Preventing prematurity: Preconception, prenatal and postpartum nursing care Caitlin O’Connor, MSN, RN, CPNP Susan Gennaro, RN, PhD, FAAN

Contact hours: 1.6 contact hours are available for this activity through 1/30/20. Continuing nursing education (CNE) contact hours may be extended past this date following content review and/or update. To take the CNE test, go to marchofdimes.org/nursing. Accreditation: March of Dimes Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Disclosures: Neither the author nor any member of the planning committee has any professional or personal relationships that could potentially bias the content. Publication of this article was supported by a generous unrestricted grant from The Procter & Gamble Company. Authors’ acknowledgment: The authors gratefully acknowledge the work of Megan Marx for her assistance in preparing this article.

Article purpose The importance of preconception The purpose of this article is to provide an overview care of nursing care for women of childbearing age from The importance of preconception care and counseling preconception to postpartum related to preventing has gained emphasis over the past decade as a result preterm labor and birth. The article also describes of the Select Panel on Preconception Care assembled areas for future research on this topic. by the Centers for Disease Control and Prevention (CDC) in 2005 (Johnson et al., 2006). The panel defined preconception care as “a set of interventions Objectives that aim to identify and modify biomedical behavioral After reading this article, the learner will be able to: and social risks to a woman’s health or 1. Describe aspects of preconception, prenatal and outcome through prevention and management” (p. 3). postpartum nursing care aimed at addressing preterm labor and birth. Thirty to 90 percent of women can benefit from 2. Summarize suggested research geared towards appropriate interventions prior to pregnancy (Hadar, addressing physiologic or sociobehavioral Ashwal & Hod, 2015). However, only 30 percent of mechanisms to prevent preterm labor and birth. women currently receive preconception care, and this number is even lower in minority women (Oza-Frank, Gilson, Keim, Lynch & Klebanoff, 2014). To make preconception care accessible to all women in this country, care must include public health resources, programs and strategies for women in need (Johnson et al., 2006).

© 2017 March of Dimes Foundation. All rights reserved. 3/17 MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 2

A number of poor pregnancy outcomes are associated of to treat these exacerbations is with potentially preventable risk factors that associated with an increased incidence of preterm can be identified, addressed and minimized with delivery (Namazy et al., 2013). preconception care and counseling. The CDC panel (Johnson et al., 2006) developed recommendations Other chronic health conditions related to increased for routine well-women health visits to guide the care incidence of preterm delivery that can be managed as of women to reduce risk factors. The promotion and part of well-woman and preconception care include management of overall health encompasses chronic kidney disease (Nevis et al., 2011) hypothyroidism disease control, avoidance of addictive behaviors and hyperthyroidism (Alkalay, 2009; Mannisto and environmental exposures (smoke, alcohol, drugs et al., 2013) and rheumatoid arthritis (Langen, and chemicals) and inclusion of preventative health Chakravart, Liaquat, El-Sayed & Druzin, 2014). measures (immunizations, vitamins, dental hygiene Lupus, an autoimmune disorder that affects various and weight management), all of which are integral body organs, primarily affects women of childbearing in primary care of women. With appropriate clinical age and has been associated with a number of guidance, health care providers and women can negative pregnancy outcomes, including , identify and modify risk factors before conception. preeclampsia, and intrauterine growth restriction (IUGR) (Madazali, Yuksel, Oncul, Chronic health conditions Imamoglu &Yilmaz, 2014). Intrauterine infections, including sexually transmitted diseases, account for Women and their health care providers must 40 percent of preterm births (Agrawal & Hirsch, work together to manage chronic diseases 2012), emphasizing the importance of diagnosing and preconceptionally to help mitigate risk for preterm treating them in the preconception period. birth and other adverse pregnancy outcomes. Providers counsel women to lose weight, lower Genetic disorders their pressure and control their blood glucose levels; they also discuss medication management and Women who have genetic disorders often experience make alterations to treatment plans as appropriate complications during pregnancy, such as preterm for impending pregnancy. Well-woman and birth. These women need special preconception preconception care can help women reach an optimal education about the effects of the disorder on state of health before pregnancy. For example, pregnancy, the impact of pregnancy on their disorder losing weight before pregnancy is important as as well as potential complications and side effects. For obesity is associated with chronic diseases, such example, although many women with cystic fibrosis as hypertension, diabetes and asthma, all of which (CF) tolerate pregnancy well, there is a higher risk increase the risk of poor pregnancy outcomes, for morbidity and mortality due to poor adaptation specifically preterm birth. to the pulmonary and respiratory changes that accompany pregnancy (Whitty, 2010). Women with Not only can preconception care help women attain CF who have moderate to severe lung disease and a a higher degree of wellness, it also helps women forced expiratory volume <60 percent tend to have optimally manage chronic health conditions before more preterm infants than women with milder disease becoming pregnant. For example, women who suffer (Whitty, 2010). ACOG (2011b) recommends genetic from chronic hypertension are at increased risk of counseling and CF carrier screening preconceptionally developing preeclampsia, which often results in an to at-risk couples of reproductive age, especially indicated premature delivery (American College those of European or Ashkenazi Jewish ancestry. of and Gynecologist [ACOG], 2013). Preconception care for women with CF focuses Thus, managing blood pressure before pregnancy is on nutrition, improving pulmonary function and essential. Likewise, the link between preterm birth preventing pulmonary infection. and type 1, type 2 and has been well documented (Rosenburg, Garbers, Lipkind & Most women with neurofibromatosis are able to have Chiasson, 2005). Achieving optimal glucose control a successful pregnancy with no apparent increase in before getting pregnant increases the likelihood of mortality for the mother. However, these women positive pregnancy outcomes. Similarly, working are susceptible to preterm labor, with one study with women during well-woman care to identify and finding almost a twofold increase in the incidence of remove triggers for asthma exacerbation is important preterm birth compared to the control group (Terry as these exacerbations are common during pregnancy et al., 2013). Preconception care for women with and often treated with oral corticosteroids; the use neurofibromoatosis focuses on controlling blood

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 3 pressure because of neurofibromatosis-associated Substance use vasculopathy. Smoking and tobacco use can have negative effects on For women with polycystic kidney disease (PKD), a woman’s overall health, not just her reproductive preconception care that focuses on achieving normal health. Tobacco exposure has been linked to various blood pressure and optimal renal functioning kinds of cancers, cardiovascular disease and lung is essential. Once a woman with PKD becomes disease in addition to reproductive health issues, pregnant, she is at risk for increased maternal and fetal including infertility and abnormal fetal development complications unless her blood pressure and kidney (ACOG, 2011a; Moos, 2013). The U.S. Preventative function are optimized (Wu et al., 2016). In one study, Services Task Force (USPSTF) (2009) supports rates of preterm birth were higher in mothers with tobacco screening and cessation counseling and PKD compared to a control group (Wu et al., 2016). encourages the use of the 5 A’s intervention (ask, advise, assess, assist, arrange) as one of the most Preconception care for women with sickle cell effective preventative health actions. ACOG (2015d) disease (SCD) focuses on ensuring adequate recommends smoking cessation programs prior to maternal hemoglobin levels with prophylactic blood and during pregnancy due to the resulting decrease in transfusions. Prophylactic red-cell transfusions preterm birth. decrease the incidence of preterm birth (Ngo et al., 2010). Eating an iron-rich diet to enhance hemoglobin Consuming alcohol and using recreational drugs levels is essential. Anemia puts women at risk for before and during pregnancy increases a woman’s folate deficiency; adequate folic acid intake (400 risk of preventable negative health outcomes for mcg per day) decreases the incidence of neural tube mother and baby. Providers counsel women engaged defects (NTDs) (CDC, 2016a). If maternal hemoglobin in these behaviors preconceptionally and refer is not optimized prior to pregnancy, the normal them for appropriate treatment. Alcohol use during physiological changes of pregnancy, including an pregnancy has been linked to miscarriage, fetal increase in blood viscosity and red cell mass, make growth restriction, birth defects and developmental managing SCD more difficult (Omole-Ohonsi, delays in babies (Moos et al., 2008). Recreational Ashimi, & Aiyedun, 2012). The rate of preterm birth drug use has been associated with low birthweight is increased in mothers with SCD compared to those (LBW), IUGR and decreased (Bailey, without the disease; Kuo and Caughey (2016) found McCook, Hodge & McGrady, 2011). Bailey and that women with SCD are approximately 2.5 times as colleagues (2011) also found that interventions that likely to have a preterm birth at <37 weeks gestation address recreational drug use are just as important as and almost 6 times as likely to have a preterm birth at smoking cessation interventions in terms of improving <32 weeks gestation. infant outcomes. Women are more likely to change their unhealthy behaviors when they are trying to get Preconception care for a woman with Turner pregnant (Chuang, Hillemeier, Dyer & Weisman, syndrome is important as screening before pregnancy 2011); therefore it becomes imperative to provide can help her know if she is at increased risk of death appropriate resources preconceptionally, such as from aortic dissection or rupture (Pfeifer et al., 2012). individual or group counseling, referral to quit lines, Preconception care involving cardiology screening local support groups and educational materials on is a necessity because pregnancy is an absolute the risks of substance use during pregnancy (ACOG, contraindication for women with Turner syndrome 2011a; ACOG, 2015d). In some cases, medications who have a cardiac anomaly (American Society for may be recommended to assist in cessation and Reproductive Medicine, 2012). Preconceptionally, minimize withdrawal symptoms. women with genetic disorders such as Turner syndrome may wish to explore interventions to Mental health decrease the likelihood of the carrying abnormal Approximately 10 percent of women of childbearing genes. Opting to plan pregnancy using donated age experience symptoms of depression (Centers for oocytes is not uncommon in women with genetic Disease Control and Prevention [CDC], 2016c). One conditions, such as Turner syndrome (Hagman et al., out of 7 women has depression during pregnancy or 2013). However, even with oocyte donation, adverse in the puerperium (ACOG, 2015c). USPSTF guidelines fetal outcomes for women with Turner syndrome still mandate screening for depression in all women (Siu occur. One study found approximately 40 percent of & USPSTF, 2016). This includes women who are infants born to mothers with Turner syndrome were trying to conceive or who are already pregnant or preterm (Chevalier et al., 2011).

