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Keywords:

  • cerebral palsy;
  • deep vein thrombosis;
  • pulmonary embolism;
  • postpartum care

Abstract

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Pregnancy can be challenging for women with cerebral palsy. Physical limitations and comorbidities can predispose them to complications during pregnancy, such as deep vein thrombosis and pulmonary embolism, making their care needs more complex. A multidisciplinary care plan, as well as clear and effective communication among different health care providers, will help ensure safe and optimal postpartum care of women with cerebral palsy and their newborns.

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I would soon discover, along with other nurses on the unit, the limitations of my skills, knowledge, resources and even my ability to communicate effectively. Our experience with Kayla and her family taught us all some valuable lessons (see Box 1 for case).

Box 1. The Case of Kayla

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About Cerebral Palsy

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Cerebral palsy is an umbrella term used to describe a complex group of disorders of movement, posture and coordination, often resulting from damage to the white matter of the brain that can occur before, during or after birth. There is permanent but not progressive impairment of varying degrees, depending on the nature of the insult and the gestational age at which it occurs. It's somewhat discouraging that despite the advent of electronic fetal monitoring, improved technologies and advancements in perinatal care, the incidence of cerebral palsy has remained constant over the past several decades.

Historically, cerebral palsy has been associated with suboptimal care during labor and delivery, resulting in perinatal asphyxia and neonatal encephalopathy. However, an increasing body of evidence supports a multifactorial, antenatal etiology in the majority of cases of cerebral palsy. It's well documented in the literature that prematurity and low birth weight are risk factors for cerebral palsy. Maternal fever and infection are also significant risk factors for cerebral palsy. Chorioamnionitis, which can be either a clinical manifestation or histologic, increases the likelihood of cerebral palsy. Pro-inflammatory cytokines produced by intrauterine tissue in response to microbial products can induce preterm labor and birth. A fetal inflammatory response can occur as well, and this is associated with an increased risk of neurologic deficits (Romero, Gotsch, Pineles, & Kusanovic, 2007). Also being investigated as risk factors are thombophilias that are inherited and possibly undiagnosed (Gibson, MacLennon, Goldwater, & Dekker, 2003).

Cerebral palsy is usually diagnosed between 18 months and 3 years of age, when parents become aware of developmental delays and abnormal posturing or gait, such as walking on toes or a crouched or “scissor” gait. Hypotonia may be seen in early infancy. Physicians will first rule out other disorders that can mimic signs of cerebral palsy, such as metabolic disorders or coagulation disorders causing fetal or neonatal stroke.

Types of Cerebral Palsy

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Cerebral palsy is classified according to the type of movement disorder; however, there can be overlapping clinical features (Hayes, 2010). Several syndromes are identified, each with subclassifications.

Spastic Cerebral Palsy

Spastic cerebral palsy results in the inability of the muscle to relax. Clinical features include slow, effortful voluntary movements, impaired fine motor functions and hypertonia/hyperflexia. There are variable degrees of impairment, ranging from mild to severe. Spastic cerebral palsy is further classified as diplegic, hemiplegic or quadriplegic. Spastic diplegia is the most common form of cerebral palsy in preterm infants. This subtype affects primarily the lower extremities, although there may be upper limb involvement. There may be flexion at the knees and elbows, and flexion adduction and internal rotation of the hips. These children may also experience some degree of sensory loss. More commonly seen in term infants is spastic hemiplegia (Nelson & Chang, 2008). With this type of spastic cerebral palsy, the arm is typically more affected than the leg. Spastic hemiplegia often is the result of fetal or neonatal stroke. Spastic quadriplegia is the most severe manifestation. These children are usually mentally challenged and often have respiratory and feeding difficulties.

Dyskinetic Cerebral Palsy

A second classification of cerebral palsy, the dyskinetic type, is typically seen in term infants and results from birth asphyxia. Dyskinetic cerebral palsy accounts for less than 10 percent of all cases (Gibson et al., 2003). Individuals with dyskinetic cerebral palsy are unable to control the voluntary movement of muscles and may exhibit tremors and uncontrollable writhing movements of their hands, legs and feet (Hayes, 2010).

