Incidental Fetal Ultrasound Findings: Interpretation and Management

Ultrasonography is a common component of prenatal care worldwide and is often used in early pregnancy to determine gestational age, number of fetuses, fetal cardiac activity, and placental location. Patients and their families may also consider ultrasonography a social event, as it provides confirmation and reassurance of a normal pregnancy. Ultrasound screening is typically scheduled in the second trimester to visualize fetal anatomy and confirm gestational age. Most ultrasound examinations are reassuring, but some incidentally identify structural anomalies and soft markers for aneuploidy, making it necessary for health care providers to correctly interpret these findings. The health care provider's ability to prepare patients prior to the ultrasound and deliver the necessary information needed to make informed decisions regarding any follow-up screening or diagnostic testing is critical to reducing parental anxiety. Preparation for the anatomic survey should include counseling for normal and abnormal findings. The ethical concepts of patient autonomy and shared decision making are used as a guide in providing this critical information and enabling informed choices during follow-up for incidental ultrasound findings.

An exploration of co-parenting in the context of caring for a child prenatally diagnosed and born with a complex health condition

AIM

The aim of this study was to describe co-parenting communication in couples in the context of caregiving for children prenatally diagnosed and born with complex health conditions.

BACKGROUND

Foetal diagnosis of complex health conditions such as heart, central nervous system, or abdominal anomalies are confirmed more often than ever before. Following diagnosis, parents face challenges beginning before birth. The quality of co-parenting, when two individuals relate to each other as parents and share parental responsibilities, can have an impact on child health and development. Yet, little is known about co-parenting during the transition to parenthood after foetal diagnosis.

DESIGN

This secondary analysis of interview data was informed by Bowlby's theoretical work on a parent's view of self as caregiver and the literature on co-parenting.

METHODS

Data were drawn from a larger, mixed methods, longitudinal study and included audio-recorded interviews conducted with 16 parents participating as eight couples after foetal diagnosis during the third trimester of pregnancy in 2011-2012 and again when children were 14-37 months old in 2014. Analysis of interviews transcribed verbatim focused on co-parenting communication.

FINDINGS

Co-parenting communication regarding support, agreement and information sharing and a new category of shared meaning were related to the diagnosis before birth. Later, couples evolved in their co-parenting communication while caring for their toddlers and working towards achieving a sense of normalcy.

CONCLUSION

Variation in co-parenting communication among couples preparing and caring for children with complex health conditions, including the development of a shared meaning of the child's diagnosis, needs further investigation to inform nursing assessment and guide tailored interventions.

Non-communicable diseases among children in Ghana: health and social concerns of parent/caregivers

BACKGROUND

Globally, there is a progressive rise in the burden of non-communicable diseases (NCDs). This paper examined the health and social concerns of parents/caregivers on in-patient care for children with NCDs in Ghana.

METHODS

This was a cross-sectional study in three large health facilities in Ghana (the largest in the South, the largest in the North and the largest in the Eastern part of Ghana. Data was collected with a structured questionnaire among 225 caregivers (≥18 years) of 149 children with NCDs in health facilities in the three regions. Data was analyzed with simple descriptive statistics.

RESULTS

Most caregivers 169(75.0%) were women, relatively young (median age 35years), mostly married and resided in urban areas. Sickle cell disease was the commonest NCD among the children. All 169(75.0%) caregivers believed children suffer NCDs because of sins of parents/ancestors, 29(12.9%) believed herbalists/spiritualists have insights into treating NCDs and 73(32.6%) have previously used herbs/traditional medicine for child's illness. NCD in children was a burden and caused financial difficulties for families. Most caregivers (>96.0%) indicated NCDs in children should be included in national health insurance benefits package and a comprehensive national NCD policy is needed.

CONCLUSION

Absence of national NCD policy for children is a major challenge. The burden of care rests mainly on the parents/caregivers. A national strategic intervention on the importance of awareness generation on the causes, risk factors, prevention and treatment of NCDs for families and communities is essential. Government support through national health and social policy initiatives are essential.

