Maternal Health and Paediatric Care - Essay Example

Maternal Health and Paediatric Care - A Case study Introduction This brief paper discusses maternal health and paediatric care concerns, such as the decisions many pregnant mothers and their prenatal care givers make during instances of abnormal pregnancies. Abnormalities in pregnancy such as when a fetus indicates risks of deformities after genetic tests have a great impact on the lives of both parents. The same transpires to nursing care accorded to such parents. As the paper establishes, the core role of nursing care at such times is to help the parents make an informed and appropriate choice between carrying the pregnancy to full time or to abort. A case study approach is adopted to develop the argument of the paper, reviewing the dilemma of parenthood in cases of problematic pregnancies against a background of ideal clinical and nursing practices. The paper begins with an introduction that broadly places the theme of the paper in context, before some background information is given. The background information simply construes an introduction into the case study and the arising issues thereof. Upon this background, the paper proceeds to examine and discuss the maternal health and paediatric care issues raised by the case study. Under maternal health and paediatric care, the paper is broken down into several accumulative subtopics namely, pregnancy screening tests, generic counseling during pregnancy, late pregnancy termination dilemmas and an appraisal of care in respect to the case study. This accomplished, the paper then proceeds to consider how some geo-spatial factors such as the remoteness of a particular location in regards to health care facilities’ accessibility, influence maternal health and paediatric care. The paper then terminates with a tenable conclusion of the issues discussed throughout the paper. Background Information The case study discussed in this paper constitutes of a 28 year old woman named Jane. Jane is currently 22 weeks into a second pregnancy. She is married to Harry, a plumber. Jane and harry have a stable and considerably happy relationship, but for a sad turn of events in their procreation attempts. As noted, this is Jane’s second pregnancy, after the first one was forced into an abortion a year ago. The abortion was advised consequent to fears that the foetus may have had an unqualified genetic defect. The particular pathology on the body done just before that abortion was inconclusive and that is why the current pregnancy warrantees great caution. In recent prenatal clinical assessments, the fact that the first abortion was inspired by a generic defect in the foetus has become an important factor in all the decisions both the parents and the care givers makes. It has called for close monitoring of the current pregnancy, which while being full of tension is still unclear. The predicament of Jane and Harry is one that triggers caution from all perspectives. For instance, the fact that they live in a rural area that is about four hours away from the nearest referral hospital is worrying. Should a complication develop, Jane would have to be transported over to the hospital, in something likely to be a critical condition coupled by any transport problems that may also arise encourse. There issues that arises out of this case study. For instance, one can question whether it would be wise for Jane to carry the pregnancy into full term with the risk of bearing a deformed child or one with great physiological and or psychological anomalies (Baum 1982, p. 106). On the other hand, given that the first genetic defect was still unqualified, perhaps Jane should take courage and hope for the best. But should she fear having a child with a genetic defect, is it wise to have an abortion when she is already onto her 22 week, a late pregnancy by all measures? The risks of terminating a late pregnancy are all too resounding at such times, to an extent that it might be deemed by most as dangerous. A few questions here will help espouse the scenario better. As the parents make these difficult decisions, what are the roles of the care givers that Jane is seeing currently? How should the couple choose between the options and who should help them? In the first place what are the options available? What are the risks, advantages, disadvantages and chances of each of the available options? These issues are central to this paper and will be discussed in detail in the proceeding sections. A few years ago, the dilemma that Jane and Harry are facing would have been impossible to diagnose. They would have probably discovered the genetic defects after the children are born. However, the world of medicine has made great advances in foetus genetic testing (Kolker and Burke 1994, p. 74). The advances have improved the doctors' ability to correctly diagnose and even treat some genetically predisposed illnesses. There are still some limits, though to how much can be done in some instances (Kolker and Burke 1994, p. 74). Modern genetic tests help in identifying a problem gene carried into the foetus from the parents. It is not always easy to predict the severity of the gene’s affect to the parent (Kolker and Burke 1994, p. 74). A good example is where a test identifies cystic fibrosis caused by a problem gene in the 7th chromosome does not necessarily predict how serious it will affect the child in such deformations as acute lung problems or at least mild respiratory symptoms (Kolker and Burke 1994, p. 74). All these concerns play out in the lives of a parent