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Maternal Newborn Nursing

3.5 Preconceptual Care

Maternal Newborn Nursing3.5 Preconceptual Care

Learning Objectives

By the end of this section, you will be able to:

  • Analyze the risk factors for persons assigned female at birth who are planning to conceive
  • Explain the importance of the preconception visit in persons who are planning to conceive

Pregnancy planning involves discussing preconception care and fertility awareness methods for individuals considering starting a family. Preconceptual counseling involves various components, including reproductive health assessment, medical and genetic history, assessment of self-care practices, nutritional assessment, immunizations, physical examination, medication review, nutrition counseling and education, psychologic support, and referrals for follow-up. The goal is to optimize a person's health and readiness for pregnancy, mitigate risks, and provide necessary support and education for a healthy conception and pregnancy journey.

Preconception Risk Factors

Factors or conditions that can increase the likelihood of complications during pregnancy or affect the fetus’s health if a person becomes pregnant are called preconception risk factors. Identifying and addressing these risk factors before conception is essential for optimizing maternal and fetal health and assists in ensuring patients can make informed choices about their reproductive goals. Some common preconception risk factors include age, preconception medical conditions, substance use, nutrition, and genetic factors. These risk factors are discussed in Table 3.22. Addressing and managing these preconception risk factors through preconception counseling, self-care practices, proper medical management, and appropriate vaccinations can help optimize the health of both the pregnant person and the fetus during pregnancy. Persons who do not receive proper preconception counseling and care may be unaware of certain risk factors or necessary preparations for a healthy pregnancy.

Preconception Risk Factors Description
Age Individuals 35 years or older at conception have an increased risk of certain pregnancy complications, such as gestational diabetes, preeclampsia, and chromosomal abnormalities in the fetus. Persons less than 18 years of age may have increased risks during pregnancy.
Chronic health conditions Preexisting medical conditions like diabetes, hypertension, thyroid disorders, and autoimmune diseases can impact pregnancy outcomes.
Medication use Certain medications may be teratogenic or require adjustments during preconception and/or pregnancy.
Substance use Smoking before or during pregnancy can lead to complications such as miscarriage, preterm birth, low birth weight, and sudden infant death syndrome (SIDS).
Consuming alcohol or using illicit drugs before or during pregnancy can negatively affect fertility and increase the risk of birth defects and developmental problems in the fetus.
Nutrition and diet Poor diet and nutritional deficiencies, particularly in folate and other essential nutrients, can impact fertility and increase the risk of birth defects.
Obesity and underweight Both extremes of weight can affect fertility and pregnancy outcomes. Being overweight or obese before pregnancy is associated with a higher risk of gestational diabetes, hypertension, cesarean delivery, and neural tube defects in the fetus.
Individuals with a low body weight may face challenges with fertility and an increased risk of delivering a baby preterm or with low birth weight.
Reproductive health conditions Conditions affecting the reproductive system, such as PCOS or endometriosis, may affect pregnancy.
Mental health Unmanaged mental health issues may impact fertility and pregnancy.
Genetic and family history A family history of genetic disorders or certain genetic conditions in the individual or the partner may warrant genetic counseling and testing before conception.
Infections and immunizations Immunity to certain infections, such as rubella and varicella, and proper vaccinations are essential for pregnancy.
Sexually transmitted infections (STIs) can affect fertility and pose risks to the developing fetus if present during pregnancy.
Environmental exposures Environmental and/or occupational hazards or exposure to certain toxins, radiation, or chemicals can impact fertility and pose risks during pregnancy.
Socioeconomic factors Socioeconomic status can influence access to health care and prenatal care.
Emotional and relationship status Stress and relationship dynamics may impact fertility and emotional well-being.
Previous pregnancy history Past pregnancy complications or previous birth outcomes may affect future pregnancies.
Table 3.22 Preconception Risk Factors

