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HIV Disease and Pregnancy: Part 3 · Postpartum Care of the HIV- Positive Woman and Her Newborn
PRINCIPLES & PRACTICE
w
CYNTHIA HERRERA, RNC, B S N
omen of childbearing age and their children are an emergent population of HIVinfected individuals. Nurses in the postpartum and newborn nursery settings assume critical roles in providing physical care, educating the woman, providing anticipatory guidance, and planning and coordinating follow-up services. The nursing management of the HIV-seropositive woman during the postpartum period and the care of her infant born exposed to HIV are discussed in this article. The appendix outlines the information that should be provided or reinforced during the hospital stay and the follow-up services that are required after discharge.
H W Disease
c a r e of the HW-Infected Woman During the Puerperium
NORMA BASTIN, RNC, BSN OLGA W I N T E R TAMAYO, RN, B S N M I N D Y B. T I N K L E , R N C , P H D , W H C N P MARIA ALVAREZ AMAYA, RN, P H D L E T I C I A R. T R E J O , R N C , B S N
and Pregnancy
Part 3. Postpartum Care of the HWPositive Woman and Hm Nmbom For women with HIV infection, physical and psychosocial adaptation during the postpartum period is fraught with ambivalence. On the one hand, there is the j o y ofparenthood, but on the other, the burden of a chronic, terminal illness and the possibility of having an infected newborn. The nursing care of the HIV. positive woman and her newborn is discussed. Guidelines for hospital discharge teaching are included.
Accepted: October 1991
March/April 1992
Physical care The postpartum nursing care of the HIV-infected woman will include the care commonly delivered to all women and the special care needs of HIV-positive women. The postpartum nurse caring for these women must be especially observant of signs and symptoms of infection or hemorrhage, or both. HIVseropositive women with varying degrees of immunosuppression may be at increased risk for postpartum infections and poor wound healing. Several studies have documented an increased incidence of postpartum infection, such as endometritis and puerperal febrile illness, among HIV-positive women (Gloeb, O'Sullivan, & Efantis, 1988; Minkoff, Nanda, Mendez, & Fikrig, 1987). These women are also at increased risk for genitourinary tract infections and may harbor a variety of sexually transmitted diseases (Fekety, 1989; Gloeb et al., 1988). Hemorrhage is another potential postpartum complication among HIV-positive women. HIV-related thrombocytopenia may predispose these women to severe postpartum bleeding. Referral and collaboration Women with HIV infection who are admitted to the postpartum unit must be under the care of or referred to a primary care physician experienced in the management of HIV disease. Women exhibiting severe compromise may need to be transferred to a specialized HIV or other infectious disease care unit (Minkoff, 1987). Women at varying stages of HIV disease may need to be referred to psychosocial services, support groups in the community, or substance abuse
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treatment programs if they are not already using such services. Self-care measures Teaching the client about self-care measures during hospitalization and after discharge is a priority. The discussion of perineal care should include proper handling of perineal pads and blood spills. A dilute household bleach (1 part bleach to 10 parts water) will effectively disinfect a blood spill site (Efantis, 1990). Educating the mother in appropriate infection control measures to use, such as good hand washing and avoiding body fluid exchange, when she interacts with her infant is important. Nurses can instruct the woman to report a persistent spiking fever; a change in the character of the lochia, such as foul smell; the return to bright red bleeding; or an excessive amount of bleeding. The nurse should also instruct the woman to report symptoms that may indicate worsening of HIV disease, such as fatigue, anorexia, weight loss, sore throat, cough, dermatologic disorders, or unusual vaginal discharge (Diagnosis and Management, 1988; Minkoff, 1987). Tampons should not be used because they may cause small vaginal abrasions and provide a port of entry for microorganisms. Douching should be avoided also, because this practice may actually encourage the growth of pathogens.
estrogens inhibit cell-mediated immune responses. The sponge, the diaphragm, and intrauterine devices are foreign objects that pose a potential risk for causing abrasions and providing a port of entry for HIV. Sterilization of neither the woman nor the man provides protection against the transmission of HIV (Hatcher et al., 1990). Thus, a combination of oral contraceptives and latex condoms with spermicide, Norplant implants and latex condoms with spermicide, or tuba1 ligation or vasectomy and latex condoms with spermicide may be recommended. Female condoms and abstinence can be offered as alternatives to women whose partners will not use condoms (Hatcher et al., 1990).
women with HIV disease face the dilemma that a contraceptive method that prevents pregnancy does not necessarily prevent the heterosexual transmission of HIV and that a contraceptive method that prevents transmission of HIV does not necessarily prevent pregnancy.
Sexual practices that carry a high risk of HIV transmission are anal or vaginal intercourse and fellatio, all with ejaculation and without a condom, and oral-anal contact. The degree of risk for many sexual practices, such as cunnilingus, deep kissing, sharing of sexual devices, and urination on or in the partner’s body is uncertain (Raider, 1990). Risk-reduction strategies must involve modification of risk-related behaviors. Safe sex practices must be discussed. These include hugging, massage, body rubbing, dry kissing, masturbation, shared fantasies, and erotic talking (Raider, 1990). Safe sex practices primarily involve using a condom. The woman should be instructed in the correct use of condoms, preferably with nonoxynol9 spermicide, with each sexual encounter. The risk of condom breakage can be reduced by using sufficient watersoluble lubricant. Because sexual activity may be unplanned, especially if the participants are under the influence of drugs or alcohol, the nurse can recommend having a condom available at all times (Pugliese & Lampinen, 1989).