carrying a pregnancy diagnosed of such genetic defects. Maternal and Paediatric Care Concerns Pregnancy Screening Tests Pregnancy tests today help predict possible birth defects of a foetus. According to Women in Good Health (2010), the major causes of known birth defects today are those caused by genetic disorders, environmental factors or a combination of these two. A whopping 70% of birth defects however, are genetically caused (Women in Good Health, 2010). Human genetics play a very central role in child development before and after birth. As in all living beings, cells contain chromosomes and in the chromosomes, genes. It is the genes that dictate all unique characteristic of any organism. The human embryo when fertilised for instance, combines an equal share of chromosomes from the mother and the father (Kolker and Burke 1994, p. 74). A birth defect may accrue if the shared chromosomes given to the child by the parents are less or even more than are required (Women in Good Health, 2010). The chromosomes may also be faulty such that the genetic defects in a foetus occur despite both parents being healthy as is the case of Jane and Harry. Genetic defects are inherited in several patterns according to (Women in Good Health, 2010). They can accrue from dominant inheritance where an embryo inherits a defect from only one parent, such as in achondroplasia (dwarfism) cases. The inheritance pattern can also be recessive, where both parents have a recessive defective gene such that there is a single chance in four for their embryo to suffer from the defect. In this case, the parents are healthy since the defect is recessive, a common case being the cystic fibrosis genes and those of the Tay Sachs disease (Women in Good Health, 2010). The third pattern is via maternal inheritance in which the defect is passed from a mother to her son, a common occurrence in haemophilia and colour blindness. Finally, the inheritance pattern can be chromosomal where the structure or number of embryo chromosomes are more or less than ideal such as is the case with the Downas syndrome (Women in Good Health, 2010). Such genetic defect in a foetus can be tested during pregnancy. Doctors can perform genetic tests (such as DNA (deoxyribonucleic acid) screening) by analyzing a sample of blood or a body tissue (skin, bone, hair, nails etc) of the parents to determine if either of them carries a gene for any inherited disorder (Kolker and Burke 1994, p. 74). Genetic testing can today help pinpoint any missing, defective or abnormal gene (Nicholson, 2010). Doctors employ particular genetic tests for specific diagnosis as informed by the illness a doctor suspects upfront (Nicholson, 2010). E-Health MD (2010) says that some of these tests are called indicated tests and are only reserved for pregnant women considered to be at increased risk. Jane for instance has a medical history for an abnormal screening test result. However, such tests as the ultrasound are today used even when the foetus or the mother have no apparent health risks (E-Health MD, 2010). The prenatal tests that may help diagnose Jane’s pregnancy as normal or abnormal include the Ultrasound, Non-stress testing, Alpha-fetoprotein, contraction stress testing, fetal motion count, Amniocentesis, and several other screening tests (E-Health MD, 2010). There are three tests applicable while testing a genetic defect in such cases as Jane’s. The Ultrasound, also called the Sonogram employs high-frequency sound wave patterns to create an image of the placenta, fetus and uterus, so as to diagnose problems or lack thereof, in fetus growth, fetus organ abnormalities (i.e. structural soundness of the limbs, heart, kidneys, brain, and stomach), birth defects, amniotic fluid amount, placenta development and location as well as gestational duration or age (E-Health MD, 2010). The test is viable at almost any stage of a pregnancy, mostly performed by placing a wand on the woman’s abdomen just above the uterus (E-Health MD, 2010). The second and perhaps the most accurate way of testing for genetic defects is Amniocentesis. The amniotic fluid surrounding a growing fetus carries very important health information of the foetus. An Amniocentesis involves collecting and analysing a sample of the amniotic fluid. The doctors use a sonogram (explained above) to guide their insertion of a long, ultra-thin, hollow needle in a space between the uterus wall and the abdominal wall until it reaches the fluid cavity that surrounds a fetus (E-Health MD, 2010). That liquid can be analysed for any gene anomalies that are most probable with the foetus. The Amniocentesis test has a slight risk of causing/inducing an accidental miscarriage. Nicholson (2010) expounds a third genetic test applicable in Jane’s case, namely the Chorionic Villus Sampling (CVS) test. The test is better performed during the 10 – 12 week of pregnancy. A doctor simply remove a piece of the placenta and analysis it for genetic problems in a fetus. Its invasiveness makes the test risky, albeit mildly, in inducing an accidental miscarriage (Nicholson, 2010). A rarely used but applicable test in Jane’s case is a Contraction Stress Testing which uses a specially designed fetal monitor to record the uterine contractions versus the foetus’ heart rate (E-Health MD, 2010). If there is a decrease in a fetal heart rate during uterine contractions, the child is at most probably having physiological anomalies (E-Health MD, 2010). Another applicable test is the Alpha-Fetoprotein, simply called the AFP. While being most advisable for an 18 weeks’ pregnancy it is