During pregnancy, there are many factors that can affect the fetus and/or the mother. It is important, as a healthcare provider, to incorporate health promotion into obstetrics care. My patient, JW, is on her third pregnancy, and is around 8 weeks and 3 days pregnant. Previously, she endured a spontaneous abortion in 2008. In 2015, at 36 weeks gestation, she went under an emergency cesarean section due to oligohydramnios, which means deficient amniotic fluid. The baby was born weighing 4 pounds and 9 ounces, so this complication was likely caused by intrauterine growth restriction of the fetus due to maternal smoking of cigarettes. She is currently still smoking and admittedly will be throughout this pregnancy, but she stated she will be cutting down on how often she smokes. JW noted smoking one pack a day, but when she found out she was pregnant, she has slowly cut down to four cigarettes a day. JW is 5’ 5”and weighed 226 pounds before pregnancy with a body mass index of 38. Currently, she weighs 223 pounds, making her body mass index 37, and she lost three pounds since conception. She is considered obesity class II, putting her at a higher risk during pregnancy. JW is unemployed, engages in a sedentary lifestyle, and admits to an unhealthy diet. Her diet did not consist of enough vitamins and nutrients before pregnancy, and now she has been nauseated since her last menstrual period. She has had to spread out small meals throughout the day to fill up and decrease nausea. Although this pregnancy was not planned, so very little preparation care was performed, she seems excited about this experience. A lot of education is needed to ensure a successful and, hopefully, healthy pregnancy for both JW and her baby. The purpose of this paper is to apply health teaching and knowledge to help to create a healthy outcome during pregnancy for both the mother and the baby. In this case, two big risk factors JW have are obesity and smoking cigarettes.
Prenatal Risk Factors
There are a handful of risk factors involved with JW’s pregnancy. She weighs more than 91 kilograms, smokes cigarettes, smokes marijuana, has depression, has a poor diet, and has a low-income level. All of these risk factors are considered modifiable because they can be improved upon or even controlled. For example, cessation of smoking cigarettes and marijuana, employment to increase income, weight loss/control, and medication/therapy control of depression. This pregnancy would be considered high risk because of the multiple factors that increase the risk of health problems in both the mom and the baby. Smoking is a major risk factor because they deemed this the likely cause of oligohydramnios in her previous pregnancy.
Obesity in pregnancy can increase risks of health problems in both the mother and the baby. The mother can have an increased risk for hypertension. Both chronic and gestational hypertension puts the mother at a higher risk for preeclampsia. Obesity increases the risk for gestational diabetes and diabetes mellitus, which can cause further complications that could affect the mother and the baby. Cephalopelvic disproportion can occur as a result of obesity in pregnancy. This is when he baby’s body or head is too small to fit through the pelvic opening, leading to the need of a cesarean section because obesity can increase the risk of macrosomia. The fetus has decreased nutrition and perfusion due to the increased blood pressure to the fetus. In order to decrease risk factors, the mother can participate in safe exercise for 30 minutes, 5 days a week. Walking and yoga are great examples of safe exercise for pregnant women to become more active and lose weight. The mother can be referred to a nutritionist who will guide her to eat healthier for both her and her baby’s wellbeing. During pregnancy, there are parameters of healthy weight gain, but if the mother is obese, it is recommended that she gain only 11 to 20 pounds throughout the nine months.
Smoking cigarettes can cause health problems in anyone with this habit, so a pregnant woman can hurt both themselves and their baby. Cigarettes risk many health problems in both the mother and the baby. The mother has increased risk of hypertension because smoking causes vasoconstriction. Just like in other people, smoking can cause cancer in the mother. Also, because of the vasoconstriction, there is poor placental perfusion, leading to decreased oxygen and nutrients to the fetus. In return, the fetus can have intrauterine growth restriction and be small for gestational age. These factors can lead to a premature delivery in order to save the baby. The biggest intervention in this risk factor is cessation of smoking. It can help lead to a healthier pregnancy and the best way to convince a mother of this is education on the health risks and the benefits of quitting.