Contraceptive counseling and safe sex practices The postpartum woman with HIV infection should be counseled on contraception and safe sex. This information is equally important for seropositive women to minimize the viral load of HIV, decrease exposure to sexually transmitted organisms that may hasten the progress of HIV disease, and decrease the risk of transmitting the infection to others. Women with HIV disease face the dilemma that a contraceptive method that prevents pregnancy does not necessarily prevent the heterosexual transmission of HIV and that a contraceptive method that prevents transmission of HIV does not necessarily prevent pregnancy. Latex condoms provide a physical barrier to HIV, and nonoxynol 9 inactivates HIV at the concentrations present in most spermicidal preparations. Using condoms exclusively as a means of protection, however, can result in an unplanned pregnancy (Allen, 1990). Oral contraceptives decrease the amount and time of menstrual flow, thus decreasing exposure time of the denuded endometrium to the HIV antigen and also decreasing the amount of HIV-infected menstrual blood exposure for the woman’s sexual partner. On the other hand, no evidence is available showing that
Avoidance of infections The woman should be instructed on practices to avoid infections other than those sexually acquired. Cook-
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ing and eating practices involving the consumption of raw meat and raw eggs should be avoided to decrease the risk of Salmonella infection. If a cat is in the household, the woman should be encouraged to avoid handling the litter box to decrease the risk of exposure to toxoplasmosis. The patient should avoid sharing toothbrushes and razors that can be contaminated with blood (Wilson, 1991). Needle-sharing precautions should be reviewed, if indicated. Special precautions such as vaccines and chemoprophylaxis may be warranted when foreign travel is planned, to avoid enteric, respiratory, and vector-borne infections (Wilson, 1991). Nutrition and hydration The importance of good nutrition and hydration must be emphasized. This is especially important for women experiencing gastrointestinal side effects of drug therapy, women who are abusing chemical substances, or women exhibiting advanced HIV disease. A referral to a dietitian may be indicated. Gynecologicfollow-up Because preliminary data indicate that the clinical manifestations of gynecologic disease may be altered by HIV infection, women with such diseases require more intensive gynecologic monitoring and more aggressive treatment of any infectious process (Minkoff & Dehovitz, 1991). Recent reports indicate that the rate of abnormal Papanicolaou (Pap) smears is significantly greater among HIV-positive women, and the course of cervical disease is more aggressive (Allen, 1990; Minkoff & Dehovitz, 1991). Although definitive gynecologic standards for HIV-infected women are pending further research, the nurse should recommend frequent Pap smears. Some clinicians are advising HIV-positive women to obtain Pap smears every 4 to 6 months and urging the liberal use of colposcopy (Allen, 1990). ~
Recent reports indicate tbat tbe rate of abnormal Papanicolaou smears is significantly greater among HWpositive women, and tbe course of cervical disease is more aggressive.
The woman should also be taught about the virulent and persistent course of sexually transmitted diseases when superimposed on HIV disease. The nurse should teach the woman the signs and symptoms of
March/Aprd 1992
these diseases and encourage frequent testing for individuals at risk.
care oftbe Infant Born Exposed to HIV Although the number of AIDS cases among children younger than 15 years accounts for fewer than 2% of the reported cases, the number of children with HIV disease can be expected to increase disproportionately in the coming years (Chu, Buehler, Oxtoby, & Kilbourne, 1991; Viscarello, 1990). Most pediatric patients have acquired AIDS perinatally, and 90% of these are black or Hispanic children (Viscarello, 1990). In New York and New Jersey, AIDS is the leading cause of death among black and Hispanic children aged 1 to 4 years. If trends continue, in the next few years HIV and AIDS will become one of the top five leading causes of death in children aged 1-4 nationwide (Chu et al., 1991). Perinatal transmission Perinatal transmission of HIV has been grouped into three potential mechanisms: transplacental, exposure to maternal blood and vaginal secretions at the time of delivery, and postnatal exposure to maternal secretions such as breast milk (Ellerbrock & Rogers, 1990). The evidence for transplacental transmission of HIV rests on the isolation of HIV from fetuses of varying gestational age (Coalition of Spanish Speaking Mental Health Organizations, 1990; Ellerbrock & Rogers, 1990). The rate of transmission attributed to the placental route is approximately 30%. Potential mechanisms for transplacental passage of the virus include infection of the syncytiotrophoblast layer, infection of the placental macrophage, and complete passage through the placenta to the fetal circulation (Valente & Main, 1990). During the time of delivery, exposure to maternal blood and vaginal secretions is possible because the neonate may have microscopic wounds that allow mixing of maternal and fetal blood, thus resulting in possible transmission of the virus. Although it has been suggested that fetal contact with maternal blood and vaginal secretions during vaginal delivery could infect the neonate, little empirical evidence is available to demonstrate that delivery by cesarean section simificantlv alters the risk of infection (Ellerbrock & Rggers, 1990; Holman, 1989; Viscarello,. 1990). Recent studies have implicated breast milk as an important route of HIV transmission in infants (Ellerbrock & Rogers, 1990; Stiehm &Vink, 1991). The virus has been detected in the cells and in the liquid portion of breast milk. Since only a minute amount of virus has
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actually been detected in the breast milk, some experts believe the virus is transmitted in the blood found on the surface of the nipple (Stiehm & Vink, 1991). HIV-positive women in countries where safe alternative means of infant feeding exist are advised not to breastfeed their infants. Women who are at high risk for HIV but who are still seronegative should receive counseling regarding the potential for seroconversion and transmission of the virus through breastfeeding (Mendez & Jule, 1990).
Immunologically compromised seropositive motbers witb T4 cell counts below 400/mtd bave been sbown to be more likely to transmit tbe HIV infection to tbeir newborns.
The rate of perinatal transmission, considering all three potential mechanisms, is estimated to be 2040% (Viscarello, 1990). This rate has been difficult to calculate because of the presence of passively acquired maternal HIV antibody for as long as 15 to 18 months in infected and noninfected infants born to HIV-positive women (Ellerbrock & Rogers, 1990). Current research is focused on identifying the predictors of HIV infection in exposed infants. Predictors that have been identified that appear to influence the vertical transmission of HIV include the level of immune suppression of the mother, continued exposure to the virus through needle sharing, and unprotected intercourse with an infected partner (Efantis, 1990). Immunologically compromised seropositive mothers with T4 cell counts below 400/mm3 have been shown to be more likely to transmit the HIV infection to their newborns. These mothers have more clinically advanced HIV disease and have higher titers of virus in their body fluids (Ryder et al., 1989).
atic during the nursery stay. Infants who are infected perinatally can be well for varying periods of time, some for several years, without developing clinical symptoms. Many children, however, will develop the symptoms and AIDS within the first 2 years of life (Boland, 1990). The median age for appearance of opportunistic infections is 9 months (Mendez & Jule, 1990). The Centers for Disease Control has developed a classification system to describe the spectrum of infection according to presentation of symptoms. Children are classified as indeterminate, asymptomatic, or symptomatic. Signs or symptoms usually detected in the first year of life include hepatosplenomegaly, lymphadenopathy, failure to thrive, neurodevelopmental abnormalities, persistent oral candidiasis, and extensive seborrheic dermatitis. Infants with severe immune dysfunction develop opportunistic infections such as chronic parotitis, lymphocytic interstitial pneumonitis, and serious recurrent bacterial infections, including Pneumocystis carinii pneumonia and meningitis (Mendez & Jule, 1990). Although controversial, reports in the literature describe a unique syndrome of infants born with HIV infection. This syndrome, HIV-induced embryopathy, includes features such as growth failure and craniofacia1 abnormalities and is thought to be related to the level of maternal viremia during fetal development. Those infants with more severe manifestations of the syndrome experience earlier and more severe infections and have a more fulminating course of their HIV disease (Efantis, 1990; Mendez & Jule, 1990).
