronic acid Action of liver glucuronyl transferase Conjugated bilirubin glucuronide

Excreted through feces or urine Fig. 25.7 Formation and excretion of bilirubin.

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of bilirubin excretion through the feces depends on the stooling pattern of the newborn and the substances in the intestine that break down conjugated bilirubin. In the newborn intestine the enzyme betaglucuronidase is able to convert conjugated bilirubin into the unconjugated form, which is subsequently reabsorbed by the intestinal mucosa and transported to the liver; this is called enterohepatic circulation. Feeding is important in reducing serum bilirubin levels because it stimulates peristalsis and produces more rapid passage of meconium, thus diminishing the amount of reabsorption of unconjugated bilirubin. Feeding also introduces bacteria to aid in the reduction of bilirubin to urobilinogen. Colostrum, a natural laxative, facilitates the passage of meconium. When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma levels of bilirubin increase and jaundice appears. Jaundice, the visible yellowish colour of the skin and sclera, is likely to appear when bilirubin levels exceed 85 to 102 mcmol/L (Blackburn, 2018). Jaundice is generally noticeable first in the head, especially in the sclera and mucous membranes, and progresses gradually to the thorax, abdomen, and extremities. The degree of jaundice is determined by serum total bilirubin measurements. The newborn is at risk for hyperbilirubinemia because of distinctive aspects of normal newborn physiology. The higher RBC mass at birth and shorter lifespan of newborn RBCs mean that greater bilirubin synthesis is needed. The ability of the liver to conjugate bilirubin is reduced during the first few days after birth; it can metabolize and excrete only about two thirds of the circulating bilirubin. In addition, there are fewer bilirubin binding sites because newborns have lower serum albumin levels. In the intestines, conjugated bilirubin becomes unconjugated and recirculated through the enterohepatic circulation, which increases serum bilirubin levels (Blackburn, 2018). Traditionally, newborn jaundice has been categorized as either physiological or pathological (nonphysiological), depending primarily on the time it appears and on serum bilirubin levels. Controversy surrounds the definitions of normal or physiological ranges of total serum bilirubin. Total serum bilirubin levels in newborns are affected by variables such as length of gestation, age, weight, ethnic background, blood group, nutritional status, mode of feeding, and presence of extravasated blood (e.g., cephalohematoma or severe bruising) (Blackburn, 2018). The time of onset of jaundice is a key factor in evaluating its cause and determining if treatment is needed. Table 25.3 lists the varying causes of neonatal hyperbilirubinemia. Among the factors that increase the risk of hyperbilirubinemia, prematurity is the most significant one. Prematurity affects liver and brain metabolism and albumin binding sites, placing preterm and late preterm newborns at greater risk for hyperbilirubinemia. Newborns of Asian and Indigenous backgrounds have higher bilirubin levels. Breastfeeding newborns are at greater risk of hyperbilirubinemia (see later discussion). Although there is no consistent definition for neonatal hyperbilirubinemia, the Canadian Paediatric Society suggests that an unconjugated bilirubin greater than 340 mcmol/L in the first 28 days of life constitutes hyperbilirubinemia (Barrington et al., 2007/2018). Physiological jaundice. Physiological or nonpathological jaundice occurs in approximately 60% of newborns born at term and 80% of preterm infants. It appears after 24 hours of age and usually resolves without treatment. Two phases of physiological jaundice have been identified in fullterm newborns. In the first phase, bilirubin levels gradually increase to approximately 85 to 100 mcmol/L by 60 to 72 hours of life, then decrease to a plateau of 35 to 50 mcmol/L by the fifth day (Blackburn, 2018). In Asian newborns, levels may reach a peak of 170 to 240 mcmol/L around the third to fifth day of life; the levels

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TABLE 25.3

Causes of Neonatal Indirect Hyperbilirubinemia Basis

Causes

Increased Production of Bilirubin Increased hemoglobin destruction Fetomaternal blood group incompatibility (Rh, ABO) Congenital red blood cell abnormalities Congenital enzyme deficiencies (G6PD, galactosemia) Sepsis Enclosed hemorrhage (cephalohematoma, bruising) Increased amount of hemoglobin

Polycythemia (maternal–fetal or twin–twin transfusion, SGA) Delayed cord clamping

Increased enterohepatic circulation

Delayed passage of meconium, meconium ileus, or plug Fasting or delayed initiation of feeding Intestinal atresia or stenosis

Altered Hepatic Clearance of Bilirubin Alteration in uridine Immaturity diphosphoglucuronyl transferase Metabolic or endocrine disorders (e.g., production or activity Criglar-Najjar syndrome, hypothyroidism, disorders of amino acid metabolism) Alteration in hepatic function and perfusion (and thus conjugating ability)

Sepsis (also causes inflammation) Asphyxia, hypoxia, hypothermia, hypoglycemia Medications and hormones

Hepatic obstruction (associated with direct hyperbilirubinemia)

Congenital anomalies (biliary atresia, cystic fibrosis) Biliary stasis (hepatitis, sepsis) Excessive bilirubin load (often seen with severe hemolysis)

G6PD, Glucose-6-phosphate dehydrogenase; SGA, small for gestational age. From Blackburn, S. T. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier.

gradually fall to 35 to 50 mcmol/L by the seventh to tenth day. Bilirubin levels maintain a steady plateau state in the second phase without increasing or decreasing until approximately 12 to 14 days, at which time levels decrease to the normal adult value of 17 mcmol/L (Blackburn, 2018). This pattern varies according to ethnicity, method of feeding (breastmilk versus formula), and gestational age. In preterm formula-fed infants, serum bilirubin levels may peak as high as 170 to 200 mcmol/L at 5 to 6 days of life and decrease slowly over a period of 2 to 4 weeks (Kamath-Rayne et al., 2021).

NURSING ALERT The appearance of jaundice during the first 24 hours of life or persistence beyond the ages previously delineated usually indicates a potential pathological process that requires investigation.

Pathological jaundice. Although physiological jaundice is usually considered benign, unconjugated bilirubin (indirect) can accumulate to hazardous levels and lead to a pathological condition. Pathological or nonphysiological jaundice is unconjugated hyperbilirubinemia that is either pathological in origin or severe enough to warrant further evaluation and treatment (see Chapter 26). Jaundice is usually considered pathological or nonphysiological if it appears within 24 hours of birth, if total serum bilirubin levels increase by more than 100 mcmcol/L in 24 hours, and if the serum bilirubin level exceeds 256 mcmol/L at any time (Blackburn, 2018; Kamath-Rayne et al., 2021). High levels of unconjugated bilirubin are usually caused by excessive production of bilirubin through hemolysis. Hemolytic disease of the newborn caused by maternal/newborn blood group incompatibility is the most common cause of hyperbilirubinemia. It can also be caused by glucose-6phosphate dehydrogenase (G6PD) deficiency, a genetic disorder that is more common among Asian and Indigenous populations. Other causes are listed in Table 25.3. If increased levels of unconjugated bilirubin are left untreated, neurotoxicity can result as bilirubin is transferred into the brain cells. Acute bilirubin encephalopathy refers to the acute manifestations of bilirubin toxicity that occur during the first weeks after birth. This can include a range of symptoms, such as lethargy, hypotonia, irritability, seizures, coma, and death. Kernicterus refers to the irreversible, longterm consequences of bilirubin toxicity, such as hypotonia, delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities. Jaundice related to breastfeeding. Two forms of breastfeedingrelated jaundice are recognized: breastfeeding-associated jaundice and breast milk jaundice. These typically occur in otherwise healthy newborns. Both types can occur in the same newborn and are not easily differentiated (Blackburn, 2018; Kamath-Rayne et al., 2021). Breastfeeding-associated jaundice (early-onset jaundice) begins at 2 to 5 days of age. Breastfeeding does not cause the jaundice; rather it is a lack of effective breastfeeding that contributes to the hyperbilirubinemia. If the newborn is not feeding effectively, there is less caloric and fluid intake and possible dehydration. Hepatic clearance of bilirubin is reduced. With less intake, there are fewer stools. As a result, bilirubin is reabsorbed from the intestine back into the bloodstream and must be conjugated again so it can be excreted (Blackburn, 2018; Lawrence & Lawrence, 2016). Breast milk jaundice (late-onset jaundice) usually occurs at 5 to 10 days of age. Newborns are usually feeding well and gaining weight appropriately. Rising levels of bilirubin peak during the second week and gradually diminish. Despite high levels of bilirubin that may persist for 3 to 12 weeks, these infants have no signs of hemolysis or liver dysfunction. The etiology of breast milk jaundice is uncertain. However, it seems to be related to factors in the breast milk (e.g., pregnanediol, fatty acids, and beta-glucuronidase) that either inhibit the conjugation or decrease the excretion of bilirubin (Blackburn, 2018). (See Chapter 27 for a discussion of these conditions in relation to newborn nutrition.) Coagulation. The liver plays an important role in blood coagulation. Coagulation factors, which are synthesized in the liver, are activated by vitamin K. The lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life. The levels of coagulation factors slowly increase to reach adult levels by age 9 months. The administration of vitamin K shortly after birth helps prevent vitamin K deficiency bleeding (VKDB), which can occur suddenly and be catastrophic (Shearer, 2017). Any bleeding issues noted in the newborn should be reported immediately and tests for clotting ordered.

Medication Metabolism. The immaturity of the liver and depressed liver enzyme systems at birth result in slower biotransformation and

CHAPTER 25 elimination of medications. This can result in slower medication clearance, increased serum levels, and longer half-lives (Blackburn, 2018).

Signs of Hepatic System Concerns. Hypoglycemia and hyperbilirubinemia are the most common liver-related conditions experienced by newborns. In most cases, these conditions are transient and require little, if any, treatment. Preterm infants are at increased risk for hepatic system complications because of the immaturity of the liver. The hematological status of all newborns should be assessed for anemia. For the first week of life, newborns are at risk for bleeding until the coagulation factors are well established. Male newborns who are circumcised prior to discharge from the birthing facility must be monitored carefully for bleeding.

Immune System Beginning early in gestation, the immune system of the fetus is developing the capacity to respond to foreign antigens. The development of the immune system is necessary to equip the newborn to meet the numerous environmental challenges (e.g., microorganisms) associated with life in the extrauterine world. Compared to adults, the immune response at birth is reduced, leading to increased susceptibility to pathogens. Newborn levels of circulating immunoglobins are low in comparison to adult levels. Most of the circulating antibodies in the newborn are immunoglobulin G (IgG) antibodies that were transported across the placenta from the maternal circulation. This transfer of antibodies from the mother begins as early as 14 weeks of gestation and is greatest during the third trimester. By term the IgG levels in the cord blood of the newborn are higher than those in maternal blood. The passive immunity afforded the newborn through the placental transfer of IgG usually provides sufficient antimicrobial protection during the first 3 months of life. Production of adult concentrations of IgG is reached by 4 to 6 years of age (Benjamin et al., 2015). The fetus is capable of producing IgM by the eighth week of gestation, and low levels are present at term (less than 10% of adult levels). IgM is important for immunity to bloodborne infections and is the major Ig synthesized during the first month. By the age of 2 years, IgM reaches adult levels. The production of IgA, IgD, and IgE is much more gradual, and maximal levels are not attained until early childhood (Benjamin et al., 2015). Natural barrier mechanisms such as the acidity of the stomach and the production of pepsin and trypsin, which maintain sterility of the small intestine, are not fully developed until ages 3 to 4 weeks. The membrane-protective IgA is missing from the respiratory and urinary tracts, and, unless the newborn is breastfed, it also is absent from the gastrointestinal tract. Breast milk provides the newborn with important immunity. The secretory IgA in human milk acts locally in the intestines to neutralize bacterial and viral pathogens. It may also lessen the risk of allergy and food intolerance through modulation of exposure to foreign milk protein antigens. Other components of breast milk strengthen the newborn’s immune system. Antimicrobial factors such as oligosaccharides, lysozyme, and lactoferrin aid in microbial clearance. Infants who are breastfed have enhanced antibody responses to vaccines. Long-term effects of breast milk on the immune system are demonstrated by lower risk for immune-mediated conditions such as allergies, inflammatory bowel disease, and type I diabetes mellitus (Turfkruyer & Verhasselt, 2015). The WBCs of the newborn display a delayed response to invading bacteria. Neutrophil levels are low; therefore, their key functions of phagocytosis, chemotaxis, and intracellular killing are limited (Greenberg et al., 2019). The influx of phagocytic cells to areas of

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inflammation is somewhat slowed, although the ability of these cells to attack and destroy bacteria is equivalent to that of adults. B cells and T cells are present in the newborn, although their function is immature (Benjamin et al., 2015). The newborn is capable of producing a protective immune response to vaccines, given as early as a few hours after birth. For example, when hepatitis B vaccine is administered at birth to the newborn born to a mother with hepatitis B, there is an excellent immune response. This holds true even if the newborn does not receive additional hepatitis B Ig.

Risk for Infection. All newborns, and preterm newborns especially, are at high risk for infection during the first several months of life. During this period infection is one of the leading causes of morbidity and mortality. The newborn cannot limit the invading pathogen to the portal of entry because of the generalized hypofunctioning of the inflammatory and immune mechanisms. Early signs of infection must be recognized so that prompt diagnosis and treatment can occur. Temperature instability or hypothermia can be symptomatic of serious infection; newborns do not typically exhibit fever, although hyperthermia can occur (temperature greater than 38°C or 100.4°F). Lethargy, irritability, poor feeding, vomiting or diarrhea, decreased reflexes, decreased body temperature, and pale or mottled skin colour are some of the clinical signs that suggest infection. Respiratory symptoms such as apnea, tachypnea, grunting, or retracting can be associated with infection such as pneumonia (Lott, 2015). The greatest risk factor for newborn infection is prematurity because of immaturity of the immune system. Other risk factors include premature rupture of membranes, chorioamnionitis, maternal fever, antenatal or intrapartal asphyxia, invasive procedures, stress, and congenital anomalies (Lott, 2015). Hand hygiene is key to prevention of serious infections.

Integumentary System All skin structures are present at birth. The epidermis and dermis are loosely bound and extremely thin. After 35 weeks’ gestation the skin is covered by vernix caseosa (a cheeselike whitish substance) that is fused with the epidermis and serves as a protective covering. Vernix caseosa is a complex substance that contains sebaceous gland secretions. It has emollient and antimicrobial properties and prevents fluid loss through the skin; it also has antioxidant properties. Removal of the vernix is followed by desquamation of the epidermis in most newborns. There is evidence that leaving residual vernix intact after birth has positive benefits for the newborn’s skin, such as decreasing the skin pH, decreasing skin erythema, and improving skin hydration (Association of Women’s Health, Obstetric, and Neonatal Nurses [AWHONN], 2018; Visscher et al., 2015). The newborn’s skin is sensitive and can be easily damaged. The term newborn has erythematous (red) skin for a few hours after birth, after which it fades to its normal colour. The skin often appears blotchy or mottled, especially over the extremities. The hands and feet appear slightly cyanotic (acrocyanosis); this is caused by vasomotor instability and capillary stasis. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days, especially with exposure to cold (see Figure 25.1). The healthy term newborn usually has a plump appearance because of large amounts of subcutaneous tissue and extracellular water content. Subcutaneous fat accumulated during the last trimester acts as insulation. Fine lanugo hair may be noted over the face, shoulders, and back. Edema of the face and ecchymosis (bruising) may be noted as a result of face presentation, forceps-assisted birth, or vacuum extraction.

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Creases can be found on the palms of the hands. A single palmar crease, is often found in Asian newborns or in newborns with Down syndrome. The soles of the feet should be inspected for the number of creases during the first few hours after birth; as the skin dries, more creases appear. Increasing numbers of creases correlate with a greater maturity rating. Premature newborns have few, if any, creases.

Sweat Glands. Distended, small, white sebaceous glands noticeable on the newborn face are known as milia. Although sweat glands are present at birth, term newborns usually do not sweat for the first 24 hours. By day 3, sweating begins on the face and later progresses to the palms. Newborns can sweat as a function of body or environmental temperature; there can also be emotional sweating from crying or pain (Hoath & Narendran, 2015).

Desquamation. Desquamation (peeling) of the skin of the term new-

A

born does not occur until a few days after birth. Large generalized areas of skin desquamation present at birth may be an indication of postmaturity.

Congenital Dermal Melanocytosis. Congenital dermal melanocytosis (also called slate grey nevi), bluish black areas of pigmentation, may appear over any part of the exterior surface of the body, including the extremities. This is more commonly noted on the back and buttocks (Figure 25.8). These pigmented areas are most frequently noted in newborns whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa (Blackburn, 2018). They fade gradually over months or years. The presence of congenital dermal melanocytosis in the newborn should be documented carefully in the medical record. These normal skin pigmentations can be mistaken for bruises once the infant is discharged, and this can raise suspicion of physical abuse. Nevi. Nevus simplex, also known as salmon patches, telangiectatic

nevi, or “angel kisses,” are the result of a superficial capillary defect and occur in up to 80% of newborns. They are usually small, flat, and pink and are easily blanched (Figure 25.9, A). The most common sites are the upper eyelids, nose, upper lip, and nape of the neck. Salmon patches tend to be symmetrical, with lesions occurring on both eyelids or both sides of midline. They have no clinical significance and require no treatment. Facial lesions usually fade between the first and second

B Fig. 25.9 A: Telangiectatic nevi. B: Erythema toxicum. (Courtesy Mead Johnson & Co., LLC.)

years of life, whereas neck lesions can be visible into adulthood (Hoath & Narendran, 2015). A port-wine stain, or nevus flammeus, is usually visible at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium. It is red to purple; varies in size, shape, and location; and is not elevated. True port-wine stains do not blanch on pressure or disappear. They are most commonly found on the face and neck (Hoath & Narendran, 2015).

Infantile Hemangioma. Infantile hemangiomas consist of dilated newly formed capillaries occupying the entire dermal and subdermal layers with associated connective tissue hypertrophy. The typical lesion is a raised, sharply demarcated, bright or dark red rough-surfaced swelling that may be present at birth or may appear during the early weeks after birth. Common sites are the scalp, face, back, and anterior chest. These lesions are sometimes called strawberry hemangiomas, although experts deem that term inappropriate. Most lesions reach maximum growth in about 6 months and then begin a slow process of involution that can take 5 to 10 years (Martin, 2016).

Fig. 25.8 Congenital dermal melanocytosis.

Erythema Toxicum. Erythema toxicum, a transient rash, is also called erythema neonatorum, or newborn rash. It first appears in term newborns during the first 24 to 72 hours after birth and can last up to 3 weeks of age. It has lesions in different stages: erythematous macules, papules, and small vesicles (see Figure 25.9, B). The lesions may appear

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suddenly anywhere on the body. The rash is thought to be an inflammatory response. Eosinophils, which help decrease inflammation, are found in the vesicles. Although the appearance is alarming, the rash has no clinical significance and requires no treatment.

Signs of Integumentary Concerns. Close observation of the newborn’s skin colour can help in early detection of potential concerns. Any pallor, plethora (deep purplish colour from increased circulating RBCs), petechiae, central cyanosis, or jaundice should be noted and described. The skin should be examined for signs of birth injuries, such as forceps marks and lesions related to fetal monitoring. Bruises or petechiae may be present on the head, neck, and face of a newborn born with a nuchal cord (cord around the neck) or in a newborn who had a face presentation at birth. Bruising can increase the risk of hyperbilirubinemia. Petechiae can be present if increased pressure was applied to an area. Petechiae scattered over the newborn’s body should be reported to the pediatric health care provider because their presence can indicate underlying issues such as low platelet count or infection. Unilateral or bilateral periauricular papillomas (skin tags) occur fairly frequently. Their occurrence is usually a family trait and of no consequence.

A

Reproductive System Female. An increase in estrogen during pregnancy, followed by a drop after birth, results in a mucoid vaginal discharge and some slight bloody spotting (pseudomenstruation). External genitalia (i.e., labia majora and minora) are usually edematous, with increased pigmentation. In term newborns, the labia majora and minora cover the vestibule (Figure 25.10, A). In preterm newborns, the clitoris is prominent and the labia majora are small and widely separated. Vaginal or hymenal tags are common findings and have no clinical significance. Vernix caseosa may be present between the labia and should not be forcibly removed during bathing. If the female was born in the breech position, the labia may be edematous and bruised. The edema and bruising resolve in a few days; no treatment is necessary. Male. A tight prepuce (foreskin) is common in newborns and completely covers the glans (see Figure 25.10, B). The urethral opening may be completely covered by the prepuce, which may not be retractable for 3 to 4 years. The position of the urethra should be at the tip of the penis. With hypospadias, or epispadias, the urethral opening is located in an abnormal position, on or adjacent to the glans, although it can be placed on the penile shaft or perineum. Smegma, a white, cheesy substance, is commonly found under the foreskin. Small, white, firm cysts called epithelial pearls may be seen at the tip of the prepuce. By 28 to 36 weeks of gestation, the testes can be palpated in the inguinal canal and a few rugae appear on the scrotum. At 36 to 40 weeks of gestation, the testes are palpable in the upper scrotum and rugae appear on the anterior portion. After 40 weeks, the testes can be palpated in the scrotum and rugae cover the scrotal sac. The post-term newborn has deep rugae and a pendulous scrotum. Undescended testes (cryptorchidism) occur in approximately 4% of term newborn males; in most cases, the testes gradually descend without intervention. The primary risk factors for cryptorchidism are preterm birth and low birth weight (Lee, 2017). The scrotum is usually more deeply pigmented than the rest of the skin, a difference that is especially apparent in darker-skinned newborns. This pigmentation is a response to maternal estrogen. If the male newborn is born in a breech presentation, the scrotum is edematous and may be bruised (see Figure 26.8). The swelling and discoloration subside within a few days.

B Fig. 25.10 External genitalia. A: Genitalia in female term newborn. B: Genitalia in uncircumcised male newborn. Rugae cover scrotum, indicating term gestation. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

A hydrocele, caused by an accumulation of fluid around the testes, may be found. This can be transilluminated with a light and usually decreases in size without treatment.

Swelling of Breast Tissue. Swelling of the breast tissue in term newborns of both sexes is caused by the hyperestrogenism of pregnancy. In a few newborns a thin discharge can be seen. This finding has no clinical significance, requires no treatment, and subsides within a few days as the maternal hormones are eliminated from the newborn’s body. The nipples should be symmetrical on the chest. Breast tissue and areola size increase with gestation. The areola appears slightly elevated at 34 weeks of gestation. By 36 weeks, a breast bud of 1 to 2 mm is palpable; this increases to 12 mm by 42 weeks. Signs of Reproductive System Concerns. The newborn must be inspected closely for ambiguous genitalia and other abnormalities. Normally, in a female newborn the urethral opening is located behind the clitoris. Any deviation from this can incorrectly suggest that the clitoris is a small penis, which can occur in conditions such as adrenal hyperplasia. Nearly all female newborns are born with hymenal tags; absence of such tags can indicate vaginal agenesis. Fecal discharge from the vagina indicates a rectovaginal fistula. Any of these findings must be reported to the pediatric health care provider for further evaluation. Hypospadias or epispadias, undescended or maldescended testes, and other abnormalities of the male genitalia must be reported.

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Circumcision is contraindicated in the presence of hypospadias or epispadias since the foreskin is used in repair of these anomalies. Inguinal hernias can be present and become more obvious when the newborn cries. They usually require no treatment because they resolve with time.

Skeletal System The infant’s skeletal system undergoes rapid development during the first year of life. At birth, more cartilage is present than ossified bone. Because of cephalocaudal (head-to-rump) development, the newborn looks somewhat out of proportion. The head at term is one fourth of the total body length. The arms are slightly longer than the legs. In the newborn, the legs are one third of the total body length but only 15% of the total body weight. As growth proceeds, the midpoint in head-to-toe measurements gradually descends from the level of the umbilicus at birth to the level of the symphysis pubis at maturity. The face appears small in relation to the skull. The skull appears large and heavy. Cranial size and shape can be distorted by moulding (the shaping of the fetal head through overlapping of the cranial bones to facilitate movement through the birth canal during labour) (Figure 25.11).

Caput Succedaneum. Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput (Figure 25.12, A). The sustained pressure of the presenting vertex against the cervix results in compression of local vessels, thereby

A

slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops. This edematous swelling, present at birth, extends across the suture lines of the skull and disappears spontaneously within 3 to 4 days. Newborns who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied.

Cephalohematoma. Cephalohematoma is a collection of blood between a skull bone and its periosteum. Thus, a cephalohematoma does not cross a cranial suture line (see Figure 25.12, B). A cephalohematoma is firmer and better defined than a caput. Often caput succedaneum and cephalohematoma occur simultaneously. Bleeding may occur with spontaneous birth from pressure against the maternal bony pelvis. Low forceps birth and difficult forceps rotation and extraction may also cause bleeding. This soft, fluctuating, irreducible fullness does not pulsate or bulge when the newborn cries. It appears several hours or the day after birth and may not become apparent until a caput succedaneum is absorbed. A cephalohematoma is usually largest on the second or third day, by which time the bleeding stops. The fullness of a cephalohematoma spontaneously resolves in 3 to 6 weeks. It is not aspirated because infection may develop if the skin is punctured. As the hematoma resolves, hemolysis of RBCs occurs and jaundice may result. Hyperbilirubinemia and jaundice may occur from a cephalohematoma after the newborn is discharged home. Subgaleal Hemorrhage. Subgaleal hemorrhage is bleeding into the subgaleal compartment (see Figure 25.12, C). The subgaleal compartment is a potential space that contains loosely arranged connective tissue; it is located beneath the galea aponeurosis, the tendinous sheath that connects the frontal and occipital muscles and forms the inner surface of the scalp. Subgaleal hemorrhage is commonly associated with difficult operative vaginal birth, especially vacuum extraction. With the vacuum extractor the scalp is pulled away from the bony calvarium; the vessels are torn, and blood collects in the subgaleal space. Blood loss can be severe, resulting in hypovolemic shock, disseminated intravascular coagulation (DIC), and death (Mangurten et al., 2015). Early detection of the hemorrhage is vital; serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are an essential aspect of assessment of newborns who are born with the assistance of a vacuum extractor. A boggy scalp, pallor, tachycardia, and increasing head circumference may also be early signs of a subgaleal hemorrhage. Computed tomography (CT) or magnetic resonance imaging (MRI) is useful in confirming the diagnosis. Replacement of lost blood and clotting factors is required in acute cases of hemorrhage. Another possible early sign of subgaleal hemorrhage is a forward and lateral positioning of the newborn’s ears, because the hematoma extends posteriorly. Monitoring the newborn for changes in level of consciousness and decreases in hematocrit is also key to early recognition and management (Mangurten et al., 2015). Spine. The bones in the vertebral column of the newborn form two

B

C

Fig. 25.11 Moulding. A: Significant moulding after vaginal birth. B: Schematic of bones with no moulding. C: Schematic of bones with moulding. (A, Courtesy Kim Molloy.)

primary curvatures—one in the thoracic region and one in the sacral region. Both are forward, concave curvatures. As the infant gains head control at approximately age 3 months, a secondary curvature appears in the cervical region. The newborn’s spine appears straight and can be flexed easily. The newborn can lift the head and turn it from side to side when prone. The vertebrae should appear straight and flat. If a pilonidal dimple is noted, further inspection is required to determine whether a sinus is present. A pilonidal dimple, especially with a sinus and nevus pilosis (hairy nevus), is significant because it can be associated with spina bifida.

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Cranium

Edema Scalp

Subgaleal hemorrhage Galea Connective tissue Skin Periosteum Bone

A

Dura mater

Periosteum

Cranium

Scalp Hemorrhage

C THE SCALP Skin Connective tissue Aponeurosis (galea)

B

Loose connective tissue Periosteum

Bone Dura mater Brain

Fig. 25.12 A: Caput succedaneum. B: Cephalohematoma. C: Subgaleal hemorrhage. (A and B from Seidel, H. M., Stewart, R. W., Ball, J. W., et al. [2006]. Mosby’s guide to physical examination [6th ed.]. Mosby.)

Extremities. The newborn’s extremities should be symmetrical and of equal length. Fingers and toes should be equal in number (five fingers on each hand and five toes on each foot) and should have nails present. Digits may be missing (oligodactyly). Extra digits (polydactyly) are sometimes found on hands or feet. Fingers or toes may be fused (syndactyly). In some newborns, there is a significant separation of the knees when the ankles are held together, resulting in an appearance of bowlegs. At birth, there is no apparent arch to the foot. The newborn is examined for developmental dysplasia of the hip (DDH). In newborns with DDH the affected hip is unlikely to be dislocated at birth; instead it is easily dislocatable. Postnatal factors determine whether the hip dislocates, subluxates, or remains stable. DDH occurs more often in first-born infants, females, breech presentations (Figure 25.13), and newborns with a family history of DDH (SonHing & Thompson, 2015). Signs of DDH are asymmetrical gluteal and thigh skinfolds, uneven knee levels, a positive Ortolani test, and a positive Barlow test. The hips are inspected for symmetry. Gluteal and thigh skin folds should be equal and symmetrical, and legs should be of equal length (Figure 25.13, A). The level of the knees in flexion should be equal (see Figure 25.13, C). Hip integrity is assessed by using the Barlow test and the Ortolani manoeuvre. For the Barlow test the examiner places the middle finger over the greater trochanter and the thumb along the midthigh. The hip is flexed to 90 degrees and adducted, followed by

gentle downward pushing of the femoral head. If the hip can be dislocated with this manoeuvre, the femoral head moves out of the acetabulum, and the examiner feels a “clunk.” The hip is then checked to determine if the femoral head can be returned into the acetabulum using the Ortolani test. As the hip is abducted and upward leverage is applied, a dislocated hip returns to the acetabulum with a clunk that is felt by the examiner (see Figure 25.13, B and D).

SAFETY ALERT Only expert examiners (physicians, nurse practitioners) should perform the Barlow test and Ortolani manoeuvre to assess for developmental dysplasia of the hip. An unskilled examiner can cause injury to the newborn.

Signs of Skeletal Concerns. Abnormalities of the skeletal system can be congenital, developmental, drug induced, or the result of intrapartum or postnatal factors. Signs of DDH, additional digits or webbing of digits, and any other abnormality should be documented and reported to the primary health care provider. A fractured clavicle may occur in macrosomic newborns and in those who had a difficult birth (e.g., shoulder dystocia). Unequal movement of the upper extremities or a crepitant feeling over the clavicular area can indicate fracture.

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B

A

C

D

Fig. 25.13 Signs of developmental dysplasia of the hip. A: Asymmetry of gluteal and thigh folds with shortening of the thigh (Galeazzi sign). B: Limited hip abduction, as seen in flexion (Ortolani test). C: Apparent shortening of the femur, as indicated by the level of the knees in flexion (Allis sign). D: Ortolani test with femoral head moving in and out of acetabulum (in newborns 1 to 2 months old). (From Hockenberry, M. J., & Wilson, D. [2013]. Wong’s essentials of pediatric nursing [9th ed.]. Mosby.)

The feet of the newborn can appear to be abnormally positioned. This can indicate a congenital deformity or be related to fetal positioning in utero. For example, clubfoot (talipes equinovarus), a deformity in which the foot turns inward and is fixed in a plantar-flexion position, is a congenital condition that warrants attention. If the foot is turned inward in the plantar-flexion position but can be moved into the normal position, it is likely caused by fetal positioning and should gradually resolve.

Neuromuscular System The neuromuscular system is almost completely developed at birth. The term newborn is a vital, responsive, and reactive being with a remarkable capacity for social interaction and self-organization. Growth of the brain after birth follows a predictable pattern of rapid growth during infancy and early childhood; growth becomes more gradual during the remainder of the first decade and minimal during adolescence. The cerebellum ends its growth spurt, which began at about 30 gestational weeks, by the end of the first year. The brain requires glucose, as a source of energy, and a relatively large supply of oxygen for adequate metabolism. Such requirements signal a need for careful assessment of the newborn’s respiratory status. The necessity for glucose requires attentiveness to those newborns who are at risk for hypoglycemia (e.g., newborns of diabetic mothers; newborns who are macrosomic or small for gestational age; and newborns experiencing prolonged birth, hypoxia, or preterm birth). Spontaneous motor activity may be seen as transient tremors of the mouth and chin, especially during crying episodes, and of the extremities, notably the arms and hands. Transient tremors are normal and can be observed in nearly every newborn. These tremors should not be present when the newborn is quiet and should not persist beyond 1 month of age. Persistent tremors or tremors involving the entire body may indicate pathological conditions. Normal tremors, tremors of hypoglycemia, and central nervous system (CNS) disorders need to be differentiated so that corrective care can be instituted as necessary. To differentiate between tremors or jitteriness and seizure activity, the nurse can consider the following signs (Ditzenberger & Blackburn, 2014):

• Tremors and jitteriness are easily elicited by motions or voice and cease with gentle restraint of the body part, whereas seizure activity continues. • Seizure activity is associated with ocular changes (eyes deviating or staring) and autonomic changes (apnea, tachycardia, pupil changes, increased salivation); these signs are not associated with jitteriness or tremors. The posture of the term newborn demonstrates flexion of the arms at the elbows and the legs at the knees. Hips are abducted and partially flexed. Intermittent fisting of the hands is common. Muscle tone and strength are directly related. The newborn with normal tone and strength exhibits some resistance to passive movement, such as when being pulled to sit or when the arm or leg is extended by the examiner. The hypotonic newborn shows little resistance and can feel like a “rag doll.” Hypertonia is evidenced by increased resistance to passive movement.

Newborn Reflexes. The newborn has many primitive reflexes. The times at which these reflexes appear and disappear reflect the maturity and intactness of the developing nervous system. Primary reflexes reflect normal brainstem activity. CNS depression should be suspected if they cannot be elicited or they are persistent beyond a certain age; this suggests damage of cortical functioning. The most common reflexes found in the healthy newborn are described in Table 26.3.

BEHAVIOURAL ADAPTATIONS The healthy newborn must accomplish behavioural and biological tasks to meet developmental milestones. Behavioural characteristics form the basis of the newborn’s social capabilities. Newborns progress through a hierarchy of developmental challenges as they adapt to their environment and caregivers. They must first be able to regulate their physiological or autonomic system, including involuntary physiological functions such as heart rate, respiration, and temperature. The next level is motor organization, in which newborns regulate or control their motor behaviour. This includes controlling random movements, improving muscle tone, and reducing excessive activity. The third level

CHAPTER 25 of behaviour is state regulation, which refers to the ability to modulate the state of consciousness. The newborn develops predictable sleep and wake states and is able to react to stress through self-regulation or through communicating with the caregiver by crying and then being consoled. Finally, the infant reaches the fourth level of attention and social interaction. The child is able to attend to visual and auditory stimulation, stay alert for long periods, and engage in social interaction (Brazelton & Nugent, 2011). This progression in behaviour is the basis for the Brazelton Neonatal Behavioral Assessment Scale (NBAS) (Brazelton & Nugent, 2011). The NBAS is an interactive examination used to assess the infant’s response to 28 areas organized according to the clusters in Box 25.2. It is generally used as a research or diagnostic tool and requires special training for use. The NBAS helps the practitioner identify where the infant falls along the continuum of behaviours and determine the type of support needed.

Sleep–Wake States Healthy newborns differ in their activity levels, feeding patterns, sleeping patterns, and responsiveness. Parents’ reactions to their newborns are often determined by these differences. Showing parents the unique characteristics of their newborn can help them develop a more positive perception of the newborn and promote increased interaction between newborn and parent. Newborn responses to environmental stimuli and to their caregivers depend on the newborn’s state or state of consciousness. In the early newborn period infants tend to alternate periods of sleep and wakefulness that resemble their fetal inactivity and activity patterns. Variations in the state of consciousness of newborns are called sleep–wake states. The six states form a continuum from deep sleep to extreme irritability (Figure 25.14): two sleep states (deep sleep and light sleep) and four wake states (drowsy, quiet alert, active alert,

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BOX 25.2

Clusters of Neonatal Behaviours in Brazelton Neonatal Behavioural Assessment Scale • Habituation—Ability to respond to and then inhibit responding to discrete stimulus (e.g., light, rattle, bell, pinprick) while asleep • Orientation—Quality of alert states and ability to attend to visual and auditory stimuli while alert • Motor performance—Quality of movement and tone • Range of state—Measure of general arousal level or arousability of newborn • Regulation of state—How newborn responds when aroused • Autonomic stability—Signs of stress (e.g., tremors, startles, skin colour) related to homeostatic (self-regulator) adjustment of the nervous system • Reflexes—Assessment of several newborn reflexes

From Brazelton, T., & Nugent, J. (2011). Neonatal behavioural assessment scale (4th ed.). MacKeith.

and crying) (Brazelton & Nugent, 2011). Each state has specific characteristics and state-related behaviours. The optimal state of arousal is the quiet alert state. During this state newborns smile, vocalize, move in synchrony with speech, watch their parents’ faces, and respond to people talking to them. They respond to internal and external environmental factors by controlling sensory input and regulating the sleep–wake states; the ability to make smooth transitions between states is called state modulation. The ability to regulate sleep–wake states is essential in the newborn’s neurobehavioural development. Term newborns are better able than preterm infants to cope with external or internal factors that affect the sleep–wake patterns.

A

B

C

D

E

F

Fig. 25.14 Newborn sleep–wake states. A: Deep sleep. B: Light sleep. C: Drowsy. D: Quiet alert. E: Active alert. F: Crying. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

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Newborns use purposeful behaviour to maintain the optimal arousal state as follows: (1) actively withdrawing by increasing physical distance, (2) rejecting by pushing away with hands and feet, (3) decreasing sensitivity by falling asleep or breaking eye contact by turning the head, or (4) using signalling behaviours such as fussing and crying. These behaviours permit the newborn to quiet themselves and reinstate readiness to interact. The first 6 weeks of life involve a steady decrease in the proportion of active REM sleep to total sleep. A steady increase in the proportion of quiet sleep to total sleep also occurs. Periods of wakefulness increase. For the first few weeks the wakeful periods seem dictated by hunger, but soon a need for socializing appears. The newborn sleeps on average approximately 17 hours a day, with periods of wakefulness gradually increasing. By the fourth week of life some infants stay awake from one feeding to the next.

Other Factors Influencing Behaviour of Newborns Gestational Age. Gestational age and level of CNS maturity affect newborn behaviour. In the preterm newborn with an immature CNS, the entire body responds to a pinprick of the foot, although the response may not be observed by an untrained observer. The more mature newborn withdraws only the foot. CNS immaturity is reflected in reflex development, sleep–wake states, and ability (or lack thereof) to regulate or modulate a smooth transition between different states. Preterm infants have brief periods of alertness but have difficulty maintaining alertness without becoming overstimulated, which leads to autonomic instability unless intervention is implemented. Premature or sick newborns show signs of fatigue or physiological stress sooner than full-term healthy newborns. Time. The time elapsed since birth affects the behaviour of newborns as they attempt to become organized initially. Time elapsed since the previous feeding and time of day also can influence newborns’ responses.

Stimuli. Environmental events and stimuli affect newborns’ behavioural responses. The newborn responds to animate and inanimate stimuli. Nurses in neonatal intensive care nurseries have observed that newborns respond to loud noises, bright lights, monitor alarms, and tension in the unit. Medication. No conclusive evidence exists regarding the effects of maternal analgesia or anaesthesia during labour on newborn behaviour. Researchers who have studied the effects of epidural medications on breastfeeding behaviours have been unable to show a cause-andeffect relationship (Hoyt & Pages-Arroyo, 2015).

Sensory Behaviours From birth, newborns possess sensory capabilities that indicate a state of readiness for social interaction. Newborns effectively use behavioural responses in establishing their first dialogues. These responses, coupled with the newborns’ “baby appearance” (e.g., facial proportions of forehead and eyes larger than the lower part of the face) and their small size and helplessness, evoke feelings of wanting to hold and protect them and to interact with them.

Vision. At birth, the eye is structurally incomplete and the muscles are immature. The process of accommodation is not present at birth but improves over the first 3 months of life. The pupils react to light, the blink reflex is easily stimulated, and the corneal reflex is activated by light touch. Term newborns can see objects as far away as 50 cm. The clearest visual distance is 17 to 20 cm, which is about the distance

the newborn’s face is from the parent’s face as they breastfeed or cuddle. Newborns seem to have a preference for faces and can recognize the mother’s face. This facilitates interaction and promotes bonding. They will engage their caregiver with eye contact. Newborns can imitate facial expressions and motions such as protruding the tongue (Gardner & Edward-Goldson, 2021). Newborns prefer complex patterns over nonpatterned stimuli. They prefer black and white, possibly because of the greater contrast. Within 2 to 3 months, they can discriminate colours. Response to movement is noticeable. If a bright light is shown to newborns (even at 15 minutes of age), they will follow it visually; some will even turn their heads to do so. Because human eyes are bright, shiny objects, newborns will track their parents’ eyes. Parents often comment on how exciting this behaviour is. The development of eye-to-eye contact is important for parent–newborn attachment. Children of blind parents and parents who have blind children develop strategies to help assist in developing this relationship.

Hearing. As soon as the amniotic fluid drains from the ears, the newborn’s hearing is similar to that of an adult. Loud sounds of about 90 decibels cause the newborn to react with a Moro reflex. Term newborns can hear and differentiate among various sounds. They will turn toward a sound and attempt to locate the source. The newborn recognizes and responds readily to a parent’s voice and shows a preference for highpitched intonation. Newborns respond to rhythmic sounds. They are accustomed to hearing the regular rhythm of the mother’s heartbeat, which was a constant sound during intrauterine life. As a result, they respond by relaxing and ceasing to fuss and cry if a regular heartbeat simulator is placed in their cribs; a lullaby can have the same effect. Hearing is integral to bonding and attachment and may be more important than vision (Gardner & Edward-Goldson, 2021). Routine hearing screening is recommended for all newborns before hospital discharge, although it is not mandatory in all provinces. See Chapter 26 for a discussion about screening of newborn hearing. Smell. Newborns have a highly developed sense of smell and can detect and discriminate distinct odours. It has been shown that preterm newborns as early as 28 weeks are capable of reacting to odours. They react to strong odours, such as alcohol or vinegar, by turning their heads away but are attracted to sweet smells. Breastfed newborns are able to smell breast milk and can differentiate their mother from other lactating women by the smell (Lawrence & Lawrence, 2016).

Taste. The newborn can distinguish among tastes, and various types of solutions elicit differing facial expressions. A tasteless solution produces no response, a sweet solution elicits eager sucking, a sour solution causes puckering of the lips, and a bitter liquid produces a grimace. Newborns are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking. The early development of circumoral sensation, muscle activity, and taste would seem to be preparation for survival in the extrauterine environment. Touch. The newborn is responsive to touch on all parts of the body. The face (especially the mouth), hands, and soles of the feet appear to be the most sensitive. Reflexes can be elicited by stroking the newborn. The newborn’s responses to touch suggest that this sensory system is well prepared to receive and process tactile messages (Gardner & Edward-Goldson, 2021). Touch and motion are essential to normal growth and development, and newborn massage is a way to increase tactile stimulation. However, each newborn is unique, and variations can be seen in responses to touch. Birth trauma or stress and depressant

CHAPTER 25 medications taken by the mother decrease the newborn’s sensitivity to touch or painful stimuli. Multiple studies have demonstrated the benefits of skin-to-skin care immediately after birth.

Response to Environmental Stimuli Temperament. Each newborn has a unique repertoire of behaviours that are influenced by various factors including temperament, sensory threshold, ability to habituate, and consolability. Temperament refers to individual variations in the reaction pattern of newborns. Newborns possess individual characteristics that affect selective responses to various stimuli present in the internal and external environments. Some newborns appear to be quiet by nature and can remain still for extended periods. Their movements may be smooth and relaxed most of the time, and they have little difficulty settling down for feeding. Other newborns are more active and seem to be in constant motion; they seem to be excited and interested in exploring the faces and sounds around them. These newborns often need help to settle; containment (swaddling), physical contact, and boundaries surrounding the newborn in the crib can facilitate a quiet alert state (Nugent et al., 2007).

Habituation. Habituation is a protective mechanism that allows the newborn to become accustomed to environmental stimuli. Habituation is a psychological and physiological phenomenon in which the response to a constant or repetitive stimulus is decreased. In the term newborn, this can be demonstrated in several ways. Shining a bright light into a newborn’s eyes causes a startle or squinting the first two or three times. The third or fourth flash elicits a diminished response, and by the fifth or sixth flash the newborn ceases to respond (Brazelton & Nugent, 2011). The same response pattern holds true for the sounds of a rattle or stroking the bottom of the foot. The ability to habituate allows the healthy term newborn to select stimuli that promote continued learning about the social world, thus avoiding overload. The intrauterine environment appears to have programmed the newborn to be especially responsive to human voices, soft lights, soft sounds, and sweet tastes. The newborn quickly learns the sounds in the home environment and is able to sleep in their midst. The selective responses of the newborn indicate cerebral organization capable of memory and making choices. The ability to habituate depends on the state of consciousness, hunger, fatigue, and temperament. These factors also affect consolability, cuddliness, irritability, and crying.

Consolability. Newborns vary in the ability to console themselves or be consoled. In the crying state most newborns initiate one of several ways to reduce their distress. Hand-to-mouth movements with or without sucking and being alert to voices, noises, or visual stimuli are common. Some newborns are consoled only if they are held and rocked (Brazelton & Nugent, 2011). Cuddliness. Cuddliness is especially important to parents because they often gauge their ability to care for the child by the child’s responses to their actions. The degree to which newborns mould into the contours of the person holding them varies. One extreme is the newborn who always resists being held with thrashing and stiffening of the body. This is in contrast to the newborn who immediately relaxes when held and moulds to the body of the person. Less extreme behaviour is demonstrated by newborns who are passive when held and those who gradually mould after being held for a while (Brazelton & Nugent, 2011). Irritability. Some newborns cry longer and harder than others. For some, the sensory threshold seems low. They are readily upset by

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unusual noises, hunger, wetness, or new experiences and thus respond intensely. Others with a high sensory threshold require a great deal more stimulation and variation to reach the active, alert state.

Crying. Crying is the language a newborn uses most often to communicate needs. It may signal hunger, discomfort, pain, desire for attention, or fussiness. Newborns may cry in response to environmental stimuli such as cold, being overstimulated, or being held by multiple persons. Responsiveness of the caregiver to the crying creates trust as the newborn learns to associate the caregiver with comfort. The amount and tone of crying vary based on gestational age, weight, and the reason for the cry (e.g., hunger, pain). A high-pitched cry can be a sign of a neurological disorder. Some mothers state that they learn to distinguish among the cries. The breastfeeding mother’s body responds physiologically to newborn crying by stimulating the milk-ejection reflex (“let-down”). The duration of crying also varies greatly in each infant; newborns may cry for as little as 5 minutes or as much as 2 hours or more per day. The amount of crying peaks in the second month and then decreases. There is a diurnal rhythm of crying, with more crying occurring in the evening hours. Parents need to learn that most crying is normal and a way for the newborn to communicate their needs. Some parents who are exhausted and overwhelmed can become frustrated with a baby who cries excessively. Parents need to be taught to recognize when they have reached their limit and that if this occurs, it is important to put the newborn in a safe place and take a few minutes away from the baby. See further discussion on interpretation of crying in Chapter 26.

KEY POINTS • By full term, the newborn’s various anatomical and physiological systems have reached a level of development and functioning that permits a physical existence apart from the mother. • The newborn’s most critical adaptation to extrauterine life is to establish effective respirations. • Heat loss in the healthy term newborn may exceed the capacity to produce heat; this can lead to metabolic and respiratory complications that threaten the newborn’s well-being. • Physiological jaundice occurs in 60% of term newborns and 80% of preterm newborns. • The appearance of jaundice during the first day of life or persistence of jaundice beyond 7 to 10 days may indicate a pathological process that requires further investigation. • Some reflex behaviours are important for the newborn’s survival. • The healthy newborn has sensory abilities that indicate a state of readiness for social interaction. Sleep–wake states and other factors influence the newborn’s behaviour. • Newborn behaviour progresses from self-regulation of autonomic processes to social interaction. • Each full-term newborn has a predisposed capacity to handle the multitude of stimuli in the external world.

REFERENCES Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2018). Neonatal skin care (4th ed.). Author. B€ackhed, F., Roswall, J., Peng, Y., et al. (2015). Dynamics and stabilization of the human gut microbiome during the first year of life. Cell Host and Microbe, 17(5), 690–703. Barrington, K. J., Sankaran, K., & Canadian Paediatric Society. (2007). Guidelines for detection, management and prevention of hyperbilirubinemia

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in term and late term newborn infants [35 or more weeks gestation]. Paediatrics & Child Health, 12(Suppl. B), 1B–12B. Reaffirmed 2018. Benjamin, J. T., Mezu-Ndibuisi, O. J., & Maheshwari, A. (2015). Developmental immunology. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Blackburn, S. T. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier. Brazelton, T., & Nugent, J. (2011). Neonatal behavioural assessment scale (4th ed.). MacKeith. Cadnapaphornchai, M. A., Soranno, D. E., Bisio, T. J., et al. (2021). Neonatal nephrology. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care (9th ed.). Elsevier. Christensen, R. D., & Ohls, R. K. (2016). Development of the hematopoietic system. In R. M. Kliegman, B. F. Stanton, J. W. St Geme, III, et al. (Eds.), Nelson textbook of pediatrics (20th ed.). Elsevier. Dell, K. M. (2015). Fluids, electrolytes, and acid-base homeostasis. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Desmond, M., Rudolph, A., & Phitaksphraiwan, P. (1966). The transitional care nursery: A mechanism for preventive medicine in the newborn. Pediatric Clinics of North America, 13(3), 651–668. Ditzenberger, G. R., & Blackburn, S. T. (2014). Neurologic system. In C. Kenner, & J. W. Lott (Eds.), Comprehensive neonatal nursing care (5th ed.). Springer. Fraser, D. (2015). Respiratory distress. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Elsevier. Gardner, S. L., & Cammack, J. H. (2021). Heat balance. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Gardner, S. L., Enzman Hines, M., & Nyp, M. (2021). Respiratory diseases. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Gardner, S. L., & Goldson, E. (2021). The neonate and the environment impact on development. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Greenberg, J. M., Haberman, B., Narendran, V., et al. (2019). Neonatal morbidities of prenatal and perinatal origin. In R. K. Creasy, R. Resnik, J. D. Iams, et al. (Eds.), Creasy & Resnik’s maternal-fetal medicine: Principles and practice (8th ed.). Elsevier. Health Canada, Canadian Paediatric Society, & Dietitians of Canada and Breastfeeding Committee for Canada. (2015). Nutrition for healthy term infants: Birth to six months. http://www.hc-sc.gc.ca/fn-an/nutrition/infantnourisson/recom/index-eng.php. Hibbs, A. M. (2015). Gastroesophageal reflux and gastroesophageal reflux disease in the neonate. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Hoath, S. B., & Narendran, V. (2015). The skin. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Hoyt, M. R., & Pages-Arroyo, E. M. (2015). Anesthesia for labor and delivery. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Kamath-Rayne, B. D., Froese, P. A., & Thilo, E. H. (2021). Neonatal hyperbilirubinemia. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Lawrence, R. A., & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. Leduc, D., Senikas, V., & Lalonde, A. B. (2018). SOGC clinical practice guideline: Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology Canada, 40(12), e841–e855.

Lee, M. M. (2017). Testicular development and descent. In R. A. Polin, S. H. Abman, D. H. Rowitch, et al. (Eds.), Fetal and neonatal physiology (5th ed.). Elsevier. Lott, J. W. (2015). Immunology and infectious disease. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Elsevier. Mangurten, H. H., Puppala, B. L., & Prazad, R. A. (2015). Birth injuries. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Martin, K. L. (2016). Vascular disorders. In R. M. Kliegman, B. F. Stanton, J. W. St. Geme, III, et al. (Eds.), Nelson textbook of pediatrics (20th ed.). Elsevier. Monagle, P. (2017). Developmental hemostasis. In R. A. Polin, S. H. Abman, D. H. Rowitch, et al. (Eds.), Fetal and neonatal physiology (5th ed.). Elsevier. Mueller, N. T., Bakacs, E., Combellick, J., et al. (2015). The infant microbiome development: Mom matters. Trends in Molecular Medicine, 21(2), 109–117. Narvey, M., Marks, S., & Canadian Paediatric Society, Fetus and Newborn Committee. (2019). The screening and management of newborns at risk for low blood glucose. Paediatrics & Child Health, 24(4), 536–544. Neu, J. (2017). The developing microbiome of the fetus and newborn. In R. A. Polin, S. H. Abman, D. H. Rowitch, et al. (Eds.), Fetal and neonatal physiology (5th ed.). Elsevier. Nugent, J. K., Keefer, C. H., Minear, S., et al. (2007). Understanding newborn behavior and early relationships: The newborn behavioral observations (NBO) system handbook. Brookes Publishing. Pagana, K. D., Pagana, T. J., & MacDonald, S. (2019). Mosby’s Canadian manual of diagnostic and laboratory tests (2nd ed.). Elsevier. Perlman, J. M., Wyllie, J., Kattwinkel, J., et al. (2015). 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 7: Neonatal resuscitation. Pediatrics, 136(Supplement 2), S120–S166. https://doi.org/ 10.1542/peds.2015-3373D. Sadowski, S. (2015). Cardiovascular disorders. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Elsevier. Shearer, M. J. (2017). Vitamin K metabolism in the fetus and neonate. In R. A. Polin, S. H. Abman, D. H. Rowitch, et al. (Eds.), Fetal and neonatal physiology (5th ed.). Elsevier. Soltau, T. D., & Carlo, W. A. (2014). Respiratory system. In C. Kenner, & J. W. Lott (Eds.), Comprehensive neonatal care (5th ed.). Springer. Son-Hing, J. P., & Thompson, G. H. (2015). Congenital abnormalities of the upper and lower extremities and spine. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. Turfkruyer, M., & Verhasselt, V. (2015). Breast milk and its impact on the maturation of the neonatal immune system. Current Opinions in Infectious Diseases, 28(3), 199–206. Verklan, M. T. (2015). Adaptation to extrauterine life. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Elsevier. Visscher, M. O., Adam, R., Brink, S., et al. (2015). Newborn infant skin: Physiology, development. Clinics in Dermatology, 33(3), 271–280. Vogt, B. A., & Dell, K. M. (2015). The kidney and urinary tract of the neonate. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff & Martin’s neonatal-perinatal medicine (10th ed.). Elsevier. World Health Organization. (2014). Guideline—Delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. https://apps.who.int/iris/bitstream/handle/10665/148793/9789241508209_ eng.pdf?ua¼1.

ADDITIONAL RESOURCE Provincial Council for Maternal and Child Health. https://www.pcmch.on.ca/.

UNIT 7 Newborn

26 Nursing Care of the Newborn and Family Jennifer Marandola Originating US Chapter by Kathryn R. Alden http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Explain the purpose and components of the Apgar score. 2. Provide nursing care to assist the newborn to transition to extrauterine life. 3. Describe a systematic approach to assessment of the newborn. 4. Recognize newborn reflexes and differential characteristic responses from abnormal responses. 5. Describe how to perform a gestational-age assessment of a newborn. 6. Compare the characteristics of preterm, late preterm, term, and post-term newborns. 7. Explain the elements of a providing a safe environment for a newborn. 8. Discuss jaundice and phototherapy and the guidelines for teaching parents about this condition and treatment.

9. Explain the purposes and methods of circumcision, the postoperative care of the circumcised newborn, and parent teaching information regarding care of the circumcised or uncircumcised penis. 10. Review the procedures for performing an intramuscular injection, performing a heel stick, collecting urine specimens, and venipuncture. 11. Evaluate pain in the newborn based on physiological changes and behavioural observations and provide pain management strategies. 12. Review anticipatory guidance that nurses provide parents before discharge.

Although most newborns make the necessary biopsychosocial adjustment to extrauterine existence without undue difficulty, their wellbeing depends on the care they receive from others. This chapter describes the assessment and care of the newborn from immediately after birth until discharge, as well as important anticipatory guidance related to ongoing infant care.

Immediate Care After Birth

BIRTH THROUGH THE FIRST 2 HOURS Nursing Care Care begins immediately after birth and is focused on assessing and stabilizing the newborn’s condition if required. The nurse works alongside the primary health care provider to ensure a safe transition. The foundation for providing comprehensive, family–newborn care is awareness of preconception and prenatal history as well as intrapartal events. Recognition of risk factors (Box 26.1) enables the nurse to be more astute in observations and assessments and more likely to identify early signs of complications. This allows for earlier intervention and promotes positive outcomes.

The primary goal of care in the first moments after birth is to assist the newborn in their transition to extrauterine life by establishing effective respirations. If the newborn is at term, is crying or breathing, and has good muscle tone, routine care can begin. The newborn is placed prone on the parent’s chest, and the nurse assesses the airway. Drying the newborn with rubbing removes moisture to prevent evaporative heat loss and provides tactile stimulation to encourage respiratory effort. The parent and newborn are covered with a warm blanket. It is important to ensure that the blanket allows for the newborn to have an unrestricted ability to lift their thorax and head and that an unobstructed airway is maintained. The heart rate is quickly assessed by auscultating the left chest with a stethoscope. The heart rate can also be felt through palpation at the base of the umbilical cord, although this has been proven in recent years to be less accurate and underestimates the true heart rate (Weiner & Zaichkin, 2016). The heart rate should be greater than 100 beats per minute (bpm). The newborn’s trunk and lips should be pink; acrocyanosis is a normal finding (see Figure 25.1).

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BOX 26.1

Newborn

Assessment of Preconception, Prenatal, and Intrapartum Risk Factors

Preconception • Age of childbearing person • Pre-existing medical conditions: Diabetes, hypertension, cardiac disease, anemia, thyroid disorder, renal disease, obesity • Genetic factors: Family history • Obstetrical history: Gravidity, parity, number of living children and their ages, history of stillbirth, previous newborn with congenital anomalies, recurrent abortions, use of assisted human reproduction, interpregnancy spacing Prenatal • Prenatal care: When started • Nutrition: Weight gain, diet, obesity, eating disorders • Health-compromising behaviours: Smoking, alcohol or substance use • Blood group or Rh sensitization

• Medications: Prescription, over-the-counter, and complementary/alternative medications • History of infection: Sexually transmitted infections, TORCH infections,* group B streptococci status Intrapartum • Length of gestation: Preterm, late preterm, term, or post-term • First stage of labour: Length, internal electronic fetal monitoring, rupture of membranes (time, presence of meconium), signs of fetal distress, labour complications (bleeding [placental abruption or placenta previa]), maternal analgesia or anaesthesia • Group B streptococci status: Treatment during labour • Second stage of labour: Length, vaginal or Caesarean, instrument assisted— forceps or vacuum extractor, complications (e.g., shoulder dystocia, cord prolapse)

*TORCH is the collective name for toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus (see further discussion in Chapter 29). Adapted from Hurst, H. M. (2015). Antepartum-intrapartum complications. In T. M. Verklan & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Saunders.

All newborns require the initial steps of resuscitation, drying, and stimulation after birth. If the newborn does not respond to initial measures or requires more aggressive respiratory or circulatory support, the nurse and other members of the health care team (e.g., attending physician or midwife, pediatrician, neonatal nurse practitioner, respiratory therapist) will perform interventions as outlined in systematic algorithms (Figure 26.1) (Finan et al., 2017). As soon as possible after birth the nurse must place identically numbered bands on the newborn and mother, and in some hospitals these are put on both parents. As part of routine precautions, with the possibility of transmission of viruses such as hepatitis B virus and human immunodeficiency virus (HIV) via blood and blood-stained amniotic fluid, the nurse should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Gloves should be worn when conducting physical assessments, when in contact with breast milk, during routine diaper changes, and at any time contact with body fluids may be evident.

often be done while the newborn is skin-to-skin with the parent. If the newborn is vigorous, Apgar scoring and further assessments can be conducted while respecting this intimate time. Skin-to-skin contact enhances the newborn’s transition to extrauterine life and initial bonding. Breastfeeding should begin shortly after birth (World Health Organization [WHO], 2019). Should the dyad be separated for stability purposes, the partner may have skin-to-skin contact with the newborn (Figure 26.2). Healthy newborns should remain with their parent(s) throughout the hospital stay, although some newborns who require extra care may be admitted to a nursery. Early contact between parent and newborn can be important in developing their and their child’s future relationships. It also has a positive effect on breastfeeding. Physiological benefits of early skin-to-skin contact include increased oxytocin and prolactin levels in the childbearing person and initiation of suckling activity in the newborn. The process of developing active immunity begins as the newborn ingests flora from the colostrum.

Apgar Scoring. The Apgar score enables a rapid assessment of the

Interventions

newborn’s transition to extrauterine existence on the basis of five signs indicating the newborn’s physiological state: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory rate, based on observed movement or auscultation of respiratory efforts; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on response to stimulation; and (5) generalized skin colour, described as pallid, cyanotic, or pink (Table 26.1). Evaluations are made at 1 and 5 minutes after birth and can be done by the nurse or birth attendant. Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life. The Apgar score is reassessed at 10 and 20 minutes if the score is less than 7 at 5 minutes. Apgar scores do not predict future neurological outcome but are useful for describing the newborn’s transition to the extrauterine environment. Resuscitation may occur at any point when the newborn is compromised and should not wait until the initial 1-minute Apgar score (Weiner & Zaichkin, 2016). All births require health care providers who are in attendance to be certified in neonatal resuscitation program (NRP). Intervention steps are outlined in the algorithm in Figure 26.1.

Changes can occur rapidly in the compromised newborn immediately after birth. Assessment must be followed by implementation of appropriate care.

Initial Physical Assessment. The nurse will complete a brief physical examination shortly after birth (Box 26.2). The first assessment can

Airway Maintenance. Generally, the healthy term newborn born vaginally has little difficulty clearing the airway. Most secretions are moved by gravity and brought by the cough reflex to the oropharynx to be drained or swallowed and suctioning is rarely necessary. The newborn who has difficulty clearing mucus from the airway may initially be placed in a side-lying position (head stabilized, not in Trendelenburg position) until secretions are cleared, and then placed supine. It is important to explain to parents that this is a temporary measure as well as the rationale for the side-lying position: to clear mucus. Parents must be instructed that newborns are normally placed on their backs when sleeping. The newborn who is choking on secretions should be supported with the head to the side or by initiating the first steps in newborn cardiopulmonary resuscitation (CPR), by tapping between the newborn’s shoulders while holding firmly in a slightly downward motion to optimize gravity for the expulsion of mucus. If needed, the mouth is suctioned first to prevent the newborn from inhaling pharyngeal secretions when gasping, as newborns are obligatory nose breathers. The centre of the newborn’s mouth should be avoided to prevent

CHAPTER 26

Nursing Care of the Newborn and Family

585

Fig. 26.1 Neonatal resuscitation algorithm. CPAP, Continuous positive airway pressure; ECG, electrocardiogram; ETT, endotracheal tube; HR, heart rate; IV, intravenous; PPV, positive pressure ventilation; SpO2, oxygen saturation; UVC, umbilical venous catheter. (Source: Weiner, G., & Zaichkin, J. [2016]. Textbook of neonatal resuscitation [7th ed.]. American Academy of Pediatrics.)

stimulation of the gag reflex. The nasal passages are suctioned one nostril at a time. It is important that hospital rooms have suctioning equipment available for use. The nurse should listen to the newborn’s respirations and auscultate lung sounds with a stethoscope to determine whether there are crackles, rhonchi, or inspiratory stridor. Fine crackles may be auscultated for several hours after birth. If air movement is adequate, suctioning is rarely necessary. If mucus is interfering with respiratory effort,

mechanical suctioning may be necessary. If the newborn has an obstruction that is not cleared with suctioning, the pediatric care provider should be notified for further investigation to determine whether there is a mechanical defect (e.g., tracheoesophageal fistula, choanal atresia) causing the obstruction. Deeper suctioning may be necessary to remove mucus from the newborn’s nasopharynx or posterior oropharynx; however, this should be performed only after assessment of the risks involved. Prevention of

586

UNIT 7

TABLE 26.1

Newborn

Apgar Score SCORE 1

2

Heart rate

Sign

Absent

0

Slow ( 90∞

Arm Recoil Popliteal Angle

180∞

45∞

30∞

0∞

180∞ 140∞–180∞ 110∞–140∞ 90∞–110∞

< 90∞

90∞

160∞

60∞

140∞

120∞

100∞

90∞

< 90∞

Scarf Sign Heel to Ear

PHYSICAL MATURITY Skin

Lanugo Plantar Surface

Breast

Eye/Ear

Genitals (male) Genitals (female)

A

MATURITY RATING

Superficial Cracking Parchment Sticky Gelatinous Smooth Leathery peeling&/ pale deep friable red, pink, cracked or rash, areas cracking transparent translucent visible veins wrinkled few veins rare veins no vessels None

Sparse

Abundant

Heel-toe >50 mm Faint 40–50 mm:–1 no crease red marks 20 seconds); periodic breathing First period (reactivity): 50–60 breaths/min Second period: 50–70 breaths/min Stabilization (1–2 days): 30–60 breaths/min Crackles (fine)

Obtain blood pressure (BP) (usually not done in healthy term newborn): Check oscillometric monitor BP cuff: BP 60–80/40–50 mm Hg Variation with change in activity cuff width affects readings; use (approximate ranges) level: awake, crying, sleeping appropriately sized cuff and palpate At birth: brachial, popliteal, or posterior tibial Systolic: 60–80 mm Hg pulse (depending on measurement Diastolic: 40–50 mm Hg site). At 2 weeks: Systolic: 68–80 mm Hg Diastolic: 40–60 mm Hg Weight* Put protective liner cloth or paper in place and adjust scale to 0 g. Protect newborn from heat loss.

Female: 3 400 g Male: 3 500 g Regaining of birth weight within first 2 weeks

2 500–4 000 g Acceptable weight loss: 10% or less in first 3–5 days Second baby often weighs more than first (on average)

Deviations From Normal Range—Possible Concerns (Etiology) Apneic episodes: >20 sec (preterm newborn: rapid warming or cooling of newborn; CNS or blood glucose instability) Bradypnea: 60 breaths/min (RDS, transient tachypnea of the newborn, congenital diaphragmatic hernia) Breath sounds: Crackles (coarse), rhonchi, wheezing Expiratory grunt (narrowing of bronchi) Distress evidenced by nasal flaring, grunting, retractions, laboured breathing Stridor (upper airway occlusion) Difference between upper and lower extremity pressures (coarctation of aorta) Hypotension (sepsis, hypovolemia) Hypertension (coarctation of aorta, renal involvement, thrombus)

Weight 2 500 g (preterm, small for gestational age, rubella syndrome) Weight
4 000 g (large for gestational age, maternal diabetes, heredity—normal for these parents) Weight loss 10–15% (growth failure, dehydration); assess breastfeeding

Weighing the newborn. The baby is placed prone on the scale, which is covered with a blanket to protect against crossinfection and heat loss. (Courtesy Lisa Keenan-Lindsay.)

Continued

594

UNIT 7

TABLE 26.2

Newborn

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure Length* Measure length from top of head to heel. Measuring is difficult in term newborns because of moulding and incomplete extension of knees. Ideally this should be done using a length board.

Average Findings

Normal Variations

Deviations From Normal Range—Possible Concerns (Etiology) 55 cm (chromosomal abnormality, heredity—normal for these parents); some syndromes result in shorter-than-average limb length (skeletal dysplasias, achondroplasia)

45–55 cm

Length, crown to heel. To determine total length, include length of legs. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

Head Circumference* Measure head at greatest diameter: occipitofrontal circumference May need to remeasure on second or third day after resolution of moulding and caput succedaneum

33–35 cm Circumference of head and chest approximately the same for first 1 or 2 days after birth; chest circumference rarely measured on routine basis

32–36.8 cm

Microcephaly: head 32 cm (maternal rubella, toxoplasmosis, cytomegalovirus, Zika virus, fused cranial sutures [craniosynostosis]) Hydrocephaly: sutures widely separated, circumference
4 cm more than chest circumference (infection) Increased intracranial pressure (hemorrhage, space-occupying lesion)

Circumference of head. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

Skin Check colour. Inspect and palpate: Inspect semi-naked newborn in well-lit, warm area without drafts; natural daylight is best. Inspect newborn when quiet and alert.

Generally pink Varying with ethnic origin; skin pigmentation beginning to deepen right after birth in basal layer of epidermis Acrocyanosis common after birth

Mottling Harlequin sign Plethora Telangiectatic nevi nevus simplex) (see Figure 25.9, A) Erythema toxicum/ neonatorum (“newborn rash”) (see Figure 25.9, B) Milia Petechiae over presenting part Ecchymoses from forceps in vertex

Dark red (preterm, polycythemia) Grey (hypotension, poor perfusion) Pallor (cardiovascular issue, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, infection) Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurological, or respiratory malformations) Generalized petechiae (clotting factor deficiency, infection) Continued

CHAPTER 26

TABLE 26.2

595

Nursing Care of the Newborn and Family

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Deviations From Normal Range—Possible Concerns (Etiology) Generalized ecchymoses (hemorrhagic disease)

Area Assessed and Appraisal Procedure

Average Findings

Normal Variations births or over buttocks, genitalia, and legs in breech births

Observe for jaundice.

None at birth

Physiological jaundice in up to 60% of term newborns in first week of life

Jaundice within first 24 hour (pathological jaundice) (increased hemolysis, Rh isoimmunization, ABO incompatibility)

Congenital dermal melanocytosis (slate grey nevi) (see Figure 25.8) in newborns of African, Asian, or other ethnicities with darkercoloured skin

Hemangiomas Nevus flammeus: port-wine stain Nevus vasculosus: strawberry hemangioma Edema on hands, feet; pitting over tibia; periorbital (overhydration; hydrops) Texture thin, smooth, or of medium thickness; rash or superficial peeling visible (preterm, post-term) Numerous vessels very visible over abdomen (preterm) Texture thick, parchment-like; cracking, peeling (post-term) Skin tags, webbing Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash) Loose, wrinkled skin (prematurity, postmaturity, dehydration: fold of skin persisting after release of pinch) Tense, tight, shiny skin (edema, extreme cold, shock, infection) Lack of subcutaneous fat, prominence of clavicle or ribs (preterm, malnutrition)

Observe for birthmarks or bruises: Inspect and palpate for location, size, distribution, characteristics, and colour, if obstructing airway or oral cavity. Check skin condition: Inspect and palpate for intactness, smoothness, texture, edema, pressure points if ill or immobilized.

Eyelid edema (result of eye prophylaxis) Opacity: few large blood vessels visible indistinctly over abdomen

Possibly puffy Slightly thick; superficial cracking, peeling, especially of hands, feet No visible blood vessels, a few large vessels clearly visible over abdomen Some fingernail scratches

Gently pinch skin between thumb and forefinger over abdomen and inner thigh to check for turgor.

After pinch is released, skin returns to original state immediately

Dehydration: loss of weight is best indicator

Note presence of subcutaneous fat deposits (adipose pads) over cheeks and buttocks.

Variation in amount of subcutaneous fat

Observe for vernix caseosa: Observe colour, amount, and odour before bath or removing clothing.

Whitish, cheesy, odourless

Usually more found in creases, folds

Absent or minimal (post-term) Abundant (preterm) Green colour (possible in utero release of meconium or presence of bilirubin) Odour (possible intrauterine infection)

Assess lanugo: Inspect for fine, downy hair, amount and distribution.

Over shoulders, pinnae of ears, forehead

Variation in amount

Absent (postmature) Abundant (preterm, especially if lanugo abundant, long, and thick over back)

Caput succedaneum, possibly showing some ecchymosis (see Figure 25.12, A) Cephalohematoma (see Figure 25.12, B)

Subgaleal hemorrhage

Head Palpate head.

Inspect shape and size.

Making up one fourth of body length Moulding (see Figure 25.11)

Slight asymmetry from intrauterine position Lack of moulding (preterm, breech presentation, Caesarean birth)

Severe moulding (birth trauma) Indentation (fracture from trauma)

Palpate, inspect, and note status of fontanels (open vs. closed).

Anterior fontanel 5-cm diamond, increasing as moulding resolves

Variation in fontanel size with degree of moulding

Fontanels: Full, bulging (tumour, hemorrhage, infection) Continued

596

UNIT 7

TABLE 26.2

Newborn

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure

Deviations From Normal Range—Possible Concerns (Etiology) Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism) Depressed (dehydration)

Average Findings Posterior fontanel triangle, smaller than anterior

Normal Variations Difficulty in feeling fontanels possible because of moulding

Palpate sutures.

Palpable and separated sutures

Possible overlap of sutures with moulding

Sutures: Widely spaced (hydrocephaly) Premature closure (fused) (craniosynostosis)

Inspect pattern, distribution, and amount of hair; feel texture.

Silky, single strands lying flat; growth pattern toward face and neck

Variation in amount

Fine, woolly (preterm) Unusual swirls, patterns, or hairline; or coarse, brittle (endocrine or genetic disorders)

Eyes and space between eyes each one-third the distance from outer (left) to outer (right) canthus

Epicanthal folds (upward sloping): characteristic in some ethnicities

Epicanthal folds when present with other signs (chromosomal disorders such as Down, cri-du-chat syndromes)

Eyes Check placement on face.

In pseudostrabismus, inner epicanthal folds cause the eyes to appear misaligned; however, corneal light reflexes are perfectly symmetrical. Eyes are symmetrical in size and shape and are well placed.

Check for symmetry in size and shape.

Symmetrical in size, shape

Check eyelids for size, movement, and blink.

Blink reflex

Edema if eye prophylaxis ointment instilled

Assess for discharge.

None No tears

Occasional presence of some tears

Discharge: purulent (infection) Chemical conjunctivitis from eye medication is common—requires no treatment

Evaluate eyeballs for presence, size, and shape.

Both present and of equal size, both round, firm

Subconjunctival hemorrhage

Agenesis or absence of one or both eyeballs Lens opacity or absence of red reflex (congenital cataracts, possibly from rubella, retinoblastoma [cat’s eye reflex]) Lesions: coloboma, absence of part of iris (congenital) Pink colour of iris (albinism) Jaundiced sclera (hyperbilirubinemia) Continued

CHAPTER 26

TABLE 26.2

597

Nursing Care of the Newborn and Family

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure Check pupils.

Average Findings Present, equal in size, reactive to light Pediatric health care provider will evaluate red reflex.

Normal Variations

Evaluate eyeball movement.

Random, jerky, uneven, focus possible briefly, following to midline

Transient strabismus or nystagmus until third or fourth month

Assess eyebrows: amount of hair, pattern.

Distinct (not connected in midline)

Nose Observe shape, placement, patency, and configuration.

Ears Observe size, placement on head, amount of cartilage, open auditory canal.

Deviations From Normal Range—Possible Concerns (Etiology) Pupils: unequal, constricted, dilated, fixed (intracranial pressure, medications, tumour) Persistent strabismus Doll’s eyes (increased intracranial pressure) Sunset (increased intracranial pressure) Connection in midline (Cornelia de Lange syndrome)

Midline Some mucus but no drainage Preferential nose breather Sneezing to clear nose

Slight deformity (flat or deviated to one side) from passage through birth canal

Copious drainage (rarely, congenital syphilis) Blockage—membranous or bone with cyanosis at rest and return of pink colour with crying (choanal atresia) Malformed (congenital syphilis, chromosomal disorder) Flaring of nares (respiratory distress)

Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch of ears (at junction with scalp) Well-formed, firm cartilage

Size: small, large, floppy Darwin’s tubercle (nodule on posterior helix)

Agenesis Lack of cartilage (preterm) Low placement (chromosomal disorder, cognitive impairment, kidney disorder) Preauricular tag or sinus Size: possibly overly prominent or protruding ears

A

B

C

Placement of ears on the head in relation to a line drawn from the inner to outer canthus of the eye. A: Normal position. B: Abnormally angled ear. C: True low-set ear. (Courtesy Mead Johnson Nutritionals, Evansville, IN.)

Assess hearing.

Responds to voice and other sounds

Ensure newborn hearing screening is completed to identify deficits (in some provinces) (see Figure 26.15).

Both ears pass.

Face Observe overall appearance and symmetry of face.

Rounded and symmetrical; influenced by birth type or any moulding

State (e.g., alert, asleep) influencing response

Lack of response to loud noise should not imply deafness. One or both ears fail.

Positional deformities associated with intrauterine positioning, cranial moulding

Asymmetrical facial features may be accompanied by other characteristics, such as low-set ears, absence of outer ear, or other structural disorders (hereditary, chromosomal aberration). Continued

598

UNIT 7

TABLE 26.2

Newborn

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure

Deviations From Normal Range—Possible Concerns (Etiology)

Average Findings

Normal Variations

Symmetry of lip movement

Transient circumoral cyanosis

Gross anomalies in placement, size, shape (cleft lip or palate, gums) Cyanosis, circumoral pallor (respiratory distress, hypothermia) Asymmetry in movement of lips (seventh cranial nerve paralysis)

Check gums.

Pink gums

Inclusion cysts (Epstein pearls— Bohn nodules, whitish, hard nodules on gums or roof of mouth)

Teeth: predeciduous or deciduous (hereditary)

Assess tongue for colour, mobility, movement, and size.

Tongue not protruding; freely movable; symmetrical in shape, movement Sucking pads inside cheeks

Short lingual frenulum (ankyloglossia- tongue-tie)

Macroglossia (preterm, chromosomal disorder) Thrush: white plaques on cheeks or tongue that bleed if touched (Candida albicans)

Assess palate (soft, hard): Arch Uvula

Soft and hard palates intact Uvula in midline

Anatomical groove in palate to accommodate nipple, disappearance by 3–4 yr of age Epstein pearls

Cleft hard or soft palate

Assess chin.

Distinct chin

Micrognathia—recessed chin with prominent overbite (Pierre Robin sequence or other syndrome)

Evaluate saliva for amount and character.

Mouth moist, pink

Excessive salivation and choking or turning blue (esophageal atresia, tracheoesophageal fistula)

Check reflexes: Rooting, sucking, extrusion (see Table 26.3)

Reflexes present

Mouth Inspect and palpate. Assess buccal mucosa: Dry or moist Pink Status intact Assess lips for colour, configuration, and movement.

Neck Inspect and palpate for movement, flexibility, masses, and bruising.

Short, thick, surrounded by skin folds; no webbing

Check sternocleidomastoid muscles, movement and position of head.

Head held in midline (sternocleidomastoid muscles equal), no masses Freedom of movement from side to side and flexion and extension; no movement of chin past shoulder

Assess trachea for position and thyroid gland.

Thyroid not palpable

Chest Inspect and palpate: Shape

Reflex response dependent on state of wakefulness and hunger

Absent (preterm)

Webbing (Turner syndrome) Transient positional deformity apparent when newborn is at rest; passive movement of head possible

Restricted movement, holding of head at angle (torticollis [wryneck], opisthotonos) Absence of head control (preterm birth, Down syndrome, hypotonia [spinal muscular atrophy]) Mass (enlarged thyroid, cystic hygroma) Distended veins (cardiopulmonary disorder) Skin tags

Almost circular, barrel shaped

Tip of sternum possibly prominent

Bulging of chest, unequal movement (pneumothorax, pneumomediastinum) Malformation (funnel chest—pectus excavatum)

Observe respiratory movements.

Symmetrical chest movements, chest and abdominal movements synchronized during respirations

Occasional retractions, especially when crying

Retractions with or without respiratory distress (preterm, RDS) Paradoxical breathing

Evaluate clavicles.

Clavicles intact

Fracture of clavicle (trauma); crepitus

Assess ribs.

Rib cage symmetrical, intact; moves with respirations

Poor development of rib cage and musculature (preterm) Continued

CHAPTER 26

TABLE 26.2

599

Nursing Care of the Newborn and Family

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure Assess nipples for size, placement, and number.

Deviations From Normal Range—Possible Concerns (Etiology) Nipples: Supernumerary, along nipple line Malpositioned or widely spaced

Average Findings Nipples prominent, well formed, symmetrically placed

Normal Variations

Breast nodule: approximately 6 mm in term newborn

Breast nodule: 3–10 mm Thin discharge from breast

Lack of breast tissue (preterm) Sounds: bowel sounds may be heard in diaphragmatic hernia (see Abdomen, below)

Two arteries, one vein Whitish grey Definite demarcation between cord and skin; no intestinal structures within cord Dry around base, drying Odourless Cord clamp may be in place

Reducible umbilical hernia

One artery (renal anomaly) Meconium stained (intrauterine distress) Bleeding or oozing around cord (hemorrhagic disease) Redness or drainage around cord (infection, possible persistence of urachus) Hernia: herniation of abdominal contents through cord opening (e.g., omphalocele); defect covered with thin, friable membrane, possibly extensive

Inspect size of abdomen and palpate contour.

Rounded, prominent, dome shaped because abdominal musculature not fully developed Liver possibly palpable 1–2 cm below right costal margin No other masses palpable No distension Few visible veins on abdominal surface

Some diastasis recti (separation) of abdominal musculature

Gastroschisis: herniation of abdominal contents to the side or above the cord; contents not covered by membranous tissue and may include liver Distension at birth (ruptured viscus, genitourinary masses or malformations: hydronephrosis, teratomas, abdominal tumours): Mild (overfeeding, high gastrointestinal tract obstruction) Marked (lower gastrointestinal tract obstruction, anorectal malformation, anal stenosis), often with bilious emesis Intermittent or transient (overfeeding) Partial intestinal obstruction (stenosis of bowel) Visible peristalsis (obstruction) Malrotation of bowel or adhesions Sepsis (infection)

Auscultate bowel sounds and note number, amount, and character of stools.

Sounds present within minutes after birth in healthy term newborn Meconium stool passing within 24–48 hour after birth

Check breast tissue.

Abdomen Inspect and palpate umbilical cord.

Assess colour.

Observe movement with respiration.

Scaphoid, with bowel sounds in chest and severe respiratory distress (congenital diaphragmatic hernia) Linea nigra possibly apparent and caused by hormone influence during pregnancy

Respirations primarily diaphragmatic, abdominal and chest movement synchronous

Decreased or absent abdominal movement with breathing (phrenic nerve palsy, congenital diaphragmatic hernia) Continued

600

UNIT 7

TABLE 26.2

Newborn

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure

Average Findings

Genitalia Female (see Figure 25.10, A) Inspect and palpate: General appearance

Normal Variations

Increased pigmentation caused by pregnancy hormones

Deviations From Normal Range—Possible Concerns (Etiology)

Ambiguous genitalia—wide variation (small phallus not well distinguished from enlarged clitoris)

Clitoris

Usually edematous

Labia majora

Usually edematous, covering labia minora in term newborns

Labia minora

Possible protrusion over labia majora

Discharge

Smegma

Vagina

Open orifice Mucoid discharge Hymenal/vaginal tag

Absence of vaginal orifice

Urinary meatus

Beneath clitoris, difficult to see

Bladder exstrophy (bladder outside abdominal cavity and turned inside out)

Assess urination.

Voiding 1 void per day for each day of life until fifth day and then 4 to 6 wet diapers. After day 7 frequent urination

Male (see Figure 25.10, B) Inspect and palpate: General appearance

Virilized female—extremely large clitoris (congenital adrenal hyperplasia) Edema and ecchymosis after breech birth Some vernix caseosa between labia possible Enlarged clitoris with urinary meatus on tip, absent scrotum, micropenis, fused labia Stenosed meatus Labia majora widely separated and labia minora prominent (preterm) Blood-tinged discharge from pseudomenstruation caused by pregnancy hormones

Fecal discharge (fistula)

Rust-stained urine (uric acid crystals)

No void within first 24 hr (renal agenesis; Potter syndrome)

Increased size and pigmentation caused by pregnancy hormones Wide variation in size of genitalia

Ambiguous genitalia Micropenis

Penis: Urinary meatus appearance Prepuce (foreskin)—do not forcibly retract foreskin if uncircumcised

Foreskin covers glans (if uncircumcised), meatus at tip of penis

Prepuce removed if circumcised

Urinary meatus not on tip of glans penis (hypospadias, epispadias, foreskin may be retracted or absent); chordee (ventral curvature) Round meatal opening

Scrotum: Rugae (wrinkles)

Large, edematous, pendulous in term newborn; covered with rugae

Scrotal edema and ecchymosis if breech birth Hydrocele, small, noncommunicating

Scrotum smooth and testes undescended (preterm, cryptorchidism) Bifid scrotum Hydrocele Inguinal hernia

Testes Check reflexes: Cremasteric

Palpable on each side Testes retracted, especially when newborn is chilled

Bulge palpable in inguinal canal

Undescended (preterm)

Voiding within 24 hour, stream adequate, amount adequate Voiding 1 void per day for each day of life until fifth day and then 4 to 6 wet diapers. After day 7 frequent urination

Rust-stained urine (uric acid crystals)

No void in first 24 hr Renal agenesis: Potter syndrome

Assess urination.

Continued

CHAPTER 26

TABLE 26.2

601

Nursing Care of the Newborn and Family

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure

Deviations From Normal Range—Possible Concerns (Etiology)

Average Findings

Normal Variations

Assuming of position maintained in utero Attitude of general flexion Full range of motion, spontaneous movements

Transient positional deformities

Limited motion (malformations) Poor muscle tone (preterm, maternal medications, CNS anomalies)

Check arms and hands. Inspect and palpate: Colour Intactness Appropriate placement

Longer than legs in newborn period Contours and movements symmetrical

Slight tremors sometimes apparent Some acrocyanosis

Asymmetry of movement (fracture or crepitus, brachial nerve trauma, malformations) Asymmetry of contour (malformations, fracture) Amelia or phocomelia (teratogens) Palmar creases Simian line with short, in-curved little fingers (Down syndrome)

Count number of fingers.

Five on each hand Fist often clenched with thumb under fingers

Webbing of fingers: syndactyly Absence or excess of fingers Strong, rigid flexion; persistent fists; positioning of fists in front of mouth constantly (CNS disorder) Yellowed nail beds (meconium staining)

Evaluate joints: Shoulder Elbow Wrist Fingers

Full range of motion, symmetrical contour

Increased tonicity, clonus, prolonged tremors (CNS disorder)

Extremities Make a general check. Inspect and palpate: Degree of flexion Range of motion Symmetry of motion Muscle tone

Check palmar and plantar grasp reflexes (see Table 26.3) Observe legs and feet. Inspect and palpate: Colour Intactness Length in relation to arms and body and to each other

Appearance of bowing because lateral muscles more developed than medial muscles

Count number of toes

Five toes on each foot

Femur

Intact femur

Head of femur as legs are flexed and abducted, placement in acetabulum (see Figure 25.13)

Feet appearing to turn in but can be easily rotated externally, positional defects tending to correct while newborn is crying Acrocyanosis

Amelia, phocomelia (chromosomal defect, teratogenic effect) Clubfoot Temperature of one leg differing from that of the other (circulatory deficiency, CNS disorder) Webbing, syndactyly (chromosomal defect) Absence or excess of digits (chromosomal defect, familial trait) Femoral fracture (difficult breech birth) Developmental dysplasia of the hip (DDH)

Major gluteal folds

Major gluteal folds even

Gluteal folds uneven: DDH

Soles of feet

Soles well lined (or wrinkled) over two thirds of foot in term newborns Plantar fat pad giving flat-footed effect

Soles of feet: Few creases (preterm) Covered with creases (post-term) Congenital clubfoot

Evaluate joints: Hip Knee Ankle Toes

Full range of motion, symmetrical contour

Hypermobility of joints (Down syndrome)

Check reflexes (see Table 26.3)

Asymmetrical movement (trauma, CNS disorder) Continued

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TABLE 26.2

Newborn

Physical Assessment of Newborn—cont’d NORMAL FINDINGS

Area Assessed and Appraisal Procedure Back Assess anatomy. Inspect and palpate: Spine, shoulders, scapulae, iliac crests

Average Findings

Normal Variations

Spine straight and easily flexed Newborn able to raise and support head momentarily when prone Shoulders, scapulae, and iliac crests lining up in same plane

Temporary minor positional deformities; correction with passive manipulation

Base of spine—pilonidal dimple or sinus

May not be apparent in first few days but is usually present in 5–6 days

If transverse lesion is present, no response below lesion; absence of response: CNS abnormality or CNS depression

Lower limbs extend as pressure applied to feet with legs in semiflexed position

Weak or exaggerated response with breech presentation

Absence suggestive of CNS damage or malformation

One anus with good sphincter tone Passage of meconium within 24 hour after birth ¼ patent

Passage of meconium within 48 hour after birth

Anal “wink” present, anal opening patent

Imperforate anus without fistula Rectal atresia and stenosis Absence of anal opening; drainage of fecal material from vagina in female or urinary meatus in male (rectal fistula) or along perineal raphe (midline area between base of penis and anus) (anorectal malformation)

Meconium followed by transitional and soft yellow stool (see Figure 25.6)

No stool (obstruction), dehydration Frequent watery stools (infection, phototherapy)

Test trunk incurvation reflex (see Table 26.3)

Trunk flexed and pelvis swings to stimulated side

Test magnet reflex.

Test for sphincter response (active “wink” reflex). Observe for the following: Abdominal distension Passage of meconium from anal opening Fecal drainage from perineum, penis, vagina Stools Observe frequency, colour, and consistency.

Limitation of movement (fusion or deformity of vertebra) Meningocele, myelomeningocele (spina bifida cystica) Pigmented nevus with tuft of hair, located anywhere along the spine, often associated with spina bifida occulta Sinus (opening to spinal cord)

Check reflexes (spinal related):

Anus Inspect and palpate: Placement Patency

Deviations From Normal Range—Possible Concerns (Etiology)

bpm, Beats per minute; CNS, central nervous system; RDS, respiratory distress syndrome. ∗ Weight, length, and head circumference should all be close to the same percentile for any child.

TABLE 26.3

Assessment of Newborn Reflexes

Reflex

Eliciting the Reflex

Characteristic Response

Comments

Sucking and rooting

Touch newborn’s lip, cheek, or corner of mouth with nipple or finger.

Newborn turns head toward stimulus and opens mouth.

Response is difficult if not impossible to elicit after newborn has been fed. Parental guidance: Avoid trying to turn head toward breast or nipple; allow newborn to root; response disappears after 3–4* mo but may persist up to 1 yr. A weak or absent response can indicate prematurity or neurological deficit.

Swallowing

Feed newborn; swallowing usually follows sucking and obtaining fluids.

Swallowing is usually coordinated with sucking and breathing and usually occurs without gagging, coughing, apnea, or vomiting.

If response is weak or absent, this may indicate preterm birth, effects of maternal analgesics, or illness that needs investigation. Sucking, swallowing, and breathing are often uncoordinated in a preterm newborn.

Palmar grasp

Place finger in palm of hand.

Newborn’s fingers curl around examiner’s fingers.

Palmar response lessens by 3–4 mo; parents enjoy this contact with newborn.

Plantar grasp

Place finger at base of toes.

Toes curl downward.

Plantar response lessens by 8 mo. Continued

CHAPTER 26

TABLE 26.3 Reflex

603

Nursing Care of the Newborn and Family

Assessment of Newborn Reflexes—cont’d

Eliciting the Reflex

Characteristic Response

Comments

Plantar grasp reflex. (From Zitelli, B. J., & Davis, H. W. [2007]. Atlas of pediatric physical diagnosis [5th ed.]. Mosby.)

Extrusion

Touch or depress tip of tongue.

Newborn forces tongue outward.

Response disappears by about 4–5 mo.

Glabellar (Myerson)

Tap over forehead, bridge of nose, or maxilla of newborn whose eyes are open.

Newborn blinks for first four or five taps.

Continued blinking with repeated taps is consistent with extrapyramidal signs.

Tonic neck or “fencing”

With newborn in a supine neutral position, turn head quickly to one side.

With newborn facing left side, arm and leg on that side extend; the opposite arm and leg flex (turn head to right, and extremities assume opposite postures).

Responses in leg are more consistent. Complete response disappears by 3–4 mo; incomplete response may be seen until 3-4 yr. After 6 wk, persistent response is a sign of an abnormality.

Classic pose in tonic neck reflex. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

Moro (or startle)

Hold newborn in semisitting position, allowing head and trunk to fall backward (with support). Place newborn supine on flat surface; make a loud, abrupt noise.

Symmetrical abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement. A cry may accompany or follow motor movement. Legs may follow similar pattern of response. Preterm newborns do not complete “embrace”;

Response is present at birth; complete response may be seen until 8 wk; body jerk only is seen between 8 and 18 wk; response is absent by 6 mo if neurological maturation is not delayed; response may be incomplete if newborn is in deep sleep state; give parental guidance about normal response. Asymmetrical response may connote injury to brachial plexus, clavicle, or humerus. Continued

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TABLE 26.3 Reflex

Newborn

Assessment of Newborn Reflexes—cont’d

Eliciting the Reflex

Characteristic Response instead, their arms fall backward because of weakness.

Comments Persistent response after 6 mo indicates possible neurological abnormality.

Moro reflex. (Courtesy Paul Vincent Kuntz, Texas Children’s Hospital.)

Stepping or “walking”

Hold newborn vertically under arms or on trunk, allowing one foot to touch table surface.

Newborn will simulate walking, alternating flexion and extension of feet; term newborns walk on soles of their feet, and preterm newborns walk on their toes.

Response is normally present for 3–4 wk.

Stepping reflex. (From Dickason, E. J., Silverman, B. L., & Kaplan, J. A. [1998]. Maternal–newborn nursing care [3rd ed.]. Mosby.)

Crawling

Place newborn on abdomen.

Newborn makes crawling movements with arms and legs.

Response should disappear at about 6 wk of age.

Crawling reflex. (Courtesy Paul Vincent Kuntz, Texas Children’s Hospital.)

Continued

CHAPTER 26

TABLE 26.3

Nursing Care of the Newborn and Family

605

Assessment of Newborn Reflexes—cont’d

Reflex Deep tendon

Eliciting the Reflex Use finger instead of percussion hammer to elicit patellar, or knee jerk, reflex; newborn must be relaxed.

Characteristic Response Reflex jerk is present; even with newborn relaxed, nonselective overall reaction may occur.

Comments It is usually more difficult to elicit upper extremity reflexes than lower extremity reflexes.

Crossed extension

With newborn in supine position, examiner extends one leg of newborn and presses down knee. Stimulation of sole of foot of fixated limb should cause free leg to flex, adduct, and extend as if attempting to push away stimulating agent.

Opposite leg flexes, adducts, and then extends.

This reflex should be present during newborn period.

Crossed extension reflex. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

Babinski (plantar)

On sole of foot, beginning at heel, stroke upward along lateral aspect of sole, then move finger across ball of foot.

All toes hyperextend, with dorsiflexion of big toe—recorded as a positive sign.

Absence requires neurological evaluation, should disappear after 1 yr of age. Response depends on newborn’s general muscle tone, maturity, and condition.

B

A C Babinski reflex. A: Direction of stroke. B: Dorsiflexion of big toe. C: Fanning of toes. (From Hockenberry, M. J., & Wilson, D. [2013]. Wong’s nursing care of newborns and children [9th ed.]. Mosby.)

Pull-to-sit (traction response); postural tone

Pull newborn up by wrists from supine position with head in midline.

Head lags until newborn is in upright position; then head is held in same plane with chest and shoulder momentarily before falling forward; newborn attempts to right head.

Response depends on general muscle tone and maturity and condition of newborn.

Truncal incurvation (Galant)

Place newborn prone on flat surface; run finger down back about 4–5 cm lateral to spine, first on one side and then down the other.

Trunk is flexed and pelvis is swung toward stimulated side.

Response disappears by fourth wk. Response varies but should be obtainable in all newborns, including preterm ones. Absence suggests general depression of central nervous system. With transverse lesions of cord, no response below the level of lesion is present. Continued

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TABLE 26.3 Reflex

Newborn

Assessment of Newborn Reflexes—cont’d

Eliciting the Reflex

Characteristic Response

Comments

Trunk incurvation reflex. (Courtesy Marjorie Pyle, RNC, Lifecircle.)