Treatments

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Treatment modalities for cerebral palsy include physical therapy, occupational therapy, speech and language therapy, orthotics and assistive devices. Medications are often prescribed for spasticity. Botulinum toxin injections have been used since the 1990s. Each injection produces therapeutic effects for 3 months (National Institute of Neurological Disorders and Stroke [NINDS], 2011). Intrathecal baclofen via implantable pump is sometimes ordered as a muscle relaxant (NINDS, 2011).

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Secondary Conditions

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

People with cerebral palsy may have associated or secondary conditions. Epilepsy, mental retardation and musculoskeletal anomalies, such as subluxation of the hip and scoliosis, are commonly seen. Speech, hearing and visual impairments are also more common in this population (Hayes, 2010). Chronic pulmonary disease is the leading cause of death in people with cerebral palsy, usually due to recurrent aspiration in patients with the more severe classifications of cerebral palsy.

Prevention

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Research on cerebral palsy is often aimed at prevention and several studies have demonstrated promising results. A study sponsored by the National Institutes of Health (Rouse et al., 2008) found that magnesium sulfate used to treat preterm labor reduced the risk of cerebral palsy by half. Nelson and Chang (2008) cite two clinical studies that linked therapeutic hypothermia in term infants to lowered risk of cerebral palsy. In another study of preterm infants with persistent pulmonary hypertension, it was found that administration of nitric oxide with 100 percent oxygen was associated with a lowered risk of cerebral palsy at 3 years of age (Nelson & Chang, 2008). Research funded by NINDS is focusing on understanding more about neurotrophins, which are substances that protect the brain from damage. This knowledge could be utilized to prevent cerebral palsy (NINDS, 2011).

Health Care Challenges for Women With Disabilities

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Great strides have been made to improve the autonomy of disabled persons since the passage of the Americans with Disabilities Act of 1990. However, women with disabilities may still encounter numerous barriers when seeking reproductive care (Signore, Spong, Krotoski, Shinowara, & Blackwell, 2011). It can be difficult to locate a provider with the skills, staff and specialized equipment necessary to accommodate women with disabilities. Transportation and compliance with frequent visits to multiple providers, not all of whom accept Medicaid payments, can be challenging, if not overwhelming for many patients (Signore et al.).

Farber (2000), Signore et al. (2011) and Barber (2008) studied attitudinal barriers experienced by women with disabilities and found that cultural beliefs and values may influence providers to wrongly assume that women with disabilities are asexual and incapable of parenting. Signore and colleagues documented that many women with disabilities report a lack of support from providers during pregnancy.

Many women with disabilities report a lack of support from providers during pregnancy

Perinatal nurses may find caring for women with disabilities daunting, as their care is complicated. They may also lack knowledge of the care needs associated with specific disabilities, such as cerebral palsy. Barber (2008) notes that women want an identity apart from their disability and some women resent being “labeled.” Barber further asserts that women with disabilities don't see themselves as victims; they want to be treated as pregnant women or mothers.

Cerebral Palsy and Pregnancy

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Although pregnancy and parenthood can be challenging for any woman, those with a physical disability may encounter seemingly insurmountable barriers. Hormonal and physiologic changes of pregnancy, compounded with weight gain and altered center of gravity, can further decrease mobility and functioning and increase the risk for fall and injury. Additionally, comorbidities and disease manifestations associated with cerebral palsy place women with cerebral palsy at risk for pregnancy complications, including DVT. These women become high-risk obstetric patients with complex care needs.