Because of passively acquired maternal antibodies, all infants born to HIV-seropositive mothers will test positive on the enzyme-linked immunosorbent assay and Western blot test. Maternal antibodies can persist for as long as 15 months, making determination of the true infection status of the newborn extremely difficult (Coalition of Spanish Speaking Mental Health Organizations, 1990). Characteristically, the newborn who is subsequently found to be infected is asymptom-
Care of the infant i n the newborn nursery Since the majority of infants born to HIV-positive mothers have no obvious physical stigmata at birth, most of these neonates can be cared for in the regular nursery. Physical care of the neonates, including skin, cord, and eye care and administration of vitamin K, is accomplished in the same manner as with all newborns, using universal precautions. With the HIV-exposed newborn, the nurse must also consider the neonate as potentially uninfected and, therefore, should minimize the infant’s exposure to maternal blood and body fluids on the skin as well as to other contaminating microorganisms. Measures should be taken to protect the infant from infection. The infant’s skin should be cleansed with soap and water and then with alcohol before performing a heel stick or administering a vitamin K injection, to prevent possible contamination of the skin surface with body fluids that could be transmitted via the puncture site. Antimicrobial agents such as triple dye and bacitracin
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Postpartum Care in HIV Infection
should be applied to the cord using sterile gloves. The infant should be protected from skin abrasions that could lead to infection. Newborns frequently have long, sharp nails, and facial abrasions are common. Using mittens on the neonate or filing the nails with disposable emery boards could reduce this risk. Infants born exposed to HIV do not require isolation, unless specific indications such as enteritis, congenital syphilis, cytomegalovirus, or other viral infections are present.
with the HN-exposed newborn, the nurse must also consider tbe neonate as potentially uninfected and, therefore, should minimize the infant’s exposure to maternal blood and body jluids on tbe skin.
Early interactions between these newborns and their mothers should be facilitated and the nature and quality of this interaction evaluated. These motherneonate dyads may be at increased risk for disturbances in attachment. Factors such as physical illness, financial hardship, depression, drug abuse, and poor support systems may interfere with parenting ability and place the infant at risk for physical and emotional abuse and neglect. Unfortunately, many seropositive infants frequently require placement in foster care (Boland, 1990; Mendez & Jule, 1990).
Discharge planning The essential components of discharge planning for the postpartum HIV-positive woman and her infant born exposed to HIV include referral, collaboration, and instructing the mother in self-care measures, contraceptive counseling, safe sex practices, and prevention of infections. The mother should also be encouraged to seek gynecologic follow-up and medical follow-up for herself and her neonate with health professionals experienced in caring for seropositive women and infants. The mother or other caretaker should be taught about the significance of HIV testing and the potential signs of HIV-related illness in the infant. In addition, the frequency and content of pediatric follow-up should be emphasized. The mother should be instructed to watch for signs of symptomatic infection in the infant, such as oral thrush, increased irritability, poor feeding, fever, diarrhea, and cough. Educating
March/April 1992
the mother or caretaker about normal infant growth and development milestones should be emphasized so that developmental delay can be recognized early The pediatric follow-up includes periodic medical, developmental, and psychosocial evaluations and interventions. Antibody testing is conducted at regular intervals until 2 years of age. Other diagnostic testing may include viral culture, polymerase chain reaction, immunoglobulin A and immunoglobulin M, and p24 antigen assay (Coalition of Spanish Speaking Mental Health Organizations, 1990). Evaluation of the CD4 lymphocyte count is also frequently performed. Zidovudine therapy and P. carinii prophylaxis are instituted for infants with symptomatic HIV infection and may be offered to asymptomatic infants with CD4 counts below 500/mm3 (Kline & Shearer, 1991). Frequent screening for developmental delays, formal evaluations by developmental specialists, and referral for early intervention are provided. A modified immunization schedule is administered, substituting the inactivated virus for live virus vaccines (Salk for Sabin polio vaccine).
Conclasion A holistic nursing approach in the care of women with
HIV disease and their newborns during the postpartum period requires a thorough assessment of the perinatal history, early recognition of postpartum complications, teaching regarding self-care requirements, promotion of maternal-infant attachment, and referral and coordination of follow-up services. Knowledge and understanding about the impact of HIV infection on women and their infants and families continue to evolve. The lack of a well-developed nursing data base to guide the care for mothers with HIV disease and their newborns makes this health problem a priority for nursing research. Unique ways in which women and their infants will be affected by the AIDS epidemic must be assessed. Perinatal nurses must contribute to this evolving body of knowledge and must stay informed about the impact of HIV disease on reproductive health and the special care needs of affected clients.
The lack of a well-developed nursing data base to guide tbe care for mothers witb HIV disease and tbeir newborns makes tbis health problem a priority for nursing researcb.
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References Allen, M. (1990). Primary care of women infected with the human immunodeficiencyvirus. Obstetrics and Gynecology Clinics of North America, 17, 557-570. Boland, M. G. (1990). HIV infection in children. In B. Sinclair & A. McCormick (Eds.), NAACOG’s clinical issues in perinatal a n d women’s health nursing: AIDS in women (Vol. 1, pp. 53-59). Philadelphia: J. B. LippinCOtt.