also used up to 22 weeks of pregnancy to test genetic defects (E-Health MD, 2010). AFP is simply a substance naturally produced by all growing fetus when healthy (E-Health MD, 2010). During an AFP test, the mother’s vein-blood sample is analyzed for AFP levels where abnormal levels indicate fetal problems (E-Health MD, 2010). As stated above, Amniocentesis is the single most efficient way of testing foetus’ chromosomes for genetic defects in a foetus, something that has led it to be referred to as the Genetic Amniocentesis test (Kolker and Burke 1994, p. 75). This method is primarily done to identify the entire range of genetic defects since the amniotic fluid is formed from the same genes as the foetus and is part of the master plan of the fetal physical makeup (E-Health MD, 2010). It can be done to confirm the other tests it positive results are reached. In most cases, the genetic amniocentesis gives results that ultimately influence parental decisions in keeping a pregnancy to its full term or to terminate it (Nicholson, 2010). It is very important to note here that this test, as effective as it is, is advisable during the fourth month of pregnancy (16 - 18 weeks). Jane is already in the 22nd week and way late for the test (Nicholson, 2010). Generic Counseling during Pregnancy While the possibility of having a generic problem in an unborn child is scary for most parents, it is always better to know for sure whether the fetus has a generic defect. From that sound knowledge, Jane and Harry can make a decision whether to terminate or carry the pregnancy to term. Professor Colin A Johnson a researcher at the University of Leeds once said, “By understanding the science behind this relatively rare condition, we can gain insight into other developmental conditions that are less serious but far more frequent” (India Server, 2010). It is better if Jane and Harry know for sure whether their second child has genetic anomalies, something that is already rate since most tests are done way earlier that after 22 weeks as discussed above. Yet continuing with ignorance may increase their anxiety and produce regrets after the child is born (Roberts, Stough and Parrish 2002, p. 49). It is important to point out here that, the burden in which Jane and Harry finds themselves is cruel to any parent (Baum 1982, p. 106). Their position as it is, can be termed as difficult, confusing and distressing. Almost every one of the decisions they make will be accompanied by significant, psychological and physiological trauma (Baum 1982, p. 106). It they decide to abort, there will be significant risks involved due to the age of that pregnancy. Jane’s health is thus at risk if this option is taken. Again, they may have to bear great psychological trauma for not having given their second child a chance to be born; or for having failed in faith that the child would be okay (Wahlberg 2006, p. 32). Should Jane and Harry decide to keep this second pregnancy, there are a host of physiological, psychological and social changes that they will have to experience throughout and after the pregnancy (Grimes 1998, p. 748). Jane and harry would have to be ready to support and commit to a child with physical and or mental abnormalities, which is itself a great challenge for parents (Grimes 1998, p. 748). There is a chance that the child may live fully dependant on them due to a particular disability. Again, the social stigma that still bedevils raising an abnormal kid, for both the child and the parents, is momentous (Grimes 1998, p. 748). The cost of the medical attention that such children require (Grimes 1998, p. 748) is also another consideration for the family whose income is Harry’s work as a plumber. Nonetheless, it is the right of Jane and Harry to decide on the course they want to take. Genetic counseling even in normal pregnancies aims at informing the parents about all possible scenarios and options so that the concerned parent can make a personal decision, the so called ‘I-decision’ (Roberts, Stough and Parrish 2002, p. 49). Once the genetic counselor gives all the information to the parents, it is upon them to make an ‘I-decision’. The genetic counseling usually involves a review of the modalities of prenatal testing, the psychological processes that accompany the decision-making of parents, the available courses of action after genetic testing results are received and the ethical issues involved in such choices (Roberts, Stough and Parrish 2002, p. 48). According to Roberts, Stough and Parrish (2002, p. 49), genetic counseling practices and skills range from conducting interviews with the parents, presenting the relevant genetic information, adopting to different cultural backgrounds of the parents involved, showing understanding and compassion to the parents, obtaining and recommending social and medical services that the parents may need, etc. Clinical genetic counseling underlies numerous ethical and legal issues as well as socio-cultural, economic and religious issues that vary from place to place (Roberts, Stough and Parrish 2002, p. 49). What is okay in Australia is rarely the practice in USA or elsewhere. There are always some health policies, social pedigrees and disability rights to consider before the counseling commences and all depending on where one is. The American Board of Genetic Counseling for instance is the national credentialing organisation in North America and it is charged with the responsibility of maintaining professionalism in genetic counselling within the US and Canada. ABGC establishes competence standards for clinical