This patient tested positive and admitted to the use of marijuana, even during pregnancy. There have been limited studies on the correlation with marijuana use during pregnancy, so there is not a lot of knowledge surrounding this act. It is thought that the use of marijuana during pregnancy can increase the risk for abruptio placentae. Abruptio placentae is when the placenta prematurely detaches from the uterus. The mother is also at higher risk for poor nutrition due to drug use. Marijuana use has been linked to withdrawal-like symptoms in the newborn. The baby may have increased tremors and crying that can last for a few days. Smoking marijuana has been seen to decrease oxygen in the blood, similarly to smoking cigarettes. This decrease in oxygen can cause malnutrition and intrauterine growth restriction, and in return, the baby can be small for gestational age. The main interventions to prevent these harmful effects would be cessation of marijuana use and education provided of the consequences involved.
During pregnancy, hormones changes cause mood swings and affect the pregnant woman constantly. Having a history of depression can put a woman at higher risk. Medications can be taken, but in JW case, she has completely stopped her medications months before she became pregnant. Depression is modifiable in that there are medications to aid the symptoms and therapy is always an option, but these interventions do not cure the mental illness. Having a sturdy support group may be helpful in woman with depression, as well. After giving birth, a woman’s hormone levels drop to normal levels. In a woman without depression, she is at risk for postpartum depression, so this mental illness puts her at a higher risk. Postpartum depression can lead to neglect or abuse of the child if no interventions are taken advantage of. Medications or therapy may need to be used to help the mother cope and deal with symptoms.
A nutritional, well-balanced diet is important for a healthy pregnancy and baby. JW admitted to having an unhealthy diet and did not understand the importance of prenatal vitamins. Especially during the first trimester, these nutrients are important in the development of the fetus. Prenatal vitamins contain a lot of essential vitamins, but folic acid is a vital component of these vitamins. Folic acid aids in the development of the fetus’ brain and spinal cord. These birth defects, also known as neural tube defects can cause meningoceles and myelomeningoceles, which are different types of spina bifida. Iron is another very important vitamin while pregnant. Iron aids in the production of red blood cells, and during pregnancy the woman’s blood volume must increase in order to increase oxygen and nutrient perfusion to the fetus. This impaired perfusion can lead to fetal malnutrition and intrauterine growth restriction, causing the baby to be small for gestational age. Deficient iron intake can cause anemia in many people. A woman needs more iron in her diet during pregnancy, so inadequate intake can lead to anemia. A poor diet can lead to too much weight gain if the woman is eating more than body requirements. This would endanger this woman more considering she is already obese. Studies have shown that a poor nutritional intake can increase the risk of a preterm birth. Although preeclampsia and eclampsia are not completely understood, they have been linked to high body fat and poor nutrition. The woman should be referred to a nutritionist in order to be taught the proper nutritional intake needed for a healthy pregnancy. Prenatal vitamins are also a vital part of a healthy pregnancy. They need to be taken daily throughout the pregnancy to promote a healthy development of the fetus.
JW explained that she has a low-income level. Both her and her boyfriend are unemployed and live with her father, and many others. This can lead to worsening problems that she already exhibits, such as poor nutrition. She may not spend the money on healthier foods and not take prenatal vitamins as often, if at all. She admitted to not having prenatal vitamins to take yet, so she will be receiving a prescription. Having a low-income level puts her at risk for insufficient or late antenatal care. Good nutrition and compliance with prenatal vitamins are important for the baby’s health and her own. Also, because of the increased risk for poor nutritional intake, she is at a higher risk for preeclampsia. Without the proper nutrients and antenatal care, preeclampsia is more prevalent, and she may not have the proper monitoring to detect these symptoms. The newborn can be born with a low birth weight and be small for gestational age due to the improper diet control. Without knowing the proper status of the baby, there can be intrauterine growth restriction and the baby is also at higher risk for a premature birth. There are many programs to help a low-income family during pregnancy and afterwards. These families can be referred to a social worker. Social workers can help the woman find certain necessities for pregnancy or the postpartum period, such as a breast pump for breastfeeding. They are a support person for the mother and family during this stressful life event. The social worker can assist to find certain programs that can be beneficial for a low-income family. Women, Infants, and Children (WIC) is a program made for low-income women to supplement nutrition for these families. Federal grants are provided from Women, Infants, and Children to support nutrition and health care referrals. This aid is continued throughout pregnancy, postpartum women, infants, and to children until the age of 5 if there is a need. Medicaid is an insurance program for people who are considered low-income and do not carry another insurance plan. This program can aid in prenatal, postpartum care, and the newborn care. The newborn can be insured under either Medicaid, or they can have the Children’s Health Insurance Program, or CHIP. Children’s Health Insurance Program covers healthcare for the newborn until adulthood. This health insurance covers doctor’s visits, vaccinations, medications, emergency visits, etc. These insurance programs are extremely beneficial to the low-income family and can promote wellness in both the mother and infant. Another program that is beneficial to these families is Healthy Beginnings, which is a program Geisinger hospitals provide. Healthy Beginnings provides a variety of aid to the pregnant and postnatal women. The hospital helps pay for prenatal visits and can pay for transportation if necessary. This program can give food to the family at a low cost or for free. A lot of education topics are covered as well to make sure the pregnant woman understands the importance of this care and care for her newborn. Some topics they cover are breastfeeding, formula feeding, preparing for delivery, caring for a newborn, etc.