Magnet

Place newborn in supine position, partially flex both lower extremities, and apply light pressure with fingers to soles of feet (Figure A). Normally, while examiner’s fingers maintain contact with soles of feet, lower limbs extend.

A

Both lower limbs should extend against examiner’s pressure (Figure B).

Absence suggests damage to central nervous system. Weak reflex may be seen after breech presentation without extended legs or may indicate sciatic nerve stretch syndrome. Breech presentation with extended legs may evoke exaggerated response.

B Magnet reflex. (Courtesy Michael S. Clement, MD.)

Additional newborn responses: yawn, stretch, burp, hiccup, sneeze

∗

These are spontaneous behaviours.

They may be slightly depressed temporarily because of maternal analgesia or anaesthesia, fetal hypoxia, or infection.

Parental guidance: Most of these behaviours are pleasurable to parents. Parents need to be assured that behaviours are normal. Sneeze is usually a response to mucus in nose and not an indicator of a cold (upper respiratory tract infection). No treatment is needed for hiccups; sucking may help. In the preterm newborn, these are signs of neurodevelopmental immaturity and physiological stress.

All durations for persistence of reflexes are based on time elapsed after 40 weeks of gestation; that is, if newborn was born at 36 weeks of gestation, add 1 month to all time limits given.

CHAPTER 26

GUIDELINES Physical Examination of the Newborn Provide a normothermic and nonstimulating examination area. Check that equipment and supplies are working properly and are accessible. Undress only the body area to be examined, to prevent heat loss. Proceed in an orderly sequence (usually head to toe), with the following exceptions: • Perform all procedures that require quiet first, such as observing position, skin colour, tone, and condition. • Next auscultate the lungs, heart, and abdomen. • Perform more disturbing procedures, such as taking temperature and testing reflexes, last. • Measure head circumference and length as a baseline for further comparison as needed. Proceed quickly to avoid stressing the newborn. Comfort the newborn during and after examination; involve parents in the following: • Talking softly to the newborn • Holding the newborn’s hands against the chest • Holding the newborn • Placing the baby skin-to-skin

General appearance. The newborn’s maturity level can be gauged by assessment of general appearance. Features to assess in the general survey include posture, activity, any overt signs of anomalies that may cause initial distress, presence of bruising or other consequences of birth, and state of alertness. The normal resting position of the newborn is one of general flexion (Figure 26.6). Vital signs. The newborn may need to be held and comforted during assessment. If the newborn is inconsolable, consider placing the newborn in skin-to-skin contact with a parent and returning shortly afterward to complete assessment. The temperature, heart rate, and respiratory rate are always obtained. BP is not routinely assessed unless cardiac issues are suspected. Before taking the temperature, the examiner may determine the apical heart rate and respiratory rate while the newborn is quiet and at rest. If the newborn is crying while assessing the vital signs, the use of a gloved finger or pacifier to suck on might be considered but only if approved by the parents. The parents should be involved in this procedure. An irregular, very slow, or very fast heart rate may indicate a need for further evaluation of circulatory status, including BP measurement. The axillary temperature is a safe, accurate measurement of temperature. Electronic thermometers have expedited this task and provide a reading within 1 minute. In 2017, Health Canada conducted a safety review of infrared thermometers for both tympanic and temporal artery

Fig. 26.6 Newborn in position of flexion in prone position while awake. (From Hockenberry, M. J., et al. [2007]. Wong’s nursing care of infants and children [8th ed., p. 274]. Mosby.)

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routes and concluded that, given new information in literature and clinical guidelines, these routes for temperature assessment were appropriate for use in children under 2 years old in the community (Health Canada, 2017). Taking a newborn’s temperature may cause the newborn to cry and struggle against the placement of the thermometer in the axilla. The normal axillary temperature ranges from 36.5° to 37.5°C (97.7° to 99.5°F).

SAFETY ALERT Rectal temperatures should not be done on a newborn because of the risk for perforation and vagal stimulation.

The respiratory rate varies with the state of alertness and activity after birth. Respirations are abdominal and can be counted by observing or by lightly feeling the rise and fall of the abdomen while listening to air entry. Newborn respirations are shallow and irregular. It is important to count the respirations for a full minute to obtain an accurate count as there can be episodes of periodic breathing during which respirations may cease for up to 20 seconds and then resume again. The examiner should also observe for symmetry of chest movement. The average respiratory rate is between 30 and 60 breaths/min or may be higher than 60 breaths/min if the newborn is very active or crying. An apical pulse rate should be obtained on all newborns. Auscultation should be for a full minute, preferably when the newborn is asleep or in a quiet alert state. The heart rate may range from 110 to 160 bpm. It is common to detect brief irregularities in the heart rate. Heart rate varies with the newborn’s behavioural state. Bradycardia is a heart rate less than 100 bpm. However, a term newborn in deep sleep may have a heart rate in the 80s or 90s; the rate should increase when the newborn awakens. Tachycardia is defined as a sustained heart rate exceeding 160 bpm. It is not unusual for a crying newborn to have a heart rate greater than 160; the heart rate should decrease when the crying ceases (Gardner & Niermeyer, 2021). Brachial and femoral pulses should be assessed for equality and strength. If BP is measured, an oscillometric monitor calibrated for newborn pressures is preferred. An appropriate-sized cuff (width-to-arm or calf ratio of 0.45 to 0.70, or approximately ½ to ¾) is essential for accuracy. Newborn BP usually is highest immediately after birth and falls to a minimum by 3 hours after birth. It then begins to rise steadily and reaches a plateau between 4 and 6 days after birth. This measurement is usually equal to that of the immediate post-birth BP. The blood pressure (BP) varies with the newborn’s activity; accurate measurement is best obtained while the newborn is at rest. BP also varies with gestational age and chronological age. Systolic pressure in a term newborn averages 60 to 80 mm Hg; diastolic pressure averages 40 to 50 mm Hg. The mean arterial pressure (MAP) should approximate the newborn’s week of gestation. According to agency protocol, four extremity BPs may be assessed routinely or only when a murmur is auscultated. If the upper extremity pressures are more than 10 mm Hg greater than those in the lower extremities, the newborn may have a cardiac defect such as coarctation of the aorta (Gardner & Niermeyer, 2021). Peripheral pulses are also palpated as part of the assessment in any newborn with a heart murmur. Pulse oximetry is completed for congenital heart disease screening (see discussion below in Critical Congenital Heart Disease). Baseline measurements of physical growth. Baseline measurements are taken and recorded to help assess the progress and determine the growth patterns of the newborn. These may be recorded on growth charts. The following measurements are made when the newborn is assessed. Weight. The newborn is usually weighed in the first few hours after birth. Care must be taken to ensure that the scales are balanced. The

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totally unclothed newborn is placed in the centre of the scale, which is usually covered with a disposable pad or cloth to prevent heat loss via conduction and prevent cross-infection. The nurse should place one hand over (but not touching) the newborn to prevent the newborn from falling off the scale. Most newborns need to be weighed only at birth and at discharge, although newborns who are SGA or who are not feeding well may require daily weighing. This should be done at the same time every day during the hospital stay. Birth weight of a term newborn typically ranges from 2 500 to 4 000 g. Head circumference and length. The head is measured at the widest part, which is the occipitofrontal diameter. The tape measure is placed around the head just above the newborn’s eyebrows. The term newborn’s head circumference ranges from 32 to 36.8 cm (12.6 to 14.5 in). The length may be difficult to obtain because of the flexed posture of the newborn. The examiner places the newborn on a flat surface and extends the leg until the knee is flat against the surface. Placing the head against a perpendicular surface and extending the leg may assist with this measurement. In the term newborn, head-to-heel length ranges from 45 to 55 cm (17.7 to 21.7 in) (see Chapter 33, Length). Neurological assessment. The physical assessment includes a neurological assessment of newborn reflexes (Table 26.3). This assessment provides useful information about the newborn’s nervous system and state of neurological maturation. Many reflex behaviours (e.g., sucking and rooting) are important for proper development. Other reflexes such as gagging and sneezing act as primitive safety mechanisms. The assessment needs to be carried out as early as possible because abnormal signs present in the early newborn period may require further investigation before the newborn is discharged home.

Fig. 26.7 Marked bruising on the entire face of a newborn born vaginally after face presentation. Less severe ecchymoses were present on the extremities. Phototherapy was required for treatment of jaundice resulting from breakdown of accumulated blood. (From O’Doherty, N. [1986]. Neonatology: Micro atlas of the newborn. Hoffmann-La Roche. Used with permission of F. Hoffmann-La Roche Ltd.)

Common Newborn Concerns Birth Injuries. Birth trauma includes any physical injury sustained by a newborn during labour and birth. Although most injuries are minor and resolve during the newborn period without treatment, some types of trauma require intervention; a few are serious enough to be fatal. See Chapter 29 for more information on birth injuries. Retinal and subconjunctival hemorrhages result from rupture of capillaries caused by increased pressure during birth. The hemorrhages clear within 5 days after birth and usually present no further issues. Parents need explanation about them and reassurance that these injuries are harmless. Erythema, ecchymoses, petechiae, abrasions, lacerations, or edema of buttocks and extremities may be present. Localized discoloration can appear over a presenting part as a result of forceps or vacuum-assisted birth. Ecchymoses and edema can appear anywhere on the body. Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper trunk and face. These lesions are benign if they disappear within 2 or 3 days of birth and no new lesions appear. Ecchymoses and petechiae may be signs of a more serious disorder, such as thrombocytopenic purpura. To differentiate hemorrhagic areas from a skin rash or discoloration, the nurse can apply pressure to the skin with two fingers. Petechiae and ecchymoses do not blanch because extravasated blood remains within the tissues, whereas skin rashes and discolorations do blanch. For further discussion regarding birthmarks see Chapter 25, Integumentary System. Trauma can occur to the presenting part during labour and birth. Caput succedaneum and cephalhematoma are normal and are discussed in Chapter 25 (see Figure 25.12). Forceps injury and bruising from the vacuum cup occur at the site of application of the instruments. A forceps injury commonly produces a linear mark across both sides of the face in the shape of the blades of the forceps, with skin integrity rarely being compromised. These injuries usually resolve spontaneously within several days with no specific therapy. If small abrasions are evident the area should be kept clean to minimize the risk

Fig. 26.8 Swelling of genitalia and bruising of the buttocks after a breech birth. (From O’Doherty, N. [1986]. Neonatology: Micro atlas of the newborn. Hoffmann-La Roche. Used with permission of F. Hoffmann-La Roche Ltd.)

of infection. A topical ointment may be ordered by the primary health care provider to optimize healing. With increased use of the vacuum extractor, the incidence of these lesions has been significantly reduced. Bruises over the face may be the result of face presentation (Figure 26.7). In a breech presentation, bruising and swelling may be seen over the buttocks or genitalia (Figure 26.8). The skin over the entire head may be ecchymotic and covered with petechiae caused by a tight nuchal cord or a precipitous birth. If the hemorrhagic areas

CHAPTER 26

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do not disappear spontaneously in 2 days or if the newborn’s condition changes, the primary health care provider should be notified. Accidental lacerations can be inflicted with a scalpel during a Caesarean birth. These cuts may occur on any part of the body but are most often found on the scalp, buttocks, and thighs. Usually they are superficial and only need to be kept clean. If skin closure is needed, an adhesive substance or strips may be applied. Rarely are sutures needed.

Physiological Conditions. Hyperbilirubinemia. Hyperbilirubinemia in the newborn, also referred to as neonatal jaundice, occurs in approximately 60% of all full-term newborns by the second through fifth day of life (Barrington et al., 2007/2018). In most cases it is physiological jaundice, which causes increased levels of bilirubin as a result of the diminished ability to conjugate and excrete an excess of bilirubin in the blood of the newborn; physiological jaundice is usually self-limiting, requires no treatment, and resolves in a few days. Physiological jaundice or neonatal hyperbilirubinemia occurs in 80% of preterm newborns. The incidence of physiological jaundice is increased in darker-skinned newborns. It must be differentiated from pathological jaundice, or hyperbilirubinemia, which is associated with higher levels of unconjugated bilirubin. Pathological jaundice can appear in the first 24 hours and often requires phototherapy to resolve. (See Chapter 25, Bilirubin Synthesis and Newborn Jaundice for further discussion on pathophysiology of hyperbilirubinemia.) See Clinical Reasoning Case Study: Home Assessment of Physiological Jaundice. ?

CLINICAL REASONING CASE STUDY

Home Assessment of Physiological Jaundice Minh and Viet have been home with their newborn son for 2 days now. As Bao was born early at 35 +5 weeks gestation, they were required to stay an extra day in the hospital for further evaluation. During the postpartum home visit, the public health nurse notices that Bao appears very lethargic and has a slight yellow tinge in his eyes. Viet reveals that Bao reminds him of their first son, who had to be readmitted to the hospital for phototherapy. Viet is breastfeeding Bao. 1. Evidence—What risk factors for physiological jaundice are present? 2. Assessment—What further information does the nurse need to gather to complete the assessment of the baby Bao? 3. What priorities for nursing care can be drawn at this time? 4. Interprofessional care—Describe the roles and responsibilities of members of the interprofessional health care team who may be involved in care management of this mother and her newborn. 5. What other factors need to be considered when planning follow-up for baby Bao and his mother Minh?

Every newborn should be assessed for jaundice; this can be easily done when vital signs are assessed. Jaundice is generally first noticed in the head, especially the sclera and mucous membranes, and then progresses gradually to the thorax, abdomen, and extremities. Visual assessment of jaundice alone does not provide an accurate assessment of the level of serum bilirubin, especially in dark-skinned newborns; only 50% of babies with a total serum bilirubin (TSB) concentration greater than 128 mcmol/L appear jaundiced (Barrington et al., 2007/ 2018). To differentiate cutaneous jaundice from normal skin colour, the nurse applies pressure with a finger over a bony area (e.g., the nose, forehead, sternum) for several seconds to empty all the capillaries in that spot. If jaundice is present, the blanched area will look yellow before the capillaries refill and further assessment will be required. The conjunctival sacs and buccal mucosa are also assessed. Assessing

Fig. 26.9 Transcutaneous monitoring of bilirubin with a transcutaneous bilirubinometry (TcB) monitor. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

for jaundice in natural light is recommended because artificial lighting and the reflection from walls can distort the actual skin colour. Noninvasive monitoring of bilirubin via cutaneous reflectance measurements (transcutaneous bilirubinometry [TcB]) allows for repetitive estimations of bilirubin; however, there are limitations to the use of TcB monitors (Figure 26.9). They are more accurate at lower TSB levels, are not accurate once phototherapy is initiated, and may be unreliable with changes in skin colour and thickness. TcB monitors may be used to screen clinically significant jaundice (Barrington et al., 2007/2018). The CPS recommends monitoring healthy newborns at 35 weeks of gestation or greater before discharge from the hospital using hour-specific serum bilirubin levels to determine the newborn’s risk for development of hyperbilirubinemia requiring medical treatment or closer screening (Barrington et al., 2007/2018; Provincial Council for Maternal & Child Health [PCMCH] & Ministry of Health and Long-Term Care, 2017). Use of a nomogram (Figure 26.10) with three levels (high, intermediate, or low risk) of rising TSB values assists in determination of newborns that might need further evaluation after discharge. Universal bilirubin screening based on hour-specific TSB may be done at the same time as the routine newborn metabolic screening (Barrington et al., 2007/2018). Adequate feeding is essential in preventing hyperbilirubinemia. Newborns should breastfeed early (within 1 hour after birth) and often. Colostrum acts as a laxative to promote stooling, which helps rid the body of bilirubin. Formula-fed newborns should be fed after birth when their physiological status has stabilized and thereafter on demand, at least every 3 to 4 hours. Newborns should be assessed for risk factors for severe hyperbilirubinemia. Factors that place newborns at high risk include gestational age of 35 to 38 weeks; exclusive breastfeeding not being well established and excessive weight loss; having a sibling who had neonatal hyperbilirubinemia; visible bruising, cephalohematoma, a positive Coombs’ test (also known as a direct antibody test [DAT]), or other known hemolytic disease; glucose-6-phosphate dehydrogenase (G6PD) deficiency (diagnosed at birth); ethnic background (East Asian); asphyxia (Apgar 0–3 beyond 5 minutes and cord pH less than 7); acidosis (pH less than 7 beyond initial cord sample); albumin less than 30 g/L; sepsis being currently treated; temperature instability; and significant lethargy or poor feeding (Barrington et al., 2007/2018; PCMCH & Ministry of Health and Long-Term Care, 2017). It is recommended that healthy newborns (35 weeks or greater) receive assessment of bilirubin at 24 hours of life.

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Newborn

40th percentile 70th percentile 95th percentile

300

one

Bilirubin (mcmol/L)

hz

Hig

250

m

ter

one

te z

a edi

one

z ate edi m H r e inte zon Low Low in igh

200 150 100 50 0 0

12

24

36

48

60 72 84 Age (hr)

96 108 120 132 144

Fig. 26.10 Nomogram for evaluation of screening total serum bilirubin (TSB) concentration in term and late preterm newborns, according to the TSB concentration obtained at a known postnatal age in hours. (From Barrington, K. J., Sankaran, K., & Canadian Paediatric Society. [2007/ 2018]. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late term newborn infants [35 or more weeks gestation]. Paediatrics & Child Health, 12[Suppl B], 1B–12B. Figure reproduced and adapted with permission from Pediatrics, 114, 297–316. Copyright © 2004 by the AAP.)

If intervention is not required, further follow-up will depend on individual risk factors. If a newborn is discharged before 24 hours of age, the newborn needs further assessment within 24 hours by someone experienced in newborn care and with access to testing (Barrington et al., 2007/2018). Close follow-up of newborns at risk for severe hyperbilirubinemia is essential; parents should be educated about the symptoms and encouraged to follow postdischarge recommendations. If a newborn is jaundiced in the first 24 hours of life, a TcB or TSB level should be measured and results interpreted on the basis of the newborn’s age in hours according to the hour-specific nomogram for newborns born at 35 weeks of gestation or later. Repeat testing is based on the risk level (low, intermediate, or high), the age of the newborn, and the progression of jaundice. Pathological jaundice is that level of serum bilirubin which, if left untreated, can result in sensorineural hearing loss, mild cognitive delays, and kernicterus, which is the deposition of bilirubin in the brain. Kernicterus describes the yellow staining of the brain cells that may result in bilirubin encephalopathy. The damage to the brain occurs when the serum concentration reaches toxic levels, regardless of cause. The key to prevention of this complication is universal screening between 24 and 72 hours. Therapy for hyperbilirubinemia. The best therapy for hyperbilirubinemia is prevention. Because bilirubin is excreted in meconium, prevention can be facilitated by early and frequent feeding, which stimulates passage of meconium. However, despite early passage of meconium, some term newborns may have trouble conjugating the increased amount of bilirubin derived from disintegrating fetal red blood cells (RBCs). As a result, the serum levels of unconjugated bilirubin may rise beyond normal limits, causing hyperbilirubinemia. The goal of treatment of hyperbilirubinemia is to help reduce the newborn’s serum levels of unconjugated bilirubin. There are two ways to reduce unconjugated bilirubin levels: phototherapy and exchange blood transfusion. Phototherapy. The purpose of phototherapy is to reduce the level of circulating unconjugated bilirubin or to keep it from increasing. Phototherapy uses light energy to change the shape and structure of

unconjugated bilirubin and convert it to molecules that can be excreted. The dose and effectiveness of phototherapy are affected by the source of light. Phototherapy units vary in the spectrum of light they deliver and in the filters that are used. The most effective therapy is achieved with special blue fluorescent tubes or a specially designed light-emitting diode (LED). Phototherapy lights do not emit significant ultraviolet radiation; the small amount that is emitted does not cause erythema. Most of the ultraviolet light is absorbed by the glass wall of the fluorescent tube and by the plastic cover of the light (Kamath-Rayne et al., 2021). Phototherapy is usually effective for treatment of hyperbilirubinemia that has not reached levels associated with acute bilirubin encephalopathy or kernicterus. The effectiveness of phototherapy is related to the distance between the light and the newborn and on the area of skin that is exposed. During phototherapy using a lamp, the newborn wearing only a diaper is placed under a bank of lights approximately 45 to 50 cm from the light source. Newborn should be placed supine for maximum exposure to the light source. Phototherapy can be used for the newborn in an isolette (Figure 26.11) or in an open crib. The distance varies according to unit protocol and type of light used. The lamp’s energy output should be monitored routinely with a photometer during treatment to ensure efficacy of therapy. If phototherapy is effective, the bilirubin level should begin to decrease within 4 to 6 hours after phototherapy is initiated and within 24 hours it should decrease by 30 to 40% (Kamath-Rayne et al., 2021). Phototherapy is used until the newborn’s serum bilirubin level decreases to within an acceptable range. The decision to discontinue therapy is based on the observation of a definite downward trend in bilirubin values.

SAFETY ALERT When a phototherapy lamp is used, the newborn’s eyes must be protected by an opaque mask to prevent retinal damage (Figure 26.12). The eye shield should cover the eyes completely but not occlude the nares. Before the mask is applied, the newborn’s eyes should be closed gently to prevent excoriation of the corneas. The mask should be removed periodically and during newborn feedings so that the eyes can be assessed and cleansed with water and the parents can have visual contact with the newborn (Kamath-Rayne et al., 2021).

Phototherapy may cause changes in the newborn’s temperature, depending partially on the bed used: bassinet, isolette, or radiant warmer. The newborn’s temperature should be closely monitored at least every 2 hours. Phototherapy lights can increase the rate of insensible water loss, which contributes to fluid loss and dehydration.

Fig. 26.11 Newborn under phototherapy lights. (iStock.com/stockstudioX)

CHAPTER 26

Fig. 26.12 Newborn with eyes covered while receiving phototherapy. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

Therefore, it is important that the newborn be adequately hydrated. The healthy newborn is kept hydrated through breastfeeding, pasteurized donor milk, or infant formula; there is no advantage or benefit to administering oral glucose or plain water because these do not promote excretion of bilirubin in stools and may in fact perpetuate enterohepatic circulation, thus delaying bilirubin excretion. It is important to closely monitor urinary output as an indicator of hydration status while the newborn is receiving phototherapy. Urine output can be decreased or unaltered; the urine can have a dark gold or brown appearance. The number and consistency of stools should also be monitored. Bilirubin breakdown increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. The newborn’s buttocks must be cleaned after each stool to maintain skin integrity. A fine maculopapular rash may appear during phototherapy, but this is transient.

SAFETY ALERT No ointments, creams, or lotions should be applied to the newborn’s skin during phototherapy because they can absorb heat and cause burns.

Additional systems used for phototherapy include a bassinet system that provides special blue light above and beneath the newborn. Another phototherapy device is a fibre-optic blanket that is connected to a light source (Figure 26.13). The blanket is flexible and can be placed around the newborn’s torso or underneath the newborn in the bassinet. There are also bilirubin beds with LED lights in a pad that covers the surface of the bassinet. The LED lights do not produce heat and can be used with radiant warmers. These devices are usually less effective when used alone than with conventional phototherapy lights. They can be very useful in combination with overhead phototherapy lights. In certain instances, the newborn’s bilirubin levels increase rapidly and intensive phototherapy is required; this situation involves the use of a combination of conventional lights and fibre-optic blankets to maximize bilirubin reduction. Although fibre-optic lights do not produce heat as conventional lights do, staff should ensure that a covering pad is placed between the newborn’s skin and the fibre-optic device

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Fig. 26.13 A mother can put her newborn skin-to-skin without interrupting phototherapy when a fibre-optic blanket is used. (Courtesy Mother and Childcare, Phillips Healthcare.)

to prevent skin burns, especially in preterm newborns. The newborn can remain in the hospital room in an open crib or in the parent’s arms during treatment. The use of eye patches depends on whether the devices are used alone or in combination with phototherapy lights. The use of home phototherapy should be reserved for healthy term newborns with bilirubin levels in the “optional phototherapy” range according to the nomogram. The concern is that home phototherapy units do not provide the same level of irradiance or body surface coverage as phototherapy devices used in the hospital. Exchange transfusion. When phototherapy is not effective in reducing serum bilirubin levels or in treating severe hyperbilirubinemia such as in hemolytic disease, exchange transfusion may be needed. This procedure is done in an intensive care setting and can reduce bilirubin levels by 45 to 85%. A portion of the newborn’s blood is replaced with donor blood (Kamath-Rayne et al., 2021). This invasive procedure is not done frequently, although it may be necessary in the very preterm newborn or newborns with other medical conditions causing the hyperbilirubinemia (see discussion in Chapter 29). Follow-up. Serum levels of bilirubin in the newborn continue to rise until the fifth day of life. Many parents leave the hospital within 24 hours of birth, and some as early as 6 hours after birth. Therefore, parents must receive education regarding jaundice and its treatment. They should have written instructions for assessing the newborn’s condition and the name of a contact person to whom they should report their findings and concerns. Close follow-up is needed for newborns who have been treated for hyperbilirubinemia. Repeat testing of serum bilirubin levels and followup visits with the pediatric health care provider are expected. Hypoglycemia. Hypoglycemia in a term newborn is defined as a blood glucose concentration less than that needed to support adequate neurological, organ, and tissue function; however, there is a lack of consensus regarding the precise level at which this concentration occurs. At birth, the maternal source of glucose is cut off with the clamping of the umbilical cord. Most healthy term newborns experience a transient decrease in glucose levels to as low as 1.7 mmol/L during the first 1 to 2 hours after birth, with a subsequent mobilization of free fatty acids and ketones to help maintain adequate glucose levels (Blackburn, 2018). Newborns who are asphyxiated or have other

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physiological stress may experience hypoglycemia as a result of a decreased glycogen supply, inadequate gluconeogenesis, or overutilization of glycogen stored during fetal life. There is concern about neurological injury as a result of severe or prolonged hypoglycemia, especially in combination with ischemia (Rozance et al., 2021). There is no need to routinely assess glucose levels of healthy term newborns (Aziz et al., 2004/2018). Breastfeeding early and often helps these newborns maintain adequate glucose levels. Glucose levels should be measured in newborns at 34 weeks of gestation or more if risk factors or clinical manifestations of hypoglycemia are present. In newborns who are at risk for altered metabolism as a result of maternal illness factors (diabetes, gestational hypertension) or newborn factors (perinatal hypoxia, infection, hypothermia, polycythemia, congenital malformations, hyperinsulinism, SGA, LGA, fetal hydrops), close observation and monitoring of blood glucose levels within 2 hours of birth, after an initial feeding, are recommended. The frequency of glucose testing is determined by the risk factors for each individual newborn. Newborns of diabetic mothers should undergo glucose screening before feedings for at least the first 12 hours after birth; further testing is done if glucose levels are less than 2.6 mmol/L. However, preterm and SGA newborns may be vulnerable up to 36 hours of age so should be screened until 36 hours of age if feeding is established and blood glucose is maintained at 2.6 mmol/L or higher (Aziz et al., 2004/2018). Early and frequent breastfeeding and skin-to-skin contact with the parent for as long as possible after birth promote thermoregulation and stabilization of glucose levels (Wight et al., 2014). The CPS recommendations state that asymptomatic, at-risk babies should receive at least one effective feeding before a blood glucose check at 2 hours of age and should be encouraged to feed regularly thereafter. Blood glucose of less than 2.8 requires follow-up, but if breastfeeding is effective, supplementation with a sugar source is not required. At-risk babies who have persistent blood glucose levels of less than 2.6 mmol/L despite subsequent feeding or symptomatic newborns should also be considered for IV dextrose therapy (Aziz et al., 2004/2018). It is also important to review organization policies regarding hypoglycemia protocols. Hypoglycemia in the low-risk term newborn is usually eliminated by feeding the newborn a source of carbohydrate (i.e., preferably human milk) or giving dextrose gel, and placing the newborn skinto-skin with a parent. Occasionally, IV administration of glucose is required for newborns with persistently high insulin levels or in those with depleted stores of glycogen. Glucose testing should be done in any newborn with clinical signs of hypoglycemia. The clinical signs can be transient or recurrent and include jitteriness, lethargy, poor feeding, abnormal cry, hypotonia, temperature instability (hypothermia), respiratory distress, apnea, and seizures (Rozance et al., 2021). It is important to remember that hypoglycemia can be present in the absence of clinical manifestations.

NURSING ALERT Late preterm newborns are at increased risk for hypoglycemia. They have decreased glycogen stores and lack hepatic enzymes for gluconeogenesis and glycogenolysis. Their hormonal regulation and insulin secretion are immature. The increased risk of cold stress and feeding difficulties adds to the risk for hypoglycemia (Premji, 2019).

Hypocalcemia. Hypocalcemia in newborns is defined as serum calcium levels less than 2 mmol/L in the term newborn and slightly lower (1.75 mmol/L) in the preterm newborn. Hypocalcemia is common in critically ill newborns but also can occur in newborns of mothers with diabetes or in those who experienced perinatal asphyxia or trauma and in

low-birth-weight and preterm newborns. Newborns born to mothers treated with anticonvulsants during pregnancy are also at risk (Halbardier, 2015). Early-onset hypocalcemia usually occurs within the first 24 to 48 hours after birth. Signs of hypocalcemia include jitteriness, tremors, twitching, high-pitched cry, irritability, apnea, and laryngospasm, although some newborns may be asymptomatic. Jitteriness is a symptom of both hypoglycemia and hypocalcemia; therefore, hypocalcemia must be considered if the therapy for hypoglycemia proves ineffective. In most instances, early-onset hypocalcemia is self-limiting and resolves within 1 to 3 days. Treatment usually includes early feeding of an appropriate source of calcium, such as fortified human milk or a preterm formula (Nyp et al., 2021). In some cases (e.g., the medically unstable, extremely low-birth-weight newborn) administration of IV elemental calcium and phosphorus may be necessary.

Laboratory and Screening Tests Because newborns experience many transitional events in the first 28 days of life, laboratory samples are often gathered to determine adequate physiological adaptation and to identify disorders that may adversely affect the child’s life beyond the newborn period. Most laboratory tests for newborn screening may be obtained from the newborn with a heel puncture, also known as a heel stick. Tests that may be performed include bilirubin levels, blood glucose, newborn metabolic screening tests (e.g., PKU, hypothyroidism [T4], sickle cell disease, and galactosemia), and drug serum levels. Box 26.5 lists standard laboratory values in a term newborn.

Universal Newborn Screening. Newborn screening (NBS) is an important public health program aimed at early detection of metabolic diseases that result in severe health conditions if not treated early. As many as 40 conditions may be screened. Earlier identification of these conditions may prevent further developmental delays and morbidities in affected children. The majority of disorders included in NBS are not symptomatic at birth. While all provinces and territories have programs for NBS, the number of conditions screened for varies by province. The core disorders that are screened for include hemoglobinopathies (e.g., sickle cell disease), inborn errors of metabolism (e.g., PKU, galactosemia), and severe combined immunodeficiency. Although NBS is considered the standard of care, it is important that prior to the test a discussion is held with the parents, informing them of the importance of NBS, as parents have the right to refuse such screening. Information about which tests

BOX 26.5

Standard Laboratory Values in a Term Newborn Hemoglobin Hematocrit Glucose Leukocytes (white blood cells) Bilirubin, total serum Blood Gases Arterial

140–240 g/L 0.37–0.48 1.7–3.3 mmol/L 9–30  109/L 1.7-180 mcmol/L pH 7.32–7.49 PCO2 26–41 mm Hg PO2 60–70 mm Hg HCO3 16-24 mmol/L

PCO2, Partial pressure of carbon dioxide; PO2, partial pressure of oxygen. Data from Pagana, K., Pagana, T., & Pike-MacDonald, S. (2019). Mosby’s Canadian manual of diagnostic and laboratory tests (2nd Canadian ed.). Elsevier.

CHAPTER 26 are performed in each province can be obtained from provincial and territorial health departments, as these vary across the country. Blood samples are obtained from newborns using a heel stick; blood is collected on a special filter paper and sent to a designated provincial/ territorial laboratory for analysis (Figure 26.14). NBS is done between 24 and 48 hours of age, although if a newborn is discharged prior to 24 hours it is recommended that the blood work be done before discharge and then again within 2 weeks (Perinatal Services BC, 2018). Nurses can provide education for parents regarding the purpose of the screening, the procedure for blood sampling, when to expect results, and the importance of follow-up.

Newborn Hearing Screening. Hearing loss is one of the most common congenital disorders, with approximately 3 in 1 000 newborns born profoundly deaf and another 3 in 1 000 having serious hearing impairment (CPS, 2020b). In Canada, newborn hearing screening has been an established routine practice in most provinces, but not all. This screening offers a potentially critical sequelae of tests to establish that the newborn is able to hear and will be aware of the early engagement in sound and language. If testing points to a hearing impairment, interventions can be implemented early to mitigate the potential for complex social barriers (Patel et al., 2011/2018). Through

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early hearing detection and intervention programs, the outcome for newborns who are deaf or hearing impaired can be maximized. Using noninvasive technology, newborn hearing screening provides information about the pathways from the external ear to the cerebral cortex. Two tests commonly are used to assess hearing function in the newborn: initial screening is done with the evoked otoacoustic emissions (EOAE) test, and the auditory brainstem response (ABR) test is used as follow-up if the initial screening is abnormal. Neither test is definitive in diagnosing hearing impairment; they are used to determine whether further, more accurate hearing testing is needed through audiological evaluation. For the EOAE test, a soft rubber earpiece that makes a soft clicking noise is placed in the newborn’s outer ear (Figure 26.15, A). A healthy ear will “echo” the click sound back to a microphone inside the earpiece that is in the newborn’s ear. The ABR test is performed by attaching sensors to the newborn’s forehead and behind each ear. An earphone is placed in the newborn’s outer ear and sends a series of quiet sounds into the sleeping newborn’s ear (Figure 26.15, B). The sensors measure the responses of the newborn’s acoustic nerve. The responses are recorded and stored in a computer. Newborns who do not pass the initial screening test should have the hearing screening test repeated as part of follow-up care. If the newborn

B Fig. 26.14 A, Nurse obtaining blood sample from newborn’s heel for universal screening. Sample is applied to filter paper. B, All circles on the filter paper must be filled in completely. (Courtesy Cheryl Briggs, RNC, Annapolis, MD.)

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B Fig. 26.15 Newborn hearing screening. A: Evoked otoacoustic emissions (EOAE) test. B: Auditory brain response (ABR) test. (A, Courtesy Julie and Darren Nelson. B, Courtesy Dee Lowdermilk.)

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still does not pass the test, a comprehensive audiological evaluation should be done by 3 months of age.

Screening for Critical Congenital Heart Disease (CCHD). Congenital heart disease (CHD) is the most common congenital malformation, with a prevalence of 12/1 000 live births in Canada. Approximately one quarter of these newborns have CCHD, defined as more severe and often duct-dependent lesions that require intervention early in life for optimal outcome (Narvey et al., 2017). Optimum screening should include prenatal ultrasound, physical examination, and pulse oximetry screening. The noninvasive screening test is performed using pulse oximetry to measure oxygen saturation for the purpose of detecting hypoxemia. Pulse oximetry testing can detect some critical congenital heart defects that present with hypoxemia in the absence of other physical symptoms. Hypoxemia can be the first sign that a congenital heart defect is present, and other symptoms can develop once the newborn has been discharged. Screening is performed at 24 to 36 hours of age. Oxygen saturation is measured in the right hand and one foot. A “passing” result is oxygen saturation of greater than or equal to 95% in the right hand or either foot, with a less than 3% absolute difference between the upper and lower extremity readings. Repeated screens are recommended for “borderline” results with oxygen saturation between 90 and 94% or less than 3% difference between extremities. An oxygen saturation less than 90% in either extremity requires immediate health care provider intervention (Narvey et al., 2017). This noninvasive test can be performed in less than 5 minutes. It is estimated that implementation of pulse oximetry screening could detect an additional 136 CCHD cases per year before the appearance of symptoms (Narvey et al., 2017).

Collection of Specimens. Ongoing evaluation and screening of a newborn often requires obtaining blood by heel stick or venipuncture or the collection of a urine specimen. Laboratory tests may be ordered routinely (e.g., NBS) or for a specific purpose as directed by the health care provider. Heel stick. Some blood specimens may be drawn by laboratory technicians. However, nurses generally have established a relationship with the family and are able to perform heel sticks at the bedside to obtain blood for glucose monitoring or NBS or other tests.

NURSING ALERT Blood samples should be collected in a manner that minimizes pain and trauma to the newborn and maximizes the accuracy of test results. If a laboratory technician is collecting the specimen, the nurse assists as needed to maximize safety and newborn comfort. It is recommended that the parent have skinto-skin contact with the newborn prior to and during the heel prick to minimize newborn pain during the procedure (Johnston et al., 2017).

It is often helpful to warm the heel before the sample is taken; application of heat for 5 to 10 minutes helps dilate the blood vessels in the area. A cloth soaked with warm water (not hot) and wrapped loosely around the foot provides effective warming (Figure 26.16, A). Disposable heel warmers are available from a variety of companies; they should be used with care to prevent burns. Nurses should wear gloves when collecting any specimen. The nurse cleanses the area with an appropriate skin antiseptic, allows the area to dry, restrains the newborn’s foot with a free hand, and then punctures the site. A springloaded automatic puncture device causes less pain and requires fewer punctures than a manual lance blade; therefore, manual lance blades should not be used on newborns. It is important that the heel is not “milked” to obtain the blood specimen. The most serious complication of newborn heel stick is necrotizing osteochondritis from lancet penetration of the bone. To prevent this, the penetration should be made at the outer aspect of the heel and should be no deeper than 2.4 mm. To identify the appropriate puncture site, the nurse should draw an imaginary line running from between the fourth and fifth toes and parallel to the lateral aspect of the foot to the heel where the puncture is made; a second line can be drawn from the great toe to the medial aspect of the heel (see Figure 26.16, B). Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that may lead to difficulties with walking later in life. After the specimen has been collected, pressure is applied with a dry gauze square. No further skin cleanser should be applied because this will cause the site to continue to bleed. The site is then covered with an adhesive bandage. The nurse needs to ensure proper disposal of equipment used, review the laboratory requisition for correct identification, and check the specimen for adequate labelling and routing.

Medial plantar nerve Lateral plantar nerve

Medial plantar artery

Lateral plantar artery

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Medial calcaneal nerves

B Fig. 26.16 Heel stick. A: Newborn with foot wrapped for warmth to increase blood flow to extremity before heel stick. B: Heel stick sites (shaded areas) on newborn’s foot for obtaining samples of capillary blood. (A, Courtesy Marjorie Pyle, RNC, Lifecircle.)

CHAPTER 26 A heel stick is traumatic for the newborn and causes pain. Nurses should ensure that they use effective newborn pain prevention programs utilizing all nonpharmacological and pharmacological methods aimed at prevention of potentially hurtful routine procedures (Barrington et al., 2007/2017) (see Management of Pain in the Newborn, later in the chapter). This will help to reassure the newborn and to promote feelings of safety. Parental reassurance is essential before, during, and after routine procedures. Venipuncture. Occasionally, laboratory tests are ordered that require larger samples of blood than can be collected with a heel stick. Venous blood samples can be drawn from antecubital, saphenous, superficial wrist, and, rarely, scalp veins. When venipuncture is required, positioning of the needle is extremely important. A 23- or 25-gauge butterfly needle or hypodermic needle with a syringe is used (Figure 26.17). Patience is required during the procedure because the blood return in small veins is slow; consequently, the small needle must remain in place longer than a larger needle. A tourniquet is optional but can help increase blood flow with venipuncture. The newborn is carefully held during the procedure to prevent injury (see Chapter 34). Pain relief is also a key component to nursing care in any venipuncture procedure. If venipuncture or arterial puncture is performed for blood gas studies, crying, fear, and agitation will affect the values; therefore, every effort must be made to keep the newborn quiet during the procedure. Pressure must be maintained over an arterial or femoral vein puncture with a dry gauze square for 3 to 5 minutes to prevent bleeding from the site. For an hour after any venipuncture, the nurse should observe the newborn frequently for evidence of bleeding or hematoma formation at the puncture site. The newborn should be cuddled and comforted when the procedure is completed and appropriate pain management measures taken. The nurse needs to assess and document the newborn’s tolerance of the procedure. Urine specimen. Analysis of urine is a valuable laboratory tool for newborn assessment; the way in which the specimen is collected can influence the results. The urine sample should be fresh and analyzed within 1 hour of collection. A urine collection bag is often used to obtain a specimen (see Chapter 44 for more information about the procedure for collecting a urine specimen from a newborn).

Interventions Protective Environment. The provision of a protective environment is basic to the care of the newborn. Hospital personnel develop their

Fig. 26.17 Venipuncture using a butterfly needle. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

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own policies and procedures for protecting newborns under their care. Prescribed standards cover areas such as environmental factors, measures to control infection, and safety factors. Current health care trends and the focus on nonseparation of parents and babies have prompted most hospitals to abandon having a separate newborn nursery. In the dyad model of care, the newborn stays in the parent’s room, which reduces the need for a separate nursery. Environmental factors. Environmental factors include provision of adequate lighting, elimination of potential fire hazards, safety of electrical appliances, adequate ventilation, and controlled temperature (i.e., warm and free of drafts) and humidity. Measures to control infection. Measures to control infection include adequate floor space for positioning bassinets at least 90 cm apart in all directions if in a newborn nursery, hand hygiene facilities, and areas for cleaning and storing equipment and supplies. Only those personnel directly involved in the care of parents and newborns are allowed in these areas, thereby reducing opportunities for the introduction of pathogenic organisms.

NURSING ALERT Proper hand hygiene is essential to preventing the spread of health care–associated infections (HAI). Personnel should wash their hands with soap and water or use an alcohol-based hand rub in accordance with hospital infection control policies. Hand hygiene should be performed before and after touching the newborn, before an invasive procedure or medication administration, after contact with potentially contaminated objects (e.g., computer keyboards, telephone, countertop surfaces), and after removing sterile or nonsterile gloves (WHO, 2009).

Health care workers must wear gloves when handling the newborn before blood and amniotic fluid have been removed from the newborn’s skin, when drawing blood (e.g., heel stick), when caring for a fresh wound (e.g., circumcision), when assisting with breastfeeding, and during diaper changes. Visitors and health care providers, including nurses, physicians, parents, siblings, and grandparents, are expected to wash their hands before having contact with newborns or equipment. Individuals with infectious conditions, including upper respiratory tract or gastrointestinal tract infections and infectious skin conditions, should be excluded from contact with newborns or must take special precautions when working with newborns. Safety factors. Personnel caring for newborns must be clearly identified by photo identification, and parents must be educated about measures to prevent abduction from the parent’s room (i.e., be certain they know the identity of anyone who cares for the newborn and never release the newborn to anyone who is not wearing the appropriate identification). Other safety measures include placing matching identification bracelets on newborns and their parents and using identification bands with radiofrequency transmitters that set off an alarm if the bracelet is removed or if a certain threshold is crossed (doorway to exit building or floor). Nurses and new parents must work together to ensure the safety of newborns in the hospital environment. Prevention of newborn falls. Newborns are at risk of injury as a result of falling. Even falls occurring from low-level surfaces such as beds or chairs can result in head injury that could include skull fracture. Most falls occurring in hospital settings appear to occur when the parent falls asleep while holding the newborn in bed or reclining chair, although some occur during transportation of the newborn. Risk factors in the parent for newborn falls include sleep deprivation,

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Caesarean birth, pain medication with sedatives, and leaving the newborn unattended. Nurses have developed programs to prevent and manage falls, emphasizing sensitization of hospital staff, parent education, assessing for falls risks, fall management algorithms, and implementing hospital policies (Ainsworth et al., 2016; Miner, 2019).

SAFETY ALERT Nurses play a critical role in newborn fall prevention. Parental exhaustion levels should be part of routine nursing assessments. Education provided to parents should include placing the newborn in a supine position for sleeping in a cot or bassinet and the potential risk associated with bed-sharing. Newborns should always be transported via newborn cot and not carried outside of the hospital room in the parent’s arms. Educating parents using a nonjudgemental approach may increase the likelihood that a parent will report a newborn fall (Ainsworth et al., 2016).

Immunizations. In some provinces the hepatitis B vaccine is given at birth, whereas in others it is given before the child is a preteen. If not routinely given at birth, hepatitis B vaccination is recommended for newborns at highest risk of contracting hepatitis B. This includes newborns born to a parent with hepatitis B or whose hepatitis B status is unknown or if another family member who lives in the home has hepatitis B. If the newborn is born to an infected mother or to a mother who is a chronic carrier, hepatitis B vaccine and hepatitis B immune globulin (HBIG) should be given within 12 hours of birth (see Medication Guides). The Public Health Agency of Canada website has the vaccination schedule for different provinces (see Additional Resources at the end of the chapter).

MEDICATION GUIDE Hepatitis B Vaccine (Recombivax HB, Engerix-B)∗ Action Hepatitis B vaccine induces protective anti–hepatitis B antibodies in 95 to 99% of healthy newborns who receive the recommended three doses. The duration of protection of the vaccine is unknown. Indication Hepatitis B vaccine provides immunization against infection caused by all known subtypes of hepatitis B virus. Newborn Dosage The usual dosage is Recombivax HB 5 mcg/0.5 mL or Engerix-B 10 mcg/0.5 mL at birth, 1 month, and 6 months. (See also Immunizations, Chapter 35.) Adverse Reactions Common adverse reactions are rash, fever, erythema, swelling, and pain at injection site. Nursing Considerations • Parental consent must be obtained before administration. • Follow proper procedure for administration of intramuscular (IM) injection (see Figure 26.4). If the newborn also needs hepatitis B immune globulin (HBIG), use separate sites for the two injections. • For newborns born to hepatitis B surface antigen (HBsAg)–positive mothers: administer HepB vaccine and HBIG within 12 hours after birth. • Document immunization administration on a vaccination card for parent(s) to have a record. ∗Note: The combination vaccines containing hepatitis B are not recommended for the birth (first) dose.

MEDICATION GUIDE Hepatitis B Immune Globulin Action Hepatitis B immunoglobulin (HBIG) provides a high titre of antibody to hepatitis B surface antigen (HBsAg). Indication The HBIG vaccine provides prophylaxis against infection in newborns born to HBsAg-positive mothers. Newborn Dosage Administer one 0.5-mL dose intramuscularly within 12 hours of birth. Adverse Reactions Hypersensitivity may occur. Nursing Considerations • Administer within 12 hours of birth. • Follow proper procedure for administration of intramuscular injection. • The HBIG vaccine may be given at the same time as hepatitis B vaccine, but at a different site. • Document immunization administration on a vaccination card for parent(s) to have a record.

Circumcision. Circumcision is the removal of all or part of the foreskin (prepuce) of the penis. Usually it is performed during the first week of life but is sometimes done at a later time for preterm or ill newborns or for religious or cultural reasons. It is often performed in the community after discharge in physician offices or clinics. The most recent reported rate of newborn male circumcision (NMC) in Canada was in 2007 and was 32%; the rates are highest in Alberta (44%) and Ontario (43%) and below 10% in Northwest Territories and Nova Scotia (Public Health Agency of Canada [PHAC], 2009; Sorokan et al., 2015/2018). Circumcision is considered an elective procedure; all provincial health insurance plans have removed nontherapeutic NMC from the schedule of procedures covered under provincial health care plans. This factor, and possibly a wider movement to holistic health, has led to a decline in the rate of NMC in Canada. The CPS policy statement regarding NMC states that NMC may have some health benefits, including prevention of urinary tract infection in male newborns younger than 1 year, reduced risk for penile cancer, and reduced risk for heterosexual acquisition of sexually transmitted infections (STIs), particularly HIV (Sorokan et al., 2015/ 2018). Despite the scientific evidence of potential medical benefits of circumcision for some boys in high-risk populations, the CPS has stated that the data are not sufficient to recommend routine circumcision. The WHO (2016) recognizes male circumcision as an important intervention in reducing the risk for heterosexually acquired HIV in men. Circumcision is a matter of personal parental choice. Parents usually decide to have their newborn circumcised on the basis of one or more of the following factors: religious conviction, tradition, culture, social norms, or perceived hygiene benefits although this is not true as hygiene with an uncircumcised penis is not a concern. Parents need to make an informed choice regarding newborn circumcision based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families can help parents make an informed choice about newborn circumcision by providing factual, unbiased, evidence-informed information that includes a discussion about the benefits and risks of the procedure (see Community Focus box: Newborn Circumcision). For parents who

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decide not to have their newborn son circumcised they need to be taught to clean the penis with soap and water and to not retract the foreskin until it is easily done, often not until the child is 3 or 4 years old and sometimes not until the child is an adolescent.

COMMUNITY FOCUS Newborn Circumcision Prepare a poster presentation to provide parents information on newborn circumcision. Because circumcision is considered an optional surgical procedure, it may not be performed until after the newborn is discharged home. Include in your display the advantages and disadvantages of circumcision, as well as the care of the uncircumcised penis in newborns and young children.

Procedure. Circumcision involves removal of the prepuce (foreskin) of the glans. The procedure is not usually done immediately after birth because of the danger of cold stress and decreased clotting factors, but it may be performed in some hospitals before the newborn’s discharge. The circumcision of a Jewish boy is performed on the eighth day after birth and is often done at home in a ceremony called a bris. The timing is logical from a physiological standpoint because clotting factors drop somewhat immediately after birth and do not return to prebirth levels until the end of the first week. Feedings may be withheld up to 2 to 3 hours before the circumcision to prevent vomiting and aspiration, although some practitioners allow newborns to breastfeed until the time they are taken for the procedure. To prepare the newborn for the circumcision, he is positioned on a plastic restraint form (Figure 26.18) and the penis is cleansed with soap and water or other prep solution such as povidone-iodine. The newborn is draped to provide warmth and a sterile field, and the sterile equipment is readied for use. Newborn circumcision is usually performed using the Gomco (Yellen) or Mogen clamp or the PlastiBell device. The technique is usually based on health care provider training and preference. The procedure takes only a few minutes to perform. Use of the Gomco or Mogen clamp involves surgical removal of the foreskin. The clamp technique minimizes blood loss (Figure 26.19). With the PlastiBell technique, the plastic bell is first fitted over the glans, a suture is tied around the rim of the bell, and excess foreskin is cut away. The plastic rim remains in place for about a week; it falls off after healing has taken place, usually within 5 to 7 days (Figure 26.20). Procedural pain management. Circumcision is painful. The pain is manifested by both physiological and behavioural changes in the newborn (see discussion on newborn pain that follows). Three types of anaesthetics are used in newborns undergoing circumcision: ring block, dorsal penile nerve block (DPNB), and topical anaesthetic such as eutectic mixture of lidocaine and prilocaine (EMLA) (prilocaine-

Fig. 26.19 Circumcision with Gomco (Yellen) clamp. After hemostasis occurs, the foreskin (over the metal dome) is cut away. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)

lidocaine). Nonpharmacological methods such as concentrated oral sucrose, non-nutritive sucking, and swaddling may be used to enhance pain management. Pain during circumcision is most effectively managed using a combination of pharmacological and nonpharmacological measures (Bellieni et al., 2013). A DPNB consists of subcutaneous injections of buffered lidocaine at the 2 o’clock and 10 o’clock positions on the dorsum of the penis.

A

B

Fig. 26.18 Proper positioning of newborn in Circumstraint. (Courtesy Paul Vincent Kuntz, Texas Children’s Hospital.)

Fig. 26.20 The PlastiBell technique. A, The PlastiBell is placed over the glans inside the prepuce. B, A string is then tied around the prepuce and positioned in the groove of the bell. The excess foreskin is trimmed, and the handle is broken off the bell. The foreskin remnant and bell are expected to slough in 1 to 2 weeks. (From Holcomb, G. W., Murphy, J. P., & Ostlie D. J. [2014]. Ashcraft’s pediatric surgery [6th ed.]. Elsevier.)

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Alternatively, buffered lidocaine may be administered using a ring block with injections around the base of the penis. To ensure adequate anaesthesia, circumcision should not be performed for at least 5 to 8 minutes after these injections (Gardner et al., 2021). A topical anaesthetic cream (EMLA) can be applied to the penis at least 1 hour before the circumcision. The area where the prepuce attaches to the glans is well coated with 1 g of the cream and then covered with a transparent occlusive dressing or finger cot. Just before the procedure, the cream is removed. Blanching or redness of the skin can occur. After the circumcision, the newborn should be comforted until he is quieted. If the parents were not present during the procedure, the newborn should be returned to them. The newborn should be positioned to breastfeed, or placed skin-to-skin with the parent or other care provider. Afterward, the newborn may be fussy for several hours and may have disturbed sleep–wake states and disorganized feeding behaviours. Some newborns will go into a deep sleep after circumcision until they are awakened for feeding. Oral acetaminophen may be administered before the procedure and every 4 hours thereafter (as ordered by the health care provider) for a maximum of five doses in 24 hours or a maximum of 75 mg/kg/day. Care of the newly circumcised newborn. Postcircumcision protocols vary. In many settings, the circumcision site is assessed for bleeding every 15 to 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse needs to monitor the newborn’s urinary output, noting the time and amount of the first voiding after the circumcision. If bleeding occurs from the circumcision site, the nurse applies gentle pressure with a folded sterile gauze pad. A hemostatic agent such as Gelfoam® powder or sponge can be applied to help control bleeding. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the physician and prepares the necessary equipment (i.e., circumcision tray and suture material) while another nurse maintains intermittent pressure until the health care provider arrives. Nurses provide education for parents that is related to care of the circumcised newborn, which includes observing for complications such as bleeding or infection (see Patient Teaching box: Care of the Circumcised Newborn).

PATIENT TEACHING Care of the Circumcised Newborn Wash hands before touching the newly circumcised penis. Check for Bleeding • Check circumcision for bleeding with each diaper change. • If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify the primary health care provider. Observe for Urination • Check to see that the newborn urinates after being circumcised. • The newborn should have wet diapers appropriate for age. Keep Area Clean • Change the diaper and inspect circumcision at least every 4 hours. • Wash the penis gently with warm water to remove urine and feces. Apply petrolatum liberally to the glans with each diaper change (omit petrolatum if PlastiBell was used). Do not use newborn wipes because they can contain alcohol. • Do not wash the penis with soap until the circumcision is healed (5 to 6 days). • Use a sponge bath only until circumcision heals. • Apply the diaper loosely over the penis to prevent pressure on the circumcised area.

Check for Infection • Glans penis is dark red after circumcision, then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. Do not attempt to remove it. • Redness, swelling, or discharge indicates infection. Notify the primary health care provider if you think the circumcision area is infected. Provide Comfort • Circumcision is painful. Handle the area gently. • Provide acetaminophen as required and ordered by the health care provider. • Provide comfort measures such as holding the newborn skin-to-skin, cuddling, rocking, and giving opportunities for non-nutritive sucking for a day or two.

Pain in the Newborn Newborn Responses to Pain. While pain in the newborn and pain in later life can be qualitatively different, research has substantiated that newborns do experience pain (Blackburn, 2018). This counters previous thinking that the immaturity of the nervous system prevented or blunted pain sensation and that newborns were incapable of remembering painful experiences. Pain has physiological and psychological components. It’s psychological component and the diffuse total body response to pain exhibited by the newborn led many health care providers in the past to believe that newborns, especially preterm newborns, do not experience pain. The central nervous system is well developed, however, as early as 24 weeks of gestation. The peripheral and spinal structures that transmit pain information are present and functional between the first and second trimesters. The pituitary–adrenal axis is also well developed at this time, and a fight-or-flight reaction is observed in response to the catecholamines released in response to stress. The physiological response to pain in newborns can be lifethreatening. Pain response can decrease tidal volume, increase demands on the cardiovascular system, increase metabolism, and cause neuroendocrine imbalance. The hormonal–metabolic response to pain in a term newborn has greater magnitude and shorter duration than that in adults. The newborn’s sympathetic response to pain is less mature and therefore less predictable than an adult’s. Pain response is influenced by a variety of factors, such as characteristics of the painful stimulus, gestational age, biological factors, and behavioural state. The source, location, and timing of the pain affect the response; newborns respond differently to acute pain than to prolonged or recurrent pain. Pain perception and stress can be greater in preterm newborns, although they often display less vigorous pain responses than term newborns (Maxwell et al., 2013). There can be genetic differences in pain responses related to the amount and type of neurotransmitters and receptors available to mediate pain. The behavioural state of the newborn also affects the pain response. Those who are more awake tend to have more robust pain responses than those in sleep states (Gardner et al., 2021). The most common behavioural sign of pain is a vocalization or crying, ranging from a whimper to a distinctive high-pitched, shrill cry. Facial expressions include grimacing, eye squeeze, brow contraction, deepened nasolabial furrows, a taut and quivering tongue, and an open mouth (Figure 26.21) (Harrison et al., 2015). The newborn will flex and adduct the upper body and lower limbs in an attempt to withdraw from the painful stimulus. The preterm newborn has a lower-than-normal threshold for initiation of this flex response (Blackburn, 2018). Pain can result in significant changes in heart rate, BP (increased or decreased), intracranial pressure, vagal tone, respiratory rate, and oxygen saturation. Newborns respond to painful stimuli with release of

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Pain should be assessed and documented on a regular basis for all newborns, and a pain management plan should be developed if required. Assessing pain in a newborn can be difficult given the nonverbal communication signs that need to be taken into account. Because of this, a minimum of 30 seconds of visual observation by the nurse is recommended to assess newborn pain. Although many validated scoring systems have been developed to help in this assessment, no universal tool has yet to be adopted (Witt et al., 2016). Validated pain scales developed for newborn assessment are summarized in Table 26.4. See Evolve website for Nursing Skills: Pain Assessment and Management in the Full-Term Newborn. Further discussion of pediatric pain management is in Chapter 34.

TABLE 26.4

Validated Pain Scales for Assessing Newborn Procedural Pain

Fig. 26.21 Signs of discomfort: note eye squeeze, brow bulge, nasolabial furrow, and wide-spread mouth. (Courtesy Kathryn Alden.)

epinephrine, norepinephrine, glucagon, corticosterone, cortisol, 11deoxycorticosterone, lactate, pyruvate, and glucose (Blackburn, 2018) (Box 26.6).

Assessment of Pain in the Newborn. In assessing pain, the nurse needs to consider the health of the newborn, the type and duration of the painful stimulus, environmental factors, and the newborn’s state of alertness. For example, severely compromised newborns may be unable to generate a pain response even though they are, in fact, experiencing pain.

BOX 26.6

Pain Scale

Assessment Parameters

NIPS (Neonatal Infant Pain Score)

Facial expression, crying, breathing, arm and leg movements

PIPP (Premature Infant Pain Profile)

Gestational age, behavioural state, heart rate, oxygen saturation, facial expression

NFCS (Neonatal Facial Coding System)

Presence of facial expressions associated with irritability: brow bulge, eye squeeze, nasolabial furrow, open lips

DAN (Douleur Aiguë du Nouveau-N
e) EDIN (
Echelle Douleur Inconfort Nouveau-N
e)

Facial responses, limb movements, vocal expression of pain Facial expression, extremity tone, sleeping pattern, comfort level, interaction level

Manifestations of Acute Pain in the Newborn

Physiological Responses Vital signs—Observe for variations. • Increased heart rate • Increased blood pressure • Rapid, shallow respirations Oxygenation • Decreased transcutaneous oxygen saturation (tcPo2) • Decreased arterial oxygen saturation (SaO2) Skin—Observe colour and character. • Pallor or flushing • Diaphoresis • Palmar sweating Laboratory evidence of metabolic or endocrine changes • Hyperglycemia • Lowered pH • Elevated corticosteroids Other observations: • Increased muscle tone • Dilated pupils • Decreased vagal nerve tone • Increased intracranial pressure Behavioural Responses Vocalizations—Observe quality, timing, and duration.

• Crying • Whimpering • Groaning Facial expression—Observe characteristics, timing, orientation of eyes and mouth. • Grimaces • Brow furrowed • Chin quivering • Eyes tightly closed • Mouth open and squarish Body movements and posture—Observe type, quality, and amount of movement or lack of movement; relationship to other factors. • Limb withdrawal • Thrashing • Rigidity • Flaccidity • Fist clenching Changes in state—Observe sleep, appetite, activity level. • Changes in sleep–wake cycles • Changes in feeding behaviour • Changes in activity level • Fussiness, irritability • Listlessness

Modified from Blackburn, S. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier; Gardner, S. L., Enzman-Hines, M., & Agarwal, R. (2021). Pain and pain relief. In S. L. Gardner, B. S. Carter, M. Enzman-Hines M, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier.

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Healthy term newborns are exposed to fewer sources of pain than preterm newborns in an NICU where painful procedures are inherent to care management. Even in low-risk newborns, nurses need to assess for signs of discomfort as part of routine assessments, especially during and after routine procedures such as heel sticks, injections, and circumcision.

Management of Pain in the Newborn. The goals of the management of pain in a newborn are to (1) minimize the intensity, duration, and physiological cost of the pain and (2) maximize the newborn’s ability to cope with and recover from the pain. Nonpharmacological and pharmacological strategies are used. It is important to note that despite research evidence, policies, and standards of practice focused on assessing and managing pain in newborns, acute newborn pain remains undermanaged and, in some cases, unmanaged (Gardner et al., 2021). Nonpharmacological management. A variety of nonpharmacological pain management techniques are used with newborns. Nurses and parents may combine two or more techniques as they seek to promote newborn comfort and reduce pain. Non-nutritive sucking on a pacifier is a common comfort measure used with newborns. Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking is safe and effective in reducing newborn pain during single events (Bueno et al., 2013; Kassab et al., 2012; Stevens et al., 2016). Oral sucrose and non-nutritive sucking given a few minutes before a painful procedure may help reduce the discomfort. Skin-to-skin contact with a parent, also known as kangaroo care, during a painful procedure can help reduce pain (Harrison et al., 2015). Breastfeeding or breast milk helps reduce pain during heel

lancing and blood collection (Cong et al., 2013; Reece-Stremtan et al., 2016). Many health care providers have integrated breastfeeding into their routine when taking blood work from the newborn as an effective and readily available method of decreasing pain. One of the most common measures is swaddling or snugly wrapping the newborn with a blanket. Swaddling limits the newborn’s boundaries, aids in self-regulation, and reduces physiological and behavioural stress resulting from acute pain (Pillai Riddell et al., 2015). Swaddling is popular among nurses and parents as a comfort measure for calming a fussy baby and for promoting sleep. However, it is important that it is done properly. Safe swaddling involves wrapping the baby snugly in a lightweight blanket with the arms extended, legs flexed, and hips in neutral position without rotation (CPS, 2018). In the early newborn period, nurses often swaddle newborns with the arms flexed (Figure 26.22). Other nonpharmacological measures for reducing pain in newborns include touch, massage, rocking, holding, and environmental modification (e.g., low noise and lighting). Combining these nonpharmacological methods results in more effective pain reduction. Distraction with visual, oral, auditory, or tactile stimulation can be helpful in managing pain in term newborns or older infants (see Evidence-Informed Practice box: Nonpharmacological Pain Relief for Newborns). Sensorial saturation uses multiple senses to diminish minor pain. This technique involves speaking softly to the newborn, massaging the face, and providing oral sucrose solution on the tongue (Bellieni et al., 2012). Pharmacological management. Pharmacological agents are used to alleviate pain in newborns that is associated with procedures. Local anaesthesia is routinely used during procedures such as circumcision and chest tube insertion. Topical anaesthesia is used for circumcision, lumbar puncture, venipuncture, and heel sticks. Nonopioid analgesia

EVIDENCE-INFORMED PRACTICE Nonpharmacological Pain Relief for Newborns Ask the Question For term newborns, what complementary or alternative pain relief is effective for minor painful procedures, such as heel stick? Search for the Evidence Search Strategies English-language research-based publications on newborn, pain, breastfeeding, heel stick, and sucrose were included. Databases Used Cochrane Collaborative Database, National Guidelines Clearinghouse (AHRQ), CINAHL, and PubMed Critically Analyze the Evidence Pain scores in newborns are used to assess physical and behavioural changes that help determine pain levels. Physical measures typically include heart rate, respiratory rate, and peripheral oxygen saturation. Other physiological measures include gas exchange across skin, skin sensitivity measures, and electroencephalogram (EEG). Ways to measure behavioural changes include various scales utilizing breathing patterns, states of arousal, facial tension, leg movement, activity, cry, and consolability. • Sucrose is effective at decreasing pain response for single painful procedures, especially when paired with sucking (Stevens et al., 2016). • Skin-to-skin contact during painful procedures such as heel stick decreases behavioural pain scores but not physiological measures and is safe. Skinto-skin with breastfeeding is the first choice for single painful procedures, for the multisensorial and synergistic comfort it brings. It also provides the parents with a caretaking role (Johnston et al., 2014). • Breastfeeding or breastmilk is an effective method of pain relief during heel lancing (Reece-Stremtan et al., 2016).

• For preterm newborns until 3 years of age, pain reactivity and immediate pain regulation were significantly improved with non-nutritive sucking, swaddling, and holding/rocking (Pillai Riddel et al., 2015). • A randomized control study of 102 newborns found that the smells of lavender and breast milk decreased both physiological and behavioural responses to pain during heel stick more than control (Akcan & Polat, 2016). • Newborns in a Canadian neonatal intensive care unit whose mothers were present during a painful procedure were more likely to receive effective pain management strategies than those newborns whose mothers were not present, indicating that parents may have a positive influence on pain management in their children (Johnston et al., 2011). Apply the Evidence: Nursing Implications • For newborns who experienced a painful stimulus, subsequent painful procedures caused increased response (Gokulu et al., 2016). This has implications for decreasing the initial pain response as much as possible, especially in the neonatal critical care setting where multiple painful stimuli may be necessary. • Nonpharmacological pain relief methods for newborns utilize the gate-control theory to distract the newborn’s attention by using strong single or multisensorial stimulation. Warmth, touch, sensory attention, swaddling, rocking, breastfeeding, sucking a sweet solution, and smells decrease pain scores. • Parents who are taught these techniques become active participants in their newborn’s procedural care. However, they need clear education that using sucrose is not an appropriate long-term strategy for use at home. • Comfort measures may work best when initiated a few minutes prior to the procedure, to allow the newborn time to relax and reorganize. • Procedures other than single heel stick or needlestick should be evaluated for pharmacological analgesia.

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References Akcan, E., & Polat, S. (2016). Comparative effect of the smells of amniotic fluid, breast milk, and lavender on newborns’ pain during heel lance. Breastfeeding Medicine, 11(6), 309– 314. Gokulu, G., Bigen, H., Ozdemir, H., et al. (2016). Comparative heel stick study showed that newborn infants who had undergone repeated painful procedures showed increased short-term pain responses. Acta Paediatrica, 105(11), e520–e525. Johnston, C., Barrington, K. J., Taddio, A., et al. (2011). Pain in Canadian NICUs: Have we improved over the past 12 years? The Clinical Journal of Pain, 27(3), 225–232. Johnston, C., Campbell-Yeo, M., Fernandes, A., et al. (2014). Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews, 2014(1), CD008435.

Pillai Riddell, R. R., Racine, N. M., Gennis, H. G., et al. (2015). Non-pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews, 2015(12), CD006275. Reece-Stremtam, S., Gray, L., & Academy of Breastfeeding Medicine. (2016). ABM Clinical Protocol #23: Nonpharmacological management of procedure-related pain in the breastfeeding infant, revised 2016. Breastfeeding Medicine, 11(9), 1–5. Stevens, B., Yamada, J., Ohlsson, A., et al. (2016). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews, (Issue 7). https://doi.org/10.1002/14651858.CD001069.pub5.

Pat Mahaffee Gingrich

Promoting Parent–Newborn Interaction

Fig. 26.22 Newborn is swaddled with arms flexed.

(oral liquid acetaminophen) is effective for mild to moderate pain from inflammatory conditions. Morphine and fentanyl are the most widely used opioid analgesics for pharmacological management of newborns’ pain. Continuous or bolus IV infusion of opioids provides effective and safe pain control. Other methods for managing newborns’ pain are epidural infusion, local and regional nerve blocks, and intradermal or topical anaesthetics (Gardner et al., 2021). See Chapter 34 for further discussion of pain management.

Nurses play an important role in promoting early social interaction between parents and their newborn. From birth throughout the hospital stay, nurses assess attachment behaviours (see Chapter 23) and provide support and education to parents as they become acquainted with the newborn. Nurses working in outpatient settings or home care provide follow-up assessments and care related to parent–child interactions. By teaching parents to recognize newborn cues and respond appropriately, the nurse facilitates development of the parents’ confidence in meeting the needs of their newborn (see Family-Centred Care box: Helping Parents Recognize, Interpret, and Respond to Newborn Behaviours). The sensitivity of the parent to social responses of the newborn is basic to development of a mutually satisfying parent–child relationship (van der Voort et al., 2014). Sensitivity increases over time as parents become more aware of their newborn’s social capabilities. In supporting parents, nurses need to consider cultural beliefs and traditions that influence parenting behaviours and newborn care practices (see Cultural Awareness box: Cultural Beliefs and Practices Regarding Newborns). The activities of daily care during the newborn period are the best times for newborn and family interactions. While caring for their newborn, the parent (or other family member) can talk to the newborn, play baby games, caress and cuddle the baby, and perhaps use massage.

FAMILY-CENTRED CARE Helping Parents Recognize, Interpret, and Respond to Newborn Behaviours Learning to read a baby’s body language can enable parents to be more effective in preventing and solving issues around the newborn’s sleeping, eating, and crying and enhances parent–newborn interaction. Nurses can teach new parents the following: 1. Identify three newborn “zones,” traditionally referred to as newborn states. “Resting zone”: also known as sleep states • Still/deep sleep: Newborn is completely still. Breathing is regular. No spontaneous activity. No movement of eyes, and eyelids stay shut. No vocalizing. Muscles are totally relaxed. • Active/light sleep: Newborn may wiggle or vocalize. Eyes may flash open. Newborn may make sucking movements—but still be asleep. “Ready zone”: alert state • Newborn’s eyes are bright. Newborn can focus on an object or person. Newborn reacts to stimulation. Motor activity is minimal. “Rebooting zone”: fussy/crying state • Newborn’s motor activity increases and is jerky. Newborn is less responsive and moves from fussing to crying. 2. Identify signs of stress. When babies are stressed or overstimulated they show changes in their body and behaviour. These changes are called SOSs (Signs of Over-Stimulation), traditionally referred to as a baby’s stress response.

• Body SOSs: changes in colour (becoming more red or pale); changes in breathing (becoming more irregular or choppy); changes in movement (becoming jerky or having more tremors) • Behavioural SOSs: “spacing out” (going from an alert state to a drowsy state); “switching off” (gaze aversion, or looking away from parent); “shutting down” (going from drowsy to a sleep state) When the baby shows an SOS, parents should decrease stimulation and increase support by doing one or several of the following: • Quiet one’s voice • Glance away from the baby • Encourage baby to suck on a finger or mother’s breast • Place the baby skin-to-skin 3. Help baby sleep well. Distinguish active/light sleep from still/deep sleep. Parent’s care: • Prepare the baby to sleep: feed in a quiet, dark room at night and an active, light environment during the day. • Get the baby to sleep: put the baby down for sleep while they are still awake. • Help the baby stay asleep: don’t pick them up during active/light sleep.

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• After breastfeeding is well established, notice when the sleeping baby moves into active/light sleep. Wait and see if the baby will transition from active/light sleep back to deep/still sleep—and sleep a bit longer. 4. Help the baby eat well. • Recognize early signs of hunger during the first few weeks: wiggling, making sucking movements, bringing hand to mouth. • Notice if a fragile baby “spaces out” or “shuts down” when trying to eat. Bring this baby skin-to-skin and decrease stimulation before resuming feeding. • If a parent needs to wake a fragile or small baby to eat, do so from active/ light sleep, not from still/deep sleep. 5. Help a crying baby: Consider what “TO DO.” • T: Talk quietly to the baby in sing-song voice.

• O: Observe to see if the baby takes self-calming actions: brings hand to their mouth, making sucking movements, or moves into the fencing reflex position. • DO: Bring the baby’s hands to their chest; encourage sucking; make gentle “shooshing” sounds; and/or bring baby skin to skin. 6. Play with the baby so they can learn and grow. • Demonstrate baby’s ability to look at a parent’s face, watch a toy move, or turn to parent’s voice. • Watch for an SOS during play. If an SOS occurs, decrease stimulation and increase support as described earlier in box. • Observe baby’s developing process of interaction: first, getting quiet and still; second, turning toward parent; third, turning toward and looking at parent. • Reinforce benefits of sensitive, face-to-face parent interaction with baby.

Data from Tedder, J. L. (2008). Give them the HUG: An innovative approach to helping parents understand the language of their newborn. Journal of Perinatal Education, 17(2), 14–20; Tedder, J. L. (n.d.) H.U.G.: Help-understanding-guidance for young families. http://www.hugyourbaby.org.

Feeding is an optimal time for interaction because the newborn is usually awake and alert, at least at the beginning of the feeding. Too much stimulation should be avoided after feeding and before a sleep period. In Figure 26.23 a great-grandmother and newborn are shown engaging in arousal, imitation of facial expression, and smiling. Older children’s contact with a newborn is encouraged and should be supervised according to the developmental level of the child (Figure 26.24).

Fig. 26.24 Mother supervising contact of older sibling with newborn. (iStock.com/lostinbids)

Discharge Planning and Teaching

Fig. 26.23 Great-grandmother and newborn enjoying social interaction. (Courtesy Freida Belding.)

CULTURAL AWARENESS Cultural Beliefs and Practices Regarding Newborns Nurses working with childbearing families from cultures and ethnic groups other than their own must be aware of cultural beliefs and practices that are important to individual families. People with a strong sense of heritage may hold traditional health beliefs despite adopting other Canadian lifestyle practices. These health beliefs may involve practices regarding the newborn. It is important for nurses to inquire with families if there are any cultural beliefs or practices that would affect their care while in hospital.

Providing newborn care can cause much anxiety for the new parent. Support from nursing staff can be an important factor in determining whether new parents seek and accept help in the future. The nurse should try to avoid covering all the content at one time because the parents can be overwhelmed by too much information and become anxious. However, because new parents go home quickly from the hospital, it can be difficult for nurses to teach all the content that is necessary. It is important to start teaching on admission to the hospital. Community health nurses may visit families after birth and provide teaching, but this is not a standard practice across the country. To set priorities for teaching, the nurse should follow parental cues. Learning needs should be identified before beginning to teach. Normal growth and development and the changing needs of the infant (e.g., for personal interaction and stimulation, growth milestones, exercise, injury prevention, and social contacts), as well as the topics that follow, should be included during discharge planning with parents. Safety issues should also be addressed (see FamilyCentred Care box: Infant Safety).

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FAMILY-CENTRED CARE Infant Safety • Never leave your baby alone on a bed, couch, or table. Even newborns can move enough to eventually reach the edge and fall off. • Never put your baby on a cushion, pillow, beanbag, or waterbed to sleep. Your baby may suffocate. Also, do not keep pillows, large floppy toys, or loose plastic sheeting in the crib. • Always lay the baby flat in bed on their back for sleep. Do not place your baby on the abdomen or side for sleep. • When using an infant carrier, place the carrier on the floor in a place where you can see the baby. It should never be on a high place, such as a table, couch, or store counter. • Infant carriers do not keep your baby safe in a car. Always place your baby in an approved car safety seat when travelling in a motor vehicle (car, truck, bus, or van). Car safety seats are recommended for travel on trains and airplanes as well. Use the car safety seat for every ride. • Your baby should be in a rear-facing infant car safety seat from birth until at minimum 1 year or until exceeding the car seat’s limits for height and weight. Do not be in a rush to turn the car safety seat to the forward-facing position. The car safety seat should be in the back seat of the car (Figure 26.25). This precaution is especially important in vehicles with front passenger air bags because when air bags inflate, they can be fatal for infants and toddlers. See Chapter 35, Motor Vehicle Injuries for further discussion on car seat safety. • When bathing your baby, never leave them alone. Infants can drown in 2 to 5 cm of water. • Be sure that your hot water heater is set at 49°C (120°F) or less. Always check bath-water temperature with your elbow before putting your baby in the bath. • Do not tie anything around your baby’s neck. Pacifiers, for example, tied around the neck with a ribbon or string can strangle your baby. • Check your baby’s crib for safety. Slats should be no more than 5.7 cm apart. The space between the mattress and sides should be less than two fingerwidths. The bedposts should have no decorative knobs. • There should be no bumper pads, pillows, blankets, stuffed toys, or other items in the baby’s crib because of the risk for suffocation. • Keep the crib or playpen away from window blind and drapery cords; your baby could strangle on them. • Keep the crib and playpen well away from radiators, heat vents, and portable heaters. Linens in the crib or playpen can catch fire if they come into contact with these heat sources. • Install smoke detectors on every floor of your home. Check them once a month to be sure they are working properly. Change batteries twice a year. • Avoid exposing your baby to cigarette or cigar smoke in your home or other places. Passive exposure to tobacco smoke greatly increases the likelihood that your baby will have respiratory symptoms and illnesses. • Be gentle with your baby. Do not pick your baby up or swing your baby by the arms or throw them up in the air. Never shake the baby.

Community Follow-up. In some jurisdictions in Canada, community health nurses will provide follow-up after birth through phone calls or home visits. During follow-up visits particular attention should be paid to the newborn regarding feeding habits, weight changes, and jaundice assessments. Parental bonding with the newborn should be assessed as well as family adaptation to their new family member. Resources and community programs should be discussed with parents, as needed, as well as reinforcement of vaccination guidelines. Warning signs of postpartum depression in either parent warrant further investigation.

Fig. 26.25 Rear-facing newborn seat in rear seat of car. Newborn is placed in seat when going home from the hospital. (Courtesy Brian and Mayannyn Sallee.)

Temperature. Parents need to understand practical information related to thermoregulation. The nurse should discuss the following topics in parent teaching: • The causes of elevation in body temperature (e.g., overwrapping, cold stress with resultant vasoconstriction, or response to infection) and the body’s response to extremes in environmental temperature • Ways to promote normal body temperature, such as dressing the newborn appropriately for the environmental air temperature and protecting the newborn from exposure to direct sunlight, and how to assess whether the newborn is hot or cold by feeling the back of the neck • Technique for taking the newborn’s axillary temperature, and normal values for axillary temperature • Signs to be reported to the primary health care provider, such as high or low temperatures with accompanying fussiness, lethargy, irritability, poor feeding, and excessive crying Respirations. The nurse can provide information to parents regarding the normal characteristics of newborn respirations, emergency procedures, and measures to protect the newborn. It is helpful to discuss signs of the common cold and to offer suggestions related to care of the newborn who experiences this type of illness. The following points are included in teaching about respirations: • Normal variations in the rate and rhythm • Reflexes such as sneezing to clear the airway (this is normal and does not mean the newborn has a cold) • Steps to take if the newborn appears to be choking • The need to protect the newborn from the following: • Exposure to people with upper respiratory tract infections and respiratory syncytial virus • Exposure to second-hand and third-hand tobacco smoke • Suffocation from loose bedding, water beds, and beanbag chairs; drowning (in bath water); entrapment under excessive bedding or in soft bedding; anything tied around the newborn’s neck; blind cords near cribs; poorly constructed playpens, bassinets, or cribs • Avoid the use of baby powder, which is a commonly aspirated substance. Whenever a powder is used, it should be placed in the caregiver’s hand and then applied to the skin. It should be kept away from the newborn’s face. • Notify the health care provider if the newborn develops symptoms such as difficulty breathing or swallowing, nasal congestion, excess

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drainage of mucus, coughing, sneezing, decreased interest in feeding, or fever. If the newborn has a respiratory illness such as the “common cold,” the following suggestions can be helpful: • Feed smaller amounts more often to prevent overtiring the newborn. • Hold the baby in an upright position to feed. • For sleeping, raise the baby’s head and chest by raising the mattress 30 degrees. (Do not use a pillow.) • Avoid drafts; do not overdress the baby. • Use only medications prescribed by a pediatric health care provider. Do not use over-the-counter medications without health care provider approval. • Use nasal saline drops in each nostril and suction well with a bulb syringe to decrease and relieve secretions.

Feeding Patterns. Nurses need to teach parents about newborn feeding and provide assistance based on whether they have chosen breastfeeding or formula feeding. The newborn should be put to the breast ideally within the first hour after birth. Newborns should be allowed to feed when they awaken and demonstrate typical hunger cues, regardless of the amount of time since the previous feeding. This concept is commonly referred to as “cue-based” or “on-demand” feeding. Breastfed babies feed more often than formula-fed babies because breast milk is digested faster than formulas made from cow’s milk and the stomach empties sooner as a result. Exclusively formula-fed newborns will typically awaken and cue to feed every 3 to 4 hours. Breastfed newborns feed an average of 8 to 12 times per day. Water and dextrose water supplements are not recommended in the newborn period as these have the tendency to decrease breastfeeding. For a thorough discussion of newborn feeding, see Chapter 27. Elimination. Awareness of the normal elimination patterns of newborns helps parents recognize issues related to voiding or stooling. The following points are included in teaching about elimination: • Colour of normal urine and number of voidings to expect each day; approximately one wet diaper for each day of life until the fifth to seventh day; then frequent, clear, pale yellow voiding (see Table 27.3 and Figure 27.9) • Changes to be expected in the colour of the stool (i.e., meconium to transitional to soft yellow or golden yellow) and the number of bowel movements, plus the odour of stools for breastfed or formula-fed newborns (see Box 25.1; Figure 25.6 and Table 27.3) • Formula-fed newborns may have as few as one stool every other day after the first few weeks of life; stools are pasty to semiformed. • Breastfed newborns should have at least five stools every 24 hours from 7 to 28 days of age (PHAC, 2018a). The stools are looser and resemble mustard mixed with cottage cheese. Prevention of Sudden Infant Death Syndrome (SIDS). By definition, sudden infant death syndrome (SIDS) is the death of an infant under the age of 1 year of age which is sudden, unexpected, and without a clear cause. SIDS usually happens during sleep or napping and is the most common cause of death in infants between the ages of 1 month and 1 year (First Nations Health Authority [FHNA], 2017). Current evidence explains SIDS as a disorder arising from a combination of environmental, genetic, and metabolic factors

(PHAC, 2018b). The rate of SIDS in Canada is 11.3 per 100 000 live births; in 2013, 43 infants died as a result of SIDS (Canadian Institute of Child Health, 2019). The rate is higher among Indigenous infants and infants from socioeconomically disadvantaged families (PHAC, 2018b). The PHAC guideline recommends placing the infant to sleep in the supine position to prevent SIDS. The prone position has been associated with an increased incidence of SIDS (see Clinical Reasoning Case Study). Other recommendations for preventing SIDS include ensuring a smoke-free environment (before and after birth), providing a safe crib environment (no toys or loose bedding), planning ahead when visiting to ensure a safe sleep place, room sharing for 6 months, avoiding instances of the infant being overheated, and no sleeping in waterbeds or on sofas (FNHA, 2017; PHAC, 2018b). Breastfeeding and pacifier use may also decrease the rate of SIDS (PHAC, 2018b). In addition, co-bedding practices may contribute to unintentional suffocation caused by entrapment or overlaying, often occurring when the infant is sharing a sleep surface with an adult or another child (PHAC, 2018b). ?

CLINICAL REASONING CASE STUDY

Safe Infant Sleep Practices The nurse is teaching new parents who live on reserve in Northern Saskatchewan about safe sleep practices for their healthy term newborn son. They ask about whether it is safe for the baby to sleep on a cradle board. The mother states they do not have a crib and thinks that this would be the safest place for the baby to sleep. What information should the nurse provide related to safety concerns for the newborn? 1. Evidence—Is there sufficient evidence to draw conclusions about the safety of the sleep environment in terms of preventing sudden infant death syndrome or infant injury? 2. Assumptions—What assumptions can be made about the following factors related to safe infant sleep? a. Infant positioning for sleep b. Safe alternatives for a sleep environment c. Risk for injury 3. What priorities for nursing care can be drawn at this time? 4. What other teaching should the nurse provide to the couple?

Anatomically, the newborn’s shape—a barrel chest and flat, curveless spine—makes it easy for the newborn to roll from the side to the prone position; thus, the side-lying position for sleep is not recommended. When the baby is awake, “tummy time” can be provided under parental supervision so that the infant may begin to develop appropriate muscle tone for eventual crawling; this tummy time is also effective in the prevention of a misshaped head (positional plagiocephaly). Newborns should be placed on their stomach several times per day for increasing lengths of time but always when they are awake and supervised by an adult (Cummings & CPS, 2011/2018). Care must also be taken to prevent the baby from rolling off flat, unguarded surfaces. When a newborn is on such a surface, the parent or nurse who must turn away from the baby even for a moment should always keep one hand placed securely on the newborn. The baby should always be held securely with their head supported because newborns are unable to maintain an erect head posture for more than a few moments. Figure 26.26 illustrates holding a newborn with adequate support.

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B

C

D

Fig. 26.26 Holding newborn securely with support for the head. A: Holding newborn while moving newborn from scale to bassinet. Baby is undressed to show posture. B: Holding baby upright in “burping” position. C: “Football” (under the arm) hold. D: Cradling hold. (A, Courtesy Kim Molloy, Knoxville, IA. B, C, and D, Courtesy Julie Perry Nelson, Loveland, CO.)

Rashes. Diaper rash. Most infants develop a diaper rash at some time. This dermatitis or skin inflammation appears as redness, scaling, blisters, or papules. Various factors contribute to diaper rash, including infrequent diaper changes, diarrhea, use of plastic pants to cover the diaper, or a change in the infant’s diet, such as when solid foods are added. Parents are instructed in measures to help prevent and treat diaper rash. Diapers should be checked often and changed as soon as the baby voids or stools. Plain water with mild soap is used to cleanse the diaper area; if baby wipes are used, they should be unscented and contain no alcohol. The baby’s skin should be allowed to dry completely before applying another diaper. See Evolve site for Nursing Skill: Changing a Diaper. When diaper rash occurs, it is helpful to use emollients, creams, or other protectants such as zinc oxide ointment to restore skin integrity while providing some protection from the irritants of urine and stool (Visscher et al., 2015).

Although diaper rash can be alarming to parents and annoying to babies, most cases resolve within a few days with simple home treatments. There are instances when diaper rash is more serious and requires medical treatment. The warm, moist atmosphere in the diaper area provides an optimal environment for Candida albicans growth; dermatitis appears in the perianal area, inguinal folds, and lower abdomen. The affected area is intensely erythematous with a sharply demarcated, scalloped edge, often with numerous satellite lesions that extend beyond the larger lesion. The usual source of infection is from handling by persons who do not practise adequate hand hygiene. It may also appear 2 to 3 days after an oral infection (thrush). Therapy consists of applications of an anticandidal ointment, such as clotrimazole or miconazole, with each diaper change. Sometimes the infant also is given an oral antifungal preparation such as nystatin or fluconazole to eliminate any gastrointestinal source of infection. Other rashes. A rash on the cheeks may result from the newborn’s scratching with long unclipped fingernails or from rubbing the face

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against the crib sheets, particularly if regurgitated stomach contents are not washed off promptly. The newborn’s skin begins a natural process of peeling and sloughing after birth. Dry skin may be treated with an emollient applied once or twice daily (Association of Women’s Health, Obstetrical and Neonatal Nurses [AWHONN], 2018). Newborn rash, erythema toxicum (see Figure 25.9, B), is a common finding and needs no treatment.

Clothing. Parents commonly ask how warmly they should dress their newborn. A simple rule of thumb is to dress the child as they would dress themselves, adding or subtracting clothes and wraps for the child as necessary. Feeling the temperature of the skin at the back of the baby’s neck is often an indicator of whether the child is too hot or cold. Overheating should be avoided (PHAC, 2018b). A hat or bonnet is needed to protect the scalp and minimize heat loss if the weather is cool, or to protect against sunburn and shade the eyes if it is sunny and hot. Overdressing in warm temperatures can cause discomfort, as can underdressing in cold weather. Overdressing the infant has also been associated with SIDS. Parents are encouraged to dress the baby in flame-retardant clothing. Infant sunglasses are available to protect the eyes when outdoors. For sleep, newborns are safest when placed to sleep in fitted onepiece sleepwear that is comfortable at room temperature and does not cause them to overheat (PHAC, 2018b). For additional warmth, the newborn can be dressed in fitted clothing in layers as needed. For the first 2 to 3 months until the infant is able to roll over, safe swaddling for sleep can be done using a lightweight blanket or wrap (not in combination with a sleep sack). The head, neck, and chin are not covered, and the wrap should not be tight around the chest or legs.

Car Seat Safety. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat (see Figure 26.25). The safest area of the car is in the middle of the back seat. A car seat that faces the rear gives the best protection for the infant’s disproportionately weak neck and heavy head. In this position, the force of a frontal crash is spread over the head, neck, and back; the back of the car seat supports the spine. Car seats have expiration dates on them as well as Canadian Standards Association stickers. A car seat that has been in a previous car accident should not be used. See Additional Resources for more information on car seat installation and Chapter 35.

NURSING ALERT A rear-facing car seat should be used for infants from birth to at least 10 kg (22 lb), and the child must be able to walk unassisted. If the child meets these criteria and is under 1 year of age, they should remain in a rear-facing car seat. It is advisable to keep a child in a rear-facing car seat even after these criteria have been met.

To secure the infant in the rear-facing car safety seat, shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness is snug, and the retainer clip is placed at the level of the infant’s armpits as opposed to on the abdomen or neck area. The car seat is secured by using the vehicle seat belts. Rear-facing infant seats should never be placed in the front seat. Serious injury can occur if the air bag inflates, because these types of infant seats fit close to the dashboard. If the infant must ride in the front seat, the air bag must be turned off. For cars with side air bags, parents should read the vehicle owner’s manual for information about placement of car seats next to a side air bag. Bulky clothing such as a coat or snow suit can compress if there is a car accident, causing the straps of the harness to loosen and placing the infant at risk for injury. Parents should dress their infant in thinner layers; for warmth, they can place a blanket or coat over the buckled

harness straps (CPS, 2018). Add-on features such as head supports that do not come with the car seat should not be used. They can affect the safety of the car seat (CPS, 2020a).

NURSING ALERT In cars equipped with air bags, rear-facing infant seats should not be placed in the front seat unless the air bag has been deactivated. Serious injury can occur if the air bag inflates, because these types of infant seats fit closer to the dashboard than a passenger does.

Non-Nutritive Sucking. Sucking is the newborn’s chief pleasure. However, sucking needs may not be satisfied by breastfeeding or bottle-feeding alone. In fact, sucking is such a strong need that newborns who are deprived of sucking, such as those with a cleft lip, will suck on their tongues. Some newborns are born with sucking pads on their fingers or lips that developed during in utero sucking. Several benefits of non-nutritive sucking have been demonstrated, such as an increased weight gain in preterm newborns, greater ability to maintain an organized state, and less crying. When parents are concerned about the sucking of fingers, thumbs, or pacifiers they may try to restrain this natural tendency. Before giving advice, nurses should investigate the parents’ feelings and base the guidance they give on the information solicited. For example, some parents may have no concerns about the use of a finger but may find the use of a pacifier objectionable. In general, there is no need to restrain either practice, unless thumb sucking persists past 4 years of age or past the time when the permanent teeth erupt. Parents are advised to consult with their health care provider on this topic. There is compelling evidence that use of pacifiers helps prevent SIDS. It is suggested that parents consider offering a pacifier for naps and bedtime (Ponti & CPS, 2003/2018). The pacifier should be used when the infant is placed supine for sleep, and it should not be reinserted once they fall asleep. No newborn should be forced to take a pacifier. Pacifiers should be cleaned often and replaced regularly and should not be coated with any type of sweet solution. Pacifier use for breastfeeding newborns should be delayed for 3 to 4 weeks to ensure that breastfeeding is well established. A parent’s excessive use of the pacifier to calm the child should also be explored, however. It is not unusual for parents to place a pacifier in the newborn’s mouth as soon as the child begins to cry, thus reinforcing a pattern of distress relief. If parents choose to let their child use a pacifier, they need to be aware of certain safety considerations before purchasing one. Homemade, improvised, or poorly designed pacifiers can be dangerous because the entire object may be aspirated if it is small, or a portion may become lodged in the pharynx. Safe pacifiers are made of one piece that includes a shield or flange large enough to prevent entry into the mouth and a handle that can be grasped (Figure 26.27). Bathing and Umbilical Cord Care Bathing. Bathing serves a number of purposes. It provides opportunities for (1) cleansing the newborn, (2) observing the newborn’s condition, (3) promoting comfort, and (4) promoting parent–child–family interaction. An important consideration in skin cleansing is preservation of the skin’s acid mantle, which is formed from the uppermost horny layer of the epidermis, sweat, superficial fat, metabolic products, and external substances such as amniotic fluid and microorganisms. To protect the newborn’s skin, it is best to use a cleanser with a neutral pH and preferably without preservatives or with preservatives recognized as

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Fig. 26.27 Design of a safe pacifier. (Courtesy Julie Perry Nelson.)

safe and well tolerated in newborns. Antimicrobial cleansers should not be used (AWHONN, 2018). Although the sponging technique may be used, bathing the newborn by immersion or swaddled bathing results in less heat loss and less crying and is thus recommended even with the umbilical cord still intact. For immersion bathing, the newborn is placed in warm water (38°C [100.4°F]) deep enough to cover the shoulders, but not the head and neck (Lund & Durand, 2021) (Figure 26.28). Swaddled bathing is a type of immersion bathing in which the newborn is swaddled in a blanket or towel and immersed in a tub of warm water. One body part at a time is unwrapped and washed (AWHONN, 2018) (Figure 26.29). Ideally the initial bath is delayed for at least 6 to 8 hours after birth until the newborn has reached thermal and cardiorespiratory stability. In some birthing facilities, the bath may be delayed for as long as 24 hours or longer as per WHO recommendations (WHO, 2018). This bath should be performed at the parent’s bedside. Tap water and a minimal amount of pH-neutral or slightly acidic cleanser are recommended. Following the bath, the newborn should be immediately dried, diapered, and either wrapped in warm blankets or placed skin-to-skin with a parent. A cap should be placed on the head. Until the initial bath is completed, hospital personnel must wear gloves to handle the newborn. Some hospitals do not recommend bathing newborns while they are in the hospital; the first bath may be done after the newborn is discharged home.

Fig. 26.28 Initial newborn bath by immersion. (Courtesy Allison and Matthew Wyatt, Eagle, CO.)

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Fig. 26.29 A swaddle immersion bath is bathing the newborn while they are loosely swaddled in a blanket. (iStock.com/Shoko Shimabukuro)

A daily bath is not necessary for achieving cleanliness and may do more harm by disrupting the integrity of the newborn’s skin; cleansing the perineum after a soiled diaper and daily cleansing of the face may suffice. In general, newborns should not be bathed more frequently than every other day; the hair can be shampooed once or twice a week. The newborn bath time provides a wonderful opportunity for parent–newborn social interaction. While bathing the baby, parents can talk to the child, caress and cuddle them, and engage in arousal and imitation of facial expressions and smiling. Parents can pick a time for the bath that is easy for them and when the baby is awake, usually before a feeding. Umbilical cord care. The goal of cord care is to prevent or decrease the risk for hemorrhage and infection. The umbilical cord stump is an excellent medium for bacterial growth and can become infected. Hospital protocol determines the technique for routine cord care. The current recommendations for cord care include cleaning the cord with water (and cleanser if needed to remove debris) during the initial bath and subsequently cleaning with plain water. Evidence does not support the routine use of antiseptic or antimicrobial preparations for cord care (AWHONN, 2018; Lund & Durand, 2021). The umbilical cord begins to dry, shrivel, and blacken by the second or third day of life. The stump deteriorates through the process of dry gangrene; thus, odour alone is not a positive indicator of omphalitis (infection of the umbilical stump). The umbilicus should be inspected often for signs of infection (e.g., foul odour, redness, swelling, and purulent discharge), granuloma (i.e., small, red, raw-appearing polyp where the umbilical cord separates), bleeding, and discharge. The cord clamp may be removed when the cord is dry, in about 24 to 36 hours, although this is not routine practice in all hospitals (Figure 26.30). Some institutions send the newborn home with the clamp still in place and it will fall off when the cord falls off. It is important to ensure that if a cord clamp remover is used, it is disinfected between uses. Cord separation time is influenced by several factors, including type of cord care, type of birth, and other perinatal events. The average cord separation time is 10 to 14 days, although it can take up to 3 weeks for this to occur. Some dried blood may be seen in the umbilicus at separation (Figure 26.31). See the Family-Centred Care box: Newborn Bath for information regarding tub and sponge bathing, skin care, cord care, trimming nails, and dressing the newborn.