The dying neonate: family-centered end-of-life care

There is a need in the NICU for an end-of-life care guideline that nurses can follow when working with dying infants and their families. Maintaining intravenous access to relieve the infant's pain, communicating sensitively to the family, and creating precious, everlasting memories are goals that should be part of every dying infant's care. The nurse's ability to partner with the family in caring for the infant is integral to helping the family take the first steps in their grief journey. Evidence-based literature provides NICU nurses with the knowledge that they are the facilitators of end-of-life care for dying infants. New mothers and fathers are not aware of the caring parental tasks they can perform for their dying baby. They look to and depend on their infant's nurses to encourage them. The guideline included here provides nurses with a tool for ensuring that families have the opportunity to create memories that will not only help them with their immediate pain, but also comfort them for a lifetime.

Fetal Concerns Program

Advances in fetal diagnostics have resulted in families facing a pregnancy complicated by a fetal health concern. Perinatal literature supports that these families benefit from extensive counseling and education presented by a multidisciplinary team. In the program described in this article, perinatal palliative care planning is offered to families who have been told that their fetus has a potentially lethal prognosis. Called the "Fetal Concerns Program," it was developed to address the complex needs of families whose fetus has anomalies. This article reviews perinatal palliative care concepts and describes the Fetal Concerns Program's development as a perinatal palliative care service within a broader program. The special role of the nurse coordinator of the Fetal Concerns Program is highlighted.

Case series of 148 tongue-tied newborn babies evaluated with the assessment tool for lingual frenulum function

OBJECTIVE

the Assessment Tool for Lingual Frenulum Function (ATLFF) is the only available tool designed to assess newborn babies for the severity of tongue-tie. The aim of this study was to describe the ATLFF scores obtained on a series of 148 tongue-tied newborn babies.

DESIGN

prospective case series.

SETTING

a 420-bed community hospital in St. Paul, Minnesota, USA.

PARTICIPANTS

newborn babies admitted to the normal newborn nursery from October 1, 2000 to May 1 2002.

MEASUREMENTS AND FINDINGS

all babies in the nursery were examined for tongue-tie. One-hundred and forty-eight tongue-tied babies were examined using the ATLFF by at least one of three examiners. The ATLFF could not be completed on five babies. Of the remaining babies, 40 (28%) received 'perfect' scores, five (3.5%) received 'acceptable' scores, and 19 (13.3%) received 'function impaired' scores. The remaining 79 (55.2%) babies received scores that did not fall into any of the three categories of scores. The inter-rater agreement on whether or not the baby had a score of 'function impaired' on the ATLFF was moderate (kappa=0.44).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

few tongue-tied babies had a score of 'function impaired' on the ATLFF. It is a major limitation of the ATLFF that it does not classify most babies. The development and testing of a useful tool to determine which tongue-tied babies will have difficulty with breast feeding remains a research priority.

End-of-life care for infants

Carey, diagnosed with Trisomy 13, was 4 months old when he died. The moment of his death was really quite beautiful. He looked so peaceful resting in his mother's arms. She kissed him softly and said her good-byes. Tears stained her cheeks as Carey's father gently put his arms around both of them. They relaxed as he took his last breath, confident that they had done their best in caring for him. They had given Carey the best 4 months he could have. They will always remember him. After a few moments alone with Carey, they handed him to the hospice nurse. She and the social worker took care of the last-minute arrangements while the extended family members consoled one another. That night, the family began a new phase of their journey, carrying the memories of Carey and his life with them forever.

Caring for Children With Special Healthcare Needs in the Managed Care Environment

Dramatic medical and technological advances over the past 15 years have resulted in the survival into adulthood of children with chronic health conditions. As this population subset has increased, the demand of caring for these children in the managed care arena has become challenging from a clinical, fiscal, and member satisfaction perspective. A disease management program was designed for children, ages birth through age 18, identified as having special needs at the time of birth or at any point throughout childhood related to disease processes such as diabetes, sickle cell disease, genetic aberrations, or the multiple complications of extreme prematurity. Components of the program included identification of the population, coordinated risk assessment, and ongoing case management interventions. Most important, outcome indicators were tracked to demonstrate program effectiveness. The formulation and function of a dedicated disease management database is also discussed.