Chu, S. Y., Buehler, J. W., Oxtoby, J. J., & Kilbourne, B. W. (1991). Impact of the human immunodeficiency virus epidemic on mortality in children, United States. Pediatrics, 87, 806-810. Coalition of Spanish Speaking Mental Health Organizations. (1990). Southwest Border Hispanic AIDS Project: Prevention of HIV. Washington, DC: Author. Diagnosis a n d management of HIV disease: A reference manual. (1988). New York: World Health Publications. Efantis,J. (1990). In-patient maternity care for the HIV-positive woman and her newborn. In B. Sinclair &A. McCormick (Eds.), NAACOG’s clinical issues in perinatal a n d women’s health nursing: AIDS in women (Vol. 1, pp. 47-52). Philadelphia: J. B. Lippincott. Ellerbrock, T. V., & Rogers, M. F. (1990). Epidemiology of human immunodeficiency virus infection in women in the United States. Obstetrics a n d Gynecology Clinics of North America, 17, 523-543. Fekety, S. E. (1989). Managing the HIV-positive patient and her newborn in a CNM service. Journal of Nurse-Midw g e y , 34, 253-258. Gloeb, D. J., O’Sullivan,J. O., & Efantis, J. (1988). Human immunodeficiencyvirus infection in women: The effects of human immunodeficiency virus on pregnancy. American Journal of Obstetrics a n d Gynecology, 159, 756761. Hatcher, R. A,, Stewart, F., Trussel, J., Kowal, D., Guest, F., Stewart, G., & Gates, W. (1990). Contraceptive technology (15th ed.). New York: Irvington Publishers. Holman, S. (1989). Epidemiology and transmission of HIV infection in women. Journal of Nurse-Midwifey, 34, 233-241. Kline, M. W., & Shearer, W. T. (1991). A national survey on the care of infants and children with human immunodeficiency virus infection. Journal of Pediatrics, 118, 817821. Mendez, H., & Jule, J. E. (1990). Care of the infant born exposed to human immunodeficiency virus. Obstetrics a n d Gynecology Clinics of North America, 17, 637-649. Minkoff, H. (1987). Care of the pregnant woman infected with human immunodeficiency virus. Journal of the American Medical Association, 258, 2714-2717. Minkoff, H., & Dehovitz, J. A. (1991). HIV in women. AIDS Clinical Care, 3, 17-19. Minkoff, H., Nanda, D., Mendez, R., & Fikrig, S. (1987). Pregnancies resulting in infants with acquired immunodeficiency syndrome or AIDS-related complex: Follow-
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up of mothers, children, and subsequently born siblings (Part 1). Obstetrics a n d Gynecology, 69,288-291. Pugliese, G., & Lampinen, T. (1989). Prevention of human immunodeficiency virus infection: Our responsibilities as health care professionals. American Journal of Infection Control, 17, 1-19. Raider, J. (1990). Safer sex for women. In B. Sinclair & A. McCormick (Eds.), NAACOG’s clinical issues inperinatal and women’s health nursing: AIDS in women (Vol. 1, pp. 28-32). Philadelphia: J. B. Lippincott. Ryder, R. W., Nsa, W., Hassig, S., Behets, M. R., Rayfield, M., Ekungola, B., Nelson, A. M., Mulenda, U., Francis, H., Mwandagalirwa, K., Davachi, F., Rogers, M., Nzilambi, N., Greenberg, A., Mann,J., Quinn, T., Piot, P., & Curran, J. (1989). Perinatal transmission of the human immunodeficiency virus type I to infants of seropositive women in Zaire. New EnglandJournal of Medicine, 320, 16371642. Stiehm, E. R., & Vink, P. (1991). Transmission of human immunodeficiency virus infection by breast-feeding. Journal of Pediatrics, 118, 410-412. Valente, P., & Main, E. K. (1990). Role of the placenta in perinatal transmission of HIV. Obstetrics and Gynecology Clinics of North America, 17, 607-615. Viscarello, R. (1990). AIDS: Natural history and prognosis. Obstetrics a n d Gynecology Clinics of North America, 17, 545-555. Wilson, M. (1991). Traveling with HIV. AIDS Clinical Care, 3, 49-51, 56. Address for correspondence: Mindy B. Tinkle, RNC, PhD, WHCNP, University of Texas at El Paso, College of Nursing and Allied Health, 1101 N. Campbell St., El Paso, TX 79902. horma Bastin is a nurse clinician in the newborn nursery and pediatrics at Providence Memortal Hospital in El Paso, Texas, and a graduate student at the University of Texas at El Paso, College of Nursing and Allied Health. Olga Winter Tamayo is a staff nurse in the postpartum untt at Providence Memorial Hospital in El Paso. Ms. Tamayo ts a graduate student at the University of Texas at El Paso, College of Nursing and Allied Health, and is a member of NAACOG. Mindy B. Tinkle is an associate professor at the Universityof Texas at El Paso, College of Nursing and Allied Health. Dr. Tinkle is a member of NAACOG.
Maria Alvarez Amaya is an assistantprofessor at the University of Texas at El Paso, College of Nursing and Allied Health. Dr. Amaya is a member of NAACOG. deticia R. Trejo is a maternal-child patient educator at Providence Memorial Hospital tn El Paso. Cynthia Herrera is the nurse manager in the newborn nursery at Providence Memorial Hospital in El Paso.
Volume 21 Number 2
Posfpartum Care in HIV Infection
Date/Nurse Initials
Appendix: Discharge Planning Guidelines All items in these guidelines should be discussed with the woman prior to hospital discharge and should be used in conjunction with the postpartum discharge plan for well women. These guidelines may also be used to identify needed services and referrals. Patient name Medical record number Date/Nurse Initials Self-care A. Handling of perineal pads B. Disinfection of blood spill sites C. Prevention of infection of the newborn D. Avoidance of shared razors or toothbrushes I1 Safer sex practices A. Inform sexual partner(s) of HIV status B. Safe sex techniques C. Avoid high-risk sex practices D. Use latex condoms and spermicide 111 Avoidance of drug abuse A. Refer to drug treatment program B. Avoid sharing needles C. Safer needle use IV Contraceptive counseling A. Review contraceptive alternatives B. Facilitate contraceptive decision making I
V. Avoidance of infection A. Cooking and eating
precautions B. Pet precautions C. Traveling guidelines
VI. Medical/gynecologic follow-up A. Refer to primary care physician expert in management of HIV disease B. Signs and symptoms of HIVrelated illness C. Frequent Pap smear and STD screening D. Avoid donating blood E. Inform health-care workers of HIV status VII. Infant care and pediatric follow-up A. Refer to pediatrician expert in management of HIV disease B. Significance of HIV testing C. Signs and symptoms of HIVrelated illness D. Normal growth and development milestones E. Frequency and content of pediatric follow-up VIII. Support systems A. Assess social network B. Refer to support group(s) C. Refer to appropriate community services IX. Other patient-teaching needs identified
Notice to Copiers Authorization to photocopy items for internalor personal use, or the internalor personal use of specific dents, is granted by NAACOG, a division of the American College of Obstetricians and Gynecdogists, for libraries and other users registered with the Copyright Clearance Center (CCC), provided that the base fee of $3 per copy is paid directly to CCC. 21 Congress St., Salem, MA 01970.0884-2175192 $3.