Critique of Teaching and Anticipatory Guidance
After watching this new prenatal visit, I feel like the teaching provided for JW was lacking in a lot of areas. As listed above, she carries a lot of risk factors and this pregnancy is considered high risk, but there was not sufficient teaching provided. There was no information given on proper weight gain during pregnancy for an obese woman, let alone a normal body mass index. The patient stated that she has not taken any prenatal vitamins, so the nurse told JW she would get her a prescription. She educated JW on the importance of these vitamins in order for her to understand and move towards a healthier pregnancy and development of her baby. The nurse gave JW a booklet with information about the antenatal and postpartum period. She read and explained a section describing the foods to be avoided during pregnancy and how many calories to increase by during pregnancy. Also, the nurse provided a booklet about smoking cessation and the risk factors it causes during pregnancy. The smoking cessation hotline was given to the patient to help her quit if she decides to. There wasn’t much information given about marijuana use during pregnancy. The nurse told the patient there has not been a lot of research related to this situation, but there was no other information provided. The patient informed the nurse that she used to be on medications for depression but stopped taking them before she became pregnant. Her depression “comes and goes,” and she felt she no longer needed them. The nurse educated her on the hormone changes during pregnancy and about the increased risk for postpartum depression. The warning signs of postpartum depression were provided. She was told that if she starts to feel like she cannot handle the symptoms anymore, especially after childbirth, to seek help from a medical provider as soon as possible. The nurse recommended healthy beginnings as an aid in the client’s prenatal/postpartum care. The nurse also educated the client on different the different programs that could aid financially for both her and the baby such as, WIC, Medicaid, and CHIP. The client refused a social worker, but the nurse educated her about what they could do for her and informed her that she can request a social worker at any time during the prenatal and postpartum period.
The nurse asked the patient if she had any learning difficulties in order to provide the best care possible that will be beneficial for JW. JW noted having difficulties with reading comprehension, but she has no other learning disabilities. The nurse provided her with the typical prenatal information booklet, which is all written information. She read through most of the booklet with the patient explaining it in further detail to help the patient understand. Since she has problems with reading comprehension, I feel a booklet isn’t a very beneficial educational source. Videos or other visuals would be a great source to use for information.
Family-centered teaching is important in hopes that it will make the information more accepted and understood. In this case, the client’s boyfriend was involved in the teaching and education. When talking about smoking cessation, the nurse informed the boyfriend that it would be easier for JW to stop if he stopped with her. Also, she informed him how second-hand smoke works and how it can affect the fetus if the mother is breathing it in, even if she has stopped. She asked about other children in their lives and how involved they will be. The father of the baby has two other children, but they do not live with him and he does not see them often. JW has one other child that lives at home with her, her boyfriend, and father.
Some of the teaching regarding prenatal vitamins and programs for low-income families seemed to be successful. She agreed to take the prenatal vitamins and understood the benefits, and she is going to take advantage of the WIC and Healthy Beginnings. I think there was a lot of missing information during this teaching, such as weight loss, smoking cessation, and basic nutrition. The education could have been more effective if there were different methods used to pass the information on.