Family-centered care in the context of fetal abnormality

Women confronted with prenatal diagnosis of fetal abnormality face emotionally challenging choice options and considerable uncertainty regarding impact of choice on their families. Prenatal diagnosis of fetal abnormality presents childbearing women with difficult choices, such as continuation of pregnancy with no intervention, abortion, and, in selected cases, experimental fetal therapy. Regardless of their decision, it is a time of transition marked by grief and loss. The experience women and families have with the option chosen has an impact on their short- and long-term well-being. Healthcare providers are paramount in facilitating this transitional time in supporting family needs.

[Reflecting about congenital malformation]

The study consisted in a bibliographical revision about congenital malformations. The objectives consist of making a survey of the nursing production about the subject, presenting the current referring contributions related to the questions of congenital malformations and to propitiate a reflection for the performance of nursing professionals when facing this situation. As results, the revision located studies that had been categorized in thematic units: mother perception, familiar questions, monitorization project and nursing care in the specific anomalies. The conclusion points out that the adequate assistance to be given to the child with congenital malformation, demands beyond technician training, ability and sensitivity of the multidisciplinary team, that becomes them capable to perceive and to intervent in the bio-psicossocial and spiritual dimension of the child and the family.

A perinatal hospice for an unborn child with a life-limiting condition

Perinatal hospice is a newly developing model of hospice care, offered to the family in the prenatal period, which provides support, guidance and comfort to families who make the difficult choice to continue a pregnancy after the diagnosis of a fatal fetal anomaly. The model is based on the hospice philosophy of living life fully and enjoying each moment. This article describes a perinatal hospice programme that is currently in place at a hospice home care programme of a children's hospital in the USA. It includes a case example of one family's experience of this programme.

Parental satisfaction with an early family intervention program

The objective of this study was to evaluate parental satisfaction with a family intervention program. The program provides help and support for parents with newborns who have specific health problems (e.g., cleft palate and/or lip; Down syndrome). Four family subscales, personal (emotional and cognitive), marital, parental, and extended family and others, were examined. The majority of parents were satisfied with the intervention. Most felt that the intervention had helped them to adapt to the unexpected situation. They received guidance in discerning and discussing their own emotions and those of their partner or spouse, and the help they received gave them confidence about the care their child would receive. Results revealed significant differences in satisfaction levels (depending on the sex of the parent), the child's diagnosis, and annual income. Mothers of newborns with Down syndrome were more satisfied than fathers with the personal-emotional support they received. Low-income families were more satisfied than those with higher incomes for all subscales. On the parental subscale, those whose child had a cleft lip/palate were more satisfied than those whose child had Down syndrome. The results raised several important questions about this type of early intervention program, which will require further in-depth investigation.

Interaction as an ethically sensitive subject of research

In this paper, Hanna Maijala, Päivi Astedt-Kurki and Eija Paavilainen discuss ethically sensitive family nursing research. A study of the interaction between caregivers and families expecting a child with an abnormality is used as an example: 29 parents and 22 caregivers were interviewed. Complementary data were obtained from essays written by five parents. This sensitive subject required discretion, especially when the parents were first asked to participate in the study, and during subsequent interviews. From the perspective of the data analysis, it was essential to obtain the informants' personal experiences unaltered. The constant comparative method of grounded theory was used to analyse the data. In the study findings, special attention was paid to presenting the results truthfully, while safeguarding the informants' anonymity. In conclusion, the ethical questions related to the subject of the study are discussed from the point of view of both the participant and the researcher.