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Prevent Heat Loss • The temperature of the room should be no cooler than 26° to 27°C (79° to 81°F), and the bathing area should be free of drafts. • The water temperature should be between 38° and 40° C (100° to 95% with titration of oxygen as indicated. Extracorporeal membrane oxygenation (ECMO). High-frequency ventilation known as ECMO is not typically used in infants less than 34 weeks’ gestation because the anticoagulant therapy required in the pump and circuits may increase the potential for IVH. Additionally, the size of the cannulae required are not suitable for preterm infants. However, institutional approaches and individual circumstances of the newborn may give rise to variations in ECMO utilization.

Patent Ductus Arteriosus. The ductus arteriosus is a muscular contractile structure in the fetus connecting the left pulmonary artery and the dorsal aorta. The ductus constricts after birth as oxygenation increases. Other factors that promote ductal closure include catecholamines, low pH, bradykinin, and acetylcholine. When the fetal ductus arteriosus fails to close after birth, a patent ductus arteriosus (PDA) exists. Ductal closure usually occurs within hours or days in the term newborn but may be delayed in preterm infants as a result of reduced oxygenation and circulating hormones (prostaglandins). The clinical presentation of an infant with a PDA includes systolic murmur, active precordium, bounding peripheral pulses, tachycardia, tachypnea, crackles on auscultation of air entry, and hepatomegaly. The systolic murmur is heard best at the second or third intercostal space at the upper left sternal border. An active precordium is caused by an increased left ventricular stroke volume. A widened pulse pressure may result in bounding peripheral pulses. Radiographic studies of infants with a large PDA typically show cardiac enlargement and pulmonary edema; with a smaller PDA, the radiograph may appear normal for the infant’s age (Swanson & Erickson, 2021). Blood gas analysis reveals hypercarbia and metabolic acidosis. A colour flow Doppler echocardiograph can demonstrate a PDA and be used to identify the direction of the shunting (left to right, right to left, or both) and quantify the amount of blood shunting across the PDA. A PDA can be managed medically or surgically. Medical management consists of ventilatory support aimed to reduce ductal shunt volume, fluid restriction, diuretics, and medications, such as indomethacin, ibuprofen, or acetaminophen. Indomethacin is a prostaglandin synthetase inhibitor that blocks the effect of the arachidonic acid products on the ductus and causes the PDA to constrict. Ibuprofen has a similar pharmacological action profile and reportedly has fewer adverse effects than indomethacin, yet a recent Cochrane review reported that they are equally effective (Ohlsson et al., 2020). Acetaminophen provided for 3 to 7 days has demonstrated a positive impact on ductal closure and is currently used as a second-line medication option (Oncel et al., 2014). Surgical ligation has been performed when a PDA is clinically significant and medical management has failed. Postligation cardiac syndrome has sometimes contributed to a period of postoperative instability requiring anticipatory management to offset hypoxia and hypoperfusion (Giesinger et al., 2019). Percutaneous PDA occlusion is an evolving alternative intervention for VLBW infants with symptomatic PDAs; comparative evidence evaluating percutaneous occlusion versus other therapies is not available (Backes et al., 2019). Nursing interventions for the newborn with a PDA focus on supportive care. The newborn requires an NTE, adequate oxygenation, and meticulous fluid balance. Periventricular-Intraventricular Hemorrhage. Periventricularintraventricular hemorrhage (PV-IVH) is one of the more common types of neurological injuries that occurs in newborns and is among the most severe in both short- and long-term outcomes. While the true

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incidence of PV-IVH is unknown, a general estimate is 15% in newborns less than 32 weeks of gestation or under 1 500 g (Volpe, 2017). Research has shown that contributing events may occur antenatally and postnatally (Merhar & Thomas, 2020). The pathogenesis of PV-IVH includes intravascular factors (e.g., fluctuating or increasing cerebral blood flow, increased cerebral venous pressure, and coagulopathy), vascular factors, extravascular factors (hypoglycemia, acidosis), and routine medical care (rapid volume expansion, blood transfusion). The developing preterm infant’s brain has highly vascularized areas with fragile blood vessels that are prone to bleeding when homeostasis is not maintained; the most commonly affected area is in and around the subependymal germinal matrix. PV-IVH events typically occur within the first 72 hours of birth; PV-IVH is classified according to severity, which informs long-term neurodevelopmental outcomes. Posthemorrhagic ventricular dilatation progresses in approximately 30 to 50% of infants with serious IVH, and without timely intervention, further damage of the white matter may occur (Leijser et al., 2018). Ventriculoperitoneal shunt insertion may also be necessary to relieve ensuing hydrocephalus. Nursing care focuses on recognition of factors that increase the risk for PV-IVH, interventions to decrease the risk of bleeding, and supportive care to infants who have bleeding episodes. The newborn is positioned with their head in midline and the head of the bed elevated to 30° to prevent or minimize fluctuations in intracranial blood pressure during the first 72 hours of life. An NTE is maintained, as well as oxygenation to target saturation levels. Rapid infusions of fluids should be avoided. Blood pressure should be monitored closely for fluctuations.

Necrotizing Enterocolitis. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the bowel with increased incidence in preterm infants. The precise cause of NEC is still uncertain, but it appears to occur in newborns whose gastrointestinal tracts have experienced vascular compromise. Intestinal ischemia of unknown etiology, immature gastrointestinal host defenses, bacterial proliferation, and feeding practices play a multifactorial role in the etiology of NEC. Preterm birth remains the most prominent risk factor for development of NEC (Brown, 2020). However, NEC does occur in term newborns, although rare. The damage to mucosal cells lining the bowel wall may be significant. Diminished blood supply causes cell death and a reduction in secreting protective, lubricating mucus. The thin, unprotected bowel wall is attacked by proteolytic enzymes; the bowel wall continues to swell and break down and is unable to synthesize protective IgM. Gas-forming bacteria invade the damaged areas to produce pneumatosis intestinalis, the presence of gas in the submucosal or subserosal surfaces of the bowel. A consistent relationship has been observed between the development of NEC and enteric feeding of hypertonic substances (e.g., formula, hyperosmolar medications). It is unclear whether this connection is a result of the formula imposing a stress on an ischemic bowel or serving as a substrate for bacterial growth or possibly a combination of these factors. Breast milk is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Donated breast milk for eligible preterm infants may help to decrease the risk of NEC (see Chapter 27, Milk Banking). The early clinical signs of NEC are subtle and nonspecific and may often be overlooked for other conditions and may include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, and cyanosis. Clinical manifestations include abdominal distension, bilious vomiting, bloody stools,

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abdominal tenderness, and erythema of the abdominal wall (Gallagher et al., 2021). Diagnosis of NEC is confirmed by radiographic examination that reveals bowel loop distension, pneumatosis intestinalis, pneumoperitoneum, portal air, or a combination of these findings. Laboratory evaluation includes a complete blood count (CBC) with differential, blood culture, coagulation studies, arterial blood gas analysis, and serum electrolyte levels. The white blood cell count may be either increased or decreased. The platelet count and coagulation studies may be abnormal, with thrombocytopenia and evidence of disseminated intravascular coagulation. Electrolyte levels may be abnormal, related to leaking capillary beds and fluid shifts seen with inflammatory illnesses. Treatment is with bowel rest and broad-spectrum antibiotic therapy, typically for 7 to 10 days, depending on severity and progression of illness. A nasogastric tube is inserted and placed to low intermittent suction to provide gastric decompression; parenteral therapy is commenced. If there is progressive deterioration or evidence of perforation, surgical intervention may be indicated. Resection and primary anastomosis may be performed; extensive bowel involvement may require establishment of an ileostomy, jejunostomy, or colostomy. Recovery may be delayed; sequelae may include short-bowel syndrome, stricture with obstruction, malabsorption, and failure to thrive secondary to intestinal dysfunction. Post-NEC intestinal failure–associated liver disease, clinically manifested as an elevated conjugated bilirubin greater than 100 mcmol/L, may be linked to parenteral lipids and septic events and requires consideration for lipid restriction or alternative lipid products, including omega-3 lipid emulsions (Mutanen & Wales, 2018). Bowel adaptation and bowel-lengthening procedures have reduced but not eliminated indications for pediatric intestinal transplantation secondary to intestinal failure (King et al., 2013).

The Post-Term Infant Post-term (or postmature) infants are those whose gestation is prolonged beyond 42 weeks, regardless of birth weight. These infants may be large or small for gestational age, but most often their weight is appropriate for gestational age. The rate of infants born post-term has been declining and was 0.3 in 2014 (Public Health Agency of Canada [PHAC], 2017). The cause of prolonged pregnancy is unknown. Postmaturity can be associated with placental insufficiency, resulting in a newborn that has a thin, emaciated appearance at birth because of loss of subcutaneous fat and muscle mass. Not all post-term infants demonstrate features of postmaturity. There may be dry, loose, peeling skin; meconium staining of the fingernails; the hair and nails may be long; and vernix may be absent. During labour and birth, increased oxygen demands of the postterm fetus may not be met. Insufficient gas exchange in the post-term placenta increases the likelihood of intrauterine hypoxia. This may result in the passage of meconium in utero and the risk for meconium aspiration syndrome. In one study, post-term infants were found to have a mortality rate almost three times higher than that of a control group of term infants (Brady & Poindexter, 2020).

Meconium Aspiration Syndrome Meconium staining of the amniotic fluid (MSAF) may be present with atypical or abnormal fetal heart rate patterns and may be indicative of stress in utero. Globally, MSAF appears in 10 to 15% of all live births, primarily in term and post-term births, with 5% being at risk of developing meconium aspiration syndrome (MAS) (Paudel et al., 2020). Many infants with meconium staining exhibit no signs of concerns at birth; however, the presence of meconium in the amniotic fluid necessitates careful supervision of labour and close monitoring of fetal

Fig. 28.10 Infant being resuscitated at birth. Note presence of meconium on abdomen and umbilical cord. (Courtesy Shannon Perry.)

well-being. The presence of a team skilled in neonatal resuscitation is required at the birth of any infant with MSAF (Figure 28.10). Current resuscitation guidelines assert that there is not enough evidence to suggest routine tracheal intubation and suctioning of meconium below the cords for nonvigorous infants who present with MSAF (Perlman et al., 2015). Instead, gentle oropharyngeal suctioning of the mouth and nose, as required, is indicated. Presence of thick meconium that appears to obstruct the newborn’s airway may require intubation for suctioning and establishing airway clearance (Perlman et al., 2015). If meconium is not removed from the airway at birth it can migrate down to the terminal airways, causing mechanical obstruction and lead to MAS. Diagnosis is premised on symptoms of respiratory distress and chest X-ray findings demonstrating hyperinflation with atelectasis. Chemical pneumonitis and pulmonary hypertension may further complicate management. Meconium inhibits surfactant function. Ventilation, exogenous surfactant, iNO, or ECMO may be used for treatment.

Persistent Pulmonary Hypertension of the Newborn Persistent pulmonary hypertension of the newborn (PPHN) is a term applied to the combined findings of pulmonary hypertension and right-to-left shunting through fetal heart communications, in the context of a structurally normal heart. PPHN may manifest either as a single entity or a sequela of MAS, congenital heart disease, RDS, hyperviscosity syndrome, neonatal pneumonia, or sepsis. PPHN may be referred to as persistent fetal circulation because the disease involves reversion to fetal pathways of blood flow. A brief review of fetal blood flow can help with visualizing the concerns with PPHN (see Figure 9.15). In utero, oxygen-rich blood leaves the placenta via the umbilical vein, goes through the ductus venosus, and enters the inferior vena cava. From there it empties into the right atrium and is mostly shunted across the foramen ovale to the left atrium, effectively bypassing the lungs. This blood enters the left ventricle, leaves through the aorta, and preferentially perfuses the carotid and coronary arteries—the heart and brain receive the most oxygenated blood. Blood drains from the brain into the superior vena cava, reenters the right atrium, proceeds to the right ventricle, and exits through the main pulmonary artery. The lungs, a high-pressure circuit, need only enough perfusion for growth and nutrition. The ductus arteriosus (connecting the main pulmonary artery and the aorta) provides a

CHAPTER 28 path of least resistance for the blood leaving the right side of the fetal heart and shunts most of the cardiac output away from the lungs and toward the systemic system. After birth, both the foramen ovale and the ductus arteriosus close in response to biochemical processes, pressure changes within the heart, and dilation of the pulmonary vessels. The reduction in pulmonary vascular resistance allows virtually all of the cardiac output to enter the lungs, become oxygenated, and provide oxygen-rich blood to the tissues. Any process that interferes with transition from fetal to newborn circulation may precipitate PPHN. PPHN characteristically proceeds into a downward spiral of increasing hypoxia, pulmonary vasoconstriction, and oxygenation failure. Infants with PPHN are often critically ill; prompt recognition and aggressive intervention are required to reverse the process. Management depends on the underlying cause of the persistent pulmonary hypertension. Optimizing ventilation support for underlying lung disease, provision of sedation and muscle relaxation, and treatment with pulmonary vasodilators, including iNO and cardiotropic medications, to support right ventricular dysfunction aid in management. ECMO therapy may be indicated in the management of term newborns with acute severe oxygenation failure that is unresponsive to other treatment modalities.

OTHER CONCERNS RELATED TO GESTATION Small-for-Gestational-Age Infants and Intrauterine Growth Restriction Newborns who are SGA or have IUGR are considered high risk, with a perimortality rate 5 to 20 times greater than that for term newborns (Kliegman, 2014). While related, SGA and IUGR are not synonymous terms. IUGR represents a reduction in fetal growth pattern as a result of a perinatal pathophysiological process, whereas SGA refers to birthweight below population growth curves, which may be familial or ethnicity related. Conditions occurring in the first trimester (e.g., infections, teratogens, chromosomal abnormalities) can affect all aspects of fetal growth and result in symmetrical IUGR (i.e., head circumference, length, and weight are all less than the tenth percentile). Infants with symmetrical growth restriction have a smaller head circumference and concomitant reduced brain growth. Growth restriction during later stages of pregnancy, due to maternal or placental factors, typically results in asymmetrical growth restriction—weight will be less than the tenth percentile, whereas length and head circumference will be greater than the tenth percentile, possibly within normal limits. Newborns with asymmetrical IUGR, referred to as head sparing, have the potential for normal growth and development. Care of the SGA newborn is guided by the accompanying clinical concerns and is comparable to the care provided to preterm infants with similar conditions. Common difficulties that affect SGA or IUGR infants are perinatal asphyxia, meconium aspiration, immunodeficiency, hypoglycemia, polycythemia, and temperature instability. Gas exchange is supported by maintaining a clear airway and preventing cold stress. Hypoglycemia is treated with oral feedings (e.g., breast milk, formula) or IV dextrose as the newborn’s condition warrants. Consideration of donor breast milk when the mother’s own milk supply is not established is warranted, in an effort to protect the newborn from NEC (Jackson & Harrington, 2018). An external heat source (radiant warmer or isolette) may be required until the newborn is able to maintain an adequate body temperature.

Hypoglycemia and Hyperglycemia. All high-risk newborns are at risk for hypoglycemia. Newborns who experience physiological stress may experience hypoglycemia as a result of a decreased glycogen

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supply, inadequate gluconeogenesis, or overutilization of glycogen stored during fetal and postnatal life. Preterm infants may also become hypoglycemic as a result of inadequate intake and increased metabolic demands due to illness (see Chapter 26, Hypoglycemia). The SGA newborn, not unlike the preterm infant, is at higher risk for hypoglycemia as a result of decreased fetal stores and decreased rate of gluconeogenesis. Hyperglycemia is defined as a blood glucose level greater than 6.9 mmol/L (whole blood) or plasma glucose of 8.0 to 8.3 mmol/L (Blackburn, 2018). Adverse outcomes associated with hyperglycemia include higher rates of sepsis, white matter brain injury, and increased mortality (Hay & Rozance, 2018). Increased circulating levels of glucose may lead to osmotic changes, increased urine output, and fluid shifts in the already compromised CNS of the preterm infant. The net result of hyperglycemia may be cellular dehydration and IVH. Physiological stress associated with surgical procedures also generates periods of hyperglycemia with increased catecholamine release, which inhibits insulin release and glucose utilization (Blackburn, 2018). Reducing glucose intake in perioperative fluid management may dampen the hyperglycemic surge.

Heat Loss. SGA newborns are particularly susceptible to temperature instability as a result of decreased brown fat deposit, decreased adipose tissue, large body surface exposure, inability to accomplish flexed position due to poor muscle tone, and decreased glycogen storage in major organs such as the liver and heart. Close attention must be given to maintenance of an NTE.

Large-for-Gestational-Age Infants A newborn is considered large for gestational age (LGA) when the birth weight is above the ninetieth percentile on growth charts or 2 standard deviations above the mean weight for gestational age. The LGA newborn has a higher incidence of birth injuries, asphyxia, and congenital anomalies such as heart defects. In Canada the rate of newborns who were LGA was 9.9% in 2017 (PHAC, 2021). LGA newborns may be preterm, term, or post-term; they may be infants of diabetic mothers. Each of these categories carries special concerns. Regardless of coexisting potential health issues, the LGA infant is at risk by virtue of size alone. The nurse needs to assess the LGA newborn for hypoglycemia and trauma resulting from vaginal or Caesarean birth. Any specific birth injuries should be identified and treated appropriately.

Infants of Diabetic Mothers The morbidity and mortality of infants of diabetic mothers (IDMs) have been reduced significantly as a result of effective control of maternal diabetes and an increased understanding of fetal disorders. Because infants born to a parent with gestational diabetes mellitus (GDM) are at risk for the same complications as IDMs, the following discussion of IDMs also includes infants born to patients with GDM. The severity of maternal diabetes is determined by the duration of the disease before pregnancy; age of onset; extent of vascular complications; and abnormalities of the current pregnancy, such as pyelonephritis, diabetic ketoacidosis, pregnancy-induced hypertension, and inability to follow treatment regimen. Stable metabolic control that begins before conception and continues during the first weeks of pregnancy may prevent malformation in an IDM. Elevated levels of hemoglobin A1c during the periconception period appear to be associated with a higher incidence of congenital malformations (see Chapter 15, Diabetes Mellitus). In the case of gestational diabetes, macrosomia is the most common finding; serious complications are rare (Feig et al., 2018). Transition-related hypoglycemia, that which occurs in the first 72 hours of life, is defined as a blood glucose level less than 2.6 mmol/L

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(Narvey & Marks, 2019). Monitoring for symptoms of hypoglycemia in an IDM include jitteriness or tremors, cyanotic episodes, seizures, intermittent apneic episodes, and difficulties feeding; informed and educated parents may also be able to provide important observations. Symptomatic hypoglycemia may contribute to neuronal injury; national practice guidelines recommend maintaining glucose levels greater than 2.6 in at-risk infants, which includes IDMs (Narvey & Marks, 2019). Hypoglycemia in IDMs is related to hypertrophy and hyperplasia of the pancreatic islet cells and thus is a transient state of hyperinsulinism. High maternal blood glucose levels during fetal life provide a continual stimulus to the fetal islet cells for insulin production (glucose easily passes the placental barrier from maternal to fetal side; however, insulin does not cross the placental barrier). When the newborn’s glucose supply is removed abruptly at the time of birth, the continued production of insulin soon depletes the blood of circulating glucose, creating a state of hyperinsulinism and hypoglycemia within 0.5 to 4 hours, especially in newborns of mothers with poorly controlled diabetes. Precipitous drops in blood glucose levels can cause serious neurological damage or death. Congenital hyperinsulinism may contribute to persistent hypoglycemia; however, this condition is usually not associated with maternal DM. IDMs have a characteristic appearance (Box 28.6 and Figure 28.11). Infants of mothers with advanced diabetes may be SGA, have IUGR, or be the appropriate size for gestational age because of the maternal vascular (placental) involvement. There is an increase in congenital anomalies in IDMs in addition to a high susceptibility for hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia, cardiomyopathy, and RDS (Landon et al., 2017). CNS anomalies such as anencephaly, spina bifida, and holoprosencephaly occur at rates 10 times higher in IDMs than in infants from any other population of mothers. Cardiac anomalies such as ventricular septal defects and

BOX 28.6

Clinical Manifestations of Infants of Diabetic Mothers • • • •

Large for gestational age Very plump and full faced Abundant vernix caseosa Plethora

• Listless and lethargic • Possibly meconium stained at birth • Hypotonia

Fig. 28.11 Large-for-gestational-age infant. This infant of a diabetic mother weighed 5 kg (11 lb) at birth and exhibits the typical round facies. (From Zitelli, B. J., & Davis, H. W. [2007]. Atlas of pediatric physical diagnosis [5th ed.]. Mosby.)

coarctation of the aorta are increased five-fold in IDMs, and sacral agenesis and caudal regression occur almost exclusively in IDMs (Landon et al., 2017). IDMs are more likely to have disproportionately large abdominal circumferences and shoulders, leading to an increased risk of shoulder dystocia and birth injury. Hyperinsulinemia and hyperglycemia in the diabetic mother may be factors in reducing fetal surfactant synthesis, thus contributing to the development of RDS. Although large, these infants may be born before term as a result of maternal complications or increased fetal size. Some IDMs are also at increased risk for deep vein thrombosis, with renal vein thrombosis and hematuria being the most common presentation. Additional health concerns in IDMs include perinatal iron deficiency and neurological impairments (seizures, lethargy, jitteriness, and changes in tone) (Hay, 2012). Important management of IDMs includes careful monitoring of serum glucose levels and observation for accompanying complications such as RDS and cardiac anomalies. Newborns are examined for the presence of any anomalies or birth injuries, and blood studies for determination of glucose, calcium, hematocrit, and bilirubin are obtained on a regular basis. Because the hypertrophied pancreas is sensitive to blood glucose concentrations, the administration of glucose may trigger an insulin surge, resulting in rebound hypoglycemia. Feedings of breast milk or formula may begin within the first hour after birth, provided that the infant’s cardiorespiratory condition is stable. Newborns born to mothers with poorly controlled diabetes may require IV dextrose infusions to prevent serious neurological sequelae (Narvey & Marks, 2019). The Canadian Paediatric Society recommends that symptomatic, hypoglycemic newborns (and asymptomatic newborns who have failed to respond to enteral supplementation) be treated with IV dextrose solution (Narvey & Marks, 2019). Symptomatic IDMs who are unable to feed should be started on a continuous IV infusion of 10% dextrose at 4 to 6 mg/min/kg unless blood glucose is below 1.8 mmol/L. In such cases a one-time bolus infusion of 10% dextrose (200 mg/kg) should be given over 2 to 4 minutes, followed by a continuous IV infusion of 10% dextrose and water as noted previously (Narvey & Marks, 2019). Evaluation of serum glucose 30 minutes after intervention is required to determine if further stepwise increases in glucose infusion are needed. Additional pharmacological agents that may be required include glucagon and diazoxide, typically after consultation with pediatric endocrinology services.

Nursing Care. The nursing care of IDMs involves early examination for congenital anomalies, signs of possible respiratory or cardiac issues, maintenance of adequate thermoregulation, early introduction of carbohydrate feedings as appropriate, and monitoring of serum blood glucose levels. Testing blood taken from the newborn’s heel with calibrated portable reflectance meters (e.g., glucometers) is a simple and effective screening evaluation that can then be confirmed by laboratory examination (see Chapter 26, Heel Stick). IV glucose infusion requires careful monitoring of the site and the newborn’s reaction to therapy; high glucose concentrations (12.5%) should be infused via a central line instead of a peripheral site. IDMs also need to be monitored for hypocalcemia and hypomagnesemia. Signs of hypocalcemia are similar to those of hypoglycemia and occur typically within the first 24 hours of age. Newborns also need to be monitored closely for hyperbilirubinemia. Because macrosomic newborns are at risk for complications associated with a difficult birth, they are monitored for birth injuries such as brachial plexus injury and palsy, fractured clavicle, and phrenic nerve palsy. See the Nursing Care Plan, The Infant of a Mother With Diabetes Mellitus on the Evolve site.

CHAPTER 28

DISCHARGE PLANNING AND TRANSPORT Discharge Planning Discharge planning for the high-risk newborn begins early in the hospitalization. Throughout the infant’s hospitalization, the nurse must gather information from the health care team members and the family. This information is used to determine the infant’s and family’s readiness for discharge. As the nurse assesses the discharge needs of the infant’s parents, steps can be taken to eliminate any knowledge deficits. Discharge teaching for the high-risk newborn’s family is extensive, requires time and planning, and cannot be accomplished on the day of discharge alone. Information should be provided about infant care, especially as it pertains to the infant’s particular needs (e.g., supplemental oxygen, gastrostomy feedings, follow-up medical visits). Parent education includes having them give return demonstrations of their infant care skills to show whether they are becoming increasingly independent in providing care for their infant. Parents of a preterm infant or one with special needs should be given the opportunity to room-in and spend a night or two providing care for their infant away from the NICU. This affords them the opportunity to become more aware of the necessary care and to have transition time during which to ask questions regarding home care. Additional parent teaching should include bathing and skin care; requirements for meeting nutritional needs after discharge; safety in the home, including supine sleep position and prevention of infection (e.g., respiratory syncytial virus); and medication administration. Medical equipment and supplies required for care of the infant in the home should be delivered to the home before discharge; parents and care providers should have education and ample practice in its use. Parents of an infant being discharged with special needs (i.e., gavage or gastrostomy feedings, oxygen, tracheostomy, or colostomy) should receive several days of carefully planned education in the various procedures before discharge. Car seat safety is an essential aspect of discharge planning. Parents should obtain an age-appropriate car seat before discharge and demonstrate its use with the infant. Current national practice guideline recommendations note that while it is clear that infants placed in a car seat are more likely to experience oxygen desaturation or bradycardia than when they are supine, this does not predict an adverse neurodevelopmental outcome or mortality postdischarge. The infant car seat challenge that had been routinely used as a screening tool is no longer recommended (Narvey & CPS Fetus and Newborn Committee, 2016). Preterm infants have a high rate of readmission to the hospital and of emergency department visits. It is imperative that the family have a health care provider they can contact for questions regarding infant care and behaviour once they are home. Before discharge, all high-risk or preterm infants should receive the appropriate immunizations, metabolic screening, hematology assessment (bilirubin risk as appropriate), and evaluation of hearing and for retinopathy of prematurity (Jefferies & CPS Fetus and Newborn Committee, 2014/2020). Successful discharge of a high-risk infant requires an interprofessional and family-centred approach. Medical, nursing, social services, and other professionals (physiotherapy, occupational therapy, developmental follow-up specialist) are crucial to the smooth transition of these infants and their families to the community and home. If the infant is retrotransferred to a facility providing less acute care, interfacility communication is essential to continuity of care. Discharge to home for high-risk infants requires timely follow-up by a practitioner familiar with the issues common to the high-risk

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newborn. Further follow-up of specific complications by qualified specialists and referral to centres for developmental interventions can help ensure the best outcome possible for these infants. Referrals for appropriate community resources are also encouraged for infants with developmental delays or those at risk for further challenges (e.g., preterm infants). Social-service support may be indicated for young or high-risk parents (e.g., parents with a history of substance use or previous child maltreatment). For the family of the child who is technology dependent, special education needs should be discussed before discharge. For further discussion of home care, see Chapter 41.

Transport to a Regional Centre If a hospital is not equipped to care for a high-risk mother and fetus or a high-risk newborn, transfer to a specialized perinatal or regional tertiary care centre is arranged. Maternal transport that occurs with the fetus in utero has two distinct advantages: (1) newborn morbidity and mortality are decreased, and (2) the mother and newborn are not separated at birth. For a variety of reasons, it is not always possible to transport the mother before the birth. Therefore, facilities must have the personnel and equipment necessary for making an accurate diagnosis and implementing emergency interventions to stabilize the newborn’s condition until transport can occur. The goal of these interventions is to maintain the newborn’s condition within the normal physiological range. Specific attention should be given to vital signs, oxygenation and ventilation, thermoregulation, acid–base balance, fluid and electrolyte status, blood glucose, and developmental interventions. Arrangements for transport to a tertiary centre should be made as soon as the high-risk infant is identified (see Community Focus box: Newborn Transport) and best done by a specially trained neonatal transport team. The infant must be kept warm and adequately oxygenated (including intubation and surfactant replacement as indicated), have vital signs and oxygen saturation monitored, and, when indicated, receive an IV infusion. The infant must be transported in a specially designed isolette containing a complete life support system and other emergency equipment that can be carried by ambulance, helicopter, or a fixed-wing aircraft (Figure 28.12).

Fig. 28.12 Total life support system for transport of high-risk newborns. (iStock.com/ollo)

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COMMUNITY FOCUS Newborn Transport During a scheduled clinical experience in the nursery at a community hospital, inquire about how newborns are transferred to other units. How are referrals made? What communication links exist between the community hospitals and the tertiary centre’s NICU? Observe a neonatal transport team working to stabilize a newborn before transport to the tertiary centre if possible. Who are the transport team members? What are their roles and responsibilities? What equipment have they brought with them? What communication links exist between the NICU and the transport team when they are stabilizing and transporting the sick newborn? To whom does the transport team report? How are the parents kept informed of the newborn’s condition during the stabilization?

The transport team may consist of physicians, nurse practitioners, nurses, respiratory therapists and paramedics. The team must have experience in resuscitation, stabilization, and provision of critical care during the transport. When a newborn is to be transported from the hospital, the parents need a description of the facility where the newborn is going. They need to know the location and nature of the facility and the care that the newborn requires at the alternative facility. The name of the newborn’s primary health care provider and the telephone number of the nursery can be given to them, and unfamiliar terms such as neonatologist, ventilator, infusion, and isolette can be explained. Providing simple explanations and opportunities to ask questions promotes family-centred care. If booklets and a website are available that describe the facility, they should be given to the family. Perhaps most important, providing parents some contact time with the newborn before the transport is vital. Being able to see, touch, and (if possible) hold their newborn may help decrease parents’ anxiety. Often a photograph or even a video recording of their newborn can serve as tangible evidence of the newborn’s existence until the parents are able to travel to the regional facility. When possible, it is often advisable to transfer the mother to the same institution as their newborn.

KEY POINTS • Preterm infants are at risk for conditions related to the immaturity of their organ systems. • Late preterm infants are at higher risk for feeding difficulties, respiratory distress, jaundice, neurodevelopmental delay, hypoglycemia, infection, and thermoregulation than their term counterparts. • RDS, retinopathy of prematurity, and chronic lung disease (BPD) are associated with preterm birth. • High-risk infants must be observed for respiratory distress and other early signs of physiological distress. • The adaptation of parents to preterm or high-risk infants differs from that of parents of term newborns. • SGA infants are considered to be at risk because of fetal growth restriction. • Health concerns of post-term infants are related to the progressive placental insufficiency that can occur in a post-term pregnancy. • Infants born to diabetic mothers (gestational or otherwise) are at risk for hypoglycemia, RDS, and birth asphyxia and trauma. • Metabolic abnormalities of diabetes mellitus in pregnancy adversely affect embryonic and fetal development. • Parents need special instruction (e.g., CPR, oxygen therapy, suctioning, developmental care) before they take a high-risk infant home. • Specially trained nurses may transport high-risk newborns to and from special care units.

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Landon, M. B., Catalano, P. M., & Gabbe, S. G. (2017). Diabetes mellitus complicating pregnancy. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Lawrence, R. A., & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. Leisjer, L. M., Miller, S. P., van Wezel-Meijler, G., et al. (2018). Posthemorrhagic ventricular dilatation in preterm infants—When best to intervene? Neurology, 90(8), e698–e706. https://doi.org/10.1212/ WNL.0000000000004984. Lund, C. H., & Kuller, J. M. (2020). Integumentary system. In C. Kenner, L. B. Altimier, & M. V. Boykova (Eds.), Comprehensive neonatal nursing care (6th ed.). Springer. Lund, C. H., & Osborne, J. W. (2004). Validity and reliability of the neonatal skin condition score. Journal of Obstetrics, Gynecology and Neonatal Nursing, 33 (3), 320–327. Merhar, S. L., Thomas, C. W. (2020). Intracranial-intraventricular hemorrhage and periventricular leukomalacia. In R. M. Kliegman, J. W. St Geme, N. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Morassutti, F. R., Cavallin, F., Zaramella, P., et al. (2015). Association of rewarming rate on neonatal outcomes in extremely low birth weight infants with hypothermia. Journal of Pediatrics, 167(3), 557–561. Mutanen, A., & Wales, P. W. (2018). Etiology and prognosis of pediatric short bowel syndrome. Seminars in Pediatric Surgery, 27(4), 209–217. doi.org/ 10.1053/j.sempedsurg.2018.07.009. Narvey, M. R., & Canadian Paedatric Society, Fetus and Newborn Committee. (2016). Assessment of cardiorespiratory stability using the infant car seat challenge before discharge in preterm infants (18 hours Premature labour Maternal urinary tract infection

Newborn

Twin or multiple gestation Male infant Meconium aspiration Congenital anomalies of skin or mucous membranes Galactosemia Absent spleen Low birth weight or prematurity Malnourishment Prolonged hospitalization Multiple interventions

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in other infants are prevented, and effects on the infant’s subsequent growth and development can be anticipated. Invasive fungal infections have become an increasing concern for preterm infants. Predisposing factors include a prolonged course of antibiotics and altered skin integrity. Candida and Malassezia species are pathogens most frequently implicated in fungal infections. Infection by any pathogen continues to be a significant factor in fetal and neonatal morbidity and mortality in Canada.

Nursing Care The antenatal record should be reviewed for risk factors associated with infection and the signs and symptoms suggestive of infection. Maternal vaginal or perineal infection may be transmitted directly to the newborn during passage through the birth canal. Psychosocial history and history of sexually transmitted infections (STIs) may indicate possible human immunodeficiency virus (HIV), hepatitis B virus (HBV), or herpes (type 2). Perinatal events should also be reviewed. Premature rupture of membranes (PROM) may be caused by maternal or intrauterine infection. Ascending infection may occur after prolonged PROM, prolonged labour, or intrauterine fetal monitoring. In some cases infection may contribute to early rupture or occur with intact membranes. A maternal history of fever during labour or the presence of foul-smelling amniotic fluid may also indicate chorioamnionitis. Antibiotic therapy initiated during labour should be noted. The newborn’s gestational age and birth weight affect the incidence and severity of infection. The newborn needs to be assessed for respiratory distress, temperature instability, skin abscesses, petechial rashes, and other indications of infection. The earliest clinical signs of newborn sepsis are characterized by a lack of specificity. The nonspecific signs include lethargy, poor feeding, poor weight gain, and irritability. The nurse or parent may simply note that the newborn is not doing as well as before. Differential diagnosis may be difficult because signs of sepsis are similar to signs of noninfectious newborn conditions such as hypoglycemia and respiratory distress. Additional clinical and laboratory information, including cultures, will substantiate the findings described. Table 29.4 outlines the clinical signs associated with newborn sepsis. Laboratory studies are important in assessing for newborn infection. Specimens for cultures include blood, cerebrospinal fluid (CSF), and urine. A complete blood cell count (CBC) with differential should be performed to assess for increased or decreased white blood cell count, both of which may signal sepsis. The total neutrophil count, immature to total neutrophil (I/T) ratio, absolute neutrophil count (ANC), and C-reactive protein may be also be used in determining the possibility of sepsis. It is important to note that these tests are often adjuncts for the confirmation of newborn sepsis; a combination of these tests and clinical signs often alert the practitioner to the need for treatment. Additional diagnostic tests that may be used to identify or exclude newborn sepsis include sedimentation rate, interleukins (IL-8, IL-2, IL-6, and IL-1β), and nucleic acid amplification testing (NAAT). Antepartum viral infection can now be treated successfully with a number of antiviral medications to decrease viral replication and fetal transmission of disease; newborns may also be treated with antiviral medications such as acyclovir and ganciclovir. In high-risk newborns with significant illness, antiviral or antibiotic treatment may begin once cultures are obtained. When the pathogen is identified, antibiotic, antiviral, or antifungal therapy may be narrowed to target the specific organism. Principles of antibiotic stewardship contribute to the future health and well-being of newborns; ensuring the right antibiotic is used to eradicate the identified organism without undue prolongation is essential. Culture-negative sepsis continues to present uncertainty and creates treatment dilemmas for neonatal health care providers.

TABLE 29.4

Sepsis∗

Clinical Signs of Newborn

System

Signs

Respiratory

Apnea, bradypnea Tachypnea Grunting, nasal flaring Retractions Decreased oxygen saturation

Cardiovascular

Bradycardia or tachycardia Hypotension Decreased perfusion Metabolic acidosis

Central nervous

Temperature instability Lethargy, reduced spontaneous movements Hypotonia Irritability, seizures

Gastrointestinal

Feeding intolerance Abdominal distension Vomiting, diarrhea Hematochezia

Integumentary

Jaundice Pallor Petechiae Mottling

∗ Laboratory findings include neutropenia, increased immature white cells, hypoglycemia or hyperglycemia, metabolic acidosis, and thrombocytopenia. Modified from Askin, D. F. (1995). Bacterial and fungal sepsis in the neonate. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(7), 635–643.

The newborn requires continuous assessment for sequelae to septicemia, which include meningitis, disseminated intravascular coagulation (DIC), pneumonia, and septic shock. Septic shock results from the toxins released into the bloodstream. The most common signs of septic shock include decreasing oxygen saturation, respiratory distress, tachycardia, and evolving features of hemodynamic instability with reduced cardiac output (prolonged capillary refill, cool extremities, mottling, reduced urine output). Monitoring an IV infusion and administering antibiotics are important nursing responsibilities. It is important to administer the prescribed dose of antibiotic within 1 hour after it is prepared in order to avoid loss of medication stability. If the IV fluid that the infant is receiving contains electrolytes, vitamins, or other medications, the nurse should ensure compatibility with the antibiotic prior to administration. The antibiotic (or other medication) may be deactivated or may form a precipitate when combined with other medications. Care must be taken in suctioning secretions from any newborn’s oropharynx or trachea. Routine suctioning is not recommended and may further compromise the infant’s immune status, cause hypoxia, and increase ICP. Efforts should also be made to prevent ventilatorassociated pneumonia in infants on mechanical ventilation. Isolation procedures are implemented as indicated according to hospital practices, based on method of pathogen spread.

Prevention. As key members of the interprofessional team, nurses are responsible for minimizing or eliminating environmental sources of infectious agents in the nursery. Hand hygiene remains the single most effective measure to reduce infection. Additional measures to be taken

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include routine practices, careful and thorough cleaning of contaminated equipment, frequent replacement of used equipment (e.g., changing IV and nasogastric tubing per hospital protocol; cleaning resuscitation and ventilation equipment, IV pumps, and isolettes), and appropriate disposal of contaminated linens and diapers. Overcrowding must be avoided in nurseries. Guidelines regarding infection control, space, and visitation in areas where newborns receive care have been established and should be followed. The newborn’s skin, its secretions, and normal flora are natural defenses that protect against invading pathogens, thus care practices that preserve this protection should be used. Warm water may be used to remove blood and meconium from the newborn’s face, head, and body. A mild nonmedicated soap (in single-use container) can be used with careful water rinsing. Vernix caseosa should not be scrubbed vigorously for removal, since this further disrupts the skin barrier properties. Breastfeeding (for medically stable infants) or feeding expressed breast milk is encouraged. Breast milk provides protective mechanisms against infection. Colostrum contains IgA, which offers protection against infection in the gastrointestinal tract. Human milk contains iron-binding protein that exerts a bacteriostatic effect on E. coli. Human milk also contains macrophages and lymphocytes. The vulnerability of infants to common mucosal pathogens such as respiratory syncytial virus (RSV) may be reduced by passive transfer of maternal immunity in the colostrum and breast milk. There is evidence that early enteral feedings with human milk are beneficial in establishing a natural barrier to infection in ELBW and VLBW infants. Human milk is also thought to provide some degree of protection from necrotizing enterocolitis (NEC) (Rodriguez & Caplan, 2015) (See Necrotizing Enterocolitis, Chapter 28). Probiotics are nutritional supplements comprised of live microorganisms that, when administered in adequate amounts, may provide benefit to healthy gut flora. Different strains of probiotics lead to different biological activities; administration of certain probiotics in infants can lead to an enhanced gut barrier and contribute to inhibition of gut colonization by pathogens (Marchand & CPS Nutrition and Gastroenterology Committee, 2012/2019). Evidence supports the use of probiotics in preterm infants for prevention of late-onset sepsis and NEC (Dermyshi et al., 2017).

NURSING ALERT Artificial and natural long fingernails worn by nurses have been associated with serious newborn infection and morbidity from Pseudomonas aeruginosa and Klebsiella organisms in the NICU. Therefore, nurses caring for newborns should keep their fingernails short.

CONGENITAL INFECTIONS The range of pathological conditions produced by infectious agents is large, and the difference between the maternal and fetal effects caused by any one agent is also great. Some maternal infections, especially during early gestation, can result in fetal loss or malformations because the fetus’s ability to handle infectious organisms is limited and the fetal immunological system is unable to prevent the dissemination of infectious organisms to various tissues. Not all prenatal infections produce teratogenic effects. Some viral agents can cause remarkably similar manifestations, and it is common to test for all of them when a prenatal infection is suspected. The acronym TORCH stands for a group of infectious diseases that may contribute to newborn illness and negative long-term sequelae: T—Toxoplasmosis O—Other (e.g., HBV, parvovirus, HIV, West Nile)

697

R—Rubella C—CMV infection H—Herpes simplex To determine the causative agent in a symptomatic newborn, tests are performed to rule out each of these infections. The O category may involve testing for several viral infections (e.g., HBV, varicella zoster, measles, mumps, HIV, syphilis, and human parvovirus). Bacterial infections are not included in the TORCH workup because they are usually identified by clinical manifestations and readily available laboratory tests. Several maternal infections, their possible effects, and specific nursing considerations are outlined in Table 29.5.

Chlamydia Infection Chlamydia trachomatis is an intracellular bacterium that causes ophthalmia neonatorum and pneumonia. Symptoms of ophthalmia neonatorum include eye discharge, pain and tenderness in the eye, and swollen eyelids; complications may include corneal scarring, ocular perforation, and permanent vision loss (Public Health Agency of Canada [PHAC], 2017). The organism may spread to the lungs from nasal secretions if left untreated, causing chlamydia pneumonia in about 33% of infected newborns (see Clinical Reasoning Case Study: Newborn With Chlamydia). Administration of prophylactic antibiotic eye drops to newborns within 1 to 2 hours after birth is presently recommended for newborns and is mandatory by law in most provinces and territories, although the practice is not supported by the Canadian Paediatric Society (CPS, 2019; Moore et al., 2015/2018) (see Chapter 26, Eye Prophylaxis). ?

CLINICAL REASONING CASE STUDY

Newborn With Chlamydia An 8-day-old male infant with eye drainage for 2 days is brought to the pediatric urgent care centre by Savannah, his 22-year-old mother. Savannah is breastfeeding and states that she was diagnosed and partially treated for sexually transmitted infections in late pregnancy; she does not remember the name but says one started with a “C.” The medications made her stomach sick, so she quit taking them after 2 days. The practitioner examines the newborn, who has a purulent yellowish discharge from both eyes but otherwise appears healthy; they suspect chlamydial conjunctivitis and orders cultures of the eye drainage. The retrieved medical record from the newborn’s birth indicates that eye prophylaxis with erythromycin ophthalmic ointment was administered. Questions 1. Evidence: Is there sufficient evidence to draw conclusions about the cause of the infant’s eye drainage? 2. List the treatments that might be ordered for the newborn and for Savannah. 3. What are the sequelae of inadequate chlamydia infection? 4. What is the evidence related to prophylaxis at birth? 5. What nursing intervention(s) should be implemented? Identify which have the highest priority. 6. Identify important patient-centred outcomes with reference to your nursing interventions.

Cytomegalovirus Infection Congenital cytomegalovirus (CMV) infection is a leading infectious cause of hearing impairment and cognitive delay in infants and children; there is no effective and safe immunization against CMV (Yinon et al., 2018). Transmission to the fetus may occur through primary or secondary infection; probability of intrauterine transmission following primary maternal infection is 30 to 40%, while the

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TABLE 29.5

Newborn

Infections Acquired From the Mother Before, During, or After Birth∗

Fetal or Newborn Effect

Transmission

Nursing Considerations†

Human Immunodeficiency Virus (HIV) No significant difference between infected and uninfected newborns at birth in some instances

Transplacental; during vaginal birth; potentially in breast milk

Administer combination antiretroviral prophylaxis to HIVpositive mother; prophylaxis to prevent perinatal transmission may begin after first trimester. Choice of regimens is determined by examining a number of factors, including mother’s current treatment. Detailed recommendations can be obtained from the SOGC (Loutfy et al., 2018). HIV-exposed newborns should commence antiretroviral prophylaxis within 48 hours of birth (Moore et al., 2019). Vaginal birth may be considered according to maternal viral load; discussion with health care provider is required. HIV-positive mothers in developed countries should avoid breastfeeding (see Chapter 27, Contraindications to Breastfeeding).

First trimester (fetal varicella syndrome); perinatal period (infection)

Provide varicella zoster immunoglobulin or IVIG to newborns born to mothers with onset of disease within 5 days before or 2 days after birth; antiviral therapy may also be indicated. Healthy term newborns exposed postnatally to varicella are protected by maternal IgG antibody; VZIG prophylaxis is not indicated (Kett, 2013). Institute isolation precautions in infant born to mother with varicella up to 21–28 days (latter time if newborn received varicella zoster immune globulin or IVIG after birth [if hospitalized]).† Prevention: Immunize all children with varicella vaccine.

Last trimester or postpartum period

Treat with oral erythromycin or oral sulfonamide for 14 days; a second course of erythromycin may be required, and follow-up of exposed infant is recommended.

Chickenpox (Varicella-Zoster Virus [VZV]) Intrauterine exposure—congenital varicella syndrome: limb dysplasia, microcephaly, cortical atrophy, chorioretinitis, cataracts, cutaneous scars, other anomalies, auditory nerve palsy, motor and cognitive delays Severe symptoms (rash, fever) and higher mortality in newborn whose mother develops varicella 5 days before to 2 days after birth

Chlamydia Infection (Chlamydia trachomatis) Conjunctivitis, pneumonia

Coxsackievirus (Group B Enterovirus [Nonpolio], Parechovirus) Poor feeding, vomiting, diarrhea, fever; cardiac enlargement, Peripartum arrhythmias, heart failure; lethargy, seizures, meningoencephalitis, pneumonitis Mimics bacterial sepsis Cytomegalovirus (CMV) Variable manifestation from asymptomatic to severe Microcephaly, cerebral calcifications, chorioretinitis Jaundice, hepatosplenomegaly Petechial or purpuric rash (Figure 29.4) Neurological sequelae—seizure disorders, sensorineural hearing loss, cognitive impairment

Parvovirus B19 (Erythema Infectiosum) Fetal hydrops and death from anemia and heart failure with early exposure Anemia with later exposure No teratogenic effects established Ordinarily low risk of adverse effect to fetus

Treatment is supportive. Provide IVIG in newborn infections.

Perinatal period

Infection acquired at birth, shortly thereafter, or via human milk is not associated with clinical illness in term newborns. Exposed preterm infants may have systemic infection, including interstitial pneumonia. Affected individuals excrete virus. Pregnant patients should avoid close contact with known cases. Infected newborns may require antiviral treatment for several weeks.

Transplacental

In pregnant patients with diagnosed infection serial ultrasonography to assess for fetal hydrops or anemia. Conduct cordocentesis to determine need for intrauterine transfusion if hydrops is present (Crane & SOGC Maternal Fetal Medicine and Infectious Diseases Committees, 2014). Aggressive cardiovascular and respiratory support is required in newborns with hydrops. Pregnant health care workers should not care for patients who might be highly contagious (e.g., child with sickle cell anemia, aplastic crisis). Occupational exposure should be minimized in pregnant patients without immunity. Continued

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TABLE 29.5

The Newborn at Risk: Acquired and Congenital Conditions

699

Infections Acquired From the Mother Before, During, or After Birth—cont’d

Fetal or Newborn Effect

Transmission

Nursing Considerations

Gonorrhea (Neisseria gonorrhoeae) Ophthalmitis Neonatal gonococcal arthritis, septicemia, meningitis

Last trimester or postpartum period

Healthy newborns exposed to N. gonorrhoeae require conjunctival culture and a single dose of IV/IM antibiotic; newborns with confirmed ophthalmia, scalp abscess, or disseminated infection should be hospitalized and cultures obtained to determine antimicrobial treatment (Moore et al., 2015/2018). Consider testing newborn for Chlamydia, HIV, and syphilis. Irrigate newborn’s eyes with saline until discharge is eliminated.

Transplacental; contaminated maternal fluids or secretions during birth

Administer HBIG to all newborns of HBsAG-positive mothers within 12 hours of birth; in addition, administer HepB vaccine at separate site. Prevention—Screen all pregnant patients. Infants born to HBsAG-positive mothers and weighing 85% of cases transmitted at birth (Money & Steben, 2017) Direct transmission from infected personnel or family

Absence of skin lesions in newborn exposed to maternal HSV does not indicate absence of disease. Contact precautions (in addition to routine precautions) should be instituted. It is recommended that swabs of mouth, nasopharynx, conjunctivae, rectum, and any skin vesicles be obtained from exposed newborn; in addition, urine, stool, blood, and CSF specimens should be obtained for culture. Therapy with IV antiviral is initiated if culture results are positive or if there is strong suspicion of herpes virus infection. Treatment is for 14 days if limited to SEM and 21 days if CNS involvement; ophthalmic treatment is required for ocular involvement in addition to IV antiviral. Therapy with oral agents for 6 months is recommended for infants with HSV CNS disease (Money & Steben, 2017). Breastfeeding is encouraged if there are no lesions on the mother’s breast.

Acquired perinatally; intrapartum antibiotics decrease early-onset but not late-onset disease.

Broad-spectrum IV antibiotics are recommended for newborns with presumptive GBS infection; in newborns who are positive for GBS, antibiotic choice will be tailored to organism sensitivity.

CBC, Complete blood count; CNS, central nervous system; CSF, cerebrospinal fluid; HBIG, hepatitis B immunoglobulin; HBsAG, hepatitis B surface antigen; IM, intramuscular; IUGR, intrauterine growth restriction; IV, intravenous; IVIG, intravenous immunoglobulin; LBW, low-birth-weight; LFT, liver function test; SEM, skin, eye, and mouth; SOGC, Society of Obstetricians and Gynaecologists of Canada; VZIG, varicella zoster immunoglobulin. ∗ This table is not an exhaustive representation of all perinatally transmitted infections. For further information regarding specific diseases or treatment not listed here, refer to American Academy of Pediatrics (AAP) Committee on Infectious Diseases, Pickering, L. (Ed.). (2018). 2018 Red book: Report of the Committee on Infectious Diseases (31st ed.). AAP. † Isolation precautions depend on institutional policy.

Fig. 29.5 Neonatal syphilis lesions on hands and feet.

Fig. 29.4 Neonatal cytomegalovirus infection. Shown here is a typical rash in a severely affected infant.

transmission rate substantially decreases to approximately 1% after a secondary infection (Yinon et al., 2018). Routine screening in pregnancy does not occur. Newborns with congenital CMV may experience intrauterine growth restriction, microcephaly, hepatosplenomegaly, thrombocytopenia, and/or jaundice at birth. Hearing impairment may not be apparent until after the first year of life (Goderis et al., 2014). Approximately 20 to 30% of symptomatic infants will die of DIC and liver dysfunction (Yinon et al., 2018). See Table 29.5 for further discussion of CMV.

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701

Hepatitis B Virus (HBV) Transmission of HBV occurs more often at birth or in the immediate postpartum period rather than transplacentally. However, risk of infection increases to 50 to 70% with maternal hepatitis occurring late in pregnancy. Hepatitis B surface antigen (HBsAg) is produced and detected in acute and chronic hepatitis B infections. Screening for HBsAg occurs for pregnant patients during routine antenatal care. Antiviral therapy may be warranted, pending viral load of the pregnant patient. Infants born to mothers who are HBsAg positive or of unknown status should be passively immunized with hepatitis B immunoglobulin (HBIG) and also receive hepatitis B vaccine within 12 hours of birth (Baley & Gonzalez, 2020) (see Chapter 26, Immunizations). Completion of the vaccination schedule should occur by 6 months. Infants born to mothers who received treatment for HBV during pregnancy still require passive and active vaccinations at birth. Vaccination for newborns not exposed to maternal HBV is provided in some provinces before discharge from the hospital. Breastfeeding may be initiated prior to receiving the vaccine; the risk of mother-to-child transmission through breastfeeding is negligible if newborns receive vaccinations at birth (Centers for Disease Control and Prevention [CDC], 2020b).

Herpes

In Canada, the overall rate of reported cases of gonorrhea increased by more than 109% between 2008 and 2017; 63% of gonorrhea cases are resistant to at least one antibiotic (PHAC, 2019). The incidence of gonococcal infection in pregnant patients ranges from 2.5 to 7.3%. After rupture of membranes, ascending Neisseria gonorrhoeae infection can be transmitted to the fetus or be transmitted during vaginal birth. The organism may invade mucosal surfaces such as the conjunctiva (ophthalmia neonatorum), rectal mucosa, and pharynx. Legislation exists in many parts of Canada that mandates ocular prophylaxis administered shortly after birth; however, routine provision may no longer be useful (Moore et al., 2015/2018).

Herpes simplex virus (HSV) infection in the pregnant patient causes a high risk of morbidity and mortality in the newborn. Pregnant patients who experienced HSV infection prior to pregnancy will have developed antibodies that will be passed to the fetus across the placenta; it is less common for newborns to develop herpes infection from a parent with recurrent disease. However, newborn infection remains possible if a recurrence of a genital HSV lesion is present at the time of a vaginal birth. Primary infections occurring in the first or second trimester may lead to spontaneous abortion or cause fetal growth restriction. Newborn herpes infections are typically acquired at or near birth from a parent experiencing primary genital infection, of which two-thirds of patients may be asymptomatic. Elective Caesarean birth is recommended for pregnant patients who experience recognizable HSV as a primary occurrence in the third trimester (Money & Steben, 2017). Breastfeeding is contraindicated if the postpartum patient has an active lesion on their breast.

Group B Streptococcus

Human Immunodeficiency Virus (Type 1)

Group B streptococci (GBS) are Gram-positive organisms that can lead to newborn GBS disease as bacteremia, meningitis, or pneumonia. Universal antepartum maternal screening and administration of penicillin have significantly decreased the incidence of GBS; however, it remains a significant cause of newborn mortality in North America. Approximately one in four pregnant patients are colonized in the lower urogenital tract with GBS; routine screening with a vaginorectal swab at 35 to 37 weeks of gestation is recommended for all pregnant patients, even for those with planned Caesarean births (Money & Allen, 2018). Intrapartum antibiotics should be provided for any labouring patient positive for GBS on vaginorectal culture, any patient with a newborn previously infected with GBS, or any patient who experienced a confirmed GBS bacteriuria in the current pregnancy (Money & Allen, 2018). GBS remains the leading cause of sepsis in term newborns; approximately 80% of cases present within 24 hours of birth. Risk factors for newborn GBS infection include less than 37 completed weeks of gestation at birth, prolonged rupture of membranes greater than 18 hours, and maternal fever during labour (Money & Allen, 2018). In the newborn with presumed or confirmed GBS infection, ampicillin or penicillin and an aminoglycoside are the therapy of choice (Jefferies & CPS Fetus & Newborn Committee, 2017).

Vertical transmission of HIV occurs in less than 2% of pregnancies in Canada (Moore & Allen, 2019). Some transmissions occur in utero but most occur at the time of birth. If there have been no interventions undertaken during pregnancy, at birth, or during the newborn period, HIV transmission may occur in up to 25% of cases (Moore et al., 2019). Documented routine HIV education and routine testing with consent are recommended for all pregnant patients in Canada (Keenan-Lindsay & Yudin, 2017). Labouring patients with undocumented HIV status undergo rapid HIV testing; if maternal screening is not achievable, newborns should undergo rapid HIV antibody testing. Commencing antiretroviral prophylaxis in the newborn requires thoughtful consideration and evaluation of risk while awaiting test results; initiation of prophylaxis should occur no later than 72 hours after birth. See Table 29.5 for further discussion of HIV infection in the newborn. Although it is rare for an infant to be born with symptoms of HIV infection, all newborns born to seropositive mothers should be presumed to be HIV positive until proven otherwise. Newborn HIV antibody testing is required; breastfeeding should be deferred until antibody test results are confirmed negative. Nursing care begins by implementing routine practices. Measures should also be taken to protect the newborn from further exposure to maternal blood and body fluids.

Fig. 29.6 Herpes simplex virus oral lesions. (Courtesy David A. Clarke.)

Gonorrhea

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Parvovirus B19 Parvovirus B19 is well known in older children as fifth disease or “slapped cheek illness” because of the characteristic facial appearance of the affected child. Transmission typically occurs through respiratory droplet contact; vertical transmission may occur in persons without established immunity prior to pregnancy. The most common adverse fetal outcome associated with infected fetuses is hydrops fetalis (Baley & Gonzalez, 2020). The estimated risk of transplacental transmission is approximately 30%, and fetal death may occur in about 9% of those affected (see Table 29.5).

Rubella Infection A pregnant patient infected with rubella has a 90% chance of transmitting the disease to the fetus (Government of Canada, 2015). Vaccination failures, failure to complete recommended vaccination schedule, and the immigration of unimmunized persons result in periodic outbreaks of rubella, also known as German measles. Congenital rubella is rare; most cases occur after primary maternal infection that causes viremia and intrauterine transmission (Baley & Gonzalez, 2020). The risk for congenital anomalies varies with the fetus’s gestational age at the time maternal infection occurs. Abnormalities are most severe if the mother contracts the virus during the first trimester, with occurrence of congenital defects as high as 85% in the first 12 weeks of gestation; infection during this time may also result in miscarriage or stillbirth (Baley & Gonzalez, 2020). Hearing impairment, a common finding, appears to be progressive after birth. Defects of the eyes, central nervous system (CNS), and heart are also associated with congenital rubella. Microcephaly, significant cognitive and behavioural challenges, and learning issues are prevalent for children with a history of congenital rubella. Screening for rubella immunity in pregnant patients occurs during routine antenatal care. Passive and active immunization do not provide benefit to the newborn at birth as the effects of congenital rubella have already transpired. See Table 29.5 for further discussion.

Syphilis Rates of reported syphilis infections in Canada have increased by 167% from 2008 to 2017 (PHAC, 2019). It is estimated that for every 100 pregnant patients diagnosed with primary or secondary disease, 2 to 5 newborns will contract congenital syphilis. Vertical transmission of syphilis can occur; if syphilis (primary or secondary) during pregnancy is left untreated, 70 to 100% of newborns born to these patients will have symptomatic congenital syphilis. In approximately 40% of pregnancies, fetal demise may occur (Robinson & CPS Infectious Diseases and Immunization Committee, 2009/2018). The most severely affected infants are born to untreated mothers. Breastfeeding in persons with syphilis is not contraindicated unless open lesions are present on the breast, including the nipple and areola. See Table 29.5 for further discussion.

NURSING ALERT The newborn with congenital syphilis may be entirely asymptomatic until after discharge from the hospital. It is therefore imperative that caregivers use routine precautions with all newborns.

Tuberculosis Congenital tuberculosis (TB) is rare. Caused by an in utero infection with Mycobacterium tuberculosis, the fetus may become infected transplacentally or by aspiration of amniotic fluid (Li et al., 2019). Canada has approximately 4.9 cases of TB per 100 000 people; however, a disproportionate increase in incidence of 21.5 cases per 100 000 people has

occurred among Canadian-born Indigenous people (Government of Canada, 2019). Additionally, adult refugees newly immigrated to Canada from global locations with a high incidence of the disease who have latent TB are at increased risk of developing active TB disease. Poverty, inadequate housing, and overcrowding are significant risk factors for TB. Clinical features of congenital TB can be nonspecific: respiratory distress, lethargy, persistent fever, hepatosplenomegaly, and poor feeding (Esper, 2020). After birth, exposed newborns contract TB through inhalation of infected droplets expelled by infected individuals, which results in pneumonia and necrosis of lung tissue. Treatment consists of a combination of antituberculosis agents and may be required for several months. Maternal–infant separation may be indicated if the mother tests positive for TB and has symptoms of active TB disease (Esper, 2020). Expressed breast milk may be administered, as the tubercle bacillus is passed through respiratory droplets, not breast milk (Gardner et al., 2021).

Varicella Zoster The varicella zoster virus responsible for chickenpox and shingles is a member of the herpes family. About 90% of persons in their childbearing years are immune; therefore, the risk of infection in pregnancy is low (Shrim et al., 2018). Maternal varicella infection in early pregnancy may cause congenital malformations including cerebral atrophy, hydronephrosis, and limb anomalies in the fetus. Newborn infection is more likely to occur when maternal infection occurs less than 5 days prior to birth; 30 to 40% of newborns will develop infections even if varicella zoster immune globulin is administered to the mother (Shrim et al., 2018). Optimal newborn care includes varicella zoster immunoglobulin and immunization. See Table 29.5 for more information.

Zika Zika virus is a mosquito-borne flavivirus; outbreaks of Zika virus disease have occurred worldwide since 2007 (World Health Organization [WHO], 2018). The bite of an infected mosquito, found mainly in tropical and subtropical regions, functions as the vector for infectious pathogen transmission to humans. Zika virus is also transmitted from the pregnant parent to the fetus in utero and can cause severe microcephaly, limb contractures, ocular abnormalities, and other neurological findings. Zika virus has also been found in breast milk, although transmission has not been confirmed. Zika virus can also be transmitted through sexual intercourse. There is no vaccine to prevent or treatment available for Zika virus disease. Sexually active men and women living in regions with active Zika virus require counselling regarding risk of transmission and contraceptive methods to prevent adverse fetal outcomes (WHO, 2018).

Candidiasis Candidiasis is a fungal infection most commonly caused by Candida albicans, a species of Candida (CDC, 2020a). Candidiasis is not a congenital infection but rather an infection that occurs after birth. Oral candidiasis, also known as oral thrush, may develop even in the first week of life and presents as creamy-white patches on the tongue or buccal mucosa. The white patches are easily differentiated from milk curds; the patches cannot be removed and may bleed when touched. In most cases the infant does not seem to be in discomfort from the infection; however, some will pull away from the breast or bottle and cry. Topical application of nystatin suspension over the surfaces of the oral cavity is usually sufficient to prevent spread of the disease and limit its course. Several other topical antifungal agents may be used, including miconazole or clotrimazole. To prevent relapse, therapy should be continued for at least 2 days after the lesions disappear (Lawrence & Lawrence, 2016). Infants who are breastfed may acquire thrush from the

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breastfeeding parent. Candida may be present on the nipples of breastfeeding parents; if the parent is colonized, antifungal treatment for the parent is recommended to prevent reinfection in the infant. Cessation of breastfeeding is not necessary, even if the breastfeeding parent is receiving systemic antifungal medications (Lawrence & Lawrence, 2016).

NURSING ALERT Nystatin is best absorbed when given 1 hour after a feeding. Using a needleless syringe or medicine dropper, apply the medication to each side of the infant’s mouth for optimal absorption.

Diaper dermatitis caused by Candida organisms manifests as a moist, erythematous eruption with a sharply demarcated edge and small white or yellow pebbly pustules; satellite lesions may extend beyond the larger lesion. Small areas of skin erosion may also be seen. Candida diaper dermatitis appears on the perianal area and inguinal folds and may include the lower portion of the abdomen. When possible, exposing the perineal area to dry air is recommended. Topical antifungal ointments assist in coating the skin and repelling moisture while treating the fungal ailment (see Chapter 52, Diaper Dermatitis).

Nursing Care Trends in emerging infections command exemplary nursing practices. Careful hand hygiene remains the single most important nursing intervention in reducing the spread of any infection. Astute recognition of risk factors and subtle changes in clinical condition assists the health care team in initiating processes to identify causative organisms of infectious processes. Implementing isolation precautions to further minimize transmission of disease may be required. Cohorting colonized patients with dedicated staff can also assist in containing infection outbreaks. Antimicrobial stewardship is pivotal in combatting antibiotic resistance; nursing staff play a pivotal role in educating families regarding the importance of optimal selection of medication and adherence to the full course of medication that is ordered, in order to lead to optimal clinical outcomes for newborns experiencing infections.

ADVERSE EXPOSURES AFFECTING NEWBORNS Adverse exposures during pregnancy include environmental toxicants that may influence critical periods of fetal development and lead to adverse health outcomes. For example, maternal exposure to teratogens, including radiation and chemotherapy, can contribute to congenital malformations, depending on timing and duration. Paternal occupations, including exposure to solvents and pesticides, have also been linked to an increased prevalence of congenital anomalies (Falck et al., 2020). Many medications and other substances easily cross the placenta and affect fetal brain development, as well as impact the pregnant patient’s circulation through the uterus and placenta. Additionally, a medication may affect the pregnant patient’s metabolic physiology, resulting in stress hormone secretion that may also affect the fetus (Ross et al., 2015). As a result, in utero substance exposure may elicit a spectrum of responses. For example, the long-reaching effects of fetal alcohol spectrum disorder (FASD) may extend to the next generation through ethanol-related changes to gene expression (Liyanage et al., 2017). The global phenomenon of opioid use has led to an increasing population of newborns that develop a passive dependence driven by prenatal exposure and resulting in withdrawal symptoms after birth. In utero substance exposure does not always lead to signs of withdrawal, nor do all newborns respond in a similar manner. Term

703

newborns experience withdrawal more significantly than preterm infants, likely because of CNS developmental immaturity in the preterm baby; males may be more affected than females (Bagwell, 2020). Data from across Canada reflect a rise in newborn withdrawal. Between 2013 and 2017, there was an increase in incidence of neonatal abstinence syndrome (NAS) by 21% (Canadian Institute for Health Information, 2018). Nurses are well positioned to observe and identify signs of withdrawal in a newborn’s early days of life, as well as provide support and education to families. Maternal substance use may be difficult to determine, as guilt and fear may drive inaccurate responses at the time of screening. Information can be garnered by asking questions privately in a nonjudgemental manner. Drug dependence in pregnancy does not sit within a homogeneous profile; persons of all ages, ethnicities, and socioeconomic backgrounds experience drug dependence. Polydrug use occurs frequently; thus nurses need to ask questions specific to the use of prescription medications, over-the-counter drugs, nutritional supplements, legal substances including alcohol, tobacco, and marijuana, and illicit or other recreational drugs. Newborn toxicology screens can be completed on urine and meconium, although both present benefits and challenges to their use. Newborn urine toxicology screens will reflect recent substance exposure only; infrequent maternal substance use or use prior to 1 week before birth may not be detected. Meconium toxicology screening helps in detecting substance exposure in the last trimester. However, specimen collection proves to be challenging and may yield false negatives, particularly when newborn substance exposure is not initially considered during the newborn’s first day or two of life. Hair testing for clinical indications of substance exposure is rarely used. Legal requirements for the drug testing of newborns vary by province; thus health care providers must be aware of the regulations in their location (Ordean et al., 2017).

Neonatal Abstinence Syndrome Initially developed by Dr. Finnegan, the term neonatal abstinence syndrome (NAS) is used to describe the set of behaviours exhibited by newborns exposed primarily to opioids; other substances in utero may also elicit features of withdrawal (Bagwell, 2020). The initial presenting symptoms of withdrawal may be seen at variable times, depending on the amount of in utero substance exposure and the associated principles of pharmacokinetics for the substance. Clinical manifestations may fall into any one or all of the following categories: CNS, and gastrointestinal, respiratory, and autonomic nervous systems. The manifestations become most pronounced between 24 and 72 hours of age and may last from 6 days to 8 weeks, depending on the severity of the withdrawal (Box 29.1). Some effects may not be identified until after the newborn period, possibly not until school age, and can include cognitive and motor delay as well as behavioural issues. Table 29.6 summarizes the effects of commonly used substances on the fetus and newborn. Several assessment tools exist to objectively evaluate symptoms associated with withdrawal and the infant’s response to interventions. The Finnegan Neonatal Abstinence Scoring System tool, or simply referred to as “the Finnegan” (see Figure 29.7), was established in 1975 and remains the mainstay for assessment and management of NAS. Several other scoring tools exist but are not as widely used and therefore will not be explored in this text. Grossman and colleagues (2018) have outlined an alternative approach to assessment for withdrawal that focuses on infant performance related to three parameters: eating, sleeping, and consolability (ESC). Infants exposed to substances in the prenatal period are cared for in the hospital within a setting that facilitates family rooming-in and control over the surrounding environment while being observed for specific outcomes: (1) feed more

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BOX 29.1

Newborn

Signs of Withdrawal in Newborns

Neurological

Autonomic

Gastrointestinal

Miscellaneous

• • • • • • •

• • • • •

• • • • •

• Disrupted sleep patterns • Excoriations (knees, face) • Temperature instability

Irritability Seizures Hyperactivity High-pitched cry Tremors Exaggerated Moro reflex Hypertonicity of muscles

Diaphoresis Fever Mottled skin Nasal stuffiness Tachypnea (>60 breaths/min)

TABLE 29.6

Summary of Effects of Commonly Used Substances on the Newborn Substance

Effects on Newborn

Alcohol

Difficult to diagnose fetal alcohol spectrum disorder (FASD) in newborn period; newborns with in utero exposure to alcohol may have increased irritability, abnormal muscle tone, tremors, weak grasp. Fetal alcohol syndrome (FAS): Facial features include short palpebral fissure (distance between inner and outer corner of eye), flat philtrum (upper lip groove), thin upper lip, flat midface; growth impairment, hyperactivity, cognitive delays, attention deficits, altered receptive and expressive communication. Partial FAS or alcohol-related neurodevelopmental disorder (ARND): These are varying forms of FAS, with cognitive, behavioural, and psychosocial issues without all physical features.

Cannabis

Possible preterm birth, low birth weight, growth restriction

Cocaine

Preterm birth, small for gestational age, microcephaly

Opioids

Low birth weight, small for gestational age, hyperirritability, tremors, inconsolability, sleep pattern disturbance, high-pitched cry, feeding difficulties, loose stools, vomiting, respiratory distress, rarely seizures

Methamphetamine

Small for gestational age, preterm birth, poor weight gain, abnormal sleep patterns, agitation, poor feeding, state disorganization

Tobacco

Preterm birth, low birth weight, increased risk for sudden infant death syndrome

Selective serotonin reuptake inhibitors

Preterm birth, sleep disturbances, tremulousness, high-pitched crying, feeding difficulties

than 30 mL/feed, (2) complete 1 hour of sleep uninterrupted, and (3) are soothed within 5 to 10 minutes of caregiver effort without pharmacological aid (Grossman et al., 2018).

Features of Neonatal Abstinence Syndrome. Maternal opioid use during pregnancy is the primary, but not exclusive, cause of NAS. The presentation of clinical symptoms depends on the type and duration of maternal opioid use, the amount of drug taken, and the time of last use prior to birth. Features of NAS may present shortly after birth, usually

Poor feeding Loose stools Dehydration Vomiting Frantic, uncoordinated sucking

within the first 72 hours (see Figure 29.7). Because of its longer half-life, infants of mothers using methadone (or buprenorphine) may not present with NAS until later in the first week of life (Lacaze-Masmonteil et al., 2020). A high-pitched cry, difficulties in settling, tremors, and poor feeding are hallmark features of NAS.

Opioid Exposure The primary cause of NAS is in utero exposure to maternal use of opioids. Opioid use may be prescribed to reduce pain, may be used illicitly to produce a “high,” or may be used as part of a therapy program to support persons recovering from opioid use disorder. Drugs classified as opioids include but are not limited to codeine, oxycodone, morphine, hydromorphone, fentanyl, and heroin. Buprenorphine and methadone are also opioids that help to prevent withdrawal symptoms without creating a “high” and are therefore used in treatment programs for opioid use disorder. Offspring of mothers treated with buprenorphine have higher birth weights than those exposed to methadone, have shorter hospital stays, and lower NAS scores. Breastfeeding persons in a methadone treatment program are encouraged to breastfeed, regardless of the methadone treatment dosage. Data to indicate the prevalence of opioid use in pregnant patients in Canada are reflected in the number of infants who are treated for NAS. The Canadian Institute for Health Information reported that in 2015–16 approximately 0.52% of all infants born in Canada had NAS (Lisonkova et al., 2019). Opioids cross the placenta; regular in utero exposure to opioids may lead to fetal passive dependence and other sequelae (see Table 29.6). The method of maternal opioid use, such as injection, places mothers at risk for possible bacterial infections or other diseases, including hepatitis or HIV, which can also compound complications for the fetus. Patients using opioids during pregnancy may experience an increased rate of spontaneous abortion. Newborns exposed to in utero opioids may be born prematurely, experience growth restriction, or have LBW (Jackson et al., 2021). Research evaluating neurodevelopmental outcomes, such as compromised school performance, yielded some evidence demonstrating an association with prenatal opioid exposure (Conradt et al., 2019). Social determinants of health affecting children with prenatal opioid exposure include poverty, which also confounds findings and is not uncommon (Conradt et al., 2019). Maintaining the mother–baby dyad intact by rooming-in, instead of admitting the baby to the NICU, helps in optimizing treatment of NAS for medically stable newborns (Lacaze-Masmonteil et al., 2020). Support and encouragement for establishing breastfeeding are recommended.

NURSING ALERT The use of naloxone (Narcan) is contraindicated in infants born to mothers who use opioids because it may exacerbate neonatal abstinence syndrome and contribute to the onset of seizures.

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The Newborn at Risk: Acquired and Congenital Conditions

NEONATAL ABSTINENCE SCORING SYSTEM

Gastrointestinal Disturbances

Metabolic/Vasomotor/Respiratory Disturbances

Central Nervous System Disturbances

System

Signs and Symptoms

Score

Excessive high-pitched (or other) cry Continuous high-pitched (or other) cry

2 3

Sleeps 3 or 4 times/interval)

1

Nasal flaring

2

Respiratory rate >60/min Respiratory rate >60/min with retractions

1 2

Excessive sucking

1

Poor feeding

2

Regurgitation Projectile vomiting

2 3

Loose stools Watery stools

2 3

AM

PM

Comments

Daily weight:

Total Score Initials of Scorer Fig. 29.7 Neonatal Abstinence Scoring (NAS) system, developed by L. Finnegan. (From Nelson, N. [1990]. Current therapy in neonatal-perinatal medicine [2nd ed.]. Mosby.)

705

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Newborn

Fig. 29.8 Child with fetal alcohol syndrome. (From Markiewicz & Abrahamson, 1999.)

Alcohol Exposure Alcohol is the most common teratogen that fetuses are exposed to in North America (Jackson et al., 2021). Alcohol (ethanol and ethyl alcohol) interferes with normal fetal development; the effects on the fetal brain are permanent, and even moderate use of alcohol during pregnancy may cause long-term postnatal difficulties, including impaired

BOX 29.2

parental–infant attachment. Maternal alcohol use during pregnancy can lead to a range of effects known as fetal alcohol spectrum disorder (FASD), which includes fetal alcohol syndrome (FAS), partial FAS (pFAS) and alcohol-related neurodevelopmental disorder (ARND) (Popova et al., 2019). Health Canada (2017) reports that, in Canada, approximately 3 000 babies with FASD are born each year. Popova and colleagues (2019) identified a 2 to 3% prevalence of FASD in a population-based study of 7- to 9-year-old elementary school students. FAS, the most severe form of FASD, may not be easily identifiable at birth; a smooth filtrum, thin vermilion border, and short palpebral fissures comprise the sentinel midfacial dysmorphic features associated with FAS, in addition to growth restriction (Figure 29.8). Damage to the CNS may lead to microcephaly, cognitive and/or behavioural issues, speech and language deficits, and visual motor impairments (Box 29.2). Partial FAS represents a diagnostic classification for infants and children with a confirmed prenatal exposure to alcohol and who may not have all of the physical features of FAS; cognitive and behavioural issues are evident. ARND represents a classification of children with a confirmed prenatal alcohol exposure and cognitive and behavioural issues only. Behavioural symptoms of FAS are nonspecific in newborns. Features include difficulty in establishing respiration, irritability, lethargy, poor suck reflex, and abdominal distension. Fetal abnormalities are not related to the amount of the mother’s alcohol intake per se, but to the amount consumed in excess of the liver’s ability to detoxify it. The liver’s capacity to detoxify alcohol is limited and inflexible; when the liver receives more alcohol than it is able to handle, the excess is continually recirculated until the organ is able to reduce it to carbon dioxide and water. This circulating alcohol has a special affinity for brain tissue. Poor nutritional state, smoking, polydrug intake, and infrequent or lack of prenatal care may compound

Characteristics for Diagnosing Fetal Alcohol Spectrum Disorder (FASD)

Facial Dysmorphia Despite consideration of ethnic norms (i.e., those appropriate for a person’s race), the person exhibits all three of the following characteristic facial features (FAS all three, pFAS any two): 1. Smooth philtrum (University of Washington Lip-Philtrum Guide* rank 4 or 5) 2. Thin upper lip (University of Washington Lip-Philtrum Guide rank 4 or 5) 3. Short palpebral fissures (
tenth percentile) Neurodevelopmental Impairment Evidence of three or more of the following neurodevelopmental domains (FAS, pFAS, ARND): • Microcephaly; abnormal neuroanatomy (e.g., reduction in size or change in shape of the frontal or parietal lobe, corpus callosum, cerebellum, hippocampus or basal ganglia) • Psychological testing to determine impairment of 2 SDs or more below the mean in: • Motor skills • Language (receptive and expressive) • Academic achievement

• • • • •

Memory Attention Executive function, including impulse control and hyperactivity Affect regulation Adaptive behaviour, social skills, or social communication

Maternal Alcohol Exposure • Confirmed prenatal exposure to alcohol • Unknown prenatal exposure to alcohol Criteria for FASD Diagnosis Diagnosis may be made based on either of the two sets of criteria: 1. Three sentinel facial features AND evidence of impairment in three or more of the identified neurodevelopmental domains (or microcephaly in infants and young children); prenatal alcohol exposure confirmed or unknown 2. Absence of all three sentinel facial features with evidence of impairment of three or more identified neurodevelopmental domains AND confirmed prenatal alcohol exposure with estimated dose exposure known to be associated with neurodevelopmental effects

*Astley, S. J. (2013). Validation of the fetal alcohol spectrum disorder (FASD) 4-digit diagnostic code. Journal of Population Therapeutics & Clinical Pharmacology, 20(3), e416–e467. Adapted from Carson, G., Cox, L. V., Crane, J., et al. (2017). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology Canada, 39(9), e220–e254; Cook, J. L., Green, C. R., Lilley, C. M., et al. (2016). Fetal alcohol spectrum disorder: A guideline for diagnosis across the lifespan. Canadian Medical Association Journal, 188(3), 191–197. ARND, Alcohol-related neurodevelopmental disorder; FAS, fetal alcohol syndrome; pFAS, partial fetal alcohol syndrome.

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The Newborn at Risk: Acquired and Congenital Conditions

the effects of alcohol use during pregnancy (May et al., 2013). Newborns born to mothers who are heavy alcohol drinkers may experience significantly more tremors, hypertonia, restlessness, excessive mouthing movements, crying, and inconsolability when compared to newborns who have had in utero exposure to other substances. Nursing care of affected infants involves the same assessment and observations employed for any high-risk newborn. Breastfeeding is not contraindicated; however, poor feeding (breast or bottle) is characteristic of newborns with FAS and can be a significant challenge throughout infancy. The provision of individualized developmental care includes the reduction of noxious environmental stimuli and helping the newborn achieve self-regulation. Special emphasis is placed on monitoring weight gain, assessing feeding behaviours, and devising strategies to promote nutritional intake. There is no cure for FASD; the effects are lifelong. Early diagnosis and access to interventions and resources may assist in providing support for infants and children with FASD, particularly as they enter school years. FASD is recognized as the leading cause of cognitive impairment in children—and it is preventable. There is no safe amount or type of alcohol-based drink to consume at any point during pregnancy (Carson et al., 2017). Pregnant patients who are unable to eliminate alcohol intake may benefit from compassionate and knowledgeable support from professional counsellors trained to assist in harm-reduction strategies.

Tobacco and Nicotine Exposure Nicotine and tobacco products that might be used during pregnancy include nicotine replacement products, e-cigarettes, rolled cigarettes, and chewing tobacco (Bordelon et al., 2019). Smoking and passive exposure to second-hand smoke during pregnancy increases the risk for LBW and preterm birth (Falck et al., 2020). The effects of tobacco on a fetus are listed in Table 29.6. Carbon monoxide found in tobacco smoke may contribute to intrauterine hypoxia and subsequent neurological injury. In utero exposure to nicotine may interfere with normal neurotransmitter function and disrupt formation of neuronal circuits, leading to issues in cognitive and emotional development (Wickstr€ om, 2007). In utero or second-hand exposure, or both, to nicotine from any source, including e-cigarettes and nicotine replacement therapies, may increase the risk of sudden infant death syndrome (SIDS). Smoking cessation during pregnancy decreases risks of associated fetal complications; thus counselling pregnant patients regarding smoking cessation programs is encouraged (see Chapter 5, Substance Use Cessation). Empowering parents through education to establish smoke-free zones at home and in vehicles may assist in reducing the frequency of asthmatic-related events, bronchitis, and ear infections in their children.

Cannabis Exposure Canada implemented legislation in 2018 that legalized nonmedicinal use of cannabis. It is the second most commonly used substance, following alcohol, and is recreationally used for its psychoactive properties (PHAC, 2018). Cannabis is usually smoked or inhaled, but it may also be found in edibles, tinctures, and oils. Cannabis is a plant made up of components known as cannabinoids, two of which are better understood: cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC). CBD does not have psychoactive properties but may be used to help reduce nausea, inflammation, or pain as well as assist in managing seizures. THC is the main psychoactive component and is a cannabinoid receptor agonist, which potentiates the effects of the endogenous cannabinoid system, producing the “high” (Lu & Mackie, 2016). The potency of THC has increased in cannabis used for inhaling; products analyzed in the 1980s demonstrated 3% THC, and in 2015, upwards of 17% potency has been noted. THC crosses the placenta;

707

there is some evidence to suggest that exposure to the fetus may contribute to an increased risk of growth restriction, preterm birth, spontaneous loss, and stillbirth. However, the data are limited by confounders including polydrug use, self-report, and small sample sizes (Thompson et al., 2019). It is recommended that pregnant patients avoid using cannabis in any form, as it may also exert a negative effect on fetal brain development, as well as on behaviour, cognitive, and academic performance throughout infancy and the pediatric years (Corsi et al., 2020; PHAC, 2018). There are extremely limited data on the effects of cannabis use while breastfeeding. Low concentrations of THC are transferred in mother’s breast milk, approximately 2.5% of the maternal dose, with peak transfer concentrations noted at 1 hour after inhaling (Baker et al., 2018). Cannabis exposure through breast milk is very unlikely to benefit the baby and may be harmful, in view of the limited data available on the effects of THC transfer through the placenta. Breastfeeding provides benefits for both mother and infant, particularly the preterm infant. Abstinence from using cannabis while breastfeeding is encouraged, as with alcohol and tobacco use (Ryan et al., 2018). However, if complete abstinence is not possible, the patient can be encouraged to reduce use of cannabis or consider breastfeeding immediately prior to use.

Cocaine Exposure Cocaine is a CNS stimulant and peripheral sympathomimetic. The effects on the fetus are secondary to maternal effects of increased blood pressure, decreased uterine blood flow, and increased vascular resistance. Consequently, the fetus suffers decreased blood flow and oxygenation as a result of placental and fetal vasoconstriction. The difficulties encountered by cocaine-exposed infants can be compounded by maternal polydrug use (see Table 29.6). Inadequate prenatal care, poor nutrition, and use of tobacco, alcohol, and other drugs during pregnancy add to the effects of cocaine exposure in the infant. Sequelae of prenatal cocaine exposure include preterm birth and reduced newborn head circumference, length, and weight. Head growth may be one of the best predictors of long-term development. Early studies of cocaine exposure identified an increased incidence of gastroschisis, genitourinary anomalies, and periventricular and intraventricular hemorrhage; however, meta-analyses have not confirmed these complications (Bandstra et al., 2010). Infants exposed to cocaine in utero do not typically experience features of abstinence syndrome (Jackson et al., 2021). Long-term sequelae for newborns exposed to cocaine may include compromised language, motor, and cognitive skills and an increased risk for learning disabilities. Cocaine has been found in breast milk and may cause the newborn to experience apnea, tremors, and seizures (Jackson et al., 2021). Mothers should be cautioned about these hazards with a strong recommendation to avoid use of breast milk if abstinence from cocaine habits is unlikely. Because mothers and their infants may live in impoverished environments, they are at further risk for lack of child health care, inadequate nutrition, and cognitive delays and may benefit from referral to early intervention programs.

Methamphetamine Exposure Methamphetamine use creates a significant burden of illness across Canada because of its inherent risk for dependence; it readily crosses the blood–brain barrier of the user, which leads to a rapid onset of euphoria and creates the “hook.” Methamphetamine interferes with the neurotransmitters serotonin and norepinephrine, which influence amniotic fluid homeostasis and fetal circulation as well as blood flow through the placenta (Wright et al., 2015). Interruption of the normal neurotransmitter transporter activity contributes to sequelae that negatively affect maternal health and pregnancy. Studies evaluating the fetal and newborn effects of maternal use of methamphetamines in

708

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Newborn

pregnancy are confounded by variables including polydrug use, poverty, and poor maternal nutrition. An increased likelihood of Caesarean birth due to maternal complications, preterm birth, and low birth weight has been reported in infants exposed to methamphetamines in utero; congenital defects are rare (Wright et al., 2015). In the newborn period, infants may experience abnormal sleep patterns, agitation, poor feeding, and state disorganization (Sherman, 2015). The long-term effects of methamphetamine exposure on children remain unclear. It is postulated that, like cocaine, methamphetamine exposure may affect areas of the brain responsible for cognitive and behavioural functioning, with effects more likely to manifest when the child reaches school age (Lester & Lagasse, 2010). Breastfeeding is contraindicated for persons unable to abstain from methamphetamine use.

Selective Serotonin Reuptake Inhibitors Depression is a condition that affects approximately 10% of pregnant patients (Eke et al., 2016). For many patients, selective serotonin reuptake inhibitors (SSRIs) provide an important therapeutic benefit. These medications may result in adverse effects in their newborns, including preterm birth. Congenital malformations, including cardiac anomalies, may occur in infants whose mothers were treated with SSRI therapy in the first trimester, particularly when combined with other adjunctive pharmacotherapy (Olivier et al., 2013). An increased risk of persistent pulmonary hypertension has been reported in newborns exposed to SSRIs early in pregnancy (Cantor Sackett et al., 2009); however, this finding has not been reported consistently (Wilson et al., 2011). Some SSRIs are transferred into breast milk. Breastfeeding newborns whose mothers are taking SSRIs require monitoring for sleep disturbances, irritability, and poor feeding.

Nursing Care Drug dependence and drug misuse in pregnant patients contribute to the growing population of newborns experiencing NAS at birth. Caring for infants experiencing NAS involves both nonpharmacological and pharmacological interventions. Individualized developmental care can be implemented to facilitate the infant’s self-consoling and self-regulating behaviours. Primary nonpharmacological strategies include reducing environmental stimuli, swaddling and rocking the child, and providing feeding on demand (Gomez-Pomar & Finnegan, 2018). Swaddling provides containment; the infant’s arms need to remain flexed with hands in close proximity of the mouth for sucking, as sucking on fingers or hands is a form of self-control and comfort. Organizing of nursing activities and clustering of care reduce the amount of handling and help decrease exogenous stimulation. Offering a pacifier can ease the characteristic frantic, excessive sucking commonly demonstrated as part of the withdrawal process. Volunteer cuddler programs may augment and support the role of nurses and parents for newborns in nursery settings. Breastfeeding, when not contraindicated, may mitigate symptoms and reduce the need for pharmacological therapies. In tandem, these interventions can reduce the severity of NAS symptoms an infant may experience. Hospital settings that facilitate rooming-in for the mother–infant dyad are well positioned to implement the Eat, Sleep, Console (ESC) assessment and supportive approach to treating NAS (Grossman et al., 2018) mentioned earlier. Reports indicate that this approach may result in a reduction in length of hospital stay and in use of pharmacological agents for some infants exposed to methadone (Hudak, 2020). Supportive and nonpharmacological measures may not meet the needs of some infants experiencing NAS. Infants who score 8 or higher on three consecutive assessments using the Finnegan scoring tool (Figure 29.7) warrant consideration for treatment with pharmacological agents (Weiner & Finnegan, 2021). Common single medication therapies include morphine or clonidine to ease the symptoms of NAS;

phenobarbital may also be used as an adjuvant therapy (Gomez-Pomar & Finnegan, 2018). Specific suggestions for providing care to infants experiencing withdrawal are listed in the Guidelines box: Care of the Infant Experiencing Withdrawal.

GUIDELINES Care of the Infant Experiencing Withdrawal • Place the infant in a side-lying position with the spine and legs flexed when awake. • Position the infant’s hands in midline. • Carry the infant in a flexed position. • When interacting with the infant, introduce one stimulus at a time. Interaction should occur when the infant is in a quiet, alert state. Monitor for timeout or distress signals (e.g., gaze aversion, yawning, sneezing, hiccups, arching, mottled colour). • When the infant is distressed, swaddle in a flexed position and rock in a slow, rhythmic fashion. • Put the infant in a sitting position with chin tucked down for feeding.

Loose stools, poor intake, and regurgitation after feeding predispose newborns with NAS to malnutrition, dehydration, and electrolyte imbalance. Infants may rapidly utilize energy sources as a result of continuous activity; thus careful monitoring of intake and output and electrolytes, provision of additional caloric supplementation, and daily weighing may be necessary. Breastfeeding is encouraged for mothers who are not using illicit substances, are negative for HIV infection, and are following a methadone program. Breastfeeding promotes maternal–infant bonding, and the small amount of methadone passed through breast milk has not proved to be harmful to the newborn (Hale, 2021; Lefevere & Allegaert, 2015). Providing prenatal education for the pregnant patient regarding the effects of the recreational drugs discussed earlier remains vital (see Nursing Care Plan The Drug-Exposed Newborn on Evolve).

HEMATOLOGICAL DISORDERS Hemolytic disease of the newborn (HDN), also called erythroblastosis fetalis, is a condition in which red blood cells (RBC) are broken down or destroyed. As the red cell destruction evolves, anemia may ensue. Anemia caused by this destruction stimulates the production of RBCs, which in turn provides increasing numbers of cells for hemolysis. Major causes of increased erythrocyte destruction are isoimmunization (primarily Rh) and ABO incompatibility. Bilirubin is a byproduct of RBC breakdown; excessive bilirubin levels may result with significant hemolysis.

Blood Incompatibility The membranes of human blood cells contain a variety of antigens, also known as agglutinogens, substances capable of producing an immune response if recognized by the body as foreign. The reciprocal relationship between antigens on RBCs and antibodies in the plasma causes agglutination, or binding of multiple particles into larger complexes (clumping). In other words, antibodies in the plasma of one blood group produce agglutination when mixed with antigens of a different blood group. In the ABO blood group system, the antibodies occur naturally. In the Rh system, exposure to the Rh antigen is required before significant antibody formation takes place and causes a sensitivity response known as isoimmunization.

Rh Incompatibility (Isoimmunization). The Rh blood group consists of several antigens. For simplicity, only the terms Rh positive (presence of antigen) and Rh negative (absence of antigen) are used in this

CHAPTER 29

The Newborn at Risk: Acquired and Congenital Conditions

discussion. The presence or absence of the naturally occurring Rh factor determines the blood type. Complications do not typically arise when the Rh blood types are the same in both the childbearing parent and the fetus or when the childbearing parent is Rh positive and the newborn is Rh negative. Complications may arise when the mother is Rh negative and the newborn is Rh positive. Although the maternal and fetal circulations are separate, there is evidence of a bidirectional trafficking of fetal RBCs and cell-free DNA to the maternal circulation (Moise, 2017). However, more commonly, fetal RBCs enter into the maternal circulation at the time of birth. The natural defence mechanism of the childbearing parent responds to these alien cells by producing anti-Rh antibodies. Under normal circumstances, this process of isoimmunization has no effect during the first pregnancy with an Rh-positive fetus because the initial sensitization to Rh antigens rarely occurs before the onset of labour. However, with the increased risk of fetal blood being transferred to the maternal circulation during placental separation, maternal antibody production is stimulated. During a subsequent pregnancy with an Rh-positive fetus, these previously formed maternal antibodies to Rhpositive blood cells may enter the fetal circulation, leading to destruction of fetal erythrocytes (Figure 29.9). Multiple gestations, placental abruption, placenta previa, manual removal of the placenta, and Caesarean birth increase the incidence of transplacental hemorrhage and subsequent isoimmunization (Diehl-Jones & Fraser, 2015). The fetus attempts to compensate for progressive hemolysis and anemia by accelerating the rate of erythropoiesis (red blood cell production). As a result, immature RBCs (erythroblasts) appear in the fetal circulation, thus the term erythroblastosis fetalis. There is wide variability in the development of maternal sensitization to Rh-positive antigens. Sensitization may occur during the first pregnancy if the pregnant patient had previously received an Rh-positive blood transfusion. No sensitization may occur in situations in which a strong placental barrier prevents transfer of fetal blood into the maternal circulation. In approximately 10 to 15% of sensitized parents there is no hemolytic reaction in the newborn. In addition, some Rh-negative patients, even though exposed to Rh-positive fetal blood, are immunologically unable to produce antibodies to the foreign antigen. In the most severe form of erythroblastosis fetalis, hydrops fetalis, the progressive hemolysis causes fetal hypoxia, cardiac failure, generalized edema (anasarca), and fluid effusions into the pericardial, pleural, or peritoneal spaces (hydrops). The fetus may be stillborn or the newborn may have severe respiratory distress. Maternal Rh immune

globulin (RhIG) administration, early intrauterine detection of fetal anemia by ultrasonography (serial Doppler assessment of the peak velocity in the fetal middle cerebral artery), and subsequent treatment by fetal blood transfusions or high-dose IVIG have dramatically improved the outcome of affected fetuses (Moise, 2017). The detection of cell-free fetal DNA in the maternal plasma of Rh(D)-negative patients to detect an Rh(D)-positive fetus has been shown to be effective and may reduce unnecessary treatment with routine anti-D immunoglobulin (Yang et al., 2019).

