ANTEPARTUM PATIENT EDUCATION
Plans for the antepartum, intrapartum, and postpartum periods provide an opportunity for patient education and interaction. The Antepartum Record in Appendix C provides a list of the issues to be discussed during ante-partum care.
A woman with an uncomplicated pregnancy can usually continue to work until the onset of labor. In a normal pregnancy, there are few restrictions concerning work, although it is beneficial to allow moderate activity and to allow for periods of rest. Strenuous work (standing or repetitive, strenuous, physical lifting) is best avoided.
A period of 4 to 6 weeks generally is required for a woman’s physical condition to return to normal. However, the patient’s individual circumstances may be a factor in determining when she returns to work. The length of a woman’s leave from work can depend on whether there are pregnancy or delivery complications, the work involved, the employer attitude, the rules of the health care system under which the patient receives care, and the wishes of the patient. The Federal Family and Medical Leave Act and state laws should be consulted to determine the family and medical leave that is available.1(p118)
In the absence of either medical or obstetric complications, up to 30 minutes of moderate exercise per day on most if not all days of the week is acceptable (Box 6.3). Each sport should be reviewed for its potential risk, and activities with a high risk for falling or for abdominal trauma should be avoided.
Overly strenuous exercise, especially for prolonged periods, should be avoided. Patients unaccustomed to reg-ular exercise should not undertake vigorous new programs during pregnancy. Supine exercises should be discon-tinued after the first trimester to minimize circulatory changes brought on by pressure of the uterus on the vena cava. Any activity should be discontinued if discomfort, significant shortness of breath, or pain in the chest or abdomen appears (Box 6.4). Changes in body contour and balance will alter the advised types of activities; abdominal trauma should be avoided.
Sitting in a hot tub or sauna after exercise is of con-cern to pregnant women. Possible hyperthermia may be teratogenic. Pregnant women might reasonably be advised to remain in saunas for no more than 15 minutes, and in hot tubs for no more than 10 minutes. In a hot tub, if a woman’s head, arms, shoulders, and upper chest are not submerged, there is less surface area to absorb heat.
Concerns about adequate nutrition and weight gain dur-ing pregnancy are common. Poor nutrition, obesity, and food faddism are associated with poor perinatal outcome. Pica, or an inclination for nonnutritional substances suchas ice, food starch, or clay or dirt, is often associated with anemia.
A complete nutritional assessment is an important part of the initial antepartum assessment, including history of dietary habits, special dietary issues or concerns, and weight trends. Anorexia and bulimia increase risks for associated problems such as cardiac arrhythmias, gastrointestinal pathology, and electrolyte disturbances.
Calculation of BMI is useful because it relates weight to height, allowing for a better indirect measurement of body fat distribution than is obtained with weight alone. Further, because of the “personalized nature” of an individual’s BMI, it is often more useful in teaching a patient about diet and weight issues than an abstract table.
Recommendations for total weight gain during preg-nancy and the rate of weight gain per month appropriate to achieve it may be made based on a body mass index calculated for the prepregnancy weight (see Table 6.3). The components that make up the average weight gain in a normal singleton pregnancy are listed in Table 6.4. The maternal component of this weight gain starts in the first trimester and increases linearly after the second trimester. Fetal growth is most rapid in the second half of pregnancy, with the normal fetus tripling its weight in the last 12 weeks.
Published recommended daily allowances (RDAs) for protein, minerals, and vitamins are useful approxima-tions. It should be kept in mind, however, that the RDAs are a combination of estimates and are values adjusted near the top of the normal ranges to encompass the estimated needs of most women. Thus, many women have an adequate diet for their individual needs, even though it does not supply all the RDAs. Vitamin supplementation is appropriate for spe-cific therapeutic indications, such as a patient’s inability or unwillingness to eat a balanced, adequate diet, or clinical demonstration of a specific nutritional risk. Except for iron, mineral supplementation is likewise not required in other-wise healthy women; the National Academy of science rec-ommends 27 mg of iron supplementation.