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 4 postpartum. However, given the relative lack of reproductive age in the United States who classify mental health resources in the United States, it is as overweight or obese, these interventions may imperative that providers assess mental health as part include nutrition counseling to improve dietary of routine well-woman screening before pregnancy content as well as recommendations and resources so women have time to access appropriate resources for increasing physical activity in the daily routine and seek appropriate counseling and care (Frieder, (IOM, 2009). Grieger, Grzeskowiak & Clifton (2014) 2010). Pregnant women may be hesitant to use found that preconception diets that consist of protein, pharmacologic treatment because of the possibility of whole grains and fruit are associated with a reduced side effects, so identification and treatment of mental likelihood of preterm birth, compared to diets with health conditions before pregnancy are warranted. high sugar or salt content. ACOG (2016a) offers an Increased anxiety, stress and depression have been obesity toolkit to help health care providers speak linked to poor birth outcomes, such as preterm birth about weight with their patients and develop weight- and LBW (Goldenberg, Culhane, Iams & Romero, loss interventions that women are willing to use. 2008; Shapiro, Fraser, Frasch & Seguin, 2013). Vitamins and supplements Immunizations Folic acid. CDC (2016a) recommends that women ACOG (2016b) encourages assessment of the immune of childbearing age consume at least 400 mcg of folic status of all women of reproductive age. Given the acid per day to prevent NTDs in their baby, and that efficacy of vaccines in preventing disease, providers they eat a diet high in folate. Because most women do evaluate women for risk and offer appropriate not achieve the recommended dose from food sources immunizations at annual physical exams. Providers alone, CDC encourages multivitamins for all women encourage women of all ages to receive the influenza of childbearing age. vaccine annually and stay current with their tetanus, diphtheria and pertussis (Tdap) immunization. The Iron. Iron deficiency can cause fatigue, pallor and hepatitis B vaccine is recommended to women of weakness; it affects many women and is one of the reproductive age as it reduces the risk for liver failure most common causes of anemia. Preconception and cirrhosis; the human papillomavirus (HPV) well-woman screening for anemia can help women vaccine decreases the risk for cervical abnormalities improve hemoglobin levels through nutrition and and cancers (CDC, 2014). consumption of multivitamins, when appropriate. CDC (2016b) provides guidelines for the Anemia has been associated with poor gestational administration of vaccines to women weight gain and an increased risk for preterm birth preconceptionally. Live vaccines, like the measles, (ACOG, 2008). Banhidy and colleagues (2011) found mumps and rubella (MMR) and the varicella that women who received iron supplementation for (chickenpox) vaccines, pose a risk to a developing anemia in the first trimester had a lower incidence fetus and are contraindicated during pregnancy; of preterm birth than those who did not receive providers counsel women to avoid pregnancy within supplementation. 3 months after receiving these vaccines (CDC, 2016b). Administering the hepatitis B vaccine in Herbal remedies the preconception period prevents transmission of As many as half of all adults in the United States infection to infants, while the HPV vaccine can help report using one or more dietary supplements, maintain cervical competency in pregnancy (CDC, including herbs (Gahche et al., 2011). Many may 2014). think that herbal remedies are more natural and, therefore, safer than more conventional medicines. Weight management Women use herbal supplements more frequently than For best pregnancy outcomes, Institute of Medicine men to alleviate many problems, including , (IOM) (2009) guidelines recommend conceiving when sleep disturbances, constipation, , fluid maternal weight (classified by body mass index or retention and anxiety (Faccinetti et al., 2012; Trabace BMI) is within the normal range. Identification of et al., 2015). Although some herbal remedies are safe, maternal weight status (underweight, normal weight, others are linked to poor obstetric outcomes when overweight or obese) during preconception care can used during pregnancy (see Table 1), emphasizing the lead to interventions targeted at achieving weight importance of preconception counseling. loss or gain, as appropriate. For most women of

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 5

Table 1. Herbal supplements commonly used other fetal complications (Table 2). It is essential that clinicians inquire about every OTC medication that in pregnancy and their association a woman is taking in order to educate her about risks with preterm birth and provide her with safer alternatives to use during Supplement Used for Associated pregnancy. with preterm birth? Prescription medications. Prescription medications are classified according to risk, with category D Almond oil Stretch marks Yes indicative of high risk during pregnancy and category X contraindicated in pregnancy. However, each year Chamomile Anxiety, Yes providers prescribe category D or X medications to digestive problems, more than 11 million women (Eisenberg, 2010). With relaxation, sleep almost half of all being unplanned (Finer & Zolna, 2011), it is imperative that providers educate Echinacea Cold symptoms No women about teratogenic risks associated with any Fennel Fluid retention Yes prescription medication they take. Nausea, No Health care providers screen and treat infections like Ginseng Fatigue No sexually transmitted diseases (STDs) with antibiotics Licorice Cold and cough Yes before pregnancy whenever possible to optimize symptoms outcomes for both the mother and baby (Lassi, Imam, Dean & Bhutta, 2014). In some instances, safer Valerian Anxiety, insomnia No medication choices can be used during pregnancy. Facchinetti et al., 2011; Heitmann et al., 2013; Heitmann Providers and patients should discuss the risks of et al., 2016; Trabace et al., 2015 certain medications and weigh the benefits against possible effects on pregnancy before use. Clinicians Medications also can offer women alternative therapies that are Over-the-counter (OTC) medications. Many safe to use during pregnancy, such as acupuncture, women use OTC medications to help alleviate acupressure, chiropractics, massage, mental common discomforts, such as nausea, heartburn, imagery and evidence-based psychotherapy, such as , backache and constipation. Studies have interpersonal therapy or cognitive behavioral therapy linked some OTC medications to preterm birth and (Huang, Coleman, Bridge, Yonkers & Katon, 2014).

Table 2. OTC medications and their associated risks Class Ailment Medications Risks Analgesic/Antipyretic Pain, fever Acetaminophen (Tylenol®) No increased risk of congenital defects, or spontaneous Aspirin Avoid in pregnancy; risk of IUGR, fetal and maternal hemorrhage and gastroschisis Ibuprofen (Motrin®) Avoid in third trimester; no increased risk of spontaneous abortion; associated with structural cardiac defects and increased risk of gastroschisis Naproxen (Aleve®) Avoid in third trimester; no increased risk of spontaneous abortion; associated with orofacial clefts and structural cardiac defects Continued on next page

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 6

Table 2. OTC medications and their associated risks (continued) Class Ailment Medications Risks Antacid: Histamine Heartburn, Calcium carbonate (Tums®) Considered safe during pregnancy H2 blockers, proton gastroesophageal Omeprazole (Prilosec®) No increased risk of preterm pump inhibitors reflux birth or spontaneous abortion Ranitidine (Zantac®) No teratogenic effects : First Allergic rhinitis, Cetirizinc (Zyrtec®) No significant risk of fetal and second generation nausea (Benedryl®) malformation or teratogenic Fexofenadine (Allegra®) effects Loratadine (Claritin®) Antidiarrheal Diarrhea Bismuth subsalicylate Insufficient data; no association (Pepto-Bismol®) with congenital anomalies but should be avoided in the second and third trimesters Anitussive Cough Dextremethorphan No increased fetal risk (Robitussin®) Decongestant Allergic rhinitis, Phenylephrine (Sudafed®) Increased risk of congenital pregnancy rhinitis malformation Expectorant Cough Guaifenesin (Mucinex®) Avoid in first trimester; weakly associated with NTDs and inguinal hernias Laxative Constipation Polyethylene glycol 2250 No increased fetal risk (Miralax®) Topical cream: Rash, skin Bacitracin Considered safe during Antifungal, irritation pregnancy; no association with antimicrobial, fetal malformation steroidal Hydrocortisone 1 percent Considered safe during pregnancy Nystatin (myocostatin) Cabbage & Neal, 2011; Servey & Chang, 2014