ABO Incompatibility. Hemolytic disease can also occur when the major blood group antigens of the fetus are different from those of the pregnant patient. The major blood groups are A, B, AB, and O. The presence or absence of antibodies and antigens determines whether agglutination will occur. Antibodies in the plasma of one blood group (except the AB group, which contains no antibodies) produce agglutination when mixed with antigens of a different blood group. Naturally occurring antibodies in the recipient’s blood cause agglutination of a donor’s RBCs. The agglutinated donor cells become trapped in peripheral blood vessels, where they hemolyze, releasing large amounts of bilirubin into the circulation. The most common blood group incompatibility in the newborn is between a mother with O blood group and an infant with A or B blood group (see Table 29.7 for possible ABO incompatibilities). Naturally occurring anti-A or anti-B antibodies already present in the parental circulation cross the placenta and attack the fetal RBCs, causing hemolysis. Usually the hemolytic reaction is less severe than in Rh incompatibility; however, rare cases of hydrops have been reported (Bagwell &

TABLE 29.7

Potential Maternal–Fetal ABO Incompatibilities Maternal Blood Group

Incompatible Fetal Blood Group

O (antibodies primarily IgG and may cross placenta leading to hemolysis)

A or B

A or B (antibodies primarily IgM and do not cross placenta)

Fetal blood type not significantly impacted by maternal blood type A, B, or AB

FIRST PREGNANCY Rh-negative mother

–

–

SECOND PREGNANCY

Antibodies

–

+

–

+

–

+ +

+

–

–

+ +

+

+

A

Rh-positive infant

Sensitization

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B

Sensitized mother

Erythroblastosis fetalis

Fig. 29.9 Development of maternal sensitization to Rh antigens. A: Fetal Rh-positive erythrocytes enter the maternal system. Maternal anti-Rh antibodies are formed. B: Anti-Rh antibodies cross the placenta and attack fetal erythrocytes.

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Steward, 2020). Unlike the Rh reaction, ABO incompatibility may occur in the first pregnancy. The risk of significant hemolysis in subsequent pregnancies is higher when the first pregnancy is complicated by ABO incompatibility.

Other metabolic and inherited conditions that increase hemolysis and may cause jaundice in the infant include galactosemia, CriglerNajjar disease, and hypothyroidism.

Therapeutic Management and Nursing Care. Early identification

nization is through prevention. The administration of RhIG, a human gamma globulin concentrate of anti-D, to all unsensitized Rh-negative mothers after birth or abortion of an Rh-positive infant or fetus prevents the development of maternal sensitization to the Rh factor. The injected anti-Rh antibodies are thought to destroy (by subsequent phagocytosis and agglutination) fetal RBCs passing into the maternal circulation before they can be recognized by the mother’s immune system. Because the immune response is blocked, anti-D antibodies and memory cells (which produce the primary and secondary immune responses, respectively) are not formed (Blackburn, 2018). The inhibition of memory cell formation is especially important because memory cells provide long-term immunity by initiating a rapid immune response after the antigen is reintroduced (McCance & Huether, 2014). To be effective, RhIG (e.g., WinRho) must be administered to unsensitized mothers within 72 hours (but possibly as long as 3 to 4 weeks) after the first birth or abortion and repeated in subsequent pregnancies or losses. The administration of RhIG at 26 to 28 weeks of gestation further reduces the risk of Rh isoimmunization. RhIG is not effective against existing Rh-positive antibodies in the maternal circulation. Intravenous immunoglobulin (IVIG) may be used to decrease the severity of RBC destruction (hemolysis) in HDN and reduce the need for exchange transfusion. However, there is a lack of evidence to support the efficacy of this intervention (Louis et al., 2014).

and diagnosis of Rh(D) sensitization are important in the management and prevention of fetal complications. A maternal antibody titre (indirect Coombs’ test) should be drawn at the first prenatal visit. Genetic testing enables early identification of paternal zygosity at the Rh(D) gene locus, thus allowing earlier detection of the potential for isoimmunization and avoiding further maternal or fetal testing (Egbor et al., 2012). Amniocentesis tests the fetal blood type of a pregnant patient whose antibody screen result is positive; the use of polymerase chain reaction (PCR) may determine the fetal blood type and presence of maternal antibodies. The fetal hemoglobin and hematocrit can also be measured. Risks associated with chorionic villus sampling may preclude its use, including possible spontaneous abortion of the fetus or fetomaternal hemorrhage. With either method, if the fetus is found to be Rh negative, no further treatment is required. Ultrasonography is considered an important adjunct in the detection of isoimmunization. Alterations in the placenta, umbilical cord, and amniotic fluid volume and the presence of fetal hydrops can be detected with high-resolution ultrasonography and enable early treatment, before the development of erythroblastosis. Doppler ultrasonography of fetal middle cerebral artery peak velocity has been used to detect and measure fetal hemoglobin and, subsequently, fetal anemia (Moise, 2017). Erythroblastosis fetalis caused by Rh incompatibility can also be monitored by evaluating rising anti-Rh antibody titres in the maternal circulation or testing the optical density of amniotic fluid (delta OD450 test) because bilirubin discolours the fluid. HDN is suspected on the basis of the timing and appearance of jaundice and can be confirmed postnatally by detecting antibodies attached to the circulating erythrocytes of affected infants (direct Coombs’ test or direct antiglobulin test). The Coombs’ test may be performed on umbilical cord blood samples from infants born to Rh-negative mothers if there is a history of incompatibility or further investigation is warranted. The primary therapeutic management of isoimmunization is prevention. Postnatal therapy includes phototherapy for mild cases of hemolysis and exchange transfusion for severe unconjugated hyperbilirubinemia. Although phototherapy may control bilirubin levels in mild cases, the hemolytic process may continue, causing severe anemia between 7 and 21 days of life. Families require education at hospital discharge regarding the importance of timely follow-up with a pediatric health care provider for possible repeat laboratory analysis of bilirubin and hemoglobin.

Other Hemolytic Disorders It is not within the scope of this text to discuss all potential causes of hemolytic jaundice in childhood. However, in some populations there is a high incidence of glucose-6-phosphate dehydrogenase deficiency (G6PD), which may cause an exaggerated jaundice in a newborn within 24 to 48 hours of birth. G6PD red cells hemolyze at a greater rate than healthy red cells, thus overwhelming the immature newborn liver’s ability to conjugate the indirect bilirubin. Some of the triggers that potentiate hemolysis include vitamin K, acetaminophen, Aspirin, sepsis, and exposure to certain chemicals. Hereditary spherocytosis may also cause serious neonatal hemolytic anemia as a result of high quantities of fetal hemoglobin; jaundice may develop rapidly and require phototherapy (Merguerian & Gallagher, 2020). Treatment remains the same as for other circumstances in newborns with rapidly rising serum bilirubin levels.

Prevention. As stated earlier, the primary way of treating isoimmu-

Therapeutic Management Intrauterine transfusion. The fetus of a parent already sensitized may be treated by intrauterine transfusion, which consists of infusing blood into the umbilical vein of the fetus. Therapy is indicated on the basis of antenatal diagnosis of fetal anemia by serial Doppler assessments of peak systolic velocity of the middle cerebral artery (Moise, 2017). With the advance of ultrasound technology, fetal transfusion may be accomplished directly via the umbilical vein, infusing type O Rh-negative packed RBCs to raise the fetal hematocrit to 40 to 50%. Fetal movement and transfusion risks are minimized by administering medication to provide temporary fetal muscle relaxation. A fetus that is severely affected may require ongoing transfusions every 1 to 4 weeks until the fetus is more mature or exhibits signs of in utero deterioration (Abbasi et al., 2017). Intraperitoneal blood transfusions are used less commonly for isoimmunization because of higher associated fetal risks; however, they may be used when intravascular access is not achievable. Exchange transfusion. Exchange transfusions occur infrequently because of the decrease in the incidence of severe hemolytic disease in newborns resulting from isoimmunization. Exchange transfusion is an advanced mode of therapy for treatment of severe hyperbilirubinemia. Exchange transfusion removes the sensitized erythrocytes, lowers the serum bilirubin level to prevent bilirubin encephalopathy, corrects the anemia, and prevents cardiac failure. Indications for exchange transfusion in full-term newborns may include a rapidly increasing serum bilirubin level and hemolysis despite intensive phototherapy. The criteria for exchange transfusions in preterm infants vary according to associated illness factors. Other factors must be considered, particularly the newborn’s clinical condition, because it is a procedure with potential complications. Guidelines for the initiation of exchange transfusion for infants 35 weeks of gestation or greater have been developed by the CPS (Barrington et al., 2007/2018). Severe unconjugated hyperbilirubinemia is considered a newborn emergency and requires prompt intervention to prevent the permanent

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The Newborn at Risk: Acquired and Congenital Conditions

sequelae of bilirubin encephalopathy. Exchange transfusion is accomplished by alternately removing a small amount of the newborn’s blood and replacing it with an equal amount of donor blood, ideally through umbilical artery and venous catheters. If the newborn has Rh incompatibility, type O Rh-negative blood is used for transfusion, so the maternal antibodies still present in the newborn do not hemolyze the transfused blood. Depending on the newborn’s size, gestational age, and condition, 5 to 20 mL of the newborn’s blood is removed at one time and replaced with an equal amount of warmed donor blood. Preservatives in donor blood lower the newborn’s serum calcium level; therefore, calcium gluconate may be required during the exchange transfusion. The newborn is monitored closely for signs of a blood transfusion reaction as well as hypotension, temperature instability, and cardiorespiratory compromise.

Nursing Care. The initial nursing responsibility is recognizing jaundice in the newborn at risk. The possibility of hemolytic disease can be anticipated from the perinatal history. Prenatal evidence of incompatibility and a positive Coombs’ test result are cause for increased vigilance for early signs of jaundice in a newborn. If an exchange transfusion is required, the nurse prepares the newborn and the family and assists the practitioner with the procedure. The newborn receives nothing by mouth (NPO) during the procedure, which may require several hours to complete; a peripheral infusion of dextrose and electrolytes is established. The nurse documents the blood volume exchanged, including the amount of blood withdrawn and infused, the time of each procedure, and the cumulative record of the total volume exchanged. Vital signs monitored electronically are evaluated frequently and correlated with the removal and infusion of blood. If signs of cardiac or respiratory distress occur, the procedure is stopped temporarily and resumed after the newborn’s cardiorespiratory function stabilizes. The nurse also observes for signs of blood transfusion reaction and maintains the newborn’s blood glucose levels and fluid balance. Throughout the procedure, the newborn’s thermoregulation must be maintained. The exchange transfusion is performed with the newborn on a radiant warming bed. Hypothermia increases oxygen and glucose consumption, causing metabolic acidosis. These consequences may inhibit the binding capacity of albumin and bilirubin and the hepatic enzymatic reactions, thus increasing the risk of kernicterus. Conversely, hyperthermia damages the donor erythrocytes, elevating the free potassium content and predisposing the newborn to cardiac arrhythmia and potential cardiac arrest. After the procedure is completed, the nurse should continue to provide phototherapy and send specimens for ongoing laboratory analysis of unconjugated bilirubin. Rebound increased bilirubin levels are not unexpected, but only occasionally achieve levels requiring a second exchange transfusion.

CONGENITAL ANOMALIES Major congenital anomalies are reported to occur in approximately 4% of newborns and are the second leading cause of newborn death, second to prematurity (PHAC, 2021). Common major congenital anomalies include congenital heart disease, abdominal wall defects, imperforate anus, neural tube defects, cleft lip or palate, clubfoot, and developmental dysplasia of the hip. The interaction of multiple genetic and environmental factors contribute to their development. Prevention and detection of some anomalies continue to improve, as are some surgical techniques for the care of the newborn with certain anomalies. Promoting availability of these services to populations at risk can challenge community health care systems. An interdisciplinary team approach is vital for providing holistic care that encompasses the

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surgical treatment, rehabilitation, and education of the child, as well as psychosocial and financial assistance for the parents. A number of congenital anomalies are discussed in the following pediatric systems and conditions chapters (Unit 12): • Cleft lip and palate, Chapter 46 • Esophageal atresia and tracheoesophageal fistula, Chapter 46 • Omphalocele and gastroschisis, Chapter 46 • Congenital cardiac defects, Chapter 47 • Congenital diaphragmatic hernia and choanal atresia, Chapter 45 • Neural tube defects and myelomeningocele, Chapter 54 • Developmental dysplasia of the hip and clubfoot, Chapter 53 • Hypospadias, disorders of sex development, and bladder exstrophy, Chapter 49

NEWBORN SCREENING FOR DISEASE A number of genetic diseases can be detected through newborn screening programs. There is no national policy for such detection in Canada; therefore, the extent of newborn screening is determined by provincial and territorial guidelines. Most provinces require screening for phenylketonuria (PKU), galactosemia, congenital hypothyroidism (CH), and hemoglobin defects such as sickle cell disease. Screening for congenital hearing impairment is recommended to be completed at the same time as disease screening in stable term newborns being prepared for discharge home, although this practice is not routine in all provinces and territories (see Chapter 26, Universal Newborn Screening). Pulse oximetry screening improves detection rates for critical congenital heart disease (CCHD); screening is recommended for all newborns in Canada between 24 and 36 hours after birth (Narvey et al., 2017). For a description of the procedure see Chapter 26, Screening for Critical Congenital Heart Disease (CCHD).

Inborn Errors of Metabolism Inborn errors of metabolism (IEM) is an umbrella term applied to a large group of inherited diseases caused by the absence or deficiency of a substance essential to cellular metabolism, usually an enzyme. When the normal metabolic process is interrupted as a result of a missing enzyme, an accumulation of substances precedes the interruption, the end product of the process is absent, or the process takes an alternate metabolic pathway. The consequence is manifested as an illness. Most IEMs are characterized by abnormal protein, carbohydrate, or fat metabolism. Biochemical techniques, including tandem mass spectrometry, provide an opportunity to detect genes responsible for causing errors in metabolism early in the newborn period so that appropriate therapies to prevent morbidity may be implemented.

Phenylketonuria. Classic phenylketonuria (PKU), an autosomal recessive error in metabolism, is caused by a deficiency in or absence of the enzyme needed to metabolize the essential amino acid phenylalanine into tyrosine, resulting in hyperphenylalaninemia. When feeding begins in the newborn period, accumulation of phenylalanine in the bloodstream and urinary excretion of abnormal amounts of its metabolites occur; tyrosine deficiency also ensues. The accumulating phenyl acids give urine the characteristic musty odour associated with the disease. Tyrosine is needed to form the pigment melanin and the hormones epinephrine and thyroxine (T4). Decreased melanin production results in similar phenotypes of most individuals with PKU, which is blond hair, blue eyes, and fair skin that is particularly susceptible to eczema and other dermatological conditions. Children with a genetically darker skin colour may be red haired or brunette.

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Clinical manifestations in untreated PKU include failure to thrive (growth failure), frequent vomiting, irritability, hyperactivity, and unpredictable, erratic behaviour. Cognitive impairment is thought to be caused by the accumulation of phenylalanine. Tyrosine is necessary for the production of neurotransmitters. Decreased levels of dopamine and tryptophan affect the normal development of the brain and CNS, resulting in defective myelinization, cystic degeneration of the grey and white matter, and disturbances in cortical lamination. Untreated older children become hyperactive with autistic behaviours, including purposeless hand movements, rhythmic rocking, and athetosis (Shchelochkov & Venditti, 2020). The objective in diagnosing and treating the disorder is to prevent cognitive impairment. Testing for PKU is not reliable until the newborn has ingested the amino acid phenylalanine, a constituent of both human and cow’s milk; the blood test should be taken between 24 and 48 hours after birth, regardless of gestation. Early discharge from the hospital has the potential to cause newborns with a disorder such as PKU not to be adequately screened. A number of agencies have developed guidelines to minimize the risk of this happening and recommend the following: • Obtain a subsequent sample by 2 weeks of age if the initial specimen is collected before the newborn is 24 hours old. • Designate a primary care provider for all newborns before discharge for adequate newborn screening follow-up. • Complete a second screen for infants born less than 33 weeks’ gestation or less than 1 500 g birthweight (Newborn Screening Ontario, n.d.; Perinatal Services BC, 2018).

recognizable by 1 or 2 months of age; cerebral damage, manifested by the symptoms of lethargy and hypotonia, is evident soon afterward. Infants with galactosemia appear healthy at birth, but within a few days of ingesting milk (which has a high lactose content) they begin to experience vomiting and diarrhea, leading to weight loss. Sepsis, particularly E. coli sepsis, is also a common presenting clinical sign. Death during the first month of life is frequent in untreated infants. Occasionally, classic galactosemia is seen with milder, chronic manifestations, such as growth failure, feeding difficulty, and developmental delay. Galactosemia is included in some provinces’ and territories’ newborn screening. Diagnosis can also be made on the basis of the infant’s history, physical examination, galactosuria, increased levels of galactose in the blood, and decreased levels of GALT activity in erythrocytes. The infant may display characteristics of malnutrition (i.e., hypoglycemia, jaundice, hepatosplenomegaly, sepsis, cataracts, and decreased muscle tone). During infancy treatment consists of eliminating all milk and lactose-containing formula, including breast milk. Traditionally, lactose-free formulas are used, with soy-protein formula being the feeding of choice. As the infant progresses to solids, only foods low in galactose can be consumed. Early recognition and treatment improve optimal growth and development. Nursing interventions are similar to those for PKU. Family support and education provide important foundations for lifelong disease management. Many medications, including some of penicillin preparations, contain lactose as filler and also must be avoided. Lactose is an unlabelled ingredient in many pharmaceuticals. Therefore, parents require supportive education to ask their local pharmacist about galactose content of any over-the-counter or prescription medication.

NURSING ALERT Avoid “layering” the blood specimen on the Guthrie testing paper. Layering is placing one drop of blood on top of the other, or overlapping the specimen, and results in a false-positive reading. Such results require arranging for a diagnostic blood phenylalanine test to determine whether the newborn truly has PKU. Best results are obtained by collecting the specimen with a pipette from the heel stick and spreading the blood uniformly over the blot paper.

Infants with PKU require a diet low in phenylalanine and typically receive a special medical formula; lifelong dietary restrictions are necessary. Breastfeeding or partial breastfeeding may be possible for some infants if the phenylalanine levels are monitored carefully and remain within acceptable limits (Lawrence & Lawrence, 2016). Many affected children have some intellectual impairment. Successful management and outcome are largely dependent on early identification of the condition, modification of the diet, and the ability to follow the treatment regimen throughout the child’s entire life.

Galactosemia. Galactosemia is a rare autosomal recessive disorder of carbohydrate metabolism that results from various gene mutations leading to three distinct enzymatic deficiencies. The most common type of galactosemia (classic galactosemia) results from a deficiency of a hepatic enzyme, galactose 1-phosphate uridyltransferase (GALT), and affects approximately 1 in 60 000 births (Kishnani & Chen, 2020). The other two varieties of galactosemia involve deficiencies in the enzymes galactokinase (GALK) and galactose 40 -epimerase (GALE); these are extremely rare disorders. All three enzymes (GALT, GALK, and GALE) are involved in the conversion of galactose into glucose (Kau & Hoe, 2020). As galactose accumulates in the blood, several organs are affected. Hepatic dysfunction leads to cirrhosis, resulting in jaundice in the infant by the second week of life. The spleen subsequently becomes enlarged as a result of portal hypertension. Cataracts are usually

Congenital Hypothyroidism. Congenital hypothyroidism (CH) is an insufficient production of thyroid hormone in newborns. Early recognition and intervention can prevent severe cognitive disability or other neurological complications. CH can be classified as either permanent or transient depending on the primary etiology. Inadequate thyroid hormone production may result from an anatomical abnormality of the thyroid gland, enzyme failure contributing to thyroid metabolism dysfunction, or iodine deficiency. Despite variations in the cause, the manifestations (Box 29.3) and management are similar. CH occurs in approximately 1 in 2 000 to 1 in 4 000 newborns, occurring more frequently in female infants (Wassner & Smith, 2020). A higher incidence of other congenital abnormalities has been observed in newborns with CH. Preterm infants may have transient hypothyroidism (hypothyroxinemia) at birth as a result of hypothalamic and pituitary immaturity. Infants born before 28 weeks of gestation may require temporary thyroid hormone replacement. All provinces in Canada routinely screen for hypothyroidism. Although a heel stick blood sample for the test is best obtained between 2 and 6 days of age, specimens are usually taken within the first 24 to 48 hours or before discharge as part of a concurrent screening for other metabolic defects. At this time, the normally expected increase in T4 would be lacking in newborns with hypothyroidism. Early screening can result in overdiagnosis (false positives) but is preferable to missing the diagnosis. In the newborn, thyroid function studies are elevated in comparison with values in older children; therefore, it is important to document the timing of the tests. Thyroid function tests are usually lower in preterm and sick full-term newborns than in healthy full-term newborns. A repeat test for T4 and thyroid-stimulating hormone (TSH) may be evaluated after 30 weeks (corrected age) in newborns born before that time and after resolution of the acute illness in the sick fullterm newborn. Treatment for CH involves lifelong thyroid hormone replacement therapy commencing as soon as possible after diagnosis to abolish all

CHAPTER 29

The Newborn at Risk: Acquired and Congenital Conditions

BOX 29.3

Clinical Manifestations of Congenital Hypothyroidism Birth∗ • Poor feeding • Irregular stool pattern • Lethargy, long sleep interval • Prolonged jaundice (>3 weeks) • Hypotonia • Respiratory difficulties • Cyanosis • Bradycardia • Hoarse cry • Large anterior and posterior fontanelles • Large for gestational age

Ages 6 to 9 Weeks† • Depressed nasal bridge • Pseudohypertelorism • Short forehead • Facial edema • Macroglossia (large tongue) • Thick, dry, mottled skin • Coarse, dry, lustreless hair • Abdominal distension • Umbilical hernia • Hyporeflexia • Bradycardia • Hypothermia • Hypotension • Anemia • Wide fontanelle with patent cranial sutures

Older Child • Short stature • Obesity • Varying degrees of cognitive deficits • Abnormal tendon reflexes • Slow, awkward movements

∗ Clinical manifestations may not be obvious at birth, possibly because of maternal transfer of thyroid hormone to the fetus. Manifestations may be delayed in infants with certain types of familial hypothyroidism and in breastfed infants (may show after weaning from breast). † If untreated, classical features.

signs of hypothyroidism and re-establish normal physical and cognitive development. The medication of choice is synthetic levothyroxine sodium (Synthroid, Levothroid). Regular measurement of T4 levels is important to ensure optimum treatment. Bone age surveys are also performed to ensure optimum growth. Nurses caring for newborns must be certain that screening is performed, especially in newborns who are preterm, discharged early, or born at home. Approximately 10% of cases are detected only by completion of a second screening at 2 to 6 weeks of age. Nurses in community health need to be aware of the earliest signs of the disorder. Parental remarks about an unusually “quiet and good” baby and demonstrated symptoms such as prolonged jaundice, constipation, and umbilical hernia should lead to a suspicion of hypothyroidism, which requires a referral for specific tests. After the diagnosis is confirmed, parents need an explanation of the disorder and the necessity of lifelong treatment. The child should be referred to a pediatric endocrinologist for care. The importance of adhering to the medication regimen for the child to achieve healthy growth and development must be stressed (Wassner & Smith, 2020). Parents also need to be aware of signs indicating overdose, such as a rapid pulse, dyspnea, irritability, insomnia, fever, sweating, and weight loss. Ideally, they should know how to count the pulse and be instructed to withhold a dose and consult their health care provider if the pulse rate is above a certain value. Signs of inadequate treatment are fatigue, sleepiness, decreased appetite, and constipation. Unless there are maternal contraindicative factors, breastfeeding is acceptable and encouraged in infants with hypothyroidism (Lawrence & Lawrence, 2016).

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Genetic Evaluation and Counselling Genetic counselling addresses the issues associated with the occurrence or risk of occurrence of a genetic disorder in a family. It involves the relaying of information about the diagnosis, treatment options, recurrence risk, and availability of prenatal diagnosis. It is essential that nurses have a basic understanding of the principles of heredity and how heredity contributes to certain disorders and be aware of the types of genetic testing available (see Chapter 9). Nurses frequently encounter children with a genetic disorder, including an IEM, as well as families in which there is a risk that a disorder may be transmitted to or occur in an offspring. Neonatal nurses are well positioned to identify situations in which parents may benefit from genetic evaluation and counselling. Nurses also need to be aware of the local genetic resources, aid the family in finding related services, and offer support and care for children and families affected by genetic conditions.

Nursing Care of Parents and Family While the infant is receiving care, the parents also have needs that must be met as they deal with the crisis of having an infant with an abnormal condition. Their reactions should be carefully assessed and are likely to be those typical of a grief response. Facilitating their understanding of the information given them about their infant’s condition is a vital nursing intervention. A newly diagnosed disorder often implies the need for implementation of a therapeutic regimen. For example, the disorder may be an IEM, such as PKU, which requires consistent and rigid adherence to a diet. The family may need help securing the required formula and may require counselling from a clinical dietitian. The importance of maintaining the diet, keeping an adequate supply of special preparations, and avoiding the use of unauthorized substitutions must be impressed upon the family. These conditions often require a drastic change in family lifestyle and functioning; families may depend on others for assistance. Family coping skills and resources may be temporarily diminished with a diagnosis such as PKU or galactosemia. Referral to appropriate agencies is another essential component of the follow-up management, and the nurse should make the parents aware of all possible sources of aid, including pertinent literature, parent groups, and national organizations. Many organizations and foundations (e.g., Canadian Organization of Rare Disorders) provide services and counselling for families of affected children. Numerous parent support groups are also available, where they can share experiences and derive mutual support in coping with issues similar to those of other group members. Nurses must be familiar with the services available in their community that provide assistance and education to families with these particular needs. A major nursing role is the provision of emotional support during all phases of care to the family of a newborn with an anomaly or disorder. The feelings that stem from the real or imagined threat posed by a congenital anomaly are varied. Responses may include apathy, denial, anger, hostility, fear, embarrassment, grief, and loss of self-esteem.

KEY POINTS • The identification of maternal and fetal risk factors in the antepartum and intrapartum periods is vital for planning adequate care of high-risk infants. • Birth injuries may be decreased by careful assessment for risk factors and anticipatory planning for birth. • Infection in the newborn may be acquired in utero, at birth, from breast milk, or from within the hospital. • The most common maternal infections during early pregnancy that are associated with various congenital malformations include toxoplasmosis, herpes, CMV, rubella, parvovirus B19, and varicella.

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• HIV transmission from mother to infant occurs transplacentally at various gestational ages, perinatally by maternal blood and secretions, and postnatally through breast milk. • The nurse often is the first person to observe signs of newborn drug withdrawal. • Maternal–fetal Rh and ABO incompatibility may cause significant hemolysis and jaundice in the newborn period. • The injection of Rho(D) immunoglobulin in Rh-negative and Coombs’ test–negative perinatal patients minimizes the possibility of isoimmunization. • The supportive care given to the parents of infants with a congenital anomaly or inborn error of metabolism begins at birth or at the time of diagnosis and continues throughout the pediatric years.

REFERENCES Abbasi, N., Johnson, J.-A., & Ryan, G. (2017). Fetal anemia. Ultrasound in Obstetrics & Gynaecology, 50(2), 145–153. Bagwell, G. A. (2020). Neonatal abstinence syndrome. In C. Kenner, L. B. Altimier, & M. V. Boykova (Eds.), Comprehensive neonatal nursing care (6th ed.). Springer. Bagwell, G. A., & Steward, D. K. (2020). Hematologic system. In C. Kenner, L. B. Altimier, & M. V. Boykova (Eds.), Comprehensive neonatal nursing care (6th ed.). Springer. Baker, T., Rewers-Felkins, K., Thompson, H., et al. (2018). Transfer of inhaled cannabis into human breast milk. Obstetrics and Gynecology, 131(5), 783– 788. https://doi.org/10.1097/AOG.0000000000002575. Baley, J. E., & Gonzalez, B. E. (2020). Viral infections in the neonate. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus (11th ed.). Elsevier. Bandstra, E. S., Morrow, C. E., Mansoor, E., et al. (2010). Prenatal drug exposure: Infant and toddler outcomes. Journal of Addictive Diseases, 29(2), 245–258. Barrington, K., Sankaran, K., & Canadian Paediatric Society, Fetus and Newborn Committee. (2007). Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation). Paediatrics & Child Health, 12(5), 1B–12B. Reaffirmed 2018. Blackburn, S. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier. Bordelon, C., Fanning, B., Meredith, J., et al. (2019). The nervous system. In A. J. Jnah, & A. N. Trembath (Eds.), Fetal and neonatal physiology for the advanced practice nurse. Springer. Canadian Institute for Health Information. (2018). Opioid-related harms in Canada. https://secure.cihi.ca/free_products/opioid-related-harms-report2018-en-web.pdf. Canadian Paediatric Society (CPS). (2019). Neonatal ocular prophylaxis: Shortage of erythromycin ophthalmic ointment for use in newborns. https:// www.cps.ca/en/media/neonatal-ocular-prophylaxis-shortage-oferythromycin-ophthalmic-ointment-for-use-in-newborns. Cantor Sackett, J., Weller, R. A., & Weller, E. B. (2009). Selective serotonin reuptake inhibitor use during pregnancy and possible neonatal complications. Current Psychiatry Reports, 11(3), 253–257. Carson, G., Cox, L. V., Crane, J., et al. (2017). Alcohol use and pregnancy consensus clinical guidelines. Journal of Obstetrics and Gynaecology Canada, 39(9), e220–e254. Centers for Disease Control and Prevention (CDC). (2020a). Fungal diseases— Candidiasis. https://www.cdc.gov/fungal/diseases/candidiasis/index.html. Centers for Disease Control and Prevention (CDC). (2020b). Hepatitis B or C infections. https://www.cdc.gov/breastfeeding/breastfeeding-specialcircumstances/maternal-or-infant-illnesses/hepatitis.html. Conradt, E., Flannery, T., Aschner, J. L., et al. (2019). Prenatal opioid exposure: Neurodevelopmental consequences and future research priorities. Pediatrics, 144(3). https://doi.org/10.1542/peds.2019-0128, e20190128. Corsi, D. J., Donelle, J., Sucha, E., et al. (2020). Maternal cannabis use in pregnancy and child neurodevelopmental outcomes. Nature Medicine, 26, 1536–1540. https://doi.org/10.1038/s41591-020-1002-5.

Crane, J., & Society of Obstetricians and Gynaecologists of Canada, Maternal Fetal Medicine and Infectious Diseases Committees. (2014). Parvovirus B19 infection in pregnancy. Journal of Obstetrics and Gynaecology Canada, 36 (12), 1107–1116. Dermyshi, E., Wang, Y., Tan, C., et al. (2017). The “golden age” of probiotics: A systematic review and meta-analysis of randomized and observational studies in preterm infants. Neonatology, 112(1), 9–23. Diehl-Jones, W. L., & Fraser, D. (2015). Hematologic disorders. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Elsevier. Egbor, M., Knott, P., & Bhide, A. (2012). Red-cell and platelet alloimmunisation in pregnancy. Best Practice & Research: Clinical Obstetrics & Gynaecology, 26 (1), 119–132. Eke, A. C., Saccone, G., & Berghella, V. (2016). Selective serotonin reuptake inhibitor (SSRI) use during pregnancy and risk of preterm birth: A systematic review and meta-analysis. British Journal of Obstetrics and Gynecology, 123(12), 1900–1907. Esper, F. (2020). Postnatal bacterial infections. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus (11th ed.). Elsevier. Falck, A. J., Mooney, S., & Bearer, C. F. (2020). Adverse exposures to the fetus and neonate. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus (11th ed.). Elsevier. Gardner, S. L., Lawrence, R. A., & Lawrence, R. M. (2021). Breastfeeding the neonate with special needs. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Goderis, J., De Leenheer, E., Smets, K., et al. (2014). Hearing loss and congenital CMV infection: A systematic review. Pediatrics, 134(5), 972–982. https://doi. org/10.1542/peds.2014-1173. Gomez-Pomar, E., & Finnegan, L. P. (2018). The epidemic of neonatal abstinence syndrome, historical references of its origins, assessment and management. Frontiers in Pediatrics, 6(33), 1–8. Government of Canada. (2015). Causes of rubella. https://www.canada.ca/en/ public-health/services/diseases/rubella/causes-rubella.html. Government of Canada. (2019). Tuberculosis: Monitoring. https://www.canada. ca/en/public-health/services/diseases/tuberculosis/surveillance.html. Grossman, M. R., Lipshaw, M. J., Osborn, R. R., et al. (2018). A novel approach to assessing infants with neonatal abstinence syndrome. Hospital Pediatrics, 8(1), 1–6. Hale, T. W. (2021). Hale’s medications and mothers’ milk (19th ed.). Springer. Haslam, D. B. (2020). Healthcare-acquired infections. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Canada, Health. (2017). Fetal alcohol spectrum disorder. https://www.canada.ca/ en/health-canada/services/healthy-living/your-health/diseases/fetalalcohol-spectrum-disorder.html. Hudak, M. L. (2020). Infants of substance-using mothers. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus (11th ed.). Elsevier. Jackson, J., Knappen, B., & Olsen, S. L. (2021). Drug withdrawal in the neonate. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Jašarevi
c, E., Howerton, C. L., Howard, C. D., et al. (2015). Alterations in the vaginal microbiome by maternal stress and reprogramming of the offspring gut and brain. Endocrinology, 156(9), 3265–3276. Jefferies, A. L., & Canadian Paediatric Society, Fetus and Newborn Committee. (2017). Management of term infants at increased risk for early onset bacterial sepsis. Paediatrics & Child Health, 22(4), 223–228. Kau, S., & Hoe, S. (2020). Metabolic system. In C. Kenner, L. B. Altimier, & M. V. Boykova (Eds.), Comprehensive neonatal nursing care (6th ed.). Springer. Keenan-Lindsay, L., & Yudin, M. (2017). HIV screening in pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(7), e54–e58. https://doi.org/10.1016/ j.jogc.2017.04.009. Kett, J. (2013). Perinatal varicella. Pediatrics in Review, 34(1), 49–51.

CHAPTER 29

The Newborn at Risk: Acquired and Congenital Conditions

Kishnani, P. S., & Chen, Y. (2020). Defects in metabolism of carbohydrates. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Lacaze-Masmonteil, T., O’Flaherty, P., & Canadian Paediatric Society, Fetus and Newborn Committee. (2020). Managing infants born to mothers who have used opioids during pregnancy. Practice point. Paediatrics & Child Health, 23(3), 220–226. https://www.cps.ca/en/documents/position/opioids-duringpregnancy. Lawrence, R. M., & Lawrence, R. A. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. Lefevere, J., & Allegaert, K. (2015). Is breastfeeding useful in the management of neonatal abstinence syndrome? Archives of Disease in Childhood, 100(4), 414–415. Lemyre, B., Chau, V., & Canadian Paediatric Society, Fetus and Newborn Committee. (2018). Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatrics & Child Health, 23(4), 285–291. Lester, B. M., & Lagasse, L. L. (2010). Children of addicted women. Journal of Addictive Diseases, 29(2), 259–276. Li, C., Liu, L., & Tao, Y. (2019). Diagnosis and treatment of congenital tuberculosis: A systematic review of 92 cases. Orphanet Journal of Rare Diseases, 14, 131. https://ojrd.biomedcentral.com/articles/10.1186/ s13023-019-1101-x#citeas. Lisonkova, S., Richter, L. L., Ting, J., et al. (2019). Neonatal abstinence syndrome and associated neonatal and maternal mortality and morbidity. Pediatrics, 144(2), e20183664. Liyanage, V. R., Curtis, K., Zachariah, R. M., et al. (2017). Overview of the genetic basis and epigenetic mechanisms that contribute to FASD pathobiology. Current Topics in Medicinal Chemistry, 17(7), 808–828. https://doi.org/ 10.2174/1568026616666160414124816. Louis, D., More, K., Oberoi, S., et al. (2014). Intravenous immunoglobulin in isoimmune haemolytic disease of newborn: An updated systematic review and meta-analysis. Archives of Disease in Childhood. Fetal and Neonatal Edition, 99(4), F325–F331. Loutfy, M., Kennedy, V. L., Poliquin, V., et al. (2018). SOGC clinical practice guideline: Canadian HIV pregnancy planning guidelines. Journal of Obstetrics and Gynecology Canada, 40(1), 94–114. Lu, H. C., & Mackie, K. (2016). An introduction to the endogenous cannabinoid system. Biological Psychiatry, 79(7), 516–525. https://doi.org/10.1016/j. biopsych.2015.07.028. Marchand, V., & Canadian Paediatric Society, Nutrition and Gastroenterology Committee. (2012). Using probiotics in the paediatric population. Paediatrics & Child Health, 17(10), 575. Updated 2019. https://www.cps.ca/ en/documents/position/probiotics-in-the-paediatric-population. May, P. A., Blankenship, J., Marais, A. S., et al. (2013). Approaching the prevalence of the full spectrum of fetal alcohol spectrum disorders in a South African population-based study. Alcoholism: Clinical and Experimental Research, 37(5), 818–830. https://doi.org/10.1111/acer.12033. McCance, K., & Huether, S. (2014). Pathophysiology: The biological basis for disease in infants and children (7th ed.). Elsevier. Merguerian, M. D., & Gallagher, P. G. (2020). Hereditary spherocytosis. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Moise, K. J. (2017). Red cell alloimmunization. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson, et al. (Eds.), Obstetrics: Normal and problem pregnancies (7th ed.). Elsevier. Money, D., & Allen, V. (2018). SOGC clinical practice guideline: The prevention of early-onset neonatal group B streptococcal disease. Journal of Obstetrics and Gynaecology Canada, 40(8), e665–e674. https://doi.org/10.1016/j.jogc. 2018.05.032. Money, D. M., & Steben, M. (2017). Guidelines for the management of herpes simplex virus in pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(8), e199–e205. Moore, D. L., Allen, U. D., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2019). HIV in pregnancy: Identification of intrapartum and perinatal HIV. Paediatrics & Child Health, 24(1), 42–45. Moore, D. L., MacDonald, N. E., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2015). Preventing ophthalmia neonatorum. Paediatrics & Child Health, 20(2), 93–96. Reaffirmed 2018.

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Narvey, M., Wong, K., Fournier, A., et al. (2017). Pulse oximetry screening in newborns to enhance detection of critical congenital heart disease. Paediatrics & Child Health, 22(8), 494–498. Nelson, M. R. (2020). Birth brachial plexus palsy. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Neu, J. (2016). The microbiome during pregnancy and early postnatal life. Seminars in Fetal and Neonatal Medicine, 21(6), 373–379. Newborn Screening Ontario. (n.d.). Information for health care providers. http:// www.newbornscreening.on.ca/bins/content_page.asp?cid¼7-272. Olivier, J. D., Akerud, H., Kaihola, H., et al. (2013). The effects of maternal depression and maternal selective serotonin reuptake inhibitor exposure on offspring. Frontiers in Cellular Neuroscience, 7. Article 73. Ordean, A., Wong, S., & Graves, L. (2017). SOGC clinical practice guideline: Substance use in pregnancy. Journal of Obstetrics and Gynaecology Canada, 39(10), 922–937. https://doi.org/10.1016/j.jogc.2017.04.028. Pammi, M., Brand, M. C., & Weisman, L. E. (2021). Infection in the neonate. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier. Perinatal Services, B. C. (2018). Neonatal guideline: Newborn metabolic screening. http://www.perinatalservicesbc.ca/Documents/GuidelinesStandards/Newborn/NewbornScreeningGuideline.pdf. Popova, S., Lange, S., Poznyak, V., et al. (2019). Population-based prevalence of fetal alcohol spectrum disorder in Canada. BMC Health, 19(1), 845–912. https://doi.org/10.1186/s12889-019-7213-3. Prazad, P. A., Rajpal, M. N., Mangurten, H. H., et al. (2020). Birth injuries. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus (11th ed.). Elsevier. Public Health Agency of Canada (PHAC). (2017). Section 5-2: Canadian guidelines on sexually transmitted infections—Management and treatment of specific infections—Chlamydial infections. https://www.canada.ca/en/publichealth/services/infectious-diseases/sexual-health-sexually-transmittedinfections/canadian-guidelines/sexually-transmitted-infections/canadianguidelines-sexually-transmitted-infections-30.html. Public Health Agency of Canada (PHAC). (2018). Thinking about using cannabis before or during pregnancy? https://www.canada.ca/content/dam/ hc-sc/documents/services/drugs-medication/cannabis/health-effects/ cannabis-before-pregnancy-eng.pdf. Public Health Agency of Canada (PHAC). (2019). Chlamydia, gonorrhea and infectious syphilis in Canada (2017). https://www.canada.ca/content/dam/ hc-sc/documents/services/publications/diseases-and-conditions/sexuallytransmitted-infections-canada-2017-infographic/2017%20STI% 20Infographic_EN.pdf. Public Health Agency of Canada (PHAC). (2021). Perinatal health indicators of Canada 2017: A report from the Canadian perinatal surveillance system. https://www.canada.ca/en/public-health/services/injury-prevention/healthsurveillance-epidemiology-division/maternal-infant-health/perinatalhealth-indicators-2017. Robinson, J. L., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2009). Practice point—Congenital syphilis: No longer just of historical interest. Paediatrics & Child Health, 14(5), 337. Reaffirmed 2018 https://www.cps.ca/en/documents/position/congenitalsyphilis. Rodriguez, N. A., & Caplan, M. S. (2015). Oropharyngeal administration of mother’s milk to prevent necrotizing enterocolitis in extremely lowbirth-weight infants. Theoretical perspectives. Journal of Perinatal and Neonatal Nursing, 29(1), 81–90. https://doi.org/10.1097/ JPN.0000000000000087. Ross, E. J., Graham, D. L., Money, K. M., et al. (2015). Developmental consequences of fetal exposure to drugs: What we know and what we must still learn. Neuropsychopharmacology, 40(1), 61–87. https://doi.org/10.1038/ npp.2014.147. Ryan, S. A., Ammerman, S. D., O’Connor, M. E., et al. (2018). Marijuana use during pregnancy and breastfeeding: Implications for neonatal and childhood outcomes. Pediatrics, 142(3), e20181889. Shchelochkov, O. A., & Venditti, C. P. (2020). Phenylalanine. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier.

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UNIT 7

Newborn

Sherman, J. (2015). Perinatal substance abuse. In M. T. Verklan, & M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed.). Saunders. Shrim, A., Koren, G., Yudin, M. H., et al. (2018). SOGC clinical practice guideline: Management of varicella infection (chicken pox) in pregnancy. Journal of Obstetrics and Gynaecology Canada, 40(8), e652–e657. Thompson, R., DeJong, K., & Lo, J. (2019). Marijuana use in pregnancy: A review. Obstetrical and Gynecological Survey, 74(7), 415–428. https:// doi.org/10.1097/OGX.0000000000000685. Valentini, P., Buonsenso, D., Barone, G., et al. (2015). Spiramycin/ cotrimoxazole versus pyrimethamine/sulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy. Journal of Perinatology, 35(2), 90–94. Wassner, A. J., & Smith, J. R. (2020). Hypothyroidism. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Weiner, S. M., & Finnegan, L. P. (2021). Drug Withdrawal in the Neonate. In S. L. Gardner, B. S. Carter, M. Enzman-Hines, et al. (Eds.), Merenstein & Gardner’s handbook of neonatal intensive care: An interprofessional approach (9th ed.). Elsevier.

Wickstr€om, R. (2007). Effects of nicotine during pregnancy: human and experimental evidence. Current Neuropharmacology, 5(3), 213–222. https:// doi.org/10.2174/157015907781695955. Wilson, K. L., Zelig, C. M., Harvey, J. P., et al. (2011). Persistent pulmonary hypertension of the newborn is associated with mode of delivery and not with maternal use of selective serotonin reuptake inhibitors. American Journal of Perinatology, 28(1), 19–24. World Health Organization (WHO). (2018). Zika virus. https://www.who.int/ news-room/fact-sheets/detail/zika-virus. Wright, T. E., Schuetter, R., Tellei, J., et al. (2015). Methamphetamines and pregnancy outcomes. Journal of Addiction Medicine, 9(2), 111–117. Yang, H., Llewellyn, A., Walker, R., et al. (2019). High-throughput, non-invasive prenatal testing for fetal rhesus D status in RhD-negative women: A systematic review and meta-analysis. BMC Medicine, 17, 37. https://doi.org/ 10.1186/s12916-019-1254-4. Yinon, Y., Farine, D., & Yudin, M. H. (2018). SOGC clinical practice guideline: Cytomegalovirus infection in pregnancy. Journal of Obstetrics and Gynaecology Canada, 40(2), e134–e141. Young, A. L. (2017). White matter injury of prematurity: Its mechanisms and clinical features. Journal of Pathology and Translational Medicine, 51(5), 449–455.

PART

3

Pediatric Nursing

Unit 8. Children, Their Families, and the Nurse, 718 Chapter 30. Pediatric Nursing in Canada, 718 Chapter 31. Family, Social, and Cultural Influences on Children’s Health, 735 Chapter 32. Developmental Influences on Child Health Promotion, 749

Chapter 42. Impact of Intellectual Disability or Sensory Impairment on the Child and Family, 1024 Chapter 43. Family-Centred Care of the Child During Illness and Hospitalization, 1047 Chapter 44. Pediatric Variations of Nursing Interventions, 1067

Unit 12. Health Conditions of Children, 1118 Unit 9. Assessment of the Child and Family, 767 Chapter 45. Respiratory Conditions, 1118 Chapter 33. Pediatric Health Assessment, 767 Chapter 46. Gastrointestinal Conditions, 1166 Chapter 34. Pain Assessment and Management, 813 Chapter 47. Cardiovascular Conditions, 1236 Chapter 48. Hematological or Immunological Unit 10. Health Promotion and Conditions, 1280 Developmental Stages, 842 Chapter 35. Promoting Optimum Health During Chapter 49. Genitourinary Conditions, 1311 Chapter 50. Neurological Conditions, 1336 Childhood, 842 Chapter 51. Endocrine Conditions, 1377 Chapter 36. The Infant and Family, 906 Chapter 52. Integumentary Conditions, 1407 Chapter 37. The Toddler and Family, 933 Chapter53.MusculoskeletalorArticularConditions,1443 Chapter 38. The Preschooler and Family, 946 Chapter 39. The School-Age Child and Family, 956 Chapter 54. Neuromuscular or Muscular Conditions, 1481 Chapter 40. The Adolescent and Family, 973 Chapter 55. Caring for the Mental, Emotional, and Unit 11. Special Needs, Illness, and Behavioural Health Needs of Children and Hospitalization, 991 Adolescents, 1504 Chapter 41. Caring for the Child With a Chronic Illness and at the End of Life, 991 717

UNIT 8 Children, Their Families, and the Nurse

30 Pediatric Nursing in Canada Cheryl Sams and Lisa Keenan-Lindsay http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify at least two ways in which knowledge of mortality and morbidity can improve child health. 2. List two major causes of illness during childhood. 3. Outline factors that impact children’s health in Canada. 4. Outline the significance of food insecurity.

5. Describe the five core domains of pediatric nursing standards in promoting the health of children. 6. Explain how pediatric nurses incorporate family-centred care. 7. Identify communication strategies for communicating with children of different age groups. 8. Identify communication strategies for interviewing parents.

In the third part of this textbook the focus is on the complex factors that influence health in the Canadian pediatric population, from the infant to the adolescent. Topics addressed include assessment of the child; health promotion; and special needs, illnesses, hospitalization, and health conditions of children. All of these topics are discussed in the context of pediatric nursing. This chapter focuses on significant factors that influence the health of Canadian children as well as how the pediatric nurse works to enhance the health of children and families.

new vaccines, decreased tobacco smoking, and improved child health outcomes. For example, hospitalization rates for all causes for males and females has declined among those 0 to 19 years of age. However, Indigenous child health still lags behind that of the non-Indigenous child population (PHAC, 2020). Advancements in the quality of care and approaches to care, as well as health care reform, have contributed to this decrease in hospitalizations (Canadian Institute of Child Health, 2021). The Canadian Institute of Health (2021) reports that while Canadian children have relatively good health compared to children in other countries in the world, some still confront challenges to their health and well-being. These challenges differ according to gender and age group. In 2019, as in previous years, infants had the highest death rate among children and youth. Male infants had a higher death rate (4.9/1 000), and the rates of female infants is 3.9/1 000 (Statistics Canada, 2021b). Between the ages of 1 and 14 years, death rates were consistently low and did not vary significantly between age groups. For youth 15 to 19 years of age, death rates were slightly higher, which is in part due to the rise in deaths caused by injuries in this age group (Statistics Canada, 2021b). UNICEF Canada (2017) has determined indicators that have an impact on Canadian children’s health and well-being. Positive indicators that have improved (i.e., have decreased rates) over time in Canada include the following: 1. Overall income inequality 2. Child income poverty 3. Neonatal mortality 4. Teen alcohol consumption 5. Teen births 6. Teen suicide 7. Child homicide

CHILDREN’S HEALTH IN CANADA In 2016, there were approximately 5 839 570 Canadian children under the age of 14 years (Statistics Canada, 2020), and in 2018 there were 7 million youth in the age range of 15 to 29 years, representing approximately 19% of the country’s population (Statistics Canada, 2021a). In 2016, one third of First Nations people (29.2%) were 14 years of age or younger. For Métis, 22.3% of the population was 14 years of age or younger, and among Inuit, one third (33.0%) were 14 years of age or younger (Statistics Canada, 2019a). The Canadian Public Health Officer reports that Canadians are among the healthiest populations in the world (Public Health Agency of Canada [PHAC], 2020), with significant positive health trends occurring across Canada. These include a decreased incidence of certain chronic and other noninfectious diseases, as well as expanded vaccine coverage, which has helped to improve children’s health. Improved social factors that contribute to healthier living include an increase in Canadians completing postsecondary education, and poverty rates, particularly for childhood, are declining (PHAC, 2020). The health of most Canadian children has continued to steadily improve over time with improvements such as the development of

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CHAPTER 30 Negative indicators that have worsened over time and need to be addressed include: 1. Disparities in income, facilitating those from higher-income families to have greater learning proficiency 2. The number of youth excluded from adequate education and employment 3. Children from families with the lowest incomes being left farther behind 4. Air pollution in cities 5. Unhealthy levels of overweight 6. Teen mental health issues 7. Bullying The COVID-19 pandemic has also had a negative impact on children’s mental health, particularly if the child had a pre-existing mental health diagnosis. The main reason for this is probably the stress from social isolation and lack of socialization due to not attending school (Cost et al., 2021). Despite these challenges, Canada has excelled at maintaining a highperforming, fair education system and has advanced preschool participation. Young people also show a high level of environmental awareness, another factor that can promote children’s health (UNICEF Canada, 2017). Other examples of advances that have helped to improve the health of children and their families include the significantly decreasing mortality rates of childhood cancer and increased survival rates of infant heart transplants. While these advances represent the role technology has played in improving health outcomes, technology has also created many challenges that can have a negative impact on the health of children and their families. For example, global warming from increased industrialization has thinned the ozone layer, leading to a significant increase in the rate of skin cancer, among other health hazards. These many factors, discussed in this and subsequent chapters, have served to both improve the health and well-being of Canadian children and pose threats to their health and well-being. Thus efforts toward child health promotion need to continue (see Chapter 35).

Childhood Mortality Over the past 50 years, the mortality rate for children who die before reaching the age of 15 has decreased significantly in Canada; the rate of infant mortality is now lower than it was in previous decades. However, Canada’s relative ranking compared to that of other countries has fallen. Other countries have seen much greater reductions in their infant mortality rates (Conference Board of Canada, 2021). Researchers suggest that Canada has had an increase in higher-risk births because of greater success in supporting early preterm newborns and more multiple births occurring from fertility programs. There is also variation in how countries define the parameters of low birth weight (LBW) and in their registration of births and deaths (Conference Board of Canada, 2021). Overall, the rate of infant mortality in Canada has remained stable and very low; in 2019, it was 4.4 deaths per 1 000 live births (Statistics Canada, 2021b). Risk factors for infant death in Canada include the following (Government of Canada, 2019b): • Low level of maternal education • Inadequate housing • Lack of access to health care • Food insecurity • Poverty • Unemployment These risk factors are further discussed in Chapter 35. Areas where more Indigenous peoples live have a seriously higher infant mortality rate and reflect many of the above risk factors. The

Pediatric Nursing in Canada

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Indigenous infant mortality rates are as follows: the Inuit rate is 3.9 times higher; First Nations, 2.3 times higher; and Métis, 1.9 times higher than rates for the non-Indigenous population (Government of Canada, 2019b). Many of the leading causes of death during infancy are issues that occur during the perinatal period. Congenital anomalies and preterm birth are the first two leading causes of infant death. The overall Canadian birth congenital anomaly prevalence rate between 1998 and 2009 decreased from 451 to 385 per 10 000 births, while the number of preterm births increased (PHAC, 2013). This decline in anomalies is likely due to increased prenatal diagnosis and subsequent pregnancy termination, implemented measures such as folic acid fortification in food, and changes in health behaviours and practices to reduce the risk for some congenital anomalies (e.g., tobacco smoking cessation and multivitamin use). Maternal obesity is also an emerging risk factor for some congenital anomalies. Alcohol use and smoking during pregnancy remain key risks that require ongoing public health measures for prevention and prevalence reduction of such anomalies (PHAC, 2013).

Childhood Morbidity Measurements of the prevalence of specific illnesses in the population at a particular time are known as morbidity statistics, generally presented as rates per 1 000 population because of their frequency of occurrence. Unlike mortality, morbidity is difficult to define and may denote acute illness, chronic disease, or disability. Sources of data for morbidity statistics include documented reasons for visits to health care providers, recorded diagnoses qualifying for hospital admission, and household interviews. Unlike death rates, which are updated annually, morbidity statistics are revised less frequently and may not represent actual prevalence of specific illnesses in the general population. Acute illness is defined as illness with symptoms severe enough to limit activity or require medical attention. Respiratory illness accounts for the majority of all acute conditions; infections, parasitic disease, and injuries are also leading causes of disease. The common cold is the illness that occurs most frequently. The types of diseases that children contract during childhood vary according to age. For example, incidence of upper respiratory tract infections and diarrhea decreases with age, but other disorders such as acne and headaches increase in occurrence among older children. Children who have had a particular type of health issue are more likely to have that issue again. Morbidity is not distributed randomly among children. Recent concern has focused on specific groups of children who tend to have increased morbidity: homeless and immigrant children; children living in poverty; Indigenous children; children in care of child services; LBW children; children with chronic illnesses; and immigrant adopted children. Examples of challenges to pediatric health that are on the rise include obesity, type 2 diabetes, injuries, violence, vaping, and substance use. Other changes in contemporary society, including disruptive social and economic influences on the family, and the increase in sedentary activity associated with use of technologies such as playing video games for long periods of time, are contributing to significant medical conditions that affect the health of children.

Social Determinants of Health In Canada, the Medicare system provides health care for all of its legal residents (see Chapter 1). The government is gradually shifting the emphasis in health care from treatment of illnesses to health promotion and prevention of illness. In order to promote good health, the many,

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complex influences on health need to be investigated and understood. To this end, the federal government has outlined the social determinants of health (Government of Canada, 2020) (see Box 1.1). These determinants provide a blueprint for health care policies and help direct population health research with the goal of improving health for its citizens. Understanding of these health determinants is continuing to evolve as researchers discover more evidence to add to the Canadian health database. An important determinant of health that affects children’s health is family income level. The Canadian government has identified income level and socioeconomic status as having the greatest impact on health, with poverty having a significant detrimental effect on children’s health. When children live in poverty, they tend to have less access to quality health care, live with food and housing insecurity, and receive inadequate maternal nutrition and prenatal care, resulting in a delay in early childhood development. While Canada’s child poverty rate has fallen slightly over the past 30 years, still, 18.6% of children under 18 are experiencing the corrosive effects of poverty (Sarangi et al., 2020). One fifth of these children are preschoolers under the age of 6 who are living in poverty (Sarangi et al., 2020).

Health Inequities Among Children The Campaign 2000 (Sarangi et al., 2020) report identified systemic discrimination in Canada that is rooted in inequality and poverty and stratified along lines of Indigenous identity, ethnicity, gender, immigration status (or lack of), and ability, among other social, cultural, and economic factors that have led to specific populations being unable to access the opportunities available to all other Canadians. For instance, Indigenous children, whether living on or off reserve, cope more than any other group with high poverty levels. Precarious and low-wage work is widespread and social assistance rates remain exceptionally low. The increase in housing costs, food prices, childcare fees, and costs of prescription medication, including other necessities, means that Indigenous families must make challenging decisions every day about what they can and cannot afford. This is particularly true of Indigenous families living in geographically isolated locations where the basic costs are much higher (Sarangi et al., 2020). Other Canadian groups that are disproportionately affected by childhood poverty include former or current landed immigrant or permanent resident children and racialized children. Racialized persons are defined as individuals who are non-White. In Canada, 1 in 5 racialized families lives in poverty, compared to only 1 in 20 nonracialized families (Canadian Observatory on Homelessness, 2021). Further, 12% of non-Indigenous, nonimmigrant, nonracialized children live in poverty (Sarangi et al., 2020). Factors such as discrimination, language barriers, historical trauma, and colonization have a cumulative effect—they are also linked to experiencing homelessness and being unable to break the cycle of homelessness in Canadian society. The major strategies toward ending poverty include the following (Sarangi et al., 2020): • Government transfers, particularly increasing the Canada Child Benefits • Labour market interventions for low-wage earners so they have decreased unemployment fund requirements and increased opportunities for skills training and career development as well as childcare support • High-quality accessible public services • Community-building innovations such as improving inadequate housing in low-income communities Nurses play an important role in advocating for social policies that reduce poverty and in referring children and families to needed services.

Food Insecurity One out of six Canadian children are food insecure. Food-insecure households do not have access to an adequate variety or quantity of food because they cannot afford it. Children in families living in poverty are at most risk for experiencing unhealthy nutrient deficiencies, developmental and growth delays, depression, hunger, and behavioural issues. Fresh fruits and vegetables, milk, and other protein-rich foods are important nutritional resources that can be difficult to obtain because of a family’s financial constraints or remote geographical location. Two examples of Canadian groups at risk for food insecurity are children in families without a home and families living in isolated Indigenous communities. Table 30.1 further discusses the impact of the determinants of health on child nutrition and physical activity. In Canada, the most recent statistics from 2011 to 2012 regarding food insecurity indicate that: • 8.3% of Canadian households experienced food insecurity. • Nunavut persons had the highest rate of food insecurity (36.7%), over four times the Canadian average. • The rate of food insecurity was more than three times higher in households where government benefits were the main source of income (21.4%) compared with households with an alternate main source of income (6.1%). • Among various household types, lone-parent families with children under 18 reported the highest rate of household food insecurity, at 22.6% (Roshanafshar & Hawkins, 2018).

Health Promotion The World Health Organization (WHO), Health and Welfare Canada, and the Public Health Agency of Canada (1986) developed the Ottawa Charter of Health Promotion which assists in providing a health prevention focus for health care in Canada. The Charter defines health promotion as the process of enabling people to increase control over and improve their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and realize goals, satisfy needs, and change or cope with the environment. Health promotion and disease prevention are important for optimizing the health of children and their families. Nurses who work with children and their families in a variety of health care settings promote health through teaching, modelling, and programming. Many of the leading causes of death, disease, and disability— including cardiovascular disease, cancer, chronic lung diseases, depression, violence, substance use, injuries, nutritional deficiencies, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)—can be significantly reduced in children and adolescents through the prevention of six categories of behaviour (Jepson et al., 2010): 1. Tobacco use 2. Drug misuse 3. Alcohol and substance use 4. Unhealthy dietary and hygienic practices that cause disease 5. Sedentary lifestyle 6. Sexual risk taking in young people that causes unintended pregnancy and disease Child health promotion opens up opportunities to reduce differences in health status among members of various groups and helps ensure that all children have equal opportunities and resources to achieve their fullest health potential.

Immunizations The Government of Canada (2021b) has identified vaccination as one of the most important public health interventions provided to Canadians. Effective vaccine protection at the population level requires

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TABLE 30.1 Determinants of Health That Influence Food Intake and Physical Activity in Childhood and Adolescence Income

Family income determines access to quality food. In isolated and northern communities, food costs are higher and fresh fruits and vegetables are very difficult to obtain. Family income shapes access to physical activity facilities and organized sports.

Education

Increased education increases resources (i.e., literacy and numeracy) available for decision making related to food and activity choices.

Social environment

Strong communities can strengthen localized food systems. Lack of control over personal lives and communities limits opportunities to promote health (e.g., in many Indigenous communities).

Physical environment/ geographic location

Children and youth living in advantaged neighbourhoods have a far lower risk of becoming obese than those in disadvantaged neighbourhoods. Parental perceptions of public safety influence child and youth physical activity. The cost of food varies widely according to community location, with prices far higher in isolated and northern communities. Access to low-fat, nutritious foods varies by location.

Values and norms

Values and norms vary widely and affect food and physical activity patterns among children and youth.

Biological/genetic factors

Indigenous and South Asian populations have a genetic susceptibility to type 2 diabetes. Availability and accessibility of quality health promotion and health intervention services vary.

Culture

Availability of television, computers, tablets, cell phones, and video games varies. Family eating patterns vary by culture. Peer group activities and eating patterns vary by culture.

Gender

Adolescent boys, on average, are more active than adolescent girls.

Adapted from Government of Canada, Report of the Standing Senate Committee on Social Affairs, Science and Technology. (2016). Obesity. A whole-ofsociety approach for a healthier Canada. https://sencanada.ca/content/sen/committee/421/SOCI/Reports/2016-02-25_Revised_report_Obesity_in_ Canada_e.pdf.

maintaining high vaccination rates of 95% for all recommended childhood vaccines across the country. See Chapter 35 for an in-depth discussion of immunizations. Measles were eliminated in Canada in 1988, but in 2017 measles vaccine coverage rate among 2-year-olds in Canada was only 90%, which is below the minimum 95% vaccination coverage needed at the population level to maintain measles elimination status (Government of Canada, 2019a). For the past 20 years, there have not been any endemic measles outbreaks, and Canada still has the status of having eliminated measles. Periodic outbreaks of measles have occurred in Canadian children who are not vaccinated, often in local communities that are vaccine hesitant, or in children who have incomplete vaccination schedules who are travelling outside of Canada. Globally, there are many measles outbreaks; the Canadian government advises parents when travelling internationally to check for countries that have current outbreaks (Sondagar et al., 2020). The WHO reported that, worldwide, more than 140 000 people died from measles in 2018, with most deaths occurring among children under 5 years of age. Babies and very young children are at greatest risk from measles, with potential complications including pneumonia and encephalitis as well as lifelong disability including permanent brain damage, blindness, or hearing impairment (WHO, 2019). Canada still needs to improve children’s vaccination rates. Without doing so, the Canadian elimination of measles status may not stand over the long term. Mumps and pertussis are also present in Canada and periodic outbreaks have occurred. Vaccinations become even more important as antimicrobial resistance becomes more prevalent (see discussion below) and in managing the COVID-19 pandemic. The Government of Canada (2021b) has sought to address the public’s concerns regarding vaccination by explaining immunization myths and tracking outbreaks of vaccinated conditions (see Additional Resources). Nonetheless, vaccine hesitancy among the public has continued, and

some parents do not want their children vaccinated. It is important for the nurse to build trust, present the benefits and risks of vaccinations, and discuss parental concerns to ensure that they have the correct information on how the vaccines work and protect their child (see Chapter 35, Vaccine Hesitancy). At each clinic visit a child’s immunization record should be reviewed and parents should be encouraged to keep immunizations current. Most children’s vaccines are paid for by the Canadian provincial and territorial governments (Government of Canada, 2021a). The immunization schedule and types of vaccines vary between provinces and territories (see Figure 35.16).

Antimicrobial Resistance Antimicrobial resistance (AMR) to antibiotics and fungal infections is reducing treatment choices for children in Canada and worldwide. AMR is categorized by the World Health Organization (WHO Advisory Board, 2020) as one of the 13 most significant dangers to the global health. For example, from 2013 to 2017 alone, over 10 000 MRSA infections were identified in Canada (Mitevska et al., 2021). The Canadian Paediatric Society (CPS) (Le Saux et al., 2014/2020) recommends the practice of antimicrobial stewardship, which represents the common-sense, cautious use of antimicrobials to decrease adverse outcomes from antimicrobials while maximizing the treatment of bacterial infections to decrease the emergence of resistant pathogens in children and adults. This stewardship includes testing to diagnose whether infections are viral or bacterial and using clinical follow-up rather than antibiotics in cases where a child is not very ill and the microbial strain is uncertain. Other stewardship-specific actions include questioning if positive urine cultures are contaminated when there is no evidence of pyuria or inflammation and confirming pneumonia with a lung X-ray (Le Saux et al., 2014/2020).

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While infection rates of some of the most resistant organisms, for example, carbapenem-resistant Enterobacteriaceae (CRE), have been steady, a five-fold increase in carriers of CRE between 2014 and 2017 is very troublesome. Canada has experienced some decrease in AMR levels, mostly in hospitals. For example, health care–associated Clostridioides difficile decreased by 36% and health care–associated MRSA infections decreased 6% from 2012 to 2017 in recent long-term studies of the effect of antimicrobial therapy (Xia et al., 2019).

Childhood Injuries Injuries are the most common cause of death and disability among children in Canada (Pike et al., 2015). For Canadian children ages 1 to 14, unintentional injuries are the leading cause of death. Injury accounts for more childhood deaths than all other causes combined, and the majority of these injuries are preventable. Indigenous children in particular have higher rates of injuries due to living in unsafe homes and unsafe communities. These rates are also linked to poverty experienced by Indigenous families and poor access to health care. See Chapter 35, Safety Promotion and Injury Prevention, for further discussion of childhood pediatric injury prevention.

Violence Children are one of the most vulnerable populations in the context of violence. Between 2017 and 2018, Canadian family violence against children and youth increased by 7% while non-family violence decreased slightly (Conroy & Statistics Canada, 2019). In 2018, there were 60 651 child and youth victims (aged 17 and younger) of police-reported violence in Canada. Of these victims, 57% were female and 43% were male. Altogether, child and youth victims of violence were most often maltreated by a casual acquaintance (32%) or a family member (31%) and less commonly by a stranger (17%) (Conroy & Statistics Canada, 2019). Often child and youth maltreatment are difficult to identify, especially in cases of family violence, because younger children may not be aware that they are being maltreated or know how to get help and report the abuse. Children and youth may be dependent on the abuser. These factors can lead to an underestimation of the level of abuse (Conroy & Statistics Canada, 2019). The rate of physical assault is higher than for sexual assault, and rates of family violence are nearly twice as high in rural communities than in urban centres (Conroy & Statistics Canada, 2019). Children who witness family violence are also at significant risk for short- and long-term harmful consequences. Children who see and hear violent acts or see violent outcomes can have emotional, behavioural, and developmental challenges over the long term (Conroy & Statistics Canada, 2019). See discussion below on toxic stress and Chapter 35 for discussion of child maltreatment.

Toxic Stress Defined from both a physiological and an emotional point of view, stress is an imbalance between demands on a person and the ability of a person to cope with those demands, which can disrupt the equilibrium of the person. There are three levels of stress that affect a child’s development. The first is positive stress, which is healthy for children’s development of their brains and bodies and helps them learn how to adapt to meet future challenges, such as joining a group. Tolerable stress occurs with more significant events, such as a flood or a pandemic; this stress can be mitigated by supportive caregivers so that it does not have long-term

effects on children’s development. The third type of stress, toxic stress, weakens brain architecture and can disturb healthy development (Alberta Family Wellness Initiative, 2021). Toxic stress originates from major, frequent, or protracted occurrences of adverse childhood events (ACE) that can have an early and profound impact across multiple systems—neurological, immunological, psychiatric, and behavioural—that can continue into adulthood (Bucci et al., 2016). Adverse childhood experiences that are stressful or traumatic events in childhood include abuse, neglect, parental separation or divorce, witnessing violence, parental addiction, or mental illness. Childhood adversity is common across all socioeconomic groups and its effects are cumulative. There are mitigating factors that help build resilience in children to help withstand, adapt to, and recover from adversity (Traub & Boynton-Jarrett, 2017). Supportive relationships with caregivers and positive parenting techniques appear to be important in helping children to develop resilience (Williams et al., 2019). Although all children experience stress, some youngsters appear to be more vulnerable than others and are affected by age, temperament, life situation, and state of health in their reactions and ability to handle stress. While it is impossible and undesirable to protect children from stress, reducing stress, building responsive relationships, and strengthening life skills can prevent the long-term negative effects of stress (Center on the Developing Child, Harvard University, 2020). It is important that parents and persons working with children understand the nature of childhood stress and ways in which it can be recognized or anticipated. Caregivers must listen to children so that they are aware of children’s fears and concerns. They need to let children know that they are important and that what they say matters. Physical contact is usually comforting and reassuring to children. Simply holding, touching, or hugging the child can be both relaxing and comforting and facilitate communication. Spending unhurried time with the child, taking family outings or vacations, and exposing the child to positive influences can help build their resilience by building strength and a sense of security. By recognizing signs of stress parents and caregivers can help children cope with stressors before they become overwhelming. When a succession of stressors produces an excessive stress load (toxic stress), children may experience a serious change in health or behaviour.

Mental Health Many children and youth in Canada have mental health issues; as many as 15%, or 1.2 million, Canadian children are affected by anxiety, attention deficit, depression, addiction, autism spectrum disorders, behavioural disorders, eating disorders, or schizophrenia, as well as other mental health issues (Butler & Pang, 2014). Mental illness in this age group is often the beginning of an adult mental disorder (Mental Health Commission of Canada, 2021). LGBTQ2 children are more likely than heterosexual Canadians to have low self-rated mental health, and these higher rates may be linked to internalized stress related to gender expectations and experienced discrimination in the LGBTQ2 population (PHAC, 2020). Mental health issues, such as developmental, emotional, and behavioural disorders, have a direct and significant impact on families and caregivers. Nurses play an important role in helping children and their families identify early signs of mental illness and psychological stressors (see Chapter 55). Teaching the child and the family resiliency strategies can help them cope with some of the stress. Unfortunately, there are many gaps in service and long waits for services for this population;

CHAPTER 30 75% of children with emotional disorders do not have access to specialized treatment services (Centre for Addiction and Mental Health, 2020). Canada needs a national program to coordinate the various mental health services. Suicide among children and youth remains a serious issue in Canada. Adolescents who have attempted suicide are a high-risk group who require assessment of their mental state, including current suicidal thoughts and behaviours, and assessment of the key risk factors known to be associated with eventual suicide. Most adolescents who die by suicide are struggling with mental illness (Korczak et al., 2015/2021) (see further discussion in Chapter 55). Indigenous adolescents are at particular risk for suicide, with four to five times greater rates of suicide in these populations compared with non-Indigenous youth. Research shows that strong cultural continuity of the band, including women leaders; pursuit of land claims; culturedesignated buildings; and community control of child services, lowering of fostering rates, band school, band health, and fire and police services help protect Indigenous youth from suicide (Chandler & Lalonde, 2009). LGBTQ2 youth also have higher rates of suicidality (Canadian Mental Health Association Ontario, 2021). Suicide is preventable; early identification and treatment of mental illness are important ways in which to assist in suicide prevention (Korczak et al., 2015/2021). Nurses are well positioned to identify the at-risk child or adolescent who may display mental health and emotional challenges. In addition, more completely integrated medical and mental health services for children and adolescents are needed. Mental health issues affecting children and youth are discussed in more detail in Chapter 55.

Substance Use Substance use is a major health problem in Canada. Early substance use and hazardous drug ingestion during adolescence can lead to the development of serious long-term challenges in adulthood, such as addiction. Evolving research in this age group suggests that some adolescents use substances to help cope with difficult environments, untreated trauma, and underlying psychological conditions (see Chapter 55). Risk-taking behaviours, particularly among males, tend to begin in the first decade of life and continue into adolescence with drinking of alcohol while driving, speeding, or using illicit drugs. In children and young adults, alcohol and illicit drug use occurs most commonly between ages 12 and 24 and is associated with violence and injury. Alcohol is the most commonly used substance. While tobacco smoking rates among adolescents have decreased, cannabis rates remain high. Daily or almost daily cannabis consumption is more common among 15- to 24-year-old Canadians (Statistics Canada, 2019b). An additional threat to health is vaping (electronic cigarettes or e-cigarettes), in which a flavoured nicotine liquid is heated into an aerosol that is inhaled into the lungs; vaping is highly addictive. Vaping can cause irreversible lung damage and, in some cases, death (Canadian Lung Association, 2021).

THE ART OF PEDIATRIC NURSING Pediatric nurses are involved in every aspect of a child’s and family’s growth and development. Nursing functions vary according to regional job structures, individual education and experience, and personal career goals. Just as patients (children and their families) have unique backgrounds, each nurse brings an individual set of variables that affect

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the nurse–patient relationship. No matter where pediatric nurses practise, their primary concern is the welfare of the child and family. The pediatric nurse has a very important role in helping children and their families achieve optimum health. The major goal of pediatric nursing is to improve the quality of health care for children. When providing nursing care to children, it is essential that the pediatric nurse do so in the context of the family. To provide effective care, the pediatric nurse must develop a trusting and collaborative relationship with the child and family. Respect for social and cultural differences and beliefs is the cornerstone of high-quality pediatric care. The practice of a pediatric nurse is based on both the science and art of nursing. Evidenceinformed nursing care provides the scientific base; the art of pediatric nursing care requires a strong sense of compassion and caring for children of all ages and stages and for their families. The qualities of an excellent pediatric nurse include creativity, effective communication skills, playfulness, patience, and resilience.

Philosophy of Care The foundation of pediatric nursing is a strengths-based approach to the protection, promotion, and optimization of health and abilities for children. Using a child and family-centred care approach, pediatric nurses require knowledge of psychomotor, psychosocial, and cognitive growth and development, as well as of the health issues and needs specific to people in this age group (Canadian Association of Pediatric Nurses [CAPN], 2017). Pediatric nursing in Canada follows the practice standards set by CAPN as well as the individual provincial and territorial regulatory bodies. The Canadian pediatric nursing standards are divided into five domains (“Standards”) that identify unique characteristics of pediatric nursing practice (Box 30.1) (CAPN, 2017). Under each domain is a description of a specific outcome that will positively impact the care experience of the child and their family. Each domain is also supported by behaviours that are so important to patients and families that health care providers must aim to perform them consistently and reliably for every patient, every time (CAPN, 2017).

Family-Centred Care The philosophy of family-centred care recognizes the family as the one constant in a child’s life. The Canadian pediatric nursing standards are built on the child- and family-centred care principles presented in Standard I (see Box 30.1). These include supporting, respecting, encouraging, and enhancing the family’s strength and competence by developing a collaborative and information-sharing partnership with parents. Nurses support families in their natural caregiving and decision-making roles by building on families’ unique strengths and acknowledging their expertise in caring for their child both within and outside the hospital setting. The needs of all family members, not just the child’s, are considered. Family-centred care addresses the diversity among family structures and backgrounds; family goals, dreams, strategies, and actions; and family support, service, and information needs. It is essential that the pediatric nurse work within the framework of family-centred care. See Additional Resources on family-centred care. The important outcomes of family-centred care are enabling and empowerment. Health care providers enable families by creating opportunities for all family members to carry out their current abilities and competencies and to acquire new ones that are necessary for meeting the needs of the child and family. Empowerment involves interaction of health care providers with families in a way that assists families

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Core Domains of Pediatric Nursing Standards

Standard I: Supporting and Partnering With the Child and the Family Pediatric nurses partner with the child and their family to achieve their optimal level of health and well-being, leading to resilient families and healthy communities. The pediatric nurse always: • Establishes an intentional therapeutic relationship with the child and family • Respects the child and family in goal setting and decision making • Collects and uses information from the child and family context to inform care • Communicates with both the child and family as partners in care • Advocates for optimal use of resources to support the child and family • Recognizes and fosters the parenting role to support child well-being Standard II: Advocating for Equitable Access and the Rights of Children and Their Family Pediatric nurses demonstrate and mobilize their understanding of the social determinants and other systemic factors that impact child health. The pediatric nurse always: • Completes a comprehensive assessment (beyond physical assessment) through an advocacy lens considering social determinants of health and child well-being • Facilitates an appropriate environment to perform assessment and intervention considering privacy and confidentiality • Builds capacity in the child and their family to self-advocate • Engages in a community of practice or network that focuses on pediatric nursing practice and knowledge and resources for children and families • Supports the child and family to navigate the health care system Standard III: Delivering Developmentally Appropriate Pediatric Care Nurses perform assessment based on growth and development and deliver pediatric-specific care. The pediatric nurse always: • Demonstrates knowledge of typical development and variation from what is considered typical • Demonstrates knowledge of safety risks appropriate for developmental stage • Provides anticipatory guidance and coaching for the family on typical development and safety related to the developmental stage of the child • Performs safety assessments at point of care to minimize risk and harm with developmental stage

• Incorporates developmentally appropriate play and/or recreational activities into care • Performs age- and developmentally appropriate biopsychosocial assessment • Uses developmentally appropriate strategies when preparing for and performing interventions • Considers development that is influenced by ethnicity, spirituality, and culture Standard IV: Creating a Child- and Family-Friendly Environment Pediatric nurses play an essential role in creating a child- and family-friendly environment that welcomes families and promotes hope and healing. It is understood that the environment changes as the child grows and is influenced by multiple factors, including, but not exclusive to, psychological, spiritual, and social factors. The pediatric nurse always: • Completes a child and family assessment • Demonstrates cultural competency and humility in all child and family interactions • Engages with the child and family in all care decisions and the plan of care in a respectful nonjudgemental, culturally safe manner • Shares information relevant to the plan of care and collaborates with and among the circle of health care providers • Recognizes and fosters family strengths and supports • Uses strategies to support and foster resiliency • Demonstrates caring and compassion to both the child and family Standard V: Enabling Successful Transitions Pediatric nurses support the child and family through health care transitions to maximize their well-being. This may include, but is not limited to, hand-off between health care providers, admission and discharge, and facility transfer (such as from pediatric to adult care institutions). The pediatric nurse always: • Uses effective communication strategies at all transitions in care • Engages in planning of health education and coaching at all transitions • Provides health education and information to optimize transition of the child and family • Assesses readiness and supports safe transition • Anticipates resources to support transitions in care • Plays an active role in facilitating effective transition

Adapted from The Canadian Association of Pediatric Nurses. (2017). Canadian paediatric nursing standards. https://paednurse.ca/resources/Documents/ FINAL-Paediatric%20Nursing%20Standards%20September%202017.pdf.

to maintain or acquire a sense of control over their lives and make positive changes through the fostering of their own strengths, abilities, and actions (Institute for Patient- and Family-Centered Care, 2017). The Hospital for Sick Children (SickKids), in Toronto, has developed a model of family-centred care (Figure 30.1). The model centres the child at the core, as the first priority. The family is adjacent to the child to represent the centrality of the family to the child’s life. The model demonstrates that children and families experience health care at SickKids through clinical practice, administration, research, and education. SickKids interacts locally, nationally, and internationally to support health care service delivery through the community and health system. Respect, communication, and partnership are the three essential integrated elements to include in the process of delivering care. The model can influence and foster positive outcomes for children and families by promoting optimal health, ensuring patient safety, achieving health equity, and maximizing the patient experience.

Atraumatic Care Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychological and physical distress experienced by children and their families in the health care system. Therapeutic care encompasses the prevention, diagnosis, treatment, and palliation of chronic or acute conditions. Setting refers to whatever place in which care is given—the home, the hospital, or any other health care setting. Personnel include anyone directly involved in providing therapeutic care. Interventions range from psychological approaches, such as preparing children for procedures, to physical interventions, such as providing space for a parent to room-in with a child. Psychological distress may include anxiety, fear, anger, disappointment, sadness, shame, or guilt. Physical distress may range from sleeplessness and immobilization to disturbing sensory stimuli such as pain, temperature extremes, loud noises, bright lights, or darkness. Thus atraumatic care is concerned with the who, what, when,

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where, why, and how of any procedure performed on a child, for the purpose of preventing or minimizing psychological and physical stress. The overriding goal in providing atraumatic care is first, do no harm. Three principles constitute the framework for achieving this goal: (1) prevent or minimize the child’s separation from the family; (2) promote a sense of control; and (3) prevent or minimize bodily injury and pain. Examples of atraumatic care include fostering the parent–child relationship during hospitalization, preparing the child before any unfamiliar treatment or procedure, controlling pain, allowing the child privacy, providing play activities for expression of fear and aggression, offering choices to children, and respecting cultural differences.

Therapeutic Relationships The establishment of a therapeutic relationship is the essential foundation for providing high-quality nursing care. Pediatric nurses need to have meaningful relationships with the children and families they encounter and yet remain separate enough to distinguish their own feelings and needs. In a therapeutic relationship, caring, well-defined boundaries separate the nurse from the child and family. These boundaries are positive and professional and promote the family’s control over the child’s health care. For effective family advocacy to occur, these boundaries need to be established and therapeutic relationships promoted. Both the nurse and the family are empowered, and open communication is maintained. In a nontherapeutic relationship, these boundaries are blurred, and many of the nurse’s actions may serve personal needs, such as a need to feel wanted and involved, rather than the family’s needs. Exploring whether relationships with patients are therapeutic or nontherapeutic can help nurses identify problem areas early in their interactions with children and families. Although questions for exploring types of involvement can be labelled negative or positive, no one action makes a relationship therapeutic or nontherapeutic.

For example, nurses may spend additional time with the family but still recognize their own needs and maintain professional separateness. An important clue to nontherapeutic relationships is the staff’s concerns about their peer’s actions with the family. See Guidelines box: Building Relationships With Children and Families.

GUIDELINES Building Relationships With Children and Families To foster therapeutic relationships with children and families, you must first become aware of your caregiving style, including how effectively you take care of yourself. The following questions should help you understand the therapeutic quality of your professional relationships. Negative Actions • Are you overinvolved with children and their families? • Do you work overtime to care for the family? • Do you spend off-duty time with children’s families, either in or out of the hospital? • Do you call frequently (either the hospital or home) to see how the family is doing? • Do you show favouritism toward certain patients? • Do you buy clothes, toys, food, or other items for the child and family? • Do you compete with other staff members for the affection of certain patients and families? • Do other staff members comment to you about your closeness to the family? • Do you attempt to influence families’ decisions rather than facilitate their informed decision making? • Are you underinvolved with children and families? • Do you restrict parent or visitor access to children, using excuses such as the unit is too busy?

Continued

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GUIDELINES—CONT’D • Do you focus on the technical aspects of care and lose sight of the person who is the patient? • Are you overinvolved with children and underinvolved with their parents? • Do you become critical when parents do not visit their children? • Do you compete with parents for their children’s affection? Positive Actions • Do you strive to empower families? • Do you explore families’ strengths and needs in an effort to increase family involvement? • Have you developed teaching skills to instruct families rather than doing everything for them? • Do you work with families to find ways to decrease their dependence on health care providers? • Can you separate families’ needs from your own needs? • Do you strive to empower yourself? • Are you aware of your emotional responses to different people and situations? • Do you seek to understand how your own family experiences influence reactions to patients and families, especially as they affect tendencies toward overinvolvement or underinvolvement? • Do you have a calming influence, not one that will amplify emotionality? • Have you developed interpersonal skills in addition to technical skills? • Have you learned about ethnic and religious family patterns? • Do you communicate directly with persons with whom you are upset or take issue? • Are you able to “step back” and withdraw emotionally, if not physically, when emotional overload occurs, yet remain committed? • Do you take care of yourself and your needs? • Do you periodically interview family members to determine their current issues (e.g., feelings, attitudes, responses, wishes), communicate these findings to peers, and update records? • Do you avoid relying on initial interview data, assumptions, or gossip regarding families? • Do you ask questions if families are not participating in care? • Do you assess families for feelings of anxiety, fear, intimidation, worry about making a mistake, a perceived lack of competence to care for their child, or fear of health care providers overstepping their boundaries into family territory, or vice versa? • Do you explore these issues with family members and provide encouragement and support to enable families to help themselves? • Do you keep communication channels open among self, family, physicians, and other care providers? • Do you resolve conflicts and misunderstandings directly with those who are involved? • Do you clarify information for families or seek the appropriate person to do so? • Do you recognize that from time to time a therapeutic relationship can change to a social relationship or an intimate friendship? • Are you able to acknowledge the fact when it occurs and understand why it happened? • Can you ensure that there is someone else who is more objective who can take your place in the therapeutic relationship?

Communication With Families and Children. Communication is the cornerstone of providing nursing care to children and their families. When a nurse meets a child and the family, they are starting the process of building a relationship with all of the individuals involved. It essential that the nurse be able to develop a rapport and a sense of trust with the family in order to encourage the child and the family to share information relevant to the child’s care. Sharing information will help in

obtaining an accurate history and health assessment of the child. The most widely used method by nurses to communicate with parents and children on a professional basis is the interview process. Unlike social conversation, interviewing is a specific form of goal-directed communication. As nurses converse with children and adults, they focus on the individuals to determine their usual mode of handling problems, whether help is needed, and the way they react to counselling. Developing interviewing skills requires time and practice, but following some guiding principles can facilitate this process. An organized approach is most effective when using interviewing skills in patient teaching. Appropriate introduction. When first meeting a patient and their family, the nurse needs to introduce themselves to the family members and ask each person’s name. Parents and other adults should be addressed by their appropriate titles, such as “Mr.,” “Mrs.,” or “Ms.,” unless they specify a preferred name. The nurse should record the preferred name on the medical record. Using formal address or their preferred names, rather than using first names or “mother” or “father” conveys respect for the parents or other caregivers (Solomon et al., 2019). At the beginning of the visit, to establish rapport, children should be included in the interaction, by asking them their name, age, grade, and favourite activities. Nurses often direct all questions to adults, even when children are old enough to speak for themselves, which can exclude a valuable source of information: the patient. When the child is a participant in the interview, the nurse should use the general rules for communicating with children that are given in the Guidelines box: Communicating With Children.

GUIDELINES Communicating With Children • Allow children time to feel comfortable. • Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as threatening. • Talk to the parent if the child is initially shy. • Communicate through transition objects such as dolls, puppets, and stuffed animals before questioning a young child directly. • Give older children the opportunity to talk without the parents present. • Assume a position that is at eye level with the child (see Figure 30.3). • Speak in a quiet, unhurried, and confident voice. • Speak clearly, be specific, and use simple words and short sentences. • State directions and suggestions positively. • Offer a choice only when one exists. • Be honest with children. • Allow them to express their concerns and fears. • Use a variety of communication techniques.

Assurance of privacy and confidentiality. The place where the interview is conducted is almost as important as the interview itself. The physical environment should allow for as much privacy as possible, with distractions such as interruptions, noise, or other visible activity kept to a minimum. If young children are present, the environment should have some toys to keep them occupied during the parent–nurse interview (Figure 30.2). Parents who are constantly interrupted by their children are unable to concentrate fully and may give brief answers in order to finish the interview as quickly as possible. Confidentiality is another essential component of the interview. One of the primary nursing values of the Canadian Nurses Association (CNA, 2017) is the importance of privacy and confidentiality; the nurse needs to protect personal, family, and community information obtained within the framework of a professional relationship. Since the interview is usually shared with other members of the health team care or possibly with a teacher (in the case of students), it is imperative

CHAPTER 30

Fig. 30.2 A child plays while the nurse interviews the parents.

to inform the family of the limits regarding confidentiality. If confidentiality is a concern in a particular situation, such as when talking to a parent suspected of child abuse or a teenager contemplating suicide, this should be dealt with directly and the person informed that, in such instances, confidentiality cannot be ensured.

Communicating With Parents. When providing nursing care for children, the nurse’s relationship with the child is frequently mediated by the parent, particularly for younger children. For the most part, information about the child is acquired by direct observation or is communicated to the nurse by the parents. Usually it can be assumed that, because of the parent’s close contact with the child, the parent is giving reliable information. To make an assessment of the child the nurse needs input from the child (verbal and nonverbal), information from the parent(s), and the nurse’s own observations of the child and interpretation of the relationship between the child and parent(s). Counselling and guidance must be directed to the caregiver of infants and small children; when children are old enough to be active participants in their own health maintenance, the parent becomes a collaborator in health care. Encouraging parents to talk. Interviewing parents provides the opportunity to not only determine the child’s health and developmental status but also to obtain information about factors that influence the child’s well-being. Whatever the parent sees as an issue should be a concern for the nurse. Such issues are not always easy to identify; nurses need to be alert for clues and signals by which a parent communicates worries and anxieties. Careful phrasing with broad, open-ended questions, such as “What is Jack eating now?” provides more information than several single-answer questions, such as “Is Jack eating what the rest of the family eats?” Sometimes the parent will take the lead without prompting. At other times it may be necessary to direct another question on the basis of an observation, such as “Angelica seems unhappy today” or “How do you feel when Jamil cries?” If the parent appears to be tired or distraught, consider asking, “What do you do to relax?” or “What help do you have with the children?” A comment such as “You handle the baby very well. What kinds of experience have you had with babies?” to new parents who appear comfortable with their first child gives positive reinforcement and provides an opening for any questions they might have regarding the infant’s care. Often all that is required to maintain communication is a nod or saying “yes” or “uh-huh.” When attempting to elicit feelings or information regarding issues more difficult for parents to address, closed-ended questions that begin with “Does … ,” “Did … ,” or “Is … ,” should be avoided as these

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usually require only a single response. Asking questions such as “Does your son have any problems at school?” subtly implies a lack of parental skills and can evoke defensiveness. Instead, use questions that begin with “What … ,” “How … ,” or “Tell me about … ,” and encourage elaboration with phrases like “You were saying …” or “You say that … ” or by reflecting back a key word. Open-ended questions are nonthreatening and encourage description. Directing the focus. The ability to direct the focus of the interview while allowing for maximum freedom of expression is one of the most difficult goals in effective communication. One approach is the use of open-ended or broad questions, followed by guiding statements. For example, if the parent proceeds to list the other children by name, say, “Tell me their ages, too.” If the parent continues to describe each child in depth, which is not the purpose of the interview, redirect the focus by stating, “Let’s talk about the other children later. You were beginning to tell me about Olivia’s activities at school.” This approach conveys interest in the other children but focuses the assessment on the patient. Listening and cultural awareness. Listening is the most important component of effective communication. When listening is truly aimed at understanding the patient, it is an active process that requires concentration and attention to all aspects of the conversation—verbal, and nonverbal. Major blocks to listening are environmental distraction and premature judgement. The nurse’s attitudes and feelings are easily injected into an interview. Often nurses’ perceptions of a parent’s behaviour are influenced by their own perceptions, prejudices, and assumptions, which may include racial, religious, and cultural stereotypes. What may be interpreted as a parent’s passive hostility or lack of interest may be shyness or an expression of anxiety. For example, in Western cultures, eye contact and directness are signs of paying attention. However, in many non-Western cultures, including some Indigenous cultures, directness, such as looking someone in the eye, is considered rude. Children are taught to avert their gaze and to look down when being addressed by an adult, especially one with authority (Solomon et al., 2019). Therefore, judgements about listening and verbal interactions need to be made with an appreciation of cultural differences (see Chapters 2 and 31). The nurse’s minimal speaking, along with active listening, can facilitate parents’ involvement. While it is tempting to spend time explaining, describing, and interpreting health information when the opportunity presents itself, it is possible to provide effective health education by timing the information properly and presenting only as much as is necessary at the moment. Careful listening relies on the use of clues, verbal leads, or signals from the interviewee to move the interview along. Frequent references to an area of concern, repetition of certain key words, or special emphasis on something or someone can serve as cues to the interviewer for directing the inquiry. Concerns and anxieties are often mentioned in a casual, offhand manner; however, they are nonetheless important and deserve careful scrutiny to identify problem areas. For example, a parent who is concerned about a child’s habit of bed-wetting may casually mention that the child’s bed was “wet this morning.” Providing anticipatory guidance. The ideal way to handle a situation is to deal with it before it becomes a concern. In nursing the best preventive measure is anticipatory guidance. Traditionally, anticipatory guidance has focused on providing families with information on children’s growth and development. Parents who are unprepared for their child’s development can be disturbed by many normal developmental changes, such as a toddler’s diminished appetite, negativism, altered sleeping patterns, and anxiety toward strangers. (See Chapter 35 for informing parents about pediatric health promotion according to developmental age.) Anticipatory guidance also includes nurturing

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child-rearing practices that promote the health of the child, for example, injury prevention. Beginning prenatally, parents need specific instructions on home safety. As the child’s developmental skills mature and change, so too should home safety measures be implemented to minimize risks to the child. However, anticipatory guidance should extend beyond giving general information during health care visits; families should also be encouraged to use the information as a means of building competence in their parenting abilities. To achieve this level of anticipatory guidance, the nurse should do the following: • Base interventions on needs identified by the family, not by the health care provider. • View the family as competent or as having the ability to be competent. • Provide opportunities for the family to achieve competence. Avoiding blocks to communication. A number of blocks or hindrances to communication can adversely affect the quality of the helping relationship. Often the interviewer unwittingly introduces some of these blocks, such as giving unrestricted advice or forming prejudged conclusions. Sometimes interviewees experience information overload when presented with too much information or information that is overwhelming and will demonstrate signs of increasing anxiety or decreasing attention. Such signals should alert the interviewer to give less information or to clarify what has been said. Box 30.2 lists some of the more common blocks to communication, including signs of information overload. Communicating with families through an interpreter. Sometimes communication is impossible because the health care provider and the patient speak different languages. In this case, it is necessary to obtain information through a third party, the interpreter. When an interpreter is used, the same interviewing guidelines as those used without an interpreter apply. Specific guidelines for using an adult interpreter are presented in Box 2.6.

Communicating With Children. Although the greatest amount of verbal communication is usually carried out with the parent, the child should not be excluded during the interview. Infants and younger children can be observed through play; occasionally, younger children can

BOX 30.2

Blocks to Communication

Communication Barriers (Nurse) • Socializing • Giving unrestricted and sometimes unasked-for advice • Offering premature or inappropriate reassurance • Giving over-ready encouragement • Defending a situation or opinion • Using stereotyped comments or clichés • Limiting expression of emotion by asking directed, closed-ended questions • Interrupting and finishing the person’s sentence • Talking more than the interviewee • Forming prejudged conclusions • Deliberately changing the focus Signs of Information Overload (Patient) • Long periods of silence • Wide eyes and fixed facial expression • Constant fidgeting or attempting to move away • Nervous habits, such as tapping, playing with hair • Sudden disruptions, such as asking to go to the bathroom • Looking around • Yawning, eyes drooping • Frequently looking at a watch or clock • Attempting to change the topic of discussion

Fig. 30.3 The nurse assumes position at the child’s level.

answer questions or respond to remarks. Older children should be included as active participants in the interview. See Nursing Skills on Evolve: Communicating With Children—Age-Related Techniques. In communication with children of all ages, the nonverbal components of the communication process convey the most significant messages. It is difficult to disguise feelings, attitudes, and anxiety when relating to children. They are alert to surroundings and attach meaning to every gesture and move that is made; this is particularly true of very young children. Active attempts to make friends with children before they have had an opportunity to evaluate an unfamiliar person tend to increase their anxiety. It is helpful to continue to talk to the child and parent but go about activities that do not involve the child directly, thus allowing the child to observe from a safe position (Figure 30.3). If the child has a special toy or doll, the nurse can “talk” to the doll first. Simple questions such as “Does your teddy bear have a name?” can be asked to ease the child into conversation. Other guidelines for communicating with children are presented in the Guidelines box: Communicating With Children. Communication and development of thought processes. The normal development of language and thought in children offers a frame of reference for communicating with children. Thought processes progress from sensorimotor to perceptual to concrete and, finally, to abstract, formal operations. An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication. Infancy. Because infants are unable to use words, they primarily use and understand nonverbal communication. Infants communicate their needs and feelings through nonverbal behaviours and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Adults interpret this to mean that an infant needs something and consequently try to alleviate the discomfort and reduce tension. Crying (or the desire to cry) persists as a part of everyone’s communication repertoire. Infants respond to adults’ nonverbal behaviours. They become quiet when they are cuddled, are patted, or receive other forms of gentle physical contact. They derive comfort from the sound of a voice, even though they do not understand the words spoken. Until infants reach the age at which they experience stranger anxiety, they readily respond

CHAPTER 30 to any firm, gentle handling and quiet, calm speech. Loud, harsh sounds and sudden movements are frightening to infants. Early childhood. Children younger than 5 years of age are egocentric. They see things only in relation to themselves and from their point of view. Therefore, communication needs to be focused on them. They should be told what they can do or how they will feel. Experiences of others are usually of no interest to them; it is futile to use another child’s experience in an attempt to gain the collaboration of small children. During the health assessment they should be allowed to touch and examine articles that will come in contact with them. A stethoscope bell will feel cold; palpating a neck might tickle. Although they have not yet acquired sufficient language skills to express their feelings and wants, toddlers are able to communicate effectively with their hands to transmit ideas without words. For example, they will push an unwanted object away, pull another person to show them something, point, and cover the mouth or ears when they wish to not say or hear something. Everything is direct and concrete to small children. They are unable to work with abstractions and they interpret words literally. Analogies escape them because they are unable to separate fact from fantasy. For example, they attach literal meaning to such common phrases as “twofaced,” “sticky fingers,” or “coughing your head off.” Children who are told they will get “a little stick in the arm” may not be able to envision an injection (Figure 30.4). Therefore, nurses should avoid using a phrase that might be misinterpreted by a small child. Young children assign human attributes to inanimate objects. Consequently, they fear that objects may jump, bite, cut, or pinch all by themselves. Children do not know that these devices are unable to perform without human direction. To minimize their fear, unfamiliar equipment should be kept out of view until it is needed. School-age years. Younger school-age children rely less on what they see and more on what they know, when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. For example, to explain a procedure such as

Fig. 30.4 A young child may take the expression “a little stick in the arm” literally.