[Parents' satisfaction at the birth of a handicapped child following a family intervention]

The aim of this study is to estimate parents' satisfaction following a surgical procedure on their child. This includes support as well as additional information and documentation for the individual parent (cognitive and emotional), conjugal, parental and other family members. The majority of parents are satisfied with the treatment program, realizing that the treatment enables them to adapt to their new situation, that is, as parents of a newborn child suffering from health problems. This support allows them to recognize and talk about their own fears and emotions as well as those of their partner, to be reassured when facing their child's treatment, and to better understand the available resources. The results of the study show that there are significant differences in regards to the sex of the parent, the diagnosis of the child and the level of income. Mothers of children inflicted with Down's syndrome are more emotionally satisfied with the treatment than fathers, and lower income families are more satisfied with the treatment as well as with the sub-system of family health-care than middle and upper-income families. Parents of children with a labial and/or palatine cleft are more satisfied with the treatment in regards to the family plan than parents of children with Down's syndrome. These results raise several questions that, with more profound deliberation on the adequacy of early medical procedures with regards to the parents of children with health problems, shall not be overlooked. Let us highlight the heuristic qualities of this evaluative approach which possess the same relevance as the questionnaires developed in order to assess the families' satisfaction. After modifications, these questionnaires could eventually be used on different clientele as well.

Neonatal surgical emergencies: stabilization and management

The transitional period following birth can be complicated by the presence of congenital anomalies requiring emergent surgical management. Newborns with congenital diaphragmatic hernia require immediate intubation and gastric decompression to minimize gastric distention, as well as cautious ventilation to avoid pneumothorax. Newborns with omphalocele and gastroschisis are at risk for bacterial contamination, as well as heat and evaporative losses from exposed viscera. These newborns benefit from the use of a protective bowel bag. Newborns with meningomyelocele require meticulous care to avoid infection and trauma to exposed portions of the spinal cord. An illustrated protocol provides guidance in the initial stabilization of these defects. Nurses providing family-centered care must be knowledgeable about congenital anomalies presenting at birth so they can properly stabilize these newborns and provide accurate information to families.

Living with disfigurement

Body-image disturbance, as a consequence of disfigurement, affects a large number of people in the UK, yet there is little research into the psychosocial consequences. There is evidence that many of the psychological difficulties can be likened to phobic behaviour, particularly in social situations. A fear-avoidance model of psychosocial difficulties following disfigurement is, therefore, potentially useful to nurses working in a variety of settings. The first of two articles on disfigurement explores some of the background to the fear-avoidance model.

Current management of infants and children with single ventricle anatomy

Children with single ventricle anatomy are among the most complicated and challenging patients encountered in pediatric cardiology. Current management involves staged surgical procedures, beginning with neonatal palliation and followed by a bidirectional cavopulmonary anastomosis in infancy and culminating in the Fontan procedure. The Fontan procedure, despite separating the circulation, remains a palliative procedure with many long-term concerns. This report discusses the staged surgical management of patients with single ventricle anatomy and the nursing issues relevant to each stage.

Identifying common pediatric neurosurgical conditions in the primary care setting

The primary care setting is crucial to the diagnosis and treatment of pediatric neurosurgical conditions. The scope of this article is to present common pediatric neurosurgical diagnoses and their typical presentation to assist the primary care advanced practice nurse in making timely and appropriate referrals. The complications from delayed treatment can be significant for the child's future development. Conditions that are addressed include cutaneous stigmata related to occult spinal cord defects, common birth-related trauma, craniosynostosis, positional molding, torticollis, hydrocephalus, mild head injury, and brain tumors.

Autosomal trisomies: what neonatal nurses need to know

Autosomal trisomies are associated with major congenital malformations that may result in prolonged hospitalization of the newborn. Knowledge about these chromosomal abnormalities is important for nurses in neonatal practice. This article identifies the causes and manifestations of most of these trisomies: trisomy 13 (Patau syndrome), trisomy 18 (Edwards syndrome), and trisomy 21 (Down syndrome). More detailed description of the manifestations, associated abnormalities, and outcomes of the most common of these, trisomy 21, is provided.

Predictors of postnatal head molding in very low birth weight infants

This study examined potential predictors of postnatal head molding in very low birth weight (VLBW) infants. Occipital-frontal circumference (OFC) and anterior-posterior (AP) and biparietal (BP) diameter measurements were obtained on 144 premature infants with birth weights of less than 1,500 gm. Measurements were obtained at four days of age (baseline) and weekly until discharge. Increasing gestational age, higher birth weight, and delivery by cesarean section predicted larger OFC at three weeks of life. Only baseline AP:BP measurements significantly predicted AP:BP measurements at week 3 and 5. Within-group t-tests indicated that the severity of head molding (as indicated by AP:BP ratio) increased throughout the first six weeks of life. Results indicate that postnatal head molding can be reliably predicted and that neonates with higher AP:BP ratios at birth are at greater risk for continued narrow, elongated head shape.