Dental care and oral hygiene An IPI of 18 to 60 months is optimal, as intervals <18 Many studies have linked poor periodontal health months or >60 months have been associated with poor to poor pregnancy outcomes, highlighting the pregnancy outcomes (Copen, Thoma, Kirmeyer & importance of good oral hygiene during childbearing Division of Vital Statistics, 2015; Moos, 2013). IPIs <6 years (Ide & Papapanou, 2013). Preconceptionally, months are associated with the greatest risk of preterm providers should encourage women to schedule birth, especially for women with a history of preterm regular dental visits to maintain optimal oral health. birth (ACOG, 2016b; DeFranco et al., 2007), with a Poor oral health and tooth decay have been linked to decrease in risk with each month gained (Moos, 2013). preterm birth (Imran, Arif, Jamal & Karim, 2015), This emphasizes the importance of reviewing available while improved maternal oral health decreases the contraceptive options with new mothers. risk of early childhood caries in offspring (Kloetzel, Many factors influence a woman’s contraceptive Huebner & Milgrom, 2011). decision, including ease and convenience of use and how it may affect breast milk supply, weight gain Interconception care and blood pressure. Health care providers should The period immediately preceding birth until the discuss all of these concerns with women to help them next conception is the interpregnancy interval (IPI). reach a contraceptive decision with which they can

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 7 comply. Given the multitude of options, including oral Nutrition contraceptive pills, intrauterine devices and physical Nutrition counseling during pregnancy is important, barriers, women may decide to use one method and not only to help women achieve appropriate weight later switch to another. Health care providers who gain, but also so women get the necessary vitamins, support a woman’s contraceptive decisions help foster minerals and nutrients for optimal pregnancy. compliance. IOM (2005) guidelines for nutrition consumption during pregnancy provide suggested quantities of macronutrients like protein, fats and carbohydrates, The importance of prenatal care as well as micronutrients like fiber and folic acid While well-woman and preconception care (Table 4). encompasses primary prevention, prenatal care focuses on surveillance and intervention. Prenatal care, A diet rich in protein, fruits and vegetables has been one of the most widely used forms of preventive health linked to appropriate birthweight and a reduced care in the United States, is associated with better birth likelihood of preterm birth (Grieger, Grzeskowiak outcomes (Alexander & Kotelchuck, 2001; Krans & & Clifton, 2014). Pregnant women should aim Davis; 2012; Van Dijk, Anderko & Stetzer, 2011). to consume 71 g of protein per day (IOM, 2005). Carbohydrates and fats are equally important Weight in appropriate proportions, though women may consume them in excess due to their affordability. In 2009, the IOM issued guidelines regarding Overconsumption of carbohydrates and fats can recommended weight gain during pregnancy to lead to obesity, which has been associated with maximize outcomes. These guidelines use pre- preterm birth (Grieger, Grzeskowial & Clifton, pregnancy BMI to categorize women as underweight, 2014). Carbohydrates generally are better tolerated normal weight, overweight and obese and provide by women who are experiencing nausea, so they may appropriate ranges for weight gain during pregnancy make up a significant portion of a pregnant woman’s for each categorization (Table 3). diet. An adequate fiber intake of at least 28 g per day can help to alleviate constipation that often occurs in Table 3. Recommended weight gain pregnancy (Jefferson & Croton, 2013) and can have during pregnancy beneficial metabolic effects, including decreasing Category BMI (kg/m^2) Total weight-gain late gestational weight gain and postpartum weight retention (Brooten, Youngblut, Golembeski, Magnus Underweight <18.5 28 to 40 lbs & Hannan, 2011; Drehmer et al., 2012; Maple-Brown Normal weight 18.5 to 24.9 25 to 30 lbs et al., 2013). Overweight 25.0 to 29.0 15 to 25 lbs Micronutrients also help foster good pregnancy Obese (includes >30.0 11 to 20 lbs outcomes. Folic acid supplementation decreases all classes) NTDs when taken preconceptionally and in the first IOM, 2009 trimester (CDC, 2016a). Adequate consumption of iron during pregnancy is necessary to prevent LBW Johnson and colleagues (2013) found that about 3 and anemia, which have been linked to preeclampsia, out of every 4 pregnant women gain more weight a risk factor for preterm birth (Endeshaw, Ambaw, than is recommended by the IOM. They also Aragaw & Ayalew, 2014; Peña Rosas, De- found that women who gain less than the IOM Regil,Dowswell & Viteri, 2012). Calcium and vitamin recommended weight during pregnancy have higher D supplementation have demonstrated protective rates of preterm birth. One of the biggest challenges effects against preeclampsia (Endeshaw et al., 2014; in optimizing weight in pregnancy is educating Hofmeyr, Lawrie, Atallah, Duley & Torloni, 2014). patients and providers that these guidelines exist and Research has shown that calcium supports bone that resources are available to help women achieve health of both mother and fetus (De Jersey, Ross, recommended weight gain. For example, health care Himstedt, McIntyre & Callaway, 2011; Thomas & providers can refer women to registered dietitians Weisman, 2006) and that vitamin D is necessary for or to online resources, such as choosemyplate.gov, effective calcium absorption (Dawodu & Akinbi, which provides pregnancy-specific information and 2013). ACOG (2015a) recommends vitamin B6 as tools for healthy eating and physical activity (Downs, a safe OTC intervention for relieving symptoms of Savage & Rauff, 2014). nausea and vomiting during pregnancy; it has not been found to have any harmful effects on the baby.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 8

Table 4. Recommended macro- and micronutrient consumption during pregnancy Macro-/Micronutrients Recommended dietary allowance Acceptable macronutrient (RDA) distribution range Macronutrients Carbohydrates 175 g/d 45 to 65 percent Protein 71 g/d 10 to 35 percent Fat N/A 20 to 35 percent Micronutrients Fiber 28 g/d N/A Folic acid 400 mcg/d N/A Iron 27 mg/d N/A Calcium 1,300 mg/d N/A Vitamin D 15 mcg/d N/A Vitamin B6 1.9 mg/d N/A IOM, 2005

Exercise restless leg syndrome also frequently affect pregnant Regular exercise during pregnancy is crucial to women (Facco, Kramer, Ho, Zee & Grobman, 2010). maintaining and gaining weight appropriately. The Poor sleep quality and quantity, both early and U.S. Department of Health and Human Services late in pregnancy, are associated with an increased (2010) recommends 150 minutes a week of moderate risk for poor pregnancy outcomes (Okun, Dunkel- exercise for pregnant women, though most do not Schetter, Glynn, 2011). Sleep disturbances have achieve this goal (Evenson & Wen, 2010). Walking been linked to exaggerated inflammatory responses, satisfies this recommendation and is a safe physical which are associated with preterm birth (Blair, activity for pregnant women (ACOG, 2015b; Porter, Leblebicioglu & Christian, 2015). Women Downs, LeMasurier & DiNallo, 2009). Exercise who report poor sleep quality also have higher levels during pregnancy offers many advantages, such as of depression, anxiety and perceived stress (Okun, managing weight gain and having fewer obstetrical Dunkel-Schetter, Glynn, 2011). complications (Price, Amini, & Kappeler, 2012; Providers should evaluate women’s sleep routines and Barakat, Pelaez, Montejo, Luaces & Zakynthinaki, recommend modifications, when possible, to allow 2011). The risk of preterm birth does not increase pregnant women the most restful sleep. Modifications when a woman gets the recommended amount of include reducing caffeine intake, changing exercise regular exercise during pregnancy (Mascio, Magro- patterns and adjusting work schedules. Providers also Malosso, Saccone, Marhefka & Berghella, 2016). should account for environmental contributors to Historically, providers have advised women at high poor sleep, including temperature, sounds and light. risk of preterm birth to restrict activity and exercise. However, there is no evidence to suggest that little to no activity can help prevent preterm birth, as rates Mental health of preterm birth are similar in women who perform Over the course of a lifetime, women are twice as physical activity during pregnancy and in those who likely as men to experience depression (Kessler, do not (Sosa, Althabe, Belizan & Bergel, 2015). 2003). One out of 7 women have depression during pregnancy or in the puerperium (ACOG, 2015c). Sleep Maternal depression is associated with preeclampsia (Kim et al., 2013) and sleep disturbances (Field et. As many as 84 percent of women experience sleep al, 2007). Maternal depression, anxiety and stress disturbance, poor sleep quality or short duration have all been linked to poor birth outcomes, such as at some point during pregnancy (National Sleep preterm birth and LBW (Goldenberg et al., 2008). Foundation, 2007). Early in pregnancy, hormonal Depression, anxiety and stress may lead women to changes are the root of most sleep disturbances, increase negative health behaviors, such as smoking while later in pregnancy, physical discomforts are and drug or alcohol use, as a means of coping the greatest cause of sleep troubles (Hashmi, Bhatia, (Becker, Weinberger, Chaudy & Schmuckler, 2016). Bhatia & Khawaja, 2016). Insomnia, snoring and Therefore, assessing mental health as part of prenatal