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taking blood pressure, the child should be shown how squeezing the bulb pushes air into the cuff and makes the arrow move. The child should be allowed to operate the bulb. An explanation for the procedure might be as simple as “I want to see how far the arrow moves when the cuff squeezes your arm.” The child then usually becomes an enthusiastic participant. School-age children have a heightened concern about body integrity. Because of the special importance they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of treasured objects. Helping children voice their concerns enables the nurse to provide reassurance and to implement activities that can reduce their anxiety. For example, if a shy child dislikes being the centre of attention, the child should be ignored, by talking and relating to other children in the family or group. When children feel more comfortable, they will usually interject personal ideas, feelings, and interpretations of events. Older children have an adequate and satisfactory use of language. They still require relatively simple explanations, but their ability to think concretely can facilitate communication and explanation. Commonly, they have sufficient experience with health care workers to understand what is transpiring and what is generally expected of them. Adolescence. As children move into adolescence, they fluctuate between child and adult thinking and behaviour. They are riding a current that is moving them rapidly toward a maturity that may be beyond their coping ability. Thus, when tensions arise, they may seek the security of the more familiar and comfortable expectations of childhood. Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently; one can expect to encounter cooperation, hostility, anger, bravado, and a variety of other behaviours and attitudes. It is as much a mistake to regard the adolescent as an adult with an adult’s wisdom and control as it is to assume that the teenager has the concerns and expectations of a child. Frequently, adolescents are more willing to discuss their concerns with an adult outside the family, and they often welcome the opportunity to interact with a nurse away from the presence of their parents. They are usually accepting of anyone who displays a genuine interest in them. However, adolescents are quick to reject persons who attempt to impose their values on them, whose interest is feigned, or who appear to have little respect for who they are and what they think or say. Interviewing the adolescent presents some special issues. The first may be whether to talk with the adolescent alone or with the adolescent and parents together. Of course, if the parent is not there, the only question is whether to suggest to the teenager that the parents be interviewed at another time. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the relationship. However, talking with the parents initially may provide insight into the family dynamics. In either case, both parties should be given an opportunity to be included in the interview. If there are time constraints, such as during history taking, this should be clarified at the outset, to avoid the appearance of “taking sides” by talking more with one person than with the other. Confidentiality is of great importance when interviewing adolescents. Parents and teenagers need to have the limits of confidentiality explained to them, specifically that young persons’ disclosures will not be shared unless they indicate a need for intervention, as in the case of suicidal behaviour. Another dilemma in interviewing adolescents is that two views of an issue frequently exist—the teenager’s and the parents’. However, providing both parties an opportunity to discuss their perceptions in an open and unbiased atmosphere can, by itself, be therapeutic.

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The demonstration of positive communication skills can help families communicate more effectively (see Guidelines box: Communicating With Adolescents).

GUIDELINES Communicating With Adolescents Build a Foundation • Spend time together. • Encourage expression of ideas and feelings. • Respect their views. • Tolerate differences. • Praise good points. • Respect their privacy. • Set a good example. Communicate Effectively • Give undivided attention. • Listen, listen, listen. • Be courteous, calm, and open-minded. • Try not to overreact. If you do, take a break. • Avoid judging or criticizing. • Avoid the “third degree” of continuous questioning. • Choose important issues when taking a stand. • After taking a stand: • Think through all options. • Make expectations clear.

Communication Techniques. Nurses use a variety of verbal techniques to encourage communication. In addition to such conventional interviewing methods as reflection and open-ended questions, a number of techniques encourage family members to express their thoughts and feelings in a less directive and confrontational manner. However, for many children and adults, talking about feelings is difficult, and verbal communication may be more stressful than supportive. In such instances, several nonverbal techniques can be used to encourage communication. Box 30.3 describes both verbal and nonverbal communication techniques used with children. Because of the importance of play in communicating with children, play is discussed more extensively in Chapter 32. Any of the verbal or nonverbal techniques can give rise to strong feelings that surface unexpectedly. The nurse should be prepared to handle them or to recognize when issues go beyond their ability to deal with them. At that point, an appropriate referral can be considered.

Family Advocacy and Caring Although nurses are responsible to themselves, the profession, and the institution of employment, their primary responsibility is to the consumer of nursing services—the child and the family. The nurse must work with family members, identify their goals and needs, and plan interventions that meet the defined concerns. As an advocate, the nurse can assist children and their families in making informed choices and acting in the child’s best interest. Advocacy involves ensuring that families are aware of all available health services, informed of treatments and procedures, involved in the child’s care, and encouraged to change or support existing health care practices. The United Nations Declaration of the Rights of the Child (Box 30.4) provides guidelines for nursing practice that can be used to ensure that every child receives optimal care. The nurse can use this knowledge to adapt care for the child’s physical and emotional well-being.

As nurses care for children and families, they must demonstrate caring, compassion, and empathy for others. Aspects of caring embody the concepts of atraumatic care and the development of a therapeutic relationship with patients. Parents perceive caring as a sign of high-quality nursing care, which is often focused on the nontechnical needs of the child and family. Parents describe “personable” care as actions by the nurse that include acknowledging the parents’ presence, listening, making the parents feel comfortable, involving both the parents and the child in care, showing interest in and concern for their welfare, showing sensitivity toward the parent and child, communicating with them, and individualizing the nursing care. Parents perceive personable nursing care as an integral part of a positive relationship.

Disease Prevention and Health Promotion Every nurse involved with child care must understand the importance of disease prevention and health promotion. A nursing care plan must include a thorough assessment of all aspects of child growth and development, including nutrition, immunizations, safety, dental care, socialization, discipline, and education. If issues are identified, the nurse can intervene directly or refer the family to other health care providers or agencies. The best approach to prevention is education and anticipatory guidance. An appreciation of the hazards or conflicts of each developmental period enables the nurse to guide parents regarding childrearing practices aimed at preventing potential problems. One of the most significant examples is safety. Because each age group is at risk for special types of injuries, preventive teaching can significantly reduce the rate of injuries, in turn lowering permanent disability and mortality rates (see Chapter 35). Prevention also involves less obvious aspects of care. In addition to preventing physical disease or injury, the nurse should also promote mental health. For example, it is not sufficient to administer immunizations without regard to the psychological trauma associated with the procedure. The nurse and all other health care providers must ensure that humane care is provided.

Health Teaching Health teaching is inseparable from family advocacy and prevention. Health teaching may be the nurse’s direct goal, such as during parenting classes, or may be indirect, such as by: • Helping parents and children understand a diagnosis or treatment • Encouraging children to ask questions about their bodies • Referring families to health-related professional or lay groups • Supplying appropriate literature • Providing anticipatory guidance Health teaching is one area in which nurses often need preparation and practice with competent role models, as it involves the transmission of information at the child’s and family’s levels of understanding and desire for information. As an effective educator, the nurse focuses on providing the appropriate health teaching along with generous feedback and evaluation to promote learning.

Support and Counselling. Attention to emotional needs requires support and sometimes counselling. The role of child advocate or health teacher requires an individualized approach. The nurse can offer support by listening, touching, and being physically present. Touching and physical presence are helpful to use with children because these interventions facilitate nonverbal communication. Counselling involves a mutual exchange of ideas and opinions that provides the basis for mutual problem solving. It involves supporting, teaching, fostering expression of feelings or thoughts, and helping families cope with stress. Optimally, counselling not only helps resolve a

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BOX 30.3

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Creative Communication Techniques With Children

First- and Second-Person Techniques “I” messages Relate a feeling about a behaviour in terms of “I.” Describe the effect that the behaviour had on the person. Avoid use of “you;” “you” messages are judgemental and provoke defensiveness. Example—“You” message: “You are being uncooperative about doing your treatments.” Example—“I” message: “I am concerned about how the treatments are going because I want to see you get better.” Third-Person Technique Express a feeling in terms of a third person (“he,” “she,” “they”). This is less threatening than directly asking children how they feel, because it gives them an opportunity to agree or disagree without being defensive. Example—“Sometimes when a person is sick a lot, he feels angry and sad because he cannot do what others can.” Either wait silently for a response or encourage a reply with a statement such as “Did you ever feel that way?” This approach allows children three choices: (1) to agree and possibly express how they feel; (2) to disagree; or (3) to remain silent, which means they probably have such feelings but are unable to express them at this time. Facilitative Response Listen carefully and reflect back to patients the feelings and content of their statements. Responses are empathic and nonjudgemental and legitimize the person’s feelings. Formula for facilitative responses: “You feel ____________ because ____________.” Example—If the child states, “I hate coming to the hospital and getting needles,” a facilitative response is, “You feel unhappy because of all the things that are done to you.” Storytelling Use the language of children to probe into areas of their thinking while bypassing conscious inhibitions or fears. The simplest technique is asking the child to relate a story about an event, such as “being in the hospital.” Other approaches: Show the child a picture of a particular event, such as a child in a hospital with other people in the room, and ask the child to describe the scene. Cut out comic strips, remove words, and have the child add statements for scenes. Mutual Storytelling Reveal the child’s thinking and attempt to change the child’s perceptions or fears by retelling a somewhat different story (more therapeutic approach than storytelling). Begin by asking the child to tell a story about something, then tell another story that is similar to the child’s tale but with differences that help the child in difficult areas. Example—The child’s story is about going to the hospital and never seeing their parents again. The nurse’s story is also about a child (using different names but similar circumstances) in a hospital, but whose parents visit every day, in the evening after work, until the child is better and goes home with them.

Bibliotherapy Use books in a therapeutic and supportive process. Provide children with an opportunity to explore an event that is similar to their own but sufficiently different to allow them to distance themselves from it and remain in control. General guidelines for using bibliotherapy are as follows: 1. Assess the child’s emotional and cognitive development in terms of readiness to understand the book’s message. 2. Be familiar with the book’s content (intended message or purpose) and the age for which it is written. 3. Read the book to the child if they are unable to read. 4. Explore the meaning of the book with the child by having child do the following: Retell the story. Read a special section with the nurse or parent. Draw a picture related to the story and discuss the drawing. Talk about the characters. Summarize the moral or meaning of the story. Dreams Dreams often reveal unconscious and repressed thoughts and feelings. Ask the child to talk about a dream or nightmare. Explore with the child what meaning the dream could have. “What If” Questions Encourage the child to explore potential situations and to consider different problem-solving options. Example—“What if you got sick and had to go the hospital?” Children’s responses reveal what they know already and what they are curious about, providing an opportunity for them to learn coping skills, especially in potentially dangerous situations. Three Wishes Ask, “If you could have any three things in the world, what would they be?” If the child answers, “That all my wishes come true,” ask the child for specific wishes. Rating Game Use some type of rating scale (numbers, sad to happy faces) to have the child rate an event or feeling. Example—Instead of asking youngsters how they feel, ask how their day has been “on a scale of 1 to 10, with 10 being the best.” Word Association Game State key words and ask children to say the first word they think of when they hear the word. Start with neutral words and then introduce more anxiety-producing words, such as “illness,” “needles,” “hospitals,” and “operation.” Select key words that relate to some relevant event in the child’s life. Sentence Completion Present a partial statement and have the child complete it. Some sample statements are as follows: The thing I like best (least) about school is _________. The best (worst) age to be is _________. The most (least) fun thing I ever did was ___________. The thing I like most (least) about my parents is _________. The one thing I would change about my family is __________. If I could be anything I wanted, I would be __________. The thing I like most (least) about myself is __________. Continued

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BOX 30.3

Children, Their Families, and the Nurse

Creative Communication Techniques With Children—cont’d

Pros and Cons Select a topic, such as “being in the hospital,” and have the child list “five good things and five bad things” about it. This is an exceptionally valuable technique when applied to relationships, such as things family members like and dislike about each other. Nonverbal Techniques Writing Writing is an alternative communication approach for older children and adults. Specific suggestions include the following: Keep a journal or diary. Write down feelings or thoughts that are difficult to express. Write “letters” that are never mailed (a variation is making up a pen pal to write to). Keep an account of the child’s progress from both a physical and an emotional viewpoint. Drawing Drawing is one of the most valuable forms of communication—both nonverbal (from looking at the drawing) and verbal (from the child’s story of the picture). Children’s drawings tell a great deal about them because they are projections of their inner selves. Spontaneous drawing involves giving the child a variety of art supplies and providing the opportunity to draw. Directed drawing involves a more specific direction, such as “draw a person” or the “three themes” approach (state three things about the child and ask the child to choose one and draw a picture). Guidelines for Evaluating Drawings Use spontaneous drawings and evaluate more than one drawing whenever possible. Interpret drawings in light of other available information about the child and family, including the child’s age and stage of development. Interpret drawings as a whole rather than focusing on specific details of the drawing. Consider individual elements of the drawing that may be significant:

crisis or problem but also enables the family to attain a higher level of functioning, greater self-esteem, and closer relationships. Although counselling is often the role of nurses in specialized areas, some counselling techniques are discussed in various sections of this text

BOX 30.4

United Nations Declaration of the Rights of the Child All children need: • To be free from discrimination • To develop physically and mentally in freedom and dignity • To have a name and nationality • To have adequate nutrition, housing, recreation, and medical services • To receive special treatment, if handicapped • To receive love, understanding, and material security • To receive an education and to develop their abilities • To be the first to receive protection in disaster • To be protected from neglect, cruelty, and exploitation • To be brought up in a spirit of friendship among people From Children’s Rights, © 1995 United Nations. Reprinted with the permission of the United Nations.

Gender of figure drawn first—Usually relates to child’s perception of their own gender role Size of individual figures—Expresses importance, power, or authority Order in which figures are drawn—Expresses priority in terms of importance Child’s position in relation to other family members—Expresses feelings of status or alliance Exclusion of a member—May denote feeling of not belonging or desire to eliminate a family member Accentuated parts—Usually express concern for areas of special importance (e.g., large hands may be a sign of aggression) Absence of or rudimentary arms and hands—Suggest timidity, passivity, or intellectual immaturity; tiny, unstable feet may express insecurity, and hidden hands may mean guilt feelings Placement of drawing on the page and type of stroke—Free use of paper and firm, continuous strokes express security, whereas drawings restricted to a small area and lightly drawn in broken or wavering lines may be a sign of insecurity Erasures, shading, or cross-hatching—Expresses ambivalence, concern, or anxiety with a particular area Magic Use simple magic tricks to help establish rapport with the child, encourage collaboration with health interventions, and provide effective distraction during painful procedures. Although the magician talks, no verbal response from the child is required. Play Play is the universal language and “work” of children. It tells a great deal about children because they project their inner selves through the activity. Spontaneous play involves giving the child a variety of play materials and providing the opportunity to play. Directed play involves a more specific direction, such as providing medical equipment or a dollhouse for focused reasons, such as exploring the child’s fear of injections or exploring family relationships.

to help students and nurses cope with immediate crises and refer families for additional professional assistance.

Coordination and Collaboration As a member of the health care team, the nurse coordinates nursing services with the activities of other health care providers. Working in isolation does not serve the child’s best interest. The concept of holistic care can only be realized through a unified, interdisciplinary approach. Being aware of individual contributions and limitations to the child’s care, the nurse collaborates with other specialists to provide highquality health services.

Health Care Planning As the largest health care profession, nursing has a valuable voice, especially as a family and consumer advocate. Nurses must become aware of community needs, be interested in the formulation of legislative bills, and be supportive of politicians to ensure passage (or rejection) of significant legislation. Nurses also need to become actively involved with groups dedicated to the welfare of children (e.g., professional nursing societies, parent–teacher organizations, parent support groups, and volunteer organizations).

CHAPTER 30 Health care planning involves not only providing new services to children and their families but also promoting the highest quality in existing services. In the past, pediatric nursing had no national or international standards of care or education. Most pediatric nurses merged pediatrics with other specialties within nursing and followed the standards of maternal-child health nursing or the standards of several of the pediatric specialties, such as pediatric oncology nursing or school nursing. However, as a profession, pediatric nursing is increasing in momentum in Canada. For example, the CNA offers the Critical Care Pediatric Certificate, and the British Columbia Institute of Technology offers the Pediatric Nursing Specialty Option. The highest standards of nursing practice are reflected in the emphasis on thorough assessment, the focus on scientific rationale as the basis for care, the summary of nursing care goals and responsibilities, and the comprehensive discussion of growth and development.

Future Trends The current shift from treatment of disease to promotion of health has expanded nurses’ roles in ambulatory care and highlighted the prevention and health-teaching aspects of nursing practice. The need for home care and community health services requires nurses to be more independent and to acquire skills useful in settings beyond the hospital. As changing social policy shapes the expanding health care arena, the focus of nursing care has shifted from what nurses do for families to what nurses do in partnership with them. The philosophy of familycentred care is no longer an option but a mandate. Changing demographics will also influence pediatric nursing. The adult population is growing faster than the pediatric population (Statistics Canada, 2020). Consequently, the decrease in the number of children in Canada means fewer hospitalized children and less need for pediatric beds. As well, medical innovations shorten hospital stays for children, and there is an increase in children being treated medically at home rather than in the hospital (see Chapter 41, General Concepts of Home Care). Pediatric units may amalgamate with obstetrical units, creating maternal-child nursing units. Because older persons make up a larger percentage of the population, health care dollars will be split between the youngest and oldest groups, with shrinking resources available to meet the needs of both. Cost containment will present an ever-present challenge to providing highquality care. As the Canadian population becomes more diverse, nurses will need to continually adapt their care to the cultural milieu in which they practise. Finally, with the general trend of increasing complexity in pediatric medicine, nurses will need to be aware of developments in this field.

KEY POINTS • The Government of Canada has broadened the health care objectives of the past and shifted the focus to health promotion as the method to accomplish health goals. • While the infant mortality rate in Canada is at an all-time low, it continues to be seriously higher among Indigenous people. • Childhood morbidity encompasses acute illness, chronic disease, and disability. • Morbidity refers to behavioural, social, and educational problems that can significantly alter a child’s health. • Many children and families in Canada experience poverty, food insecurity, and health inequities. • Immunizations is one of the most important health promotion strategies for Canadian children.

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• The philosophy of family-centred care recognizes the family as the constant in a child’s life and that service systems and personnel must support, respect, encourage, and enhance the family’s strength and competence. • Children’s vulnerability and reaction to stress depend to a large extent on their age, coping behaviours, and support systems. • Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychological and physical distress experienced by children and their families in the health care system. • In order to effectively establish a setting for communication, nurses must make an appropriate introduction and ensure privacy and confidentiality. • When communicating with parents, nurses need to encourage parental involvement, listen carefully, use silence, and be empathic. • Communication with children needs to reflect their developmental stage. • Roles of the pediatric nurse include establishing a therapeutic relationship, advocating for families, preventing disease and promoting health, providing health teaching, providing support and counselling, coordinating and collaborating on care, making ethical decisions, and doing research. • With the shift in focus from treatment of disease to promotion of health, nurses’ roles have expanded beyond working in traditional health care facilities to providing care in ambulatory care centres, schools, the family’s home, and the community.

REFERENCES Alberta Family Wellness Initiative. (2021). Stress: How positive, tolerable, and toxic stress impact the developing brain. https://www.albertafamilywellness. org/what-we-know/stress. Bucci, M., Marques, S. S., Oh, D., et al. (2016). Toxic stress in children and adolescents. Advances in Pediatrics, 63(1), 403–428. Butler, M., & Pang, M. (2014). Current issues in mental health in Canada: Child and youth mental health. Publication No. 2014-13-E. https://publications.gc. ca/collections/collection_2014/bdp-lop/eb/2014-13-eng.pdf. Canadian Association of Pediatric Nurses (CAPN). (2017). Canadian Paediatric nursing standards. https://paednurse.ca/resources/Documents/ FINAL-Paediatric%20Nursing%20Standards%20September%202017.pdf. Canadian Institute of Child Health. (2021). Children and youth in Canada. The context of their lives. https://cichprofile.ca/module/1/. Canadian Lung Association. (2021). Vaping—What you need to know. https:// www.lung.ca/lung-health/vaping-what-you-need-know. Canadian Mental Health Association Ontario. (2021). Mental health services for gender-diverse and sexual-minority youth. Lesbian, gay, bisexual, trans & queer identified people and mental health. https://ontario.cmha.ca/documents/ mental-health-services-for-gender-diverse-and-sexual-minority-youth/. Canadian Nurses Association. (2017). Code of ethics for registered nurses. https:// www.cna-aiic.ca/
/media/cna/page-content/pdf-en/code-of-ethics-2017edition-secure-interactive. Canadian Observatory on Homelessness. (2021). About homelessness. Supporting communities to prevent and end homelessness: Poverty. https:// www.homelesshub.ca/about-homelessness/education-trainingemployment/poverty. Center on the Developing Child, Harvard University. (2020). ACEs and toxic stress: Frequently asked questions. https://developingchild.harvard.edu/ resources/aces-and-toxic-stress-frequently-asked-questions/. Centre for Addiction and Mental Health. (2020). The crisis is real. https://www. camh.ca/en/driving-change/the-crisis-is-real. Chandler, M. J., & Lalonde, C. E. (2009). Cultural continuity as a moderator of suicide risk among Canada’s First Nations. In L. J. Kirmayer, & G. Valaskakis (Eds.), Healing traditions: The mental health of Aboriginal peoples in Canada (pp. 221–248). UBC Press.

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Conference Board of Canada. (2021). Infant mortality. https://www. conferenceboard.ca/hcp/Details/Health/infant-mortality-rate.aspx. Conroy, S., & Statistics Canada. (2019). Section 1: Police-reported family violence against children and youth in Canada, 2018. https://www150.statcan.gc.ca/ n1/pub/85-002-x/2019001/article/00018/01-eng.htm. Cost, K. T., Crosbie, J., Anagnostou, E., et al. (2021). Mostly worse, occasionally better: Impact of COVID-19 pandemic on the mental health of Canadian children and adolescents. European Child & Adolescent Psychiatry, Feb, 26, 1–4. https://doi.org/10.1007/s00787-021-01744-3. Government of Canada. (2019a). Highlights from the 2017 childhood National Immunization Coverage Survey (cNICS). https://www.canada.ca/en/services/ health/publications/vaccines-immunization/vaccine-uptake-canadianchildren-preliminary-results-2017-childhood-national-immunizationcoverage-survey.html. Government of Canada. (2019b). Infographic: Inequalities in infant mortality in Canada. https://www.canada.ca/en/public-health/services/publications/ science-research-data/inequalities-infant-mortality-infographic.html. Government of Canada. (2020). Social determinants of health and health inequalities. https://www.canada.ca/en/public-health/services/healthpromotion/population-health/what-determines-health.html. Government of Canada. (2021a). Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada. https://www. canada.ca/en/public-health/services/provincial-territorial-immunizationinformation/provincial-territorial-routine-vaccination-programs-infantschildren.html. Government of Canada. (2021b). Vaccine safety and possible side effects. https:// www.canada.ca/en/public-health/services/vaccination-children/safetyconcerns-side-effects.html. Institute for Patient- and Family-Centered Care. (2017). Advancing the practice of patient- and family-centered care in hospitals: How to get started. https:// www.ipfcc.org/resources/getting_started.pdf. Jepson, R. G., Harris, F. M., Platt, S., et al. (2010). The effectiveness of interventions to change six health behaviours: A review of reviews. BMC Public Health, 10, 538. https://doi.org/10.1186/1471-2458-10-538. Korczak, D. L., updated by Charach, C., & Andrews, D., & Canadian Paediatric Society, Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee. (2015). Suicidal ideation and behaviour. Paediatrics & Child Health, 20(5), 257–260. Reaffirmed 2021. https://www.cps.ca/en/ documents/position/suicidal-ideation-and-behaviour. Le Saux, N., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2014). Antimicrobial stewardship in daily practice: Managing an important resource. Paediatrics & Child Health, 19(4), 261–265. Reaffirmed 2020. https://www.cps.ca/en/documents/position/ antimicrobial-stewardship. Mental Health Commission of Canada. (2021). What we do: Children and youth. https://www.mentalhealthcommission.ca/English/what-we-do/childrenand-youth. Mitevska, E., Wong, B., Surewaard, B. G. J., et al. (2021). The prevalence, risk, and management of methicillin-resistant Staphylococcus aureus infection in diverse populations across Canada: A systematic review. Pathogens, 10(4), 393. https://doi.org/10.3390/pathogens10040393. Pike, I., Richmond, S., Rothman, L., et al. (Eds.). (2015). Canadian injury prevention resource: An evidence informed guide to injury prevention in Canada. https://parachute.ca/wp-content/uploads/2019/08/CanadianInjury-Prevention-Resource.pdf. Public Health Agency of Canada (PHAC). (2013). Congenital anomalies in Canada 2013: A perinatal health surveillance report. http://publications.gc. ca/collections/collection_2014/aspc-phac/HP35-40-2013-eng.pdf. Public Health Agency of Canada (PHAC). (2020). Addressing stigma in Canada’s health system: Towards a more inclusive health system. Chief Public Health Officer of Canada annual report 2019. https://www.canada.ca/en/publichealth/corporate/publications/chief-public-health-officer-reports-state-

public-health-canada/addressing-stigma-toward-more-inclusive-healthsystem.html. Roshanafshar, S., & Hawkins, E. (2018). Food insecurity in Canada. https:// www150.statcan.gc.ca/n1/en/pub/82-624-x/2015001/article/14138-eng.pdf? st¼LXdoB3_0. Sarangi, L., Calabro, C., Ferankel, S., et al. (2020). Setting the stage for a povertyfree Canada: 2019 Report card on child and family poverty in Canada. https:// campaign2000.ca/wp-content/uploads/2020/01/campaign-2000-reportsetting-the-stage-for-a-poverty-free-canada-january-14-2020.pdf. Solomon, B., Ball, J., Flynn, J., et al. (2019). Seidel’s guide to physical examination (9th ed.). Elsevier. Sondagar, C., Xu, R., MacDonald, N. E., et al. (2020). Vaccine acceptance: How to build and maintain trust in immunization. Canada Communicable Disease Report (CCDR), 46–45, (May 20). https://www.canada.ca/en/publichealth/services/reports-publications/canada-communicable-disease-reportccdr/monthly-issue/2020-46/issue-5-may-7-2020/canvax-building-trustimmunization.html. Statistics Canada. (2019a). Aboriginal peoples in Canada: Key results from the 2016 census. https://www150.statcan.gc.ca/n1/daily-quotidien/171025/ dq171025a-eng.htm. Statistics Canada. (2019b). National cannabis survey, first quarter 2019. https:// www150.statcan.gc.ca/n1/daily-quotidien/190502/dq190502a-eng.htm. Statistics Canada. (2020). Age and sex highlight tables, 2016 census. https:// www12.statcan.gc.ca/census-recensement/2016/dp-pd/hlt-fst/as/index-eng. cfm. Statistics Canada. (2021a). A portrait of Canadian youth: March 2019 updates. https://www150.statcan.gc.ca/n1/pub/11-631-x/11-631-x2019003-eng.htm. Statistics Canada. (2021b). Deaths and mortality rates, by age group. https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310071001. Traub, F., & Boynton-Jarrett, R. (2017). Modifiable resilience factors to childhood adversity for clinical pediatric practice. Pediatrics, 139(5), e20162569. https://doi.org/10.1542/peds.2016-2569. UNICEF Canada. (2017). UNICEF report card 14: For youth. Canadian companion: Oh Canada! Our kids deserve better. https://www.unicef.ca/sites/ default/files/2017-06/UNICEF%20RC14%20for%20youth.pdf. Williams, R. C., Biscaro, A., Clinton, J., et al. (2019). Relationships matter: How clinicians can support positive parenting in the early years. Paediatrics & Child Health, 24(5), 340–347. World Health Organization (WHO). (2019). More than 140,000 die from measles as cases surge worldwide. https://www.who.int/news-room/detail/05-122019-more-than-140-000-die-from-measles-as-cases-surge-worldwide. World Health Organization (WHO) Advisory Board. (2020). The 13 biggest threats to global health, according to WHO. https://www.advisory.com/en/ daily-briefing/2020/01/15/who-health-challenges. World Health Organization (WHO), Health and Welfare Canada, & Public Health Agency of Canada (PHAC). (1986). Ottawa Charter for health promotion. http://www.phac-aspc.gc.ca/ph-sp/docs/charter-chartre/pdf/charter.pdf. Xia, Y., Tunis, M. C., Frenette, C., et al. (2019). Epidemiology of Clostridioides difficile infection in Canada: A six-year review to support vaccine decisionmaking. Canada Communicable Disease Report, 45(7/8), 191–211. https:// doi.org/10.14745/ccdr.v45i78a04.

ADDITIONAL RESOURCES About Kids Health: https://www.aboutkidshealth.ca/. Canadian Paediatric Society—Caring for Kids: https://www.caringforkids. cps.ca/. Canadian Task Force on Preventive Health Care: https://canadiantaskforce.ca/. Government of Canada—Bullying: Services and Prevention: https:// healthycanadians.gc.ca/healthy-living-vie-saine/bullying-intimidation/ index-eng.php.

UNIT 8 Children, Their Families, and the Nurse

31 Family, Social, and Cultural Influences on Children’s Health Valerie Bertoni Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Discuss the relationship that the nurse builds with the child and family. 2. Discuss role transitions experienced by new parents. 3. Explain various parenting behaviours, such as parenting styles, disciplinary patterns, and communication skills. 4. Demonstrate an understanding of particular parenting situations, such as adoption, divorce, lone parenting, parenting in reconstituted families, and LGBTQ2 parenting, and how these situations affect the child.

5. Discuss key influences that parents have on their children’s socialization. 6. Identify key social determinants of health and be able to describe the influences of socioeconomic status, culture, religion, peer groups, and schools on child development. 7. Identify the importance of culture in the health care of a child. 8. Demonstrate an understanding of health beliefs and practices that can have an impact on a family’s view of their child’s illness and their treatment-seeking behaviours.

PEDIATRIC NURSING AND THE FAMILY

a broad knowledge base is required in order to adequately assess and act on challenging health issues faced by families (Kaakinen, 2018).

Nurses need to be aware of the various family structures, functions, and processes within a family. Once a child is brought into a new family, the nurse needs to understand how this changes the family dynamics. The nurse can provide guidance for directing family-oriented interventions as needed and how to care for children in the context of individual families (Kaakinen, 2018).

Family Nursing Interventions In working with children, nurses must include family members in their care plan. To discover family dynamics, strengths, and weaknesses, a thorough family assessment is necessary (see Chapters 2 and 33). For example, family systems theory is a common approach that nurses use to understand and assess families as a whole, as well as in understanding and assessing the individuals that make up that whole, by using concepts that help one think about the family as a system. The various theories and assessment models that are relevant to family nursing practice are summarized in Table 2.2. When working with families, the nurse’s choice of interventions depends on the theoretical family model that is used (Box 31.1). Nurses need to be cautious not to rely too heavily on one specific theoretical model or framework when working in diverse settings, as

Families’ Roles, Relationships, and Strengths Each family has its own traditions and values and sets its own standards for interaction within and outside the group. Each family decides on and influences the experiences their children should have, those they are to be shielded from, and how each of these experiences meets the needs of family members. When family ties are strong, social control is highly effective, and most members conform to their roles willingly and with commitment. Conflicts arise when people do not fulfill their roles in ways that meet other family members’ expectations, either because they are unaware of the expectations, they choose not to meet them, or they are incapable of meeting them. Knowledge of characteristics that help families function effectively can help the nurse predict ways that families may cope and respond to a stressful event, such as a child’s illness. It is important for the nurse to provide individualized support that builds on family strengths and unique functioning style and to assist family members in obtaining requisite resources. Family strengths and their unique ways of functioning are significant resources that nurses can use to meet family needs (Box 31.2). By building on qualities that make a family work well and including supportive family resources, the family

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BOX 31.1 • • • • • • • • • • • • • •

Children, Their Families, and the Nurse

Family Nursing Interventions

Behaviour modification Case management and coordination Collaborative strategies Contracting Counselling, including support, cognitive reappraisal, and reframing Empowering families through active participation Environmental modification Family advocacy Family crisis intervention Networking, including use of self-help groups and social support Providing information and technical expertise Role modelling Role supplementation Teaching strategies, including stress management, lifestyle modifications, and anticipatory guidance

From Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family nursing: Research theory and practice (5th ed.). Pearson Education.

BOX 31.2

Qualities of Strong Families

• A belief and sense of commitment toward promoting the well-being and growth of individual family members, as well as the family unit • Appreciation for the small and large things that individual family members do well and encouragement to do better • Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event • A sense of purpose that permeates the reasons and basis for “going on” in both bad and good times • A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs • The ability to communicate with one another in a way that emphasizes positive interactions • A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behaviour • A varied repertoire of coping strategies that promote positive functioning in dealing with both normative and non-normative life events • The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources • The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and difficulties as an opportunity to learn and grow • Flexibility and adaptability in the roles necessary to procure resources to meet needs • A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future From Dunst, C., Trivette, C., & Deal, A. (1988). Enabling and empowering families: Principles and guidelines for practice. Brookline Books.

unit can become even stronger, or increasingly resilient, taking into account that all families have strengths as well as vulnerabilities (Kaakinen, 2018). It is important for the nurse to remember that the family has a crucial impact on the well-being of a child. For example, a child with a chronic illness such as cystic fibrosis requires a significant amount of time and commitment from family members to optimize the child’s well-being; a specific diet, chest physiotherapy, medication administration, and physical activity are only some of the tasks to be carried out by family members to meet the child’s needs.

Parental Roles Historically, the family was headed by socially recognized and sanctioned roles of father (male) and mother (female). These traditional roles modelled what were considered appropriate sexual behaviour and family responsibilities, including child-rearing. The behaviours these gender roles served were intended to provide stability and prolonged care for children. Parental roles have changed and continue to change significantly as a result of shifts in the economy, increased opportunities for women, evolving gender roles within family structures, and greater variety in family configurations. Women have achieved and continue to achieve equality with men in education, more women have entered the workforce, and the number of women who choose to have fewer children or none at all is increasing. As the roles of women have changed, the complementary roles of men have also changed. Many fathers are taking a more active part in child-rearing and household tasks. In Canada, new family structures such as lone-parent families and families with samesex or transgender parents have also redefined traditional gender roles (see Chapter 2, Family Organization and Structure). Role conflicts in families may still occur because of a cultural lag of persisting traditional role definitions assumed by some of the family members.

Role Learning Roles are learned through the socialization process. During all stages of development, children learn and practise, through interaction with others and in their play, a set of social roles and characteristics of other roles. They behave in patterned and more or less predictable ways because they learn roles that define mutual expectations in typical social relationships. Although role definitions are changing, the basic determinants of parenting remain the same. Several determinants of parenting infants and young children are parental personality and mental well-being, systems of support, and child characteristics. These determinants have been used as consistent measurements to determine a person’s success in fulfilling the parental role. Parents, peers, and authority figures (such as care providers and teachers), who use positive and negative sanctions to ensure conformity, transmit role conceptions to children. Role behaviours positively reinforced by rewards, such as love, affection, friendship, and honours, are strengthened. Negative reinforcement can take the form of ridicule, withdrawal of love, expressions of disapproval, or banishment. In some cultures, the role behaviour expected of children conflicts with desirable adult behaviour. One of the family’s responsibilities is to develop what they feel is culturally appropriate role behaviour in children. Children learn to perform in expected ways consistent with their position in the family and culture. The observed behaviour of each child is a single manifestation—a combination of social influences and individual psychological processes. In this way, the uniting of the child’s intrapersonal system (the self) with the interpersonal system (the family) is simultaneously understood as the child’s conduct (Figure 31.1). Role structuring initially takes place within family units, in which children fulfill a set of roles and respond to the roles of their parents and other family members. Children’s roles are shaped primarily by their parents or primary caregivers, who apply direct or indirect pressure to induce or force children into desired patterns of behaviour or direct their efforts toward modification of the child’s role responses on a mutually acceptable basis. Children respond to life situations according to behaviours learned in reciprocal transactions. As they acquire important role-taking skills, their relationships with others change. For instance, when a teenager is also a mother but lives in a household with their grandmother, the teenager may be viewed more as an adolescent than as a mother. Children become proficient at understanding others as they acquire the ability to discriminate their

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health

Fig. 31.1 Older school-age children often enjoy taking responsibility for the care of a younger sibling.

own perspectives from those of others. Children who get along well with others and attain status in the peer group have well-developed role-taking skills. The ability of parents to provide optimal care and support is dependent on having an adequate structure for healthy growth and development, sufficient income, a safe family environment, appropriate housing, adequate nutrition, opportunities to participate in recreational activities, healthy coping strategies, and timely health care, as well as on using noncoercive discipline (Deatrick, 2017; Kaakinen, 2018).

Special Parenting Situations Parenting is a demanding task under ideal circumstances, but when parents and children face challenges the potential for family disruption is increased. Situations that can present challenges are divorce, lone parenthood, blended families, adoption, and dual-career families. In addition, as cultural diversity increases in our communities, many immigrants are making the transition to parenthood and to a new country, culture, and language simultaneously. Other situations that create unique parenting challenges are parental alcoholism, homelessness, and incarceration.

Parenting the Adopted Child. While adoption laws in Canada vary among provinces and territories, in general they follow similar requirements and guidelines from child protection legislation, defining parent as anyone who has decision-making authority over a child and assumes all the rights, duties, obligations, and responsibilities of the child. Certain provincial and territorial government offices and adoption agencies may have specific requirements for adoptive parents, but in general anyone who is over 18 years of age and is a Canadian citizen without a criminal record is eligible to adopt a child (Canada Adopts, 2021). Adoption establishes a legal relationship between a child and parents who are not related by birth but who have the same rights and obligations that exist between children and their biological parents. In the past, the biological parent alone made the decision to relinquish the rights to their child. In recent years, the courts have acknowledged the legal rights of the biological father regarding this decision. Concerned child advocates have questioned whether decisions that honour the father’s rights are in the child’s best interests. As the rights of the child have become recognized, older children have successfully dissolved their legal bond with their biological parents to pursue adoption by adults of their choice. Furthermore, there is a growing demand among lesbian, gay, bisexual, transgender, queer, and two-spirit (LGBTQ2) adults to adopt.

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Fig. 31.2 An older sister lovingly embraces her adopted sister.

Unlike biological parents, who prepare for their child’s birth with prenatal classes and the support of friends and relatives, adoptive parents may have fewer opportunities to prepare, although they often have support of family and friends. Nurses can provide added information, support, and reassurance needed to reduce parental anxiety regarding the adoptive process and can refer adoptive parents to parental support groups. See Additional Resources at the end of the chapter for further information. The sooner infants enter their adoptive home, the better the chances of parent–infant attachment. The more caregivers the infant had before adoption, the greater the risk for attachment issues. The infant must break the bond with the previous caregiver and form a new bond with the adoptive parents. Difficulties in forming an attachment depend on the amount of time infants have spent with earlier caregivers (e.g., birth mother, nurse, adoption agency personnel). Siblings, adopted or biological, who are old enough to understand should be included in decisions regarding the commitment to adopt, with reassurance that they are not being replaced. Ways in which the siblings can interact with the adopted child should be stressed (Figure 31.2). Issues of origin. The task of telling children that they are adopted can be a cause of deep concern and anxiety. There are no clear-cut guidelines for parents to follow in determining when and at what age children are ready for the information. Parents are naturally reluctant to present children with such potentially unsettling news. It is important that parents not withhold knowledge of the adoption from the child, since it is an essential component of the child’s identity. The timing arises naturally, as parents become aware of the child’s readiness. Most authorities believe that children should be informed at an age young enough so that, as they grow older, they do not remember a time when they did not know they were adopted. The time is highly individual but must be right for parents and the child. It may be when children ask where babies come from, at which time children can also be told the facts of their adoption. If they are told in a way that conveys the idea that they were active participants in the selection process, they will be less likely to feel that they were abandoned, helpless victims. For example, parents can tell children that their personal qualities drew the parents to them. It is wise for parents to tell children that they are adopted before the children enter school, to avoid having them hear it from third parties. Complete honesty between parents and children strengthens the relationship. Parents should anticipate behaviour changes after disclosure, especially in older children. Children who are struggling with the revelation that they are adopted may benefit from individual and family counselling. Children may use the fact of their adoption as a weapon to

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manipulate and threaten parents. Statements such as “My real mother would not treat me like this” or “You don’t love me as much because I’m adopted” can hurt parents and increase their feelings of insecurity. Such statements may also cause parents to become overpermissive. Adopted children need the same undemanding love, combined with firm discipline and limit setting, as any other child. Cross-racial and international adoption. Since 1993, Canadian parents considering international adoption must follow the laws of the adopting countries, which are governed by the Hague Convention. The Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption’s main goals are to (1) protect the best interests of adopted children, (2) standardize the process between countries, and (3) prevent child abuse and child trafficking. Since 2000, 1 500 to 2 000 international adoptions have been reported in Canada every year, with the majority of children being welcomed from China, followed by the United States, Russia, Ethiopia, Vietnam, South Korea, and Haiti (Baxter, 2018). Canadian law offers parents seeking international adoptions two avenues: (1) the citizenship process, which makes the child a Canadian citizen, or (2) the immigration process, which makes the child a permanent resident (Government of Canada, 2017a). Adoption of children of a racial or ethnic background different from that of the family is commonplace. In addition to the issues faced by adopted children in general, children of a cross-racial adoption must deal with physical and sometimes cultural differences. It is advised that parents who adopt such children do everything possible to preserve the adopted children’s cultural heritage.

NURSING ALERT As a health care provider, it is important not to ask insensitive questions, such as the following: “Is she yours?” “Is she adopted?” “What do you know about the ‘real’ mother?” “Do they have the same father?” “How much did it cost to adopt him?” “Your children look so different, which one is yours?”

Although cross-racial adopted children are full-fledged members of an adopting family and citizens of the adopted country, if they have a strikingly different appearance from other family members or exhibit distinct racial or ethnic characteristics, challenges may be encountered outside the family. Strangers may make thoughtless comments and talk about the children as though they were not members of the family. It is vital that family members declare to others that this is their child and a cherished member of the family. It may help to have a response already prepared in anticipation of insensitive remarks. In international adoptions the medical information that parents receive may be incomplete or inaccurate; weight and height, and sometimes head circumference are often the only objective information present in the child’s medical record. There are potential health risks for children who are being adopted internationally and the prevalence of these risks depends on the child’s country of origin as well as the child’s individual health patterns. Adoptive children come from many different parts of the world, and countries often open and then close the option of allowing international adoptions. International children may be healthy and well cared for while others may have received very little medical care. Children who come from institutions overseas may be more prone to developmental or language delays, while some have complex emotional or neurobehavioural needs (Baxter, 2018). Some children have serious or multiple health conditions, which can be stressful for the parents. Adolescence. Adolescence may be an especially trying time for parents of adopted children. Whether adopted children have more adjustment issues than nonadopted children is debatable; more

evidence-informed research on this area needs to be done in Canada. The normal confrontations of adolescents and parents can assume more painful aspects in adoptive families. Adolescents may use their adoption to defy parental authority or as a justification for aberrant behaviour. As they attempt to master the task of identity formation, the feeling of abandonment by their biological parents can come into awareness and may be intensified. Gender differences in reacting to adoption may surface. Adopted children can fantasize about their biological parents and may feel the need to discover their parents’ identity to define themselves and their own identity. It is important for parents to keep the lines of communication open and to reassure their child that they understand the need to search for their identity. Access to biological birth certificates differs between provinces and territories. Some provinces and territories make them legally available to adopted children when they come of age, while others require court orders to have the original birth record released. Adoptive parents should be honest with questioning adolescents and tell them of this possibility (the parents themselves are unable to obtain the birth certificate; it is the children’s responsibility if they desire it).

Parenting and Divorce. Since the introduction of the divorce laws in 1968, there has been a steady increase in the Canadian divorce rate. However, since the 1990s, the divorce rate has remained relatively stable, with a less than 2% increase per year. Out of the 19.9 million people aged 25 to 64 in Canada in 2017, the majority were married (56%) or living in a common-law union (15%); 6% were separated or divorced from a marriage and 8% were separated from a common-law union (Statistics Canada, 2019b). The process of divorce begins with a period of marital conflict of varying length and intensity, followed by a separation, the actual legal divorce, and re-establishment of different living arrangements. Because a function of parenthood is to provide for the security and emotional welfare of children, disruption of the family structure often engenders strong feelings of guilt in the divorcing parents. During a divorce, parents’ coping abilities may be compromised. The parents may be preoccupied with their own feelings, needs, and life changes and unable to be available and supportive to their children. Newly employed parents, usually mothers, are likely to leave children with new caregivers, in strange settings, or alone after school. The parent may also spend more time away from home, searching for or establishing new relationships. Sometimes, the adults feel frightened and alone and begin to depend on children as a substitute for the absent parent, which places an enormous burden on the child. Impact of divorce on children. Numerous studies indicate that divorce has a profound effect on children. Many youngsters suffer for years from psychological and social difficulties associated with continuing or new stresses in the post-divorce family. Even when a divorce is amicable and open, children recall parental separation with the same emotions felt by victims of a natural disaster: loss, grief, and vulnerability to forces beyond their control. Children may also exhibit physiological symptoms as a result of the stress related to the changes caused by the divorce. It is important for the nurse in any setting (hospital, community health care facility, home) to include observations and assessments in order to accurately determine if the divorce is affecting the child. The impact of divorce on children depends on several factors, including children’s age and gender, the outcome of the divorce, and the quality of the parent–child relationship and parental care during the years following the divorce. Family characteristics are more crucial to the child’s well-being than specific child characteristics, such as age or gender. High levels of ongoing family conflict are related to issues of social development, emotional stability, and cognitive skills for the child.

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health Complications associated with divorce include efforts on the part of one parent to subvert the child’s loyalties to the other, abandonment to other caregivers, and adjustment to a stepparent. A major difficulty is when children are “caught in the middle” between divorced parents. They become message bearers between parents, are often quizzed about activities of the other parent, and have to listen to one parent criticize the other. A nurse may be able to intercede by helping the child get out of the middle by using “I messages” based on the formula of “I feel . . . (state the feeling) when you . . . (state the source). I would like it if you. . . .” An example of an “I message” is as follows: “I do not feel comfortable when you ask me questions about Mom; maybe you could ask her yourself.” This approach enables children to feel in control. Feelings of children toward divorce vary with age (Box 31.3). Some children feel a sense of shame and embarrassment about the family situation. Some feelings cause children to see themselves as different, inferior, or unworthy of love, especially if they feel responsible for the family dissolution. Although the social stigma attached to divorce no longer produces the emotions it did in the past, such feelings may still exist in small towns or in some cultural groups and can reinforce children’s negative self-image. The lasting effects of divorce depend on the children’s and parents’ adjustment to the transition from an intact family to a lone-parent family and, often, to a reconstituted family. Although most studies have concentrated on the negative effects of divorce on youngsters, some positive outcomes of divorce have been

BOX 31.3

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reported. A successful post-divorce family, either a lone-parent or a reconstituted family, can improve the quality of life for adults and children. If conflict is resolved, a better relationship with one or both parents may result, and some children may have less contact with a disturbed parent. Greater stability in home settings and the removal of arguments between parents at home can be a positive outcome for children’s long-term well-being. Telling the children. Parents are understandably hesitant to tell children about their decision to divorce. Most parents neglect to discuss either the divorce or its inevitable changes with their preschool child. Without preparation, even children who remain in the family home are confused by parental separations. Frequently, children are already experiencing vague, uneasy feelings that are more difficult to cope with than being told the truth about the situation. If possible, the initial disclosure should include both parents and siblings, followed by individual discussions with each child. Sufficient time should be set aside for these discussions in a period of calm, not after an argument, and include reasons for the divorce (if age appropriate) and reassurance that the divorce is not the children’s fault. Parents should not fear crying in front of the children because their crying gives the children permission to cry also. Children may feel guilt, a sense of failure, or that they are being punished for misbehaviour. They normally feel anger and resentment and should be allowed to communicate these feelings without punishment. They need

Children’s Feelings and Behaviours Related to Divorce

Infants • Effects of reduced mothering or lack of mothering • Increased irritability • Disturbance in eating, sleeping, and elimination • Interference with attachment process Toddlers (Ages 2 to 3 Years) • Frightened and confused • Blame themselves for the divorce • Fear of abandonment • Increased irritability, whining, tantrums • Regressive behaviours (e.g., thumb sucking, loss of elimination control) • Separation anxiety Preschool Children (Ages 3 to 4 Years) • Fear of abandonment • Blame themselves for the divorce; decreased self-esteem • Bewilderment regarding all human relationships • Become more aggressive in relationships with others (e.g., siblings, peers) • Engage in fantasy to seek understanding of the divorce Early School-Age Children (Ages 5 to 6 Years) • Depression and immature behaviour • Loss of appetite and sleep disorders • May be able to verbalize some feelings and understand some divorce-related changes • Increased anxiety and aggression • Feelings of abandonment by departing parent Middle School-Age Children (Ages 6 to 8 Years) • Panic reactions • Feelings of deprivation—loss of parent, attention, money, and secure future • Profound sadness, depression, fear, and insecurity • Feelings of abandonment and rejection • Fear about the future

• • • • •

Difficulty expressing anger at parents Intense desire for reconciliation of parents Impaired capacity to play and to enjoy outside activities Decline in school performance Altered peer relationships—become bossy, irritable, demanding, and manipulative • Frequent crying, loss of appetite, sleep disorders • Disturbed routine, forgetfulness Later School-Age Children (Ages 9 to 11 Years) • More realistic understanding of divorce • Intense anger directed at one or both parents • Divided loyalties • Ability to express feelings of anger • Ashamed of parental behaviour • Desire for revenge; may wish to punish the parent they hold responsible • Feelings of loneliness, rejection, and abandonment • Altered peer relationships • Decline in school performance • May develop somatic discomforts or illnesses • May engage in aberrant behaviour such as lying, stealing • Temper tantrums • Dictatorial attitude Adolescents (Ages 12 to 18 Years) • Able to disengage themselves from parental conflict • Feelings of a profound sense of loss—of family, childhood • Feelings of anxiety • Worry about themselves, parents, siblings • Expression of anger, sadness, shame, embarrassment • May withdraw from family and friends • Disturbed concept of sexuality • May engage in acting-out behaviours

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consistency and order in their lives. They want to know where they will live, who will take care of them, if they will be with their siblings, and if there will be enough money to live on. Children fear that if their parents stopped loving each other, they could stop loving them. Their need for love and reassurance is tremendous at this time. Children may also wonder what will happen on special days such as birthdays and holidays, whether both parents will come to school events, and whether they will still have the same friends. Custody and parenting partnerships. In the past, when parents separated, mothers were given custody of the children, with visitation agreements for fathers. Now both parents and the courts are seeking alternatives. Current belief is that neither fathers, partners, nor mothers should be awarded custody automatically. Custody should be awarded to parents who are best able to provide for the children’s welfare. In some cases, children experience severe stress when living or spending time with a parent. Two other types of custody arrangements are divided custody and joint custody. Divided, or split, custody means that each parent is awarded custody of one or more of the children, thereby separating siblings. For example, sons might live with the father and daughters with the mother. Joint custody takes one of two forms. In joint physical custody, the parents alternate the physical care and control of the children on an equitable basis while maintaining shared parenting responsibilities legally. This custody arrangement works well for families who live close to each other and whose occupations permit an active role in the care and rearing of the children. In joint legal custody, children reside with one parent but both parents are the children’s legal guardians and participate in child-rearing. Co-parenting offers substantial benefits for the family: children can be close to both parents, and life with each parent can be more normal (as opposed to having, for instance, a disciplinarian mother and a recreational father). To be successful, parents in these arrangements must place high value on the commitment to provide normal parenting and to separate their marital conflicts from their parenting roles. No matter what type of custody arrangement is awarded, the primary consideration is the welfare of the children. The nurse providing care to a child of divorced parents must be aware of the family situation and of the details regarding custody. Depending on the details of the custody, one of the parents or both if they have joint custody have the legal right to make decisions about the child’s health treatment. It is important to ask the parent for the details about custody and to document them in the child’s health record to ensure that all health care providers caring for the child are aware of the situation. Although one parent might have legal custody, it is not uncommon for both parents to participate in decision making regarding their children, especially in the matter of health. Nurses have a unique role in supporting the child and family through an illness, but if custody issues are complex or if challenges arise, the nurse should involve others who can assist with moving the family forward toward resolution—this could include social workers and hospital legal counsel.

Lone Parenting. An individual may become a lone parent as a result of divorce, separation, death of a spouse, or birth or adoption of a child. Although divorce rates have stabilized, the number of lone-parent households continues to rise. In 2016, these families accounted for 19.2% of all Canadian families, compared to 16.3% in 2011, and 81.3% of children aged 0 to 14 in lone-parent families were living with their mother, and 18.7% were living with their father (Statistics Canada, 2019d). Although some women are lone parents by choice, some never planned on being parents on their own, and may feel pressures to be in a long-term relationship.

Managing shortages of money, time, and energy is often a concern for lone parents. These families are often forced by their financial status to live in communities with inadequate housing and personal safety concerns. Lone parents are singly responsible for ensuring the financial viability of the family. This can lead to long hours away from the home, relying on other caregivers or their adolescents to provide care to the younger children. This can result in lone parents feeling guilty about the time spent away from their children and the burden they may feel they are placing on others. Many lone parents have trouble arranging for adequate child care, particularly for a sick child. Teen mothers are often lone parents, with all the additional challenges faced when trying to further their education, establish long-term relationships, and provide for their child over the short and long term. Teenage pregnancy rates have been steadily declining in Canada; in 2018, the rate of adolescent pregnancies was 1.7% of all births (Statistics Canada, 2021). Teen mothers should be encouraged to seek out programs that enable them to finish high school while still caring for their child. These programs typically exist within high schools and include services such as case management services, collaboration with community agencies designed to support teenage mothers, on-site child care, on-site counselling, and academic support services that also assist with career preparation. Fathers and partners who have custody of their children face many of the same challenges that single mothers do. They feel overburdened by the responsibility, depressed, and concerned about their ability to cope with the emotional needs of their children. Some partners find it difficult at first to coordinate household tasks, school visits, and other activities associated with managing a household alone. Social supports and community resources needed by lone-parent families include health care services that are open on evenings and weekends; high-quality child care; respite child care to relieve parental exhaustion and prevent burnout; and parent enhancement centres for advancing education and job skills, providing recreational activities, and offering parenting education. Lone parents need social contacts separate from their children for their own emotional growth and that of their children.

Parenting in Reconstituted Families. In North America, many of the children living in homes where parents have divorced will experience another major change in their lives, such as the addition of a stepparent or new siblings. The Canadian 2016 census revealed 9.8% of total families are stepfamilies (Statistics Canada, 2019d). The entry of a stepparent into an existing family requires adjustments for all family members. Some obstacles to the role adjustments and family problem solving include disruption of previous lifestyles and interaction patterns, complexity in the formation of new ones, and lack of social supports. Despite these issues, most children from divorced families want to live in a two-parent home. Cooperative parenting relationships can allow more time for each set of parents to be alone to establish their own relationship with the children. Under ideal circumstances, power conflicts between the two households can be reduced, and tension and anxiety can be lessened for all family members. In addition, the children’s self-esteem can be increased, and there is a greater likelihood of continued contact with grandparents. Flexibility, mutual support, and open communication are critical to forming successful relationships in stepfamilies and step-parenting situations.

LGBTQ2 Marriages and Parenting. In Canada, same-sex marriage became legal in 2005. The 2016 census reported 0.9% same-sex couple families, an increase of more than 42% from the 2006 census. Among married same-sex couples, 12% had children in their home in 2016

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health compared to 8.6% in 2001; in 2016, female couples accounted for fourfifths of the couples who were living with children (Statistics Canada, 2019e). The cultural and legal conflicts that drive many of the concerns for children of LGBTQ2 married parents have become less pronounced as LGBTQ2 family living arrangements have become more commonplace. See Additional Resources for information on working with LGBTQ2 families.

Foster Parenting. Foster care can be defined as the placement of a child in a stable and approved environment with a nonrelated family. The living situation may be an approved foster home, possibly with other children, or a preadoptive home. The 2016 census indicated that there are more than 28 000 children aged 14 years and under living in foster households across Canada (Statistics Canada, 2019d). The Child Welfare Services from each province and territory offer training and ongoing education for foster parents. Each province and territory has guidelines regarding the relative health of the prospective foster parents and their families, background checks regarding legal issues for the adults, personal interviews, and a safety inspection of the residence and surroundings. The 2016 census in Canada indicated that 52.2% of children in foster care are Indigenous but they account for only 7.7% of the child population. This means that 14 970 out of 28 665 foster children in private homes under the age of 15 are Indigenous (Indigenous Services Canada, 2021). The Canadian government has co-developed, with Indigenous peoples, provinces, and territories, new legislation that is designed to decrease the number of Indigenous children and youth in care and improve child and family services. This new legislation, enacted in January 2020, permits Indigenous governing bodies to exercise their jurisdiction over child and family services, and their laws on child and family services prevail over federal, provincial, and territorial laws (Indigenous Services Canada, 2021). Children in foster care tend to have a higher-than-normal incidence of acute and chronic health conditions and may experience feelings of isolation or confusion (Ponti & Canadian Paediatric Society, 2008/ 2018). Foster children are often at risk because of their previous caregiving environment. Nurses should strive to implement strategies to improve the health care for this group of children. In particular, assessment and case management skills are required to involve other disciplines in meeting their needs.

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of life present a crucial period during which they are susceptible to both negative and positive influences. If the exposure to negative influences outweighs that to positive ones, their adaptation can be compromised, setting the stage for greater difficulties later in life. While very young children are dependent on supportive caregiving for healthy development, older children are more dependent on relationships with peers and on school, neighbourhood, and community environments (Institute of Medicine and National Research Council, 2015).

Culture. Children interact within a cultural context every day and are affected by its influences. Social values and beliefs differ among cultures, and children learn directly through the teachings of their families and indirectly through the behaviours around them. Children learn and apply the values and beliefs common to their culture; for example, in some cultures, competition and individual achievement are highly valued, whereas in other cultures collaboration and working with others are highly valued. Culture also influences health and illness, as there are differences in the ways people of diverse cultures conceptualize sickness, seek health care, relate to health care providers, and accept treatments (Mayhew, 2018). If the adults have their own cultural biases or interpretations about illness and appropriate treatments, their description and management of the illness may be shaped and altered by these beliefs and understandings. Demonstrating awareness of a patient’s culture can promote trust, better health care, lead to higher rates of acceptance of diagnoses, and improve treatment adherence (Mayhew, 2018). Except in rare situations, children grow and develop in a blend of cultures and subcultures (Figure 31.3). In a large, complex society such as that of Canada, different groups have their own sets of standards, values, and expectations within the collective ways of the larger culture. Although many cultural differences are related to geographic boundaries, subcultures are not always restricted by location, especially in the context of Internet support groups and social media. Considering children, in particular, some subcultures are related to the stages of development. For example, the behaviour of school-age children and of adolescents demonstrate age-related subcultures. Although there are countless subcultures or co-cultures within Canada, those that seem to exert great influence on children and their families are ethnicity,

SOCIAL AND CULTURAL FACTORS THAT IMPACT HEALTH The health of Canadians is not dependent primarily on the health care provided but rather by access to the social determinants of health, or broadly speaking, the living conditions to which people are subjected. Since the mid-1800s the impact of living conditions on health has been recognized, and since the 1970s this view has been embedded in Canadian government policy (Raphael, 2016). Social determinants of health exist at an individual as well as a population level, and they affect the degree to which each person has the necessary resources to meet their daily needs and achieve their goals. The key determinants that are generally accepted as affecting the health of Canadians are listed in Box 1.1.

Social Determinant Influences There is strong evidence that social factors are interconnected and complex and that they have a significant influence on health. Health is a developmental process, a product of interactions among personal, physical, and environmental factors. Children are particularly sensitive to social determinants, especially in their younger years; the first 3 years

Fig. 31.3 Children grow up within a shared cultural, social, and linguistic heritage.

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social class, minority group membership, religion or spirituality, schools, communities, and peer groups. Social roles. Family roles, like cultural beliefs and values, are learned and transmitted through generations. A role prohibits some behaviours and allows others. Much of children’s self-concept comes from their ideas about their social roles. Parents use praise, punishment, and role modelling to teach children culturally acceptable roles. Because roles are shaped and clarified according to the prevailing culture, it has a significant influence on the development of children’s selfconcept (i.e., attitudes and beliefs they have about themselves). To establish their place in the group, children learn to follow a mode of behaviour that is in agreement with the standards specific to the group and learn how they can expect others to behave toward them. They take their cues by observing and imitating those to whom they are exposed consistently. When discussing social roles it is helpful to define what constitutes a social group. A social group consists of a system of roles carried out in primary and secondary groups. A primary group is characterized by intimate, continued, face-to-face contact; mutual support of members; and the ability to order or constrain a considerable proportion of individual members’ behaviour. Two such groups are the family and the peer group, both of which exert a great deal of influence on the child. Secondary groups are groups that have limited, intermittent contact and in which there is generally less concern about members’ behaviour. These groups offer little in terms of support or pressure toward conformity except in rigidly limited areas. Examples of secondary groups are church organizations, Girl Guides and Boy Scouts, sports organizations, and formal recreational children’s play groups. None of these groups is highly dominant in its influence; children are exposed to an eclectic set of values, some in agreement and some in conflict with the others. From these they must ultimately select those values that they determine to be best for them and adopt them to form a consistent set of roles and behaviours to be incorporated into their self-concept. Self-esteem. Culture influences a child’s sense of self-esteem, often referred to as self-view or self-evaluation. People from different cultures share a common motivation to be a good person—to live up to the standards of what is perceived to be appropriate and significant in the context of their own culture. These perceptions vary greatly across cultures. In North America, a highly individualistic environment, the most valued attributes are those associated with self-evaluation of competence, talent, independence, and risk-taking to achieve success. In East Asia, by contrast, it is how others perceive an individual’s competence and success and their ability to apply the criticisms to self-improvement that dictate self-esteem. In other cultures, it is the achievements and successes of group efforts that lead to more positive self-esteem. For children, school experiences that focus on personal achievement may promote positive self-esteem in some children but not in others who are more dependent on the success of a whole family or peer group. A child’s sense of control may not come from individual selfreliance but rather from a feeling of worthiness in their family or community.

Socioeconomic Status. Socioeconomic status relates to a family’s economic and education levels. As a determinant of health, the influence of socioeconomic class cannot be overlooked; the most overwhelming adverse influence on health is low socioeconomic status. At any one time, a higher percentage of low-income individuals suffers from some health condition than any other group. The number of children living in poverty has continued to increase into the twenty-first century. The child poverty rate in Canada is among the highest in the developed world. In 2017, an average of 19% of children were living in poverty, despite the continued economic growth in

Canada and the introduction of a Canadian Child Tax Benefit and National Child Benefit Supplement for lower-income families (Sarangi et al., 2020). In 7 of Canada’s 35 large urban centres, one in five children are living in a low-income household (Statistics Canada, 2019a). Persistent poverty puts children at risk for suffering health challenges, including infant mortality, asthma, obesity, low literacy, developmental delays, and behavioural and mental health difficulties. These children also tend to attain lower levels of education and are more likely to live in poverty as adults (Fleury, 2008). Families living in poverty struggle to provide health care for themselves and for their children. Travel to health care facilities often requires finding money for public transit or a taxi, borrowing a car, or seeking other means of transportation. They must find care for dependents, such as other infants and small children, or have them accompany them when taking the child for care. Families tend to delay preventive care indefinitely unless health services are relatively accessible. They are more likely to consult traditional practitioners or other persons within their community. Day-to-day needs of food, clothing, and lodging take precedence over health care as long as the ailing person feels able to perform activities of daily living. One of the more pressing concerns in Canada is the growing number of homeless families. Homeless children experience all of the health conditions associated with poverty, as well as other types of disorders. Most of these children experience poor health. They may not have a regular source of health care, and the focus of their care may not be preventive. Their care is likely fragmented, crisis oriented, and often sought in urgent care centres or emergency departments of hospitals. Another group of homeless children are “runaway” adolescents, who are at risk for violence, victimization, sexually transmitted infections, and substance use (Kidd et al., 2017).

Social Supports Communities. The child’s or adolescent’s community is made up of the family, school, neighbourhood, youth organizations, and other members. Communities can be sites of opportunity and growth for children and families. Communities can also be a site where poverty and disenfranchisement are minimized through connections with high-quality early childhood education, job training for adolescents and parents, and safe, effective schools. Communities can also contribute to toxic stress if violence and poverty are pervasive and resources are absent. Assets within a community can bolster healthy decision making, minimize high-risk behaviours, and support positive child and adolescent development and decrease the impact of toxic stress (Center on the Developing Child, Harvard University, 2020). Four categories of external assets that youth receive from the community are as follows (Search Institute, 2021): 1. Support—Young people need to feel support, care, and love from their families, neighbours, and others. They also need organizations and institutions that offer positive, supportive environments. 2. Empowerment—Young people need to feel valued by their community and be able to contribute to others. They need to feel safe and secure. 3. Boundaries and expectations—Young people need to know what is expected of them and what actions and behaviours are within the community boundaries and what are outside of them. 4. Constructive use of time—Young people need opportunities for growth through constructive, enriching opportunities and quality time at home. Internal assets must also be nurtured in the community’s younger members. These internal qualities guide choices and create a sense of centredness, purpose, and focus. The four categories of internal assets are as follows (Search Institute, 2021):

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health 1. Commitment to learning—Young people need to develop a commitment to education and life-long learning. 2. Positive values—Youth need to have a strong sense of values that direct their choices. 3. Social competencies—Young people need competencies that help them make positive choices and build relationships. 4. Positive identity—Young people need a sense of their own power, purpose, worth, and promise. School. When children enter school, their radius of relationships extends to include a wider variety of peers and a new source of authority. Although parents continue to exert the major influence on children, in the school environment, teachers have the most significant psychological impact on children’s development and socialization. In addition to academic and cognitive progress, teachers are concerned with the emotional and social development of the children in their care. Both parents and teachers act to model, shape, and promote positive behaviour, constrain negative behaviour, and enforce standards of conduct. Ideally, parents and teachers work together for the benefit of the children in their care. Next to family, schools are a major force in providing continuity between generations by conveying a vast amount of culture from older members of society to the young. In this way, children are prepared to carry out the traditional social roles expected of them as adults in society. School rules and regulations regarding attendance, authority relationships, and the system of sanctions and rewards based on achievement transmit to the child the behavioural expectations of the adult world of employment and relationships. School is often the only institution in which children systematically learn about the negative consequences of behaviours that deviate from societal expectations. Teachers are expected to stimulate and guide the intellectual development of children and their sense of aesthetics and to foster their capacity for creative problem solving. Access to education is an important determinant of health. Through education, individuals of lower socioeconomic status are offered the opportunity and capacity to move up in the social strata. Traditionally, the socialization process of school began when the child entered kindergarten or first grade. Today, with almost 70% of mothers whose youngest child is aged 3 to 5 years old working outside the home, this socialization process begins much earlier for a significant number of children in a variety of child care settings. This statistic increases to more than 78% for mothers whose youngest child is 6 to 15 years old (Moyser, 2017). For adolescents, close school connectedness and socialization has been linked with fewer health risk behaviours and better long-term health outcomes (Centers for Disease Control and Prevention, 2020). Peer groups. The aspects of everyday life that are most important to people are typically family life, time with friends, school, work, and play—all involving relationships with other humans. From birth, humans are social beings who spend their lifetime actively engaging with others in small and large groups. Through social interactions children gain a sense of belonging, companionship, and social stimulation; they learn about themselves and how the world works. Personal and interpersonal skills are developed and children learn what is expected of them and about the values inherent in the society in which they live. Children are active learners, not waiting for others to provide information or opportunities for learning. They make sense of social experiences through observing, experimenting in situations, interacting with other people, and reflecting on what happens. Through these activities they form ideas about how their social world works, gradually adjusting their thinking and constructing new ideas about codes of behaviour and strategies to use. Peer groups provide natural opportunities for social learning as children are able to practise and receive feedback about skills (e.g., sharing)

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rather than just hearing or talking about skills and behaviours. The social negotiation that occurs helps children learn to understand others’ thoughts, emotions, and intentions and results in better understanding about consequences of their behaviours both for themselves and for others. The value systems that children are exposed to can vary greatly as they grow. Their family, social class, and ethnic group provide some value constancy from a young age, while peer groups typically provide a diverse set of values. These peer group values can compel children to change their own values, since acceptance to the group is largely based on conformity. If there is a fair degree of similarity between the values of the peer group and those of family and teachers, the small difference creates the separation between children and the adults in their lives, strengthening the bond with their peers. Although the peer group has neither the traditional authority of the parents nor the legal authority of the schools for teaching information, it manages to convey a substantial amount of information to its members, especially on taboo subjects such as sex and drugs. Children’s need for the friendship of their peers brings them into an increasingly complex social system (Figure 31.4). The peer-group culture has secrets, mores, and codes of ethics that promote group solidarity and detachment from adults. Through peer relationships, children learn to deal with dominance and hostility and to relate with people in positions of leadership and authority. Other functions of the peer subculture are to relieve boredom and to provide the recognition that individual members do not receive from teachers and other authority figures.

The Child and Family in North America In North America there tends to be a basic optimistic view of the world, a belief that things can be better and that the children can and will be better off than their parents. This hopeful outlook and a general future orientation, together with the possibility of upward social mobility, have created a pervasive attitude of optimism. Increasing development of self-confidence and autonomy in children is fostered and encouraged. Children in North America are generally permitted a greater degree of freedom than in some more tradition-oriented cultures, where individuals remain in one class for life. Family life in North America is characterized by increasing geographic and economic mobility. There is less reliance on tradition, families are fragmented, and there may be fewer opportunities to transmit and acquire traditional and accepted customs of a culture. Consequently, young adults rely to a greater extent on professed experts,

Fig. 31.4 Youngsters from different cultural backgrounds interact within the larger culture. (iStock.com/FatCamera)

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peers, and mass media for acquisition of acceptable patterns of behaviour, including child-rearing practices. Conflicting information can be a source of confusion and frustration as parents attempt to determine the comparatively stable, essential components of the culture and transmit these to their children. In Canada, diversity is embraced and valued. People of all races and ethnicities need to be respected and children encouraged to feel secure and confident in their racial or ethnic identity. As with all children, the most important influences on development of a positive self-image are warm, understanding parents who take an active interest in fostering their children’s growth. Parents who have established a healthy and loving relationship with their children and react positively will help their children develop feelings of self-worth, self-esteem, and selfacceptance. The more adequate children feel, generally, the more positive their attitudes will be toward children of all backgrounds. Parents who have not established a close relationship with their children and who treat them in nonsupportive ways put their children at risk of acting aggressively and bullying others, particularly those who appear or act differently (Davison, 2016).

Indigenous People. Unlike the rest of Canada’s population, Indigenous youth make up over 50% of the Indigenous populations (Figure 31.5). This population comprises the youngest population in Canada, with 44% under the age of 25 years in 2016 (Government of Canada, 2017b). Indigenous peoples tend to experience health conditions that are common to people living in poverty, related largely to the position they have historically held in Canadian society. The health of Indigenous children under 16 years of age lags behind that of other Canadian children. Infant mortality rates are three times higher, immunization rates are lower, and infectious diseases continue to be a key factor of morbidity for Indigenous children. The rates of diabetes for Indigenous adolescents are higher, and the number of deaths related to injuries (motor vehicle accidents, fires, self-harm, and harm to others) is four times higher than that for the overall Canadian population. In addition, the suicide rate is almost four times higher than the national average, and suicide frequently occurs in clusters. The most common reasons for poorer health status among Indigenous peoples are lower incomes, a higher jobless rate, poor shelter, lower education level, inadequate water and sewage systems, living in remote communities, discrimination, historical trauma, and colonization (see discussion in Chapter 1, Indigenous People) (National Collaborating Centre for Aboriginal Health, 2013).

Immigrant Families. Immigration to Canada has been on the rise over the past two decades. In the 2016 census, immigrants made up 21.9% of the population, up from 17.4% in 1996 (Statistics Canada, 2019c). In 2019, more 341 000 people immigrated to Canada, many of whom are children (Immigration, Refuges and Citizenship Canada, 2020). Since 2015, Canada has welcomed over 44 000 new immigrants from Syria (Government of Canada, 2021). For decades it was generally accepted that immigrants to Canada arrived with a variety of health issues and needed health care that was absent in their countries of origin. More recent research and observations have indicated that new immigrants arrive with relatively better overall health (lower chronic disease and age-standardized mortality rates) than that of their Canadian-born counterparts (with the exception of HIV/AIDS and tuberculosis)—this is termed the healthy migrant effect (Lu & Ng, 2019). Social determinants of health are thought to affect immigrants to Canada more significantly than native-born Canadians, leading to a phenomenon known as immigrant overshoot, where immigrants’ health not only deteriorates to the Canadian average but also may get worse as a result of the impact of the social determinants of health that affect immigrants more powerfully (Vang et al., 2015). Immigrant families face unique challenges, including language barriers, lack of recognition of their skills and credentials, lack of access to affordable housing and to appropriate community and settlement supports, limited health care coverage until provincial or territorial health insurance is arranged, limited access to and navigation of the health care system, and health care providers who lack any significant knowledge of and sensitivity to their diverse health care needs.

UNDERSTANDING CULTURES IN THE HEALTH CARE ENCOUNTER Cultures and co-cultures contribute to the uniqueness of children in such a subtle way and at such an early age that children grow up believing their beliefs, attitudes, values, and practices are the “correct” or “normal” ones. A set of values learned in childhood may characterize children’s attitudes and behaviours for life, influencing long-range goals and short-range impulses. Thus every society socializes each succeeding generation to its cultural heritage (see Chapter 2 for further discussion). By observing the various influences on the child’s and the family’s lives, nurses can better understand how these factors affect their health and how they make decisions about their health.

Bridging the Gap

Fig. 31.5 This Inuit family represents a subculture that interrelates with the larger Canadian culture. (iStock.com/Ryerson Clark)

Some health care institutions may depend on teachings about cultural competence to ensure that holistic care is provided to their patients. Teachings based on cultural competence, while informative, do not provide nurses with the skills to effectively engage with families and are a short-sighted way to approach this contextualized part of children’s lives. Cultural competence does spur reflection on elements of society that perpetuate social inequity or injustices, such as racism, ageism, or homophobia. Cultural safety is the goal and outcome of practising in a culturally competent environment (Canadian Nurses Association [CNA], 2018). Cultural humility, by contrast, recognizes that children and families are affected by the intersection of social elements of society and that this can contribute to health inequity or poor health outcomes. Cultural humility is a “commitment and active engagement in a lifelong process that individuals enter into for an ongoing basis with patients, communities, colleagues, and themselves” (First Nations Health Authority,

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health 2016). Cultural humility includes the following tenets (Chavez, 2012; CNA, 2018): • Lifelong commitment to self-reflection and critique • Addressing the power imbalances in the nurse–patient relationship • Developing mutually beneficial and nonpaternalistic partnerships with the community in which one is working Similarly, Furlong and Wright (2011) encourage health care providers to be “critically aware.” This means that nurses should engage with children and families from a stance of curiosity and “informed not-knowing” by changing the dynamic of the encounter to learn from the family, rather than only being the expert clinician (Furlong & Wright, 2011). This liberates the nurse from a reliance on static knowledge that may not be relevant for the patient and allows the nurse to be a “knowledge-seeker” who tries to understand what life is like for the child and family. This critical awareness also calls nurses to assess their own history and the contextual factors that have shaped their own lives. Critical awareness draws nurses to reflect on aspects of North American culture that may be invisible or taken for granted, such as emphasis on independence and individualism, and the ways in which this may not match the needs of children and families. The manner and sequence of growth and development are universal and fundamental features of all children; however, children’s varied behavioural responses to similar events are often determined by their culture. Culture plays a critical role in the parenting behaviors that facilitate children’s development. Children acquire the skills, knowledge, beliefs, and values that are important to their own family and culture. Standards and norms vary from culture to culture and from location to location; a practice that is accepted in one area may meet with disapproval or create tension in another. The extent to which cultures tolerate divergence from the established norm also varies among cultures and subcultural groups. Although conforming to cultural norms provides a degree of security, it is a decided deterrent to change.

NURSING ALERT North American cultures and co-cultures can be so diverse that it is essential that nurses be aware of and knowledgeable about the predominant groups in their work community and apply this knowledge in their practice. It is also essential that nurses practise with an openness to learning about cultures and co-cultures different from their own and have some questions that they can use to ask families about what shapes their lives, what they find meaningful, and how they carry that out in their lives. These questions should be simple and open-ended, such as “What is important to you in caring for your child?” “Please tell me a little bit about your family,” and “What is important to you as a family?”

HEALTH BELIEFS AND PRACTICES For many families, traditional practices and beliefs are an integral part of their daily lives. Health care workers should be aware that other people might live by different rules and priorities that decisively influence their health-related behaviours. A model for learning about health traditions that differ from the Western health care system is based on the following three dimensions: 1. What are the physical aspects of caring for the body (e.g., are there special clothes, foods, medicines)? 2. What are the mental components of caring for health (e.g., feelings, attitudes, rituals, actions)? 3. What are the spiritual aspects of health (e.g., self-discovery, spiritual customs, prayers, healers)? For each of these dimensions, one must consider the cultural traditions used to maintain health, protect health, and restore health (Spector, 2017).

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Health Beliefs Generally speaking, health care providers in North America and many other parts of the world believe that illness is a result of a biological cause and use scientific methods and processes to diagnose and address health issues. A family’s cultural heritage fundamentally shapes their beliefs related to the cause of illness and the maintenance of health. These beliefs can be closely linked with religious or spiritual beliefs and influence the way families cope with illness and respond to health care providers. Families can assign meaning to illnesses and believe that the illness is a result of some wrongdoing on their part or the part of the child. Predominant among many cultures are beliefs related to natural forces, supernatural forces, and imbalance between forces. Because families are such an important part of the care process, it is important to understand their health beliefs in developing and carrying out a child’s plan of care.

Natural and Supernatural Forces. The most common natural forces blamed for ill health if the body is not adequately protected are cold air entering the body and impurities in the air. For example, a Chinese parent may overdress an infant in an effort to keep cold wind from entering the child’s body. The innate energy, chi, is an example of this. A lack of chi is believed to cause fatigue and a variety of ailments. Alternatively, some cultures view supernatural forces as a cause of illness, especially illnesses that cannot be explained by other means. Examples of such forces include voodoo, witchcraft, or evil spirits. Belief in the “evil eye” is another example. It stems from a belief in health as a state of balance and illness as a state of imbalance. As long as an individual’s strength and weakness remain in balance, they are unlikely to become a victim of the evil eye. Weaknesses are not necessarily physical. For example, an excess of some emotion, such as envy, can create weakness. Infants and small children, because of immature development of their internal strength-weakness states, are especially vulnerable to the gaze of the evil eye. Imbalance of Forces. The concept of balance or equilibrium is widespread throughout the world. One of the most common imbalances is the one between “hot” and “cold.” This belief derived from the ancient Greek concept of body humors, which states that illness is caused by imbalance of the four humors. Such imbalance is thought to cause internal damage or altered function. Treatment of the illness is directed at restoring balance. The hot and cold understanding of disease is based in this concept. Diseases, areas of the body, foods, and illnesses are classified as either “hot” or “cold.” Foods and beverages are designated hot or cold based on the effect they exert, not their actual temperature. In traditional Chinese medicine, the forces are termed yin (cold) and yang (hot) (Spector, 2017). Health care workers who are aware of such beliefs are better able to understand why some people refuse to eat certain foods. It is often useful to discuss the diet with the family to determine their beliefs regarding food choices. Nurses can help families devise a diet that contains the necessary balance of basic food groups prescribed by the medical subculture while conforming to the beliefs of the ethnic subculture (Figure 31.6). By determining a family’s preferences during well-child visits or prior to discharge, the nurse can help prevent adverse effects.

Health Practices There are numerous similarities among cultures regarding prevention and treatment of illness. All cultures have some types of home remedies that are applied before seeking help from other persons. Within some ethnic communities, traditional healers who are endowed with the ability to treat maladies are sought for special situations or when home remedies are unsuccessful. Chinese traditional medicine has a very long

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Fig. 31.6 Food customs outside the home can differ significantly from traditional cultural practice. (iStock/SolStock)

history and is commonly used. Asian families frequently consult herbalists, who are knowledgeable in herbal remedies and tonics, or ethnic practitioners experienced in Asian therapies, including acupuncture (insertion of needles), acupressure (application of pressure), and moxibustion (application of heat). These traditional remedies are frequently applied in addition to Western medical treatments. Indigenous peoples may consult a variety of traditional healers with specific skills and knowledge. The Truth and Reconciliation Commission (2015) has recommended that health care providers work with traditional healers when caring for Indigenous people. Specialized healers diagnose illness, provide nonsacred treatments (usually by way of massage and herbs), and care for souls. Other specialists perform services or effect cures through spiritual means. Traditional healers are powerful and respected persons in their community. They “speak the language” of the family who seeks help and often combine their rituals and potions with prayer and entreaties to God or other spiritual powers. They also are able to create an atmosphere conducive to healing and often can acquire important information about the illness without asking too many probing questions. Furthermore, they exhibit a sincere interest in the family and their situation. Nurses must respect traditional practices that do not harm patients. Overcoming the effect of the evil eye usually requires specialized rituals conducted by the appropriate practitioner. Sometimes the faith in the traditional practitioner results in a delay in obtaining needed medical treatment, although the practitioner will usually suggest medical care if their ministrations are unsuccessful.

BOX 31.4

Health practices of different cultures may also present issues of assessment and interpretation. For example, certain cultural practices or remedies can be mistakenly judged as evidence of child abuse by uninformed professionals (Box 31.4). It is important to keep the lines of communication open with families and approach the situation with a sense of cultural humility. Faith healing and religious rituals are closely allied with many traditional healing practices. The wearing of amulets, medals, and other religious relics believed by the culture to protect the individual and facilitate healing is a common practice. It is important for health workers to recognize the value of this practice and keep the items where the family has placed them or nearby. Such objects can offer comfort and support and rarely impede medical and nursing care. If an item must be removed during a procedure, it should be replaced, if possible, when the procedure is completed. The reason for its temporary removal should be explained to the family, and they should be reassured that their wishes will be respected (see Cultural Awareness box: Being Culturally Mindful).

CULTURAL AWARENESS Being Culturally Mindful Three-year-old Han is in the respiratory clinic with her parents, who emigrated to Canada from Vietnam less than a year ago. Han has been treated for asthma since her arrival in Canada and was hospitalized once for a short period when her asthma flared as a result of a respiratory illness. Han and her family live with her maternal grandparents. When entering Han’s examination room the nurse notes that the parents appear quite tentative. They speak little English and have some difficulty answering the health care provider’s initial questions. The nurse knows that it is important that the health care provider have a thorough understanding of how Han has been doing and if they are having any challenges with her medication regime (inhalers and steroids), so the nurse asks their permission to contact an interpreter through a telephone interpretation service. The nurse gives the family sufficient time to answer the questions through the interpreter, keeping a calm and steady voice. The nurse understands that in the Vietnamese culture, being loud or appearing in a rush is considered impolite. The nurse ensures that the interpreter stays on the line while the nurse performs a physical assessment and also when the health care provider is in the examination room so that any additional information can be relayed immediately. Toward the end of the visit, the family appears significantly more relaxed, and through the interpreter they ask if the nurse and health care provider could assist them by providing information that would help the grandfather understand how his smoking might be negatively affecting Han’s asthma, as they are concerned that if she gets another respiratory infection she might need hospitalization again, a very distressing event for them.

Cultural Practices the Dominant Culture May Consider Abusive

Coin rubbing or spooning—An Asian practice of repeated pressured strokes with the smooth edge of a coin, cup, or other object with a smooth edge over skin lubricated with water or oil to rid the body of a disease. Cupping—An Old World practice (also practised by the Vietnamese) of placing a container (e.g., tumbler, bottle, jar) containing steam against the skin to “draw out the poison” or other evil element. When the heated air in the container cools, a vacuum is created that produces a bruise-like blemish on the skin directly beneath the mouth of the container. Burning—A practice of some Southeast Asian groups whereby small areas of skin are burned with specific herbs to treat enuresis and temper tantrums.

Female genital cutting (FGC)—Removal of or injury to any part of the female genitalia; practised in Africa, the Middle East, Latin America, India, Asia, North America, Australia, and Western Europe. Forced kneeling—A discipline measure of some Caribbean groups in which a child is forced to kneel for long periods of time. Topical garlic application—A practice of Yemenite Jews in which crushed garlic cloves or garlic–petroleum jelly plaster is applied to the wrists to treat infectious disease. The practice can result in blisters or garlic burns. Traditional remedies that contain lead—Greta and azarcon (Mexico; used for digestive issues), paylooah (Southeast Asia; used for rash or fever), and surma (India; used as a cosmetic to improve eyesight).

CHAPTER 31 Family, Social, and Cultural Influences on Children’s Health Concepts that come from medical anthropology can provide a framework for addressing health care issues and their use can have a direct impact on patient care. In this framework the nurse moves away from an ethnocentric or medicocentric view of the health care encounter into the health care reality as constructed by the patient and family. It is also important for nurses to recognize that disease and illness are distinct entities. Clinicians diagnose and treat diseases—that is, abnormalities in the structure and function of body organs and systems. Illness and disease are not interchangeable; illness may occur even when disease is not present, and the course of a disease may vary substantially from the experience of illness. Illness is culturally constructed; an individual’s culture influences how a sickness is perceived, labelled, and explained. Culture also influences the meaning assigned to the illness, the role the individual with the sickness adopts, and the response of the family and community to the sickness. Tension may arise when the perception of the illness and disease varies widely among the patient, family, and health care team. Failure of health care providers to recognize these disparities may be partially to blame in cases of difficulty carrying out proposed treatment, delivery of inadequate care, and patient or family dissatisfaction. To begin addressing these issues, it is important for nurses to understand the various domains of health care in which individuals operate in Canadian society, including professional (health care providers and institutions), popular (family, community, and lay literature), and folk (nonprofessional healers). Each domain possesses a method for defining and explaining the sickness and what should be done to address it. The challenge for nurses and other health care providers is to address the tensions that may exist in understanding these domains with families and develop mutually agreed-upon goals. Nurses are in a prime position to facilitate this process because understanding the human response to disease is central to their role. In addition, collaboration with the child and family is central to the role of the pediatric nurse. One method of addressing families and beginning the process of collaboration is by understanding the family’s explanatory model of illness. The questions in Box 31.5 aid in eliciting an individual’s beliefs about illness, the meaning that is attached to it, goals and expected outcomes, and the roles of health care providers. Nurses can use these questions to discern areas of discrepancy for further dialogue, negotiation, and collaboration. This discussion, when conducted with a genuine interest in the family’s and child’s perspective, is a significant step

BOX 31.5

Exploring a Family’s Culture, Illness, and Care Significant understanding can be gained by asking the family straightforward questions, such as: • What do you think is causing your child’s illness? • Why do you think it started when it did? • How severe do you think your child’s illness is, and do you think it will be a short or long illness? • How do you think this illness affects the rest of the family? • What are the major issues that this illness has caused? • What have you done for the illness until now? • What kind of treatment do you think your child should receive? • What are the most important results you hope to receive from your child’s treatment? • What do you fear most about your child’s illness?

Adapted from Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258.

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toward building trusting relationships, promoting treatment adherence, decreasing disparities, and increasing health care satisfaction. Nurses are frequently asked by family members to provide advice about or assistance with using traditional health practices, including practices that seem extraordinary or abusive. The nurse needs to ensure that personal feelings are not used to guide the interaction; the focus should be instead on attempting to understand the meaning of the practice. For example, if asked about how to arrange for the excision of female genitalia (a practice most common in Africa, Asia, and the Middle East), the nurse should explore fully with the family what their motivation is and provide information on the potential health risks and the illegal nature of the practice in Canada. Through an open and sincere approach, the nurse has the ability to help the family find alternative options toward achieving their goal.

KEY POINTS • Because there is no consensus on the definition of family, a family is what an individual considers it to be. • Three areas of special concern to adoptive families include the initial attachment process, the task of telling children that they are adopted, and identity formation during adolescence. • Marital factors within the home significantly influence a child’s development. The impact of divorce on a child depends on the child’s age, the outcome, and the quality of the parent–child relationship and parental care following the divorce. • Lone parenting and stepparenting can create adjustment difficulties and add stress to the already demanding parental role. Significant numbers of children will live in a lone-parent or reconstituted family at some point. • A child’s self-concept evolves from ideas about their social roles. • Socioeconomic influences play a major role in opportunities for health promotion and wellness. • Groups of children who have more physical and mental health issues are those living in poverty; those who are homeless; Indigenous children; and those who are recent immigrants to Canada. • Culture is the pattern of assumptions, beliefs, and practices encompassing other products of human work and thoughts specific to members of an intergenerational group, community, or population. • No cultural group is homogeneous; every racial and ethnic group contains great diversity. • The practice of cultural humility is continual and an important concept in the nursing process. Nurses can facilitate this process by recognizing cultural differences, integrating cultural knowledge, being aware of their own beliefs and practices, and acting in a culturally appropriate manner. • Cultural and religious beliefs related to the cause of illness and maintenance of health may focus on natural forces, supernatural forces, or imbalance of forces.

REFERENCES Baxter, C. (2018). International adoption: Preparing to adopt a child from overseas. https://www.kidsnewtocanada.ca/health-promotion/adoptionpreparing. Canada Adopts. (2021). Adopting in Canada: FAQs. http://www.canadaadopts. com/adopting-in-canada/adopting-canada-faqs/. Canadian Nurses Association (CNA). (2018). Position statement: Promoting cultural competence in nursing. https://www.cna-aiic.ca/-/media/cna/pagecontent/pdf-en/position_statement_promoting_cultural_competence_in_ nursing.pdf?la¼en&hash¼4B394DAE5C2138E7F6134D59E505DCB0597 54BA9.

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Center on the Developing Child, Harvard University. (2020). Toxic stress. https://developingchild.harvard.edu/science/key-concepts/toxic-stress/. Centers for Disease Control and Prevention. (2020). Adolescent connectedness. https://www.cdc.gov/healthyyouth/protective/youth-connectednessimportant-protective-factor-for-health-well-being.htm. Chavez, V. (2012). Cultural humility: People, principles, and practices (documentary film). https://www.youtube.com/watch?v¼SaSHLbS1V4w. Davison, C. (2016). Home and family. In J. Freeman, M. King, & W. Pickett (Eds.), Health behaviour in school-aged children (HBSC) in Canada: Focus on relationships. https://healthycanadians.gc.ca/publications/science-researchsciences-recherches/health-behaviour-children-canada-2015comportements-sante-jeunes/index-eng.php. Deatrick, J. A. (2017). Where is ‘family’ in the social determinants of health? Implications for family nursing practice, research, education, and policy. Journal of Family Nursing, 23(4), 423–433. https://doi.org/10.1177/ 1074840717735287. First Nations Health Authority. (2016). #itstartswithme. Creating a climate for change: Cultural safety and humility in health services delivery for First nations and Aboriginal peoples in British Columbia. https://www.fnha.ca/ Documents/FNHA-Creating-a-Climate-For-Change-Cultural-HumilityResource-Booklet.pdf. Fleury, D. (2008). Low-income children. Perspectives on Labour and Income, 9(5). (Cat. No. 75-001-X). Statistics Canada. https://www150.statcan.gc.ca/ n1/en/pub/75-001-x/75-001-x2008105-eng.pdf?st¼TbrQutD5. Furlong, M., & Wright, J. (2011). Promoting critical awareness and critiquing cultural competence: Towards disrupting received professional knowledge. Australian Social Work, 64(1), 38–54. Government of Canada. (2017a). Choose a process—Intercountry adoption. https://www.canada.ca/en/immigration-refugees-citizenship/services/ canadians/adopt-child-abroad/processes/choose-process.html. Government of Canada. (2017b). Indigenous peoples and communities. https://www.rcaanc-cirnac.gc.ca/eng/1100100013785/1529102490303. Government of Canada. (2021). #WelcomeRefugees: Key figures. https://www. canada.ca/en/immigration-refugees-citizenship/services/refugees/welcomesyrian-refugees/key-figures.html. Immigration, Refugees and Citizenship Canada. (2020). 2020 Annual report to parliament on immigration. https://www.canada.ca/en/immigrationrefugees-citizenship/corporate/publications-manuals/annual-reportparliament-immigration-2020.html#immigration2019. Indigenous Services Canada. (2021). Reducing the number of Indigenous children in care. https://www.sac-isc.gc.ca/eng/1541187352297/ 1541187392851. Institute of Medicine and National Research Council. (2015). Transforming the workforce for children birth through age 8: A unifying foundation. The National Academies Press. https://doi.org/10.17226/19401. Kaakinen, J. R. (2018). Theoretical foundations for the nursing of families. In J. R. Kaakinen, D. P. Coehlo, R. Steele, et al. (Eds.), Family health care nursing: Theory, practice, and research (6th ed.). F.A. Davis. Kidd, S. A., Gaetz, S., & O’Grady, B. (2017). The 2015 National Canadian Homeless Youth Survey: Mental health and addiction findings. Canadian Journal of Psychiatry, 62(7), 493–500. https://doi.org/10.1177/ 0706743717702076. Lu, C., & Ng, E. (2019). Healthy immigrant effect by immigrant category in Canada. Statistics Canada. https://www150.statcan.gc.ca/n1/en/pub/82-003x/2019004/article/00001-eng.pdf?st¼KpAP_2Uf. Mayhew, E. (2018). How culture influences health. https://www. kidsnewtocanada.ca/culture/influence.

