Hanson, Lisa

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Marquette Universitye-Publications@MarquetteCollege of Nursing Faculty Research andPublications Nursing, College of10-1-2008Prenatal Education: Priorities for Perinatal NursesLisa HansonMarquette University, lisa.hanson@marquette.eduAccepted version. Journal of Perinatal & Neonatal Nursing, Vol. 22, No. 4 (October-December 2008):254-256. DOI. © 2008 Lippincott Williams & Wilkins, Inc. Used with permission Marquette University e-Publications@Marquette  Nursing Faculty Research and Publications/College of Nursing  This paper is NOT THE PUBLISHED VERSION; but the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in th citation below.  he Journal of Perinatal & Neonatal Nursing, Vol. 22, No. 4 (October-December 2008): 254-256. DOI. This article is © Lippincott Williams & Wilkins and permission has been granted for this version to appear in e-Publications@Marquette. Lippincott Williams & Wilkins does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Lippincott Williams & Wilkins.   Prenatal Education: Priorities for Perinatal Nurses  Lisa Hanson Marquette University College of Nursing, Milwaukee, WI  Arecent weekend in the obstetric triage of a local tertiary care hospital led this author to note the volume of women being seen for common discomforts of pregnancy. In the obstetric triage area, experienced certified nurse-midwives work alongside experienced labor and delivery nurses. Together they examine pregnant women and notify providers, who make decisions about their disposition. Few of the women evaluated called their provider before coming to the hospital. More than 7 of the 14 patients seen in the 12-hour shift came in for round ligament pain or other benign discomforts of pregnancy. The logical question to ask is, “what happened to prenatal education?” Easily half of these visits could have been prevented by preparing the woman for the discomfort that she would likely experience before her next prenatal visit. Round ligament pain is a nearly universal discomfort of pregnancy. Women experience sharp, stabbing unilateral or bilateral lower abdominal pain usually associated with movement beginning at or around 20 weeks of pregnancy that continues until the time of birth. This discomfort can be reproduced during abdominal palpation as a part of patient examination. Round ligament pain can be improved by the knowledge that it is a benign discomfort. However, this pain is assumed to be abnormal if the woman is unprepared. Preparation can easily take place anytime a nurse encounters a pregnant woman and has an opportunity to provide prenatal education. Nurses can incorporate prenatal education into client encounters in any setting. However, some labor and delivery nurses may not feel skilled or prepared to deliver prenatal education. Some nurses may feel compelled to focus on acute problem solving rather than on preparing their antepartum patients for life after hospital discharge. Others may be unaware of concerns that are common to women in the various trimesters of pregnancy or how to fully address them. Table 1 contains a review of the common discomforts of pregnancy and their time of occurrence. Both nurses and midwives learn that anticipatory guidance was an important aspect of antenatal education. Revisiting the basic tenants of prenatal education may improve the care to women in all antenatal areas.  Table 1 Discomforts of pregnancy by trimester  First Second Third trimester trimester trimester  Fatigue X  X Breast tenderness X  X Urinary frequency X  X Constipation X  X Increased vaginal discharge X X X Round ligament pain  X X Lower back pain  X X Heartburn  X X Shortness of breath   X Pelvic pressure   X Edema   X  Prenatal education that takes place as a part of routine prenatal care has long been identified as an important component of antenatal care. This concept has been reinforced by the finding that only 30% of contemporary women attend formal prenatal education classes.1 Therefore, the education that is provided during routine prenatal visits and other antenatal encounters may be the only education that the majority of pregnant women receive. Nurses provide prenatal education to women in a variety of settings including prenatal clinics and office settings, perinatal assessment centers, birthing facilities, home healthcare and antenatal units as a part of routine nursing care. These settings all pose multiple demands on nurses including limited staffing, heavy patient loads, and time constraint for each patient encounter. The nurse attempting to meet the multiple demands of patient care in these settings may find that they are left with less time to discuss nonurgent concerns and anticipatory education. Furthermore, the quantity and quality of patient education provided by prenatal providers may be unknown and highly variable in both quality and quantity. The nurse can use the time spent with the patient to reinforce positive health behaviors, discuss strategies to modify risk factors, and help women anticipate and learn about the normal changes and discomforts of pregnancy. Keeping in mind that most women have 10 to 14 prenatal visits and potentially several other healthcare visits, topics can be portioned out across these visits or antenatal encounters. A reexamination of the priorities of prenatal education can serve both the needs of prenatal patients and the constraints placed on busy nurses. With the goal of time efficient and complete prenatal education, it is important to determine which issues need to be addressed including the timing and the educational approach to be employed with each individual woman. Nurses can introduce topics in a manner that meets women's needs for gestationally appropriate information as well as their readiness to learn. Nurses can consider the following priorities in offering education within each prenatal visit or prenatal care encounter.2 The first priority is to address questions, concerns, or discomforts that the woman is currently experiencing. The second level of priority for nursing