Pregnancy Planning

Discussing pregnancy planning, preconception care, and fertility awareness methods is important for those considering starting a family. The recommended spacing of pregnancies, also known as interpregnancy interval, refers to the time between the birth of one child and the conception of the subsequent pregnancy. The March of Dimes (2017) recommends a minimum interpregnancy interval of at least 18 to 24 months after a full-term birth before attempting another pregnancy. By allowing the person's body to recover from the previous pregnancy, the risks of premature birth and low birth weight are reduced. Replenishing essential nutrients, such as folic acid, helps prevent birth defects associated with folic acid deficiency such as neural tube defects (March of Dimes, 2017). People 35 years or older at the time of birth are considered to be at advanced maternal age and may require additional considerations due to increased risks associated with fertility decline and age-related pregnancy complications. Those with certain medical conditions, such as diabetes or high blood pressure, may benefit from longer interpregnancy intervals to optimize their health and manage their condition before the subsequent pregnancy. People who experience pregnancy complications, such as preterm birth or cesarean delivery, may require longer intervals for proper healing and reduced risk of recurrence.

Preconceptual education and assessment involve several components to address various aspects of an individual’s health and readiness for pregnancy. Table 3.23 lists key components of preconceptual counseling.

Category of Assessment Steps Involved
Reproductive health assessment
  • evaluating the individual's menstrual history, including cycle regularity, duration, and any issues related to fertility
  • assessing the history of previous pregnancies, including complications, miscarriages, or birth defects
  • discussing the use of contraception and family planning methods
Medical and genetic history
  • reviewing the person's medical history, including chronic conditions, surgeries, or medication usage, and assessing their impact on pregnancy
  • assessing the presence of any genetic disorders or a family history of genetic conditions that may impact the pregnancy or require further evaluation
Self-care practices and behavioral factors
  • discussing the individual's lifestyle factors, such as nutrition, physical activity, substance use (including alcohol, tobacco, and drugs), and stress management
  • assessing any occupational hazards or environmental exposures that may pose risks during pregnancy
  • identifying any psychosocial factors, such as history of trauma, mental health concerns, or social support systems
Nutritional assessment and supplementation
  • assessing the individual's dietary habits and providing guidance on a balanced diet rich in essential nutrients needed for a healthy pregnancy
  • recommending preconception supplementation, including folic acid, to reduce the risk of neural tube defects and other prenatal vitamins as needed
Immunizations
  • reviewing the individual's immunization status and ensuring that they are up to date with recommended vaccinations, such as rubella and varicella, to protect both the individual and the developing fetus.
Physical examination and screening
  • conducting a comprehensive physical examination to evaluate general health, including weight, blood pressure, and signs of underlying conditions
  • recommending or performing specific screenings or tests based on the individual's medical and reproductive history, such as sexually transmitted infection (STI) testing, cervical cancer screening, or other indicated tests
Medication review and management
  • reviewing the individual's current medications and assessing their safety during pregnancy
  • collaborating with the health-care provider to make any necessary medication adjustments or changes to ensure their safety during conception and pregnancy
Preconception counseling and education
  • providing information and education on preconception care, healthy self-care practices, fertility awareness, and timing intercourse for optimal conception
  • discussing potential risks and precautions related to specific occupations, travel, and exposures during the preconception period
Psychologic support and mental health screening
  • assessing the individual's mental health status and providing resources for stress management, coping strategies, and emotional support during the preconception period
  • identifying any history of mental health concerns and coordinating with mental health professionals if needed
Referrals and follow-up
  • referring the individual to appropriate health-care providers, specialists, or support services based on identified needs or risks
  • scheduling follow-up appointments to monitor progress, address any concerns, and provide ongoing support throughout the preconception period
Table 3.23 Components of Preconceptual Counseling

It is important to note that preconceptual education should be tailored to the person's unique circumstances, considering their medical history, self-care practices, social determinants of health, and personal preferences. The goal is to optimize the person's health and readiness for pregnancy, mitigate potential risks, and provide necessary support and education to promote a healthy conception and pregnancy journey.

Pharmacology Connections

Folate (vitamin B9)

People need adequate folate intake even before they become pregnant, as the neural tube forms very early in pregnancy. Ideally, people should begin taking folic acid supplements or consuming foods rich in folate at least 1 month before conceiving and continue throughout the first trimester of pregnancy.