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 9 care and identifying interventions acceptable to acetaminophen (Cabbage & Neal, 2011; Servey & women (such as cognitive behavioral therapy) are Chang, 2014). As many as 50 percent of pregnant warranted. women report taking at least one prescription medication during pregnancy (Mitchell et al., Preventing disease 2011). Medication use during the first trimester is particularly concerning as this is the time of fetal Vaccines have demonstrated efficiency in preventing organ development (Mitchell et al., 2011; Moos, many infectious diseases that affect women of 2013). childbearing age. Though limited data is available on the safety of vaccines during pregnancy due Antibiotics. Antibiotics to combat infection are to lack of randomized control trials, a number of among the most frequent medications prescribed observational studies support the administration of to pregnant women (Tejada, 2014). Maternal certain inactivated immunizations during pregnancy. infections are common causes of preterm labor, but For example, Walls and colleagues (2016) found no the impact of antibiotic therapy alone on preterm significant difference in gestational age at birth with birth has not been established. Antibiotic treatment women who received the Tdap vaccine compared with the sole goal of preventing preterm birth has to those who did not. Nordin and colleagues (2014) been ineffective (Tejada, 2014). However, through found that receiving the influenza vaccine during the use of antibiotics, maternal infections are more pregnancy does not increase a woman’s risk of a effectively managed and treated, which is beneficial preterm birth. In some cases, such as with pertussis in preventing preterm birth. When possible, health and influenza, administering the vaccine during care providers should screen and treat infections like pregnancy provides maternal protection from disease, STDs with antibiotics before pregnancy to optimize and the mother passes antibodies to her baby in the outcomes for both mother and baby (Lassi, Imam, womb that have protective properties for the infant Dean & Bhutta, 2014). until they receive their first vaccinations, generally at 2 months of age. Specifically, the effectiveness Antidepressants. In the United States, of the maternal Tdap vaccination is as high as antidepressant use during pregnancy has steadily 91 percent in protecting infants from developing increased from a rate of 1 percent in the early 1990s pertussis (Amirthalingam et al., 2014). The Advisory to as high as 8 percent in 2008 (Huybrechts, Sanghani, Committee on Immunization Practices (2012) Avorn & Urato, 2014). There is an increased risk of recommends Tdap vaccines to all pregnant women preterm birth in women who take antidepressants, regardless of previous vaccination history. such as selective serotonin reuptake inhibitors (Huybrechts et al., 2014). Providers use a risk-benefit Infections ratio to help women make decisions about whether or not to continue antidepressant use during pregnancy. Intrauterine infections are one of the most common causes of early preterm birth (Goldenberg, Culhane, . Up to 80 percent of pregnant women Iams & Romero, 2008). Preterm birth is associated experience nausea and vomiting (Anderka et al., with infections of the , placenta, , 2012). Providers may prescribe antinausea and urinary tract and peritoneal cavity (Romero et al., antimetic medications to pregnant women if diet and 2007). Local infections like bacterial vaginosis (BV), lifestyle changes, such as increasing fluids and eating an imbalance of vaginal flora, increase a woman’s small, frequent, bland meals, do not help (Anderka risk of delivering preterm (Donders et al., 2009). et al., 2012). is the most frequently However, some strands of BV, such as BVAB3, prescribed among pregnant women actually decrease the risk of preterm birth, so treating (Pasternak, Svanstrom & Hviid, 2013). In one cohort BV during pregnancy remains a conflicting matter study, exposure to ondansetron during pregnancy was (Foxman et al., 2014). Systemic infections, like malaria not found to significantly increase chances of preterm and periodontal infections, are associated with an birth (Pasternak, Svanstrom & Hviid, 2013). increased risk of premature birth (ACOG, 2012). Herbal remedies. According to Facchinetti and Medications colleagues (2012), as many as 45 percent of pregnant women use herbal remedies at some point during More than 90 percent of pregnant women use OTC pregnancy. Herbal supplements, such as chamomile medications to alleviate common symptoms of and licorice, have been linked to preterm labor and pregnancy, with at least two-thirds of them taking threatened miscarriage, and women who regularly

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 10 use topical almond oil throughout pregnancy are manage their weight, lower their risk for preterm at higher risk for preterm birth than those who do birth and improve birth outcomes. not (Facchinetti et al., 2012). Echinacea, commonly ingested to alleviate upper respiratory and common Prenatal access to doulas contributes positively to cold symptoms, has not been found to increase the pregnancy outcomes. Kozhimmanil and colleagues risk of preterm birth, LBW or small for gestational (2016) found that preterm birth decreased among age (Heitmann, Havnen, Holst & Nordeng, 2016). women who received care from doulas. Receiving Similarly, the use of ginger during pregnancy does group prenatal care, like CenteringPregnancy®, has not seem to increase the risk of negative pregnancy demonstrated reduced rates of preterm birth (Ickovics outcomes, including preterm birth, LBW, stillbirth et al., 2007; Picklesimer, Billings, Hale, Blackhurst & or congenital malformations (Heitmann, Nordeng & Covington-Kolb, 2012). Holst, 2013). When compared to non-users, regular consumption of fennel during pregnancy has been Environmental hazards and workplace linked to preterm birth (Trabace et al., 2015). Use of exposure valerian however, has not been shown to significantly With more women working during their childbearing affect rates of preterm birth or any other years, there is increased likelihood of exposure to (Trabace et al., 2015). The use of ginseng during environmental toxins and occupational hazards at the pregnancy has not been thoroughly studied in workplace that may impact birth outcomes (Burdorf humans, but research has shown teratogenic effects et al., 2011). The Occupational Safety and Health in rodents (Liu et al., 2015). Though it has not been Administration (2017), part of the U.S. Department associated with adverse pregnancy outcomes like of Labor, has standards specific to chemicals such as preterm labor, Paik and Lee (2015) support avoiding lead, ethylene oxide and radiation therapies, which ginseng in the first trimester of pregnancy. are known to be hazardous to women’s reproductive health. Figà-Talamanca (2006) found that exposure Community resources and support to certain chemicals and physical demands in the Many women depend on resources in their workplace are linked to LBW, preterm birth and community and various financial, environmental, spontaneous abortion. medical, social and emotional support systems during and after pregnancy. Community resources can be as Physical load. Heavy workloads and long hours simple as open green spaces or safe neighborhoods standing are risk factors for preterm birth and LBW that allow women the opportunity for physical (Figà-Talamanca, 2006). Providers should counsel activity, like walking. Or resources can be programs, women with strenuous jobs to modify their workload like Women, Infants and Children (WIC), which during pregnancy to minimize their risk for preterm provides education and assistance to purchase healthy birth. foods to low-income pregnant, breastfeeding and Phthalates. Phthalates are a group of chemicals postpartum women (U.S. Department of Agriculture used in products that pregnant women may come in and Nutrition Services, 2016). contact with on a regular basis, including lotions, Young, Laurent, Chung & Wu (2016) describe the deodorants, perfumes and contaminated food and association between neighborhood resources, such as water (Ferguson, McElrath & Meeker, 2014). Women availability of supermarkets and grocery stores, with a who are exposed to these chemicals during pregnancy decreased risk for adverse pregnancy outcomes, such have significantly higher risk for preterm birth as gestational diabetes and preeclampsia. Farmer’s (Ferguson, McElrath & Meeker, 2014). Prenatal care markets provide opportunities for women to purchase includes educating women so they can modify their locally grown seasonal fruits and vegetables, often at behaviors to lower their risk. more affordable cost than larger grocery stores. Atrazine. Atrazine is a pesticide commonly used to Living in a neighborhood that is concentrated with control weeds at private residences, on golf courses fast food restaurants has been linked to risk factors and in crop fields. It has been found in contaminated for preterm birth, such as excessive maternal weight drinking water as a result of soil run-off. Rinksy and gain, gestational diabetes, increased stress and colleagues (2012) linked high exposure to atrazine increased depression (Young, Laurent, Chung & Wu, with increased risk of preterm birth. Providers 2016). In contrast, having the ability to eat healthy should educate women about exposure to pesticides foods and participate in regular exercise helps women like atrazine and counsel them about limiting their exposure to prevent adverse birth outcomes.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 11

The importance of postpartum Support groups can be formally hosted mom groups lead by nursing staff in a hospital or clinic setting. Or care they may be informal community or neighborhood Postpartum care encompasses physical, social and groups or even virtual groups where moms participate psychological well-being of mothers in the period online through outlets like Facebook. Participation following . Women typically return to in any kind of support group can help decrease their obstetric provider for a comprehensive physical depression and stress in the prenatal and postpartum exam approximately 6 weeks after giving birth. This periods, thus improving the health outcomes of visit includes anticipatory guidance for postpartum mother and baby (Anderson, 2013; Holtz, Smock recovery (Table 5) and a discussion of family & Reyes-Gastelum, 2015; Kratz, Wong & Vaughn, planning. 2013).

