THE PREGNANT

ADOLESCENT
Unit IV – Nursing Care of the High Risk Pregnant Client with Special
Needs
 is not a new phenomenon.
ADOLESCENT Historically, it was common
PREGNANCY for women to marry as early
as age 12 or 13 and have
their first baby at age 15.
 ✓ Earlier age of menarche in girls
(the average age is 12.4 years;
many girls begin menstruating at
age 10 and so are ovulating and
Reasons for
able to conceive by age 11)
the high
✓ Increase in the rate of sexual
number OF activity among teenagers
Adolescent ✓ Lack of knowledge about (or
Pregnancies: failure to use) contraceptives or
abstinence
✓ Desire by young girls to have a
child
 Adolescence is a
vulnerable time for
Developmental pregnancy because the
Tasks of developmental tasks of
Adolescence pregnancy are
superimposed on those of
adolescence.
The developmental tasks of the average
adolescent are fourfold:

to establish
to
a sense of
emancipate
self-worth or
from
a value
parents
system

to adjust to and to
a new body choose a
image vocation
A girl in the process of separating from her
parents may be devastated by the reality
of someone else being dependent on her.
She may need her parents’ financial help
more than ever to obtain prenatal care
and buy clothing for her new baby.
 If she must depend on her parents’ health
insurance, she may feel virtually trapped
into dependence.
 THE PREGNANT
ADOLESCENT

Parents may have difficulty allowing a daughter to make her own health
care decisions this way.

You may need to remind them that a pregnant adolescent is regarded as

an emancipated minor or a mature minor—a person capable of making
health care decisions—and so may sign permission for her own care.

Soon she will be caring for an infant, so she needs this practice in
independence and responsibility.
 Adolescents are considered high-risk clients
because they have:
 a high incidence of pregnancy-induced
hypertension
 iron-deficiency anemia
Prenatal  and premature labor
Assessment  higher incidence of low-birth-weight infants,
 a disproportion between fetal and pelvic
size,
 and a high rate of intimate partner abuse
 • Denial she is pregnant
Other factors • Lack of knowledge of the
contributing to
importance of prenatal care
the lack of
prenatal care • Dependence on others for
include: transportation
• Feeling awkward in a prenatal
setting (an adult setting)
• Fear of a first pelvic examination
• Difficulty relating to authority figures
  Take a detailed health history at the first
prenatal visit of an adolescent to
establish individual risks.
 This is best done without the girl’s
parents present.
 The girl needs practice in being
Health History responsible for her own health, and
having to account for her health
practices helps her do this.
 It also helps prevent her from
fabricating an answer to please a
parent.
 Some adolescents come to a
facility with concerns such as
“weight gain” or “feeling tired all
the time” rather than saying they
are pregnant, hoping health
Health History care providers will think of
pregnancy as a possible reason
for their symptoms.
 This is part denial and part
pregnancy protection.
  Always be alert to the possibility of pregnancy
when an adolescent describes symptoms that are
vague and hard to define.
 If the importance of what she is saying when she
mentions feeling “tired” or “nauseated” is missed,
Health History she may ask if someone will feel her stomach.
 If told this is not necessary for any of the symptoms
she has mentioned, she may describe bigger
symptoms, such as “terrible stomach pain.”
 Think of possible pregnancy when you hear such
a “growing” history
  Many adolescents want to keep their
world totally separate from the adult
world and, to keep it separate, they
do not voluntarily share information
Health with adults.