prenatal education is providing information that is essential for the safety of the woman and/or her fetus (eg, avoidance of teratogens and harmful substances, warning signs). The third level of priority concerns providing anticipatory guidance, for example, knowledge of common discomforts, such as round ligament pain, that she may experience before her next prenatal visit. The woman's psychologic adjustment to the pregnancy should also be considered when determining routine topics to be discussed to ensure that she will comprehend the patient teaching and identify with its relevance. During the first trimester, the woman is self-focused and therefore is compelled to address issues concerning the physical and emotional changes of pregnancy.3 Prenatal education at this time should address her symptoms as well as suggestions for coping with these changes and the related normal pregnancy discomforts. She may not yet view the infant as being a separate individual and therefore may not relate to educational topics concerning the fetus as much as she will after she experiences fetal movement. During the second trimester, quickening verifies the pregnancy for the woman causing the woman to change her focus from herself to the infant.3 During the second trimester, most women are comfortable and have good energy for work and leisure activities. However, this is the time that round ligament pain can first appear. The third trimester is a period of watchful waiting and the woman is well aware of the growing fetus inside of her.3 She begins to address issues related to becoming a mother and preparing for the arrival of the newborn. This can be a time of great fear if the woman is unprepared for childbirth. Table 2 contains a prenatal teaching outline that can be used when approaching prenatal education in any antenatal setting. This outline was developed using guidelines from both the Institute for Clinical Systems Improvement4 and the Veterans Health Administration, Department of Veterans Affairs, and Health Affairs.5 Both of these prenatal guidelines had specific recommendations for the inclusion of prenatal education topics. Visual aides and handouts can supplement the educational interaction. The nurse can first address client concerns and then maternal and fetal safety issues, and finally a topic from the gestationally appropriate list of topics can be selected to discuss with the woman and her family. If the nurse sees the patient at multiple encounters, different topics can be addressed at subsequent visits. Documenting specific topics addressed at each visit will prevent omissions and redundancies. The outcomes of the education can be demonstrated by having the woman explain her understanding of what was taught verbally to the nurse.  Table 2 Prenatal education topics and the trimester to address them Prenatal education topics First trimester  Second trimester  Third trimester Course of prenatal care  X   Initial prenatal laboratories including human immunodeficiency virus X   Disease-specific genetic testing X  X  Ultrasound  X  X  Nutrition and weight gain  X  X  X Tobacco, alcohol, or drug cessation as necessary X  X  X Physiologic changes of pregnancy X  X  X Warning signs/provider contact information X  X  X Fetal growth and development X  X  X Physical activity/exercise  X  X  X Discomforts anticipation and management  X  X  X Employment  X   X Travel/safety  X   X Breast-feeding  X   X Sexual activity  X   X Contraceptive options  X   X Preterm labor signs and symptoms   X  X Fetal movement counting   X  X Antepartum rhogam   X  Quickening   X  Options for childbirth education classes   X  GBS testing and results management    X Signs and symptoms of labor    X Birth planning    X Pediatric provider choice    X Abbreviation: GBS, group B strep. Strengthening prenatal education would benefit pregnant women, obstetric providers, and even hospital systems. Staff education on prenatal education may be a starting point. For example, hospital labor and delivery nurse educators could review discomforts of pregnancy for staff nurses. Furthermore, for antepartum patients who are hospitalized, a prenatal education care plan may be developed with the woman's individual educational needs and taken into consideration. Even in obstetric triage, basic prenatal education and documentation of what is taught could reinforce the patient's awareness of normal discomforts of pregnancy as well as of danger signs. Prenatal education delivered by nurses is an important component of comprehensive care to antenatal clients. Nursing education about patient concerns and discomforts, maternal and fetal safety, and anticipatory guidance can help prevent patient anxiety and unnecessary phone calls and trips to the hospital. Lisa Hanson, PhD, CNM, FACNM Marquette University College of Nursing, Milwaukee, WI.  REFERENCES 1. Declerq ER, Sakala C, Corry MP, Appelbaum S, Risher P. Listening to Mothers: Report of the First National US Survey of Women's Childbearing Experiences. New York: Maternity Center Association; 2002. 2. Roberts JE. Priorities in prenatal education. Obstet Gynecol Neonatal Nurs. 1976;5(3):17–20. 3. Varney H, Kriebs JM, Gegor CL. Normal pregnancy database: adaptations of the mother, development and growth of the embryo and the fetus, and the placenta. In: Varney H, Kriebs JM, Gegor CL, eds. Varney's Midwifery (4th ed.). Sudbury, MA: Jones and Bartlett Publishers; 2004:553–554. 4. Institute for Clinical Systems Improvement. Knowledge Resources. Routine Prenatal Care.2007.. Accessed July 17, 2008. 5. VA/DOD Evidence Based Clinical Practice Guideline Working Group. Veterans Health Administration, Department of Veterans Affairs, and Health Affairs, Department of Defense. Management of uncomplicated pregnancy in the primary care setting, 2002.. Accessed October 28, 2005.  © 2008 Lippincott Williams & Wilkins, Inc.  

Prenatal Education: Priorities for Perinatal Nurses

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Prenatal Education: Priorities for Perinatal Nurses

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