Table 5. Topics to address in a postpartum visit Areas for future research • Resolution of pregnancy complications, such as With advancing technologies and new research, hypertension and gestational diabetes nursing practice is constantly evolving to best meet the needs of patients. Preventing preterm birth is • Fatigue and sleep deprivation a huge goal that cannot be accomplished until the • Nutrition and physical activity as part of weight phenomenon is better understood. While we have management identified risk factors and discovered ways to modify • of them to reduce risk preconceptionally, prenatally and and other mental health concerns postpartum, more research is necessary. • Return to sexual activity ACOG, 2016b Disparities Racial disparities of preterm birth are well documented, with black women being at greatest Postpartum depression risk (Goldenberg et al., 2008). However, additional Siu and the USPSTF (2016) recommend screening research should focus on other factors that contribute for depression in all adults 18 and older, including to preterm birth, such as age, marital status and postpartum women. Implementing this screening annual income. Chronic stress and depression, often ensures diagnosis and appropriate intervention experienced by minority women as a result of racism and treatment of depressed women. Interventions, or poverty, also are potential contributing factors. including referral to appropriate mental health providers for therapy, medications or cognitive Physiologic markers behavioral therapy, help improve clinical outcomes. The physiologic response to infection and inflammation has been associated with preterm Support systems labor and birth. Infections trigger immune responses Many hospitals and birthing centers staff lactation that increase pro-inflammatory cytokines, while consultants (LCs) or offer breastfeeding classes to inflammation causes an increase in the production new mothers. While troubleshooting breastfeeding of stress like corticotrophin-releasing- issues, such as latching, engorgement and pumping, (CRH). CRH is involved in the stress certified LCs provide nutritional guidance to help response and shows promising potential as a women boost and maintain breast milk supply. They biomarker that could be used to predict preterm birth, offer appointments in office settings and through especially in the presence of other identifiable risk home visits to allow for maximum comfort of new factors (Ruiz et al., 2016). mothers. Considerable research has been conducted linking Many women turn to support groups for camaraderie various pro-inflammatory cytokines to preterm birth; and advice; they may benefit from conversing and however, the exact mechanisms are still unknown sharing ideas with other women who facing new (Goldenberg, Culhane, Iams & Romero, 2008). motherhood and challenges in the . Additional research is needed to determine particular Kratz, Wong and Vaughn (2013) found an increase levels of cytokines (such as IL-1B, IL-6, TNF-a) to be in health-promoting behaviors associated with social used as markers to identify and intervene with women support. at risk for preterm labor.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 12

Conclusion American College of Obstetricians and Gynecologists (ACOG). (2011b). Update on carrier screening for The etiology of preterm birth is multifactorial, and cystic fibrosis. (Committee opinion 486). Obstetrics no single intervention is going to be successful in and Gynecology, 117(4), 1028-1031. preventing it. A variety of strategies are necessary to address the multifaceted risks. Providers must American College of Obstetricians and Gynecologists implement interventions aimed at promoting the (ACOG). (2012). Management of preterm labor general health of women of childbearing age. (Practice bulletin 127). Obstetrics and Gynecology, 119(6), 1308-1317. Health care providers can seize the opportunity to engage patients and encourage healthy lifestyle American College of Obstetricians and Gynecologists modifications in the preconception, prenatal and (ACOG). (2013). Hypertension in pregnancy. postpartum periods to optimize birth outcomes. Washington, DC: ACOG Task Force on By addressing modifiable risk factors, such as weight, Hypertension in Pregnancy. disease management, substance abuse and medication use, providers help reduce poor birth outcomes and American College of Obstetricians and Gynecologists prevent preterm birth. (ACOG). (2015a). Morning sickness: Nausea and vomiting of pregnancy: Frequently asked questions, FAQ126. Accessed 8/26/16 at: https://www.acog.org/-/ References media/For-Patients/faq126.pdf Advisory Committee on Immunization Practices. American College of Obstetricians and Gynecologists (2012). Updated recommendatins for use of tetanus (ACOG). (2015b). Physical activity and exercise toxoid, reduced diphtheria toxoid and acellular during pregnancy and postpartum period (Committee pertussis vaccine (Tdap) in pregnant women. opinion 650). Obstetrics and Gynecology, 126(6), Accessed 10/6/16 at: http://www.cdc.gov/mmwr/ e135-142. preview/mmwrhtml/mm6207a4.htm American College of Obstetricians and Gynecologists Agrawal V & Hirsch E. (2012). Intrauterine infection (ACOG). (2015c). Screening for perinatal and preterm labor. Seminars in Fetal Neonatal depression (Committee opinion 630). Obstetrics and Medicine, 17(1), 12-19. DOI 10.1016/j.siny.2011.09.001. Gynecology, 125(5), 1268-1271. DOI 10.1097/01. Alexander GR & Kotelchuck M. (2001). Assessing AOG.0000465192.34779.dc. the role and effectiveness of prenatal care: History, American College of Obstetricians and Gynecologists challenges and directions for future research. Public (ACOG). (2015d). Smoking cessation during Health Reports, 116(4), 306-316. pregnancy (Committee opinion 471). Obstetrics Alkalay A. (2009). Guidance for preconception care and Gynecology, 116(5), 1241-1244. DOI 10.1097/ of Women with thyroid disease. Before, between AOG.0b013e3182004fcd. and beyond pregnancy: The national preconception American College of Obstetricians and Gynecologists curriculum and resources guide for clinicians. (ACOG). (2016a). ACOG obesity toolkit. Accessed Accessed 8/26/16 at: http://www.beforeandbeyond. 8/26/16 at: http://www.acog.org/About-ACOG/ org/uploads/Thyroid%20Guidance.pdf ACOG-Departments/Toolkits-for-Health-Care- American College of Obstetricians and Gynecologists Providers/Obesity-Toolkit (ACOG). (2008). Anemia in pregnancy (Practice American College of Obstetricians and Gynecologists bulletin 95). Obstetrics and Gynecology, 112(1), 201- (ACOG). (2016b). Optimizing postpartum 207. care (Committee Opinion 666). Obstetrics and American College of Obstetricians and Gynecologists Gynecology, 127(6), e187-192. DOI 1097.AOG. (ACOG). (2011a). Tobacco use and women’s 0000000000001487. health (Committee opinion 503). Obstetrics American Society for Reproductive Medicine. and Gynecology, 118(3), 746-50. DOI 10.1097/ (2012). Increased maternal cardiovascular mortality AOG.0b013e3182310ca9. associated with pregnancy in women with Turner syndrome. Fertility and Sterility, 97(2), 283-284.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 13