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omen of childbearing age and their children are an emergent population of HIVinfected individuals. Nurses in the postpartum and newborn nursery settings assume critical roles in providing physical care, educating the woman, providing anticipatory guidance, and planning and coordinating follow-up services. The nursing management of the HIV-seropositive woman during the postpartum period and the care of her infant born exposed to HIV are discussed in this article. The appendix outlines the information that should be provided or reinforced during the hospital stay and the follow-up services that are required after discharge.
H W Disease
c a r e of the HW-Infected Woman During the Puerperium
NORMA BASTIN, RNC, BSN OLGA W I N T E R TAMAYO, RN, B S N M I N D Y B. T I N K L E , R N C , P H D , W H C N P MARIA ALVAREZ AMAYA, RN, P H D L E T I C I A R. T R E J O , R N C , B S N
and Pregnancy
Part 3. Postpartum Care of the HWPositive Woman and Hm Nmbom For women with HIV infection, physical and psychosocial adaptation during the postpartum period is fraught with ambivalence. On the one hand, there is the j o y ofparenthood, but on the other, the burden of a chronic, terminal illness and the possibility of having an infected newborn. The nursing care of the HIV. positive woman and her newborn is discussed. Guidelines for hospital discharge teaching are included.
Accepted: October 1991
March/April 1992
Physical care The postpartum nursing care of the HIV-infected woman will include the care commonly delivered to all women and the special care needs of HIV-positive women. The postpartum nurse caring for these women must be especially observant of signs and symptoms of infection or hemorrhage, or both. HIVseropositive women with varying degrees of immunosuppression may be at increased risk for postpartum infections and poor wound healing. Several studies have documented an increased incidence of postpartum infection, such as endometritis and puerperal febrile illness, among HIV-positive women (Gloeb, O'Sullivan, & Efantis, 1988; Minkoff, Nanda, Mendez, & Fikrig, 1987). These women are also at increased risk for genitourinary tract infections and may harbor a variety of sexually transmitted diseases (Fekety, 1989; Gloeb et al., 1988). Hemorrhage is another potential postpartum complication among HIV-positive women. HIV-related thrombocytopenia may predispose these women to severe postpartum bleeding. Referral and collaboration Women with HIV infection who are admitted to the postpartum unit must be under the care of or referred to a primary care physician experienced in the management of HIV disease. Women exhibiting severe compromise may need to be transferred to a specialized HIV or other infectious disease care unit (Minkoff, 1987). Women at varying stages of HIV disease may need to be referred to psychosocial services, support groups in the community, or substance abuse
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treatment programs if they are not already using such services. Self-care measures Teaching the client about self-care measures during hospitalization and after discharge is a priority. The discussion of perineal care should include proper handling of perineal pads and blood spills. A dilute household bleach (1 part bleach to 10 parts water) will effectively disinfect a blood spill site (Efantis, 1990). Educating the mother in appropriate infection control measures to use, such as good hand washing and avoiding body fluid exchange, when she interacts with her infant is important. Nurses can instruct the woman to report a persistent spiking fever; a change in the character of the lochia, such as foul smell; the return to bright red bleeding; or an excessive amount of bleeding. The nurse should also instruct the woman to report symptoms that may indicate worsening of HIV disease, such as fatigue, anorexia, weight loss, sore throat, cough, dermatologic disorders, or unusual vaginal discharge (Diagnosis and Management, 1988; Minkoff, 1987). Tampons should not be used because they may cause small vaginal abrasions and provide a port of entry for microorganisms. Douching should be avoided also, because this practice may actually encourage the growth of pathogens.
estrogens inhibit cell-mediated immune responses. The sponge, the diaphragm, and intrauterine devices are foreign objects that pose a potential risk for causing abrasions and providing a port of entry for HIV. Sterilization of neither the woman nor the man provides protection against the transmission of HIV (Hatcher et al., 1990). Thus, a combination of oral contraceptives and latex condoms with spermicide, Norplant implants and latex condoms with spermicide, or tuba1 ligation or vasectomy and latex condoms with spermicide may be recommended. Female condoms and abstinence can be offered as alternatives to women whose partners will not use condoms (Hatcher et al., 1990).
women with HIV disease face the dilemma that a contraceptive method that prevents pregnancy does not necessarily prevent the heterosexual transmission of HIV and that a contraceptive method that prevents transmission of HIV does not necessarily prevent pregnancy.
Sexual practices that carry a high risk of HIV transmission are anal or vaginal intercourse and fellatio, all with ejaculation and without a condom, and oral-anal contact. The degree of risk for many sexual practices, such as cunnilingus, deep kissing, sharing of sexual devices, and urination on or in the partner’s body is uncertain (Raider, 1990). Risk-reduction strategies must involve modification of risk-related behaviors. Safe sex practices must be discussed. These include hugging, massage, body rubbing, dry kissing, masturbation, shared fantasies, and erotic talking (Raider, 1990). Safe sex practices primarily involve using a condom. The woman should be instructed in the correct use of condoms, preferably with nonoxynol9 spermicide, with each sexual encounter. The risk of condom breakage can be reduced by using sufficient watersoluble lubricant. Because sexual activity may be unplanned, especially if the participants are under the influence of drugs or alcohol, the nurse can recommend having a condom available at all times (Pugliese & Lampinen, 1989).