Financial problems, the inability to get to a grocery store, and foodstuffs unique to a patient’s social group that differ in substantial quantitative ways with respect to important nutrients, may prevent some women from obtaining adequate nutrition, even if the volume of food-stuffs seems sufficient. The WIC Federal Supplemental food program, food stamp programs, and Aid for Families with Dependent Children are resources that may help in these situations.
The benefits of breastfeeding include, for the newborn, excellent nutrition and provision of immunologic protec-tion; and, for the mother, more rapid uterine involution, economy, maternal–child bonding, to some extent natural contraception, and, often, more rapid weight loss associ-ated with extra calorie expenditure. Contraindications to breastfeeding include certain maternal infections and use of medications. It is important to support a woman who chooses not to breastfeed. The use of breast pumps and milk storage may allow a mother to continue breastfeed-ing while continuing to work.
Sexual intercourse is not restricted during a normal preg-nancy, although advice about more comfortable positions in later pregnancy may be appreciated—for example, side-to-side or the female-superior position. Sexual activity may be restricted or prohibited under certain high-risk circumstances, such as known placenta previa, premature rupture of membranes, or actual or history of preterm
labor (or delivery). Education of the patient (and partner) about safe sex practices is as important in antepartum as in regular gynecologic care.
Up to 36 weeks of gestation, women can safely fly. Air travel is not recommended for women who have medical or obstetric complications, such as hypertension, poorly controlled diabetes mellitus, or sickle cell disease. This recommendation is not due to substantial risk to either mother or fetus, but because of the likelihood that labor may ensue away from home and customary health care providers. If a long trip near term is planned, it is useful for the patient to carry a copy of her obstetric record in case she requires obstetric care. When traveling, patients are advised to avoid long periods of inactivity, such as sit-ting. Walking every 1 to 2 hours, even for short periods, promotes circulation, especially in the lower legs, and decreases the risk of venous stasis and possible thrombo-embolism. Additionally, preventive antiemetic medicine should be considered for pregnant women with increased nausea. Education about the regular use of a seat belt is especially important, with the seat belt worn low on the hip bones, between the protuberant abdomen and the pelvis.
Many patient inquiries concern the teratogenic potential of environmental exposures. Major birth defects are apparent at birth in 2% to 3% of the general population, and the possible occurrence of fetal malformations or mental retardation is a frequent cause of anxiety among pregnant women. Of these, about 5% may be a result of maternal exposure to drugs or environmental chemicals, and only approximately 1% can be attributed to pharma-ceutical agents. The most important determinants of the developmental toxicity of an agent are timing, dose, and fetal susceptibility. Many agents have teratogenic effects only if taken while the susceptible fetal organ system is forming.
The health care provider may wish to consult with or refer such patients to health care professionals with special knowledge or experience in teratology and birth defects. The Organization of Teratology Information Services provides information on teratology issues and exposures in pregnancy (www.otis pregnancy.org).
Very few medications have been proven to be true human teratogens (Box 6.5). Most commonly prescribed medica-tions are relatively safe in pregnancy. The Food and Drug Administration assigns medications a pregnancy risk factor based on information about the medication and its risk– benefit ratio.
These pregnancy risk factors help guide the appropriate use of medications in pregnancy (see Table 6.5). Table 6.6 provides a summary of the teratogenicity of many common medications.
Ionizing radiation exposure is universal; most radiation originates from beyond the earth’s atmosphere, from the land, and from endogenous radionuclides. The total radiation exposure from these sources is approximately 125 mrads per year. Although radiation exposure has the potential to cause gene mutations, growth impairment, chromosome damage and malignancy, or fetal death, large doses are required to produce discernible fetal effects. Large doses (10 rads) during the first two weeks after fertilization are required to produce a deleterious effect. In the first trimester, 25 rads are required to pro-duce detectable damage, and 100 rads are required later in pregnancy. Diagnostic radiation usually exposes the fetus to much less than 5 rads, depending on the number of radiographs taken and the maternal site examined (Table 6.7).
Industrial pollution is the major source of mercury entry in our ecosystem. Large fish, such as tuna, shark, and king mackerel, retain higher levels of mercury from the smaller fish and organisms they consume. Hence, women who eat these fish are storing high levels of mercury.