Amirthalingam G, Andrews N, Campbell H, Ribeiro Burdorf A, Brand T, Jaddoe VW, Hofman A, S, Kara E, Donegan K et al. (2014). Effectiveness Mackenbach JP & Steegers EAP. (2011). The of maternal pertussis vaccination in England: An effects of work-related maternal risk factors observational study. The Lancet, 384(9953), 1521- on time to pregnancy, preterm birth and birth 1528. DOI 10.1016/S0140-6736(14)60686-3. weight: The Generation R study. Occupational and Environmental Medicine, 68(3), 197-204. DOI Anderka M, Mitchell A, Louik C, Werler M, 10.1136/oem.2009.046516. Hernandez-Diaz S, & Rasmussen S. (2012). Medications used to treat nausea and vomiting of Cabbage L & Neal J. (2011). Over-the-counter pregnancy and the risk of selected birth defects. Birth medications and pregnancy: An integrative review. Defects Research Part A: Clinical and Molecular The Nurse Practitioner, 36(6), 22-28. DOI 10.1097/01. Teratology, 94(1), 22-30. DOI 10.1002/bdra.22865. NPR.0000397910.59950.71. Anderson L. (2013). Functions of support group Centers for Disease Control and Prevention (CDC). communication for women with postpartum (2014). Preconception health and health care: Immun- depression: How support groups silence and ization. Retrieved online from: http://www.cdc.gov/ encourage voices of motherhood. Journal of preconception/careforwomen/immunization.html Community Psychology, 41(6), 709-724. DOI 10.1002/ jcop.21566. Centers for Disease Control and Prevention (CDC). (2016a). Folic acid. Accessed 8/26/16 at: https://www. Bailey B, McCook J, Hodge A & McGrady L. (2011). cdc.gov/ncbddd/folicacid/index.html Infant birth outcomes among substance using women: Why quitting smoking during pregnancy is just as Centers for Disease Control and Prevention (CDC). important as quitting illicit drug use. Maternal and (2016b). Guidelines for vaccinating pregnant women. Child Health Journal, 16(2), 414-422. DOI 10.1007/ Accessed 11/9/16 at: http://www.cdc.gov/vaccines/ s10995-011-0776-y. pregnancy/hcp/guidelines.html Banhidy F, Acs N, Puhó E & Czeizel A. (2011). Iron Centers for Disease Control (CDC). (2016c). Mental deficiency anemia: Pregnancy outcomes with or health among women of reproductive age. Accessed without iron supplementation. Journal of Nutrition, 8/26/16 at: http://www.cdc.gov/reproductivehealth/ 27(1), 65-72. DOI 10.1016/j.nut.2009.12.005. depression/pdfs/mental_health_women_repo_age.pdf Barakat R, Pelaez M, Montejo R, Luaces M & Chevalier N, Letur H, Lelannou D, Ohl J, Cornet Zakynthinaki M. (2011). Exercise during pregnancy D, Chalas-Boissonnas C et al. (2011). Materno-fetal improves maternal health perception: A randomized cardiovascular complications in Turner Syndrome controlled trial. American Journal of Obstetrics after oocyte donation: Insufficient prepregnancy and Gynecology, 204(5), 1-7. DOI 10.1016/j. screening and pregnancy follow-up are associated with ajog.2011.01.043. poor outcome. Journal of Clinical Endocrinology and Metabolism, 96(2), 260-267. DOI 10.1210/jc2010-0925. Becker M, Weinberger T, Chandy A & Schmukler S. (2016). Depression during pregnancy and postpartum. Chuang C, Hillemeier M, Dyer A & Weisman Current Psychiatry Reports, 18(32). DOI 10.1007/ C. (2011). The relationship between pregnancy s11920-016-0664-7. intention and preconception health behaviors. Preventive Medicine, 53(1-2), 85-88. DOI 10.1016/j. Brooten D, Youngblut JM, Golembeski S, Magnus ypmed.2011.04.009. MH & Hannan J. (2011). Perceived weight gain, risk and nutrition in pregnancy in five racial Copen C, Thoma M & Kirmeyer S. (2015). groups. Journal of the American Academy of Nurse Interpregnancy intervals in the United States: Data Practitioners, 24(1), 32-42. DOI 10.1111/j.1745- from the birth certificate and the National Survey of 7599.2011.00678.x. Family Growth. National Vital Statistics Reports, 64(3), 1-11. Dawodu A & Akinbi H. (2013). Vitamin D nutrition in pregnancy: Current opinion. International Journal of Women’s Health, 5, 333-343.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 14

DeFranco E, Stamilio D, Boslaugh S, Gross G & Facchinetti F, Pedrielli G, Benoni G, Joppi M, Verlato Muglia L. (2007). A short interpregnancy interval G, Dante G et al. (2012). Herbal supplements in is a risk factor for preterm birth and its recurrence. pregnancy: Unexpected results from a multicentre American Journal of Obstetrics and Gynecology, study. Human Reproduction, 27(11), 3161-3167. DOI 197(3). DOI 10.1016/j.ajog.2007.06.042. 10.1093/humrep/des303. De Jersey S, Ross L, Himstedt K, McIntyre D & Facco FL, Kramer J, Ho KH, Zee PC & Grobman Callaway L. (2011). Weight gain and nutritional WA. (2010). Sleep disturbances in pregnancy. intake in obese pregnant women: Some clues for Obstetrics and Gynecology, 115(1), 77-83. DOI intervention. Nutrition and Dietetics, 68(1), 53-59. 10.1097/AOG.0b013e3181c4f8ec. DOI 10.1111/j.1747-0080.2010.01470.x. Ferguson K, McElrath T & Meeker, J. (2014). Donders GG, Calsteren KV, Bellen G, Reybrouck R, Environmental phthalate exposure and preterm birth. Van den Bosch T, Riphagen I et al. 2009). Predictive The Journal of the Medical Association Pediatrics, value for preterm birth of abnormal vaginal flora, 168(1), 61-67. DOI 10.1001/jamapediatrics.2013.3699. bacterial vaginosis and aerobic vaginitis during the first trimester of pregnancy. British Journal of Field T, Diego M, Hernandez-Reif M, Figueiredo B, Obstetrics and Gynaecology, 116(10), 1315-1324. DOI Schanberg S & Kuhn C. (2007). Sleep disturbances 10.1111/j.1471-0528.2009.02237.x. in depressed women and their newborns. Infant Behavior & Development, 30(1), 127-133. DOI Downs D, LeMasurier G & DiNallo J. (2009). Baby 10.1016/j.infbeh.2006.08.002 steps: Pedometer-determined and self-reported leisure-time exercise behaviors of pregnant women. Figà-Talamanca I. (2006). Occupational risk factors Journal of Physical Activity and Health, 6(1), 63-72. and reproductive health of women. Occupational Medicine, 56(8), 521-531. DOI 10.1093/occmed/ Downs D, Savage J & Rauff E. (2014). Falling short kql114. of guidelines? Nutrition and weight gain knowledge in pregnancy. Journal of Women’s Health Care, 3 Finer LB & Zolna MR. (2011). Unintended pregnancy (184). DOI 10.4172/2167-0420.1000184. in the United States: Incidence and disparities, 2006. Contraception, 84(5), 478-485. DOI 10.1016/j. Drehmer M, Camey SA, Nunes MA, Duncan BD, contraception.2011.07.013. Lacerda M, Pinheiro AP et al. (2012). Fibre intake and of BMI: From pre-pregnancy to Foxman B, Wen A, Srinivasan U, Goldberg D, Marrs postpartum. Public Health Nutrition, 16(8), 1403- C, Owen K et al. (2014). Mycoplasma, bacterial 1413. DOI 10.1017/S1368980012003849. vaginosis-associated bacteria BVAB3, race and risk of preterm birth in a high-risk cohort. American Journal Eisenberg D, Stika C, Desai A, Baker D & Yost K. of Obstetrics and Gynecology, 210(3), 1-7. DOI (2010). Providing contraception for women taking 10.1016/j.ajog.2013.10.003 potentially teratogenic medications: A survey of internal medicine physicians’ knowledge, attitudes Frieder A. (2010). Guidance for preconception care of and barriers. Journal of General Internal Medicine, women with psychiatric disorders. Before, between 25(4), 291-297. DOI 10.1007/s11606-009-1215-2. and beyond pregnancy: The National Preconception Curriculum and Resources Guide for Clinicians. Endeshaw M, Ambaw F, Aragaw A & Ayalew A. Accessed 8/26/16 at: http://www.beforeandbeyond. (2014). Effect of maternal nutrition and dietary habits org/uploads/Bipolar%20disorders.pdf on preeclampsia: A case-control study. International Journal of Clinical Medicine, 5(21), 1405-1416. DOI Gahche J, Bailey R, Burt V, Hughes J, Yetley E, 10.4236/ijcm.2014.521179. Dwyer J et al. (2011). Dietary supplement use among U.S. adults has increased since NHANES III (1988- Evenson KR & Wen F. (2010). National trends in self- 1994). National Center for Health Statistics Data reported physical activity and sedentary behaviors Brief, 2011(61), 1-8. among pregnant women: NHANES 1999-2006. Preventive Medicine, 50(3), 123-128. DOI 10.1016/j. Goldenberg RL, Culhane JF, Iams JD & Romero R ypmed.2009.12.015. (2008). Epidemiology and cause of pre-term birth. The Lancet, 371(9606), 75-84. DOI 10.1016/S0140- 6736(08)60074-4.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 15