Comorbidities

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Henderson et al. (2009) documented that women with cerebral palsy have a higher incidence of obesity, gastroesophageal reflux, urinary tract infections, dysphagia and osteoporosis. Skin ulcerations, respiratory compromise, interpersonal abuse, substance abuse and mood disorders are more common among this population as well (Signore et al., 2011). Women with cerebral palsy often have poor dental health due, in part, to difficulty finding dentists skilled in treating patients with spasticity (Henderson et al., 2009). Adults with disabilities have a depression rate three to four times higher than the population in general. Additionally, many adults with cerebral palsy and other disabilities are less likely to engage in community activities and may lack social support (NINDS, 2011). Because women with cerebral palsy may be mentally challenged or sensory impaired, communication and health education can be challenging. These patients may also take a number of medications, which further complicates the pregnancy and adds increased risk.

Pain and Fatigue

Although cerebral palsy is not a progressive disorder, its manifestations are not static, and aging often results in increased loss of function, especially mobility (Lipak, 2008). Pain, fatigue and muscle weakness result from bone deformities, muscle abnormalities, arthritis and “overuse syndrome,” or repetitive motion injury (Lipak, 2008). Pain may be acute or chronic, with back and leg pain being the most commonly reported (Lipak, 2008, NINDS, 2011). Malone and Vogtle (2010) found that pain and fatigue were consistently reported by adults with cerebral palsy and resulted in decreased ability to participate in daily life. People with cerebral palsy expend three to five times more energy than able-bodied individuals when performing activities of daily living (NINDS, 2011).

Pain and fatigue were consistently reported by adults with cerebral palsy and resulted in decreased ability to participate in daily life

Pain and fatigue are common concerns of many women having an uncomplicated pregnancy and birth. Anemia, hormone fluctuations, sleep disruption and adjustment to parenting roles all contribute to fatigue. The “discomforts” of pregnancy are many and include constipation, heartburn, muscle aches and backache, to name a few. When one considers the added stress of pregnancy for a woman with cerebral palsy, pain and fatigue become significant issues.

Pregnancy-related complications reported in the literature for women with cerebral palsy include preeclampsia, preterm birth and an increased rate of cesarean delivery (Signore et al., 2011). Further, women with upper motor neuron disorders such as cerebral palsy may have an increase in spasticity during pregnancy. Gastrointestinal comorbidities, such as dysphagia and reflux, can limit healthy food choices and lead to nutrient deficiencies. Women with limited mobility may experience more problems with constipation; this can result in lowered compliance with prenatal vitamin and iron supplements, increasing the risk for anemia (Signore et. al., 2011). Many women with cerebral palsy have osteoporosis and may need vitamin D supplementation.

Deep Vein Thrombosis

Women who develop deep vein thrombosis (DVT) during pregnancy often have multiple risk factors, including impaired mobility, obesity, surgical delivery, hemorrhage and sepsis. Women with inherited and acquired thrombophilias, such as Factor V Leiden, have a significantly higher risk for DVT in pregnancy and the postpartum. It's interesting to note that Factor V Leiden mutation and other thrombophilias are associated with an increased risk for cerebral palsy (Gibson et. al., 2003).

The risk for DVT is four to six times greater in pregnant women when compared to nonpregnant women of the same age group. The true incidence may be even higher (Stone & Morris, 2005). Women in late pregnancy may experience shortness of breath, tachypnea, edema of the lower extremities and leg pain. Common signs and symptoms of DVT and pulmonary embolism may be vague, or are often attributed to physiologic changes of pregnancy, thereby increasing the chances for undiagnosed DVT. Even asymptomatic patients are at risk for pulmonary embolism. Pulmonary embolism is life threatening and has emerged as one of the leading causes of maternal mortality and morbidity, largely due to the rise in cesarean births (Stone & Morris, 2005).

Hypercoagulability is a physiologic change in pregnancy resulting from venous stasis, altered levels of clotting factors and hormonal influences during pregnancy. Blood flow is normally slower in the venous system, where the primary clotting mechanism occurs with activation of the thrombin system and the production of fibrin. Strands of fibrin trap red blood cells with platelets to form a clot. Left-sided DVT is more commonly seen because venous stasis is more pronounced on the left side, partly due to compression of the left common iliac vein (Stone & Morris, 2005).