Contraceptive counseling and safe sex practices The postpartum woman with HIV infection should be counseled on contraception and safe sex. This information is equally important for seropositive women to minimize the viral load of HIV, decrease exposure to sexually transmitted organisms that may hasten the progress of HIV disease, and decrease the risk of transmitting the infection to others. Women with HIV disease face the dilemma that a contraceptive method that prevents pregnancy does not necessarily prevent the heterosexual transmission of HIV and that a contraceptive method that prevents transmission of HIV does not necessarily prevent pregnancy. Latex condoms provide a physical barrier to HIV, and nonoxynol 9 inactivates HIV at the concentrations present in most spermicidal preparations. Using condoms exclusively as a means of protection, however, can result in an unplanned pregnancy (Allen, 1990). Oral contraceptives decrease the amount and time of menstrual flow, thus decreasing exposure time of the denuded endometrium to the HIV antigen and also decreasing the amount of HIV-infected menstrual blood exposure for the woman’s sexual partner. On the other hand, no evidence is available showing that
Avoidance of infections The woman should be instructed on practices to avoid infections other than those sexually acquired. Cook-
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ing and eating practices involving the consumption of raw meat and raw eggs should be avoided to decrease the risk of Salmonella infection. If a cat is in the household, the woman should be encouraged to avoid handling the litter box to decrease the risk of exposure to toxoplasmosis. The patient should avoid sharing toothbrushes and razors that can be contaminated with blood (Wilson, 1991). Needle-sharing precautions should be reviewed, if indicated. Special precautions such as vaccines and chemoprophylaxis may be warranted when foreign travel is planned, to avoid enteric, respiratory, and vector-borne infections (Wilson, 1991). Nutrition and hydration The importance of good nutrition and hydration must be emphasized. This is especially important for women experiencing gastrointestinal side effects of drug therapy, women who are abusing chemical substances, or women exhibiting advanced HIV disease. A referral to a dietitian may be indicated. Gynecologicfollow-up Because preliminary data indicate that the clinical manifestations of gynecologic disease may be altered by HIV infection, women with such diseases require more intensive gynecologic monitoring and more aggressive treatment of any infectious process (Minkoff & Dehovitz, 1991). Recent reports indicate that the rate of abnormal Papanicolaou (Pap) smears is significantly greater among HIV-positive women, and the course of cervical disease is more aggressive (Allen, 1990; Minkoff & Dehovitz, 1991). Although definitive gynecologic standards for HIV-infected women are pending further research, the nurse should recommend frequent Pap smears. Some clinicians are advising HIV-positive women to obtain Pap smears every 4 to 6 months and urging the liberal use of colposcopy (Allen, 1990). ~
Recent reports indicate tbat tbe rate of abnormal Papanicolaou smears is significantly greater among HWpositive women, and tbe course of cervical disease is more aggressive.
The woman should also be taught about the virulent and persistent course of sexually transmitted diseases when superimposed on HIV disease. The nurse should teach the woman the signs and symptoms of
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these diseases and encourage frequent testing for individuals at risk.
care oftbe Infant Born Exposed to HIV Although the number of AIDS cases among children younger than 15 years accounts for fewer than 2% of the reported cases, the number of children with HIV disease can be expected to increase disproportionately in the coming years (Chu, Buehler, Oxtoby, & Kilbourne, 1991; Viscarello, 1990). Most pediatric patients have acquired AIDS perinatally, and 90% of these are black or Hispanic children (Viscarello, 1990). In New York and New Jersey, AIDS is the leading cause of death among black and Hispanic children aged 1 to 4 years. If trends continue, in the next few years HIV and AIDS will become one of the top five leading causes of death in children aged 1-4 nationwide (Chu et al., 1991). Perinatal transmission Perinatal transmission of HIV has been grouped into three potential mechanisms: transplacental, exposure to maternal blood and vaginal secretions at the time of delivery, and postnatal exposure to maternal secretions such as breast milk (Ellerbrock & Rogers, 1990). The evidence for transplacental transmission of HIV rests on the isolation of HIV from fetuses of varying gestational age (Coalition of Spanish Speaking Mental Health Organizations, 1990; Ellerbrock & Rogers, 1990). The rate of transmission attributed to the placental route is approximately 30%. Potential mechanisms for transplacental passage of the virus include infection of the syncytiotrophoblast layer, infection of the placental macrophage, and complete passage through the placenta to the fetal circulation (Valente & Main, 1990). During the time of delivery, exposure to maternal blood and vaginal secretions is possible because the neonate may have microscopic wounds that allow mixing of maternal and fetal blood, thus resulting in possible transmission of the virus. Although it has been suggested that fetal contact with maternal blood and vaginal secretions during vaginal delivery could infect the neonate, little empirical evidence is available to demonstrate that delivery by cesarean section simificantlv alters the risk of infection (Ellerbrock & Rggers, 1990; Holman, 1989; Viscarello,. 1990). Recent studies have implicated breast milk as an important route of HIV transmission in infants (Ellerbrock & Rogers, 1990; Stiehm &Vink, 1991). The virus has been detected in the cells and in the liquid portion of breast milk. Since only a minute amount of virus has
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actually been detected in the breast milk, some experts believe the virus is transmitted in the blood found on the surface of the nipple (Stiehm & Vink, 1991). HIV-positive women in countries where safe alternative means of infant feeding exist are advised not to breastfeed their infants. Women who are at high risk for HIV but who are still seronegative should receive counseling regarding the potential for seroconversion and transmission of the virus through breastfeeding (Mendez & Jule, 1990).
Immunologically compromised seropositive motbers witb T4 cell counts below 400/mtd bave been sbown to be more likely to transmit tbe HIV infection to tbeir newborns.
The rate of perinatal transmission, considering all three potential mechanisms, is estimated to be 2040% (Viscarello, 1990). This rate has been difficult to calculate because of the presence of passively acquired maternal HIV antibody for as long as 15 to 18 months in infected and noninfected infants born to HIV-positive women (Ellerbrock & Rogers, 1990). Current research is focused on identifying the predictors of HIV infection in exposed infants. Predictors that have been identified that appear to influence the vertical transmission of HIV include the level of immune suppression of the mother, continued exposure to the virus through needle sharing, and unprotected intercourse with an infected partner (Efantis, 1990). Immunologically compromised seropositive mothers with T4 cell counts below 400/mm3 have been shown to be more likely to transmit the HIV infection to their newborns. These mothers have more clinically advanced HIV disease and have higher titers of virus in their body fluids (Ryder et al., 1989).
atic during the nursery stay. Infants who are infected perinatally can be well for varying periods of time, some for several years, without developing clinical symptoms. Many children, however, will develop the symptoms and AIDS within the first 2 years of life (Boland, 1990). The median age for appearance of opportunistic infections is 9 months (Mendez & Jule, 1990). The Centers for Disease Control has developed a classification system to describe the spectrum of infection according to presentation of symptoms. Children are classified as indeterminate, asymptomatic, or symptomatic. Signs or symptoms usually detected in the first year of life include hepatosplenomegaly, lymphadenopathy, failure to thrive, neurodevelopmental abnormalities, persistent oral candidiasis, and extensive seborrheic dermatitis. Infants with severe immune dysfunction develop opportunistic infections such as chronic parotitis, lymphocytic interstitial pneumonitis, and serious recurrent bacterial infections, including Pneumocystis carinii pneumonia and meningitis (Mendez & Jule, 1990). Although controversial, reports in the literature describe a unique syndrome of infants born with HIV infection. This syndrome, HIV-induced embryopathy, includes features such as growth failure and craniofacia1 abnormalities and is thought to be related to the level of maternal viremia during fetal development. Those infants with more severe manifestations of the syndrome experience earlier and more severe infections and have a more fulminating course of their HIV disease (Efantis, 1990; Mendez & Jule, 1990).