  • Generic Name: folate, folic acid, vitamin B9
  • Trade Name: n/a
  • Class/Action: vitamin
  • Route/Dosage: 400 to 800 mcg daily; 4 mg daily if at high risk for neural tube defect (history of child with neural tube defect)
  • High Alert/Black Box Warning: none
  • Indications: folate deficiency, megaloblastic anemia, sprue, neural tube prevention, dietary supplement
  • Mechanism of Action: DNA synthesis and erythropoiesis
  • Contraindications: undiagnosed anemia
  • Adverse Reactions/Side Effects: nausea, abdominal pain, flatulence, irritability, overactivity, erythema, rash, pruritis
  • Nursing Implications: Discuss neural tube defect risks to determine appropriate dosage
  • Parent/Family Education: People in the preconception period are advised to consume foods rich in folate, such as leafy green vegetables (e.g., spinach, kale), legumes (e.g., lentils, chickpeas), fortified cereals, citrus fruits, and avocados.

Self-Care Practices

Preconception is the time for persons to become as healthy as possible to have a safe, noncomplicated pregnancy and birth. Important self-care practices to prepare for pregnancy include starting the pregnancy at a healthy weight. Obesity can cause problems with infertility and increases the risk for pregnancy complications such as gestational diabetes, stillbirth, and preeclampsia. Nurses can encourage nutrition and exercise strategies for patients to consider during the preconception phase.

Smoking cessation is important prior to trying to conceive. Smoking can cause infertility due to decreased hormone production and damage to the DNA carried in the sperm (U.S. Food and Drug Administration, 2021). Nurses can discuss the importance of smoking cessation for parents. Nicotine is a very addictive drug, and cessation can be difficult. Nurses can support parents and provide them with helpful information regarding smoking cessation programs, nicotine patches and gum, and medications that can aid in smoking cessation prior to conception.

Substance use is also important to identify, and aiding parents in decreasing and abstaining from alcohol and other substances is vital. According to research, one to five drinks per week can affect a person’s fertility by interrupting the timing of ovulation and reducing the quantity and quality of sperm (Wild, 2022). Like nicotine, alcohol and other substances are very addictive, and many parents need help in quitting. Health-care providers and nurses must be nonjudgmental and present options for support groups, rehabilitation centers, and medications to help with alcohol and drug abstinence.

Nutrition plays an important role in good health for appropriate hormone development and function and prevention of disease. Studies have shown difficulty with ovulation in those who have a diet low in nutrients and high in sugars; however, those who follow a Mediterranean diet and exercise have better fertility rates (Silvestris et al., 2019). Nurses can educate patients to increase protein, decrease simple carbohydrates, increase complex carbohydrates, increase essential fatty acids, and increase foods high in folate and vitamin C. Providing patients with guidance on diet and exercise will not only help with fertility but also decrease risks for pregnancy complications. Figure 3.13 shows an example of a Mediterranean diet.

Mediterranean Diet: top - red meat, sweets (infrequent consumption); middle - fish, seafood, white meat, eggs, yogurt, cheese (regular consumption); bottom – fruits, vegetables, whole grain, olive oil, nuts, legumes, spices (daily consumption).
Figure 3.13 Mediterranean Diet The Mediterranean Diet is an excellent diet for persons considering pregnancy and those who are pregnant. (credit: “The Mediterranean pyramid of nutrition style and weekly organization of meals" by E. Silvestris, D. Lovero, and R. Palmirotta/Frontiers in Endocrinology, CC BY)

Stress can be a result and/or a cause of infertility. Research has found that cognitive behavior therapy (CBT) is associated with increased rates of pregnancy in persons dealing with infertility (Rooney & Domar, 2018). Relaxation techniques, mindfulness, and group support have also been shown to increase pregnancy rates (Rooney & Domar, 2018). Nurses can discuss the stress associated with infertility and provide resources for therapy and support groups.

Preexisting Conditions

During the preconception visit, the person’s medical history is examined for preexisting conditions that could interfere with conception and increase risk for pregnancy complications. Persons with type 1 and 2 diabetes mellitus should talk with their endocrinologist or diabetes health-care provider prior to conception. These persons should be told their risk factors for increased risk of complications during pregnancy and the importance of maintaining good glucose control while trying to conceive and during pregnancy.

Chronic hypertension has been associated with poor egg quality related to increased estrogen caused by high blood pressure; if the egg is fertilized, the risk for miscarriage is increased (Zimlich & Rainford, 2022). Chronic hypertension can also affect sperm motility, semen volume, and total sperm count (Zimlich & Rainford, 2022). The nurse can educate people on the importance of controlling hypertension prior to and after conception.