Women who require anticoagulation during pregnancy will also need to be fully anticoagulated after delivery (see Box 2). Heparin is the drug of choice for treating a DVT and pulmonary embolism surrounding delivery. Intravenous heparin allows for rapid anticoagulation and it has a short half life. More importantly, it does not cross the placenta, and therefore cannot be teratogenic and will not cause fetal hemorrhage. Heparin and warfarin are also safe for breastfeeding mothers, as heparin is not found in breast milk and amounts of warfarin secreted in human milk are insignificant (Duhl et al., 2007).

Box 2. Considerations for Heparin Anticoagulation

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Heparin anticoagulation is not without risks. According to Duhl and colleagues (2007), patients may develop thrombophilias that can be either heparin-associated or heparin-induced. Heparin-induced throbophilia is immune-mediated and more severe. Anticoagulation should be discontinued if the platelet count drops below 150,000 (Duhl et al.). Heparin-induced thrombophilia is uncommon during pregnancy. Allergic reaction and heparin-induced osteopenia are additional risks.

A disadvantage of heparin is difficulty maintaining a therapeutic response. Pregnant women may require higher doses of heparin due to increased levels of heparin binding proteins, increased plasma volume, increased glomerular filtration rate, and increased degradation of the drug by the placenta (Stone & Morris, 2005). Physicians commonly utilize the activated partial thromboplastin time (aPTT) lab value for monitoring and dosing heparin. This value has poor correlation with blood heparin concentration. Use of the antifactor Xa or functional heparin assay has been proposed in the literature to achieve therapeutic heparin dosing (Smith & Wheeler, 2010).

Bleeding is a significant risk, especially during the postpartum and postoperative recovery. Postpartum hemorrhage can be life threatening. Other potentially fatal bleeds are retroperitoneal, ovarian (corpus luteum) and intracranial. Bleeding risk is dosage- and age-related, with patients receiving higher doses and those over age 70 at greatest risk.

Wound hematoma is a common complication with anticoagulation, especially those with a transverse incision. Collections of blood in or around the wound may not cause symptoms, or symptoms may be attributed to incisional pain, or “gas pain.” Increased abdominal pain, swelling and/or drainage occurring several days after surgery should be investigated. If the hematoma is infected, there may be fever, erythema, wound induration and leukocytosis. Diagnosis can be made by ultrasound. Large hematomas are treated by opening up the wound and negative pressure wound therapy. It's important to note that people with diabetes often experience poor wound healing. Wound healing can also be hindered by anemia secondary to blood loss after delivery.

Patients with DVT may initially benefit from bed rest with elevation of the affected leg to promote venous return; however, there is no evidence that bed rest prevents detachment of the clot.

A Multidisciplinary Care Plan

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Optimal outcomes are best achieved with a multidisciplinary care plan. The central focus of care is the patient and her family (see Box 3). Women with cerebral palsy and other disabilities are not helpless and they have adapted to meet their own needs (Barber, 2008). Families will often provide necessary support. Nurses work with patients and their families in assessing a patient's needs and wishes.

Box 3. Considerations When Caring for a Patient With Cerebral Palsy

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Although a patient's needs may be complex, facilitating maternal newborn attachment is a priority. Despite their complex care needs, these women, like all new mothers, need close physical proximity to their infants, which allows them to interact with their newborns and respond to their cues. Supportive nursing care can include rooming-in, breastfeeding assistance and encouragement, skin-to-skin care with the newborn and infant massage (Karl, Beal, O'Hare, & Rissmille, 2006). Assigning primary nurses who will become familiar with and comfortable with a patient's care allows for consistency and continuity. It's important to consider that while people with disabilities often have adaptive home environments, hospitalization may challenge them with unfamiliar surroundings and routines, making safety a priority. Nursing care activities can be clustered to allow time for rest and minimize a patient's fatigue.