Moyser, E. (2017). Women and paid work. Statistics Canada. https://www150. statcan.gc.ca/n1/pub/89-503-x/2015001/article/14694-eng.htm. National Collaborating Centre for Aboriginal Health (NCCAH). (2013). An overview of Aboriginal health in Canada. https://www.ccnsa-nccah.ca/docs/ context/FS-OverviewAbororiginalHealth-EN.pdf. Ponti, M., & Canadian Paediatric Society, Community Paediatrics Committee. (2008). Position statement: Special considerations for the health supervision of children and youth in foster care. Paediatrics & Child Health, 13(2), 129–132. Reaffirmed 2018. Raphael, D. (2016). Social determinants of health, Canadian perspectives (3rd ed.). Canadian Scholar’s Press. Sarangi, L., Calabro, C., Frankel, S., et al. (2020). 2020: Setting the stage for a poverty free Canada–2019 report card on child & family poverty in Canada. Campaign 2000 https://campaign2000.ca/wp-content/uploads/2020/01/ campaign-2000-report-setting-the-stage-for-a-poverty-free-canadaupdated-january-24-2020.pdf. Search Institute. (2021). The Developmental Assets® Framework. http://www. search-institute.org/what-we-study/developmental-assets. Spector, R. E. (2017). Cultural diversity in health and illness (9th ed.). Pearson. Statistics Canada. (2019a). Children living in low-income households. https:// www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016012/ 98-200-x2016012-eng.cfm. Statistics Canada. (2019b). Family matters: Being common law, married, separated or divorced in Canada. https://www150.statcan.gc.ca/n1/dailyquotidien/190501/dq190501b-eng.htm. Statistics Canada. (2019c). Focus on geography series, 2016 census. https:// www12.statcan.gc.ca/census-recensement/2016/as-sa/fogs-spg/Facts-caneng.cfm?Lang¼Eng&GK¼CAN&GC¼01&TOPIC¼1. Statistics Canada. (2019d). Portrait of children’s family life in Canada in 2016. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/ 2016006/98-200-x2016006-eng.cfm. Statistics Canada. (2019e). Same-sex couples in Canada in 2016. https://www12. statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016007/98-200x2016007-eng.cfm. Statistics Canada. (2021). Live births by age of mother. https://www150.statcan. gc.ca/t1/tbl1/en/tv.action?pid¼1310041601. Truth and Reconciliation Commission of Canada. (2015). Calls to action. http:// trc.ca/assets/pdf/Calls_to_Action_English2.pdf. Vang, Z., Sigouin, J., Flenon, A., et al. (2015). The healthy immigrant effect in Canada: A systematic review. Population Change and Lifecourse Strategic Knowledge Cluster Discussion Paper Series, 3(1). https://ir.lib.uwo.ca/pclc/ vol3/iss1/4/.

ADDITIONAL RESOURCES Adoption Council of Canada—Adoption Resources in Canada: https://www. adoption.ca/adoption-resources. Canadian Institute of Child Health—The Health of Canada’s Children and Youth: https://cichprofile.ca/. Child Development Institute—Early Intervention Services: https://childdevelop. ca/programs/early-intervention-services?gclid=EAIaIQobChMIyLSjgd3 H5wIVwsDACh3EhgMMEAAYASAAEgKrkvD_BwE. Government of Canada—First Nations Child and Family Services: https://www. sac-isc.gc.ca/eng/1100100035204/1533307858805. Key Assets— The Fostering Process: https://www.keyassets.ca/want-to-foster/ the-fostering-process/.

UNIT 8 Children, Their Families, and the Nurse

32 Developmental Influences on Child Health Promotion Constance O’Connor Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe major trends in growth and development. 2. Explain the alterations in the major body systems that take place during the process of growth and development. 3. Discuss the development and relationships of personality, cognition, language, morality, spirituality, and self-concept.

FOUNDATIONS OF GROWTH AND DEVELOPMENT Growth and development, usually referred to as a unit, express the sum of the numerous changes that take place during the lifetime of an individual. The entire course is a dynamic process that encompasses several interrelated dimensions: Growth—An increase in the number and size of cells as they divide and synthesize new proteins; results in increased size and weight of the whole or any of its parts Development—A gradual change and expansion; advancement from lower to more advanced stages of complexity; the emerging and expanding of the individual’s capacities through growth, maturation, and learning Maturation—An increase in competence and adaptability; aging; usually used to describe a qualitative change; a change in the complexity of a structure that makes it possible for that structure to begin functioning; to function at a higher level Differentiation—Processes by which early cells and structures are systematically modified and altered to achieve specific and characteristic physical and chemical properties; development from simple to more complex activities and functions All of these processes are interrelated, simultaneous, and ongoing; none occurs apart from the others. The processes depend on a sequence of endocrine, genetic, constitutional, environmental, and nutritional influences (Ball et al., 2019). The child’s body becomes larger and more complex; the personality simultaneously expands in scope and complexity. Very simply, growth can be viewed as a quantitative change, and development as a qualitative change.

4. Describe the role of play in the growth and development of children. 5. Demonstrate an understanding of the role of innate and environmental factors in the physical and emotional development of children. 6. Describe the influence of mass media on children and how parents can help children to grow and develop within this context.

Stages of Development Most authorities in the field of child development conveniently categorize child growth and behaviour into approximate age stages or in terms that describe the features of an age group. The age ranges of these stages are admittedly arbitrary and, because they do not take into account individual differences, cannot be applied to all children with any degree of precision. However, categorization affords a convenient means to describe the characteristics associated with the majority of children at periods when distinctive developmental changes appear and specific developmental tasks must be accomplished. (A developmental task is a set of skills and competencies peculiar to each developmental stage that children must accomplish or master in order to deal effectively with their environment.) It is also significant for nurses to know that there are characteristic health issues peculiar to each major phase of development. The sequence of descriptive age periods and subperiods that are used here and elaborated on in subsequent chapters is listed in Box 32.1.

Patterns of Growth and Development There are definite and predictable patterns in growth and development that are continuous, orderly, and progressive. While these patterns, or trends, are universal and basic to all human beings, each person accomplishes these in a manner and time unique to that individual.

Directional Trends. Growth and development proceed in regular, related directions, or gradients, and reflect the physical development and maturation of neuromuscular functions (Figure 32.1). The first pattern is the cephalocaudal, or head-to-tail, direction. The head end of the organism develops first and is large and complex, whereas the 749

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BOX 32.1

Children, Their Families, and the Nurse

Developmental Age Periods

Prenatal Period—Conception to Birth Germinal—Conception to approximately 2 weeks Embryonic—2 to 8 weeks Fetal—8 to 40 weeks (birth) A rapid growth rate and total dependency make this one of the most crucial periods in the developmental process. The relationship between maternal health and certain manifestations in the newborn emphasizes the importance of adequate prenatal care to the health and well-being of the infant. Infancy Period—Birth to 12 Months Newborn—Birth to 27 or 28 days Infancy—Birth to approximately 12 months The infancy period is one of rapid motor, cognitive, and social development. Through mutuality with the caregiver (parent), the infant establishes a basic trust in the world and the foundation for future interpersonal relationships. The critical first month of life, although part of the infancy period, is often differentiated from the remainder because of the newborn major physical adjustments to extrauterine existence and the psychological adjustment of the parent. Early Childhood—1 to 6 Years Toddler—1 to 3 years Preschool—3 to 4 years This period, which extends from the time children attain upright locomotion until they enter school, is characterized by intense activity and discovery. It is a time of marked physical and personality development. Motor development

lower end is small and simple and takes shape at a later period. While the physical evidence of this trend is most apparent during the period before birth, it also applies to postnatal behaviour development. Infants achieve structural control of the head before they have control of the trunk and extremities, hold their back erect before they stand, use their eyes before their hands, and gain control of their hands before they have control of their feet.

Fig. 32.1 Directional trends in growth.

advances steadily. Children at this age acquire language and wider social relationships, learn role standards, gain self-control and mastery, develop increasing awareness of dependence and independence, and begin to develop a selfconcept. Middle Childhood—5 to 12 Years Frequently referred to as the school age, this period of development is one in which the child is directed away from the family group and centred on the wider world of peer relationships. There is steady advancement in physical development and sexual maturity, which is measured by the Tanner stages of development tool (see Chapter 40 for more information). Mental and social development is occurring with emphasis on developing skill competencies. Social cooperation and early moral development take on more importance with relevance for later life stages. This is a critical period in the development of a self-concept. Later Childhood—12 to 18 Years Prepubertal—10 to 13 years Adolescence—13 to approximately 18 years The tumultuous period of rapid maturation and change known as adolescence is considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world—usually high school graduation. Biological and personality maturation are accompanied by physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent period, the young person begins to internalize all previously learned values and to focus on an individual, rather than a group identity.

The second pattern, the proximodistal, or near-to-far, trend, applies to midline-to-peripheral development. A conspicuous illustration is the early embryonic development of limb buds, which is followed by rudimentary fingers and toes. In the infant, shoulder control precedes mastery of the hands, the whole hand is used as a unit before the fingers can be manipulated, and the central nervous system develops more rapidly than the peripheral nervous system. These trends or patterns are bilateral and appear symmetrical (i.e., each side develops in the same direction and at the same rate as the other). For some of the neurological functions, this symmetry is only external because of unilateral differentiation of function at an early stage of postnatal development. For example, by the age of approximately 5 years, the child has demonstrated a decided preference for the use of one hand over the other, even though previously either one had been used. The third trend, differentiation, describes development from simple operations to more complex activities and functions. From broad, global patterns of behaviour, more specific, refined patterns emerge. All areas of development (physical, mental, social, and emotional) proceed in this direction. Through the process of development and differentiation, early embryonal cells with vague, undifferentiated functions progress to an immensely complex organism composed of highly specialized and diversified cells, tissues, and organs. Generalized development precedes specific or specialized development; gross, random muscle movements take place before fine muscle control.

Sequential Trends. In all dimensions of growth and development there is a definite, predictable sequence, with each child normally passing through every stage. Children crawl before they creep, creep before they stand, and stand before they walk. Later facets of the personality are built on the early foundation of trust. The child babbles, then forms words and, finally, sentences; writing emerges from scribbling.

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Developmental Pace. Although development has a fixed, precise

Sensitive Periods. There are limited times during the process of growth when the organism will interact with a particular environment in a specific manner. Periods termed critical, sensitive, vulnerable, and optimal are those times in the life of an organism when it is more susceptible to positive or negative influences. The quality of interactions during these sensitive periods determines whether the effects on the organism will be beneficial or harmful. For example, physiological maturation of the central nervous system is influenced by adequacy and timing of contributions from the environment, such as stimulation and nutrition. The first 3 months of prenatal life are sensitive periods for physical growth of the fetus. Children are increasingly exposed to environmental exposures during critical periods of growth. For example, infants, toddlers, and preschoolers are engaged in a lot of hand-to-mouth activities and those closer to the ground, which can expose them to increased levels of toxins such as garden pesticides and new carpet toxins. It is also a time of rapidly dividing cells and active development, and exposure to toxins can have a detrimental effect. For example, lead exposure from lead paint on toys and furniture can have a negative impact on a child’s intelligence quotient. Psychological development also appears to have sensitive periods when an environmental event has maximal influence on the developing personality. For example, primary socialization occurs during the first year, when the infant makes the initial social attachments and establishes a basic trust in the world. A close relationship with a parent figure is fundamental to a healthy personality. The same concept might be applied to readiness for learning skills such as toilet independence or reading. In these instances, there appears to be an opportune time when the skill is best learned.

Individual Differences. Each child grows in their own unique and personal way. Great individual variation exists in the age at which developmental milestones are reached. The sequence is predictable; the exact timing is not. Rates of growth vary, and measurements are defined in terms of ranges to allow for individual differences. Some children are fast growers, others are moderate, and some are slower to reach maturity. Periods of fast growth, such as the pubescent growth spurt, may begin earlier or later in some children than in others. Children may grow fast or slowly during the spurt and may finish sooner or later than other children. Gender is an influential factor; girls seem to be more advanced in physiological growth at all ages.

Biological Growth and Physical Development As children grow, their external dimensions change. These changes are accompanied by corresponding alterations in structure and function of internal organs and tissues that reflect the gradual acquisition of physiological competence. Each part has its own rate of growth, which may be directly related to alterations in the child’s size (e.g., the heart

200 180 160 Lymphoid 140 120 Percent

order, it does not progress at the same rate or pace in each child. There are periods of accelerated growth and periods of decelerated growth in both total body growth and the growth of subsystems. Not all areas develop at the same pace. When a spurt occurs in one area such as gross motor, minimal advances may take place in language, fine motor, or social skills. Once the gross motor skill has been achieved, then development will shift to another area. The rapid growth before and after birth gradually levels off throughout early childhood. Growth is relatively slow during middle childhood, markedly increases at the beginning of adolescence, and levels off in early adulthood. Each child grows at their own pace. Distinct differences are observed between children as they reach developmental milestones.

Neural 100 80 60 General 40 20 0 B

Genital

2

4

6

8

10

12

14

16

18

20

Age (yr) Fig. 32.2 Growth rates for the body as a whole and examples of some specific tissue growth patterns. Lymphoid: thymus, lymph nodes, and intestinal lymph masses. Neural: brain, dura, spinal cord, optic apparatus, and head dimensions. Genital: reproductive tissues. General: body as a whole; external dimension; and respiratory, digestive, renal, circulatory, and musculoskeletal systems. B, Birth. (From Jackson, J. A., Patterson, D. G., & Harris, R. E. [1930]. The measurement of man. University of Minnesota Press.)

rate). Skeletal muscle growth approximates whole-body growth; brain, lymphoid, adrenal, and reproductive tissues follow distinct and individual patterns (Figure 32.2). When growth deficiency has a secondary cause, such as severe illness or acute malnutrition, recovery from the illness or establishment of an adequate diet will produce a dramatic acceleration of the growth rate that usually continues until the child’s individual growth pattern is resumed.

External Proportions. Variations in the growth rate of different tissues and organ systems produce significant changes in body proportions during childhood. The cephalocaudal trend of development is most evident in total body growth as indicated by these changes. During fetal development, the head is the fastest-growing body part, and at 2 months of gestation the head constitutes 50% of total body length. During infancy, growth of the trunk predominates; the legs are the most rapidly growing part during childhood; in adolescence, the trunk once again elongates. In the newborn, the lower limbs are one third the total body length but only 15% of the total body weight; in the adult, the lower limbs constitute one half of the total body height and 30% or more of the total body weight. As growth proceeds, the midpoint in head-to-toe measurements gradually descends from a level even with the umbilicus at birth to the level of the symphysis pubis at maturity. Biological Determinants of Growth and Development. The most prominent feature of childhood and adolescence is physical growth (Figure 32.3). Throughout development various tissues in the body undergo changes in size, composition, and structure. In some tissues the changes are continuous (e.g., bone growth and dentition); in others,

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Skeletal Growth and Maturation. The most accurate measure of

Fig. 32.3 Changes in body proportions occur dramatically during childhood.

significant alterations occur at specific stages (e.g., appearance of secondary sex characteristics). When these measurements are compared with standardized norms, a child’s developmental progress can be determined with a high degree of confidence. The Canadian pediatric growth charts have been developed jointly by the Canadian Paediatric Society (CPS), Dietitians of Canada, the College of Family Physicians of Canada, Community Health Nurses of Canada, and the Canadian Pediatric Endocrine Group (Marchand et al., 2010/2018) and are based on the 2007 World Health Organization (WHO) reference growth charts. These charts are based on the child’s gender, height, weight, body mass index (BMI), and head circumference. The charts define growth norms and obesity levels for Canadian children. Some pediatric illnesses will lead to slower growth patterns. Pediatric disorders of genetic, developmental, intellectual, or other types have growth patterns that are different from the standard growth charts. Growth in children with Down syndrome differs from that in other children. They have slower growth velocity between 6 months and 3 years of age and then again in adolescence. Puberty occurs earlier, and they achieve shorter stature. In this population, patients are frequent users of the health care system, often with multiple providers, and benefit from the use of the Down syndrome growth chart to monitor their growth (Zemel et al., 2015). Linear growth, or height, occurs almost entirely as a result of skeletal growth and is considered a stable measurement of general growth. Growth in height is not uniform throughout life but ceases when maturation of the skeleton is complete. The maximum rate of growth in length occurs before birth, but the newborn continues to grow at a rapid, though slower, rate. At birth, weight is more variable than height and is, to a greater extent, a reflection of the intrauterine environment. The average newborn weighs from 3 175 to 3 400 g. In general, the birth weight doubles by 4 to 7 months of age and triples by the end of the first year. By the age of 2 to 2½ years the birth weight usually quadruples. After this point the “normal” rate of weight gain, just as the growth in height, assumes a steady annual increase of approximately 2 to 2.75 kg per year until the adolescent growth spurt. Both bone age determinants and state of dentition are used as indicators of development. These indicators are discussed elsewhere in the text (see next section for bone age; see also Chapter 35 for dentition).

NURSING ALERT Double the child’s height at 2 years of age to estimate how tall they may be as an adult.

general development is skeletal or bone age, the radiological determination of osseous maturation. Skeletal age appears to correlate more closely with other measures of physiological maturity (such as onset of menarche) than with chronological age or height. Bone age is determined by comparing the mineralization of ossification centres and advancing bony form to age-related standards. Bone formation begins during the second month of fetal life when calcium salts are deposited in the intercellular substance (matrix) to form calcified cartilage first and then true bone. In small bones, the bone continues to form in the centre and cartilage continues to be laid down on the surfaces. In long bones, the ossification begins in the diaphysis (the long central portion of the bone) and continues in the epiphysis (the end portions of the bone). Between the diaphysis and the epiphysis an epiphyseal cartilage plate (or growth plate) unites with the diaphysis by columns of spongy tissue, the metaphysis. Active growth in length takes place in the epiphyseal growth plate. Interference with this growth site by trauma or infection can result in deformity. The first centres of ossification appear in the 2-month-old embryo, and at birth the number is approximately 400, about half the number at maturity. New centres appear at regular intervals during the growth period and represent bone age. Postnatally the earliest centres to appear (at 5 to 6 months of age) are those of the capitate and hamate bones in the wrist. Therefore, radiographs of the hand and wrist provide the most useful areas for screening to determine skeletal age, especially before age 6 years. These centres appear earlier in girls than in boys. Nurses must understand that the growing bones of children possess many unique characteristics. Bone fractures occurring at the growth plate may be difficult to discover and may significantly affect subsequent growth and development. Factors that may influence skeletal muscle injury rates and types in children and adolescents include the following factors related to overuse injuries (Karlin et al., 2020): • Extrinsic factors: training errors, poor equipment, workout surface, or less emphasis placed on conditioning, especially flexibility • Intrinsic factors: athlete’s anatomy or medical conditions In adolescents, fractures are more common than ligamentous ruptures because of the rapid growth rate of the physeal (segment of tubular bone that is concerned mainly with growth) zone of hypertrophy. Twenty five percent of those fractures involve an epiphyseal growth plate or physis (Karlin et al., 2020) (see Soft-Tissue Injury, Chapter 53 for further information).

Neurological Maturation. In contrast to other body tissues, which grow rapidly after birth, the nervous system grows proportionately more rapidly before birth. Two periods of rapid brain cell growth occur during fetal life: a dramatic increase in the number of neurons between 15 and 20 weeks of gestation and another increase at 30 weeks, which extends to 1 year of age. The rapid growth of infancy continues during early childhood and then slows to a more gradual rate during later childhood and adolescence. Postnatal growth consists of increasing the amount of cytoplasm around the nuclei of existing cells, increasing the number and intricacy of communications with other cells, and advancing their peripheral axons to keep pace with expanding body dimensions. This allows for increasingly complex movement and behaviour. Neurophysiological changes also provide the foundation for language, learning, and behaviour development. Neurological or electroencephalographic development is sometimes used as an indicator of maturational age in the early weeks of life.

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Lymphoid Tissues. Lymphoid tissues contained in the lymph nodes, thymus, spleen, tonsils, adenoids, and blood lymphocytes follow a growth pattern unlike that of other body tissues. These tissues are small in relation to total body size, but they are well developed at birth. They increase rapidly to reach adult dimensions by 6 years of age and continue to grow. At about age 10 to 12 years, they reach a maximum development that is approximately twice their adult size. This is followed by a rapid decline to stable adult dimensions by the end of adolescence. For example, children are constantly fighting off new organisms and infections and their lymphatic system quickly responds to fight these antigens. Because of this response, it is quite common for children to have slightly enlarged lymph nodes in certain areas of the body some of the time. However, changes in the lymph nodes can also indicate certain conditions or diseases that need special treatment.

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Development of Organ Systems. All tissues and organ systems undergo changes during development. Some are striking; others are subtle. Many have implications for assessment and care. Because the major importance of these changes relates to their dysfunction, the developmental characteristics of various systems and organs are discussed throughout the book as they relate to these areas. Physical characteristics and physiological changes that vary with age are included in age group descriptions; see Unit 10.

metabolic consequences, such as hypoglycemia, elevated bilirubin levels, and metabolic acidosis (see Figure 25.5). Skin-to-skin contact is an effective way to prevent hypothermia in newborns (see Chapter 27, Evidence-Informed Practice box: Skin-to-Skin Contact for Full-Term Newborns). The unclothed, diapered newborn is placed on the parent’s bare chest after birth, promoting thermoregulation and attachment. After the unstable regulatory ability in the newborn period, heat production steadily declines as the infant grows into childhood. Individual differences of 0.7 of a Celsius degree are normal, and occasionally a child will normally display an unusually high or low temperature. Beginning at approximately 12 years of age, girls’ temperature remains relatively stable, whereas the temperature in boys continues to fall for a few more years. Females maintain a temperature slightly above that of males throughout life. Even with improved temperature regulation, infants and young children are highly susceptible to temperature fluctuations. Body temperature responds to changes in environmental temperature and is increased with active exercise, crying, and emotional stress. Infections can cause a higher and more rapid temperature increase in infants and young children than in older children. In relation to body weight, an infant produces more heat per unit than adolescents. Consequently, during active play or when heavily clothed, an infant or small child is likely to become overheated.

Physiological Changes

Sleep and Rest. Sleep, a protective function in all organisms, allows

Physiological changes that take place in all organs and systems are discussed in this book as they relate to abnormalities or health conditions. Other changes such as pulse and respiratory rates and blood pressure are an integral part of physical assessment (see Chapter 33). In addition, changes occur in basic functions, including metabolism, temperature, and patterns of sleep and rest.

Metabolism. The rate of metabolism when the body is at rest (basal metabolic rate [BMR]) demonstrates a distinctive change throughout childhood. Highest in the newborn, the BMR closely relates to the proportion of surface area to body mass, which changes as the body increases in size. In both sexes the proportion decreases progressively to maturity. The BMR is slightly higher in boys at all ages and further increases during pubescence over that in girls. The rate of metabolism determines the child’s caloric requirements. The basal energy requirement is about 108 kcal/kg of body weight in newborns and decreases to 40 to 45 kcal/kg at maturity. Water requirements throughout life remain at approximately 1.5 mL/calorie of energy expended. Children’s energy needs vary considerably at different ages and with changing circumstances. The energy requirement to build tissue steadily decreases with age, following the general growth curve; however, energy needs vary with the individual child and may be considerably higher. For short periods (e.g., during strenuous exercise) and more prolonged periods (e.g., illness) the needs can be very high.

NURSING ALERT Each degree of fever increases the basal metabolism 10%, with a correspondingly increased fluid requirement.

Temperature. Body temperature, reflecting metabolism, decreases over the course of development. Thermoregulation is one of the most important adaptation responses of the newborn during the transition from intrauterine to extrauterine life (see Chapter 25, Thermogenesis). In the healthy newborn, hypothermia can result in several negative

for repair and recovery of tissues after activity. As in most aspects of development, there is wide variation among individual children in the amount and distribution of sleep at various ages. As children mature, the total time they spend in sleep and the amount of time they spend in deep sleep change. Newborns sleep much of the time. As infants grow older, the total sleep time gradually decreases, they remain awake for longer periods, and they sleep longer at night. The average sleep patterns for different age groups are listed in Box 35.1. The quality of sleep changes as children mature. As children develop through adolescence, their need for sleep does not decline, but their opportunity for sleep may be affected by social activity and academic schedules. The time spent in deep, restful sleep increases from 50% in infancy to 80% in the older child.

Nutrition Nutrition is probably the single most important influence on growth. Dietary factors regulate growth at all stages of development, and their effects are exerted in numerous and complex ways. During the rapid prenatal growth period, poor nutrition may influence development from the time of implantation of the ovum until birth. During infancy and childhood, the demand for calories is relatively great, as evidenced by the rapid increase in both height and weight. At this time, protein and caloric requirements are higher than at almost any period of postnatal development. As the growth rate slows, with its concomitant decrease in metabolism, there is a corresponding reduction in caloric and protein requirements. Growth is uneven during the periods of childhood between infancy and adolescence, when there are plateaus and small growth spurts. The child’s appetite fluctuates in response to these variations until the turbulent growth spurt of adolescence, when adequate nutrition is extremely important but may be subject to numerous emotional influences. Adequate nutrition is closely related to good health throughout life, and an overall improvement in nourishment is evidenced by the gradual increase in size and early maturation of children in this century (see Community Focus box: Healthy Food Choices).

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Canada’s Food Guide was revised in 2019 to meet nutrient standards (Dietary Reference Intakes [DRI] for vitamins, elements [minerals], and macronutrients) and to be consistent with evidence linking diet to a reduced risk of chronic diseases. See Appendix A to review Canada’s Food Guide. The new guide recommends plenty of vegetables and fruits (half a dinner plate) with one-quarter protein and one-quarter whole-grain foods. Water is the drink of choice (Health Canada, 2020) (see Chapter 35 for specific age group recommendations).

COMMUNITY FOCUS Healthy Food Choices Canada remains the only G7 country without a national school food program. Canada’s current patchwork of school food programming reaches only a small percentage of over five million students (Critch & CPS Nutrition and Gastroenterology Committee, 2020; Hernandez et al., 2018). Because students consume about 30% of their daily food at school, this situation can contribute to a higher rate of obesity. Indeed, obesity is on the increase in the pediatric population in Canada, which can have a long-term negative impact on health. Provision of healthy food at school can improve children’s health and academic outcomes while creating economic opportunities for local, sustainable agriculture. The federal government has recently committed to developing a national program with the provinces and territories but needs to establish food procurement criteria and regulations to protect against corporate food and beverage companies, which may offer less healthy foods, from gaining entry into schools (Hernandez et al., 2018). The Canadian Paediatric Society (CPS) has supported the development and implementation of nutrition policies and guidelines in Canadian schools (Critch & CPS Nutrition and Gastroenterology Committee, 2020). These polices align with the Canada’s Food Guide recommendations and have increased the availability and consumption of nutrient-rich foods while decreasing access to and consumption of foods and beverages that are high in sugars, sodium, and saturated fats. These changes can result in improved health outcomes for children and youth, such as improved body mass indices (Critch & CPS Nutrition and Gastroenterology Committee, 2020). More research is needed and strategic planning required to encourage lower-fat and low-salt food options. For example, a study was done to evaluate out-of-school snack programs. The research showed that children chose sliced fruit over whole fruit. Fruit was chosen over unflavoured grain product. However, fruit was rarely chosen over sugarsweetened and salty snacks (6% vs. 58%). Snack policies that want to serve fruit need to limit less-healthful snack options simultaneously (Beet et al., 2014). The provision of healthier choices in food delivery in schools remains a challenge.

Temperament Temperament is defined as the manner of thinking, behaving, or reacting characteristic of an individual and comprises traits that stay relatively constant over time and refers to the way in which a person deals with life (Baum, 2020). From the time of birth, children exhibit marked individual differences in the way they respond to their environment and the way that others, particularly the parents, respond to them and their needs. A genetic basis has been suggested for some differences in temperament. Nine characteristics of temperament have been identified through interviews with parents (Box 32.2). Temperament refers to behavioural tendencies, not to discrete behavioural acts; there are no implications of good or bad. Most children can be placed into one of three common categories, based on their overall pattern of temperamental attributes: The easy child—Easy-going children are even-tempered, are regular and predictable in their habits, and have a positive approach to new stimuli. They are open and adaptable to change and display

BOX 32.2

Attributes of Temperament

Activity—Level of physical motion during activity such as sleep, eating, play, dressing, and bathing Rhythmicity—Regularity in the timing of physiological functions such as hunger, sleep, and elimination Approach–withdrawal—Nature of initial responses to new stimuli such as people, situations, places, foods, toys, and procedures (Approach responses are positive and are displayed by activity or expression; withdrawal responses are negative expressions or behaviours.) Adaptability—Ease or difficulty with which the child adapts or adjusts to new or altered situations Threshold of responsiveness (sensory threshold)—Amount of stimulation, such as sounds or light, required to evoke a response in the child Intensity of reaction—Energy level of the child’s reactions, regardless of quality or direction Mood—Amount of pleasant, happy, friendly behaviour compared with unpleasant, unhappy, crying, unfriendly behaviour exhibited by the child in various situations Distractibility—Ease with which a child’s attention or direction of behaviour can be diverted by external stimuli Attention span and persistence—Length of time a child pursues a given activity (attention) and the continuation of an activity in spite of obstacles (persistence)

a mild to moderately intense mood that is typically positive. Approximately 40% of children fall into this category. The difficult child—Difficult children are highly active, irritable, and irregular in their habits. Negative withdrawal responses are typical, and they require a more structured environment. These children adapt slowly to new routines, people, or situations. Mood expressions are usually intense and primarily negative. They exhibit frequent periods of crying, and frustration often produces violent tantrums. This group represents about 10% of children. The slow-to-warm-up child—Slow-to-warm-up children typically react negatively and with mild intensity to new stimuli and, unless pressured, adapt slowly with repeated contact. They respond with only mild but passive resistance to novelty or changes in routine. They are inactive and moody but show only moderate irregularity in functions. Approximately 15% of children demonstrate this temperament pattern. Roughly 35% of children either have some, but not all, of the characteristics of one of the categories or are inconsistent in their behavioural responses. Many children demonstrate this wide range of behavioural patterns.

Significance of Temperament. Observations indicate that children who display the difficult or slow-to-warm-up patterns of behaviour are more vulnerable to the development of behavioural problems in early and middle childhood. Any child can develop behavioural issues if there is dissonance between the child’s temperament and the environment. Demands for change and adaptation that are in conflict with the child’s capacities can become excessively stressful. However, authorities emphasize that it is not the children’s temperament patterns that place them at risk; it is the degree of fit between children and their environment, specifically their parents, that determines the degree of vulnerability. The potential for optimal development exists when environmental expectations and demands fit with the individual’s style of behaviour and the parents’ ability to navigate this period (Baum, 2020).

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BOX 32.3

Activities to Promote Mastery Motivation in Infants • • • • • • • •

Provide inconspicuous assistance during play. Share pleasure with infant in accomplishments. Do not give immediate assistance during tasks. Do not interrupt infant during tasks. Let infant initiate activities. Limit controlling feedback during play. Provide audio and visually responsive toys. Provide early kinesthetic stimulation (picking up, rocking).

From Morrow, J. D., & Camp, B. W. (1996). Mastery motivation and temperament of 7-month-old infants. Pediatric Nursing, 22(3), 211–217.

Early identification of temperament provides a useful tool for caregivers in anticipating probable areas of difficulty or risk associated with development. For example, “difficult” children may be prone to colic in infancy, active children require more vigilance to prevent injury, and school entry requires different approaches for children with different temperaments. Research indicates that irritable and uncooperative infants can raise doubts in mothers about the mother’s competence. Additional research indicates that a child’s temperament can affect parent–child

TABLE 32.1 Psychosexual (Freud)

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interactions and influence the parents’ self-esteem, marital harmony, mood, and overall satisfaction as parents. Studies on the relationship between temperament and the ability to perform a task successfully (mastery motivation) have found that infants with high mastery are more easy-going. Activities that parents can use to promote their infants’ mastery of performing tasks are listed in Box 32.3. Pediatric nurses play an important role in helping parents understand the normal growth and development of their children. The nurse can use anticipatory guidelines that are age specific to help parents develop tools and techniques for managing their child’s behaviour in a preventative, positive way.

DEVELOPMENT OF PERSONALITY AND COGNITIVE FUNCTION Personality and cognitive skills develop in much the same manner as biological growth—new accomplishments build on previously mastered skills. Many aspects depend on physical growth and maturation. The following discussion acts as an introduction to the multiple facets of personality and behaviour development; many aspects of this development are also integrated into the book’s later discussion of children’s emotional and social development at various ages. Table 32.1 summarizes some of the relevant developmental theories.

Summary of Personality, Cognitive, and Moral Development Theories Psychosocial (Erikson)

I. Infancy—Birth to 1 Year Oral-sensory Trust vs. mistrust If an infant is hungry and not given food consistently then fear and a sense that the world is unpredictable can result II. Toddlerhood—1 to 3 Years Anal-urethral Autonomy vs. shame and doubt If a child is not consistently allowed to choose clothing to wear or food to eat then a sense of inadequacy and self-doubt can result III. Early Childhood—3 to 5 Years Phallic-locomotion Initiative vs. guilt If a child is not encouraged to play and be creative then if over-directed by adults, may struggle to develop a sense of initiative and confidence in their own abilities IV. Middle Childhood—5 to 12 Years Latency Industry vs. inferiority

V. Adolescence—12 to 18 Years Genitality Identity vs. role confusion Those who do not receive encouragement and reinforcement through personal experiences may struggle to develop a strong sense of self and feeling of independence and control and feel insecure and uncertain of the future

Cognitive (Piaget)

Moral Judgement (Kohlberg)

Sensorimotor (birth–2 years)

Spiritual (Fowler) Undifferentiated

Preoperational thought, preconceptual phase (transductive reasoning [e.g., specific to specific]) (2–4 years)

Preconventional (premoral) level Punishment and obedience orientation

Intuitiveprojective

Preoperational thought, intuitive phase (transductive reasoning) (4–7 years)

Preconventional (premoral) level Naive instrumental orientation

Mythical-literal

Concrete operations (inductive reasoning and beginning logic) (7–11 years)

Conventional level Good-boy, nice-girl orientation Law-and-order orientation

Syntheticconvention

Formal operations (deductive and abstract reasoning) (11–15 years)

Postconventional or principled level Social-contract orientation Universal ethical principle orientation

Individuatingreflexive

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Theoretical Foundations of Personality Development Psychosexual Development (Freud). According to Freud (1923/ 1961), all human behaviour is energized by psychodynamic forces, and this psychic energy is divided among three components of personality: the id, the ego, and the superego. The id, the unconscious mind, is the inborn component that is driven by instincts (Freud, 1923/1961). The id obeys the pleasure principle of immediate gratification of needs, regardless of whether the object or action can actually do so. The ego, the conscious mind, serves the reality principle. It functions as the conscious or controlling self that is able to find realistic means for gratifying the instincts while blocking the irrational thinking of the id. The superego, the conscience, functions as the moral arbitrator and represents the ideal. It is the mechanism that prevents individuals from expressing undesirable instincts that might threaten the social order. Freud considered the sexual instincts to be significant in the development of the personality. However, he used the term psychosexual to describe any sensual pleasure. During childhood, certain regions of the body assume a prominent psychological significance as the source of new pleasures and new conflicts gradually shifts from one part of the body to another at particular stages of development: Oral stage (birth to 1 year)—During infancy, the major source of pleasure seeking is centred on oral activities such as sucking, biting, chewing, and vocalizing. Children may prefer one of these over the others, and the preferred method of oral gratification can provide some indication of the personality they develop. Anal stage (1 to 3 years)—Interest during the second year of life centres on the anal region as sphincter muscles develop and children are able to withhold or expel fecal material at will. At this stage, the climate surrounding toilet training can have lasting effects on children’s personalities. Phallic stage (3 to 6 years)—During the phallic stage, the genitalia become an interesting and sensitive area of the body. Children recognize differences between the sexes and become curious about the dissimilarities. This is the period around which the controversial issues of the Oedipus and Electra complexes, penis envy, and castration anxiety are centred. Latency period (6 to 12 years)—During the latency period, children elaborate on previously acquired traits and skills. Physical and psychic energy are channelled into acquisition of knowledge and into vigorous play. Genital stage (age 12 and older)—The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The genital organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friendships and preparing for permanent relationships.

Psychosocial Development (Erikson). The most widely accepted theory of personality development is that advanced by Erikson (1963). Although built on Freudian theory, it is known as psychosocial development and emphasizes a healthy personality as opposed to a pathological approach. Erikson also uses the biological concepts of critical periods and epigenesis, describing key conflicts or core problems that the individual strives to master during critical periods in personality development. Successful completion or mastery of each of these core conflicts is built on the satisfactory completion or mastery of the previous stage. Each psychosocial stage has two components—the favourable and the unfavourable aspects of the core conflict—and progress to the next stage depends on resolution of this conflict. No core conflict is ever mastered completely but remains a recurrent problem throughout life. No life situation is ever secure. Each new situation presents the conflict in a new form. For example, when children who have satisfactorily

achieved a sense of trust encounter a new experience (e.g., hospitalization), they must again develop a sense of trust in those responsible for their care in order to master the situation. Erikson’s lifespan approach to personality development consists of eight stages; however, only the first five relating to childhood are included here: 1. Trust versus mistrust (birth to 1 year)—The first and most important attribute to develop for a healthy personality is basic trust. Establishment of basic trust dominates the first year of life and describes all of the child’s satisfying experiences at this age. Corresponding to Freud’s oral stage, it is a time of “getting” and “taking in” through all the senses. It exists only in relation to something or someone; therefore, consistent, loving care by a mothering person is essential for development of trust. Mistrust develops when trustpromoting experiences are deficient or lacking or when basic needs are inconsistently or inadequately met. Although shreds of mistrust are sprinkled throughout the personality, from a basic trust in parents stems trust in the world, other people, and oneself. The result is faith and optimism. 2. Autonomy versus shame and doubt (1 to 3 years)—Corresponding to Freud’s anal stage, the problem of autonomy can be symbolized by the holding on and letting go of the sphincter muscles. The development of autonomy during the toddler period is centred on children’s increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves, using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selecting and decision making. Much of their learning is acquired by imitating the activities and behaviour of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control. The favourable outcomes are self-control and willpower. 3. Initiative versus guilt (3 to 6 years)—The stage of initiative corresponds to Freud’s phallic stage and is characterized by vigorous, intrusive behaviour; enterprise; and a strong imagination. Children explore the physical world with all their senses and powers (Figure 32.4). They develop a conscience. No longer guided only by outsiders, they have an inner voice that warns and threatens. Children sometimes undertake goals or activities that are in conflict with those of parents or others, and being made to feel that their activities or imaginings are bad produces a sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights and privileges of others. The lasting outcomes are direction and purpose. 4. Industry versus inferiority (6 to 12 years)—The stage of industry is the latency period of Freud. Having achieved the more crucial stages in personality development, children are ready to be workers and producers. They want to engage in tasks and activities that they can carry through to completion; they need and want real achievement. Children learn to compete and cooperate with others, and they learn the rules. It is a decisive period in their social relationships with others. Feelings of inadequacy and inferiority may develop if too much is expected of them or if they believe that they cannot measure up to the standards set for them by others. The ego quality developed from a sense of industry is competence. 5. Identity versus role confusion (12 to 18 years)—Corresponding to Freud’s genital period, the development of identity is characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appear in the eyes of others as compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions

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Fig. 32.4 The stage of initiative is characterized by physical activity and imagination while children explore the physical world around them.

adopted by their peers, to integrate their concepts and values with those of society, and to come to a decision regarding an occupation. Inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity to others and to values and ideologies.

Cognitive Development (Piaget). The term cognition refers to the process by which developing individuals become acquainted with the world and the objects it contains. Children are born with inherited potential for intellectual growth, but they must develop that potential through interaction with the environment. By assimilating information through the senses, processing it, and acting on it, they come to understand relationships between objects and between themselves and their world. With cognitive development, children acquire the ability to reason abstractly, to think in a logical manner, and to organize intellectual functions or performances into higher-order structures. Language, morals, and spiritual development emerge as cognitive abilities advance. Cognitive development consists of age-related changes that occur in mental activities. The best-known theory regarding children’s thinking, and a more comprehensive developmental theory than those already described, was developed by the Swiss psychologist Jean Piaget (1969). According to Piaget, intelligence enables individuals to make adaptations to the environment that increase the probability of survival, and through their behaviour individuals establish and maintain equilibrium with the environment. Piaget (1969) proposed three stages of reasoning: (1) intuitive, (2) concrete operational, and (3) formal operational. When children enter the stage of concrete logical thought at about age 7 years, they are able to make logical inferences, classify, and deal with quantitative relationships about concrete things. Not until adolescence are they able to reason abstractly with any degree of competence. Each stage is derived from and builds on the accomplishments of the previous stage in a continuous, orderly process. The course of intellectual development is both maturational and invariant and is divided into the following stages (ages are approximate):

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Sensorimotor (birth to 2 years)—The sensorimotor stage of intellectual development consists of six substages (see Chapter 36 for more in-depth discussion) that are governed by sensations in which simple learning takes place. Children progress from reflex activity through simple repetitive behaviours to imitative behaviour. They develop a sense of cause and effect as they direct behaviour toward objects. Problem solving is primarily by trial and error. They display a high level of curiosity, experimentation, and enjoyment of novelty and begin to develop a sense of self as they are able to differentiate themselves from their environment. They become aware that objects have permanence— that an object exists even though it is no longer visible. Toward the end of the sensorimotor period, children begin to use language and representational thought. Preoperational (2 to 7 years)—The predominant characteristic of the preoperational stage of intellectual development is egocentrism, which in this sense does not mean selfishness or self-centredness but the inability to put oneself in the place of another. Children interpret objects and events not in terms of general properties but in terms of their relationships or their use to them. They are unable to see things from any perspective other than their own; they cannot see another’s point of view, nor can they see any reason to do so. Preoperational thinking is concrete and tangible. Children cannot reason beyond the observable, and they lack the ability to make deductions or generalizations. Thought is dominated by what they see, hear, or otherwise experience. However, they are increasingly able to use language and symbols to represent objects in their environment. Through imaginative play, questioning, and other interactions, they begin to elaborate concepts and to make simple associations between ideas. In the latter stage of this period, their reasoning is intuitive (e.g., the stars have to go to bed just as children do), and they are only beginning to deal with problems of weight, length, size, and time. Reasoning is also transductive—because two events occur together, they cause each other, or knowledge of one characteristic is transferred to another (e.g., all women with big bellies have babies). Concrete operations (7 to 11 years)—At this age, thought becomes increasingly logical and coherent. Children are able to classify, sort, order, and otherwise organize facts about the world to use in problem solving. They develop a new concept of permanence—conservation (see Chapter 38, Cognitive Development [Piaget]); that is, they realize that physical factors such as volume, weight, and number remain the same even though outward appearances are changed. They are able to deal with a number of different aspects of a situation simultaneously. They do not have the capacity to deal in abstraction; they solve problems in a concrete, systematic fashion based on what they can perceive. Reasoning is inductive. Through progressive changes in thought processes and relationships with others, thought becomes less self-centred. They can consider points of view other than their own. Thinking has become socialized. For example, a child can classify objects according to several features, such as choose dolls with blond hair and blue eyes and put the dolls in order along a single dimension such as size. Formal operations (11 to 15 years)—Formal operational thought is characterized by adaptability and flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. For example, they can solve the following question: If A is larger than B, and B is larger than C, which symbol is the largest? (The answer is A.) They can make hypotheses and test them; they can consider abstract, theoretical, and philosophical matters. Although they may confuse the ideal with the practical, most contradictions in the world can be dealt with and resolved.

Moral Development (Kohlberg). Children also acquire moral reasoning in a developmental sequence. Moral development, as described

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by Kohlberg (1968), is based on cognitive developmental theory and consists of the following three major levels, each of which has two stages: Preconventional level—The preconventional level of moral development parallels the preoperational level of cognitive development and intuitive thought. Culturally oriented to the labels of good/bad and right/wrong, children integrate these in terms of the physical or pleasurable consequences of their actions. At first, children determine the goodness or badness of an action in terms of its consequences. They avoid punishment and obey without question those who have the power to determine and enforce the rules and labels. They have no concept of the basic moral order that supports these consequences. Later, children determine that the right behaviour consists of that which satisfies their own needs (and sometimes the needs of others). Although elements of fairness, give and take, and equal sharing are evident, they are interpreted in a practical, concrete manner without loyalty, gratitude, or justice. Conventional level—At the conventional stage, children are concerned with conformity and loyalty. They value the maintenance of family, group, or community expectations regardless of consequences. Behaviour that meets with approval and pleases or helps others is considered good. One earns approval by being “nice.” Obeying the rules, doing one’s duty, showing respect for authority, and maintaining the social order are the correct behaviours. This level is correlated with the stage of concrete operations in cognitive development. Postconventional, autonomous, or principled level—At the postconventional level, the individual has reached the cognitive stage of formal operations. Correct behaviour tends to be defined in terms of general individual rights and standards that have been examined and agreed on by the entire society. Although procedural rules for reaching consensus become important, with emphasis on the legal point of view, there is also emphasis on the possibility for changing law in terms of societal needs and rational considerations. The most advanced level of moral development is one in which selfchosen ethical principles guide decisions of conscience. These are abstract and ethical but universal principles of justice and human rights with respect for the dignity of persons as individuals. Kohlberg believed that few persons reach this stage of moral reasoning.

Spiritual Development (Fowler). Spiritual beliefs are closely related to the moral and ethical portion of the child’s self-concept and, as such, must be considered as part of the child’s basic needs assessment. Children need to have meaning, purpose, and hope in their lives. Also, the need for confession and forgiveness is present, even in very young children. Extending beyond religion (an organized set of beliefs and practices), spirituality affects the whole person: mind, body, and spirit. Fowler (1981) identified six stages in the development of faith, four of which are closely associated with and parallel cognitive and psychosocial development in childhood: Stage 0: Undifferentiated—This stage of development encompasses the period of infancy, during which children have no concept of right or wrong, no beliefs, and no convictions to guide their behaviour. However, the beginnings of a faith are established with the development of basic trust through their relationships with the primary caregiver. Stage 1: Intuitive-projective—Toddlerhood is primarily a time of imitating the behaviour of others. Children imitate the religious gestures and behaviours of others without comprehending any meaning of or significance to the activities. During the preschool years, children assimilate some of their parents’ values and beliefs.

Parental attitudes toward moral codes and religious beliefs convey to children what they consider to be good and bad. Children still imitate behaviour at this age and follow parental beliefs as part of their daily lives rather than through an understanding of their basic concepts. Stage 2: Mythic-literal—Through the school-age years, spiritual development parallels cognitive development and is closely related to children’s experiences and social interaction. Many have a strong interest in religion during the school-age years. They accept the existence of a deity, and petitions to an omnipotent being are important and expected to be answered; good behaviour is rewarded, and bad behaviour is punished. Their developing conscience bothers them when they disobey. They have a reverence for thoughts about spiritual matters and are able to articulate their faith. They may even question its validity. Stage 3: Synthetic-conventional—As children approach adolescence, however, they become increasingly aware of spiritual disappointments. They recognize that prayers are not always answered (at least on their own terms), and they may begin to abandon or modify some religious practices. They begin to reason, to question some of the established parental religious standards, and to drop or modify some religious practices. Stage 4: Individuative-reflective—Adolescents become more skeptical and begin to compare their parents’ religious standards with those of others. They attempt to determine which to adopt and incorporate into their own set of values. They also begin to compare religious standards with a scientific viewpoint. It is a time of searching rather than reaching conclusions. Adolescents are uncertain about many religious ideas but will not achieve profound insights until late adolescence or early adulthood.

Language Development. Children are born with the mechanism and capacity to develop speech and language skills. However, they do not speak spontaneously. The environment must provide a means for them to acquire these skills. Speech requires intact physiological structure and function (including respiratory, auditory, and cerebral) plus intelligence, a need to communicate, and stimulation. The rate of speech development varies from child to child and is directly related to neurological competence and cognitive development. Gesture precedes speech, and in this way a small child communicates satisfactorily. As speech develops, gesture recedes but never disappears entirely. Research suggests that infants can learn sign language before vocal language and that it may enhance the development of vocal language. Therapists frequently teach alternative-communication systems, such as picture exchanges or manual signs, to individuals with developmental disabilities who present with expressive language deficits. The picture exchange proved to be an alternative technique to help these children enhance their learning (Barlow et al., 2013). At all stages of language development, children’s comprehension vocabulary (what they understand) is greater than their expressed vocabulary (what they can say), and this development reflects a continuing process of modification that involves both the acquisition of new words and the expansion and refinement of word meanings previously learned. By the time they begin to walk, children are able to attach a name to objects and persons. The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination words (such as “bye-bye”). Responses are usually structurally incomplete during the toddler period, although the meaning is clear. Next they begin to use adjectives and adverbs to qualify nouns, followed by adverbs to qualify nouns and verbs. Later, pronouns and gender words are added (such as “he” and “she”). By the

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time children enter school, they are able to use simple, structurally complete sentences that average five to seven words.

Development of Self-Concept Self-concept is how an individual describes themselves. The term selfconcept includes all the beliefs and convictions that constitute an individual’s self-knowledge and that influence relationships with others. It develops gradually as a result of unique experiences within the self, with significant others, and with the realities of the world. However, an individual’s self-concept may or may not reflect reality. In infancy the self-concept is primarily an awareness of one’s independent existence learned in part as a result of social contacts and experiences with others. The process becomes more active during toddlerhood as children explore the limits of their capacities and the nature of their impact on others. School-age children are more aware of differences among people, are more sensitive to social pressures, and become more preoccupied with issues of self-criticism and selfevaluation. During early adolescence, children focus more on physical and emotional changes taking place and on peer acceptance. Selfconcept is crystallized during later adolescence as young people organize their self-concept around a set of values, goals, and competencies acquired throughout childhood.

Body Image. A vital component of self-concept, body image refers to the subjective concepts and attitudes that individuals have toward their own bodies. It consists of the physiological (the perception of one’s physical characteristics), psychological (values and attitudes toward the body, abilities, and ideals), and social nature of one’s image of self (the self in relation to others). All three components interrelate with one another. Body image is a complex phenomenon that evolves and changes during the process of growth and development. Any actual or perceived deviation from the “norm” (no matter how this is interpreted) is cause for concern and is influenced by the attitudes and behaviour of those around them. The significant others in children’s lives exert the most important and meaningful impact on children’s body image. Labels that are attached to them (such as “skinny,” “pretty,” or “fat”) or body parts (such as “ugly mole,” “bug eyes,” or “yucky skin”) are incorporated into the body image. Because they lack the understanding of deviations from the physical standard or norm, children notice prominent differences in others and unwittingly make rude or cruel remarks about such minor deviations as large or widely spaced front teeth, large or small eyes, moles, or extreme variations in height. Infants receive input about their bodies through self-exploration and sensory stimulation from others. As they begin to manipulate their environment, they become aware of their bodies as separate from others. Toddlers learn to identify the various body parts and are able to use symbols to represent objects. Preschoolers become aware of the wholeness of their bodies and discover the genitalia. Exploration of the genitalia and the discovery of differences between the sexes become important. At this age, children have only a vague concept of internal organs and function. School-age children begin to learn about internal body structure and function and become aware of differences in body size and configuration. They are highly influenced by the cultural norms of society and current fads. Children whose bodies deviate from the norm are often criticized or ridiculed. Adolescence is the age when children become most concerned about the physical self. The unfamiliar body changes, and the new physical self must be integrated into the self-concept. Adolescents face conflicts over what they see and what they visualize as the ideal body structure. Body image formation during adolescence is a

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crucial element in the shaping of identity, the psychosocial crisis of adolescence.

Self-Esteem. Self-esteem is the value that an individual places on themselves and refers to an overall evaluation of oneself. Self-esteem is described as the affective component of the self, whereas self-concept is the cognitive component; however, the two terms are almost indistinguishable and are often used interchangeably. The term self-esteem refers to a personal, subjective judgement of one’s worthiness derived from and influenced by the social groups in the immediate environment and individuals’ perceptions of how they are valued by others. Self-esteem changes with development. Highly egocentric toddlers are unaware of any difference between competence and social approval. By contrast, preschool and early school-age children are increasingly aware of the discrepancy between their competencies and the abilities of more advanced children. Being accepted by adults and peers outside the family group becomes more important to them. Positive feedback enhances their self-esteem; they are vulnerable to feelings of worthlessness and are anxious about failure. As children’s competencies increase and they develop meaningful relationships, their self-esteem rises. Their self-esteem is again at risk during early adolescence when they are defining an identity and sense of self in the context of their peer group. Unless children are continually made to feel incompetent and of little worth, a decrease in self-esteem during vulnerable times is only temporary. Children assess the following aspects of themselves in forming an overall evaluation of their self-esteem: Competence—How adequate are my cognitive, physical, and social skills? Sense of control—How well can I complete tasks needed to produce desired actions? Are my successes or failures due to someone or something specific or are they due to luck? Moral worth—How well do my actions and behaviours meet moral standards that have been set? Worthiness of love and acceptance—How worthy am I of love and acceptance from parents, other significant adults, siblings, and peers? Factors that influence the formation of a child’s self-esteem include (1) the child’s temperament and personality, (2) abilities and opportunities available to accomplish age-appropriate developmental tasks, (3) how significant others interact with the child, and (4) social roles assumed and the expectations surrounding these roles.

ROLE OF PLAY IN DEVELOPMENT Through the universal medium of play, children learn what no one can teach them. They learn about their world and how to deal with this environment of objects, time, space, structure, and people. They learn about themselves operating within that environment—what they can do, how to relate to things and situations, and how to adapt themselves to the demands that society makes on them. Play is the work of the child. In play, children continually practise the complicated, stressful processes of living, communicating, and achieving satisfactory relationships with other people. From a developmental point of view, patterns of children’s play can be categorized according to content and social character. In both there is an additive effect; each pattern builds on past accomplishments, and some element of each is maintained throughout life. At each stage in development, the new predominates.

Content of Play The content of play involves primarily the physical aspects of play, although social relationships cannot be ignored. Play follows the simple to the complex:

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Social-affective play—Play begins with social-affective play, in which infants take pleasure in relationships with people. As adults talk to, touch, and nuzzle an infant and in various ways elicit a response from an infant, the infant soon learns to provoke parental emotions and responses with such behaviours as smiling, cooing, or initiating games and activities. The type and intensity of the adult behaviour with children vary among cultures. Sense-pleasure play—Sense-pleasure play is a nonsocial stimulating experience that originates from without. Objects in the environment—light and colour, tastes and odours, textures and consistencies—attract children’s attention, stimulate their senses, and give them pleasure. Pleasurable experiences are derived from handling raw materials (water, sand, food), from body motion (swinging, bouncing, rocking) and from other uses of senses and abilities (smelling, humming) (Figure 32.5). Skill play—After infants have developed the ability to grasp and manipulate, they persistently demonstrate and exercise their newly acquired abilities through skill play, repeating an action over and over (Figure 32.6). The element of sense-pleasure play is often evident in practising a new ability, but frequently the determination to conquer the elusive skill produces pain and frustration (e.g., putting blocks into a box and taking them out). Unoccupied behaviour—In unoccupied behaviour, children are not playful but focusing their attention momentarily on anything that strikes their interest. Children daydream, fiddle with clothes or other objects, or walk aimlessly. This role differs from that of onlookers, who actively observe the activity of others. Dramatic, or pretend, play—One of the vital elements in children’s process of identification is dramatic play, also known as symbolic or pretend play. It begins in late infancy (11 to 13 months) and is the predominant form of play in the preschool child. After children begin to invest situations and people with meanings and to attribute affective significance to the world, they can pretend and fantasize almost anything. By acting out events of daily life, children learn and practise the roles and identities modelled by the members of their family and

Fig. 32.6 After infants develop new skills to grasp and manipulate, they begin to conquer new abilities, such as getting on a play motorcycle.

society. Children’s toys, replicas of the tools and pastimes of society, provide a medium for learning about adult roles and activities that may be puzzling and frustrating to them. Interacting with the world is one way children get to know it. The simple, imitative, dramatic play of the toddler, such as using the telephone or computer, driving a car, or rocking a doll, evolves into more complex, sustained dramas of the preschooler, which extend beyond common domestic matters to the wider aspects of the world and the society, such as playing police officer, storekeeper, teacher, or nurse. Older children work out elaborate themes, act out stories, and compose plays. Games—Children in all cultures engage in games alone and with others. Solitary activity involving games begins as very small children participate in repetitive activities and progress to more complicated games that challenge their independent skills, such as puzzles, solitaire, and computer or video games. Very young children participate in simple, imitative games, such as pat-a-cake and peek-a-boo. Preschool children learn and enjoy formal games, beginning with ritualistic, selfsustaining games, such as ring-around-a-rosy and London Bridge. With the exception of some simple board games, preschool children do not engage in competitive games. Preschoolers hate to lose and will try to cheat, want to change rules, or demand exceptions and opportunities to change their moves. School-age children and adolescents tend to enjoy competitive games, including computer or smartphone video games, cards, chess, and physically active games such as baseball.

Social Character of Play

Fig. 32.5 Children derive pleasure from handling raw materials. (Paints in this picture are nontoxic.)

The play interactions of infancy are between the child and an adult. Children continue to enjoy the company of adults but are increasingly able to play alone. As children grow, interaction with age-mates increases in importance and becomes an essential part of the socialization process. Through interaction, highly egocentric infants, unable to tolerate delay or interference, ultimately acquire concern for others and the ability to delay gratification or even to reject gratification at the expense of another. A pair of toddlers will engage in considerable combat because their personal needs cannot tolerate delay or compromise. By the time they reach age 5 or 6 years, children are able to arrive at a compromise or make use of arbitration, usually after they have attempted but failed to gain their own way. Through continued interaction with peers and the growth of conceptual abilities and social skills,

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children are able to increase participation with others in the following types of play: Onlooker play—During onlooker play, children watch what other children are doing but make no attempt to enter into the play activity. There is an active interest in observing the interaction of others but no movement toward participating. Watching an older sibling bounce a ball is a common example of the onlooker role. Solitary play—During solitary play, children play alone with toys different from those used by other children in the same area. They enjoy the presence of other children but make no effort to get close to or speak to them. Their interest is centred on their own activity, which they pursue with no reference to the activities of the others. Parallel play—During parallel activities, children play independently but among other children. They play with toys similar to those that the children around them are using but as each child sees fit, neither influencing nor being influenced by the other children (Figure 32.7). There is no group association. Parallel play is the characteristic of toddlers, but it may occur at other ages. Individuals who are involved in a creative craft with each person separately working on an individual project are engaged in parallel play. Associative play—In associative play, children play together and are engaged in a similar or even identical activity, but there is no organization, division of labour, leadership assignment, or mutual group goal. Children borrow and lend play materials, follow each other with wagons and tricycles, and sometimes attempt to control who may or may not play in the group. Each child acts according to their own wishes; there is no group goal (Figure 32.8). For example, two children play with dolls, borrowing articles of clothing from each other and engaging in similar conversation, but neither directs the other’s actions or establishes rules regarding the limits of the play session. There is a great deal of behavioural contagion: when one child initiates an activity, often, the entire group follows the example. Cooperative play—Cooperative play is organized, and children play in a group with other children (Figure 32.9). They discuss and plan activities for the purposes of accomplishing an end—to make something, to attain a competitive goal, to dramatize situations of adult or group life, or to play formal games. The group is loosely formed, but there is a marked sense of belonging or not belonging. The goal and its attainment require organization of activities, division of labour, and role playing. The leader–follower relationship is definitely established, and the activity is controlled by one or two members who assign roles and direct the activity of the others. The activity is organized to allow one child to supplement another’s function to complete the goal.

Fig. 32.7 Parallel play at the beach.

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Fig. 32.8 Associative play.

Fig. 32.9 Cooperative play. (iStock.com/Kuzmichstudio)

Functions of Play Sensorimotor Development. Sensorimotor activity is a major component of play at all ages and is the predominant form of play in infancy. Active play is essential for muscle development and serves a useful purpose as a release for surplus energy. Through sensorimotor play, children explore the nature of the physical world. Infants gain impressions of themselves and their world through tactile, auditory, visual, and kinesthetic stimulation. Toddlers and preschoolers revel in body movement and exploration of objects in space. With increasing maturity, sensorimotor play becomes more differentiated and involved. Whereas very young children run for the sheer joy of body movement, older children incorporate or modify the motions into increasingly complex and coordinated activities, such as racing, playing games, skateboarding, and bicycle riding.

Intellectual Development. Through activities involving exploration and manipulation of objects, children learn colours, shapes, sizes, textures, and the significance of objects. They learn the significance of numbers and how to use them; they learn to associate words with objects; and they develop an understanding of abstract concepts and spatial relationships, such as up, down, under, and over. Activities such as puzzles and games help them develop problem-solving skills. Books,

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stories, films, and collections expand knowledge and provide enjoyment as well. Play provides a means to practise and expand language skills. Through play, children continually rehearse past experiences to assimilate them into new perceptions and relationships. Play helps children comprehend the world in which they live and distinguish between fantasy and reality.

Socialization. From very early infancy children show interest and pleasure in the company of others. Their initial social contact is with the mothering person, but through play with other children they learn to establish social relationships and solve the problems associated with these relationships. They learn to give and take, which is more readily learned from critical peers than from more tolerant adults. They learn the sex role that society expects them to fulfill and approved patterns of behaviour and deportment. Closely associated with socialization is development of moral values and ethics. Children learn right from wrong, the standards of the society, and to assume responsibility for their actions. Creativity. In no other situation is there more opportunity to be creative than in play. Children can experiment and try out their creative ideas in play through every medium at their disposal, including raw materials, fantasy, and exploration. Creativity is stifled by pressure toward conformity; therefore, striving for peer approval may inhibit creative endeavours in the school-age or adolescent child. Creativity is primarily a product of solitary activity, yet creative thinking is often enhanced in group settings where listening to others’ ideas stimulates further exploration of one’s own ideas. After children feel the satisfaction of creating something new and different, they transfer this creative interest to situations outside the world of play. Self-Awareness. Beginning with active explorations of their bodies and awareness of themselves as separate from the mother, the process of developing a self-identity is facilitated through play activities. Children learn who they are and their place in the world. They become increasingly able to regulate their own behaviour, to learn what their abilities are, and to compare their abilities with those of others. Through play, children are able to test their abilities, to assume and try out various roles, and to learn the effect their behaviour has on others. They learn the gender role that society expects them to fulfill, as well as approved patterns of behaviour and deportment.

Therapeutic Value. Play is therapeutic at any age (Figure 32.10). In play, children can express emotions and release unacceptable impulses in a socially acceptable fashion. Children are able to experiment and test fearful situations and can assume and vicariously master the roles and positions that they are unable to perform in the world of reality. Children reveal much about themselves in play. Through play, children are able to communicate to the alert observer the needs, fears, and desires that they are unable to express with their limited language skills. Throughout their play, children need the acceptance of adults and their presence to help them control aggression and channel their destructive tendencies. Moral Value. Although children learn at home and at school those behaviours considered right and wrong in the culture, the interaction with peers during play contributes significantly to their moral training. Nowhere is the enforcement of moral standards as rigid as in the play situation. If they are to be members of the group, children must adhere to the accepted codes of behaviour of the culture (e.g., fairness, honesty, self-control, consideration for others). Children soon learn that their

Fig. 32.10 Play is therapeutic at any age and provides a means for release of tension and stress.

peers are less tolerant of violations than are adults and that to maintain a place in the play group, they must conform to the group’s standards.

Toys The type of toys chosen by or provided for children can support and enhance the child’s development in the areas just described. Although no scientific evidence shows that any toy is necessary for optimal learning, toys offer an opportunity to bring the child and parent together. Toys that are small replicas of the culture and its tools help children assimilate into their culture. Toys that require pushing, pulling, rolling, and manipulating teach them about physical properties of the items and help develop muscles and coordination. Rules and the basic elements of cooperation and organization are learned through board and some video games. Because they can be used in a variety of ways, raw materials allow children to exercise their own creativity and imagination and are sometimes superior to ready-made items. For example, building blocks can be used to construct a variety of structures, to count, and to learn shapes and sizes.

SELECTED FACTORS THAT INFLUENCE DEVELOPMENT Heredity Inherited characteristics have a profound influence on development. The child’s sex, determined by random selection at the time of conception, directs both the pattern of growth and the behaviour of others toward the child. In all cultures, attitudes and expectations are shaped by the child’s sex. Sex and other hereditary determinants strongly affect

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the progress and end result of growth. There is a high correlation between parent and child with regard to traits such as height, weight, and rate of growth. Most physical characteristics, including shape and form of features, body build, and physical peculiarities, are inherited and can influence the way in which children grow and interact with their environment. Many dimensions of personality, such as temperament, activity level, responsiveness, and a tendency toward shyness, are believed to be inherited. Differences in children’s health and vigour may be attributed to hereditary traits. An inherited physical or emotional disorder will alter or modify a child’s physical or emotional growth and interactions. Altered growth and development are one of the clinical manifestations in a number of hereditary disorders. Growth impairment is particularly marked in skeletal disorders, such as the various forms of dwarfism and at least one of the chromosomal anomalies (Turner syndrome). Many of the disorders of metabolism, such as vitamin D–resistant rickets, the mucopolysaccharidoses, and the numerous endocrine disorders, interfere with the normal growth pattern. In other disorders (e.g., Klinefelter and Marfan syndromes) the tendency is toward the upper percentile of height. Many chronic illnesses associated with varying degrees of growth failure are congenital cardiac anomalies, chronic renal disease, and respiratory disorders, such as cystic fibrosis. Any disorder characterized by the inability to digest and absorb body nutrients will have an adverse effect on growth and development.

Genes, Genetics, and Genomics. All nurses need to be prepared to use genetic and genomic information and technology when providing care. Often the nurse is the first one to recognize the need for genetic evaluation by identifying an inherited disorder in a family history or noting physical, cognitive, or behavioural abnormalities when performing a nursing assessment. Evidence is also growing that genes play an important role in human susceptibility and resistance to infection, even in cases with a clear environmental cause of the infectious disease. Evidence for this genetic element in resistance gained heightened recognition during the first decade of the acquired immunodeficiency syndrome (AIDS) epidemic. Researchers discovered that adults with a specific deletion in both copies of the CCR5 genes did not become infected with human immunodeficiency virus (HIV) despite repeated exposures. Later it was discovered that children exposed in utero to HIV typically had a significantly delayed onset of disease if at least one of their CCR5 genes had the specific mutation (McLaren & Carrington, 2015).

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The mothering person is unquestionably the single most influential person during early infancy who meets the infant’s basic needs of food, warmth, comfort, and love. They stimulate the child’s senses and facilitate the child’s expanding capacities. Through this person the child learns to trust the world and feel secure to venture in increasingly wider relationships. Generally, the parents or caregivers are most influential in helping the child to assume sex-role identification. Parents define and reinforce sex-role behaviour and provide sex-appropriate role models for the child. In the absence of a same-sex role model in the family setting, the child may adopt some characteristics of the opposite-sex parent or sibling. Frequently, the child identifies with a teacher or other significant person of the same sex. Siblings are children’s first peers, and the way in which they learn to relate to each other affects later interactions with peers outside the family group. The sphere of persons from whom children seek approval widens to include other members of their family, their peers, and, to a lesser extent, other authority figures (e.g., teachers) (Figure 32.11). The increasing importance of the peer group in determining the behaviour of school-age children and adolescents is well documented. When children fail to have high-quality interpersonal relationships with mothering persons they experience emotional deprivation. The most prominent feature of emotional deprivation, particularly during the first year, is developmental delays. The term masked deprivation has been used to describe children reared in homes in which there is a distorted parent–child relationship or otherwise disordered home environment. Infants do not thrive if the caregiving person is hostile, fearful of handling them, or indifferent to them and their needs. Such children exhibit poor growth even though they are apparently free of physical disease. Growth delays in these children are believed to be caused by a psychologically induced endocrine imbalance that interferes with growth. These same infants and children display “catchup” growth in a changed environment, however (see Chapter 36, Failure to Thrive [Growth Failure]). Children who have been adopted from orphanages in foreign countries where they may have received minimal

Neuroendocrine Factors The hypothalamic–pituitary axis produces a number of releasing and inhibitory hormones that influence growth. Probably all hormones affect growth in some fashion. Three hormones—growth hormone, thyroid hormone, and androgens—when given to persons deficient in these hormones, stimulate protein anabolism and thereby produce retention of elements essential for building protoplasm and bony tissue. It appears that each of the hormones that has a significant influence on growth manifests its major effect at a different period of growth (see Chapter 51).

Interpersonal Relationships Relationships with significant others play a critical role in development, particularly in emotional, intellectual, and personality development. Not only do the quality and quantity of contacts with other persons exert an influence on the growing child, but the widening range of contacts is essential to learning and developing a healthy personality.

Fig. 32.11 Peers become increasingly important as children develop friendships outside the family group.

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mothering often have growth delays when they are adopted but they usually thrive and achieve normal growth. Although catch-up growth is viewed as a positive improvement among post-institutionalized children, rapid or continuous increases in body size can pose a health concern. It is important to pay attention to monitoring weight gain, diet, and physical activity (Tang et al., 2018).

Socioeconomic Level The family’s socioeconomic level can have a significant impact on children’s growth and development as significant determinants of health. At all ages, children from upper- and middle-class families are taller than comparative children of families in lower socioeconomic strata. The cause of these differences is less definite, although the poorer health and nutrition of children in lower socioeconomic levels are probably significant factors. Families from lower socioeconomic groups may lack the knowledge or resources needed to provide the safe, stimulating, and enriched environment that fosters optimum development for children (see Chapter 30, Social Determinants of Health).

Environmental Hazards Hazards in the environment, another determinant of health, are a source of concern to health care providers and others interested in health and safety. Physical injuries are the most prevalent consequences of environmental dangers. Children are at a high risk for harm resulting from the chemical residues present in the environment. The hazards of these chemical residues relate to their potential carcinogenicity, enzymatic effects, and accumulation. The harmful agents most often associated with health risks are chemicals and radiation, including sun exposure. Water, air, and food contamination from a variety of sources are well documented. Significant means of exposure are substances such as asbestos and lead in the immediate environment; secretion of chemicals in breast milk (especially prescribed medications and nicotine); and contamination within wellinsulated homes (especially from disinfectants or burning of substances that produce toxic fumes). Passive inhalation of tobacco or cannabis through smoking or vaping is a hazard at all stages of development (see Chapter 45). The harmful effects of large doses of radiation are unquestioned, although the effects of low-dose or short-term radiation are debatable, as are the dosage levels that are considered safe or harmful.

Stress and Coping Coping refers to a special class of individual reactions to stressors—specifically, a reaction to a stressor that resolves, reduces, or replaces the affective state classified as stressful. Coping strategies are the specific ways in which children cope with stressors, as distinguished from coping styles, which are relatively unchanging personality characteristics or outcomes of coping. As children age, they tend toward a more internal locus of control and use more vigilant modes of coping. Children, like adults, respond to everyday stress by trying to change the circumstances or trying to adjust to circumstances the way they are. Any strategy that provides relaxation is effective in reducing stress, and most children have their own natural methods of dealing with stress, such as withdrawing, engaging in physical activity, reading, listening to music, working on a project, or taking a nap. Some turn to parents to solve their problems, or they may develop socially unacceptable strategies, such as cheating, stealing, or lying. Children can be taught stress-reduction techniques to use in coping. First, they must be helped to recognize signs of tension in themselves. Then they can be taught any of a variety of appropriate strategies— special exercises, relaxation and breathing, mental imagery, and numerous other simple activities. Also, parents and other caregivers can anticipate possible stress-provoking events and prepare children for coping by role playing a scenario or “talking it through” so that they

can learn how to solve problems. When children can view any new situation as a problem to be solved and an opportunity to learn, they are not vulnerable to the control of others. It provides them with a sense of mastery over their own lives and reinforces the fact that they have within themselves the ability and information to handle whatever comes their way. Problem-solving skill gives them the confidence to know where and how to seek help when they need it. When a succession of stressors produces an excessive stress load (toxic stress), children may experience a serious change in health or behaviour. Parents and other caregivers can try to recognize signs of stress to help children deal with stressors before they become overwhelming (see Chapter 30, Toxic Stress for further discussion).

Mass Media The media can have an enormous influence on the developing child. There is no doubt that the media provide children with a means of extending their knowledge about the world in which they live and have helped narrow the differences between classes. However, there is growing concern about the enormous influence that the media can have on the developing child because of the large number of hours that children spend watching media, such as movies, video games, and television shows. The portable technology of hand-held electronic devices has given children even more access to the multitude sources of media. For instance, the images of risky behaviour presented in the media may establish or reinforce teenagers’ perceptions of their social environment. Children may identify closely with and be influenced by people or characters portrayed in reading materials, movies, video games, and television programs and commercials. Most researchers have concluded that protracted electronic device viewing can have detrimental effects on children. For example, in one study, technology use was implicated as contributing to irregular sleep schedules in children; evidence indicated a substantial association between longer electronic screen viewing and shorter sleep duration among very young children (under 2 years of age) (Chen et al., 2019). Use of any electronic device at bedtime was associated with significantly increased use of multiple forms of technology at bedtime and use in the middle of the night, both of which reduced sleep quantity and quality. A significant association was also found between bedtime technology use and elevated body mass index (Fuller et al., 2017). Recognizing the negative effects of electronic device use, the CPS (2017) recommends that children under age 2 not participate in screen-based activities and that children ages 2 to 5 years old limit routine or regular screen time to less than 1 hour per day and that older children watch no more than 1 to 2 hours of high-quality television a day. For all children, house rules that specify the type and amount of television can help children understand limits, and recorded selections of appropriate programs can be substituted for less desirable offerings. Parents need to carefully monitor cable and other pay-television programming. Lockboxes, V-chips, and blocking devices are available for cable receivers to prevent children from viewing uncensored programs when unsupervised. Like movies, some television programs and commercials contain many implicit and explicit messages that promote consumerism, alcohol consumption, smoking, violence, and promiscuous or unsafe sexual activity. There is evidence, although limited, documenting a relationship between viewing these activities on television and the actual use of alcohol or tobacco, exposure to violence, and aggressive behaviour (Mitrofan et al., 2014). Children are vulnerable to advertising, which can encourage unhealthy habits, such as asking parents for sugary, low-fibre cereals. Parents can help children evaluate violence on television by pointing out the subtleties that children miss, such as the aggressor’s motives

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and intentions and the unpleasant consequences that the perpetrators suffer as a result of their aggressive acts. Often the consequence is separated from the act by a commercial, thus children cannot make the correlation. Parents need to point out that conflicts can be resolved without resorting to violent behaviour. They can also stress the program’s purpose—primarily entertainment—and explain why they like or dislike something on television (e.g., “This show is trying to tell you that crime does not pay and that if people do wrong, they will go to jail”). Explanations and discussions can take place between shows (with the volume turned down), and young children can learn from both older children and adults. These discussions can be effective when begun early and carried out consistently. Television is the medium by which most children learn of a natural disaster or act of terrorism. Research on the effects of these terrorist attacks suggests that post-traumatic stress reactions increase with greater exposure to media coverage. Reading about the event rather than watching it on television may produce less traumatic associations of the experience (Hamblen & Dart Center for Journalism and Trauma, 2016). In addition, parents should limit the exposure to media coverage of traumatic events, talk to their child about the event, and maintain daily routines as much as possible. Digital media has been shown, however, to also have a positive influence on children’s abilities to deal with a variety of social issues, such as divorce, the arrival of a new baby, discrimination, honesty, and helpfulness. Children who view educational programming for an extended period tend to become more affectionate, considerate, cooperative, and helpful toward their playmates. Preschoolers who watched digital programming found that educational viewing can increase their knowledge, positively affect their attitudes toward racial difference, and increase their imaginative behaviour (CPS, 2017). In short, parents need to supervise the amount and type of media programs their children watch and to teach their children how to watch media (Family-Centred Care box: Media Viewing). As the CPS (2017) recommends, parental role modelling may have a more positive influence on the child’s behaviour than media programming. Parents watching media with their child can help the child understand the difference between their own life and habits and those of persons represented on television.

FAMILY-CENTRED CARE Media Viewing Provide a positive role model by developing media substitutes such as reading, athletics, physical conditioning, and hobbies. Together with your child, construct a time chart of activities (homework, media viewing, scheduled and other outside activities, playing with a friend). Require that the child choose doing something from this list before watching media. For children over 5 years of age, limit the child’s viewing to 2 hours or less per day. Rule out media viewing at specific times (e.g., mealtimes, before breakfast, or on school nights). Discuss the purpose of a program and of commercial content with the child: • Distinguish between the real and the unreal. • Correlate consequences with actions. • Point out subtle messages. • Explore alternatives to aggressive conflict resolution. Remove televisions and hand-held electronic devices from children’s bedrooms. Limit use of media viewing as a distraction to potentially stressful times (e.g., keeping the children occupied while the parent gets organized after a difficult day).

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Nurses and parents can be powerful forces in influencing the media. They can watch closely for an increase in violence and other undesirable programming and express their concerns to sponsors and television stations if they believe it is not appropriate. Good programming can be both educational and entertaining.

Internet. The use of computers and personal tablets in both the classroom and home has affected childhood learning and development. Many schools offer computer programs and use digital devices that enable children of all ages to research a range of topics and broaden their world view. These technologies can be used for interactive learning, and their use can improve hand–eye coordination. Parents have a wide variety of computer software to choose from for their children’s learning and gaming. The Internet and email have made correspondence and information available to children from around the world in seconds. Social networking sites (e.g., Twitter, Facebook, Tumblr, Instagram, Kik Messenger, Snapchat, Tik-Tok) provide opportunities for children and adolescents to express themselves through blogs, music, pictures, and videos, and the overwhelming majority of adolescents use these sites responsibly (Holloway et al., 2014; Steeves et al., 2020). Although computer and digital technology has enhanced many forms of learning and recreation, there are potential dangers to children. The negative aspects of television and video games also apply to the Internet. It is important for parents to be aware of the websites that their children access, as they are vulnerable to exposure to pornographic sites. Children can also be lured into interactions with pedophiles. Locks that block certain websites should be considered. Children can also spend too much time sitting in front of a computer screen. With excessive use of digital devices such as smartphones they can also develop repetitive-use injuries. Another potential serious risk is the rise of bullying, including cyberbullying. Cyberbullying involves the use of social media and other Internet sites to bully children, which can have a powerful impact on vulnerable children. Victims of bullying often report a negative effect on their body image and experience worry, sadness, anxiety, depression, and nightmares. Their response can also include self-harm behaviours such as cutting, suicidal ideation, and violence (see Chapters 39, 40, and 55). Nurses should encourage parents to be knowledgeable of their children’s Internet activities and to provide appropriate learning activities unique to computers and digital devices. One helpful strategy is to locate the computer in a public area of the home, such as the kitchen or family room, to enable parents to easily monitor its use. Nurses can engage parents in conversations about the negative and positive consequences of watching too much television and of their child viewing shows that are inappropriate for their age. In hospitals, many bedsides have a television or computer and video games with Wi-Fi available for children to use. Nurses can help to set limits on viewing and encourage other activities for these children. See Additional Resources for Canada’s Centre for Digital and Media Literacy, which helps children and parents navigate the Web with safety tips.

KEY POINTS • Growth describes a change in quantity and occurs when cells divide and synthesize new proteins. • Maturation, a qualitative change, describes the aging process or an increase in competence and adaptability. • Differentiation refers to biological processes by which early cells and structures are modified and altered to achieve specific and characteristic physical and chemical properties.

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• Development involves change from a lower to a more advanced stage of complexity. • The five major developmental periods are prenatal, infancy, early childhood, middle childhood, and later childhood (pubescence and adolescence). • Growth and development proceed in predictable patterns of direction, sequence, and pace. • The directional trends in growth and development are cephalocaudal, proximodistal, and mass to specific. • Physical development includes increase in height and weight and changes in body proportion, dentition, and some body tissues. • The three broad classifications of child temperament are the easy child, the difficult child, and the slow-to-warm-up child. • The developmental theories most widely used in explaining child growth and development are Freud’s psychosexual stages, Erikson’s stages of psychosocial development, Piaget’s stages of cognitive development, Kohlberg’s stages of moral development, and Fowler’s stages of spiritual development. • To develop a positive self-concept, children need recognition for their achievements and the approval of others. • Through play, children learn about their world and how to relate to objects, people, and situations. • Play provides a means of development in the areas of sensorimotor and intellectual progress, socialization, creativity, self-awareness, and moral behaviour; it serves as a means for the release of tension and expression of emotions. • Growth and development are affected by a variety of conditions and circumstances, including heredity, physiological function, gender, disease, physical environment, nutrition, and interpersonal relationships. • All nurses should be familiar with genetic or genomics information as it relates to their patient’s care. • Mass media can be influential in children’s learning and behaviour.

REFERENCES Ball, J. W., Dains, J. E., Flynn, J. E., et al. (2019). Seidel’s guide to physical examination (9th ed.). Elsevier. Barlow, K. E., Tiger, J. H., Slocum, S. K., et al. (2013). Acquisition of exchangebased and signed mands with children with autism. Analysis Verbal Behavior, 29, 59–69. https://doi.org/10.1007/BF03393124. Baum, R. A. (2020). Positive parenting and support. In R. M. Kliegman, J. W. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Beet, M. W., Tilley, F., Kyryliuk, R., et al. (2014). Children select unhealthy choices when given a choice among snack offerings. Journal of Academy of Nutrition and Dietetics, 114(9), 1440–1446. https://doi.org/10.1016/j. jand.2014.04.022. Canadian Paediatric Society (CPS). (2017). Screen time and young children. https://www.caringforkids.cps.ca/handouts/screen-time-and-youngchildren. Center on the Developing Child, Harvard University. (2020). ACEs and toxic stress: Frequently asked questions. https://developingchild.harvard.edu/ resources/aces-and-toxic-stress-frequently-asked-questions/. Chen, B., van Dam, R. M., Tan, C. S., et al. (2019). Screen viewing behavior and sleep duration among children aged 2 and below. BMC Public Health, 19(1), 59. https://doi.org/10.1186/s12889-018-6385-6. Critch, J. N., & Canadian Paediatric Society (CPS), Nutrition and Gastroenterology Committee. (2020). School nutrition: Support for providing healthy food and beverage choices in schools. Paediatrics & Child Health, 25(1), 33–38. https://www.cps.ca/en/documents/position/schoolnutrition-support.

Erikson, E. H. (1963). Childhood and society (2nd ed.). Norton. Fowler, J. (1981). Stages of faith: The psychology of human development and the quest for meaning. HarperCollins. Freud, S. (1961). The ego and the id. Ed. and Trans In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 3–66). Hogarth Press (Original work published 1923). Fuller, C., Lehman, E., Hicks, S., et al. (2017). Bedtime use of technology and associated sleep problems in children. Global Pediatric Health, 4. https://doi. org/10.1177/2333794X17736972. Hamblen, J., & Dart Center for Journalism and Trauma. (2016). Media coverage of traumatic events: Research on effects. PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/type/media_coverage_trauma. asp. Health Canada. (2020). Canada’s food guide. Healthy food choices. https://foodguide.canada.ca/en/healthy-food-choices. Hernandez, K., Engler-Stringer, R., Kirk, S., et al. (2018). The case for a Canadian national school food program. Canadian Food Studies, 5(3), 208–229. https://doi.org/10.15353/cfs-rcea.v5i3.260. Holloway, I. W., Dunlap, S., Del Pino, H. E., et al. (2014). Online social networking, sexual risk and protective behaviors: Considerations for clinicians and researchers. Current Addiction Reports, 1(3), 220–228. Karlin, A. M., Goyeneche, N. P., & Murphy, K. P. (2020). Management of musculoskeletal injury. In R. M. Kliegman, J. W. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Kohlberg, L. (1968). Moral development. In D. L. Sills (Ed.), International encyclopedia of the social sciences Macmillan. Marchand, V., & Canadian Paediatric Society, Dietitians of Canada, College of Family Physicians of Canada, & Community Health Nurses of Canada. (2010). Promoting optimal monitoring of child growth in Canada: Using the new WHO growth charts—Executive summary. Paediatrics & Child Health, 15(2), 77–79. Reaffirmed 2018 http://www.cps.ca/documents/position/ child-growth-charts. McLaren, P. J., & Carrington, M. T. (2015). The impact of host genetic variation on infection with HIV-1. Nature Immunology, 16(6), 577–583. https://doi. org/10.1038/ni.3147. Mitrofan, B., Paul, M., Weich, S., et al. (2014). Aggression in children with behavioural/emotional difficulties: Seeing aggression on television and video games. BioMed Central Psychiatry, 14, 287. Piaget, J. (1969). The theory of stages in cognitive development. McGraw-Hill. Steeves, V., McAleese, S., & Brisson-Boivin, K. (2020). Young Canadians in a wired world, phase IV: Talking to youth and parents about online resiliency. MediaSmarts. https://mediasmarts.ca/sites/mediasmarts/files/publicationreport/full/report_ycwwiv_talking_youth_parents_online_resiliency.pdf. Tang, A., Slopen, N., Nelson, C. A., et al. (2018). Catch-up growth, metabolic, and cardiovascular risk in post-institutionalized Romanian adolescents. Pediatric Research, 84(6), 842–848. https://doi.org/10.1038/s41390-0180196-4. Williams, R. C., Biscaro, A., Clinton, J., et al. (2019). Relationships matter: How clinicians can support positive parenting in the early years? Paediatrics & Child Health, 24(5), 340–347. Zemel, B. S., Pipan, M., Stallings, V. A., et al. (2015). Growth charts for children with Down syndrome in the U.S. Pediatrics, 136(5), e1204–e1211. https:// doi.org/10.1542/peds.2015-1652.

ADDITIONAL RESOURCES Dietitians of Canada (A comprehensive resource for healthy nutrition programs and safe food supplies; a tracking system is available that can help individuals make healthy choices): http://www.dietitians.ca. MediaSmarts: Canada’s Centre for Digital and Media Awareness (formerly Media Awareness Network): http://www.mediasmarts.ca/. Motion Picture Association—Film Ratings. https://www.motionpictures.org/ film-ratings/.

UNIT 9 Assessment of the Child and Family

33 Pediatric Health Assessment Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. State the components of a complete health history. 2. List three areas that are evaluated as part of a nutritional assessment. 3. Identify developmental assessment tools that can be used to perform a developmental assessment. 4. Prepare a child for a physical examination on the basis of their developmental needs.

5. Perform a comprehensive physical examination in a sequence appropriate to the child’s age. 6. Recognize expected findings for children at various ages. 7. Record the physical examination according to the head-to-toe format.

Pediatric health assessment is a critical skill that every nurse must perform in order to accurately assess the level of health of a child. Building a rapport and trust with the child and the family is key to gathering precise information that will allow the nurse to analyze the data (see Chapter 30 for communication techniques to develop trust). Health assessment of a child and family consists of many different components. To formulate the assessment the nurse collects information from many sources, including direct dialogue with the child and family, medical records, other practitioners, and other health-related sources.

history taking provides an opportunity to ask about such information and to help them feel more comfortable. One of the important elements of identifying information is the informant, the person(s) who furnish the information. The nurse should record (1) who the person is (child, parent, or other), (2) an impression of reliability and willingness to communicate, and (3) any special circumstances, such as the use of an interpreter or conflicting answers by more than one person.

Presenting Health Issue or Concern

HISTORY TAKING The format used for history taking may be (1) direct, where the nurse asks for information via direct interview with the child, parent(s), or both, or (2) indirect, where the patient or authorized family member supplies the information by completing some type of questionnaire. The direct method is superior to the indirect approach or a combination of both. However, in view of time constraints of health assessments the direct approach is not always practical. If the direct approach cannot be used, the parents’ written responses should be reviewed and the parents questioned regarding any unusual answers. The categories listed in Box 33.1 encompass children’s current and past health status and information about their psychosocial environment.

The presenting health concern is the specific reason for the child’s visit to the clinic, office, or hospital. It may be viewed as the theme, with the present illness providing the description of the health concern. The health issue is elicited by asking open-ended, neutral questions, such as “What seems to be the matter?” “How may I help you?” or “Why did you come here today?” Labelling-type questions, such as “How did you get sick?” and wording such as “What is the problem?” should be avoided; it is possible that the reason for the visit is not an illness or problem. Occasionally, it is difficult to isolate one symptom or condition as the health issue because the parent may identify many. In this situation, the nurse should be as specific as possible when asking questions. For example, asking informants to state which one issue or symptom prompted them to seek help now may help them focus on the most immediate concern.

Identifying Information

Present Illness. The history of the present illness is a narrative of the

Much of the identifying information may already be available from other recorded sources. However, if the parent and child seem anxious,

health issue from its earliest onset through its progression to the present. The term illness is used in its broadest sense to denote any concern

Performing a Health History

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Assessment of the Child and Family

Outline of a Pediatric Health History

Identifying information • Name • Address • Telephone and email address • Birth date and place • Gender • Religion • Date of interview • Informant Presenting health issue—To establish the major specific reason for the child’s and parents’ seeking professional health attention History of present illness (PI)—To obtain all details related to the chief health concern Past history (PH)—To elicit a profile of the child’s previous illnesses, injuries, or operations • Birth history (pregnancy, labour and birth, perinatal history) • Previous illnesses, injuries, or operations • Allergies • Current medications • Immunizations • Growth and development • Habits Family medical history—To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child’s health, such as smoking and chemical use Family history—To develop an understanding of the child as an individual and as a member of a family and a community • Family composition

of a physical, emotional, or psychosocial nature. It is actually a history of the health issue. The four major components are (1) the details of onset, (2) a complete interval history, (3) the present status, and (4) the reason for seeking help now. The focus of the present illness is on all factors relevant to the main issue, even if they have disappeared or changed during the onset, interval, and present. Analyzing a symptom. Because pain is often the most characteristic symptom denoting the onset of a physical condition, it is used as an example for analysis of a symptom. Assessment includes type, location, severity, duration, and influencing factors (see Guidelines box: Analyzing the Symptom: Pain and also Chapter 34, Pain Assessment).

GUIDELINES Analyzing the Symptom: Pain Type Be as specific as possible. With young children, asking the parents how they know the child is in pain may help describe its type, location, and severity. For example, a parent may state, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help.” Help older children describe the “hurt” by asking them if it is sharp, throbbing, dull, or stabbing. Record whatever words they use in quotes. Location Be specific. “Stomach pains” is too general a description. Children can better localize the pain if they are asked to “point with one finger to where it hurts” or to “point to where Mommy or Daddy would put a Band-Aid.” Determine if the pain radiates, by asking, “Does the pain stay there or move? Show me with your finger where the pain goes.”

• Home and community environment • Occupation and education of family members • Cultural and religious traditions • Family function and relationships Review of systems (ROS)—To elicit information concerning any potential health issue • General • Integument • Head • Eyes • Ears/nose/mouth/throat • Neck • Chest • Respiratory • Cardiovascular • Gastrointestinal • Genitourinary • Gynecological • Musculoskeletal • Neurological • Endocrine Psychosocial history—To elicit information about the child’s self-concept Sexual history—To elicit information about the child’s sexual concerns or activities and any pertinent data regarding adults’ sexual activity that influences the child Nutritional assessment—To elicit information on the adequacy of the child’s nutritional intake and needs • Dietary intake • Clinical examination

Severity Severity is best determined by finding out how it affects the child’s usual behaviour. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. Assess pain intensity using a rating scale, such as a numeric or Wong-Baker FACES® Pain Rating Scale (see Table 34.2). Duration Include the duration, onset, and frequency of the pain. Describe this in terms of activity and behaviour, such as “pain reported to last all night, child refused to sleep and cried intermittently.” Influencing Factors Include anything that causes a change in the type, location, severity, or duration of the pain: (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down), and (5) associated events (meals, stress, coughing).

History The history contains information relating to all previous aspects of the child’s health status and concentrates on several areas that are ordinarily passed over in the history of an adult. Since a great deal of information is included in this section, a combination of open-ended and fact-finding questions should be used. For example, interviewing for each section can start with an open-ended statement, such as “Tell me about your child’s birth,” to provide the informants with the opportunity to relate what they think is most important. Fact-finding questions related to specific details can be asked whenever necessary to focus the interview on certain topics.

CHAPTER 33

Birth History. The birth history includes all data concerning (1) the mother’s health during pregnancy, (2) the labour and birth, and (3) the newborn’s condition immediately after birth. Since prenatal influences have significant effects on a child’s physical and emotional development, a thorough investigation of the birth history is essential. Because parents may question what relevance pregnancy and birth have on the child’s present condition, particularly if the child is past infancy, the nurse needs to explain why such questions are included. An appropriate statement may be “I will be asking you some questions about your pregnancy and ____’s [refer to child by name] birth. Your answers will give me a more complete picture of your child’s overall health.” Because emotional factors also affect the outcome of pregnancy and the subsequent parent–child relationship, it is important to investigate (1) concurrent crises during pregnancy and (2) presence of perinatal mood disorders (see Chapter 24). It is best to approach the topic of feelings about pregnancy and crisis through indirect questioning. Parents should be encouraged to disclose this information by asking openended questions such as “Tell me about your stresses or emotions during pregnancy and after the birth.” Parents can choose to explore such statements with further explanations or, for the moment, may not be able to reveal related feelings. If the parents or parent remains silent, this topic can be revisited later in the interview.

Previous Illnesses, Injuries, and Operations. When inquiring about past illnesses, the nurse should begin with a general statement, such as “What other illnesses has your child had?” Since parents are most likely to recall serious health conditions, they should be asked specifically about colds; earaches; and childhood diseases such as measles, rubella (German measles), chicken pox, mumps, pertussis (whooping cough), diphtheria, tuberculosis, scarlet fever, strep throat, tonsillitis, or allergic manifestations. In addition to illnesses, the nurse needs to ask about injuries that required medical intervention, operations, and any other reason for hospitalization, including the dates of each incident. It is important to focus on injuries such as accidental falls, poisoning, choking, or burns, since these may be potential areas for parental guidance.

Allergies. It is important to ask about commonly known allergic disorders, such as hay fever and asthma; unusual reactions to medications, food, or latex products; and reactions to other contact agents, such as poisonous plants, animals, household products, or fabrics. If asked appropriate questions, most people can give reliable information about medication reactions (see Guidelines box: Taking an Allergy History).

GUIDELINES Taking an Allergy History • Has your child ever taken any medications or tablets that have disagreed with them or caused an allergic response? If yes, can you remember the name(s) of these medications? • Can you describe the reaction? • Was the medication taken by mouth (as a tablet or syrup), or was it an injection? • How soon after starting the medication did the reaction happen? • How long ago did this happen? • Did anyone tell you it was an allergic reaction, or did you decide for yourself? • Has your child ever taken this medication, or a similar one, again? If yes, did your child experience the same symptoms? • Have you told the doctors or nurses about your child’s reaction or allergy? • Has your child had allergy testing?

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NURSING ALERT Information about allergic reactions to medications or other products is essential. Failure to document a serious reaction places the child at risk if the medication is given.

Current Medications. The nurse should inquire about current medication regimens, including prescription medications and over-thecounter medications, such as antipyretics, vitamins, minerals, herbal remedies, or supplements, and the use of illegal or illicit drugs (appropriate to age). All medications should be listed, including name, dose, schedule, duration, and reason for administration. Often parents are unaware of the medication’s actual name. Whenever possible, parents should bring the containers with them to the next visit, or the nurse can ask for the name of the pharmacy and call for a list of all the child’s recent prescription medications. However, this list will not include over-the-counter medications or herbal remedies, which are important to know. Immunizations. A record of all immunizations is essential. Since many parents are unaware of the exact name and date of each immunization, the most reliable source of information is a private practitioner’s record or an “Immunization Record” (either on paper or on an online version) provided to the family to keep and updated after each vaccine. All immunizations and “boosters” will be listed, stating (1) the name of the specific disease, (2) the number of injections, (3) the dosage (sometimes lesser amounts are given if a reaction is anticipated), (4) the ages when administered, and (5) the occurrence of any reaction following the immunization. See Chapter 35 for more information on specific age-group immunizations.