Thyroid disorder is a common risk factor for infertility. Persons AFAB have higher incidences of thyroid disease than persons AMAB, and the most common reason for hypothyroidism is autoimmune thyroiditis (Koyyada & Orsu, 2020). Hypothyroidism can cause irregularities in the menstrual cycle leading to anovulation and infertility (Koyyada & Orsu, 2020). It can also lead to preterm birth, miscarriage, and fetal death. Research has shown that treating hypothyroidism with levothyroxine (Synthroid) in persons with infertility led to a 90.5 percent to 100 percent success rate in conception, pregnancy, and term birth (Koyyada & Orsu, 2020). Nurses can help educate persons with thyroid disease on the importance of taking medications consistently to help increase their fertility.

Family History

Family history for both parents can contribute to risks for pregnancy complications. Testing that can be offered prior to or during pregnancy to determine if a couple is at risk for having a child with a particular recessive genetic disorder is called carrier screening. Common recessive conditions that carrier screens can detect are sickle cell disease, Tay-Sachs disease, cystic fibrosis, spinal muscular atrophy, hemophilia, and other hemoglobin conditions; these conditions may be associated with specific ethnic groups (ACOG, 2022). To have the recessive disease, the parent must have two recessive genes for that strand of DNA. If a parent has one recessive gene and one dominant gene, they are a carrier. The carrier screen identifies if the parent is negative (2 dominant genes), positive (2 recessive genes), or a carrier (1 recessive and 1 dominant gene). The screening results for both parents are compared, and the chances of them having a child with the disorder are calculated (ACOG, 2022). Figure 3.14 is a visual description of recessive gene expression. (The term "parent" in the sense of genetic inheritance refers only to the contributors of the child's genes, and may differ from the people who actually parent the child.)

Chart displaying unaffected carrier parents and how results show in four children: unaffected child, two unaffected carrier children, and affected child (all having 1 in 4 chance).
Figure 3.14 Recessive Gene Expression “R” is the dominant gene. “r” is the recessive gene. A carrier screen determines if a parent has only dominant genes, only recessive genes, or one of each. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Reviewing family history for other chronic conditions allows for increased monitoring for these conditions during pregnancy. The nurse or health-care provider will inquire about a family history of hypertension, diabetes, gestational diabetes, preeclampsia, bleeding disorders, problems with anesthesia, strokes, cardiovascular disease, and thyroid disorders. The history of complications during pregnancy for the patient’s mother or sister can give insight into possible pregnancy complications for the patient.

Teratogens

Substances or agents that can cause congenital abnormalities or birth defects in a developing embryo or fetus during pregnancy are called teratogens. These substances can harm fetal development and may result in structural or functional abnormalities in the baby. The impact of teratogens on the fetus depends on factors such as the type of teratogen, the timing and duration of exposure during pregnancy, and individual susceptibility.

Gestational age at exposure greatly influences the effect of the teratogen. The most harmful time for exposure is during weeks 1 through 8, when organs are developing (Cleveland Clinic, 2022t). The entire first trimester is a critical time for teratogen exposure leading to major birth defects of structures and organs. Teratogen exposure during the second and third trimesters usually affects fetal growth and causes minor birth defects because organs and structures have already developed (Mother to Baby, 2021). Functional defects, such as learning defects, occur more often with teratogen exposure in the second and third trimesters. Other adverse outcomes can be preterm birth and oligohydramnios (Mother to Baby, 2021).

Teratogens can include various environmental factors, medications, infections, and other exposures. Table 3.24 lists many common teratogens and their effects.