The FDA recommends that pregnant women limit their ingestion of albacore tuna to 6 ounces per week or to 12 ounces per week of fish and shellfish varieties thought to be low in mercury.
Herbal remedies are not regulated as prescription or over-the-counter drugs, the identity and quantity of their ingredients are unknown, and there are virtually no studies of their teratogenic potential. Because it is not possible to assess their safety, pregnant women should be counseled to avoid these substances. Remedies contain-ing substances with pharmaceutical properties that could theoretically have adverse fetal affects include the following:
· Echinacea—causes fragmentation of hamster sperm at high concentrations
· Black cohosh—contains a chemical that acts like an estrogen
· Garlic and willow barks—have anticoagulant properties
· Ginkgo—can interfere with effects of monamine oxidase inhibitors; has anticoagulant effects
· Real licorice—has hypertensive and potassium-wasting effects
· Valerian—intensifies the effects of prescription sleep aids
· Ginseng—interferes with the effects of monamine oxidase inhibitors
· Blue cohosh and pennyroyal—stimulate uterine muscu-lature; pennyroyal also can cause liver damage, renal fail-ure, disseminated intravascular coagulation, and maternal death
Alcohol is the most common teratogen to which a fetus is exposed, and alcohol consumption during pregnancy is a leading preventable cause of mental retardation, develop-mental delay, and birth defects in the fetus. There is substan-tial evidence that fetal toxicity is dose-related and that the exposure time of greatest risk is the first trimester. There is no established safe level of alcohol use during pregnancy. Women who are pregnant or who are at risk for pregnancy should not drink alcohol. Although consumption of small amounts of alcohol early in pregnancy is unlikely to cause serious fetal problems, patients are best advised to refrain from alcohol entirely.
Fetal alcohol syndrome (FAS) is a congenital syn-drome characterized by alcohol use during pregnancy and by three findings:
· Growth restriction (which may occur in the prenatal period, the postnatal period, or both)
· Facial abnormalities, including shortened palpebral fissures, low-set ears, midfacial hypoplasia, a smooth philtrum, and a thin upper lip
· Central nervous system dysfunction, including micro-cephaly; mental retardation; and behavioral disorders, such as attention deficit disorder
The exact risk incurred by maternal alcohol use is difficult to establish, because the complex pattern of symptoms asso-ciated with FAS can make diagnosis difficult. Consumption of 8 or more drinks daily throughout pregnancy confers a 30% to 50% risk of having a child with FAS. However, even low levels of alcohol consumption (two or fewer drinks per week) have been associated with increased aggressive behavior in children.
The risks of smoking during pregnancy have been well-established and include risks to the fetus such as intrauterine growth restriction, low birth weight, and fetal mortality. It is important for the obstetrician to take advantage of the pre-natal visits to educate patients about the risks of smoking for both themselves and their newborns and to coordinate appropriate resources to help patients quit. Counseling pro-grams are available to help patients quit smoking. Nicotine replacement products may be considered, although their safety in pregnancy has not been documented.
The use of illicit substances by women of childbearing age has led to an increased number of neonates having had in utero exposure and subsequent risk of adverse effects from a variety of drugs. Fetal drug exposure often is unrecog-nized because of the lack of overt symptoms or structural anomaly following birth.
Illicit drugs may reach the fetus via placental transfer or may reach the newborn through breast milk. The spe-cific effect on the fetus and newborn varies with the respec-tive substances. An opiate-exposed fetus may experience withdrawal symptoms in utero if the woman stops or when the woman goes through withdrawal, either voluntarily or under supervision, or after birth when the delivery by way of the placenta ceases.
Universal screening, using biologic specimens, of women and newborns for substance abuse is not recom-mended. However, all pregnant women should be asked at their first prenatal visit about past and present use of alcohol, nicotine, and other drugs, including recreational use of prescription and over-the-counter medications. Use of specific screening questionnaires may improve detection rates. A woman who acknowledges use of these substances should be counseled about the perinatal implications of their use during pregnancy, and offered referral to an appropriate drug-treatment program if chemical dependence is sus-pected. Careful follow-up during the postpartum period is also recommended.