Grieger J, Grzeskowiak L & Clifton V. (2014). Huybrechts KF, Sanghani RS, Avorn J & Urato AC. Preconception dietary patterns in human pregnancies (2014). Preterm birth and antidepressant medication are associated with preterm delivery. Journal use during pregnancy: A systematic review and meta- of Nutrition, 144(7), 1075-1080. DOI 10.3945/ analysis. PLOS ONE 9(3), e92778. DOI 10.1371/ jn.114.190686. journal.pone.0092778. Hadar E, Ashwal E & Hod M. (2015). The Ickovics J, Kershaw T, Westdahl C, Magriples U, preconceptional period as an opportunity for pre- Massey Z, Reynolds H et al. (2007). Group prenatal diction and prevention of noncommunicable disease. care and perinatal outcomes: A randomized control Best Practice and Research Clinical Obstetrics trial. Obstetrics and Gynecology, 110(2), 330-339. and Gynaecology, 29(1), 54-62. DOI 0.1016/j. DOI 10/1097/01.AOG.0000275284.24298.23. bpobgyn.2014.05.011. Ide M & Papapanou PN. (2013). Epidemiology of Hagman A, Loft A, Wennerholm U, Pinborg A, Bergh association between maternal periodontal disease and C, Aittomaki K et al. (2013). Obstetric and neonatal adverse pregnancy outcome — Systematic review. outcome after oocyte donation in 106 women with Journal of Clinical Periodontology, 40(Suppl. 14), Turner syndrome: A Nordic cohort study. Human S181-S194. Reproduction, 28(6), 1598-1609. DOI 10.1093/ humrep/det082. Imran A, Arif A, Jamal S & Karim SA. (2015). Oral hygiene and gestational age at delivery; A cross- Hashmi A, Bhatia S, Bhatia S & Khawaja I. (2016). sectional survey conducted at a tertiary care hospital. Insomnia during pregnancy: Diagnosis and rational Annals of Abbasi Shaheed Hospital and Karachi interventions. Pakistan Journal of Medical Sciences, Medical and Dental College, 20(1), 40-44. 32(4), 1030-1037. DOI 10.12669/pjms.324.10421. Institute of Medicine (IOM). (2009). Weight gain Heitmann K, Havnen G, Holst L & Nordeng H. during pregnancy: Reexamining the guidelines. (2016). Pregnancy outcomes after prenatal exposure Rasmussen KM & Yaktine AL (Eds.) The National to echinacea: The Norwegian mother and child cohort Academies Press, Washington, DC. study. European Journal of Clinical Pharmacology, 72(5), 623-630. DOI 10.1007/s00228-016-2021-5. Institute of Medicine (IOM) Panel on Macronutrients, Panel on the Definition of Dietary Heitmann K, Nordeng H & Holst L. (2013). Safety Fiber, Subcommittee on Upper Reference Levels of of ginger use in pregnancy: Results from a large Nutrients, Subcommittee on Interpretation and Uses population-based cohort study. European Journal of of Dietary Reference Intakes and Standing Committee Clinical Pharmacology, 69(2), 269-277. DOI 10.1007/ on the Scientific Evaluation of Dietary Reference s00228-012-1331-5. Intakes. (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, Hofmeyr G, Lawrie T, Atallah A, Duley L & protein and amino acids (macronutrients). Torlani M. (2014). Calcium supplementation Washington, DC: The National Academies Press. during pregnancy for preventing hypertensive disorders and related problems. The Cochrane Jefferson A & Croton J. (2013). Using wheat bran Database of Systematic Reviews, 6(CD001059). DOI fibre to improve bowel habits during pregnancy – A 10.1002/14651858.CD001059.pub4. call to action. British Journal of 21(5), 331- 341. DOI 10.12968/bjom.2013.21.5.331 Holtz B, Smock A & Reyes-Gastelum D. (2015). Connected motherhood: Social support for moms Johnson J, Clifton R, Roberts J, Myatt L, Hauth and moms-to-be on Facebook. Telemedicine and J, Spong C et al. (2013). Pregnancy outcomes e-Health, 21(5), 415-421. DOI 10.1089/tmj.2014.0118. with weight gain above or below the 2009 Institute of Medicine Guidelines. Obstetrics Huang H, Coleman S, Bridge J, Yonkers K & Katon and Gynecology, 121(5), 969-975. DOI 10.1097/ W. (2014). A meta-analysis of the relationship AOG.0b013e31828aea03. between antidepressant use in pregnancy and the risk of preterm birth and low birth weight. General Hospital Psychiatry, 36(1), 13-18. DOI 10.1016/j. genhosppsych.2013.08.002.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 16

Johnson K, Posner SF, Biermann J, Cordero JF, Liu P, Xu Y, Yin H, Wang J, Chen K & Li Y. (2005). Atrash HK, Parker CS et al. (2006). Recommendations Developmental toxicity research of ginsenoside to improve preconception health and health care Rb1 using a whole mouse embryo culture model. — United States. A report of the CDC/ATSDR Birth Defects Research Part B: Developmental and Preconception Care Work Group and the Select Panel Reproductive Toxicology, 74(2), 207-209. on Preconception Care. MMWR Recommendations and Report, 55(RR-6), 1-23. Madazali R, Yuksel MA, Oncul M, Imamoglu M & Yilmaz H. (2014). Obstetric outcomes and prognostic Kessler RC. (2003). Epidemiology of women and factors of lupus pregnancies. Archives of Gynecology depression. Journal of Affective Disorders, 74(1), and Obstetrics, 289(1), 49-53. DOI 10.1007/s00404- 5-13. 013-2935-4. Kim DR, Sockel LE, Sammel MD, Kelly C, Moseley Mannisto T, Mendola P, Grewal J, Xie Y, Chen Z M et al. (2013). Elevated risk of adverse obstetric & Laughon K. (2013). Thyroid diseases and adverse outcomes in pregnant women with depression. pregnancy outcomes in a contemporary US cohort. Archives of Women’s Mental Health, 16(6), 475-482. Journal of Clinical Endocrinology and Metabolism, DOI 10.1007/s00737-013-0371-x. 98(7), 2725-2733. DOI 10.1210/jc.2012-4233. Kloetzel M, Huebner C & Milgrom P. (2011). Maple-Brown LJ, Roman NM, Thomas A, Presley Referrals for dental care during pregnancy. Journal of LH & Catalano PM. (2013). Perinatal factors relating Midwifery and Women’s Health, 56(2), 110-117. DOI to changes in maternal body fat in the late gestation. 10.1111/j.1542-2011.2010.00022. Journal of Perinatology, 33(12), 934-938. DOI 10.1038/jp.2013.109. Kozhimannil K, Hardeman R, Alarid-Escudero F, Vogelsang C, Blauer-Peterson C & Howell, E. Mascio D, Magro-Malosso E, Saccone G, Marhefka (2016). Modeling the cost-effectiveness of doula care GD & Berghella V. (2016). Exercise during pregnancy associated with reductions in pre-term birth and in normal-weight women and risk of preterm birth: cesarean delivery. Birth, 43(1), 20-27. DOI 10.1111/ A systematic review and meta-analysis of randomized birt.12218. controlled trials. American Journal of Obstetrics and Gynecology, 2016(1). DOI 10.1016/j.ajog.2016.06.014. Krans EE & Davis MM. (2012). Preventing low birthweight: 25 years, prenatal risk and the failure to Mitchell AA, Gilboa SM, Werler MM, Kelley KE, reinvert prenatal care. American Journal of Obstetrics Louik C, Hernandez-Diaz S et al. (2011). Medication and Gynecology, 206(5), 398-403. DOI 10.1016/j. use during pregnancy, with particular focus on ajog.2011.06.082. prescription drugs: 1976-2008. (1), 51.e1-e8. DOI Kratz LM, Wong YJ & Vaughn EL. (2013). Health 10.1016/j.ajog.2011.02.029. behaviors among pregnant women: The influence of social support. In Chen S. (Ed.), Social support and Moos M. (2013). Preconception health promotion: health: Theory, research and practice with diverse The foundation for a healthier tomorrow. Accessed populations, 109-122. New York: Nova Publishers. 8/26/16 at: https://www.marchofdimes.org/nursing/ index.bm2?cid=00000003&spid=ne_s4_1&tpid=ne_ Kuo K & Caughey AB. (2016). Contemporary sm01_preconception_home outcomes of sickle cell disease in pregnancy. American Journal of Obstetrics and Gynecology, Moos M, Dunlop AL, Jack BW, Nelson L, Coonrod 215(4), 505e1-e5. DV, Long R et al. (2008). Healthier women, healthier reproductive outcomes: Recommendations for Langen ES, Chakravarty EF, Liaquat M, El-Sayed the routine care of all women of reproductive age. Y & Druzin ML. (2014). High rate of preterm birth American Journal of Obstetrics and Gynecology, in pregnancies complicated by rheumatoid arthritis. 199(6 Supple 2), S280-S289. DOI 10.1016/j. American Journal of Perinatology, 31(1), 9-14. DOI ajog.2008.08.060. 10.1055/s-0033-1333666. Namazy JA, Murphy VE, Powell H, Gibson PG, Lassi Z, Imam A, Dean S & Bhutta Z. (2014). Chambers C & Schatz M. (2013). Effects of asthma Preconception care: Preventing and treating severity, exacerbations and oral corticosteroids on infections. Reproductive Health, 11(3). DOI perinatal outcomes. European Respiratory Journal, 10.1186/1742-4755-11-S3-S4. 41(5), 1082-1090. DOI 10.1183/09031936.00195111.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 17