Teratogen Effect on Fetus
Alcohol Fetal alcohol spectrum disorder, abnormal facial features, small head and brain, physical and behavioral disabilities
Cigarettes and tobacco Fetal growth restriction, premature birth, miscarriage, lung and brain issues
Recreational drugs Low birth weight, heart problems, neonatal abstinence syndrome, infections
Certain medications:
Isotretinoin (Accutane)
Thalidomide
Warfarin (Coumadin)
Methotrexate
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blockers (ARBs)
Lithium
Valproic acid (Depakote)
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Misoprostol (Cytotec)
Trimethoprim-sulfamethoxazole (Bactrim)
Aminoglycosides
Fluconazole (Diflucan)
Paroxetine (Paxil)
Congenital abnormalities, organ malformation, developmental issues, cognitive impairments, increased risk for pre-eclampsia and gestational hypertension
Infections and Viruses:
Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex virus
Zika virus
Parvovirus B19
Syphilis
Varicella zoster virus
Human immunodeficiency virus
Listeriosis
Hepatitis B and C
Miscarriage, birth defects, pregnancy complications, developmental disorders
Table 3.24 Teratogens and Their Effects on the Fetus

Preconception Visit

The preconception visit includes a thorough history and physical examination, laboratory studies, and preconception education. The nurse plays a large role in providing anticipatory guidance and education.

Physical Exam

A preconception physical examination aims to assess the person's overall health and identify any medical conditions or risk factors that may affect their ability to conceive and have a healthy pregnancy. During the preconception physical exam, the health-care provider will conduct a thorough gynecologic exam. Preconception lab tests will be ordered to assess the person's overall health and identify any underlying medical conditions. The specific lab tests ordered will vary based on the person's medical history, risk factors, and needs. Table 3.25 lists common preconception tests and the reasons for them.

Testing Rationale
Blood tests
  • complete blood count (CBC): to check for anemia or other blood disorders
  • blood type and Rh factor: important to identify blood type and Rh compatibility with the partner to monitor potential blood type incompatibility issues during pregnancy
  • blood glucose: to screen for diabetes or prediabetes
  • blood lipid profile: to assess cholesterol levels and cardiovascular health
  • thyroid function tests: to evaluate thyroid hormone levels, as thyroid disorders can impact fertility and pregnancy
  • folic acid and vitamin D levels: to assess nutritional status and determine if supplementation is needed
  • rubella antibody test: to determine immunity to rubella (German measles), as rubella infection during pregnancy can cause birth defects
  • rubella titer: to measure rubella immunity, especially if there is no vaccination history or history of prior infection
  • varicella (chickenpox) titer: to check for immunity to varicella, as varicella infection during pregnancy can cause complications
STI tests
  • human immunodeficiency virus (HIV): to check for HIV infection, which can be transmitted to the fetus during pregnancy or childbirth
  • syphilis: to screen for syphilis, which can lead to serious complications during pregnancy
  • hepatitis B and C: to test for hepatitis B and C infections, which can be transmitted to the fetus during childbirth
Urinalysis
  • to check for urinary tract infections or other kidney-related issues
Genetic screening
  • may be offered depending on the individual's family history and ethnic background, to identify carrier status for certain genetic disorders that could be passed on to the fetus
Pap smear
  • to screen for cervical cancer or detect abnormal cervical cells
Pelvic ultrasound/Transvaginal ultrasound
  • to evaluate the health of the reproductive organs and check for any abnormalities
Table 3.25 Common Preconception Tests

Preconception Education

The nurse can provide preconception education to both partners. Education can cover the fertile window surrounding ovulation and how the person can discover that window using natural family planning methods or ovulation predictor kits. Figure 3.15 is an example of a natural family planning chart that can be used to track the fertile window. Ovulation predictor kits predict the presence of LH (the hormone that causes the release of the egg from the follicle). Temperature monitoring allows the person to see that ovulation has occurred by detecting an increase in temperature caused by the corpus luteum’s production of progesterone.

Fertility chart for documenting: Charting cycle, Day 1 date, Cycle length, Luteal phase length, dates, times waking temperatures, intercourse, blood, vulva sensation, cervical position, texture, and opening, cramps, mood, and notes.
Figure 3.15 Fertility Awareness Chart The nurse can educate the patient on tracking signs of fertility to increase the chance of conception. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The nurse can also educate the couple on the importance of both partners’ health. Alcohol, drugs, tobacco, obesity, and other chronic illnesses negatively affect sperm production and quality. Therefore, partners can work together to abstain from harmful substances and maintain a healthy body weight. The nurse will discuss nutrition and exercise. Nurses can educate couples on the mental and emotional issues that surround trying to conceive. They can encourage couples to discuss their feelings and provide counseling resources especially for couples having difficulty in conceiving.

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