Although a patient's needs may be complex, facilitating maternal newborn attachment is a priority

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Occupational therapists can assist with energy conservation techniques, suggest modifications to the home, offer adaptive technologies and teach body mechanics to conserve energy. Physical therapists can employ techniques to reduce spasticity, utilize relaxation techniques and assist with pain management and mobility. Pharmacists can also be consulted for pain management. Lactation nurses can develop an individualized care plan, and recommend the use of pillows such as the Boppy® or My Brest Friend™ for positioning ease. Respiratory therapist can be consulted for management, as respiratory compromise is common in women with cerebral palsy secondary to muscle weakness and bony deformities. Pregnancy may further compromise respiratory status as respiratory reserve decreases with the enlarging uterus (Signore et al., 2011). Pulmonary embolism, surgical delivery with general anesthesia and narcotic pain management further diminish respiratory function.

Discharge planning is a high priority for high-risk patients. Patients with a DVT transitioning to warfarin need to receive warfarin concurrently with heparin for at least 5 days until the INR is greater than 2.0 for 24 hours. They need education on warfarin if this is a new medication for them. Case managers should be involved with discharge planning to assess follow-up needs, coordinate community resources and provide postpartum depression screening. A wound management nurse should become involved if there are wound healing concerns.

Improving Communication

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Kayla represents only the tip of the iceberg with regard to caring for women with high-risk pregnancies. Traditionally, perinatal care occurs within multiple “silos.” Silos represent fragmented or compartmentalized care that increases the risk for suboptimal outcomes for high-risk patients (Shirey, 2006). Women with high-risk pregnancies may experience numerous encounters with providers in the outpatient setting and may be transferred within the hospital several times, including visits to the emergency room or triage area, medical-surgical units, antepartum units, labor and delivery and postpartum. Additionally, women may require home care, or have a newborn admitted to the neonatal intensive care unit (NICU).

Improving care begins with improving communication. Not only is communication limited among care silos, but it's often hierarchal and not team-oriented (Miller, 2005). Physician and nurse communication frequently occurs within separate realms and there is limited interfacing. High-risk obstetric patients can benefit from improved multidisciplinary communication and teamwork. Teamwork results in improved patient outcomes, improved delivery of services and increased patient satisfaction (Harris, Treanor, & Salisbury, 2006).

Conclusion

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies

Many high-risk patients have uncommon or non-obstetric-related problems that are infrequently encountered in the realm of perinatal nursing. This population represents not only a challenge for the multidisciplinary team to provide optimal care, but also an opportunity for nurses, in particular, to increase their knowledge and skills by becoming proactive in coordinating multidisciplinary care. Nurses can take initiative in planning pre-admission interdisciplinary care conferences for high-risk patients. Care plans can then be developed to address patient needs, potential complications and identify the need for specialized equipment or staff (Hiner, White, & Fields, 2009). Retrospectively, nursing grand rounds can present unique high-risk cases providing an avenue for process improvement. Our common goal as perinatal nurses is to maximize patient safety and satisfaction with the birth experience. Will we be ready for the next Kayla? NWH

Our common goal as perinatal nurses is to maximize patient safety and satisfaction with the birth experience