Because of passively acquired maternal antibodies, all infants born to HIV-seropositive mothers will test positive on the enzyme-linked immunosorbent assay and Western blot test. Maternal antibodies can persist for as long as 15 months, making determination of the true infection status of the newborn extremely difficult (Coalition of Spanish Speaking Mental Health Organizations, 1990). Characteristically, the newborn who is subsequently found to be infected is asymptom-
Care of the infant i n the newborn nursery Since the majority of infants born to HIV-positive mothers have no obvious physical stigmata at birth, most of these neonates can be cared for in the regular nursery. Physical care of the neonates, including skin, cord, and eye care and administration of vitamin K, is accomplished in the same manner as with all newborns, using universal precautions. With the HIV-exposed newborn, the nurse must also consider the neonate as potentially uninfected and, therefore, should minimize the infant’s exposure to maternal blood and body fluids on the skin as well as to other contaminating microorganisms. Measures should be taken to protect the infant from infection. The infant’s skin should be cleansed with soap and water and then with alcohol before performing a heel stick or administering a vitamin K injection, to prevent possible contamination of the skin surface with body fluids that could be transmitted via the puncture site. Antimicrobial agents such as triple dye and bacitracin
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should be applied to the cord using sterile gloves. The infant should be protected from skin abrasions that could lead to infection. Newborns frequently have long, sharp nails, and facial abrasions are common. Using mittens on the neonate or filing the nails with disposable emery boards could reduce this risk. Infants born exposed to HIV do not require isolation, unless specific indications such as enteritis, congenital syphilis, cytomegalovirus, or other viral infections are present.
with the HN-exposed newborn, the nurse must also consider tbe neonate as potentially uninfected and, therefore, should minimize the infant’s exposure to maternal blood and body jluids on tbe skin.
Early interactions between these newborns and their mothers should be facilitated and the nature and quality of this interaction evaluated. These motherneonate dyads may be at increased risk for disturbances in attachment. Factors such as physical illness, financial hardship, depression, drug abuse, and poor support systems may interfere with parenting ability and place the infant at risk for physical and emotional abuse and neglect. Unfortunately, many seropositive infants frequently require placement in foster care (Boland, 1990; Mendez & Jule, 1990).
Discharge planning The essential components of discharge planning for the postpartum HIV-positive woman and her infant born exposed to HIV include referral, collaboration, and instructing the mother in self-care measures, contraceptive counseling, safe sex practices, and prevention of infections. The mother should also be encouraged to seek gynecologic follow-up and medical follow-up for herself and her neonate with health professionals experienced in caring for seropositive women and infants. The mother or other caretaker should be taught about the significance of HIV testing and the potential signs of HIV-related illness in the infant. In addition, the frequency and content of pediatric follow-up should be emphasized. The mother should be instructed to watch for signs of symptomatic infection in the infant, such as oral thrush, increased irritability, poor feeding, fever, diarrhea, and cough. Educating
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the mother or caretaker about normal infant growth and development milestones should be emphasized so that developmental delay can be recognized early The pediatric follow-up includes periodic medical, developmental, and psychosocial evaluations and interventions. Antibody testing is conducted at regular intervals until 2 years of age. Other diagnostic testing may include viral culture, polymerase chain reaction, immunoglobulin A and immunoglobulin M, and p24 antigen assay (Coalition of Spanish Speaking Mental Health Organizations, 1990). Evaluation of the CD4 lymphocyte count is also frequently performed. Zidovudine therapy and P. carinii prophylaxis are instituted for infants with symptomatic HIV infection and may be offered to asymptomatic infants with CD4 counts below 500/mm3 (Kline & Shearer, 1991). Frequent screening for developmental delays, formal evaluations by developmental specialists, and referral for early intervention are provided. A modified immunization schedule is administered, substituting the inactivated virus for live virus vaccines (Salk for Sabin polio vaccine).
Conclasion A holistic nursing approach in the care of women with
HIV disease and their newborns during the postpartum period requires a thorough assessment of the perinatal history, early recognition of postpartum complications, teaching regarding self-care requirements, promotion of maternal-infant attachment, and referral and coordination of follow-up services. Knowledge and understanding about the impact of HIV infection on women and their infants and families continue to evolve. The lack of a well-developed nursing data base to guide the care for mothers with HIV disease and their newborns makes this health problem a priority for nursing research. Unique ways in which women and their infants will be affected by the AIDS epidemic must be assessed. Perinatal nurses must contribute to this evolving body of knowledge and must stay informed about the impact of HIV disease on reproductive health and the special care needs of affected clients.
The lack of a well-developed nursing data base to guide tbe care for mothers witb HIV disease and tbeir newborns makes tbis health problem a priority for nursing researcb.
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References Allen, M. (1990). Primary care of women infected with the human immunodeficiencyvirus. Obstetrics and Gynecology Clinics of North America, 17, 557-570. Boland, M. G. (1990). HIV infection in children. In B. Sinclair & A. McCormick (Eds.), NAACOG’s clinical issues in perinatal a n d women’s health nursing: AIDS in women (Vol. 1, pp. 53-59). Philadelphia: J. B. LippinCOtt.