Additional Teaching or Anticipatory Guidance
Obesity
I would teach JW the risks with obesity during pregnancy and the ways to promote wellness for her and her baby. Dutton, Borengasser, Gaudet, Barbour, and Keely note that women with obesity are at a higher rate for spontaneous abortions and decreased fertility rates, making it harder to become pregnant and continue through a pregnancy full-term. I would explain the risks to JW and provide visual education tools to accommodate her reading comprehension difficulties. Videos providing information and pictures showing the effects on her and her baby might be the most beneficial. For example, showing JW a picture of a baby that has macrosomia because there is an increased risk, compared to a baby that is average weight for gestational age. The most beneficial action to take to minimize risks would be weight loss before conception, but in this case, JW is already 8 weeks pregnant. So, my main teaching point with JW would be limiting gestational weight gain. The recommended weight gain for an obese pregnancy is between 11-20 pounds total throughout the pregnancy. Weight gain should be at its highest during the second and third trimesters because nutritional intake should not be increased during the first trimester. Gaining too much weight during this time increases her risk for gestational diabetes and increased birth weight of her baby. Showing a video with his information may also be a good teaching method for JW because it would include visuals and auditory explanations, rather than written information.
Poor Nutrition
Weight gain is an inevitable and important part of pregnancy. Kominarek explains that the weight gained consists of the baby, amniotic fluid, placenta, increased blood volume, and other body changes during this time. Calorie intake should not increase during the first trimester, but in the second and third trimesters, the woman should increase 300 calories a day (Kominarek, 2016). A woman with a normal body mass index should gain around 25 to 35 pounds throughout the pregnancy, but it is recommended that a woman with a body mass index over 30 should gain 11 to 20 pounds. This is vital information for JW to be taught to aim towards a healthy pregnancy. Again, I would use visuals such as videos and pictures to provide education that would be beneficial to this patient. A picture showing proper portion sizes with an increase of around 300 calories a day in healthy foods. Using the teach-back method may be useful for this patient as well. If she is able to teach the information back to you, it shows that she understands the education. Another topic that needs to be taught to JW would be the nutritional intake during breast feeding. She has a plan to breast feed and pump breast milk after the baby is born. Breastfeeding burns a lot of calories, so in return, she will need to increase calorie intake more than she already has. It is recommended to increase 500 calories more each day than a nonpregnant woman. JW would need to be taught the importance of this increase, in order to continue milk production, and provide her baby with the proper nutrients. Educational videos would be beneficial, in this case, to provide JW with proper education. I would, also, refer her to a nutritionist for better information about proper diet while pregnant. Breastfeeding classes, such as La Leche League, would be beneficial to educate JW about the nutrients needed while breastfeeding her baby.
Conclusion
JW is on her third pregnancy, and this pregnancy is considered high risk. She has many factors that come together to consider her high risk. She is considered obesity class II with a body mass index of 37. She is currently still smoking cigarettes, which has affected one of her pregnancies in the past. Her most recent pregnancy needed an emergency cesarean section to save her newborn. Her baby had oligohydramnios resulting from smoking cigarettes during pregnancy. She, also, is using marijuana throughout her pregnancy and eats a poor diet. She is low-income, putting her at risk for insufficient antenatal care, but with the help of Healthy Beginnings and Medicaid, she is able to receive care in the clinic and receive prescriptions for prenatal vitamins and a breast pump. JW has a history of depression and used medications, but currently has taken herself off of the medications, putting her at a higher risk for postpartum depression. All of these risk factors are considered modifiable, so with the right healthcare provider and education, the pregnant mother should be able to decrease her risk factors and have a healthier pregnancy. In this case, the nurse provided some of the prenatal education well, but I feel like there was some information missing. This patient would have benefited from a more visual or hands-on educational experience. Without proper teaching, a high-risk pregnancy can become worse as time goes on. If a risk factor is modifiable, it is vital to address the situation, so the mother can make educated decisions on how she is going to handle it. Health promotion is an important component when working with pregnant women because these women are generally healthy and health risks are the most prevalent issue.
References
Davidson, M., London, M., & Ladewig, P. (2016). Maternal-newborn nursing & women’s health. USA: Julie Levin Alexander.
Dutton, H., Borengasser, S. J., Gaudet, L. M., Barbour, L. A., & Keely, E. J. (2018). Obesity in pregnancy: optimizing outcomes for mom and baby. Medical Clinics of North America, 102(1), 87-106. https://doi.org/10.1016/j.mcna.2017.08.008
Kominarek, M. A. (2016). Nutrition recommendations in pregnancy and lactation. Medical Clinics of North America, 100(6), 1199-1215. https://doi.org/10.1016/j.mcna.2016.06.004