[Description of activities in the neonatal department at Rigshospitalet during the period 1983-1990]

Since 1983, the gestational age (GA in completed weeks), use of mechanical ventilation, duration of hospitalization and the diagnosis-related group were registered routinely for all infants admitted to the Neonatal Department, Rigshospitalet, Copenhagen. The data were analysed concerning the 6,636 infants treated during the seven-year period until the end of 1991. The annual number of admissions decreased during the period (p < 0.001) whereas the number of extremely preterm infants (GA < 28 weeks) increased from 30 to 45 annually (p < 0.05). The total mortality remained constant at about 7% of all admissions but decreased significantly for the extremely preterm infants. The use of mechanical ventilation was almost halved during the period: from 235 to 146 annually. Even where the extremely preterm infants were concerned, the use of mechanical ventilation decreased from 77% to 51% (p < 0.05). The gestational age specific duration of hospitalization for the surviving infants remained constant. The number of infants with surgical anomalies or congenital heart disease increased among the infants born at term. The cost of treatment increased by 40% in fixed prices to DDK 4,000 per day (approximately 333 pounds). The authors conclude that the introduction of nasal continuous positive airway pressure (CPAP) has permitted treatment of moderately preterm infants in county hospitals and has also resulted in avoidance of mechanical ventilation in extremely preterm infants without preventing improved survival. Although the patients have become more selected, the duration of hospitalization remains unchanged.

Birth defect prevention. Nursing interventions

Nurses who are knowledgeable about the principles of teratology can effectively assist families in preventing neonatal malformation and dysfunction. A review of the history and development of the field of teratology, related research purposes and methods, a list of currently known teratogenic agents, and recommendations for nursing interventions for primary and secondary prevention are provided.

Tongue-tie (ankyloglossia) and breastfeeding: a review

Tongue-tie (partial ankyloglossia) is a congenital condition in which the membrane under the tongue is too short or may be attached too near the tip of the tongue, thereby preventing tongue protrusion. Considerable controversy among health professionals persists regarding the appropriate treatment of partial ankyloglossia. Therefore, lactation consultants need to be aware of tongue-tie and its potential negative impact on breastfeeding. This discussion examines issues relating to the possible need for treatment and the role of the lactation consultant in the evaluation and care of the infant who presents with ankyloglossia.

Tricuspid atresia. Surgical treatment, pediatric nursing care

Tricuspid atresia is one of the least common congenital heart defects representing less than 3% of all reported cases. The course and prognosis depends on the underlying anatomy; however, the prognosis is guarded in all cases. Intraoperative mortality is between 5% to 7%. Without surgical treatment, these children die. Of those who have surgery, more than half survive until their second decade. At approximately 15 years of age, the mortality rate increases as a result of congestive heart failure, pulmonary vascular obstructive disease, and dysrhythmias. Surgical repair for children with tricuspid atresia involves palliative surgery in infancy followed by corrective surgery when the child is three to four years of age. The Fontan procedure is the surgical procedure of choice for children undergoing corrective surgery for tricuspid atresia. It involves anastomosing the pulmonary artery to the right atrium to create a connection between the systemic venous and pulmonary circulation. Children undergoing corrective surgery for tricuspid atresia require diversified nursing care. Nurses from the cardiovascular unit, the operating room, and the pediatric intensive care unit work interdependently to facilitate the transition of the child and family through the various stages of the hospitalization. As a result of a collaborative and comprehensive nursing approach, these children and families may have a more positive experience.

The experience of black parents/caretakers with the births and care of a child with profound congenital defects

The reaction of Black families to the birth and care of a baby with profound congenital defects was researched using twenty case studies. It was found that the families went through stages of the grieving process, that they shifted from the Western/Christian viewpoint to the traditional viewpoint in their struggle to cope and that they find the existing services grossly inadequate.