Chu, S. Y., Buehler, J. W., Oxtoby, J. J., & Kilbourne, B. W. (1991). Impact of the human immunodeficiency virus epidemic on mortality in children, United States. Pediatrics, 87, 806-810. Coalition of Spanish Speaking Mental Health Organizations. (1990). Southwest Border Hispanic AIDS Project: Prevention of HIV. Washington, DC: Author. Diagnosis a n d management of HIV disease: A reference manual. (1988). New York: World Health Publications. Efantis,J. (1990). In-patient maternity care for the HIV-positive woman and her newborn. In B. Sinclair &A. McCormick (Eds.), NAACOG’s clinical issues in perinatal a n d women’s health nursing: AIDS in women (Vol. 1, pp. 47-52). Philadelphia: J. B. Lippincott. Ellerbrock, T. V., & Rogers, M. F. (1990). Epidemiology of human immunodeficiency virus infection in women in the United States. Obstetrics a n d Gynecology Clinics of North America, 17, 523-543. Fekety, S. E. (1989). Managing the HIV-positive patient and her newborn in a CNM service. Journal of Nurse-Midw g e y , 34, 253-258. Gloeb, D. J., O’Sullivan,J. O., & Efantis, J. (1988). Human immunodeficiencyvirus infection in women: The effects of human immunodeficiency virus on pregnancy. American Journal of Obstetrics a n d Gynecology, 159, 756761. Hatcher, R. A,, Stewart, F., Trussel, J., Kowal, D., Guest, F., Stewart, G., & Gates, W. (1990). Contraceptive technology (15th ed.). New York: Irvington Publishers. Holman, S. (1989). Epidemiology and transmission of HIV infection in women. Journal of Nurse-Midwifey, 34, 233-241. Kline, M. W., & Shearer, W. T. (1991). A national survey on the care of infants and children with human immunodeficiency virus infection. Journal of Pediatrics, 118, 817821. Mendez, H., & Jule, J. E. (1990). Care of the infant born exposed to human immunodeficiency virus. Obstetrics a n d Gynecology Clinics of North America, 17, 637-649. Minkoff, H. (1987). Care of the pregnant woman infected with human immunodeficiency virus. Journal of the American Medical Association, 258, 2714-2717. Minkoff, H., & Dehovitz, J. A. (1991). HIV in women. AIDS Clinical Care, 3, 17-19. Minkoff, H., Nanda, D., Mendez, R., & Fikrig, S. (1987). Pregnancies resulting in infants with acquired immunodeficiency syndrome or AIDS-related complex: Follow-
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up of mothers, children, and subsequently born siblings (Part 1). Obstetrics a n d Gynecology, 69,288-291. Pugliese, G., & Lampinen, T. (1989). Prevention of human immunodeficiency virus infection: Our responsibilities as health care professionals. American Journal of Infection Control, 17, 1-19. Raider, J. (1990). Safer sex for women. In B. Sinclair & A. McCormick (Eds.), NAACOG’s clinical issues inperinatal and women’s health nursing: AIDS in women (Vol. 1, pp. 28-32). Philadelphia: J. B. Lippincott. Ryder, R. W., Nsa, W., Hassig, S., Behets, M. R., Rayfield, M., Ekungola, B., Nelson, A. M., Mulenda, U., Francis, H., Mwandagalirwa, K., Davachi, F., Rogers, M., Nzilambi, N., Greenberg, A., Mann,J., Quinn, T., Piot, P., & Curran, J. (1989). Perinatal transmission of the human immunodeficiency virus type I to infants of seropositive women in Zaire. New EnglandJournal of Medicine, 320, 16371642. Stiehm, E. R., & Vink, P. (1991). Transmission of human immunodeficiency virus infection by breast-feeding. Journal of Pediatrics, 118, 410-412. Valente, P., & Main, E. K. (1990). Role of the placenta in perinatal transmission of HIV. Obstetrics and Gynecology Clinics of North America, 17, 607-615. Viscarello, R. (1990). AIDS: Natural history and prognosis. Obstetrics a n d Gynecology Clinics of North America, 17, 545-555. Wilson, M. (1991). Traveling with HIV. AIDS Clinical Care, 3, 49-51, 56. Address for correspondence: Mindy B. Tinkle, RNC, PhD, WHCNP, University of Texas at El Paso, College of Nursing and Allied Health, 1101 N. Campbell St., El Paso, TX 79902. horma Bastin is a nurse clinician in the newborn nursery and pediatrics at Providence Memortal Hospital in El Paso, Texas, and a graduate student at the University of Texas at El Paso, College of Nursing and Allied Health. Olga Winter Tamayo is a staff nurse in the postpartum untt at Providence Memorial Hospital in El Paso. Ms. Tamayo ts a graduate student at the University of Texas at El Paso, College of Nursing and Allied Health, and is a member of NAACOG. Mindy B. Tinkle is an associate professor at the Universityof Texas at El Paso, College of Nursing and Allied Health. Dr. Tinkle is a member of NAACOG.
Maria Alvarez Amaya is an assistantprofessor at the University of Texas at El Paso, College of Nursing and Allied Health. Dr. Amaya is a member of NAACOG. deticia R. Trejo is a maternal-child patient educator at Providence Memorial Hospital tn El Paso. Cynthia Herrera is the nurse manager in the newborn nursery at Providence Memorial Hospital in El Paso.
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Date/Nurse Initials
Appendix: Discharge Planning Guidelines All items in these guidelines should be discussed with the woman prior to hospital discharge and should be used in conjunction with the postpartum discharge plan for well women. These guidelines may also be used to identify needed services and referrals. Patient name Medical record number Date/Nurse Initials Self-care A. Handling of perineal pads B. Disinfection of blood spill sites C. Prevention of infection of the newborn D. Avoidance of shared razors or toothbrushes I1 Safer sex practices A. Inform sexual partner(s) of HIV status B. Safe sex techniques C. Avoid high-risk sex practices D. Use latex condoms and spermicide 111 Avoidance of drug abuse A. Refer to drug treatment program B. Avoid sharing needles C. Safer needle use IV Contraceptive counseling A. Review contraceptive alternatives B. Facilitate contraceptive decision making I
V. Avoidance of infection A. Cooking and eating
precautions B. Pet precautions C. Traveling guidelines
VI. Medical/gynecologic follow-up A. Refer to primary care physician expert in management of HIV disease B. Signs and symptoms of HIVrelated illness C. Frequent Pap smear and STD screening D. Avoid donating blood E. Inform health-care workers of HIV status VII. Infant care and pediatric follow-up A. Refer to pediatrician expert in management of HIV disease B. Significance of HIV testing C. Signs and symptoms of HIVrelated illness D. Normal growth and development milestones E. Frequency and content of pediatric follow-up VIII. Support systems A. Assess social network B. Refer to support group(s) C. Refer to appropriate community services IX. Other patient-teaching needs identified
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