practice in genetic counselling through certifying and recertifying the professional genetic counsellors such that, it protects the public from malpractice while also promoting growth of the profession. The American genetic counselling industry is highly developed and very standardized due to this central regulation and certification. It varies greatly from what you would find in Australia. According to Hulston (2006), Genetic counseling in Australia started at around 1990 as NWS Health, and has since then been practiced as part of the general clinical genetics unit of hospitals or outreach programs of the Australian public health sector. There lacks a central professional body for the industry in Australia. The Royal North Shore Hospital and the Children’s Hospital both in Sidney have been instrumental in providing prenatal genetic counseling service, currently having several clinical geneticists and outreach paediatric geneticists (Hulston, 2006). Growth of the practice has been sporadic and disorganized in Australia due to lack of a central regulatory body. Main Australian practitioners of have been private establishments such as the Sydney Ultrasound for Women, which is a private enterprise offering gynecological and obstetric ultrasound based genetic counseling (Hulston, 2006). However, it is becoming an integral part of prenatal testing services even in public hospitals as chromosomal disorders testing gains ground globally. The most common professionals in the Australian industry who offer genetics counseling currently, albeit without central regulation include obstetricians, maternal fetal medicine teams, obstetric ultrasound operators, genetics clinical specialists and obstetric sonographers. Hulston (2006) however sees a new age having begun in Australia for the genetics counseling practice. Late Pregnancy Termination While the choices that Jane has to make are all accompanied by adverse repercussions as highlighted above, one that deserves special mention is that of terminating her second pregnancy if the foetus is diagnosed with genetic defects. She already 22 weeks into the pregnancy and aborting it will mean that it is going to be a late-term abortion. A late-term abortion means that it is performed during the later stage of the pregnancy to an extent that the developed fetus may be viable for birth (Torres 1988, p. 171). Most experts concur that any abortion induced past the 27th week of gestation is a late-term abortion, although that timing has been deemed controversial (Sprang and Neerhof 1998, p. 744-747). A huge number of experts also concur that any abortion procedure at the 20th week of pregnancy is a late-term (Sprang and Neerhof 1998, p. 744-747). Some experts have even gone as far as terming an abortion past the 12th week of gestation as a late-term abortion, while others place it at past the 16th week (Torres 1988, p. 173). The late-term classification is ideally placed at the point at which the foetus is viable and can survive outside a uterus and thus the term a post-viability abortion (Torres 1988, p. 173). A fetus cannot survive outside a uterus before the 21st week and is fully viable at the 27th week with variations in individual pregnancies (Grimes 1998, p. 748). While Jane may benefit from the grey area abounding in defining the age of a pregnancy when it comes to late-term abortion, at 22 weeks she must consider the risks of aborting. Her abortion may carry such risks as rupturing the uterus, injuring or defacing the ovaries as well as an increased level of post-abortion psychological trauma (Wahlberg 2006, p. 32). Over 54% of complications during abortion in USA according to a 1998 survey, involved late-term abortions (Wahlberg, V 2006, p. 32). But if a fetal problem is diagnosed this late into her pregnancy, and she decides to abort, the burden of not aborting versus the risks of aborting should be weighed and decided upon (Grimes 1998, p. 748). Appraisal of Care in Respect to the Case Study As already pointed out, the role of the nurse here is to advise the both Jane and Harry on the options available to them. For a nurse who undertakes a genetic counseling of the couple, she or he will need to conduct several interviews with the parents to understand their fears and preferences (Roberts, Stough and Parrish 2002, p. 50). To begin with, it is important that the modalities of genetic testing and screening be communicated effectively to Jane and Harry so that the results can help shape the decisions they make With this in mind, the nurse should then present the relevant genetic information to them giving them all the options available in both keeping the pregnancy and terminating it. Ideally, the counseling should spell out consequences and implications of each viable option the parents may choose (Grimes 1998, p. 748). In this, the nurse must ideally adapt to the cultural background of the parents and show both understanding and compassion to them (Roberts, Stough and Parrish 2002, p. 49). The counseling also needs to be comprehensive in expounding on the psychological, physiological and social impacts of the scenario and help the parents to deal with their predicament from all these angles (Roberts, Stough and Parrish 2002, p. 49). Jane and Harry will have to consider the financial repercussions of their decisions within their social set up as well as their ability to commit to any choice they make. The nurse should in this case afford all the medical and social services help available to the parents in their locality given their homes location in a rural area, such as