Growth and Development. The most important previous growth patterns to record are the following: • Approximate weight at 1 week, 2 months, 4 months, 6 months, 12 to 13 months, and 18 months, then yearly (Greig et al., 2016; Rourke et al., 2020) • Approximate length at 1 week, 2 months, 4 months, 6 months, 12 to 13 months, and 18 months, then yearly (Greig et al., 2016; Rourke et al., 2020) • Dentition, including age of onset, number of teeth, and symptoms during teething • Developmental milestones include the following: • Age of holding up head steadily • Age of sitting alone without support • Age of walking without assistance • Age of saying first words with meaning • Present grade in school • Scholastic grades • If the child has a best friend • Interactions with other children, peers, and adults • Family income insecurity • Presence of bullying • Mental health concerns • Substance use The nurse should use specific and detailed questions when inquiring about each developmental milestone. For example, “sitting up” can mean many different activities, such as sitting propped up, sitting in someone’s lap, sitting with support, sitting up alone but in a hyperflexed position for assisted balance, or sitting up unsupported with the back slightly rounded. A clue to misunderstanding of the requested

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BOX 33.2

Assessment of the Child and Family

Habits to Explore During a Health

Interview • Behaviour patterns such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals (“security” blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes) • Activities of daily living, such as the hour of going to sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting • Unusual disposition; response to frustration • Use of alcohol, drugs, coffee, or tobacco

activity may be an unusually early age of achievement. See Developmental Assessment tools later in this chapter.

Habits. Habits are an important area to explore during the interview (Box 33.2). Parents frequently express concerns during this part of the history. The nurse needs to encourage their input, by saying, “Please tell me any concerns you have about your child’s habits, activities, or development.” Any concerns expressed should be investigated further. One of the most common concerns relates to sleep. Many children develop a normal sleep pattern, and all that is required during the assessment is a general overview of nighttime sleep and nap schedules. However, a number of children also develop sleep challenges (see Sleep in Chapter 35). When issues with sleep do occur, a more detailed sleep history is required to guide appropriate interventions. Habits related to misuse of substances apply primarily to older children and adolescents. If a youngster admits to smoking, drinking, or using drugs, they should be asked about the quantity and frequency. Questions such as “Many kids your age are experimenting with drugs and alcohol; have you ever had any drugs or alcohol?” may give more reliable data than questions such as “How much do you drink?” or “How often do you drink or take drugs?” Clarify that “drinking” includes all types of alcohol, including beer and wine. When quantities such as a “glass” of wine or a “can” of beer are given, the size of the container needs to be determined. If older children deny use of substances, they should be asked about past experimentation. Asking, “You mean you never tried to smoke or drink?” implies that the nurse expects some such activity, and the youngster may be more inclined to answer truthfully. It is important to be aware of the confidential nature of such questioning, the adverse effect that the parents’ presence may have on the adolescent’s willingness to answer, and the fact that self-reporting may not be an accurate account of substance use.

Family Health History The family health history is used primarily for discovering the potential existence of hereditary or familial diseases in the parents and child. In general, it is confined to first-degree relatives (parents, siblings, grandparents, and immediate aunts and uncles). Information for each family member includes age, state of health if living, cause of death if deceased, and any evidence of the following conditions: early heart disease, stroke, sudden death from unknown cause, hypercholesterolemia, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergies, asthma, seizures, tuberculosis, abnormal bleeding, sickle cell disease, cognitive impairment, hearing or visual deficits, and mental health disorders such as depression or psychosis, or emotional disorders. The nurse needs to confirm the accuracy of the reported disorders by inquiring about the symptoms, course, treatment, and sequelae of each diagnosis.

Geographic Location. One of the important areas to explore when assessing the family health history is geographic location, including the patient’s birthplace and travel to different areas in or outside of the country, for identification of possible exposure to endemic diseases. Relevant information includes current and past housing, whether they rent or own, whether they reside in an urban or rural location, the age of the home, and whether there are significant threats such as moulds or pests within the housing structure. Although the primary interest focuses on the child’s temporary residence in various localities, the nurse should also inquire about close family members’ travel, especially travel during tours of military service or business trips. Children are particularly susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases, such as those from mosquitoes or ticks in warm and humid or heavily wooded regions.

Family Structure. Assessment of the family, both its structure and function, is an important component of the history-taking process. Because the quality of the relationship between the child and family members is a major factor in emotional and physical health, family assessment is discussed here separately and in greater detail apart from the more traditional health history. Family assessment is the collection of data about the family’s composition and the relationships among its members. In its broadest sense, family refers to all those individuals who are considered by the patient to be significant to the nuclear unit, including relatives, friends, and social groups (e.g., school and church). Although family assessment is not family therapy, it can be therapeutic. Involving family members in the discussion of family characteristics and activities can provide insight into family dynamics and relationships. See Chapter 2 for more discussion on family assessment models. Because of the time involved in performing an in-depth family assessment as presented here, the nurse needs to be selective in deciding when knowledge of family function may facilitate nursing care (see Guidelines box: Initiating a Comprehensive Family Assessment). During brief contacts with families, a full assessment is not appropriate; screening with one or two questions from each category may reflect the health of the family system or the need for additional assessment.

GUIDELINES Initiating a Comprehensive Family Assessment Perform a comprehensive assessment in the following situations: • Children receiving comprehensive well-child care • Children experiencing major stressful life events (e.g., chronic illness, disability, parental divorce, death of a family member) • Children requiring extensive home care • Children with developmental delays • Children with repeated accidental injuries and those with suspected child abuse • Children with behavioural or physical issues that could be caused by family dysfunction

The most common method of eliciting information on the family structure is to interview family members. The principal areas of concern (Box 33.3) are family composition, home and community environment, occupation and education of family members, and cultural and religious traditions.

NURSING ALERT In assessing family composition, it is sometimes difficult to ascertain the status of the adult relationships. If the parent fails to mention the other parent, ask, “Is there another parent in the child’s life?” Avoid saying “husband” or “wife” because this assumes that only marital relationships exist and also assumes heterosexuality.

BOX 33.3

Family Assessment Interview

General Guidelines Schedule the interview with the family at a time that is most convenient for all parties; include as many family members as possible; clearly state the purpose of the interview. Begin the interview by asking each person’s name and their relationship to one another. Restate the purpose of the interview and the objective. Keep the initial conversation general to put members at ease and to learn the “big picture” of the family. Identify major concerns and reflect these back to the family to be certain that all parties receive the same message. Terminate the interview with a summary of what was discussed and a plan for additional sessions, if needed. Structural Assessment Areas Family Composition Immediate members of the household (names, ages, and relationships) Significant extended family members Previous marriages, separations, death of spouses, or divorces Home and Community Environment Type of dwelling, number of rooms, occupants Sleeping arrangements Number of floors, accessibility of stairs and elevators Adequacy of utilities Safety features (fire escape, smoke and carbon monoxide detectors, guardrails on windows, use of car restraint) Environmental hazards (e.g., chipped paint, poor sanitation, pollution, heavy street traffic) Availability and location of health care facilities, schools, play areas Relationship with neighbours Recent crises or changes in home Child’s reaction and adjustment to recent stresses Occupation and Education of Family Members Types of employment Work schedules Work satisfaction Exposure to environmental or industrial hazards Sources of income and adequacy Effect of illness on financial status Highest degree or grade level attained Cultural and Religious Traditions Religious beliefs and practices Cultural and ethnic beliefs and practices Language spoken in home Assessment questions include the following: • Does the family identify with a particular religious or ethnic group? Are both parents from that group? • How is religious or ethnic background part of family life? • What special religious or cultural traditions are practised in the home (e.g., food choices and preparation)? • Where were family members born, and how long have they lived in this country? • What language does the family speak most often? • Do they speak and understand English? • What do they believe causes health or illness? • What religious or ethnic beliefs influence the family’s perception of illness and its treatment? • What methods are used to prevent or treat illness? • How does the family know when a health issue needs medical attention? • Whom does the family contact when a member is ill? • Does the family rely on cultural or religious healers or remedies? If so, ask them to describe the type of healer or remedy.

• Whom does the family go to for support (clergy, medical healer, relatives)? • Does the family experience discrimination because of their race, beliefs, or practices? Ask them to describe. Functional Assessment Areas Family Interactions and Roles Interactions refer to ways in which family members relate to each other. The chief concern is the amount of intimacy and closeness among the members, especially spouses. Roles refer to behaviours of people as they assume a different status or position. Observations include the following: • Family members’ responses to each other (cordial, hostile, cool, loving, patient, short tempered) • Obvious roles of leadership versus submission • Support and attention shown to various members Assessment questions include the following: • What activities does the family perform together? • Whom do family members talk to when something is bothering them? • What are members’ household chores? • Who usually oversees what is happening with the children, such as at school or for health care? • How easy or difficult is it for the family to change or accept new responsibilities for household tasks? Power, Decision Making, and Problem Solving Power refers to individual member’s control over others in the family; it is manifested through family decision making and problem solving. The chief concern is clarity of boundaries of power between parents and children. One method of assessment involves offering a hypothetical conflict or problem, such as a child failing school, and asking the family how they would handle this situation. Assessment questions include the following: • Who usually makes the decisions in the family? • If one parent makes a decision, can the child appeal to the other parent to change it? • What input do children have in making decisions or discussing rules? • Who makes and enforces the rules? • What happens when a rule is broken? Communication Communication is concerned with clarity and directness of communication patterns. Further assessment includes periodically asking family members if they understood what was just said and to repeat the message. Observations include the following: • Who speaks to whom? • If one person speaks for another or interrupts • If members appear uninterested when certain individuals speak • If there is agreement between verbal and nonverbal messages Assessment questions include the following: • How often do family members wait until others are through talking before “having their say”? • Do parents or older siblings tend to lecture and preach? • Do parents tend to “talk down” to the children? Expression of Feelings and Individuality Expressions are concerned with personal space and freedom to grow with limits and structure needed for guidance. Observing patterns of communication offers clues to how freely feelings are expressed. Assessment questions include the following: • Is it OK for family members to get angry or sad? • Who gets angry most of the time? What do they do? • If someone is upset, how do other family members try to comfort this person? • Who comforts specific family members? • When someone wants to do something, such as try out for a new sport or get a job, what is the family’s response (offer assistance, discouragement, or no advice)?

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Psychosocial History The traditional medical history includes a personal and social section that concentrates on children’s personal status, such as school adjustment and any unusual habits, and the family and home environment. Since several personal aspects are covered under development and habits, only those issues related to children’s ability to cope and their self-concept are presented here. Through observation, the nurse can obtain a general idea of how confident children are in dealing with others, answering questions, and coping with new situations. It is important to observe the parent–child relationship for the types of messages sent to children about their coping skills and self-worth. Do the parents treat the child with respect, focusing on strengths, or is the interaction one of constant reprimands, with emphasis on weaknesses and faults? Do the parents help the child learn new coping strategies or support the ones the child uses? Parent–child interactions also convey messages about body image. Do the parents label the child and body parts, such as “bad boy,” “skinny legs,” or “ugly scar”? Do the parents handle the child gently, using soothing touch to calm an anxious child, or do they treat the child roughly, using slaps or restraint to force compliance? If the child touches certain parts of the body, such as the genitalia, do the parents make comments that suggest a negative connotation? With older children many of the communication strategies discussed earlier in the chapter are useful in eliciting more definitive information about their coping and self-concept. Children can write down five things they like and dislike about themselves. The nurse can use

sentence-completion statements, such as “The thing I like best (or least) about myself is ____________,” “If I could change one thing about myself, it would be ____________,” or “When I am scared, I ____________.”

Mental Health Screening. During the interview and history taking, the nurse may become concerned about potential psychosocial or mental health issues in the child or family being assessed. The Canadian Paediatric Society (CPS) has recommended preliminary mental health screening tools that are available that can help the nurse assess potential concerns in areas such as sleep habits, social skills, family relationships, and learning difficulties. More detailed information on mental health concerns in children is provided in Chapter 55.

Review of Systems The review of systems is a specific review of each body system, following an order similar to that of the physical examination (see Guidelines box: Review of Systems). Often the history of the present illness provides a complete review of the system involved in the chief health concern. Since asking questions about other body systems may appear unrelated and irrelevant to the parents or child, the questioning should be preceded by an explanation of why the data are needed (similar to the explanation concerning the relevance of the birth history) and the parents reassured that the child’s main health concern has not been forgotten.

GUIDELINES Review of Systems General—Overall state of health, fatigue, recent or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living Integument—Pruritus, pigment or other colour changes, acne, eruptions, rashes (location), tendency for bruising, petechiae, excessive dryness, general texture, disorders or deformities of nails, hair growth or loss, hair colour change (for adolescents, use of hair dyes or other potentially toxic substances, such as hair straighteners) Head—Headaches, dizziness, injury (specific details) Eyes—Visual issues (behaviours indicative of blurred vision, such as bumping into objects, clumsiness, sitting close to television, holding a book close to the face, writing with head near the desk, squinting, rubbing the eyes, bending head in an awkward position), cross-eyes (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last vision exam Ears/nose/mouth/throat: Earaches, ear discharge, evidence of hearing impairment (ask about behaviours such as the need to repeat requests, loud speech, inattentive behaviour), results of any previous auditory testing, nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell, mouth breathing, gum bleeding, number of teeth and pattern of eruption/loss, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to the dentist (especially if temporary dentition is complete), sore throats, difficulty swallowing, choking, hoarseness or other voice irregularities Neck—Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses Chest—Breast enlargement, discharge, masses, enlarged axillary nodes Respiratory—Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty breathing, sputum production,

infections (pneumonia, tuberculosis), date of last chest X-ray examination, skin reaction from tuberculin testing Cardiovascular—Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, tachycardia, syncope, edema Gastrointestinal (questions in regard to appetite, food tolerance, and elimination habits are asked elsewhere)—Nausea, vomiting (not associated with eating, may be indicative of brain tumour or increased intracranial pressure), jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change of colour, diarrhea, or constipation) Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odour to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis Gynecological—Menarche, date of last menstrual period, regularity or difficulties with menstruation, vaginal discharge, pruritus, if sexually active, type of contraception, sexually transmitted infection and type of treatment Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level Neurological—Seizures, tremors, dizziness, memory impairment, general affect, fears, nightmares, speech issues, any unusual habits Endocrine—Intolerance to weather changes, excessive thirst or urination, excessive sweating, salty taste to skin, signs of early or late puberty Hematological/lymphatic: Easy bruising or bleeding, anemia, date and result of last blood count, blood transfusions, swollen or painful lymph nodes (cervical, axillary, inguinal) Allergic/immunological: Allergic responses, anaphylaxis, eczema, rhinitis, unusual sneezing, autoimmunity, recurrent infections, infections associated with unusual complications Mental health: General affect, anxiety, depression, mood changes, hallucinations, attention span, tantrums, behaviour issues, suicidal ideation, substance use

CHAPTER 33 The review of a specific system begins with a broad statement such as “How has your child’s general health been?” or “Has your child had any problems with his eyes?” If the parent states that the child has had difficulties with some body function, this should be pursued with an encouraging statement, such as “Tell me more about that.” If the parent denies any concerns, the nurse can query for specific symptoms: “No headaches, bumping into objects, or squinting?” If the parent reconfirms the absence of such symptoms, the nurse should record positive statements in the history, such as “Parent denies headaches, bumping into objects, or squinting.” In this way, anyone who reviews the health history is aware of exactly what symptoms were investigated.

Reproductive Health History. The sexual history is an essential component of adolescents’ health assessment. The history uncovers areas of concern related to sexual activity, alerts the nurse to circumstances that may indicate screening for sexually transmitted infections (STIs) or testing for pregnancy, and provides information related to the need for sexual counselling, such as safer sex practices. Guidelines for anticipatory guidance topics for parents and adolescents are found in Box 33.4. One approach to initiating a conversation about sexual concerns is to begin with a history of peer interactions. Open-ended statements such as “Tell me about your social life” or “Who are your closest friends?” generally lead into a discussion of dating and sexual issues. To probe further, the nurse can include questions about the adolescent’s attitudes on such topics as sex education, having an intimate friend or partner, living together, and premarital sex. Such questions should be phrased to reflect concern rather than judgement or criticism of sexual practices. In any conversation regarding sexual history, it is important to be aware of the language used in either eliciting or conveying sexual information. For example, the nurse should avoid asking whether the adolescent is “sexually active,” because this term is broadly defined. “Are you having sex with anyone?” is probably the most direct and best understood question. Since same-sex experimentation may occur, all sexual contacts should be referred to in nongender terms, such as “anyone” or “partners,” rather than “girlfriends” or “boyfriends.” A detailed account of sexual partners is needed if the patient has a history of, displays any symptoms of, or asks for treatment of an STI. A difficult but necessary part of the interview is to determine BOX 33.4

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the sites of possible infection. Since sexual diseases can be contracted in any of the body orifices, the adolescent should be informed that an STI can be acquired without visible signs of disease at nongenital sites.

Performing a Nutritional Assessment Dietary Intake. Knowledge of the child’s dietary intake is an essential component of a nutritional assessment. However, it is also one of the most difficult factors to assess. Individuals’ recall of food consumption, especially amounts eaten, is frequently unreliable. The food intake history of children and adolescents is prone to reporting error, mostly in the form of underreporting. Also, people from different cultures may have difficulty adequately describing the types of food they eat. Despite these obstacles, it is important to include a dietary evaluation in the child’s assessment. Specific questions used to conduct a nutritional assessment are listed in Box 33.5. Every nutritional assessment should begin with a dietary history. The exact questions used to elicit a dietary history vary with the child’s age. In general, the younger the child, the more specific and detailed the history should be. The overview elicited from the dietary history can be helpful in evaluating food frequency records. The history should also be concerned with food security and cultural factors that influence food selection and preparation (see Cultural Awareness box: Food Practices).

CULTURAL AWARENESS Food Practices Because cultural practices are prevalent in food preparation, the kinds of questions asked and the judgements made during the assessment need to be considered carefully. For example, many cultures eat food that is different from food listed in Canada’s Food Guide (see Appendix A).

The most common and probably easiest method of assessing daily intake is the 24-hour recall. The child or parent recalls every item eaten in the past 24 hours and the approximate amounts. The 24-hour recall is most beneficial when it represents a typical day’s intake. Some of the difficulties with a daily recall are the family’s inability to remember

Anticipatory Guidance—Sexuality

Ages 12 to 14 Years Have the adolescent identify a supportive adult to discuss sexuality issues and concerns with. Discuss advantages of delaying sexual activity and provide an opportunity to practice saying no. Discuss making responsible decisions regarding normal sexual feelings and activity. Discuss roles of gender, peer pressure, and the media in sexual decision making. Discuss contraceptive options (advantages and disadvantages). Provide education regarding sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection; clarify risks, and discuss the use of condoms. Discuss abuse prevention: avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defence. Have the adolescent clarify values, needs, and the ability to be assertive. If the adolescent is sexually active, discuss the use of condoms and contraceptive options.

Have a confidential interview with the adolescent (including a sexual history). Discuss the evolution of sexual identity and expression. Ages 15 to 18 Years Clarify values; encourage responsible decision making. Discuss alternatives to intercourse. Discuss “When are you ready for sex?” Discuss consequences of unprotected sex: early pregnancy; STIs, including HIV infection. Discuss negotiating with the partner and barriers to safer sex. If the adolescent is sexually active, discuss the use of condoms and contraceptive options. Emphasize that sex should be safe and pleasurable for both partners. Have a confidential interview with the adolescent. Discuss concerns about sexual identity and expression.

Data from Fonseca, H., Greydanus, D. (2007). Sexuality in the child, teen and young adult: Concepts for the clinician. Primary Care Clinical Office Practice, 34, 275–292; Wright, K. (1997). Anticipatory guidance: Developing a healthy sexuality. Pediatric Annals, 26(2 Suppl.), S142–S144, C3.

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BOX 33.5

Assessment of the Child and Family

Dietary Assessment for a Child

Dietary History What are the family’s usual mealtimes? Do family members eat together or at separate times? Who does the family grocery shopping and meal preparation? Does the child help with food preparation? How much money is spent to buy food each week? How are most foods prepared—baked, broiled, fried, other? How often does the family or child eat out? • What kinds of restaurants do they go to? • What kinds of food does the child typically eat at restaurants? Does the child eat breakfast regularly? Where does the child eat lunch? What are the child’s favourite foods, beverages, and snacks? • What are the average amounts eaten per day? • What foods are artificially sweetened? • What are the child’s snacking habits? • When are sweet foods usually eaten? What special cultural practices are followed? What ethnic foods are eaten? What foods and beverages does the child dislike? How would parents describe the child’s usual appetite (hearty eater, picky eater)? What are the child’s feeding habits (breast, bottle, cup, spoon, eats by self, needs assistance, any special devices)? Does the child take vitamins or other supplements? Do they contain iron or fluoride? Does the child have any known or suspected food allergies? Is the child on a special diet? Has the child lost or gained weight recently? Are there any feeding difficulties (excessive fussiness, spitting up, colic, difficulty sucking or swallowing)? Are there any dental issues or appliances, such as braces, that affect eating?

exactly what was eaten and inaccurate estimation of portion size. To increase accuracy of reporting portion sizes, the use of food models and additional questioning are recommended. In general, this method is most useful in providing qualitative information about the child’s diet. To improve the reliability of the daily recall, the family can complete a food diary by recording every food and liquid consumed for a certain number of days. A 3-day record consisting of 2 weekdays and 1 weekend day is representative for most people. Providing specific charts to record intake can enhance completion of the form. The family should record items immediately after eating.

Clinical Examination of Nutrition. A significant amount of information regarding nutritional deficiencies can be elicited from a clinical examination, especially from assessing the skin, hair, teeth, gums, lips, tongue, and eyes. The hair, skin, and mouth are vulnerable because of the rapid turnover of epithelial and mucosal tissue. Table 33.1 summarizes clinical signs of possible nutritional deficiency or excess. Few are diagnostic for a specific nutrient, and if suspicious signs are found, they must be confirmed with dietary and biochemical data. Generally, the clinical examination does not reveal children’s risk for a deficiency or excess. Anthropometry, an essential parameter of nutritional status, is the measurement of height, weight, head circumference, proportions, skin fold thickness, and arm circumference in young children. Height and head circumference reflect past nutrition, whereas weight, skin fold thickness, and arm circumference reflect present nutritional status,

Is there a family history of cancer, diabetes, heart disease, high blood pressure, or obesity? Additional Questions Regarding Infants What was the infant’s birth weight? When did it double? Triple? Was the infant preterm? Is the mother breastfeeding or have they breastfed their infant? For how long? If formula is used, what is the brand? • When was formula feeding started? • How many millilitres does the infant drink a day? • Is the infant receiving cow’s milk (whole, low fat, skim)? • When was it started? Does the infant receive extra fluids (water, juice)? If the infant takes a bottle to bed at nap time or nighttime, what is in the bottle? At what age did the child start on cereal, meat or other protein sources, vegetables, fruit or juice, finger food, table food? Do the parents make their own baby food or use commercial foods, such as infant cereal? Does the infant take a vitamin or mineral supplement? If so, what type? Has the infant had an allergic reaction to any food(s)? If so, list the foods and describe the reaction. Does the infant spit up frequently; have unusually loose stools; or have hard, dry stools? If so, how often? How often is the infant fed? How would the parents describe their infant’s appetite?

especially of protein and fat reserves. Skin fold thickness is a measurement of the body’s fat content; approximately half the body’s total fat stores are directly beneath the skin. The upper arm muscle circumference is correlated with measurements of total muscle mass. Since muscle serves as the body’s major protein reserve, this measurement is considered an index of the body’s protein stores. Ideally, growth measurements are recorded over time, and comparisons are made regarding the velocity of growth based on previous and present values. Numerous biochemical tests available for assessing nutritional status include analysis of plasma, blood cells, urine, and tissues from liver, bone, hair, and fingernails. Many of these tests are complicated and are not performed routinely. Common laboratory procedures for nutritional status include measurement of hemoglobin, hematocrit, transferrin, albumin, creatinine, and nitrogen. Laboratory values for these tests and more specific nutrient measurements are given in Appendix B.

Evaluation of Nutritional Assessment. After collecting the data needed for a thorough nutritional assessment, the nurse needs to evaluate the findings to plan appropriate counselling. From the data, assessment can be made as to whether the child is malnourished, at risk for becoming malnourished, or well-nourished with adequate reserves or overweight or obese. The Dietary Reference Intakes (DRIs) are a set of four nutrientbased reference values that provide quantitative estimates of nutrient intake for use in assessing and planning dietary intake (Government of Canada, 2006). The specific DRIs include the following:

TABLE 33.1

Clinical Assessment of Nutritional Status

Evidence of Adequate Nutrition

Evidence of Deficient or Excess Nutrition

Deficiency or Excess∗

General Growth Normal weight gain, growth velocity, and head growth for age and gender

Weight loss or poor weight gain, growth failure

Protein, calories, fats, and other essential nutrients, especially vitamin A, pyridoxine, niacin, calcium, iodine, manganese, zinc

Excess weight gain

Excess calories

Sexual development appropriate for age

Delayed sexual development

Excess vitamins A, D

Hardening and scaling

Vitamin A

Seborrheic dermatitis

Excess niacin

Dry, rough, petechiae

Riboflavin

Skin Smooth, slightly dry to touch Elastic and firm Absence of lesions Colour appropriate to genetic background

Delayed wound healing

Vitamin C

Scaly dermatitis on exposed surfaces

Riboflavin, vitamin C, zinc

Wrinkled, flabby

Niacin

Crusted lesions around orifices, especially nares

Protein, calories, zinc

Pruritus

Excess vitamin A, riboflavin, niacin

Poor turgor

Water, sodium

Edema

Protein, thiamine Excess sodium

Yellow tinge (jaundice)

Vitamin B12 Excess vitamin A, niacin

Depigmentation

Protein, calories

Pallor (anemia)

Pyridoxine; folic acid; vitamins B12, C, E (in preterm infants); iron Excess vitamin C, zinc

Hair Lustrous, silky, strong, elastic

Paresthesia

Excess riboflavin

Stringy, friable, dull, dry, thin

Protein, calories

Alopecia

Protein, calories, zinc

Depigmentation

Protein, calories, copper

Raised areas around hair follicles

Vitamin C

Head Even moulding, occipital prominence, symmetrical facial features

Softening of cranial bones, prominence of frontal bones, skull flat and depressed toward middle

Vitamin D

Fused sutures after 18 months

Delayed fusion of sutures

Vitamin D

Hard, tender lumps in occiput

Excess vitamin A

Headache

Excess thiamine

Thyroid enlarged, may be grossly visible

Iodine

Eyes Clear, bright

Hardening and scaling of cornea and conjunctiva

Vitamin A

Good night vision

Night blindness

Vitamin A

Conjunctiva—Pink, glossy

Burning, itching, photophobia, cataracts, corneal vascularization

Riboflavin

Ears Tympanic membrane—Pliable

Calcified (hearing impairment)

Excess vitamin D

Nose Smooth, intact nasal angle

Irritation and cracks at nasal angle

Riboflavin

Neck Thyroid not visible, palpable in midline

Excess vitamin A Mouth Lips—Smooth, moist, darker colour than skin

Fissures and inflammation at corners

Riboflavin

Gums—Firm, coral pink, stippled

Spongy, friable, swollen, bluish red or black, bleed easily

Vitamin C

Mucous membranes—Bright pink, smooth, moist

Stomatitis

Niacin

Glossitis

Niacin, riboflavin, folic acid

Excess vitamin A

Continued

TABLE 33.1

Clinical Assessment of Nutritional Status—cont’d

Evidence of Adequate Nutrition Tongue—Rough texture, no lesions, taste sensation Teeth—Uniform white colour, smooth, intact

Chest In infants, shape almost circular

Evidence of Deficient or Excess Nutrition Diminished taste sensation

Deficiency or Excess Zinc

Brown mottling, pits, fissures

Excess fluoride

Defective enamel

Vitamins A, C, D; calcium; phosphorus

Caries

Excess carbohydrates

Depressed lower portion of rib cage

Vitamin D

In children, lateral diameter increased in proportion to anteroposterior diameter

Sharp protrusion of sternum

Vitamin D

Smooth costochondral junctions

Enlarged costochondral junctions

Vitamins C, D

Breast development—Normal for age

Delayed development

See under General Growth; especially zinc

Cardiovascular System Pulse and blood pressure (BP) within normal limits

Palpitations

Thiamine

Rapid pulse

Potassium

Arrhythmias

Magnesium, potassium

Increased BP

Excess sodium

Decreased BP

Thiamine

Excess thiamine Excess niacin, potassium

Excess niacin Abdomen In young children, cylindrical and prominent

Distended, flabby, poor musculature Prominent, large

Excess calories

In older children, flat

Potbelly, constipation

Vitamin D

Normal bowel habits

Diarrhea

Niacin

Protein, calories

Excess vitamin C Musculoskeletal System Muscles—Firm, well developed, equal strength bilaterally

Constipation

Excess calcium, potassium

Flabby, weak, generalized wasting

Protein, calories

Weakness, pain, cramps

Thiamine, sodium, chloride, potassium, phosphorus, magnesium

Muscle twitching, tremors

Magnesium

Excess thiamine Muscular paralysis

Excess potassium

Spine—Cervical and lumbar curves (double S curve)

Kyphosis, lordosis, scoliosis

Vitamin D

Extremities—Symmetrical; legs straight with minimum bowing

Bowing of extremities, knock-knees

Vitamin D, calcium, phosphorus

Epiphyseal enlargement

Vitamins A, D

Bleeding into joints and muscles, joint swelling, pain

Vitamin C

Thickening of cortex of long bones with pain and fragility, hard tender lumps in extremities

Excess vitamin A

Osteoporosis of long bones

Calcium

Joints—Flexible, full range of motion, no pain or stiffness

Excess vitamin D Neurological System Behaviour—Alert, responsive, emotionally stable Absence of tetany, convulsions

Listless, irritable, lethargic, apathetic (sometimes apprehensive, anxious, drowsy, cognitively delayed, confused)

Thiamine, niacin, pyridoxine, vitamin C, potassium, magnesium, iron, protein, calories

Masklike facial expression, blurred speech, involuntary laughing

Excess manganese

Convulsions

Thiamine, pyridoxine, vitamin D, calcium, magnesium

Excess vitamins A, D; thiamine; folic acid; calcium

Excess phosphorus (in relation to calcium)

∗

Intact peripheral nervous system

Peripheral nervous system toxicity (unsteady gait, numb feet and hands, fine motor clumsiness)

Excess pyridoxine

Intact reflexes

Diminished or absent tendon reflexes

Thiamine, vitamin E

Nutrients listed are deficient unless specified as excess.

CHAPTER 33 Estimated Average Requirement (EAR)—Nutrient intake estimated to meet the requirement of half the healthy individuals (50%) for a specific age and gender group. The EAR is used to examine the possibility of inadequacy. Recommended Dietary Allowance (RDA)—Sufficient to meet the nutrient requirement of nearly all healthy individuals for a specific age and gender group. Dietary intake at or above this level usually has a low probability of inadequacy. Adequate Intake (AI)—Recommended intake level based on estimates of nutrient intake by healthy groups of individuals. Dietary intake at or above this level usually has a low probability of inadequacy. Tolerable Upper Intake Level (UL)—Highest average daily nutrient intake level likely to pose no risk of adverse health effects. As intake increases above the UL, risk of adverse effects increases. Dietary intake above this level usually places an individual at risk for adverse effects from excessive nutrient intake. Another resource for assessing nutrition is Canada’s Food Guide (see Appendix A). The Food Guide is based on current nutritional science and is intended to help individuals make good food choices that promote health and prevent nutrition-related illnesses. When assessing a child’s food intake, it is important to analyze the daily food diary for the variety and amounts of foods suggested in Canada’s Food Guide. For example, if the list includes no vegetables, the nurse can inquire about this rather than assuming that the child dislikes vegetables, since it could be that none were served that day. Also, information should be evaluated in terms of the family’s ethnic practices and financial resources. Further nutritional information is available on the Dietitians of Canada website (see Additional Resources).

DEVELOPMENTAL ASSESSMENT One of the essential components of a complete health appraisal of children includes a developmental surveillance to assess if children are

TABLE 33.2 Type

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achieving their developmental milestones. The surveillance includes assessment of age-appropriate developmental milestones that have been sequentially acquired for gross- and fine-motor, social, emotional, language, and cognitive domains. Milestone ages should be based on the oldest age by which the skill should have been achieved. The Canadian Task Force on Preventive Health Care (2016) recommends against screening for developmental delay using standardized tools in children aged 1 to 4 years with no apparent signs of developmental delay and whose parents and clinicians have no concerns about development. If the parents do have concerns, a variety of standardized developmental screening tools can be used to further assess development in children ages 1 to 4 years. Tools that are commonly used to provide consistent and accurate data across Canada are presented in Table 33.2. Screening tools are designed to quickly and reliably identify whether a child’s developmental level is what is expected for their age and whether the child requires further investigation because of not meeting common developmental levels. They also provide a means of recording objective measurements of present developmental function for future reference. Nurses play a vital role in providing a developmental assessment of children, particularly children with disabilities. The procedures discussed in this section can be administered in a variety of settings, such as home, school, day care centres, hospitals, health care providers’ offices, or clinics. Parents and teachers sometimes complete them as well and the information is analyzed by the practitioner. Most physicians and nurse practitioners perform a developmental screening of some kind during the well-child visits, but it is unknown how many use a consistent, standardized assessment. Often, nurses perform the developmental assessment. The Canadian Task Force on Preventive Care (2016) notes that it is important to achieve a balance between identifying children as developmentally delayed and identifying too many as such (i.e., too many false-positive findings) as the latter scenario can lead to unnecessary stigma, caregiver anxiety, and excess cost. False-negative results, by contrast, can lead to delays in treatment.

Developmental Assessment Screening Tools Description

Physical, Cognitive, and Social Development Assessment Nipissing District Tests 13 critical developmental stages. Developmental Screen The Screen examines a child’s skills in the following areas: • Vision • Hearing • Speech and language • Communication • Gross motor and fine motor • Cognitive • Social/emotional • Self-help

Age Group

Who Performs the Test

1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months, 3 to 6 years

Parent, caregiver, nurse, or physician

Ages and Stages Questionnaires (ASQ)

Assesses a child’s global development: gross motor, fine motor, language functions and social-emotional development, adaptive skills. Screening tool for developmental delay and to identify specific strengths and weaknesses a child may have

4 months to 5 years

Parent, caregiver, nurse, physician, or teacher

Child Developmental Inventory (CDI)

Assesses development in eight areas of functioning, including cognitive and language

15 months to 6 years

Parent, nurse, physician, or teacher

Children’s Sleep Habits Questionnaire

Evaluates sleep on the basis of child’s behaviour within eight different subscales: bedtime resistance, sleep-onset delay, sleep duration, sleep anxiety, night wakenings, parasomnias, sleep-disordered breathing, daytime sleepiness

4 to 10 years

Parent

Continued

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TABLE 33.2

Assessment of the Child and Family

Developmental Assessment Screening Tools—cont’d Who Performs the Test Parent, teacher, or caregiver

Type Conners Early Childhood

Description Assesses a child’s social, emotional, and behavioural development

Age Group 2 to 6 years

HEADSS for Adolescents

Identifies risky behaviours and used for health promotion, such as seat belt, helmet, protective gear use

12 to 18 years

Nurse or physician with the patient

PEDS: Parents’ Evaluation of Developmental Status

Screens for developmental delays in children

Birth to 11 years

Parent or caregiver

Youth Resiliency: Assessing Development Strengths (YR:ADS)

Assesses factors associated with adolescent resilience: parental support/ expectations, peer relationships, community cohesiveness, commitment to learning, school culture, cultural sensitivity, self-control, empowerment, self-concept, social sensitivity

13 to 18 years

Self-report

WHO Growth Charts for Canada

Charts to measure BMI for age and gender and used to assess weight relative to height

Growth chart for males and females, birth to 24 months, 2 to 19 years

Nurse or physician

1 ½ to 5 and 6 to 18 years

Parent, teacher, or patient, depending on the version

Preliminary Mental Health Assessment Achenbach Child Behaviour Provides information on general functioning (e.g., social skills, family Checklists (CBCL) relationships, learning) Pediatric Symptom Checklist

A brief screening questionnaire used by pediatricians and other health care providers to improve recognition and treatment of psychosocial challenges in children

4 years of age and older

Parent and self-report

Child/Adolescent Psychiatry Screen (CAPS)

Initial screening for 18 mental health issues

3 to 21 years

Parent

Weiss Symptom Record

A nonvalidated, comprehensive screening tool for various mental health conditions

5 to 19 years

Parent/teenager or teacher

Weiss Function Impairment Scales (Self-Report and Parent-Report)

A nonvalidated tool, recommended to collect systematic information from patient and parent about various disorders, including learning, developmental, and personality difficulties

14 to 19 years

Parent/teenager

BMI, Body mass index.

More research is needed to investigate the effectiveness of developmental screening tools and that of early intervention treatment of developmental delay. Early diagnosis and intervention may be critical to improving long-term outcomes. Developmental delay affects between 4 and 16% of children and is the leading cause of disability among children younger than 4 years of age in Canada (Limbos et al., 2010). However, only 30% of children with disabilities are identified before starting school (Limbos et al., 2010). Furthermore, it is estimated that up to one quarter of first-grade children have learning, health, and behavioural issues that will interfere with their academic and social performance (Limbos et al., 2010).

HEALTH SUPERVISION GUIDES Children need to have periodic health checkups, conducted by health care providers, in order to optimize their health. These checkups are means of following health patterns, providing preventive care, and making early diagnoses of health issues. Such visits customarily occur at 1 and 2 weeks of age; at 1, 2, 4, 6, 9, 12, and 18 months of age; and subsequently at 1- or 2-year intervals.

Rourke Baby Record The Rourke Baby Record is a guide for health care providers in their health supervision of children in the first 5 years of life (Rourke et al., 2020). The Rourke Baby Record consists of guides for charting wellbaby/child visits, an immunization chart, and resources pages. It also

includes information regarding growth monitoring, assessing nutrition, physical examination, education, and health care advice. The Rourke Baby Record can be used to chart development, child behaviour, parenting resources, immunization, and infectious diseases (see Additional Resources at the end of this chapter for checklists and record forms).

Greig Health Record The Greig Health Record is an evidence-informed health promotion guide for clinicians caring for children and adolescents aged 6 to 17 years (Greig et al., 2016). It provides a template for periodic health visits that is easy to use and is easily adaptable for electronic medical records. Checklist templates are divided into three age ranges: 6 to 9, 10 to 13, and 14 to 17 years (inclusive) (Greig et al., 2016). The checklist templates include sections for weight, height, and body mass index; psychosocial history and development; nutrition; education and advice; specific concerns; examination; an assessment, immunization; and medications. There are resource sheets for each age group with more details to help assess for items such as injury prevention, poverty, child abuse, and bullying (see Additional Resources at the end of this chapter for checklists, resource sheets, and record forms).

GENERAL APPROACHES TOWARD EXAMINING THE CHILD Although the approach to and sequence of the physical examination differs according to the child’s age, the traditional model for physical

CHAPTER 33 assessment, outlined here, can be used for all pediatric age groups and as a baseline for conducting assessments that are more age specific (see Chapter 26 for a detailed discussion of a newborn assessment).

Sequence of the Examination Ordinarily, the sequence for examining patients follows a head-to-toe direction. The main function of such a systematic approach is to provide a general guideline for assessment of each body area to avoid omitting segments of the examination. The standard recording of data also facilitates exchange of information among different health care providers. This orderly sequence is frequently altered to accommodate the child’s developmental needs, although the examination is recorded following the head-to-toe model. Using developmental and chronological age as the main criteria for assessing each body system accomplishes several goals: • Minimizes stress and anxiety associated with assessment of various body parts • Fosters a trusting nurse–child–parent relationship • Allows for maximum preparation of the child • Preserves the essential security of the parent–child relationship, especially with young children • Maximizes the accuracy and reliability of assessment findings

Preparation of the Child Although the physical examination consists of painless procedures, to a child the use of a tight arm cuff, probes in the ears and mouth, pressure on the abdomen, and a cold piece of metal to listen to the chest can be stressful. Therefore, the same considerations discussed in Chapter 44 for preparing children for procedures are followed here. In addition to that discussion, general guidelines related to the examining process are presented in the Guidelines box: Performing a Pediatric Physical Examination.

GUIDELINES Performing a Pediatric Physical Examination Perform the examination in an appropriate, nonthreatening area. • Have the room well lit. • Have room temperature comfortably warm. • Place all strange and potentially frightening equipment out of sight. • Have some toys, dolls, stuffed animals, and games available for the child. • If possible, have rooms decorated and equipped for different-age children. • Provide privacy, especially for school-age children and adolescents. Provide time for play and becoming acquainted. Observe behaviours that signal the child’s readiness to collaborate: • Talking to the nurse • Making eye contact • Accepting the offered equipment • Allowing physical touching • Choosing to sit on the examining table rather than the parent’s lap If signs of readiness are not observed, use the following techniques: • Talk to the parent while essentially “ignoring” the child; gradually focus on the child or a favourite object, such as a doll. • Make complimentary remarks about the child, such as appearance, dress, or a favourite object. • Tell a funny story or play a simple magic trick. • Have a nonthreatening “friend” available, such as a hand puppet to “talk” to the child for the nurse (see Figure 33.21, A). If the child refuses to assist, use the following techniques:

Pediatric Health Assessment

779

• Assess reason for behaviour; consider that a child who is unduly afraid may have had a traumatic experience. • Try to involve the child and parent in the process. • Avoid prolonged explanations about the examining procedure. • Use a firm, direct approach regarding expected behaviour. • Perform the examination as quickly as possible. • Have an attendant gently restrain the child. • Minimize any disruptions or stimulation. • Limit the number of people in the room. • Use an isolated room. • Use a quiet, calm, confident voice. Begin the examination in a nonthreatening manner for young children or children who are fearful: • Use activities that can be presented as games, such as the test for cranial nerves (see Table 33.3) or parts of developmental screening tests. • Use approaches such as “Simon Says” to encourage the child to make a face, squeeze a hand, stand on one foot, and so on. • Use the paper-doll technique: 1. Lay the child supine on an examining table or floor that is covered with a large sheet of paper. 2. Trace around the child’s body outline. 3. Use body outline to demonstrate what will be examined, such as drawing a heart and listening with a stethoscope, before performing the activity on the child. If several children in the family will be examined, begin with the child who is most willing to be examined to model desired behaviour. Involve the child in the examination process: • Provide choices, such as sitting on the table or in the parent’s lap. • Encourage the child to handle or hold equipment. • Encourage the child to use equipment on a doll, family member, or examiner. • Explain each step of the procedure in simple language. Examine the child in a comfortable and secure position: • Sitting in a parent’s lap • Sitting upright if in respiratory distress Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions: • Alter sequence to accommodate needs of different-age children (see Table 33.3). • Examine painful areas last. • In an emergency situation, examine vital functions (airway, breathing, and circulation) and injured area first. Reassure the child throughout examination, especially about bodily concerns that arise during puberty. Discuss findings with the family (if appropriate) at the end of the examination. Praise the child for their assistance during the examination; give a reward such as a small toy or sticker.

The physical examination should be as pleasant as possible as well as educational. The paper-doll technique is a useful approach to teaching children about the body part that is being examined (Figure 33.1). At the conclusion of the visit, the child can bring home the paper doll as a memento. Table 33.3 summarizes guidelines for positioning, preparing, and examining children at various ages. Because no child fits precisely into one age category, it may be necessary to vary the approach after a preliminary assessment of the child’s developmental achievements and needs. Even with the best approach, many toddlers find the procedure difficult and are inconsolable for much of the physical examination. However, some seem intrigued by the new surroundings and unusual equipment and respond more like preschoolers than toddlers. Likewise,

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TABLE 33.3

Assessment of the Child and Family

Age-Specific Approaches to Physical Examination of Children

Position Infant Before able to sit alone—Supine or prone, preferably in parent’s lap; before 4–6 months, can place on examining table After able to sit alone—Sitting in parent’s lap whenever possible; if on table, place with parent in full view.

Toddler Sitting or standing on or by parent Prone or supine in parent’s lap

Preschool Child Prefer standing or sitting Usually most helpful prone or supine Prefer parent’s closeness

School-Age Child Prefer sitting Helpful in most positions Younger child prefers parent’s presence. Older child may prefer privacy.

Adolescent Same as for school-age child Offer option of parent’s presence.

Sequence

Preparation

If quiet, auscultate heart, lungs, abdomen. Record heart and respiratory rates. Palpate and percuss same areas. Proceed in usual head-to-toe direction. Perform traumatic procedures last (eyes, ears, mouth [while crying]). Elicit reflexes as body part is examined. Elicit Moro reflex last.

Completely undress infant if room temperature permits. Leave diaper on male infant. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft, gentle voice. Use pacifier (with parent’s permission) or feeding if necessary. Enlist parent’s aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.

Inspect body area through play: “count fingers,” “tickle toes.” Use minimum physical contact initially. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic procedures last (same as for infant).

Have parent remove outer clothing. Remove child’s underwear as body part is examined. Encourage child to inspect equipment; demonstrating use of equipment is usually ineffective. Perform procedures quickly if child has difficulty cooperating. Use restraint when appropriate; request parent’s assistance. Talk about examination; use short phrases. Praise for assisting.

Proceed in head-to-toe direction unless child is having difficulty with examination. If having difficulty, proceed as with toddler.

Request self-undressing. Encourage child to wear underpants if shy. Offer equipment for inspection; briefly demonstrate use. Make up story about procedure (e.g., “I’m seeing how strong your muscles are” [blood pressure]). Use paper-doll technique. Give choices when possible. Use positive statements (e.g., “Open your mouth”).

Proceed in head-to-toe direction. May examine genitalia last in older child

Respect need for privacy. Request self-undressing. Encourage to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing. Teach about body function and care.

Same as older school-age child May examine genitalia last

Encourage to undress in private. Give gown. Expose only area to be examined. Respect need for privacy. Explain findings during examination: “Your muscles are firm and strong.” Matter-of-factly comment about sexual development: “Your breasts are developing as they should be.” Emphasize normalcy of development. Examine genitalia as any other body part; may leave to end.

some early preschoolers may require more of the “security measures” employed with younger children, such as continued parent–child contact, and less of the preparatory measures used with preschoolers, such as playing with the equipment before and during the actual examination (Figure 33.2).

Physical Examination Although the variations in the general approaches are numerous, some common ones are elaborated on here. For example, the suggested

sequence may change considerably when the child is in pain or when obvious physical defects are present. In either situation, the affected area needs to be examined last, to minimize distress early in the examination and to focus on healthy, functioning body parts.

Growth Measurements. Measurement of physical growth in children is a key element in evaluating their health status. Physical growth parameters include weight, height (length), skin fold thickness, arm circumference, and head circumference. Values for these growth

CHAPTER 33

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781

Fig. 33.1 Using paper-doll technique to prepare child for physical examination.

Fig. 33.3 These children of identical age (8 years) are markedly different in size. The child on the left, is at the fifth percentile for height and weight. The child on the right is above the ninety-fifth percentile for height and weight. However, both children demonstrate normal growth patterns.

Fig. 33.2 Preparing children for physical examination.

parameters are plotted on percentile charts, and the child’s measurements in percentiles are compared with those of the general population. See Nursing Skills on Evolve: Measuring Physical Growth. Growth charts. The growth charts used in Canada were adapted in 2014 from the 2006 and 2007 World Health Organization (WHO) Growth Standards and Growth References (Dietitians of Canada et al., 2014b). The charts were adapted to provide health care providers with consistent practices in monitoring growth and assessing patterns of linear growth and weight gain to support healthy children. These new charts reflect the 0- to 19-years-of-age population with optimal health conditions. It also reflects an increase in the multiethnic international population and an improvement in the tool to identify children at risk for obesity. (See Additional Resources at the end of this chapter for a parent handout on using growth charts.) Children whose growth may be questionable include the following: • Children whose height and weight percentiles are widely disparate (e.g., height in the tenth percentile and weight in the ninetieth percentile, especially with above-average skin fold thickness) • Children who fail to show the expected growth rates in height and weight, especially during the rapid growth periods of infancy and adolescence

• Children who show a sudden increase (except during puberty) or decrease in a previously steady growth pattern • Children who are short in the absence of short parents Because growth is a continuous but uneven process, the most reliable evaluation lies in comparing growth measurements over time. It is important to remember that normal growth patterns vary among children of the same age (Figure 33.3). Special groups. The WHO growth charts do not include premature infants or very low-birth-weight infants who weigh less than 1 500 g. These infants do not grow in the same manner as full-term infants. Once these preterm infants are discharged from the neonatal intensive care unit, the WHO charts can then be used for them. Measurements should be plotted with the corrected postnatal age for prematurity (40 weeks—gestational age in weeks) until the child is 24 to 36 months of age. As an alternative, Fenton’s growth chart (Fenton & Kim, 2013) can be used for plotting growth from 22 gestational weeks to 10 weeks post-term (Dietitians of Canada, 2014b). Children with specific intellectual, developmental, genetic, or other conditions often have growth patterns that are different from those of healthy children (e.g., children with Down syndrome). Their growth can also be plotted on the WHO growth charts alone or in conjunction with specific growth curves that exist for some of these disorders (Dietitians of Canada, 2014a). Length. The term length refers to measurements taken when children are supine (also referred to as recumbent length). Until children are 24 months old (or 36 months if using the chart for birth to 36 months), recumbent length is measured. Because of the normally flexed position during infancy, the body should be fully extended by (1) holding the head in midline, (2) grasping the knees together gently, and (3) gently pushing down on the knees until the legs are fully extended and flat against the table. If using a measuring board, the nurse should place the head firmly at the top of the board and the heels of the feet firmly against the footboard.

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If such a measuring device is not available, length can be measured by placing the child on a paper-covered surface, marking the end points of the top of the head and the heels of the feet, and measuring between these two points (Figure 33.4). For accurate measurement, the nurse should hold the writing utensil at a right angle to the table when marking the cephalic point; the feet are positioned with the toes pointing directly to the ceiling when marking the heel point. Regardless of the method used, someone needs to assist the nurse in holding the child’s head in midline while extending the legs and taking the measurements. Height. The term height (or stature) refers to the measurement taken when children are standing upright. Wall charts and flip-up Head circumference

Abdominal circumference Chest circumference 0

50 cm 25 cm Crown-to-heel (recumbent) length

76 cm

Fig. 33.4 Measurement of head, chest, and abdominal circumference and crown-to-heel (recumbent) length.

horizontal bars (floppy-arm devices) mounted to weighing scales should not be used to measure the height of children (Foote et al., 2011). These devices are not steady and do not maintain a right angle to the vertical ruler, preventing an accurate and reliable height. Height is measured by having the child, with shoes removed, stand as tall and straight as possible, with the head in midline and the line of vision parallel to the ceiling and floor (Frankfort plane). The child’s back needs to be against the wall or other vertical flat surface, with the heels, buttocks, and back of the shoulders touching the wall and the medial malleoli touching, if possible (Figure 33.5). The nurse should check for and correct bending of the knees, slumping of the shoulders, or raising of the heels. For the most accurate measurement, a wall-mounted unit (stadiometer; see Figure 33.5) can be used. The movable measuring rod of platform scales is accurate only if it maintains a parallel position to the floor and rests securely on the topmost part of the head. To improvise a flat surface for measuring length, the nurse should attach a paper or metal tape or yardstick to the wall, position the child adjacent to the tape, and place a three-dimensional object, such as a thick book or box, on top of the head. The side of the object should rest firmly against the wall to form a right angle. Length or stature should be measured to the nearest 1 mm. Weight. Weight is measured with an electronic or appropriately sized beam balance scale, which measures weight to the nearest 10 g for infants and 100 g for children. With a balance scale, before the child is weighed, the nurse needs to zero the scale prior to use. When precise measurements are needed, two nurses should take the weight independently; if there is a discrepancy, a third reading should be taken.

A

B Fig. 33.5 Measurement of height. A, Infant. B, Child. (Courtesy of Jan M. Foote.)

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B Fig. 33.6 A: Infant on scale. B: Toddler on scale. Note presence of nurse to prevent falls. (B, Courtesy Paul Vincent Kuntz.)

Measurements should be taken in a comfortably warm room. When the birth–to–2-year or birth–to–36-month growth charts are used, children should be weighed nude. Older children are usually weighed while wearing their underpants or a light gown. However, the privacy of all children should always be respected. If the child must be weighed wearing some article of clothing or some type of special device, such as a prosthesis or an armboard for an intravenous device, the nurse needs to note this when recording the weight. Children who are measured for recumbent length are usually weighed on an infant platform scale and placed in a lying or sitting position. When weighing an infant, the nurse should place a hand lightly above the infant’s body to prevent the child from accidentally falling off the scale (Figure 33.6, A). When weighing a toddler, the nurse should stand close to the child, ready to prevent a fall (see Figure 33.6, B). For maximum infection control, the scale should be covered with a clean sheet of paper and cleaned between each child’s measurement. Skin fold thickness and arm circumference. Measures of relative weight and stature cannot distinguish between adipose (fat) tissue and muscle. One convenient measure of body fat is skin fold thickness, which is increasingly recommended as a routine measurement. Skin fold thickness is measured with special calipers, such as the Lange calipers. The most common sites for measuring skin fold thickness are the triceps (most practical for routine clinical use), subscapula, suprailiac, abdomen, and upper thigh. For greatest reliability, the nurse needs to follow the exact procedure for measurement and record the average of at least two measurements of one site. Arm circumference is an indirect measure of muscle mass. Measurement of arm circumference follows the same procedure as that for skin fold thickness, except the midpoint is measured with a paper or steel tape. The tape is placed vertically, along the posterior aspect of the upper arm from the acromial process to the olecranon process; half the measured length is the midpoint. Head circumference. Head circumference in children is measured up to 36 months of age and in any child whose head size is questionable. The head is measured at its greatest circumference, usually slightly above the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull (see Figure 33.4). Because head shape can affect the location of the maximum circumference, more than one measurement at points above the eyebrows may be needed to obtain the most accurate measure. A paper or metal tape should be used, since a cloth tape can stretch and give a falsely small measurement. For greatest accuracy, devices with tenths of a centimetre are best, since the percentile charts have only 0.5-cm increments. The nurse can plot the head size on the appropriate growth chart under head circumference. Generally, head and chest circumferences

are equal at about 1 to 2 years of age. During childhood, chest circumference exceeds head size by about 5 to 7 cm (for newborns, see Table 26.2).

Vital Signs Physiological measurements, key elements in evaluating physical status of vital functions, include temperature, pulse, respiration, and blood pressure (BP). Each physiological recording should be compared with normal values for that age group. In addition, the values taken on preceding health visits need to be compared with present recordings. For example, a falsely elevated BP reading may not indicate hypertension if previous recent readings have been within normal limits. The isolated recording may indicate some stressful event in the child’s life. As in most procedures carried out with children, older children and adolescents are treated much the same as adults. However, special consideration must be given to preschool children (see Atraumatic Care box: Reducing Young Children’s Fears). For best results in taking vital signs of infants, the nurse should count respirations first (before the infant is disturbed), take the pulse next, and measure temperature last. If vital signs cannot be taken without disturbing the child, the nurse should record the child’s behaviour, such as crying, along with the measurement.

ATRAUMATIC CARE Reducing Young Children’s Fears Young children, especially preschoolers, fear intrusive procedures because of their poorly defined body boundaries. Therefore, avoid invasive procedures, such as measuring rectal temperature, whenever possible. Also, avoid using the word “take” when measuring vital signs, since young children interpret words literally and may think that their temperature or other function will be taken away. Instead, say, “I want to know how warm you are.”

Temperature. Temperature is the measure of heat content within an individual’s body. The core temperature most closely reflects the temperature of the blood flow through the carotid arteries to the hypothalamus. Core temperature is relatively constant despite wide fluctuations in the external environment. When a child’s temperature is altered, receptors in the skin, spinal cord, and brain respond in an attempt to achieve normothermia, a normal temperature state. In pediatrics, there is a lack of consensus on what temperature constitutes normothermia for every child. For rectal temperatures in children, 36.6° to 38°C is an acceptable range, where heat loss and heat production are balanced (CPS, 2020). For newborns, a core body temperature between 36.5° and 37.5°C is a desirable range (see Chapter 26). In the newborn,

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temperature measurements are obtained for monitoring adequacy of thermoregulation, not fever; therefore, temperature measurements in each infant should be carefully considered in the context of the purpose and the environment. See Appendix C for normal temperature values. The nurse can measure temperature in healthy children at several body sites via oral, rectal, axillary, tympanic membrane, temporal artery, or skin route (Box 33.6). See Nursing Skills on Evolve: Measuring Body Temperature. For the ill child, other sites for temperature measurement have been investigated. The pulmonary artery is the closest to the hypothalamus and best reflects the core temperature (Batra et al., 2012). Other sites used are the distal esophagus, urinary bladder, and nasopharynx (Box 33.7). All of these methods are invasive and difficult to use in clinical practice. One of the most important influences on the accuracy of temperature is improper temperature-taking technique. Detailed discussion of temperature-taking methods and visual examples of proper techniques are given in Table 33.4.

BOX 33.6

Recommended Temperature Screening Routes in Infants and Children Birth to 2 Years Axillary Rectal—if definitive temperature reading is needed 2 to 5 Years Oral—when a child is able to hold a thermometer under the tongue Axillary Tympanic or temporal artery—if in hospital for screening Rectal—if definitive temperature reading is needed Over 5 Years Oral—definitive Axillary, tympanic or temporal artery—if in hospital for screening

Adapted from Canadian Paediatric Society. (2020). Fever and temperature taking. https://www.caringforkids.cps.ca/handouts/healthconditions-and-treatments/fever_and_temperature_taking.

BOX 33.7

The following sites are used for temperature measurement in children. The site that is used depends on the age of the child as well as the condition of the child. • Rectal temperature is the clinical gold standard for the precise diagnosis of fever in infants and children, compared with other methods (Fortuna et al., 2010; Holzhauer et al., 2009). However, this procedure is more invasive and is not recommended in young children because of the risk for rectal perforation. Children with recent rectal surgery, diarrhea, or anorectal lesions or who are receiving chemotherapy (cancer treatment usually affects the mucosa and causes neutropenia) should not undergo rectal thermometry. • Oral temperature (OT): OT indicates rapid changes in core body temperature, but accuracy may be an issue compared with the rectal site (Batra et al., 2012). OTs are considered the standard for temperature measurement, but they are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are younger than 5 years of age. Limitations of OT include the effects of ambient room temperature and recent oral intake. • Axillary temperature: This method is recommended for initial assessment of newborns, although it is not as accurate as a rectal or oral temperature. In newborns with fever, the axillary temperature should not be used interchangeably with rectal measurement (Hissink Muller et al., 2008). It can be used as a screening tool for fever in young infants (Batra et al., 2012). • Ear (aural) temperature: This is not a precise measurement of core body temperature and should not be used for a diagnosis of fever. • Temporal artery temperature (TAT): TAT is as not predictable for fever in young children but can be used as a screening tool for detecting fever less than 38°C (100.4°F) in children 3 months to 4 years of age (Fortuna et al., 2010). A study by Batra and Goyal (2013) found that TAT correlated better with rectal temperature than axillary and tympanic measures in a group of 50 afebrile children between 2 and 12 years of age. Based on this information, there is no single site used for temperature assessment that provides unequivocal estimates of core body temperature. When an accurate method of obtaining a correct reflection of core temperature is needed, the rectal temperature is recommended in

Alternative Temperature Measurement Sites for the Ill Child

Skin Probe is placed on the skin to determine heat output in response to changes in the patient’s skin temperature. Skin temperature sensors are most often used for newborns placed in radiant heat warmers or isolettes (using servocontrol feature of the apparatus). In turn, the heater unit warms to a set point to maintain the newborn’s temperature within a specified range. Urinary Bladder A thermistor or thermocouple is placed within the in-dwelling bladder catheter. The catheter tip immersed in the bladder provides a continuous temperature readout on the bedside monitor. This is not a true measure of core temperature but responds better than rectal and skin temperatures to core body changes. Because of thermistor sizes, this method is unusable in newborns and small infants.

Pulmonary Artery A catheter is placed into the heart to obtain a reading in the pulmonary artery. It is used in critical care settings or operating rooms only in patients requiring aggressive monitoring. The catheter is not available in sizes for newborns or small infants. Esophageal Site Probe is inserted into the lower third of the esophagus at the level of the heart. This is used in critical care settings or operating rooms. Several companies have esophageal stethoscopes with temperature probe monitors that show a continuous temperature reading for patients in the operating room. Nasopharyngeal Site Probe is inserted into the nasopharynx, posterior to the soft palate, and provides an estimate of hypothalamic temperature. This is used in critical care settings or operating rooms.

Data from Kumar, P. R., Nisarga, R., & Gowda, B. (2004). Temperature monitoring in newborns using ThermoSpot. Indian Journal of Pediatrics, 71(9), 795–796; Martin, S. A., & Kline, A. M. (2004). Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clinical Issues, 15(2), 254–266; Maxton, F. J., Justin, L., & Gilles, D. (2004). Estimating core temperature in infants and children after cardiac surgery: A comparison of six methods. Journal of Advanced Nursing, 45(2), 214–222.

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TABLE 33.4

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Temperature Measurement Locations for Infants and Children

Temperature Site Oral Place tip under tongue in right or left posterior sublingual pocket, not in front of tongue. Have child keep the mouth closed without biting on thermometer. Oral method is used only when a child is capable of holding onto a thermometer. Pacifier thermometers measure intraoral or supralingual temperature and are available but lack support in the literature. Several factors affect mouth temperature: eating and mastication, hot or cold beverages, open-mouth breathing, and ambient temperature.

Axillary Place tip under the arm in centre of axilla and keep close to the skin, not clothing. Hold child’s arm firmly against side. Temperature may be affected by poor peripheral perfusion (results in lower value), clothing or swaddling, use of radiant warmer, or amount of brown fat in cold-stressed newborns (results in higher value). The advantage is that use of this site avoids an intrusive procedure and eliminates the risk of rectal perforation.

Ear Based (Aural) Insert small infrared probe deeply into canal to allow sensor to obtain measurement. The size of probe (most are 8 mm) may influence accuracy of the result. In young children this may be a concern because of the small diameter of the canal. For proper placement of the ear, it is debated as to whether the pinna should be pulled in a manner similar to that used during otoscopy (see Figure 33.19). Aural thermometers are not recommended for children under age 2 years because of small diameter of ear canal, which makes the temperature more inaccurate.

Continued

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Temperature Measurement Locations for Infants and Children—cont’d

Rectal Place well-lubricated tip at maximum 2.5 cm into rectum for children and 1.5 cm for infants; securely hold thermometer close to anus. Child may be placed in side-lying, supine, or prone position (i.e., supine with knees flexed toward abdomen); cover the penis, since the procedure may stimulate urination. A small child may be placed prone across the parent’s lap.

Temporal Artery An infrared sensor probe scans across the forehead, capturing heat from arterial blood flow. The temporal artery is the only artery close enough to the skin’s surface to provide access for accurate temperature measurement. These probes have been shown to be more accurate than tympanic thermometry and are better tolerated than rectal thermometry.

Oral, axillary, rectal, and temporal artery images courtesy Paul Vincent Kuntz. Data from Leduc, D., Woods, S., & Canadian Paediatric Society, Community Paediatrics Committee. (2000). Temperature measurement in paediatrics. https://academic.oup.com/pch/article/5/5/273/2655772.

younger children and the oral route in children older than 5 years, although the axillary route is recommended as the next preferred site (CPS, 2020). Temperature depends on the time of day, age, and physical activity. In general, fever is defined as a temperature of 38°C or greater (100.4°F) rectally (see Appendix C). The most frequently used temperature measurement devices in infant and children include the following: Electronic intermittent thermometers—Measure the patient’s temperature at oral, rectal, and axillary sites and are used as primary diagnostic indicators Infrared thermometers—Measure the patient’s temperature by collecting emitted thermal radiation from a particular site (e.g., tympanic membrane) Electronic continuous thermometers—Measure the patient’s temperature during the administration of general anaesthesia, treatment of hypothermia or hyperthermia, and other situations that require continuous monitoring

NURSING ALERT The belief that core temperature can be estimated by adding 1°C to the temperature taken in the axilla is incorrect. Do not add a degree to the finding obtained by taking a temperature by the axillary route.

Pulse. A satisfactory pulse can be taken radially in children older than 2 years of age. However, in infants and young children, the apical impulse (heard through a stethoscope held to the chest at the apex of the heart) is more reliable (see Figure 33.28 for location of apical pulse). The pulse is counted for 1 full minute in infants and young children because of possible irregularities in rhythm. However, when frequent apical rates are needed, shorter counting times (e.g., 15- or 30second intervals) can be used. For greater accuracy, the apical rate should be measured while the child is asleep if possible and the child’s behaviour recorded along with the rate. Pulses may be graded according to the criteria in Table 33.5. Radial and femoral pulses need to be compared at least once during infancy to detect the presence of circulatory TABLE 33.5 Grade

Grading of Pulses

Description

0

Not palpable

+1

Difficult to palpate, thready, weak, easily obliterated with pressure

+2

Difficult to palpate, may be obliterated with pressure

+3

Easy to palpate, not easily obliterated with pressure (normal)

+4

Strong, bounding, not obliterated with pressure

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impairment, such as coarctation of the aorta. (See Appendix C for normal rates for pediatric age groups.)

Respiration. The respiratory rate in children is measured in the same manner as for the adult patient. However, in newborns and infants, respirations are auscultated at the same time as observing the abdomen for movement, since respirations are primarily diaphragmatic. Because the movements are irregular, they should be counted for 1 full minute for accuracy (see also Appendix C).

Acromion

Blood Pressure. BP measurement by noninvasive methods is part of a routine vital sign determination. Routine regular BP screening in children over 3 years of age is recommended (Nerenberg et al., 2018). BP may be measured with a mercury sphygmomanometer, aneroid sphygmomanometer, or oscillometric device. Oscillometric devices measure mean arterial BP and then calculate systolic and diastolic values. The algorithms used by companies are proprietary and differ from company to company and device to device. These devices can yield results that vary widely when one is compared with another, and they do not always closely match BP values obtained by auscultation. An elevated BP reading obtained with an automated or oscillometric device should be repeated using auscultation. Abnormal oscillometric values should be confirmed with auscultation (Nerenberg et al., 2018). Oscillometric devices may serve as a suitable alternative to auscultation for initial BP screening in the pediatric population (Duncombe et al., 2017). See Appendix C for pediatric parameters of blood pressure values. Selection of cuff. No matter what type of noninvasive technique is used, the most important factor in accurately measuring BP is the use of an appropriately sized cuff (cuff size refers only to the inner inflatable bladder, not the cloth covering). A technique to establish an appropriate cuff size is to choose a cuff having a bladder width that is approximately 40% of the arm circumference midway between the olecranon and the acromion. This will usually be a cuff bladder that covers 80 to 100% of the circumference of the arm (Nerenberg et al., 2018) (Figure 33.7). Cuffs that are either too narrow or too wide affect the accuracy of BP measurements. If the cuff size is too small, the reading on the device is falsely high. If the cuff size is too large, the reading is falsely low (Table 33.6). When using a site other than the arm, BP measurements using noninvasive techniques may differ. Generally, systolic BP in the lower extremities (thigh or calf) is greater than pressure in the upper extremities, and systolic BP in the calf is higher than that in the thigh (Schell et al., 2011) (Figure 33.8).

Olecranon

NURSING ALERT When taking BP, use an appropriately sized cuff. When the correct size is not available, use an oversized cuff rather than an undersized one, or use another site that more appropriately fits the cuff size. Do not choose a cuff based on the name of the cuff (e.g., an “infant” cuff may be too small for some infants). When taking an extremity BP, ensure that the cuff is specific for taking extremity BP measurements.

NURSING ALERT Comparing BP in the upper and lower extremities will help detect abnormalities, such as coarctation of the aorta, in which the lower extremity pressure is less than the upper extremity pressure.

40% of circumference at midpoint

A

Acromion

Olecranon

B

Cubital fossa

C Fig. 33.7 Determination of proper cuff size. A: Cuff bladder width should be approximately 40% of circumference of arm measured at a point midway between olecranon and acromion. B: Cuff bladder length should cover 80 to 100% of circumference of arm. C: Blood pressure should be measured with cubital fossa at heart level. The arm should be supported. The stethoscope bell is placed over brachial artery pulse, proximal and medial to cubital fossa and below the bottom edge of the cuff. (From National Institutes of Health, National Heart, Lung, and Blood Institute. [1996, September]. Update on the Task Force Report [1987] on high blood pressure in children and adolescents: A working group report from the National High Blood Pressure Education Program [NIH Pub No 963790]. Author.)

Measurement and interpretation. Measuring and interpreting BP in infants and children requires additional attention to correct procedure because (1) limb sizes vary and cuff selection must accommodate the circumference; (2) excessive pressure on the antecubital fossa affects the Korotkoff sounds; (3) children easily become anxious,

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TABLE 33.6

Recommended Dimensions for Blood Pressure Cuff Bladders Age Range

Width (cm)

Length (cm)

Maximum Arm Circumference (cm)∗

Newborn

4

8

10

Infant

6

12

15

Child

9

18

22

Small adult

10

24

26

Adult

13

30

34

Large adult

16

38

44

Thigh

20

42

52

BP, Blood pressure. From Nerenberg, K. A., Zarnke, K., Leung, A., et al. (2018). Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Canadian Journal of Cardiology, 34(5), 506–525. https://doi.org/10.1016/j.cjca.2018.02.022.

∗

Calculated so that largest arm would still allow bladder to encircle arm by at least 80%. From National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. (2004). The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Reproduced with permission from Pediatrics, 114(2 Suppl. 4th Rep.), 555–576. Copyright © 2004 by the AAP.

Popliteal artery

Brachial artery Radial artery

A

B

• If BP is stage 1, BP measurements should be repeated on two more occasions within 1 month; if hypertension is confirmed, evaluation should be initiated within 1 month. • If BP is stage 2, prompt referral should be made for evaluation and therapy. • All children with suspected or confirmed hypertension should undergo a hypertension-focused history and physical evaluation.

Dorsalis pedis artery

C

Posterior tibial artery

D

Fig. 33.8 Sites for measuring blood pressure. A: Upper arm. B: Lower arm or forearm. C: Thigh. D: Calf or ankle.

which can elevate BP; and (4) BP values change with age and growth. The right arm is the preferred location to assess BP in children (Nerenberg et al., 2018). In children and adolescents, the normal range of BP is determined by body size and age. BP standards that are based on gender, age, and height provide a more precise classification of BP according to body size. This approach avoids misclassifying children who are very tall or very short. The revised BP tables include the 50th, 90th, 95th, and 99th percentiles (with standard deviations) by gender, age, and height (see Additional Resources and Appendix C). See Guidelines box: Diagnosing Hypertension in Children.

GUIDELINES Diagnosing Hypertension in Children • Using office BP measurements, children can be diagnosed as hypertensive if the systolic blood pressure (SBP) or diastolic blood pressure (DBP) is greater than or equal to the 95th percentile for age, sex, and height, measured on at least three separate occasions. • If the BP is greater than or equal to the 95th percentile, BP should be staged: • Stage 1 is defined by BP between the 95th percentile and 99th percentile plus 5 mm Hg. • Stage 2 is defined by BP greater than the 99th percentile plus 5 mm Hg.

Orthostatic hypotension. Orthostatic hypotension (OH), also called postural hypotension or orthostatic intolerance, is often manifested as syncope (fainting), vertigo (dizziness), or lightheadedness and is caused by decreased blood flow to the brain (cerebral hypoperfusion). Normally, blood flow to the brain is maintained at a constant level by a number of compensating mechanisms that regulate systemic BP. When one assumes a sitting or standing position from a supine or recumbent position, peripheral capillary vasoconstriction occurs, and blood that was pooling in the lower vasculature is returned to the heart for redistribution to the head and remainder of the body. When this mechanism fails or is slow to respond, the person may experience vertigo or syncope. One of the most common causes of OH is hypovolemia, which may be induced by medications such as diuretics, vasodilators, and prolonged immobility or bed rest. Other causes of OH include dehydration, diarrhea, emesis, fluid loss from sweating and exertion, alcohol intake, dysrhythmias, diabetes mellitus, sepsis, and hemorrhage. BP measurements taken with the child first supine then standing (at least 2 minutes in each position) may demonstrate variability and assist in the diagnosis of OH. The child with a sustained drop in systolic pressure of more than 20 mm Hg or in diastolic pressure of more than 10 mm Hg after standing for 2 minutes without an increase in heart rate of more than 15 beats/min most likely has an autonomic deficit. Non-neurogenic causes of OH have a compensatory increase in pulse of more than 15 beats/min as well as a drop in BP, as noted previously. For the child or adolescent who is seen with vertigo, lightheadedness, nausea, syncope, diaphoresis, and pallor, it is important to monitor BP and heart rate to determine the original cause. BP is an important diagnostic measurement in children and adolescents and must be a part of the routine monitoring of vital signs.

NURSING ALERT Published norms for BP are valid only if the same method of measurement (auscultation and cuff size determination) is used in clinical practice.

General Appearance The child’s general appearance is a cumulative, subjective impression of the child’s physical appearance, state of nutrition, behaviour, personality, interactions with parents and nurse (also siblings, if present), posture, development, and speech. Although general appearance is recorded at the beginning of the physical examination, it encompasses all the observations of the child during the interview and physical assessment. The nurse should note the facies (the child’s facial expression and appearance). For example, the facies may give clues to children who are in pain; have difficulty breathing; feel frightened, discontented, or unhappy; are emotionally delayed; or are acutely ill. The posture, position, and types of body movement should also be observed. The child with hearing or vision impairment may characteristically tilt the head in an awkward position to hear or see better. The child in pain may favour a body part. The child with low self-esteem or

CHAPTER 33 a feeling of rejection may assume a slumped, careless, and apathetic pose. Likewise, a child with confidence, a feeling of self-worth, and a sense of security usually demonstrates a tall, straight, well-balanced posture. While observing such body language, the nurse should not interpret too freely but rather record objectively. The child’s hygiene is noted in terms of cleanliness; unusual body odour; the condition of the hair, neck, nails, teeth, and feet; and the condition of the clothing. Such observations are excellent clues to possible instances of neglect, inadequate financial resources for childcare, housing difficulties (e.g., no running water), or lack of knowledge concerning children’s needs. Behaviour includes the child’s personality, activity level, reaction to stress, requests, frustration, interactions with others (primarily the parent and nurse), degree of alertness, and response to stimuli. Some questions the nurse can keep in mind that serve as reminders for observing behaviour include the following: • What is the child’s overall personality? • Does the child have a long attention span, or are they easily distracted? • Can the child follow two or three commands in succession without the need for repetition? • What is the child’s response to delayed gratification or frustration? • Does the child use eye contact during conversation? • What is the child’s reaction to the nurse and family members? • Is the child quick or slow to grasp explanations?

Skin Skin is assessed for colour, texture, temperature, moisture, turgor, lesions, acne, and rashes. Examination of the skin and its accessory organs primarily involves inspection and palpation. Touch allows the nurse to assess the texture, turgor, and temperature of the skin. Several variations in skin colour can occur, some of which warrant further investigation. The types of colour change and their appearance in children with light or dark skin are summarized in Table 33.7.

TABLE 33.7

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Normally the skin texture of young children is smooth, slightly dry, and not oily or clammy. Skin temperature is evaluated by symmetrically feeling each part of the body and comparing upper areas with lower ones. Any difference in temperature should be noted. Tissue turgor, or elasticity in the skin, can be determined by grasping the skin on the abdomen between the thumb and index finger, pulling it taut, and quickly releasing it. Elastic tissue immediately assumes its normal position without residual marks or creases. In children with poor skin turgor, the skin remains suspended or tented for a few seconds before slowly falling back on the abdomen. Skin turgor is one of the best estimates of adequate hydration and nutrition.

Accessory Structures. Inspection of the accessory structures of the skin may be performed while the skin is being examined or when the scalp and extremities are being assessed. The hair is inspected for colour, texture, quality, distribution, and elasticity. Children’s scalp hair is usually lustrous, silky, strong, and elastic. Genetic factors affect the appearance of hair. Hair that is stringy, dull, brittle, dry, friable, and depigmented may suggest poor nutrition. The nurse should record any bald or thinning spots. Loss of hair in infants may indicate lying in the same position and may be a clue for counselling parents concerning the child’s stimulation needs. The hair and scalp are inspected for general cleanliness. Some people condition their hair with oils or lubricants that, if not thoroughly washed from the scalp, can clog the sebaceous glands, causing scalp infections. The area should also be examined for lesions; scaliness; evidence of infestation, such as lice or ticks; and signs of trauma, such as ecchymosis, masses, or scars. In children who are approaching puberty, the nurse should look for growth of secondary hair as a sign of normally progressing pubertal changes. Precocious or delayed appearance of hair growth should be noted because, although not always suggestive of hormonal dysfunction, it may be of great concern to the early- or late-maturing adolescent.

Differences in Colour Changes Based on Skin Colour

Description

Appearance in Light Skin

Appearance in Dark Skin

Cyanosis—Bluish tone through skin; reflects reduced (deoxygenated) hemoglobin

Bluish tinge, especially in palpebral conjunctiva (lower eyelid), nail beds, earlobes, lips, oral membranes, soles, and palms

Ashen grey lips and oral membranes

Pallor—Paleness; may be sign of anemia, chronic disease, edema, or shock

Loss of rosy glow in skin, especially face

Assess the palms, there is reduced darkness in the palmar creases; pale pink or white lower eyelid

Erythema—Redness; may be result of increased blood flow from climatic conditions, local inflammation, infection, skin irritation, allergy, or other dermatoses, or may be caused by increased numbers of red blood cells as compensatory response to chronic hypoxia

Redness easily seen anywhere on body

Much more difficult to assess; rely on palpation for warmth or edema; shiny, smooth appearance with burgundy undertone

Ecchymosis—Large, diffuse areas, usually black and blue, caused by hemorrhage of blood into skin; typically result of injuries

Purplish to yellow-green areas; may be seen anywhere on skin

Purple or dark-brown; more difficult to assess; compare both sides of body

Petechiae—Same as ecchymosis except for size: small, distinct, pinpoint hemorrhages
2 mm in size; can denote some type of blood disorder, such as leukemia

Purplish pinpoints most easily seen on buttocks, abdomen, and inner surfaces of arms or legs

Usually invisible except in oral mucosa, conjunctiva of eyelids, and conjunctiva covering eyeball

Jaundice—Yellow staining of skin usually caused by bile pigments

Yellow staining seen in sclerae of eyes, skin, fingernails, soles, palms, and oral mucosa

Most reliably assessed in sclerae, hard palate, palms, and soles; often very subtle yellow colour

More yellowish brown colour in brown skin

Source: Mukwende, M., Tamonv, P., & Turner, M. (2020). Mind the gap: A handbook of clinical signs in black and brown skin (1st ed.). https://www. blackandbrownskin.co.uk/mindthegap.

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A

are normally present. During assessment of the nodes in the head and neck, the child’s head is tilted upward slightly but without tensing the sternocleidomastoid or trapezius muscles. This position facilitates palpation of the submental, submandibular, tonsillar, and cervical nodes. The nurse should palpate the axillary nodes with the child’s arms relaxed at the sides but slightly abducted. The inguinal nodes are assessed with the child in the supine position. The nurse needs to note size, mobility, temperature, and tenderness, as well as reports by the parents regarding any visible change of enlarged nodes. In children, small, nontender, movable nodes are usually normal. Tender, enlarged, warm lymph nodes generally indicate infection or inflammation close to their location. Such findings need to be reported for further investigation.

B

Fig. 33.9 Examples of flexion creases on palm. A: Normal. B: Transpalmar crease.

The nails are inspected for colour, shape, texture, and quality. Normally the nails are pink, convex, smooth, and hard but flexible (not brittle). The edges, which are usually white, should extend over the fingers. Dark-skinned individuals may have more deeply pigmented nail beds. Short, ragged nails are typical of habitual biting. The palm normally shows three flexion creases (Figure 33.9, A). In some situations, such as Down syndrome, the two distal horizontal creases are fused to form a single horizontal crease (the single transverse palmar crease, or transpalmar crease) (see Figure 33.9, B). If grossly abnormal lines or folds are observed, the nurse should sketch a picture to describe them and refer the finding to a specialist for further investigation.

Lymph Nodes Lymph nodes are usually assessed when the part of the body in which they are located is examined. The body’s lymphatic drainage system is extensive; the usual sites for palpating accessible lymph nodes are shown in Figure 33.10. Nodes are palpated using the distal portion of the fingers and gently but firmly pressing in a circular motion along the regions where nodes

Head and Neck The head is observed for general shape and symmetry. A flattening of one part of the head, such as the occiput, may indicate that the child continually lies in this position. Marked asymmetry is usually abnormal and may indicate premature closure of the sutures (craniosynostosis).

NURSING ALERT Significant head lag after 6 months of age strongly indicates cerebral injury and is referred for further evaluation.

The nurse should note head control in infants and head posture in older children. Most infants by 4 months of age should be able to hold the head erect and in midline when in a vertical position. Range of motion is evaluated by asking the older child to look in each direction (to either side, up, and down) or by manually putting the younger child through each position. Limited range of motion may indicate wryneck, or torticollis, in which the child holds the head to one side with the chin pointing toward the opposite side as a result of injury to the sternocleidomastoid muscle.

Posterior auricle

Subclavicular Axillary

Epitrochlear

Occipital

Preauricle Maxillary

Superficial cervical Posterior cervical

Buccinator Submental (sublingual) Submandibular

Superficial inguinal nodes (superior and lateral)

Superficial inguinal nodes (inferior and medial)

Tonsillar Superior deep cervical nodes Supraclavicular Deep subinguinal nodes

Subclavicular

Fig. 33.10 Location of superficial lymph nodes. Arrows indicate directional flow of lymph.

CHAPTER 33

NURSING ALERT Hyperextension of the head (opisthotonos) with pain on flexion is a serious indication of meningeal irritation and needs to be referred for immediate medical evaluation.

The skull is palpated for patent sutures, fontanels, fractures, and swellings. Normally the posterior fontanel closes by the second month of life, and the anterior fontanel fuses between 12 and 18 months of age. When lightly palpated, the fontanels normally feel firm and very slightly curved inward to the touch. The fontanels may look like they are bulging when an infant is crying or vomiting. However, they should return to normal when the infant is in a calm, head-up position. A tense or bulging fontanel occurs when fluid builds up in the brain or the brain swells, causing increased pressure inside the skull, and a depressed fontanel can indicate dehydration. Early or late closure should be noted, since either may be a sign of a pathological condition. While examining the head, the nurse should observe the face for symmetry, movement, and general appearance. The nurse should ask the child to “make a face,” to assess symmetrical movement and disclose any degree of paralysis. Any unusual facial proportion, such as an unusually high or low forehead, wide- or close-set eyes, or a small, receding chin needs to be noted. In addition to assessment of the head and neck for movement, the neck is inspected for size and its associated structures palpated. The neck is normally short, with skin folds between the head and shoulders during infancy; however, it lengthens during the next 3 to 4 years.

NURSING ALERT If any masses are detected in the neck, report them for further investigation. Large masses can block the airway.

Pediatric Health Assessment

791

The inside lining of the lids, the palpebral conjunctiva, also needs to be inspected. To examine the lower conjunctival sac, the lid is pulled down while the patient looks up. To evert the upper lid, the nurse should hold the upper lashes and gently pull down and forward as the child looks down. Normally the conjunctiva appears pink and glossy. Vertical yellow striations along the edge are the meibomian, or sebaceous, glands near the hair follicle. Located in the inner or medial canthus and situated on the inner edge of the upper and lower lids is a tiny opening, the lacrimal punctum. Any excessive tearing, discharge, or inflammation of the lacrimal apparatus should be noted. The bulbar conjunctiva, which covers the eye up to the limbus, or junction of the cornea and sclera, should be transparent. The sclera, or white covering of the eyeball, should be clear. Tiny black marks in the sclera of heavily pigmented individuals are normal. The cornea, or covering of the iris and pupil, should be clear and transparent. The nurse needs to record opacities because they can be signs of scarring or ulceration, which can interfere with vision. The best way to test for opacities is to illuminate the eyeball by shining a light at an angle (obliquely) toward the cornea. The pupils are compared for size, shape, and movement. They should be round, clear, and equal. Their reaction to light is tested by quickly shining a light toward the eye and removing it. As the light approaches, the pupils should constrict; as the light fades, the pupils should dilate. The pupil is tested for any response of accommodation by having the child look at a bright, shiny object at a distance and quickly moving the object toward the face. The pupils should constrict as the object is brought near the eye. Normal findings on examination of the pupils may be recorded as PERRLA, which stands for “Pupils Equal, Round, React to Light, and Accommodation.” The iris and pupil are inspected for colour, size, shape, and clarity. Permanent eye colour is usually established by 6 to 12 months of age. While inspecting the iris and pupil, the nurse should look for the lens. Normally the lens is not visible through the pupil.

Eyes Inspection of External Structures. The lids should be inspected for proper placement on the eye. When the eye is open, the upper lid should fall near the upper iris (Figure 33.11). When the eyes are closed, the lids should completely cover the cornea and sclera. The general slant of the palpebral fissures or lids is determined by drawing an imaginary line through the two points of the medial canthus and across the outer orbit of the eyes and aligning each eye on the line. Usually the palpebral fissures lie horizontally. However, in Asians the slant is normally upward. Palpebral fissure

Pupil Upper eyelid

Sclera

Caruncle

Lateral canthus

Medial canthus

Limbus Lower eyelid

Iris

Fig. 33.11 External structures of the eye.

Inspection of Internal Structures. The ophthalmoscope enables visualization of the interior of the eyeball with a system of lenses and a high-intensity light. The lenses permit clear visualization of eye structures at different distances from the nurse’s eye and correct visual acuity differences in the examiner and child. Use of the ophthalmoscope requires practice to know which lens setting produces the clearest image. The ophthalmic and otic heads are usually interchangeable on one “body” or handle, which encloses the power source, either disposable or rechargeable batteries. The nurse should practise changing the heads, which snap on and are secured with a quarter turn, and replacing the batteries and light bulbs. Nurses who are not directly involved in physical assessment are often responsible for ensuring that the equipment functions properly. Preparing the child. The nurse can prepare the child for the ophthalmoscopic examination by showing the child the instrument, demonstrating the light source and how it shines in the eye, and explaining the reason for darkening the room. For infants and young children who do not respond to such explanations, it is best to use distraction to encourage them to keep their eyes open. Forcibly parting the lids results in a watery-eyed child who is even less likely able to comply with the examination. Usually, with some practice, the nurse can elicit a red reflex almost instantly while approaching the child and may also gain a momentary inspection of the blood vessels, macula, or optic disc. Funduscopic examination. Figure 33.12 shows the structures of the back of the eyeball, or the fundus. The fundus is immediately apparent as the red reflex. The intensity of the colour increases in darkly pigmented individuals.

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Superior temporal arteries and veins

Superior nasal arteries and veins

Fovea centralis

Optic disc

Macula

Inferior nasal arteries and veins

Inferior temporal arteries and veins

Fig. 33.12 Structures of the fundus. (From Ball, J. W., Dains, J. E., Flynn, J. A., et al. [2015]. Seidel’s guide to physical examination, [8th ed.]. Mosby.)

NURSING ALERT A brilliant, uniform red reflex is an important sign because it rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. Any dark shadows or opacities should be recorded because they indicate some abnormality in any of these structures.

As the ophthalmoscope is brought closer to the eye, the most conspicuous feature of the fundus is the optic disc, the area where the blood vessels and optic nerve fibres enter and exit from the eye. The colour of the disc is creamy pink; it is lighter in colour than the surrounding fundus. Normally it is round or vertically oval. After the optic disc is located, the area is inspected for blood vessels. The central retinal artery and vein appear in the depths of the disc and emanate outward with visible branching. The veins are darker and about one fourth larger than the arteries. Normally the branches of the arteries and veins cross one another. Other structures that may be seen are the macula, the area of the fundus with the greatest concentration of visual receptors, and, in the centre of the macula, a minute glistening spot of reflected light called the fovea centralis, which is the area of most perfect vision.

Vision Testing. Several tests are available for assessing vision. This discussion focuses on ocular alignment, visual acuity, peripheral vision, and colour vision. Vision screening should be performed at the earliest

A

possible age and at regular intervals. Preschoolers should undergo at least one eye examination between the ages of 2 and 5 years. Schoolage children and adolescents should undergo an eye examination annually (Canadian Association of Optometrists, 2020). It has been estimated that about 25% of school-age children have vision challenges. Behavioural and physical signs of visual impairment are discussed in Chapter 42. Ocular alignment. Normally, by the age of 3 to 4 months, children are able to fixate on one visual field with both eyes simultaneously (binocularity). One of the most important tests for binocularity is alignment of the eyes to detect nonbinocular vision, or strabismus. In strabismus, or cross-eye, one eye deviates from the point of fixation. If the misalignment is constant, the weak eye becomes “lazy,” and the brain eventually suppresses the image produced by that eye. If strabismus is not detected and corrected by ages 4 to 6 years, blindness from disuse, known as amblyopia, may result. Tests commonly used to detect misalignment are the corneal light reflex and the cover tests. To perform the corneal light reflex test, or Hirschberg test, the examiner shines a flashlight or the light of the ophthalmoscope directly into the patient’s eyes from a distance of about 40.5 cm. If the eyes are orthophoric, or aligned, the light falls symmetrically within each pupil (Figure 33.13, A). If the light falls off centre in one eye, the eyes are misaligned. Epicanthal folds, excess folds of skin that extend from the roof of the nose to the inner termination of the eyebrow and that partially or completely overlap the inner canthus of the eye, may give a false impression of misalignment (pseudostrabismus) (see Figure 33.13, B). Epicanthal folds are often found in Asian children. In the cover test, one eye is covered, and the movement of the uncovered eye is observed while the child looks at a near (33 cm) or distant (6 m) object. If the uncovered eye does not move, it is aligned. If the uncovered eye moves, a misalignment is present because, when the stronger eye is temporarily covered, the misaligned eye attempts to fixate on the object. In the alternate cover test, occlusion shifts back and forth from one eye to the other, and movement of the eye that was covered is observed as soon as the occluder is removed while the child focuses on a point in front of them (Figure 33.14). If normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move. If misalignment is present, eye movement will occur when the cover is moved. This test takes more practice to perform than the other cover test because the occluder must be moved back and forth quickly and accurately to see the eye move. Because deviations can occur at different ranges, it is important to perform the cover tests at both close and far distances.

B

Fig. 33.13 A: Corneal light reflex test demonstrating orthophoric eyes. B: Pseudostrabismus. Inner epicanthal folds cause eyes to appear misaligned; however, corneal light reflexes fall perfectly symmetrically.

CHAPTER 33

Pediatric Health Assessment

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B

A

Fig. 33.14 Cover–Uncover test to detect amblyopia in patient with strabismus. A: Eye is occluded, and child is fixating on light source. B: If eye does not move when uncovered, eyes are aligned.

NURSING ALERT The cover test is usually easier to perform if the examiner uses their own hand rather than a card-type occluder (see Figure 33.14). Attractive occluders fashioned like an ice cream cone or happy-face lollipop cut from cardboard are also well received by young children.

Photoscreening is a technique used to screen for amblyopia, refractive disorders, and media opacities. Using a camera, the examiner obtains images of the pupillary reflexes (reflections) and red reflexes (Bruckner test). Photoscreening offers an effective way to screen infants, preverbal children, and those with developmental delays who are difficult to screen. The CPS (Amit & CPS Community Paediatrics Committee, 2009/2018) recommends photoscreening but states that is not practical for office-based primary care of children. Visual acuity testing in children beyond infancy. Table 33.8 provides a list of visual screening tests for children and guidelines for referral. The CPS (Amit et al., 2009/2018) recommends that vision testing be done during periodic health review and when concerns are noted. The most common test for measuring visual acuity is the Snellen letter chart, which consists of lines of letters of decreasing size (see Additional Resources at the end of this chapter). The child stands 3 metres from the chart with their heels at the 3-metre line. When screening for visual acuity in children, the right eye is tested first by covering the left eye. Children who wear glasses should be screened with them on. The child needs to keep both eyes open during the examination. The child begins moving down the chart until they fail to read the line. To pass each line, the child must correctly identify four of six symbols on the line. The procedure is repeated, with the child covering the right eye. For children unable to read letters and numbers, the tumbling E or HOTV test is useful. The tumbling E test uses the capital letter E pointing in four different directions. The child is asked to point in the direction that the E is facing. The HOTV test consists of a wall chart composed of the letters H, O, T, and V. The child is given a board containing a large H, O, T, and V. The examiner points to a letter on the wall chart, and the child matches the correct letter on the board held in their hand. The tumbling E and HOTV tests are excellent tests for preschool-age children. When a child is unable to perform the tumbling E or HOTV test, the LEA symbol or Allen card test may be used. The Allen card test uses common figures to test the child’s vision. It is important to assess whether the child is able to identify the pictures before actual vision testing. The examiner walks backward slowly, flipping through the

cards and presenting different pictures to the child. The examiner continues to move backward as the child correctly calls out the figures. When the child begins to miss the figure on the cards, the examiner moves forward to confirm that the child is able to identify the figures at that point. All Allen card figures are 20/30 in size. The farthest distance at which the child is able to accurately identify the pictures becomes the numerator, and 30 becomes the denominator. For example, if the child is able to identify the pictures accurately at 4.5 metres, the visual acuity is recorded as 15/30. This is equivalent to 20/40 or 10/ 20 visual acuity. Visual acuity testing in infants and difficult-to-test children. In newborns, vision is tested mainly by checking for light perception by shining a light into the eyes and noting responses such as pupillary constriction, blinking, following the light to midline, increased alertness, or refusal to open the eyes after exposure to the light. Although the simple manoeuvre of checking light perception and eliciting the pupillary light reflex indicates that the anterior half of the visual apparatus is intact, it does not confirm that the newborn can see. In other words, this test does not assess whether the brain receives the visual message and interprets the signals. Another test of visual acuity is the infant’s ability to fix on and follow a target. Although any brightly coloured or patterned object can be used, the human face is excellent. The infant is held upright while the examiner moves their face slowly from side to side. Other signs that may indicate visual impairment or other serious eye conditions include fixed pupils, strabismus, constant nystagmus, the setting-sun sign, and slow lateral movements. Unfortunately, it is difficult to test each eye separately; the presence of such signs in one eye could indicate unilateral blindness. Special tests are available for testing infants and other difficult-totest children to assess acuity or confirm blindness. For example, in visually evoked potentials, the eyes are stimulated with a bright light or pattern, and electrical activity to the visual cortex is recorded through scalp electrodes. Acuity is assessed by using progressively smaller patterns.

NURSING ALERT If visual fixation and following are not present by 3 to 4 months of age, further ophthalmological evaluation is needed.

Peripheral vision. In children who are old enough to assist, peripheral vision, or the visual field of each eye, can be estimated by having children fixate on a specific point directly in front of them as an object,

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TABLE 33.8 Function

Assessment of the Child and Family

Eye Examination Guidelines∗ Recommended Tests

Ages 3–5 Years Distance visual Snellen letters acuity Snellen numbers Tumbling E HOTV test Picture test • Allen figures • LEA symbols

Referral Criteria

Comments

1. Fewer than 4 of 6 correct on 6-m line with either eye tested at 3 m monocularly (i.e., 12 yr: Start with 2 tablets once a day; maximum: 4 tablets twice a day Liquid: 1 mo–1 yr: 1.25–5 mL qhs 1–5 yr: 2.5–5 mL qhs 5–15 yr: 5–10 mL qhs > 15 yr: 10–25 mL qhs Polyethylene glycol-electrolyte solution 100 mL/yr of age/hr PO/NG Dose limit: 1 L/hr (4 L total) Adolescents: 240 mL PO q10min Bisacodyl: PO or PR 3–12 yr: 5 mg/dose/day >12 yr: 5–10 mg/dose/day Lactulose 5–10 mL/day PO, double daily dose until stool produced Adult: 15–30 mL/day PO Mineral oil: 1–2 tsp/day PO Magnesium citrate < 6 yr: 1–3 mL/kg PO OD 6–12 yr: 100–150 mL PO once/day >12 yr: 150–300 mL PO once/day follow with 250 mL water Milk of Magnesia 12 yr: 30–60 mL PO once/day

Increase water intake. Prune juice, bran cereal, vegetables Increase ambulation.