References

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies
  • Barber, G. (2008). Supporting pregnant women with disabilities. Practice Nursing, 19(7), 330334.
  • Duhl, A. J., Paidas, M. J., Serdar, H. U., Branch, W., Casele, H., Cox-Gill, J.,... Zehnder, J. L. (2007). Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcome. American Journal of Obstetrics and Gynecology, 197, 457.e1457.e21. doi: 10.1016/j.ajog.2007.04.022
  • Farber, R. (2000). Mothers with disabilities: In their own voice. American Journal of Occupational Therapy, 54(3), 260268.
  • Gibson, C., MacLennon, A., Goldwater, P., & Dekker, G. (2003). Antenatal causes of cerebral palsy: Associations between inherited thrombopilias, viral and bacterial infections, and inherited susceptibility to infection. Obstetrical and Gynecological Survey, 58(3), 209220.
  • Harris, K., Treanor, C., & Salisbury, M. (2006). Improving patient safety with team coordination: Challenges and strategies of implementation. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(4), 557566.
  • Hayes, C. (2010). Cerebral palsy: Classification, diagnosis, and challenges of care. British Journal of Nursing, 19(6), 368373.
  • Henderson, C. M., Rosasco, M., Robinson, L. M., Meccarello, J., Janicki, M. P., Turk, M. A., & Davidson, P. W. (2009). Functional impairment severity is associated with health status among older persons with intellectual disability and cerebral palsy. Journal of Disability Research, 53(11), 887897.
  • Hiner, J., White, S., & Fields, W. (2009). Infusing evidence-based practice into interdisciplinary perinatal morbidity and mortality conferences. Journal of Perinatal and Neonatal Nursing, 23(3), 251257.
  • Karl, D., Beal, J., O'Hare, C., & Rismille, P. (2006). Reconceptualizing the nurse's role in the newborn period as the “Attacher.” MCN: The American Journal of Maternal/Child Nursing, 312(4), 257261.
  • Lipak, G. (2008). Health and well being of adults with cerebral palsy. Current Opinions in Neurology, 21(2), 136142.
  • Malone, L.A., & Vogtle, L.K. (2010). Pain and fatigue consistency in adults with cerebral palsy. Disability and Rehabilitation, 32(5), 385391.
  • Miller, L. (2005). Patient safety and teamwork in perinatal care. Journal of Perinatal and Neonatal Nursing, 19(1), 4651.
  • National Institute of Neurological Disorders and Stroke (NINDS). (2011). Cerebral palsy: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm
  • Nelson, K., & Chang, T. (2008). Is cerebral palsy preventable? Current Opinion in Neurology, 21, 129135.
  • Romero, R., Gotsch, F., Pineles, B., & Kusanovic J.,(2007) Inflammation in pregnancy: Its roles in reproductive physiology, obstetrical complications, and fetal injury. Nutrition Reviews, 65(12), S194202.
  • Rouse, D. J., Hirtz, D. G., Thom, E., Varner, M. W., Spong, C. Y., Mercer, B. M.,... Shriver, E.K. (2008). A randomized controlled trial of magnesium sulfate for the prevention of cerebral palsy. New England Journal of Medicine, 359(9), 895905.
  • Shirey, M. (2006). On intrapreneurship: From silos to collaboration. Clinical Nurse Specialist, 20(5), 229232.
  • Signore, C., Spong, C., Krotoski, D., Shinowara, N., & Blackwell, S. (2011). Pregnancy in women with physical disabilities. Obstetrics and Gynecology, 117(4), 935947.
  • Smith, M., & Wheeler, K. (2010). Weight based heparin protocol using antifactor Xa monitoring. American Journal of Health System Pharmacy, 67(1), 371374.
  • Stone, S., & Morris, T. (2005). Pulmonary embolism during and after pregnancy. Critical Care Medicine, 33(10), S294S300. doi: 10.1097/01.CCM.0000183157.15533.4C

Biographies

  1. Top of page
  2. Abstract
  3. About Cerebral Palsy
  4. Types of Cerebral Palsy
  5. Treatments
  6. Secondary Conditions
  7. Prevention
  8. Health Care Challenges for Women With Disabilities
  9. Cerebral Palsy and Pregnancy
  10. Comorbidities
  11. A Multidisciplinary Care Plan
  12. Improving Communication
  13. Conclusion
  14. References
  15. Biographies
  • Cathi Phillips, MSN, RNC-OB, is a clinical nurse IV-A at UPMC Hamot in Erie, PA.

  • Jean Bulmer, DNP, RN-BC, is director of organizational development and provides education support to maternal child services at UPMC Hamot in Erie, PA. The authors report no conflicts of interest or relevant financial relationships.