pediatricians, obstetricians, psychological counselors, religious experts and consultations etc. There will also be numerous ethical and legal issues underlying the clinical genetic counseling in respect to the locality they are in (Roberts, Stough and Parrish 2002, p. 49). While the nurse cannot outrightly coerce the couple to either choice, she or he has a role in helping shape the most informed and appropriate decision. The risks of late-term abortion must be reviewed in length while also remembering that the genetic defects of the child may not be very serious if around to play out into full term pregnancy (Grimes 1998, p. 748). On the other hand the significant demands and burden of raising a child with disabilities must be considered and the parents left to choose either alternative (Grimes 1998, p. 748). Geo-Spatial Influence on Maternal and Paediatric Care The fact that Jane and Harry live in a remote area with a long distance to cover in case of an emergency before they find help; is also an important consideration. Had Jane been living in an urban area close to a health care facility, carrying the pregnancy would in a way be more tenable that it is in their current situation. The fact that the nearest source of medical help is 4 hours away means that there are very many people coming to the referral hospital and thus there will be more delays in waiting time even if a complication accrues. A complication in the pregnancy, which is to be expected if the foetus has genetic defects, makes it risky for Jane to continue with the pregnancy while living in a remote area. Such a complication may occur unpredictably and travelling from their rural home, for four hours or more due to traffic problems and then having to wait in a long line before seeing a doctor could further endanger Jane’s life. A risky pregnancy, such as Jane’s, would be less risky if she were living in an area served by more health care establishments and where access and waiting times are relatively minimal. Harry is a plumber and may not have a reliable vehicle to use during such an emergency. However, the risks would be compounded if the couple were living in a remote area (inaccessible i.e. not served by roads, airports or railways) and not just a rural area (not in an urban setting although relatively accessible). Nonetheless the risks involved are significant and should still be considered in deciding to keep or terminate the pregnancy. Conclusion This paper has used a case study of Jane and Harry to develop an evaluation of the dilemma of parenthood in cases of problematic pregnancies against a background of ideal clinical and nursing practices. Jane’s second pregnancy (22 weeks old) is faced by the risk of genetic defects that had triggered the first pregnancy’s abortion. The paper has examined all the problems facing Jane and Harry which include physiological dangers, psychological trauma, social stigma, financial and upbringing burdens that exist whether or not the pregnancy is carried to full term. The paper also introduced pregnancy screening tests in general and then highlighting those tests that would be applicable in Jane’s case of genetic deformity during pregnancy namely, the Ultrasound, Chorionic Villus Sampling, Contraction Stress Testing, Alpha-Fetoprotein and the most appropriate, Genetic Amniocentesis test. The paper then went ahead to examine generic counseling during pregnancy, its components, application to Jane’s case and the practice in various nations such as Australia (sporadic but developing) and the USA (highly standardized). Further the paper examined the viability of a late-term abortion, its definition, risks and dilemmas, before appraising the general care that Jane and Harry needs. This section specifically highlighted what the nurse needs to do to help Jane and her husband. Finally, the paper has reviewed the repercussions of Jane and Harry living in a rural area and how this influences their decisions. The paper established that although the rural area setting has many risks, it is way better that it would have been had the family been living in a remote area. References Baum, A, ed 1982, Handbook of Psychology and Health, Volume 2, Lawrence Erlbaum Associates, Hillsdale, NJ, p. 106. “Birth Defects,” 2010, Women in Good Health, Viewed 22 July 2010, “Gene Defect May Lead to Foetal Abnormalities,” India Server, Viewed 22 July 2010, Grimes, D 1998, The continuing need for late abortions, Journal of the American Medical Association, Vol. 280, No. 8, p. 747-750 Hulston, L 2006, “Genetic counselling in private practice - an Australian perspective, Sydney Ultrasound for Women, Australia”, An Abstract for presentation at 11th International Congress of Human Genetics, Viewed on 22 July 210, Kolker, A and Burke, M 1994, Prenatal Testing: A Sociological Perspective, Bergin & Garvey, Westport, CT, p. 74. Nicholson, L 2010, “Genetic Testing during Pregnancy,” Genetic Testing, Viewed 22 July 2010, “Prenatal Testing,” 2010, E-Health MD, Viewed 22 July 2010, Roberts, C, Stough, L and Parrish, L 2002, The Role of Genetic Counseling in the Elective Termination of Pregnancies Involving Fetuses with Disabilities, Journal of Special Education, Vol. 36, No. 1, p. 48-55. Sprang, M and Neerhof, M 1998, Rationale for banning abortions late in pregnancy, Journal of the American Medical Association, Vol. 280, No. 8, p. 744-747. Torres, A and Forrest, J 1988, Why Do Women Have Abortions, Family Planning Perspectives, Vol. 20, No. 4, p. 169-176. Wahlberg, V 2006, Memories After Abortion, Radcliffe Publishing, Abingdon, UK, p. 32. Read More