Sedation∗ (without respiratory depression)

Consider dose reduction and monitor analgesia closely; if analgesia is inadequate at reduced dose, consider opioid switch and continue to monitor analgesia and sedation closely.

Nausea, vomiting

Dimenhydrinate 1.25 mg/kg/dose q6h PO/IV/PR—prn maximum 50 mg/dose and 300 mg/day Ondansetron: 0.1–0.15 mg/kg IV or PO q4h; maximum: 8 mg/dose Granisetron: 10–40 mcg/kg q2–4h; maximum: 1 mg/dose

Imagery, relaxation Deep, slow breathing Small amounts of fluids frequently Dry foods—crackers, toast

Pruritus

Diphenhydramine: 1 mg/kg IV or PO q4–6h prn; max: 25 mg/dose Hydroxyzine: 0.6 mg/kg/dose PO q6h; maximum: 50 mg/dose Naloxone: 0.25–2 mcg/kg/hr, not to exceed upper dose recommendation or else analgesia may reverse

Oatmeal baths, good hygiene Exclude other causes of itching. Change opioids.

Respiratory depression: mild to moderate

Hold dose of opioid Reduce subsequent doses by 25%

Arouse gently, give oxygen, encourage to deep breathe.

Respiratory depression: severe

Naloxone During disease pain management: Administer in increments until breathing improves. Reduce opioid dose if possible. Consider opioid switch. During sedation for procedures: Administer until breathing improves. Reduce opioid dose if possible. Consider opioid switch.

Oxygen, bag and mask if indicated

Dysphoria, confusion, hallucinations

Evaluate medications, eliminate adjuvant medications with central nervous system effects as symptoms allow. Consider opioid switch if possible.

Rule out other physiological causes.

Urinary retention

Evaluate medications, eliminate adjuvant medications with anticholinergic effects (e.g., antihistamines, tricyclic antidepressants). Occurs more frequently with epidural analgesia than with systemic opioid use

Rule out other physiological causes. In/out or in-dwelling urinary catheter

hs, At bedtime; IV, intravenously; PO, by mouth; PR, by rectum; prn, as needed; q, every. ∗ Although pharmacological treatment options for sedation do exist as noted in this table, in the pediatric population this is not the recommended treatment approach. For patients with mild sedation but adequately controlled pain, consider a dose reduction. If pain is not well controlled and the patient is sedated, consider changing to a different opioid and ensuring maximal use of adjuvants that are nonsedating are being used. Sources: Lau, E. (Ed.). (2020). 2020 SickKids drug handbook and formulary. The Hospital for Sick Children; Canadian Pharmacists Association. (2020). Compendium of Pharmaceuticals and Specialties (CPS). Author.

CHAPTER 34 frequently used to relieve anxiety, cause sedation, and provide amnesia are diazepam (Valium) and midazolam (Versed). However, these medications are not analgesics and should be used to enhance the effects of analgesics, not as a substitute for analgesics. Other adjuvants include tricyclic antidepressants, such as amitriptyline, nortriptyline, imipramine; antiepileptics, such as gabapentin, pregabalin, carbamazepine; ketamine for neuropathic pain; stool softeners and laxatives for constipation; antiemetics for nausea and vomiting; diphenhydramine for itching; and steroids for inflammation and bone pain.

NURSING ALERT The optimum dosage of an analgesic is one that controls pain without causing adverse effects. This usually requires titration, the gradual adjustment of medication dosage (usually by increasing the dose), until optimum pain relief, without excessive sedation or adverse effects, is achieved. It is imperative to follow monitoring guidelines as directed by an organization’s policy and procedure statements. The accessibility of a valid medication reference or formulary is required for review of opioid doses and dose ranges. It is also imperative that for a child who is discharged home on opioids the child and family are provided with verbal and written education on dosing instructions, potential adverse effects, safe storage and disposal, safe prescribing (only one licensed prescriber), and emergency instructions (e.g., contact information, when to seek urgent medical attention, such as depressed breathing). The provision of a naloxone kit for accidental overdose should be considered.

BOX 34.2

Pain Assessment and Management

827

Choosing the Pain Medication Dose. Children (except infants younger than about 3 to 6 months) metabolize medications more rapidly than adults and show great variability in medication elimination and adverse effects. Younger children may require higher doses of opioids to achieve the same analgesic effect. Therefore, the therapeutic effect and duration of analgesia vary. Children’s dosages are usually calculated according to body weight, except in children with a weight greater than 50 kg, where the weight formula may exceed the average adult dosage. In this case, the adult dosage may be considered. Conversion factors for selected opioids must be used when a change is made from IV (preferred) or IM to oral. Immediate conversion from IM or IV to the suggested equianalgesic oral dose may result in a substantial error. For example, the dose may be significantly more or less than that which the child requires. Opioid rotation is used when one opioid must be switched to another in an effort to improve clinical outcomes (benefits or harms). It begins with the selection of a new medication at a starting dose that minimizes potential risks while ideally maintaining analgesic efficacy. The selection of a starting dose must be informed by an estimate of the relative potency between the existing opioid and the new one (Fine & Porenoy, 2009; Lau & Hall, 2017). Opioid rotation is not an exact science and should be done in consultation with a pain specialist or pharmacist. Guidelines are available but should be combined with an individualized pain assessment and close monitoring (Rennick et al., 2016). Several routes of analgesic administration can be used (Box 34.2); the most effective and least traumatic route should be selected.

Routes and Methods of Analgesic Medication Administration

Oral Oral route preferred because of convenience, cost, and relatively steady blood levels Higher dosages of oral form of opioids required for equivalent parenteral analgesia Peak medication effect after 1 to 2 hours for most analgesics Delay in onset is a disadvantage when rapid control of severe pain or of fluctuating pain is desired. Sublingual, Buccal, or Transmucosal Tablet or liquid placed under tongue (sublingual), between cheek and gum (buccal), or through the mucous membrane (transmucosal) Highly desirable because more rapid onset than with oral route • Produces less first-pass effect through liver than with oral route, which normally reduces analgesia from oral opioids (unless sublingual or buccal form is swallowed, which occurs often in children) Few medications are commercially available in this form. Many medications can be compounded into sublingual troche or lozenge. • Actiq—Oral transmucosal fentanyl citrate in hard confection base on a plastic holder; indicated only for management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant of opioid therapy, but can be used for preoperative or preprocedural sedation and analgesia Intravenous (IV) (Bolus) Preferred for rapid control of severe pain Provides most rapid onset of effect, usually in about 5 minutes Advantage for acute pain, procedural pain, and breakthrough pain Not recommended if continuous pain control is required Preferable for medications with short half-life (morphine, fentanyl, hydromorphone) to avoid toxic accumulation of medication

Intravenous (Continuous) Preferred over bolus and intramuscular injection for maintaining control of pain Provides steady blood levels Easy to titrate dosage Subcutaneous (Continuous) Used when oral and IV routes not available Provides equivalent blood levels to continuous IV infusion Suggested initial bolus dose to equal 2-hour IV dose; total 24-hour dose usually requires concentrated opioid solution to minimize infused volume; use smallest-gauge needle that accommodates infusion rate. Teflon subcutaneous catheters are available for continuous infusion. These materials tend to cause less inflammation than metal needles. Policies should be followed regarding cannula changes. Patient-Controlled Analgesia (PCA) Generally refers to self-administration of medications, regardless of route Typically involves programmable infusion pump (IV, epidural, subcutaneous) that permits self-administration of boluses of medication at preset dose and time interval (lockout interval is time between doses) PCA bolus administration can be combined with bolus and continuous (basal or background) infusion of opioid. Lockout interval is based on dose and indication for the therapy • Should effectively control pain during movement or procedures • Longer lockout requires larger dose monitoring of dose; effectiveness is key. Policies and procedures should be available for PCA administration. PCA by Proxy PCA by proxy describes administration of a medication via PCA pump by someone other than the patient. There is controversy over this practice and inherent risks. Continued

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BOX 34.2

Assessment of the Child and Family

Routes and Methods of Analgesic Medication Administration—cont’d

Family-Controlled Analgesia One family member (usually a parent) or other caregiver is designated as child’s primary pain manager with responsibility for pressing PCA button Guidelines for selecting a primary pain manager for family-controlled analgesia: • Spends a significant amount of time with the patient • Is willing to assume responsibility of being primary pain manager • Is willing to accept and respect patient’s reports of pain (if able to provide) as best indicator of how much pain the patient is experiencing; knows how to use and interpret a pain rating scale • Understands the purpose and goals of patient’s pain management plan • Understands concept of maintaining a steady analgesic blood level • Recognizes signs of pain and adverse reactions to opioid Nurse-Activated Analgesia/Nurse-Controlled Analgesia (NCA) Child’s primary nurse is designated as primary pain manager and is the only person who presses PCA button during that nurse’s shift. Guidelines for selecting primary pain manager for family-controlled analgesia are also applicable to nurse-activated analgesia. May be used in addition to a basal rate to treat breakthrough pain with bolus doses; patients need to be assessed regularly for need of a bolus dose May be used without a basal rate as a means of providing rapid analgesic for sudden painful episodes or care procedures Intramuscular Not recommended for pain control; not current standard of care Painful administration (feared by children) Tissue and nerve damage possible with some medications Wide fluctuation in absorption of medication from muscle Faster absorption from deltoid than from gluteal sites Shorter duration and more expensive than oral medications Time-consuming for staff and unnecessary delay for child Intranasal Used for rapid access of medication for pain Commonly used in emergency departments and critical care units for rapid relief of pain related to procedures Can be used to effectively manage pain without an IV cannula being in place Intradermal Used primarily for skin anaesthesia (e.g., before lumbar puncture, bone marrow aspiration, arterial puncture, skin biopsy) Local anaesthetics (e.g., lidocaine) cause stinging, burning sensation Duration of stinging depends on type of “caine” used To avoid stinging sensation associated with lidocaine: • Buffer the solution by adding 1 part sodium bicarbonate (1 mmol/mL) to 9 or 10 parts 1% or 2% lidocaine with or without epinephrine. Normal saline with preservative, benzyl alcohol, used to anaesthetize venipuncture site • Use same dose as for buffered lidocaine. Topical or Transdermal EMLA (eutectic mixture of local anaesthetics [lidocaine and prilocaine]) cream and anaesthetic disk or LMX4 (4% lidocaine cream) • Eliminates or reduces pain from most procedures involving skin puncture • Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anaesthetic disk for 30 to 60 minutes (product dependent) before procedure • May cause skin blanching and vasoconstriction, therefore may make venous access slightly more challenging

AMETOP (4% tetracaine) Maxiline (lidocaine) • Eliminates or reduces pain from most procedures involving skin puncture • Must be placed on intact skin over puncture site and covered by occlusive dressing or for 30 minutes or more before procedure • May cause vasodilation, therefore may make venous access easier LAT (lidocaine-adrenaline-tetracaine), LET (lidocaine-epinephrine-tetracaine) or tetracaine-phenylephrine (tetraphen) • Provides skin anaesthesia about 15 minutes after application on nonintact skin • Gel (preferable) or liquid placed on wounds for suturing • Adrenaline not for use on end arterioles (fingers, toes, tip of nose, penis, earlobes) because of vasoconstriction Transdermal fentanyl (Duragesic) • Available as patch for continuous pain control • Safety and efficacy not established in children younger than 12 years of age (used at the discretion of the care team; palliative care use is often the circumstance) • Not appropriate for initial relief of acute pain because of long interval to peak effect (12 to 24 hours); for rapid onset of pain relief, an immediate-release opioid is given. • Orders for “rescue doses” of an immediate-release opioid recommended for breakthrough pain (a flare of severe pain that breaks through the medication being administered at regular intervals for persistent pain) • Has duration of up to 72 hours for prolonged pain relief • If respiratory depression occurs, possible need for several doses of naloxone • Patch should not be cut or modified in any way. Gloves are needed to handle. Soap, alcohol, or any other solvent should not be used on the skin before application as this may affect medication absorption. Patch should be applied only to intact skin. Patch should not be exposed to external heat sources as this may increase medication release and has resulted in fatalities. Must be removed before magnetic resonance imaging (MRI). Vapocoolant • Use of prescription spray coolant, such as Fluori-Methane (Spray and Stretch) or ethyl chloride (Pain EaseTM) • Applied to the skin for 10 to 15 seconds immediately before the needle puncture; anaesthesia lasts about 15 seconds • Cold disliked by some children • Child must be able to describe the degree of cold sensation to avoid tissue damage. • Application of ice to the skin for 30 seconds found to be ineffective Rectal* Alternative to oral or parenteral routes Variable absorption rate Generally disliked by children Regional Techniques/Peripheral Nerve Blocks Use of long-acting local anaesthetic (bupivacaine or ropivacaine) injected into tissue surrounding nerves to block pain at site of injury or surgery. A nerve block is a deliberate interruption of signals that travel along a nerve pathway for the purpose of pain control. A peripheral nerve block can last hours to days depending on the medication and modality being used (e.g., a single shot or continuous infusion of an anaesthetic agent). Peripheral nerve block infusions are used as a postoperative pain management modality. A single injection intraoperatively can be used to provide longer pain control in the postoperative phase of care. Nerve blocks are inserted at the site where the nerve roots are innervated around a surgical site and administered Continued

CHAPTER 34

BOX 34.2

Pain Assessment and Management

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Routes and Methods of Analgesic Medication Administration—cont’d

as an infusion. Common peripheral nerve blocks include femoral, fascia iliaca, popliteal, intercostal, and paravertebral (Roberts et al., 2019). Inhalation Use of anaesthetics, such as nitrous oxide, to produce partial or complete analgesia for painful procedures Adverse effects (e.g., headache) possible from occupational exposure to high levels of nitrous oxide Epidural or Intrathecal Involves a catheter placed into epidural or intrathecal space for continuous infusion or single or intermittent administration of opioid with or without a longacting local anaesthetic (e.g., bupivacaine, ropivacaine)

Analgesia primarily from medication’s direct effect on opioid receptors in spinal cord and from action of local anaesthetic on spinal nerves Respiratory depression is rare but may have slow and delayed onset; can be prevented by checking level of sedation and respiratory rate and depth hourly for initial 24 hours and decreasing dose when excessive sedation is detected Nausea, itching, and urinary retention are common dose-related adverse effects from the epidural opioid. Mild hypotension, urinary retention, and temporary motor or sensory deficits are common unwanted effects of epidural local anaesthetic. Catheter for urinary retention is inserted during surgery to decrease trauma to child; if inserted when child is awake, anaesthetize urethra with lidocaine.

*Many medications can be compounded into rectal suppositories. For further information about compounding medications in troche or suppository form, contact Professional Compounding Centers of America (PCCA), Canada, 744 Third Street, London, ON, N5V 5J2, 800.668.9453, http://www. pccarx.ca/.

Timing of Analgesia. The right timing for administering analgesics depends on the type of pain. For continuous pain control, such as for postoperative or cancer pain, a preventive schedule of medication around the clock (ATC) is effective. The ATC schedule avoids the low concentrations of medications in plasma that permit breakthrough pain. If analgesics are administered only when pain returns (a typical use of the prn, or “as needed,” order), pain relief may take several hours. The patient may then require higher doses, leading to a cycle of undermedication of pain, alternating with periods of overmedication and medication toxicity. This cycle of erratic pain control also promotes “clock watching,” which may be erroneously equated with addiction. Nurses can effectively use prn (as needed) orders by giving the medication at regular intervals, since “as needed” should be interpreted as “as needed to prevent pain,” not “as little as possible.” Continuous oral doses of an opioid ATC can be as effective as an IV infusion and potentially have fewer adverse effects. Breakthrough medication can be administered intravenously or orally as ordered but not exceeding the timing of the medication’s expectation of effectiveness. If many breakthrough doses are required, the scheduled dose of the medication should be re-evaluated or a different opioid administered for better efficacy. For extended pain control with fewer administration times for a child with complex pain, medications that provide longer duration of action (e.g., some NSAIDs, time-released/controlled release morphine, hydromorphone, oxycodone, or methadone) can be used. The challenge with controlled-release medications can be the dose availability for the pediatric patient. Continuous analgesia is not always appropriate, since not all pain is continuous. Frequently, temporary pain control or conscious sedation is needed to provide analgesia or anti-anxiety effects before a scheduled procedure. When pain can be predicted, the medication’s peak effect should be timed to coincide with the painful event. For example, with opioids the peak effect is approximately a half-hour for the IV route; with nonopioids the peak effect occurs about 2 hours after oral administration. For rapid onset and peak of action, opioids that quickly penetrate the blood–brain barrier (e.g., IV fentanyl) provide excellent pain control. Patient-Controlled Analgesia. A significant advance in the administration of IV, epidural, or subcutaneous analgesics is the use of patient-controlled analgesia (PCA). As the name implies, the patient controls the amount and frequency of the analgesic, which is typically delivered through a special infusion device. Children who

are physically able to “push a button” and who can understand the concept of pushing a button to obtain pain relief can use PCA, that is, children over 6 years of age (DiGiusto et al., 2014). Although controversial, the IV PCA system for children has been used by parents and nurses (see Box 34.2). Children can use the IV PCA system if they are old enough and capable of effectively managing their own pain. Nurses can efficiently use the PCA device on a child of any age to administer analgesics to avoid signing for and preparing opioid injections every time one is needed (Figure 34.5). When PCA is used “by proxy” (administered by a nurse or parent), the concept of patient control is negated, and the inherent safety of PCA needs to be monitored. Human error can occur in this situation, and education is key (Ocay et al., 2018).

Fig. 34.5 Nurse programming a patient-controlled analgesia pump to administer analgesic.

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PCA infusion devices typically allow for three methods or modes of medication administration to be used alone or in combination: 1. Patient-administered boluses that can only be infused according to the preset amount and lockout interval (time between doses). More frequent attempts at self-administration usually mean that the patient may need the dose and time adjusted for better pain control. Patient understanding of how to use the device should be evaluated and further education may be required. 2. Nurse-controlled analgesia (NCA) using a PCA device is often used for rapid administration of an opioid. The nurse makes the assessment that the child is in pain and can press the button without leaving the patient’s beside to access pain medication. The child is often too young or unable to understand the concept of pressing the button. The nurse can also use the button for preemptive pain management if a care process will be painful for the child (e.g., diaper change for a child with severe mucositis affecting the rectal mucosa). Dose and lockout periods maybe altered (generally longer) for safety according to organizational policy and patient care requirements. Clear documentation and assessment parameters for using an NCA should be in place. 3. Continuous basal rate infusion that delivers a constant amount of analgesic and prevents pain from intensifying during times when the patient cannot control the amount of analgesic they receive, such as during sleep. A PCA may have the capability to have a continuous basal infusion as well as bolus dosing capabilities. As with any type of analgesic management plan, continued assessment of the child’s pain relief is essential for the greatest benefit from PCA. Typical uses of PCA are for controlling pain from surgery, sickle cell crisis, trauma, and cancer. Morphine is the medication of choice for PCA and standard concentrations are used for safety. Hydromorphone is often used when patients are not able to tolerate morphine because of the adverse effects, such as pruritus and nausea, from the morphine PCA.

NURSING ALERT Close attention must be paid to programming a PCA device. The medication, dose, modality (bolus only, bolus and continuous infusion), lockout parameters, and maximum time-limited dose (1 hour, 2 hours, 4 hours) should be checked against the health care provider orders to avoid any programming errors. Standardized concentrations of opioids limit the potential for errors (Institute for Safe Medication Practices Canada, 2014).

Epidural Analgesia. Epidural analgesia may be used to manage pain intraoperatively and postoperatively, in selected cases. An epidural catheter is placed into the epidural space of the spinal column at the lumbar, thoracic, or caudal level (Figure 34.6). The direct thoracic level is most often used for older children or adolescents who have had an upper abdominal or thoracic procedure, such as a lung transplant. It is important to understand where the catheter is placed, as it has implications for assessment. An opioid (usually fentanyl, hydromorphone, or preservative-free morphine, which is often combined with a longacting local anaesthetic such as bupivacaine or ropivacaine) is instilled via single or intermittent bolus, continuous infusion, or patientcontrolled epidural analgesia. Analgesia results from the medication’s effect on opiate receptors in the dorsal horn of the spinal cord, rather than the brain. As a result, respiratory depression is rare, but if it occurs, it develops slowly, typically 6 to 8 hours after administration.

Fig. 34.6 Epidural analgesia catheter placement.

Careful securing of the epidural catheter with an occlusive dressing decreases the possibility of soiling or inadvertently displacing the catheter. Careful monitoring of sedation level and respiratory status is critical to prevent opioid-induced respiratory depression. Assessment of pain, sensory and motor block, as well as the skin condition around the catheter site is an important aspect of related nursing care. Proper positioning and change of position should occur for any child with an epidural in place. Close monitoring of urinary output and function is important if the child has a lumbar epidural infusion. Depending on the level of the epidural, catheter urinary retention may occur, as the epidural may affect the motor and sensory nerve fibres of the pelvis and may interfere with the function of the bladder. A urinary catheter is often placed intraoperatively to avoid this issue.

Transmucosal and Transdermal Analgesia. Oral transmucosal fentanyl (Oralet) provides nontraumatic preoperative and preprocedural analgesia and sedation. Fentanyl is also available as a transdermal patch (Duragesic). Although contraindicated for acute pain management, it may be used for children and adolescents who have cancer pain or for palliative pain management. One of the most significant pain management improvements in the ability to provide atraumatic needle stick care to children is with an anaesthetic cream, which is a 4% liposomal lidocaine preparation (Maxilene, Ametop) or EMLA (a eutectic mixture of local anaesthetics). The eutectic mixture (lidocaine 2.5% and prilocaine 2.5%), whose melting point is lower than that of the two anaesthetics alone, permits effective concentrations of the medication to penetrate intact skin (Figure 34.7). In some situations, refrigerant sprays such as ethyl chloride and fluoromethane can be used. When sprayed on the skin, these sprays vaporize, rapidly cooling the area and providing superficial anaesthesia. Hospital formularies may have other products with lidocaine, prilocaine, or amethocaine topical preparations that require less time for application. The intradermal route is sometimes used to inject a local anaesthetic, typically lidocaine, into the skin to reduce the pain from a lumbar puncture, bone marrow aspiration, or venous or arterial access. One concern with the use of lidocaine is the stinging and burning that initially occurs. However, the use of buffered lidocaine with sodium bicarbonate reduces the stinging sensation.

CHAPTER 34

Fig. 34.7 LMX is an effective analgesic before intravenous insertion or blood draw.

Intranasal Route. The intranasal route is another option in the delivery of medication. The nasal mucosa are highly vascularized and provide rapid absorption in the central nervous system. The onset of action is similar to the IV route as it avoids first-pass metabolism. A first-pass effect or metabolism is a phenomenon whereby the concentration of a medication that is administered enterally is reduced and only a proportion of the medication reaches the systemic circulation. Bioavailability is the term used to describe the amount of a medication that remains unchanged after first-pass metabolism. It is important to note many factors can affect bioavailability. The intranasal route is used most often in the emergency department when rapid access to medication is required and vascular access has not been established. A number of medications can be administered via the intranasal route, including opioids and benzodiazepines (e.g., fentanyl, midazolam, lorazepam). An atomization device can be used as it breaks down the medications into a fine mist and is easily inhaled and well tolerated (Baily et al., 2017). Cannabinoids. Cannabinoids are derived from the cannabis plant. Cannabidiol and tetrahydrocannabinol (THC) are the most studied chemical agents. These chemicals interact with receptors in the endocannabinoid system, which moderates functions such as neurodevelopment, cognition, and motor control (Libzon et al., 2018). There are two cannabinoid receptors, CB1 and CB2. CB1 is believed to be responsible for psychological effects on pleasure, memory, thought, concentration, sensory and time perceptions, and coordinated movement. CB2 is thought to play an anti-inflammatory and immunosuppressive role (Campbell et al., 2017). THC is a partial agonist at both CB1 and CB2 receptors and achieves its psychoactive properties likely through modulation of gamma-aminobutyric acid (GABA) and glutamine, two neurotransmitters within the central nervous system that have significant neurodevelopmental effects on the brain (Marzo et al., 2004).

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The frontal cortex, responsible for higher-order cognitive processes such as judgement and decision making, is undergoing rapid change during adolescence and, as such, is more susceptible to THC (Blakemore, 2013). Conversely, cannabidiol does not appear to bind to either CB1 or CB2 but does possess neuroprotective and antiinflammatory effects, the exact mechanism of which is unknown and the subject of recent debate and clinical trials. Since the legalization of cannabis in Canada, many patients and families are requesting medical cannabis for a variety of conditions. It is important that patients and families are provided with upto-date, unbiased information to allow for informed decision making. Wong and Wilens (2017) completed a systematic review on the use of medical cannabinoids in children and adolescents and found evidence for benefit was strongest for chemotherapy-induced nausea and vomiting, with increasing evidence of benefit for treating epilepsy. However, they found insufficient evidence to support its use for neuropathic pain, as well as for spasticity, post-traumatic stress disorder, and Tourette syndrome. Additional research is needed to evaluate the potential role of medical cannabinoids in treating children and adolescents, especially given the increasing accessibility and the potential psychiatric and neurocognitive adverse effects identified from studies of recreational cannabis use (Wong & Wilens, 2017). In addition, a recent study by Gobbi et al. (2019) found that adolescent cannabis consumption was associated with increased risk of developing depression and suicidal behaviour later in life, even in the absence of a premorbid condition. Given what is known about the ongoing development of the brain throughout childhood and adolescence, caution should be used when introducing cannabis in this age group, and only when supported by research-based evidence (Grant & Belanger, 2017; Lisdahl et al., 2014). As this area of treatment continues to move forward, policies and procedures must be in place to address the prescribing, dispensing, administration, monitoring, and storage of cannabinoids. It is imperative that high-quality studies be done to understand the indications and risks for the use of cannabinoids in pediatrics.

Monitoring Adverse Effects of Analgesic Management. Anticipation and early management of adverse effects of pharmacological interventions is an important and vital aspect of pain treatment (RNAO, 2013). Commonly occurring adverse events anticipated with the use of NSAIDs include nausea, vomiting, and constipation but can also include GI bleeding. The use of Aspirin in children with chickenpox or influenza is associated with Reye syndrome, thus alternatives should be used. Commonly occurring adverse effects anticipated with use of opioids include sedation, nausea, vomiting, constipation, and itching (Box 34.3). Nurses, in partnership with the interprofessional health team, the family and caregivers, and the child if the child is able to contribute information, need to judiciously monitor the effectiveness of the treatment and anticipate and monitor adverse effects of treatment (Table 34.4). Respiratory depression is the most serious complication and poses increased risk in sedated children and infants. The respiratory rate may decrease gradually, or respirations may cease abruptly and thus must be monitored closely. Any significant change from a previous rate calls for increased vigilance. A slower respiratory rate does not necessarily reflect decreased arterial oxygenation; an increased depth of ventilation may compensate for the altered rate. If respiratory depression or arrest occurs, the nurse must be prepared to intervene quickly (see Guidelines box: Managing Opioid-Induced Respiratory Depression).

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BOX 34.3

Assessment of the Child and Family

Adverse Effects of Opioids

General Constipation (possibly severe) Respiratory depression Sedation Nausea and vomiting Agitation, euphoria Confusion Hallucinations Orthostatic hypotension Pruritus Urticaria Sweating Miosis (may be sign of toxicity) Anaphylaxis (rare) Signs of Tolerance Decreasing pain relief Decreasing duration of pain relief

GUIDELINES Managing Opioid-Induced Respiratory Depression If Respirations Are Depressed • Assess sedation level. • Reduce infusion by decrements (25% reduction when possible). • Stimulate patient (shake shoulder gently, call by name, ask to breathe). • Administer oxygen. If Patient Cannot Be Aroused or Is Apneic Administer naloxone (Narcan) For resuscitation: • Titrate to achieve a positive response with 0.01 mg/kg/dose increments intravenously (IV) or via endotracheal tube (ETT) or 0.1 mg/kg/dose IV/ETT repeat prn. Dose limit is 2 mg/dose. • Administer bolus by slow IV push every 2 minutes until effect is obtained. • Naloxone’s duration of antagonist action may be shorter than that of opioid, requiring repeated doses of naloxone. Management of adverse opioid effects: • Administer 0.001–0.01 mg/kg IV dose; observe and repeat every 10 minutes prn to a maximum total dose of 0.1 mg/kg or continuous infusion 0.5 to 1 mcg/kg/hr starting dose range (0.25–2 mcg/kg/hr). Following the administration of naloxone, the patient must be monitored with constant care and discharged only when they are fully awake and a minimum of 3 hours from the last dose has elapsed. Note: Respiratory depression caused by benzodiazepines (e.g., diazepam [Valium] or midazolam [Versed]) can be reversed with flumazenil (Romazicon), a benzodiazepine antagonist: use dose of 0.01 mg/kg (10 mcg/kg) over 15 seconds; if there is no (or inadequate) response after 1 to 3 minutes repeat dose; if necessary, dose may be repeated up to 4 times at 1- to 3-minute intervals to a total dose of 50 mcg/kg. Dose limit is 1 000 mcg/dose, total dose 3 000 mcg. Adapted from Lau, E. (Ed.). (2016). 2016 SickKids drug handbook and formulary. The Hospital for Sick Children.

Although respiratory depression is the most feared adverse effect, constipation is a common, and sometimes serious, adverse effect of opioids. If ongoing use of opioids is expected, prevention with stool softeners and laxatives is more effective than treatment once constipation occurs. Dietary treatment, such as increased fibre, is usually not

Signs of Withdrawal Syndrome in Patients With Physical Dependence The use of a withdrawal assessment tool to identify signs and symptoms of withdrawal is important if opioids or benzodiazepines are being decreased. Initial Signs of Withdrawal Lacrimation Rhinorrhea Yawning Sweating Later Signs of Withdrawal Restlessness Irritability Tremors Anorexia Dilated pupils Gooseflesh Nausea, vomiting

sufficient to promote regular bowel evacuation. However, dietary measures, such as greater fluid and fruit intake, and physical activity are encouraged. Another common adverse effect is pruritus from epidural or IV infusion. Pruritus can be treated with low doses of IV naloxone most often in the form of an infusion, nalbuphine, or diphenhydramine. Nausea and vomiting usually subside after 2 days of opioid administration; however, oral or rectal antiemetics may be necessary. Opioid rotation may be helpful with any unwanted effects from opioids. Tolerance and physical dependence. Tolerance occurs when the dose of an opioid needs to be increased to achieve the same analgesic effect that was previously achieved at a lower dose (see Family-Centred Care box: Fear of Opioid Addiction). Tolerance may develop after only a few days of therapy; physiological response and genetic factors can affect the time for someone to become tolerant to a medication. Treatment of tolerance involves increasing the dose or decreasing the duration between doses. Physical dependence is a normal, natural, physiological state of “neuroadaptation.” When opioids are abruptly discontinued without weaning, withdrawal symptoms occur. Withdrawal is the physical signs and symptoms that occur after an opioid or benzodiazepine is stopped abruptly or weaned too quickly after continuous use. Withdrawal may occur after 5 consecutive days of use or occasionally as short as 3 days and is more common in critically ill children. Treatment of physical dependence involves gradually reducing the medication to prevent withdrawal (Kanwaljeet et al., 2010). Medications known to cause withdrawal symptoms include opioids, benzodiazepines, clonidine, dexmedetomidine, barbiturates, and chloral hydrate. Risk factors for withdrawal from analgesia and sedation agents include newborns, children, and adolescents who (SickKids, 2018): • Have required analgesia or sedation for greater than 5 days • Require high doses of multiple agents • Have had previous experience of withdrawal • Are less than 6 months of age The use of a withdrawal assessment tool should be considered if an infant or child has been on opioids or benzodiazepines for 5 days or more and is being tapered from their use. The Withdrawal Assessment Tool–1 (WAT-1) is one example and may be used to assess and monitor withdrawal symptoms in children (Franck et al., 2008) (Figure 34.8). See Chapter 29 for more information on care of the drug-exposed newborn.

WITHDRAWAL ASSESSMENT TOOL VERSION 1 (WAT – 1) © 2007 L.S. Franck and M.A.Q. Curley. All Rights reserved. Reproduced only by permission of Authors.

Patient Identifier Date: Time: Information from patient record, previous 12 hours Any loose /watery stools

No = 0 Yes = 1 No = 0 Yes = 1 No = 0 Yes = 1

Any vomiting/retching/gagging o

Temperature > 37.8 C

2 minute pre-stimulus observation 1

State

SBS < 0 or asleep/awake/calm = 0 1 SBS > +1 or awake/distressed = 1 Tremor None/mild = 0 Moderate/severe = 1 Any sweating No = 0 Yes = 1 Uncoordinated/repetitive movement None/mild = 0 Moderate/severe = 1 Yawning or sneezing None or 1 = 0 >2 = 1

1 minute stimulus observation Startle to touch

None/mild = 0 Moderate/severe = 1 Normal = 0 Increased = 1

Muscle tone

Post-stimulus recovery 1

Time to gain calm state (SBS < 0)

< 2min = 0 2 - 5min = 1 > 5 min = 2

Total Score (0-12) Fig. 34.8 Withdrawal Assessment Tool Version 1 (WAT-1) for monitoring withdrawal syndrome in pediatric patients. SBS, State behavioural scale. From Curley, M.A., Harris, S.K., Fraser, K.A., Johnson, R.A., Arnold, J.H. (2006). State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatric Critical Care Medicine, 7(2), 107-114. https://doi.org/10.1097/01.PCC. 0000200955.40962.38.

FAMILY-CENTRED CARE Fear of Opioid Addiction One of the reasons for the unfounded but prevalent fear of addiction from opioids used to relieve pain is a misunderstanding of the differences between physical dependence, tolerance, and addiction. Health care providers and community members often confuse addiction with the physiological effects of opioids, when, in reality physical dependence, tolerance, and addiction differ in important ways. The Canadian Pain Society defines these terms as follows: Physical dependence is a state of adaptation that often includes tolerance and is manifested by a medication class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the medication, or administration of an antagonist. It is not the same thing as addiction. The symptoms of withdrawal include signs of neurological excitability (irritability, tremors, seizures, increased motor tone, insomnia), gastrointestinal dysfunction (nausea, vomiting, diarrhea, abdominal cramps), autonomic dysfunction (sweating, fever, chills, tachypnea, nasal congestion, rhinitis), hypertension, and muscle aches. These symptoms can be minimized by slowly decreasing the dose of opioids. Weaning should be planned for any patient who has been taking opioids for more than 5 to 7 days. Tolerance is a state of adaptation in which exposure to a medication induces changes that result in a diminution of one or more of the medication’s effects over time. This is also not the same as addiction.

Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviours that include one or more of the following (4 C’s): • Impaired Control over drug use • Compulsive use • Craving • Continued use despite harm (Consequences) Unfortunately, individuals who have severe, unrelieved pain may become intensely focused on finding relief. Sometimes behaviours such as “clock watching” make patients appear to others to be preoccupied with obtaining opioids. However, this preoccupation centres on finding relief of pain, not on using opioids for reasons other than pain control. This phenomenon has been termed pseudoaddiction and must not be confused with clinical addiction. Nurses are in an ideal position to educate children, parents, and other health care providers about the risk of addiction (less than 1%) from the use of opioids to treat pain. Helping families and caregivers to understand that infants, young children, and comatose or terminally ill children have a low risk of addiction is integral to the role of the nurse caring for these children.

Data from The Canadian Pain Society. (2005). Accreditation pain standard: Making it happen! https://acclaimhealth.ca/wp-content/uploads/2019/01/ Canadian-Pain-Society-Accreditation-Standards.pdf.

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Patients requiring more than 5 to 7 days of opioids should have tapering doses to avoid the physiological symptoms of withdrawal (dysphoria, nasal congestion, diarrhea, nausea and vomiting, sweating, and seizures) (Figure 34.9). Appropriate weaning of the PCA

schedules start with reduction of the continuous infusion rate before discontinuation while the patient continues to use demand doses for analgesia. Morphine-equivalent equianalgesic conversions may be used to convert continuous infusion rates to equivalent oral analgesics.

Weaning Algorithm for Combination Use of Opioids and Benzodiazepines OPIOIDS

BENZODIAZEPINES (BZD) Lorazepam ≥ 3 doses/day for ≥ 5 days

Infusion of ≥ 5 days

or Midazolam infusion > 5 days

Order WAT – 1 Withdrawal Scoring

NICU: Continue midazolam infusion or IV lorazepam Q6H

Establish enteral or IV Diazepam Q6H

Non-CCU: Discontinue all PRN boluses STOP: If PRN needed, NOTIFY MD for reassessment of wean

CCU: Reorder only the previous ordered PRN’s as: x Opioid: Morphine 0.1mg/kg IV Q12H PRN x Chloral: 20mg/kg PO Q12H PRN x Lorazepam: 0.1mg/kg IV Q12H PRN

If at any time during wean WAT–1 ≥ 3 or trending up consider:

Begin Opioid Wean Consider switch to PO opioid

≥ 6 months old with Opioid use 5-10 days

Wean by 20% of original dose Q24H

< 6 months old with Opioid ≥5 days OR ≥ 6 months old with Opioid>10 days

Wean by 10% of original dose Q24H

P R O B L E M S O L V I N G

Opioid wean at 50% of original dose Ÿ START BZD wean by 10% Q24H and continue to wean opioid at same rate CHANGE TO ENTERAL AND CONTINUE SAME % WEAN

MORPHINE: Wean enteral dose until at 0.1mg/kg/dose q4 hours then keep dose the same and increase the interval to q6hours, then 8 hours, then q12 hours, then q24hours before ceasing

x Non-pharmacological methods x Contacting primary health care provider x OPIOID withdrawal: 1Bolus opioid 2-Increase to previous dose 3-Ensure symptoms resolve 4-hold wean for 24H a. If above does not work, consider bolus of BZD and increase regular dose b. Consider slowing wean c. Consider alternate day weans of opioid and BZD d. Consider adding adjuncts x Consult Pain Team for ward follow up in difficult weans

DIAZEPAM: Wean enteral dose until at 0.05mg/kg/dose q6hours, then keep dose the same and increase the interval to q8hours, then q12 hours, then q24hours before ceasing

Fig. 34.9 Weaning algorithm. CCU, Critical care unit; D/C, discontinue; IV, intravenous; NICU, neonatal intensive care unit; PO, by mouth; PRN, as needed; Q12/24H, every 12/24 hours; WAT-1, Withdrawal Assessment Tool Version 1.

CHAPTER 34 Doses of long-acting oral analgesics, such as sustained-release oral morphine, may also be used to replace continuous infusion dosing. The demand doses can be subsequently reduced if analgesia remains adequate. Parents and older children may fear addiction when opioids are prescribed. The nurse should address these concerns with assurance that any such risk is extremely low. It may be helpful to ask the question, “If you did not have this pain, would you want to take this medicine?” The answer is invariably no, which reinforces the solely therapeutic nature of the medication. It is also important to avoid making statements to the family such as “We don’t want you to get used to this medicine,” or “By now you shouldn’t need this medicine,” which may reinforce the fear of becoming addicted. Whereas both physical dependence and tolerance are physiological states, addiction or psychological dependence is a psychological state and implies a “cause–effect” mode of thinking, such as “I need the drug because it makes me feel better.” The use of opioid analgesics early in life has not been demonstrated to increase the risk for addiction later in life. Nurses need to explain to parents the differences between physical dependence, tolerance, and addiction and allow parents to express concerns about the use and duration of use of opioids. Infants, when treated appropriately with opioids, may be at risk for physical tolerance and physical dependence, but not psychological dependence or addiction.

COMMON PAIN STATES IN CHILDREN Painful and Invasive Procedures Procedures that infants and children must experience as part of routine medical care often cause pain and distress. For example, infants and children experience a substantial amount of pain due to routine immunizations. Combining pharmacological and mind–body interventions provides the best approach for reducing pain. Local anaesthetic administration is crucial to minimize pain from the procedure and is discussed in the Transmucosal and Transdermal Analgesia section earlier in this chapter.

Procedural Sedation and Analgesia Severe pain associated with invasive procedures and anxiety associated with diagnostic imaging can be managed with sedation and analgesia. Sedation involves a wide range of levels of consciousness (Box 34.4). A thorough patient assessment, including the child’s history, is essential before procedural sedation.

BOX 34.4

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BOX 34.5

Procedural Sedation and Analgesia Equipment Needs • High-flow oxygen and delivery method • Airway management materials: endotracheal tubes, bag valve masks, and laryngoscopes • Pulse oximetry, blood pressure monitor, electrocardiography, capnography • Suction and large-bore catheters • Vascular access supplies • Resuscitation drugs, intravenous (IV) fluids • Reversal agents, including flumazenil and naloxone

Key components to include in the patient history include the following: • Past medical history: major illnesses, previous hospitalizations or surgeries; history of previous anaesthesia or sedation • Allergies assessment and an up-to-date medication reconciliation • Current medications • Illicit drug use: narcotics, benzodiazepines, barbiturates, drugs not prescribed by a health care provider, cannabis, cocaine, and alcohol • Last oral intake and volume status To provide a safe environment for procedural sedation and analgesia (PSA), equipment should be readily available to prevent or manage adverse events and complications (Box 34.5). The patient must have an IV access for titration of sedation and analgesic medications and for administration of possible antagonists and fluids. Trained personnel who are members of the interprofessional care team (physician, registered nurse, respiratory therapist) whose sole responsibility is to monitor the patient (rather than performing or assisting with the procedure) should be present to monitor for adverse events and complications.

Postoperative Pain Surgery and traumatic injuries (fractures, dislocations, strains, sprains, lacerations, burns) generate a catabolic state as a result of increased secretion of catabolic hormones and lead to alterations in blood flow, coagulation, fibrinolysis, substrate metabolism, and water and electrolyte imbalance and increase the demands on the cardiovascular and respiratory systems. Themajor endocrineandmetabolic changesoccurduringthe first48hours after surgery or trauma. Local anaesthetics and opioid neural blockade may effectively mitigate the physiological responses to surgical injury. Pain associated with surgery to the chest (e.g., repair of congenital heart defects, chest trauma) or abdominal regions (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications.

Levels of Sedation

Minimal Sedation (Anxiolysis) Patient responds to verbal commands. Cognitive function may be impaired. Respiratory and cardiovascular systems are unaffected.

Deep Sedation Patient cannot be easily aroused except with repeated or painful stimuli. Ability to maintain airway may be impaired. Spontaneous ventilation may be impaired; cardiovascular function is maintained.

Moderate Sedation (Previously Conscious Sedation) Patient responds to verbal commands but may not respond to light tactile stimulation. Cognitive function is impaired. Respiratory function is adequate; cardiovascular system is unaffected.

General Anaesthesia Loss of consciousness, patient cannot be aroused with painful stimuli. Airway cannot be maintained adequately, and ventilation is impaired. Cardiovascular function may be impaired.

From Meredith, J. R., O’Keefe, K. P., & Galwankar, S. (2008). Pediatric procedural sedation and analgesia. Journal of Emergencies, Trauma and Shock, 1(2), 88–96.

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Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications (such as pneumonia and atelectasis) is high. Severe postoperative pain also results in sympathetic overactivity that leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. The patient eventually experiences an increase in cardiac demand and myocardial oxygen consumption and a decrease in oxygen delivery to the tissues. The basis for good postoperative pain control in children is preemptive analgesia (Michelet et al., 2012). Preemptive analgesia involves administration of medications (e.g., local and regional anaesthetics, analgesics) before the child experiences the pain or before surgery is performed so that the sensory activation and changes in the pain pathways of the peripheral and central nervous systems can be controlled. Preemptive analgesia lowers postoperative pain, decreases analgesic requirement, decreases length of hospital stay, results in fewer complications after surgery, and minimizes the risks for peripheral and central nervous system sensitization that can lead to persistent pain. A combination of medications (multimodal or balanced analgesia) is used for postoperative pain and may include NSAIDs, local anaesthetics, nonopioids, and opioid analgesics to achieve optimum relief and minimize adverse effects. Opioids administered ATC during the first 48 hours or administered via PCA are commonly prescribed. Perioperative NSAID administration has been shown to reduce opioid consumption and postoperative nausea and vomiting in children (Michelet et al., 2012). Scheduled acetaminophen is supported as the preferred medication in children after tonsillectomy. The combination of the IV NSAID ketorolac and morphine using a PCA device is frequently prescribed after thoracic surgery. Morphine delivered by PCA leads to a lower total dosage of opioid analgesia when compared with the administration of intermittent doses of analgesic as required. After bowel surgery, a mixture of a local anaesthetic (bupivacaine) and a low-dose opioid (fentanyl) delivered by epidural route improves the rate of recovery and minimizes the GI effects (e.g., bowel stasis, nausea, vomiting). In older children, once bowel function has been restored, oral opioids (e.g., immediate-release and controlledrelease preparations) are preferred. Controlled-release opioids facilitate ATC dosing and improve sleep. They are also associated with a lower incidence of nausea, sedation, and breakthrough pain.

Burn Pain Because burn pain has multiple components, involves repeated manipulations over the injured painful sites, and has changing patterns over time, it is difficult and challenging to control. Burn pain includes a constant background pain that is felt at the wound sites and surrounding areas. Burn pain is exacerbated (breakthrough pain) by movements, such as changing position, turning in bed, walking, or even breathing. Areas of normal skin that have been harvested for skin grafts (donor sites) also are painful. Pain is commonly experienced with intense tingling or itching sensations when skin grafting is required. During the healing process, when the tissue and nerves regenerate, the necrotic tissue (eschar) is excised until viable tissue is reached. The healing process may last for months to years. Pain or paresthetic sensations (itching, tingling, cold sensations) may persist. In addition, discomfort may be associated with immobilization of limbs in splints or garments, as well as multiple surgical interventions such as skin grafting and reconstructive surgery. Multiple therapeutic procedures are carried out during the course of treatment. These procedures (dressing changes, wound debridement and cleansing, physiotherapy) occur daily or even several times per

day (see Chapter 52). Providing proper analgesia without interfering with the patient’s awareness during and after the procedure is the biggest challenge in the management of burn pain. Fentanyl or alfentanil has a major advantage over morphine because of the short duration. Fentanyl can prevent oversedation after the procedure. For less painful procedures, premedication with oral morphine, oral ketamine, or milder opioids 15 minutes before the procedure may be sufficient. Depending on the patient’s anxiety level, a benzodiazepine (e.g., lorazepam) before the procedure may be beneficial. For longer procedures, morphine is the mainstay of treatment. Some patients may require moderate to deep sedation and analgesia. Oral oxycodone with midazolam and acetaminophen, in addition to nitrous oxide, may be needed. IV ketamine administered at subtherapeutic doses has been one of the most extensively used anaesthetics for burn patients. The dysphoria and unpleasant reactions associated with ketamine administration may be minimized with premedication with a benzodiazepine. If ketamine is used with either morphine or fentanyl, the regimen could have opioid-sparing actions and reduce the opioid-related adverse effects. Mind–body strategies are helpful in the treatment of burn pain. These interventions include hypnosis, relaxation training (breathing exercises, progressive muscle relaxation), biofeedback, stress inoculation training, cognitive-behavioural strategies (guided imagery, distraction, coping skills), and group and individual psychotherapy. They can be used alone or in combination. All of these techniques can help the patient relax and maintain a sense of control. A major disadvantage of these interventions is that they require time and discipline, and often patients are too stressed, fatigued, disoriented, or sick to engage in them.

Recurrent Headaches in Children Recurrent headaches in children can be caused by several factors, including tension, dental braces, imbalance or weakness of eye muscles causing deviation in alignment and refractive errors, sequelae to accidents, sinusitis and other cranial infection or inflammation, increased intracranial pressure, epileptic attacks, medications, obstructive sleep apnea, and, rarely, hypertension. Other causes may include arteriovenous malformations, disturbances in cerebrospinal fluid flow or absorption, intracranial hemorrhages, ocular and dental diseases, bacterial infections, and brain tumours. Severe pain is the most disturbing symptom in migraine. Tensiontype headache is usually mild or moderate, often producing a pressing feeling in the temples, like a “tight band around the head.” Continuous, daily, or near-daily headache with no specific cause, or due to chronic daily use of simple analgesics such as acetaminophen and NSAIDS, occurs in a small subgroup of children. In epilepsy, headaches commonly occur immediately before, during, or after a seizure attack. Treatment of recurrent headaches requires an understanding of the antecedents and consequences of headache pain. Using a headache diary, the child can record the time of onset, activities before the onset, any worries or concerns as far back as 24 hours before the onset, severity and duration of pain, pain medications taken, and activity pattern during headache episodes. The headache diary enables ongoing monitoring of headache activity, indicates the effects of interventions, and guides treatment planning. Headache management involves two main behavioural approaches: (1) teaching patients self-control skills to prevent headache (biofeedback techniques and relaxation training), and (2) modifying behaviour patterns that increase the risk for headache occurrence or reinforce headache activity (cognitive-behavioural stress management techniques). Families may be able to identify factors that trigger the headache and avoid the triggers in the future. Biofeedback is a technologybased form of relaxation therapy that can be useful in assessing and

CHAPTER 34 reinforcing learning of relaxation skills, such as progressive muscle relaxation, deep breathing, and imagery. Children as young as 7 years of age are able to learn these skills and with 2 to 3 weeks of practice are able to decrease the time needed to achieve relaxation.

Recurrent Abdominal Pain in Children Recurrent abdominal pain (RAP) or functional abdominal pain is defined as pain that occurs at least once per month for 3 consecutive months, accompanied by pain-free periods, and is severe enough that it interferes with a child’s normal activities. Management of RAP is highly individualized to reflect the causes of the pain and the psychosocial needs of the child and family. A clear understanding of the child’s characteristics (anxiety, physical health, temperament, coping skills, experience, learned response, depression), the impact on the child’s life (school attendance, activities with family, social interactions, pain behaviours), environmental factors (family attitudes and behavioural patterns, school environment, community, friendships), and the pain stimulus (disease, injury, stress) is important in planning management strategies (Oakes, 2011). Before any workup of the pain, the nurse needs to inform the family that RAP is common in children and that only 10% of children with RAP have an identifiable organic cause for their pain symptom. Medical workup is determined by the child’s symptoms and signs in combination with knowledge about common organic causes of RAP. If an organic cause is found, it will be treated appropriately. Even if no organic cause is found, the nurse needs to communicate to the child and family a belief that the pain is real. Usually the abdominal pain goes away, but even if problems are identified, they may not be the actual cause, and pain may persist, may be replaced by another symptom, or may go away on its own. The management plan includes regular follow-up at 3- to 4-month intervals, a list of symptoms that call for earlier contact, and biobehavioural pain management techniques. The goal is to minimize the impact of the pain on the child’s activities and the family’s life. The use of cognitive behavioural therapy has been documented to reduce or eliminate pain in children with RAP and highlights the involvement of parents in supporting their child’s self-management behaviour. Case reports have demonstrated the effectiveness of implementing a time-out procedure, token systems, and positive reinforcement based on operant theory treatment modalities. Stressmanagement strategies have also been successful. Parent training in how to avoid positive reinforcement of sick behaviours and focus on rewarding healthy behaviours is important. Over the course of several sessions, parents are educated about RAP, how to distinguish between sick and well behaviours, a reward system for well behaviours, and the importance of reinforcing relaxation and coping skills taught to children for pain management. Treatment may consist of a varying number of sessions over 1 to 6 months and may include various components, such as monitoring symptoms, limiting parent attention, relaxation training, increasing dietary fibre, and requiring school attendance.

Pain in Children With Sickle Cell Disease A painful episode is the most frequent cause for emergency department visits and hospital admissions among children with sickle cell disease (see Chapter 48). The acute painful episode in sickle cell disease is the only pain syndrome in which opioids are considered the major therapy and are started in early childhood and continued throughout adult life. A source of frustration for patients and clinicians is that most current analgesic regimens are inadequate in controlling some of the most severe painful episodes. An interprofessional approach that involves both pharmacological and mind–body modalities (cognitive-behavioural

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intervention, heat, massage, physical therapy) is needed but not often implemented. The goals of treatment of the acute episode may not be to take all the pain away, which is usually impossible, but to make the pain tolerable to the patient until the episode resolves and to increase function and patient participation in activities of daily living. Patients coming to an emergency department for acute painful episodes usually have exhausted all home care options or outpatient therapy. The nurse should ask patients what the usual medication, dosage, and adverse effects were in the past; the usual medication taken at home; and medication taken since the onset of present pain. The patient may be on long-term opioid therapy at home and therefore may have developed some degree of tolerance. A different potent opioid or a larger dose of the same medication may be indicated. Because mixed opioid-agonist-antagonists may precipitate withdrawal syndromes, these should be avoided if patients were taking long-term opioids at home. A “passport” card with patient information about the diagnosis, previous complications, suggested pain management regimen, and name and contact information of the primary hematologist is helpful for parents and can facilitate management of pain in the emergency department. The patient is admitted for inpatient management of severe pain if adequate relief is not achieved in the emergency department. For severe pain, IV administration with bolus dosing and continuous infusion using a PCA device may be necessary. Patients who are administered doses of opioids that are inadequate to relieve their pain or whose doses are not tapered after a course of treatment may develop iatrogenic pseudoaddiction, which resembles addiction. Pseudoaddiction or clock-watching behaviour may be resolved by communicating with patients to ensure accurate assessment, involving them in decisions about their pain management, and administering adequate opioid doses. See discussion above in Tolerance and Physical Dependence on how to wean opioid medication.

Cancer Pain in Children Pain in children with cancer may be present before diagnosis and treatment and may resolve after initiation of anticancer therapy, although treatment-related pain is also common. Pain may be related to an operation, mucositis, a phantom limb, or infection. Pain can also be related to chemotherapy and procedures, such as bone marrow aspiration, needle puncture, and lumbar puncture. Tumour-related pain frequently occurs when the child relapses or when tumours become resistant to treatment. Intractable pain may occur in patients with solid tumours that metastasize to the central or peripheral nervous system. In young adult survivors of childhood cancer, chronic pain conditions may develop, including complex regional pain syndrome of the lower extremity, phantom limb pain, avascular necrosis, mechanical pain related to bone that failed to unite after tumour resection, and postherpetic neuralgia. Oral mucositis (ulceration of the oral cavity and throat) may occur in patients undergoing chemotherapy or radiotherapy and in patients undergoing bone marrow transplant. No present therapy adequately relieves the pain of these lesions. Antihistamines, local anaesthetics, and opioids provide only temporary relief, may block taste perception, or may produce additional adverse effects, such as lethargy and constipation. Initial treatment includes single agents (saline, opioids, sodium bicarbonate, hydrogen peroxide, sucralfate suspension, clotrimazole, nystatin, viscous lidocaine, amphotericin B, dyclonine) or mouthwash mixtures using a combination of agents (lidocaine, diphenhydramine, Maalox or Mylanta, nystatin). The mucositis after bone marrow transplantation may be prolonged, continuously intense, exacerbated by mouth care and swallowing, or worse during waking hours. The patient

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may be unable to eat or swallow. Mucositis may affect the entire GI tract, including the rectum. Morphine administered as a continuous infusion or delivered by PCA device may be required until mucositis is resolved (Hickman et al., 2014). Other treatment-related pain includes (1) abdominal pain after allogeneic bone marrow transplantation, which may be associated with acute graft-versus-host disease; (2) abdominal pain associated with typhlitis (infection of the cecum), which occurs when the patient is immunocompromised; (3) phantom sensations and phantom limb pain after an amputation; (4) peripheral neuropathy after administration of vincristine; and (5) medullary bone pain, which may be associated with administration of granulocyte colony-stimulating factor. Survivors of childhood cancer describe vivid memories of their experience with repeated painful procedures during treatment. These procedures include needle puncture for IM chemotherapy (L-asparaginase), IV lines, port access, blood draws, lumbar puncture, bone marrow aspiration and biopsy, removal of central venous catheters, and other invasive diagnostic procedures. Fear and anxiety related to these procedures may be minimized with parent and child preparation. The preparation starts with obtaining information from the parent about the child’s coping styles, explaining the procedure, and enlisting their support, followed by an age-appropriate explanation to the child. Cognitive behavioural therapy (guided imagery, relaxation, music therapy, hypnosis), conscious sedation, and general anaesthesia have been effective in decreasing pain and distress during the procedure. Topical analgesics (cold sprays, EMLA, amethocaine gels), as discussed previously, are effective in providing analgesia before needle procedures. Lumbar puncture for administration of chemotherapy (e.g., cytarabine, methotrexate) and collection of cerebrospinal fluid may lead to a leak at the puncture site and low intracranial pressure. Some children may experience postdural puncture headache, which may be treated by administering nonopioid analgesics and placing the patient in the supine position for 1 hour after the procedure. The pain related to bone marrow aspiration is due to the insertion of a large needle into the posterior iliac space and the unpleasant sensation experienced at the time of marrow aspiration. If the patient is neutropenic (absolute neutrophil count 44 mcg/dL

Follow guidance for BLLs 15 to 44 mcg/dL. Confirm BLL with repeat venous testing at 48 hours. Consider hospitalization and/or chelation therapy in consultation with local poison control centre. Mitigating lead exposures at home, identifying other possible sources, assessing the family’s social situation, and chronicity of the exposure will influence management.

CBC, Complete blood count; CRP, C-reactive protein; PEHH, pediatric environmental health history. ∗ To convert mcmoL/L to mcg/dL, multiply by 20.72. For example: 0.483 mcmoL/L¼ 10 mcg/dL. Source: Buka, I., Hervouet-Zeiber, C., Canadian Paediatric Society, Paediatric Environmental Health Section. (2019). Lead toxicity with a new focus: Addressing low-level lead exposure in Canadian children. Paediatrics & Child Health, 24(4), 293. https://www.cps.ca/en/documents/position/leadtoxicity.

CHAPTER 46 It is unclear whether chelation affects lead stores in bones. Although not an antidote in the truest sense, it does serve a similar purpose in that the toxic substance or poison is removed from the body. However, chelation does not counteract any effects of the lead. Historically, a chelating agent that has been used consistently is calcium disodium edetate (CaNa2EDTA or calcium EDTA). British antiLewisite (BAL, dimercaprol, dimercaptopropanol) is used in conjunction with EDTA. All the agents have potential toxic adverse effects and contraindications. Renal, hepatic, and hematological parameters must be monitored. Because of the equilibration process among blood, soft tissues, and other sites in the body, there is often a rebound of the BLL after chelation. After the body burden of lead is reduced enough to stabilize the BLL, rebound ceases. Multiple chelation treatments may be necessary. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys. Severe lead toxicity (lead level 70 mcg/dL) requires immediate inpatient treatment, whether symptoms are present or not. BAL is contraindicated in children with peanut allergies or hepatic insufficiency, nor should it be given in conjunction with iron. It should also be used with caution in children with renal impairment or hypertension; children must be monitored for hemolysis with presence of glucose 6phosphate dehydrogenase deficiency. BAL must be given only at a deep intramuscular site, in repeated doses over several days. Calcium EDTA should be given intravenously or intramuscularly (in a different site from BAL). The IV route should not be used in children with cerebral edema. For lead levels of 45 to 69 mcg/dL and an absence of symptoms, DMSA can be used. The capsule is opened and sprinkled on a small amount of food or may be swallowed whole. DMSA can be used in conjunction with iron. Adverse effects include nausea, vomiting, diarrhea, loss of appetite, rash, elevated LFTs, and neutropenia. Because the chelates are excreted via the kidneys, adequate hydration is essential. An oral chelating agent, d-penicillamine, is sometimes used to treat lead poisoning, but low doses should be used in children, and monitoring of renal function and blood counts during administration is essential (Dapul & Laraque, 2014).

Prognosis. Although most of the pathophysiological effects of lead are reversible, the most serious consequences of both high and low lead exposure are the effects on the CNS. In children with lead encephalopathy, permanent brain damage can result in intellectual disability, behaviour changes, possible paralysis, and seizures. However, moderate- to low-dose exposure may also cause permanent neurological deficits. Increased distractibility, short attention span, impulsivity, reading disabilities, and school failure have been associated with lead exposure. There is some evidence that treatment of moderate levels of lead poisoning can result in cognitive improvement (Centers for Disease Control and Prevention, Advisory Committee on Childhood Lead Poison Prevention, 2012).

Nursing Care. The primary nursing goal in lead poisoning is to prevent the child’s initial or further exposure to lead. For children with low-level exposure, this requires identifying the sources of lead in the environment. Careful history-taking is the most useful and valuable tool and should concentrate on personal risk questions. Suggestions for reducing lead in the child’s environment are listed in the Community Focus box: Reducing Blood Lead Levels.

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COMMUNITY FOCUS Reducing Blood Lead Levels • Make sure the child does not have access to peeling paint or chewable surfaces painted with lead-based paint, especially window sills and wells. • If a house was built before 1978 and has hard-surface floors, wet mop them at least once per week. Wipe other hard surfaces (e.g., window sills, baseboards). If there are loose paint chips in an area, such as a window well, use a wet disposable cloth to pick them up and discard them. Do not vacuum hard-surfaced floors or window sills or wells, because this spreads dust. Use vacuum cleaners with agitators to remove dust from rugs rather than vacuum cleaners with suction only. If a rug is known to contain lead dust and cannot be washed, it should be discarded. • Wash and dry child’s hands and face frequently, especially before eating. • Wash toys and pacifiers frequently. • If soil around the home is or is likely to be contaminated with lead (e.g., if the home was built before 1978 or is near a major highway), plant grass or other ground cover; plant bushes around the outside of the house so that the child cannot play there. • During remodelling of older homes, be sure to follow correct procedures. Be certain children and pregnant persons are not in the home, day or night, until the process is completed. After deleading, thoroughly clean house using cleaning solution to damp mop and dust before inhabitants return. • In areas where the lead content of water exceeds the drinking water standard and a particular faucet has not been used for 6 hours or more, “flush” the cold-water pipes by running the water until it becomes as cold as it will get (30 seconds to more than 2 minutes). The more time water has been sitting in pipes, the more lead it may contain.* • Use only cold water for consumption (drinking, cooking, and especially for making infant formula). • Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. First-flush water may be used for nonconsumption uses. • Have water tested by a competent laboratory. This action is especially important for apartment dwellers; flushing may not be effective in high-rise buildings or in other buildings with lead-soldered central piping. • Do not store food in open cans, particularly if cans are imported. • Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service. Do not store drinks or food in lead crystal. • Avoid traditional remedies or cosmetics that contain lead. • Make sure that home exposure is not occurring from parental occupations or hobbies. Household members employed in occupations such as lead smelting should shower and change into clean clothing before leaving work. Construction and lead abatement workers may also bring home lead contaminants. • Make sure the child eats regular meals, because more lead is absorbed on an empty stomach. • Make sure the child’s diet contains sufficient iron and calcium and does not include excessive fat. For general information on lead go to Health Canada’s lead information page: http://www.hc-sc.gc.ca/ewh-semt/contaminants/lead-plomb/asked_ questions-questions_posees-eng.php. *More information on quality of drinking water is available on Health Canada’s website: http://www.hc-sc.gc.ca/ewh-semt/water-eau/drinkpotab/index-eng.php.

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For children undergoing chelation therapy, the nurse needs to prepare the child for the injections and institute measures to reduce injection pain. Chelating agents are administered deeply into a large muscle mass. To lessen the pain from EDTA, the local anaesthetic procaine is injected with the medication. Rotation of sites is essential to prevent the formation of painful areas of fibrotic tissue. Because EDTA and lead are toxic to the kidneys, the nurse needs to keep records of fluid intake and output and assess the results of urinalysis to monitor renal functioning.

• • •

NURSING ALERT Calcium EDTA is only administered when there is adequate urinary output. Children receiving the medication intramuscularly must be able to maintain adequate oral intake of fluids.

• •

Discharge planning for children with lead poisoning must include thorough education of families regarding safety from lead hazards, clear instructions regarding medication administration and follow-up, and confirmation that the child will be discharged to a home without lead hazards. Although caution must be used to avoid alarming parents unnecessarily, it is important that they know the risk implications for their child’s behaviour and cognitive function. Nurses should observe the development and behaviour of children who are hospitalized. Any concerns that are identified should be thoroughly evaluated. Referral to a child development or speech and language specialist may be indicated. As in any situational crisis, parents need support and understanding if their child is treated for lead poisoning. Many families at the highest risk for lead poisoning have the fewest resources to adhere to measures such as relocation or removing lead from the environment where the child experiences exposure. Nurses should advocate on behalf of families at risk to ensure that homes and communities are safe and lead free.

KEY POINTS • Common nutritional disorders of infancy and early childhood may result from vitamin and mineral deficiency or excess, severe acute malnutrition, and food intolerance. • Severe acute malnutrition may occur as a complication of underlying disease, lack of parental education about infant nutrition, inappropriate management of food allergy, or incorrect preparation of formula. • Food intolerance encompasses food allergies and food sensitivities, which can have a number of systemic and local clinical manifestations. • Infants are subject to fluid depletion because of their greater surface area relative to body mass, high rate of metabolism, and immature kidney function. • Dehydration can be classified as isotonic, hypotonic, and hypertonic. • Vomiting and diarrhea account for significant fluid depletion, especially in infants and small children. • The amount, frequency, and characteristics of stool and vomitus are important nursing observations. • Diarrhea can be caused by an inflammatory process of infectious origin, a toxic reaction to ingestion of poisonous substances, dietary indiscretions, or infections outside the alimentary tract. The

• • • • •

• • • • • • •

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primary treatment of diarrhea is the use of an oral rehydrating solution. Hirschsprung disease requires surgical removal of aganglionic segments of bowel. Postoperative care of the child with abdominal surgery involves assessing the abdomen and providing hydration and nutrition, IV fluids, proper positioning, wound care, and psychological support. Nursing care related to gastroesophageal reflux is aimed at identifying children with suggestive symptoms, helping parents with home care feeding and positioning, and caring for the child undergoing surgical intervention. Intestinal parasitic diseases constitute the most common infections in the world; giardiasis and enterobiasis are the most widespread parasitic infections among children in Canada. Although the cause of appendicitis is poorly understood, it is typically a result of obstruction of the lumen, usually by a fecalith. Common signs and symptoms are right lower quadrant abdominal pain, tenderness, and fever. Meckel diverticulum is a congenital malformation of the GI tract characterized by bloody stools. Inflammatory bowel disease (IBD) refers to ulcerative colitis (UC) and Crohn disease (CD). Peptic ulcers are poorly understood, but contributing factors include interference with the normal protective mechanisms of the mucosal lining and the presence of Helicobacter pylori. Viral hepatitis is most commonly caused by hepatitis A (HAV), hepatitis B (HBV) and hepatitis C (HCV) viruses. HAV is spread by the fecal–oral route, whereas HBV and HCV are transmitted primarily by the parenteral route. The most effective measure in prevention and control of hepatitis in any setting is hand hygiene. Structural disorders of the GI tract include cleft lip (CL), cleft palate (CP), esophageal atresia (EA), transesophageal fistula (TEF), anorectal malformations, and biliary atresia (BA). BA is a serious disorder, causing progressive liver failure, which is an indication for liver transplantation. CL, CP, and CL/P are the most common facial malformations; they may involve nutritional, dental, and speech issues. Hernias related to the GI tract can be minor (umbilical) or lifethreatening (diaphragmatic, gastroschisis, omphalocele). General signs of abdominal obstruction include colicky abdominal pain, nausea and vomiting, abdominal distension, and decreased stool output. HPS is recognized by characteristic projectile vomiting, malnutrition, dehydration, and a palpable mass in the epigastrium and is relieved by pyloromyotomy. Intussusception is one of the most common causes of intestinal obstruction during infancy and is characterized by abdominal pain and blood in stools. Treatment is either nonsurgical hydrostatic reduction or surgical reduction. Malabsorption syndromes are disorders associated with some degree of impaired digestion or absorption. They include digestive, absorptive, and anatomical defects. Celiac disease is characterized by intolerance to gluten. It is thought to be either an inborn error of metabolism or an immunological response. Short bowel syndrome is characterized by a loss of intestine resulting in a diminished ability to absorb a regular diet normally.

CHAPTER 46

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• • •

Specialized enteral and parenteral nutrition is a major element of care for these children. Although the incidence of poisoning has decreased in the past 30 years as a result of more stringent packaging regulations, childhood poisoning remains a serious health concern. The major principles of treatment for poisoning include assessment and the CABs of resuscitation (cardiovascular supportive measures, airway, and breathing), minimization of poison absorption, prevention of complications, family support, and prevention of recurrence. Communication with the area poison control centre is essential in the treatment of any poisoning. The most important factor contributing to lead poisoning is its availability in the child’s environment. Lead-based paint is the most toxic source of lead. Because of increasing awareness of the detrimental effects of low levels of lead on the developing nervous system, acceptable BLLs have been decreasing; but children with cognitive and health effects are still seen. The latest guidelines recommend using a BLL reference value of 5 mcg/dL to guide treatment.

REFERENCES Abrams, E. A., Hildebrand, K., Blair, B., et al. (2019). Timing of introduction of allergenic solids for infants at high risk. Paediatrics & Child Health, 24(1), 56. Updated 2020. https://www.cps.ca/en/documents/position/allergenic-solids. Aiken, J. J. (2020). Acute appendicitis. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Albertson, T. E., Owen, K. P., Sutter, M. E., et al. (2011). Gastrointestinal decontamination in the acutely poisoned patient. International Journal of Emergency Medicine. 4(65). https://doi.org/10.1186/1865-1380-4-65. Alqurashi, W., Stiell, I., Chan, K., et al. (2015). Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis. Annals of Allergy, Asthma & Immunology, 115(3), 217–223. American Academy of Pediatrics (AAP). (2014). Pediatric nutrition handbook (7th ed.). AAP. American Academy of Pediatrics, Committee on Infectious Diseases. (2018). In D. W. Kimberlin, & M. T. Brady, et al. (Eds.), Red book 2018: Report of the committee on infectious diseases (31st ed.). Author. Angulo, P., & Lindor, K. D. (2010). Primary biliary cirrhosis. In M. Feldman, L. S. Friedman, & L. J. Brandt (Eds.), Sleisenger and Fordtran’s gastrointestinal and liver disease. (9th ed.). Saunders. Ashworth, A. (2020). Nutrition, food security, and health. In R. M. Kliegman, J. St. Geme, N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Bass, D. M. (2020). Rotaviruses, caliciviruses, and astroviruses. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Benson, B. E., Hoppu, K., Troutman, W. G., et al. (2013). Position paper update: Gastric lavage for gastrointestinal decontamination. Clinical Toxicology (Philadelphia), 51(3), 140–146. Blackburn, S. (2018). Maternal, fetal, and neonatal physiology: A clinical perspective (5th ed.). Elsevier. Blanchard, S. S., & Czinn, S. J. (2020). Peptic ulcer disease in children. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Bonney, A. G., Mazor, S., & Goldman, R. D. (2013). Laundry detergent capsules and pediatric poisoning. Canadian Family Physician, 59(12), 1295–1296. Boyce, J. A., Assa’ad, A., Burks, A. W., et al. (2011). Guidelines for the diagnosis and management of food allergy in the United States: Summary of the NIAID-sponsored expert panel report. Nutrition Research, 31(1), 61–75. Bronstein, A. C., Spiker, D. A., Cantilena, L. R., et al. (2012). 2011 Annual report of the American Association of Poison Control Centers National Poison Data System (NPDS): 29th annual report. Clinical Toxicology, 50(10), 911–1161. https://doi.org/10.3109/15563650.2012.746424.

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Buckley, N. A., Dawson, A. H., Juurlink, D. N., et al. (2016). Who gets antidotes? Choosing the chosen few. British Journal of Clinical Pharmacology, 81(3), 402–407. Buka, I., Hervouet-Zeiber, C., & Canadian Paediatric Society, Paediatric Environmental Health Section. (2019). Lead toxicity with a new focus: Addressing low-level lead exposure in Canadian children. Paediatrics & Child Health, 24(4), 293. https://www.cps.ca/en/documents/position/leadtoxicity. Butler, A. E., Schreiber, R. A., Yanchar, N., et al. Canadian Biliary Atresia Registry. (2016). Improving the care of Canadian infants with biliary atresia. Paediatrics & Child Health, 21(3), 131–134. Canadian Celiac Association. (2008). Blood testing for celiac disease. https:// www.celiac.ca/wp-content/uploads/2019/04/CD_BloodTesting.pdf. Canadian Paediatric Society (CPS). (2014). WHO growth charts: Promoting optimal monitoring of child growth in Canada using the WHO growth charts. http://www.cps.ca/tools-outils/who-growth-charts. Caracappa, D., Gullá, N., Lombardo, F., et al. (2014). Incidental finding of carcinoid tumor on Meckel’s diverticulum: Case report and literature review, should prophylactic resection be recommended? World Journal of Surgical Oncology, 12, 144. Carter, S. L., & Attel, S. (2013). The diagnosis and management of patients with lactose-intolerance. Journal for Nurse Practitioners, 38(7), 23–28. Centers for Disease Control and Prevention, Advisory Committee on Childhood Lead Poison Prevention (2012). Low level lead exposure harms children: A renewed call for primary prevention. http://www.cdc.gov/nceh/lead/ ACCLPP/Final_Document_030712.pdf. Cheng, A., & Canadian Paediatric Society, Acute Care Committee. (2011). Emergency treatment of anaphylaxis in infants and children. Paediatrics & Child Health, 16(1), 35–40. Reaffirmed 2018. http://www.cps.ca/documents/ position/emergency-treatment-anaphylaxis. Churgay, C. A., & Aftab, Z. (2012a). Gastroenteritis in children: Part I. Diagnosis. American Family Physician, 85(11), 1059–1062. Churgay, C. A., & Aftab, Z. (2012b). Gastroenteritis in children: Part II. Prevention and management. American Family Physician, 85(11), 1066–1070. Coffin, C., Fung, S., Alvarez, F., et al. (2018). Management of hepatitis B viral infection: 2018 Guidelines from the Canadian Association for the Study of the Liver and Association of Medical Microbiology and Infectious Disease Canada. Canadian Liver Journal, 1(4), 156–217. Critch, J., & Canadian Paediatric Society (CPS). (2014). Nutrition for healthy term infants, six to 24 months: An overview. Paediatrics & Child Health, 19(10), 547–549. Reaffirmed 2020. https://www.cps.ca/en/documents/ position/nutrition-healthy-term-infants-6-to-24-months. Crohn’s and Colitis Canada (2019). Treatment and medication. https:// crohnsandcolitis.ca/Living-with-Crohn-s-Colitis/Treatments-medications. Dapul, H., & Laraque, D. (2014). Lead poisoning in children. Advances in Pediatrics, 61, 313–333. Dhar, V. (2020). Cleft lip and palate. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Dore-Bergeron, M., Chauvin-Kimoff, L., & Canadian Paediatric Society, Acute Care Committee. (2018). Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children. https://www. cps.ca/en/documents/position/oral-ondansetron. Dupont, C. (2014). Diagnosis of cow’s milk allergy in children: Determining the gold standard? Expert Review of Clinical Immunology, 10(2), 257–267. Ertem, D. (2012). Clinical practice: Helicobacter pylori infection in childhood. European Journal of Pediatrics, 171(9), 1–8. Esona, M. D., & Gautam, R. (2015). Rotavirus. Clinics in Laboratory Medicine, 35(2), 363–391. Findlay, L. C., & Janz, T. A. (2012). The health of Inuit children under age 6 in Canada. International Journal of Circumpolar Health. 71, https://doi.org/ 10.3402/ijch.v71i0.18580. Glenn, L. (2015). Pick your poison: What’s new in poison control for the preschooler. Journal of Pediatric Nursing, 30(2), 395–401. Godel, J. C., & Canadian Paediatric Society, First Nations, Inuit and Metis Health Committee (2007). Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatrics & Child Health, 12(7), 583–589. Reaffirmed 2017. https://www.cps.ca/en/documents/position/vitamin-d.

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Government of Canada. (2019). Clostridium difficile associated diarrhea. https://www.canada.ca/en/public-health/services/diseases/c-difficile/ national-case-definition.html. Government of Canada. (2021a). Canadian immunization guide. Part 4: Active vaccines. https://www.canada.ca/en/public-health/services/ publications/healthy-living/canadian-immunization-guide-part-4-activevaccines.html. Government of Canada. (2021b). Food safety and you. https://www.canada.ca/ en/health-canada/services/general-food-safety-tips/food-safetyyou.html. Greenbaum, L. A. (2020). Deficit therapy. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Guidry, C., & McGahren, E. D. (2012). Pediatric chest I: Developmental and physiologic conditions for the surgeons. Surgical Clinics of North America, 92(3), 615–643. https://doi.org/10.1016/j.suc.2012.03.013. Hassan, H. H., & Balistreri, W. F. (2020). Neonatal cholestasis. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Hayman, R. M., & Dalziel, S. R. (2012). Acute vitamin A toxicity: A report of three paediatric cases. Journal of Paediatrics and Child Health, 48(3), e98–e100. Health Canada (2013). Lead. What is lead? http://www.hc-sc.gc.ca/ewh-semt/ contaminants/lead-plomb/index-eng.php. Jensen, M. K., & Balistreri, W. G. (2020). Viral hepatitis. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Jindal, M. K., & Khan, S. Y. (2013). How to feed cleft patient? International Journal of Clinical Pediatric Dentistry, 6(2), 100–103. Jung, J. K. H., & Skinner, K. (2017). Foodborne and waterborne illness among Canadian Indigenous populations: A scoping review. Canadian Communicable Disease Report, 43(1), 7–13. https://doi.org/10.14745/ccdr. v43i01a02. Kaplan, G. G., Bernstein, C. N., Coward, S., et al. (2019). The impact of inflammatory bowel disease in Canada 2018: Epidemiology. Journal of the Canadian Association of Gastroenterology, 2(Suppl 1), S6–S16. https://doi. org/10.1093/jcag/gwy054. Kehar, M., Parekh, R. S., Stunguris, J., et al. (2019). Superior outcomes and reduced wait times in pediatric recipients of living donor liver transplantation. Transplant Direct, 5(3), e430, https://doi.org/10.1097/ TXD.0000000000000865. Kennedy, M., Maqbool, A., & Liacouras, C. A. (2020). Meckel diverticulum and other remnants of the omphalomesenteric duct. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Khan, S., Kumar, S., & Matta, S. K. R. (2020). Esophageal atresia and tracheoesophageal fistula. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Khan, S., & Matta, S. K. R. (2020). Gastroesophageal reflux disease. In R. M. Kliegman, J. S. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Kotloff, K. L. (2020). Acute gastroenteritis in children. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Kunisaki, S. M., & Foker, J. E. (2012). Surgical advances in the fetus and neonate: Esophageal atresia. Clinics in Perinatology, 39(2), 349–361. https://doi.org/ 10.1016/j.clp.2012.04.007. Le Saux, N., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2020). Recommendations for the use of rotavirus vaccines in infants. Paediatrics & Child Health, 22(5), 290–294. https://www.cps.ca/en/documents/position/rotavirus-vaccines. Liang, C. M., Ji, D. M., Yuan, X., et al. (2014). RET and PHOX2B genetic polymorphisms and Hirschsprung’s disease susceptibility: A meta-analysis. PLoS ONE, 9(3), e90091. Maqbool, A., & Liacouras, C. A. (2020a). Congenital aganglionic megacolon (Hirschsprung disease). In R. M. Kliegman, J. S. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics. (21st ed.). Elsevier. Maqbool, C. A., & Liacouras, C. A. (2020b). Hypertrophic pyloric stenosis. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier.

Maqbool, C. A., & Liacouras, C. A. (2020c). Ileus, adhesions, intussusceptions, and closed-loop obstructions. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Marchand, V., & Canadian Paediatric Society, Nutrition and Gastroenterology Committee. (2012). Using probiotics in the paediatric population. Paediatrics & Child Health, 17(10), 575. Updated 2019. https://www.cps.ca/ en/documents/position/probiotics-in-the-paediatric-population. McCabe, M. A., Toughill, E. H., Parkhill, A. M., et al. (2012). Celiac disease: A medical puzzle. American Journal of Nursing, 112(19), 34–44. Nowak-Wegrzyn, A., Sampson, H. A., & Sicherer, S. A. (2020). Food allergy and adverse reactions to foods. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Ontario Poison Centre. (2020). Current top 10: 2020 data. https://www. ontariopoisoncentre.ca/common-poisons/current-top-10/. Paganelli, M., Stephenne, X., & Sokal, E. M. (2012). Chronic hepatitis B in children and adolescents. Journal of Hepatology, 57(4), 885–896. Public Health Agency of Canada (PHAC). (2013). Congenital anomalies in Canada 2013—A perinatal health report. http://publications.gc.ca/site/eng/ 443924/publication.html. Pulitzer Center. (2019). ‘My ears keep ringing all the time’: Mercury poisoning among Grassy Narrows First Nation. https://pulitzercenter.org/reporting/myears-keep-ringing-all-time-mercury-poisoning-among-grassy-narrows-firstnation. Rashid, A. N., Taminiau, J. A., Benninga, M. A., et al. (2016). Definitions and outcome measures in pediatric functional upper gastrointestinal tract disorders: A systematic review. Journal of Pediatric Gastroenterology and Nutrition, 62(4), 581–587. Robbins, J. M., Damiano, P., Druschel, C. M., et al. (2010). Prenatal diagnosis of orofacial clefts: Association with maternal satisfaction, team care, and treatment outcomes. Cleft Palate Craniofacial Journal, 47(5), 476–481. https://doi.org/10.1597/08-177. Rosen, R., Vandenplas, Y., Singendonk, M., et al. (2018). Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 66(3), 516–554. https://doi.org/10.1097/ MPG.0000000000001889. Rowan-Legg, A., & Canadian Paediatric Society, Community Paediatrics Committee. (2011). Managing functional constipation in children. Paediatrics & Child Health, 6(10), 661–665. Reaffirmed 2018. http://www. cps.ca/en/documents/position/functional-constipation. Shah, H., Bilodeau, M., Burak, K., et al. (2018). The management of chronic hepatitis C: 2018 guideline update from the Canadian Association for the Study of the Liver. Canadian Medical Association Journal, 190(22), E677–E687. https://doi.org/10.1503/cmaj.170453. Shamir, R. (2020). Disorders of malabsorption. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Singhi, S. C., Shah, R., Bansal, A., et al. (2013). Management of a child with vomiting. Indian Journal of Pediatrics, 80(4), 318–325. Sood, M. R. (2021). Chronic functional constipation and fecal incontinence in infants and children, and adolescents: Treatment. UpToDate. http://www. uptodate.com/contents/chronic-functional-constipation-and-fecalincontinence-in-infants-and-children-treatment. Stein, R. E., & Baldassano, R. N. (2020). Inflammatory bowel disease. In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. Sullivan, P. (2010). Peptic ulcer disease in children. Paediatrics and Child Health, 20(10), 462–464. Temple, S. J., Shawyer, A., & Langer, J. C. (2012). Is daily dilatation by parents necessary after surgery for Hirschsprung disease and anorectal malformations? Journal of Pediatric Surgery, 47(1), 209–212. Titova, O. E., Ayvazova, E. A., Bichkaeva, F. A., et al. (2012). The influence of active and passive smoking during pregnancy on umbilical cord blood levels of vitamins A and E and neonatal anthropometric indices. British Journal of Nutrition, 108(8), 1241–1345. Trehan, I., & Manary, M. J. (2015). Management of severe acute malnutrition in low-income and middle-income countries. Archives of Disease in Childhood, 100(3), 283–287.

CHAPTER 46 Troncone, R., & Shamir, R. (2020). Celiac disease (gluten-sensitive enteropathy). In R. M. Kliegman, J. St. Geme, & N. J. Blum, et al. (Eds.), Nelson textbook of pediatrics (21st ed.). Elsevier. van der Pol, R. J., Smits, M. J., Wijk, M. P., et al. (2011). Efficacy of proton pump inhibitors in children with gastroesophageal reflux disease: A systematic review. Pediatrics, 127(5), 925–935. https://doi.org/10.1542/peds.2010-2719. Vogiatzi, M., Jacobson-Dickman, E., & DeBoer, M. D. (2014). Vitamin D supplementation and risk of toxicity in pediatrics: A review of current literature. Journal of Clinical Endocrinology and Metabolics, 99(4), 1132–1141. World Health Organization (WHO). (2017). Diarrhoeal disease. https://www. who.int/news-room/fact-sheets/detail/diarrhoeal-disease. Zhou, S., Sullivan, T., Gibson, R., et al. (2014). Nutritional adequacy of goat milk infant formulas for term infants: A double-blind randomised controlled trial. British Journal of Nutrition, 111(9), 1641–1651. https://doi.org/10.1017/ S0007114513004212.

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ADDITIONAL RESOURCES About Face—Support for persons with cleft lip and palate and other facial differences: https://www.aboutface.ca. Canadian Celiac Association: https://www.celiac.ca. Canadian Liver Foundation: https://www.liver.ca. Crohn’s and Colitis Canada: https://crohnsandcolitis.ca/. Food Allergy Canada—Information on food allergies: https:// foodallergycanada.ca/. Health Canada—Dietary Reference Intake Report List: http://www.hc-sc.gc.ca/ fn-an/nutrition/reference/dri_rep-rap_anref-list/index-eng.php. Ostomy Canada Society: https://www.ostomycanada.ca. Parachute—Poison Prevention Policy: http://www.parachutecanada.org/policy/ item/poison-prevention.

UNIT 12 Health Conditions of Children

47 Cardiovascular Conditions Cheryl Sams Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal

OBJECTIVES On completion of this chapter the reader will be able to: 1. Design a plan for assisting a child during a cardiac diagnostic procedure. 2. Demonstrate an understanding of the hemodynamics, distinctive manifestations, and therapeutic management of congenital heart disease. 3. Outline a care plan for an infant or child with heart failure. 4. Describe the care for a child who has hypoxia. 5. Describe the care for an infant or a child with a congenital heart defect and its surgical repair.

6. Discuss the nurse’s role in helping the child and family cope with congenital heart disease. 7. Describe the care for a child with bacterial endocarditis. 8. Differentiate between rheumatic fever and rheumatic heart disease. 9. List the criteria for selected cholesterol screening of children. 10. Discuss the assessment and management of hypertension in children and adolescents. 11. Outline a care plan for a child with Kawasaki disease. 12. Describe the emergency treatment for shock, including anaphylaxis.

CARDIOVASCULAR DYSFUNCTION

In assessing infants it is important to ask details about the birthing parent’s health history, pregnancy, and birth history. Parents with chronic health conditions, such as diabetes or lupus, are more likely to have infants with heart disease. Some medications, such as phenytoin (Dilantin), are teratogenic to the fetus. Alcohol use or illicit drug use during pregnancy increases the risk of congenital heart defects. Exposures to infections, such as rubella, early in pregnancy may result in congenital anomalies. Infants with low birth weight resulting from intrauterine growth restriction are more likely to have congenital anomalies. Highbirth-weight infants also have an increased incidence of heart disease. A detailed family history is also important. There is an increased incidence of congenital cardiac defects if either parent or a sibling has a heart defect. Some diseases, such as Marfan syndrome, and some cardiomyopathies are hereditary. A family history of frequent fetal loss, sudden infant death, and sudden death in adults may indicate heart disease. Congenital heart defects are seen in many syndromes such as Down and Turner syndromes. The physical assessment of suspected cardiac disease begins with observation of general appearance and proceeds with more specific observations. The following elements are supplementary to the general assessment techniques described for physical examination of the chest and heart in Chapter 33.

Cardiovascular disorders in children are divided into two major groups, congenital heart disease and acquired heart disorders. Congenital heart disease (CHD) includes primarily anatomical abnormalities present at birth that result in abnormal cardiac function. The clinical consequences of congenital heart defects fall into two broad categories: heart failure (HF) and hypoxemia. Acquired cardiac disorders are disease processes or abnormalities that occur after birth and can be seen in the normal heart or in the presence of congenital heart defects. They result from various factors, including infection, autoimmune responses, environmental factors, and familial tendencies. The pathophysiology review found in Figure 47.1 describes the flow of blood through the heart.

History and Physical Examination Taking an accurate health history is an important first step in assessing an infant or child for possible heart disease. Parents may have specific concerns, such as an infant with poor feeding or fast breathing, or a 7-year-old who can no longer keep up with friends on the soccer field. Others may not realize that their child has a medical condition because their baby has always been pale and fussy.

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Right pulmonary artery Right pulmonary vein

LA

RA RV Right lung capillaries

Left pulmonary artery Left pulmonary vein

LV

Liver circulation

Vena cava

Left lung capillaries Aorta Systemic circulation

Hepatic portal system

Intestinal capillaries Renal capillaries

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Inspection. The following features need to be assessed: Nutritional state—Failure to thrive or poor weight gain is associated with heart disease. Colour—Cyanosis is a common feature of CHD; pallor is associated with poor perfusion. Chest deformities—An enlarged heart sometimes distorts the chest configuration. Unusual pulsations—Visible pulsations of the neck veins are seen in some patients. Respiratory excursion—This refers to the ease or difficulty of respiration (e.g., tachypnea, dyspnea, expiratory grunt). Clubbing of fingers—This is associated with cyanosis.

Palpation and Percussion. On palpation or percussion the following should be assessed: Chest—These manoeuvres help discern heart size and other characteristics (e.g., thrills) associated with heart disease. Abdomen—Hepatomegaly or splenomegaly may be evident. Peripheral pulses—Rate, regularity, and amplitude (strength) may reveal discrepancies. Auscultation. Listen for the following: Heart rate and rhythm—Listen for fast heart rates (tachycardia), slow heart rates (bradycardia), or irregular rhythms. Character of heart sounds—Listen for distinct or muffled sounds, murmurs, and additional heart sounds.

Systemic capillary beds

Fig. 47.1 Diagram showing serially connected pulmonary and systemic circulatory systems and how to trace the flow of blood. Right heart chambers propel unoxygenated blood through the systemic circulation. LA, Left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. (From McCance, K. L., & Heuther, S. E. [2010]. Pathophysiology: The biological basis for disease in adults and children [6th ed.]. Mosby.)

TABLE 47.1

Cardiovascular Conditions

Diagnostic Evaluation A variety of invasive and noninvasive tests may be used in the diagnosis of heart disease (Table 47.1). Some of the more common diagnostic tools that require nursing assessment and intervention are described in the following sections.

Procedures for Cardiac Diagnosis

Procedure

Description

Chest radiograph (X-ray)

Provides information on heart size and pulmonary blood flow patterns

Electrocardiography

Graphic measure of electrical activity of heart

Holter monitor

24-hr continuous electrocardiogram (ECG) recording used to assess dysrhythmias

Echocardiography

Use of high-frequency sound waves obtained by a transducer to produce an image of cardiac structures

Transthoracic

Done with transducer on chest

M-mode

One-dimensional graphic view used to estimate ventricular size and function

Two-dimensional

Real-time, cross-sectional views of heart used to identify cardiac structures and cardiac anatomy

Doppler

Identifies blood flow patterns and pressure gradients across structures

Fetal

Imaging fetal heart in utero

Transesophageal (TEE)

Transducer placed in esophagus behind heart to obtain images of posterior heart structures or in patients with poor images from chest approach

Cardiac catheterization

Imaging study using radiopaque catheters placed in a peripheral blood vessel and advanced into heart to measure pressures and oxygen levels in heart chambers and visualize heart structures and blood flow patterns

Hemodynamics

Measures pressures and oxygen saturations in heart chambers

Angiography

Use of contrast material to illuminate heart structures and blood flow patterns

Biopsy

Use of special catheter to remove tiny samples of heart muscle for microscopic evaluation; used in assessing infection, inflammation, or muscle dysfunction disorders and to evaluate for rejection after heart transplant

Electrophysiology (EPS)

Special catheters with electrodes used to record electrical activity from within heart; used to diagnose rhythm disturbances

Exercise stress test

Monitoring of heart rate, blood pressure, ECG, and oxygen consumption at rest and during progressive exercise on a treadmill or bicycle

Cardiac magnetic resonance imaging (MRI)

Noninvasive imaging technique; used in evaluation of vascular anatomy outside of heart (e.g., coarctation of the aorta, vascular rings), estimates of ventricular mass and volume; uses for MRI are expanding

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Electrocardiogram. Electrocardiography is used to measure the electrical activity of the heart; it provides a graphic display and supplies information on heart rate and rhythm, abnormal rhythms or conduction, ischemic changes, and other information. A standard electrocardiogram (ECG) uses 12 leads to get different views of the heart. An ECG takes about 15 minutes to perform; infants and young children may be fussy with lead placement. Bedside cardiac monitoring with the ECG is commonly used in pediatrics, especially in the care of children with heart disease. An alarm can be set with parameters for individual patient requirements and will sound if the heart rate is above or below the set parameters. Gelfoam electrodes are commonly used and placed on the right side of the chest (above the level of the heart) and the left side of the chest, and a ground electrode is placed on the abdomen. Electrodes should be changed every 1 or 2 days because they irritate the skin. Bedside monitors are an adjunct to patient care and should never be substituted for direct assessment and auscultation of heart sounds. The nurse should assess the patient, not the monitor.

NURSING ALERT Electrodes for cardiac monitoring are often colour coded: white for right, green (or red) for ground, and black for left. Always check to ensure that these colours are placed correctly.

and before surgical repair. They are divided into (1) right-sided catheterizations, in which the catheter is introduced through a vein (usually the femoral vein) and threaded to the right atrium (most common), and (2) left-sided catheterizations, in which the catheter is threaded through an artery into the aorta and then into the heart. • Interventional catheterizations (therapeutic catheterizations)—A balloon catheter or other device is used to alter the cardiac anatomy. Examples include dilating stenotic valves or vessels or closing abnormal connections (Table 47.2). • Electrophysiology studies— Catheters with tiny electrodes that record the impulses of the heart directly from the conduction system are used to evaluate dysrhythmias. Other catheters can destroy abnormal pathways that cause rapid rhythms (called ablation). Nursing care. Cardiac catheterization has become a routine diagnostic procedure and may be done on an outpatient basis. However, it is not without risks, especially in newborns and seriously ill infants and children. Possible complications include acute hemorrhage from the entry site (more likely with interventional procedures because larger catheters are used), low-grade fever, nausea, vomiting, loss of pulse in the catheterized extremity (usually transient, resulting from a clot, hematoma, or intimal tear), and transient dysrhythmias (generally catheter induced) (Krasemann, 2015). Rare risks include stroke, seizures, tamponade, and death. Preprocedural care. A complete nursing assessment is necessary to ensure a safe procedure with minimum complications. This assessment

Echocardiography. Echocardiography involves the use of ultrahigh-frequency sound waves to produce an image of the heart’s structure. A transducer placed directly on the chest wall delivers repetitive pulses of ultrasound and processes the returned signals (echoes). It is the most frequently used test for describing cardiac anatomy and detecting cardiac dysfunction in children. In many cases, a prenatal diagnosis of CHD can be made by fetal echocardiography. Although the test is noninvasive, painless, and associated with no known side effects, it can be stressful for children. A full echocardiogram can take 1 hour, and the child must lie quietly in the standard echocardiographic positions (on left side with arms above head). Therefore, infants and young children may need a mild sedative; older children benefit from psychological preparation for the test. The distraction of a movie or music is often helpful.

TABLE 47.2

Current Interventional Cardiac Catheterization Procedures in Children Intervention

Diagnosis

Balloon atrioseptostomy: Use well established in newborns; may also be done under echocardiographic guidance

Transposition of great arteries Some complex single-ventricle defects

Balloon dilation: Treatment of choice

Valvular pulmonic stenosis Branch pulmonary artery stenosis Congenital valvular aortic stenosis Rheumatic mitral stenosis Recurrent coarctation of aorta Further follow-up required in: Native coarctation of aorta in patients older than 7 months Congenital mitral stenosis

Coil occlusion: Accepted alternative to surgery

PDA (15.5 or 8

>13.50 or 11 or