National Sleep Foundation. (2007). Summary of Pena-Rosas J, De-Regil L, Dowswell T & Viteri F. Findings. National Sleep Foundation, Washington, D.C. (2012). Intermittent oral iron supplementation during pregnancy. The Cochrane Database of Systematic Nevis IF, Reitsma A, Dominic A, McDonald S, Reviews, 11(7). DOI 10.1002/14651858.CD009997. Thabane L, Ald EA et al. (2011). Pregnancy outcomes in women with chronic kidney disease: A systematic Pfeifer S, McClure D, Catherino W, Cedars M, review. Clinical Journal of the American Society Collins J, Davis O et al. (2012). Increased maternal of Nephrology, 6(11), 2587-2598. DOI 10.2215/ cardiovascular mortality associated with pregnancy in CJN.10841210. women with Turner syndrome. Fertility and Sterility, 97(2), 282-284. DOI 10.1016/j.fertnstert.2011.11.049. Ngo C, Kayem G, Habibi A, Benachi A, Goffinet F, Galacteros F et al. (2010). Pregnancy in sickle cell Picklesimer A, Billings D, Hale N, Blackhurst disease: Maternal and fetal outcomes in a population D & Covington-Kolb S. (2012). The effect of receiving prophylactic partial exchange transfusions. CenteringPregnancy group prenatal care on preterm European Journal of Obstetrics and Gynecology and birth in a low-income population. American Journal Reproductive Biology, 152(2), 138-142. DOI 10.1016/j. of Obstetrics and Gynecology, 206(5), 1-7. DOI ejogrb.2010.05.022. 10.1016/j.ajog.2012.01.040. Nordin J, Kharbanda E, Benitez G, Lipkind H, Price B, Amini S & Kappeler K. (2012). Exercise in Vellozzi C & DeStefano F. (2014). Maternal influenza pregnancy: Effect on fitness and obstetric outcomes vaccine and risks for preterm or small for gestational — A randomized trial. Medicine and Science in age birth. The Journal of Pediatrics, 164(5), 1051- Sports and Exercise, 44(12), 2263-2269. DOI 10.1249/ 1057. DOI 10.1016/j.jpeds.2014.01.037. MSS.0b013e318267ad67. Occupational Safety and Health Administration. Rinksy JL, Hopenhayn C, Golla V, Browning S (2017). OSHA law & regulations. Accessed 1/17/17 at: & Bush HM. (2012). Atrazine exposure in public https://www.osha.gov/law-regs.html drinking water and preterm birth. Public Health Reports, 127(1), 72-80. Okun ML, Dunkel-Schetter C & Glynn LM. (2011). Poor sleep quality is associated with preterm birth. Romero R, Espinoza J, Goncalves LF, Kusanovic JP, Sleep, 34(11), 1493-1498. DOI 10.5665/sleep.1384. Friel L & Hassan S. (2007). The role of inflammation and infection in preterm birth. Seminars in Omole-Ohonsi A, Ashimi OA & Aiyedun TA. Reproductive Medicine, 25(1), 21-39. DOI 10.1055/s- (2012). Preconception care and sickle cell anemia 2006-956773. in pregnancy. Journal of Basic and Clinical Reproductive Sciences, 1(1), 12-18. DOI 10.4103/2278- Rosenburg TJ, Garbers S, Lipkind H & Chiasson 960X.104290. MA. (2005). Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: Differences Oza-Frank R, Gilson E, Keim SA, Lynch CD & among 4 racial/ethnic groups. American Journal Klebanoff MA. (2014). Trends and factors associated of Public Health, 95(9), 1545-1551. DOI 10.2105/ with self-reported receipt of preconception care: AJPH.2005.065680. PRAMS, 2004-2010. Birth Issues in Perinatal Care, 41(4), 367-373. DOI 10.1111/birt.12122. Ruiz J, Gennaro S, O’Connor C, Dwivedi A, Gibeau A, Keshinover T et al. (2016). CRH as a Paik D & Lee C. (2015). Review of cases of patient predictor of preterm birth in minority women. risk associated with ginseng abuse and misuse. Biologic Research in Nursing, 18(3), 316-21. DOI Journal of Ginseng Research, 39(2), 89-93. DOI 10.1177/1099800415611248. 10.1016/j.jgr.2014.11.005. Servey J & Chang J. (2014). Over-the-counter Pasternak B, Svanstrom H & Hviid A. (2013). medications in pregnancy. American Family Ondansetron in pregnancy and risk of adverse fetal Physician, 90(8), 548-555. outcomes. The New England Journal of Medicine, 368(9), 814-823. DOI 10.1056/NEJMoa1211035. Shapiro GD, Fraser WD, Frasch MG & Seguin JR. (2013). Psychosocial stress in pregnancy and preterm birth: Associations and mechanisms. Journal of Perinatal Medicine, 41(6), 631-645. DOI 10.1515/jpm- 2012-0295.

MARCHOFDIMES.ORG/NURSING Preventing prematurity: Preconception, prenatal and postpartum nursing care 18

Siu AL & U.S. Preventative Services Task Force U.S. Department of Health and Human Services. (2010). (USPSTF). (2016). Screening for depression in adults: The Surgeon General’s vision for a healthy and fit USPSTF recommendations. Journal of American nation. U.S. Department of Health and Human Services, Medical Association, 315(4), 380-387. DOI 10.1001/ Office of the Surgeon General, Rockville, MD. jama.2015.18392. U.S. Preventive Services Task Force (USPSTF). Sosa C, Althabe F, Belizan J & Bergel E. (2015). Bed (2009). Counseling and interventions to prevent rest in singleton pregnancies for preventing preterm tobacco use and tobacco-caused disease in adults birth. Cochrane Database of Systematic Reviews, and pregnant women: U.S. Preventive Services Task 3(CD003581). DOI 10.1002/14651858.CD003581. Force reafirmation recommendation statement. pub3. Accessed 10/6/16 at: http://annals.org/article. aspx?articleid=744446 Tejada B. (2014). Antibiotic use and misuse during pregnancy and delivery: Benefits and risks. Van Dijk JA, Anderko L & Stetzer F. (2011). International Journal of Environmental Research The impact prenatal care coordination on birth and Public Health, 11(8), 7993-8009. DOI 10.3390/ outcomes. Journal of Obstetric, Gynecologic and ijerph110807993. Neonatal Nursing, 40(1), 98-108. DOI 10.1111/j.1552- 6909.2010.01206.x. Terry A, Barker F, Leffert L, Bateman B, Souter I & Plotkin S. (2013). Neurofibromatosis type 1 and Walls T, Graham P, Petousis-Harris H, Hill L & pregnancy complications: A population-based study. Austin N. (2016). Infant outcomes after exposure to American Journal of Obstetrics and Gynecology, Tdap vaccine in pregnancy: An observational study. 209(46), 1-8. DOI 10.1016/j.ajog.2013.03.029. British Medical Journal, 6(1), 1-6. DOI 10.1136/ bmjopen-2015-009536. Thomas M & Weisman S. (2006). Calcium supplementation during pregnancy and lactation: Whitty J. (2010). Cystic fibrosis in pregnancy. Effects on the mother and the fetus. American Journal Clinical Obstetrics and Gynecology, 53(2), 369-376. of Obstetrics and Gynecology, 194(4), 937-945. DOI DOI 10.1097/GRF.0b013e3181deb448. 10.1016/j.ajog.2005.05.032. Wu M, Wang D, Zand L, Harris P, White W, Trabace L, Tucci P, Ciuffreda L, Matteo M, Garovic V et al. (2016). Pregnancy outcomes in Fortunato F, Campolongo P et al. (2015). “Natural” autosomal dominant polycystic kidney disease: relief of pregnancy-related symptoms and neonatal A case-control study. Journal of Maternal-Fetal outcomes: Above all do no harm. Journal of and Neonatal Medicine, 29(5), 807-812. DOI Ethnopharmacology, 174(4), 396-402. DOI 10.1016/j. 10.3109/14767058.2015.1019458. jep.2015.08.046. Young C, Laurent O, Chung JH & Wu J. (2016). U.S. Department of Agriculture Food and Nutrition Geographic distribution of healthy resources and Services. (2016). Women, infants and children (WIC). adverse pregnancy outcomes. Journal of Maternal Accessed 8/26/16 at: http://www.fns.usda.gov/wic/ Child Health, 20(8), 1673-1679. DOI 10.1007/s10995- women-infants-and-children-wic 016-1966-4.

MARCHOFDIMES.ORG/NURSING