History  Do not accept statements such as “I

eat okay” as a nutrition history or “I’m
a very active person” as a history of
rest and activity.
 Ask for details.
 The best intervention for
reducing an increasing
Complications
blood pressure during
of Adolescent
pregnancy is bed rest,
Pregnancy
preferably in a sidelying
position.
 Many adolescent girls are
deficient in iron because their
low protein intake cannot
Iron- balance the amount of iron lost
with menstrual flows.
Deficiency
 Deficiency is revealed by
Anemia chronic fatigue, pale mucous
membranes, and a hemoglobin
level less than 11 g/dL.
 As if the girl’s body has identified
a mineral lack, iron-deficiency
anemia is associated with pica,
Iron-
or the ingestion of inedible
Deficiency substances
Anemia Cravings for ice cubes or
blackboard chalk may develop
because of this.
 A pregnancy compounds iron-
deficiency anemia because a girl
must now supply enough iron for fetal
growth and her increasing blood
Iron- volume.
Deficiency  All pregnant women should take an
iron and folic acid supplement (folic
Anemia
acid is important for red blood cell
growth and prevention of neural tube
defects) and these are especially
important for the adolescent
 Adolescents are at high risk for
preterm labor, probably
because their uteruses are not
fully grown
Review the signs of labor with
them by the third month of
Preterm Labor pregnancy.
Stress that labor contractions
begin as only a sweeping
contraction no more intense
than menstrual cramps.
  Any vaginal bleeding is suspicious of labor
and should be reported.
 Adolescent girls have gained much of
their knowledge of labor from television
(where a woman suddenly announces
Preterm she is in labor and within 15 minutes gives
birth).
Labor  Therefore, they may dismiss light
contractions as simple discomfort, not
realizing they might be the start of labor.
 Adolescents who recognize labor
contractions early can seek care to have
premature labor halted.
Complications 1. Cephalopelvic Disproportion
of Adolescent ➢ Cephalopelvic disproportion is
Labor, Birth, suggested by lack of
and the engagement at the beginning
Postpartum of labor, a prolonged first stage
Period of labor, and poor fetal descent.
 Young adolescents are more
prone to postpartum hemorrhage
than the average woman
because if a girl’s uterus is not yet
2. Postpartum fully developed, it becomes
overdistended by pregnancy.
Hemorrhage
 An overdistended uterus does not
contract as readily as a normally
distended uterus in the postpartum
period
 The immediate postpartum
period may be an almost unreal
time for an adolescent
3. Inability to Adapt
Giving birth is such a stress and a
Postpartally
major crisis that all women have
difficulty integrating it into their
life.
It may be particularly difficult for
the adolescent.
 Adolescents show the same positive
bonding behavior with their infants as
their more mature counterparts
Lack of They may consider themselves to be
Knowledge knowledgeable in child care because
About Infant they have babysat for a neighbor’s
child or a younger sibling, they can
Care be overwhelmed in the postpartum
period to realize that when the baby
is their own, child care is not as simple
as it once seemed.
Adolescent pregnancy is a major concern, because
although it is decreasing in incidence, it still occurs at a high
rate and can interfere with the development of both an
adolescent and fetus.

Nursing care needs to be individualized to meet the

prepartal, intrapartal, and postpartum needs of this age
group.

Helping adolescents view a pregnancy as a growth

experience can help them mature in their ability to parent.
 The Pregnant
Women over
age 40.
 The incidence of women
delaying their first pregnancy
until their late 30s or early 40s is
The Pregnant
increasing.
Women over
Twelve percent of births in the
age 40. United States today are to
women over age 35; 2% to 4%
are to women over age 40
 In the past, it was assumed a
woman of this age was past the
optimal age for childbearing and
was at risk for many complications.
The
Today, with the exception of a
Pregnant greater incidence of chromosomal
Women over abnormality, there is little evidence
age 40 of serious complications in women
older than age 40 as long as
prenatal care is begun early in the
pregnancy.
 The incidence of women
delaying their first pregnancy
The until their late 30s or early 40s is
Pregnant increasing.
Women over Twelve percent of births in the
age 40 United States today are to
women over age 35; 2% to 4%
are to women over age 40
  In the past, it was assumed a woman
of this age was past the optimal age
for childbearing and was at risk for
The many complications.
Pregnant  Today, with the exception of a
greater incidence of chromosomal
Women over abnormality, there is little evidence of
age 40 serious complications in women older
than age 40 as long as prenatal care
is begun early in the pregnancy.
 The developmental challenge of
the over-40 age group is to
expand their awareness or
Developmental develop generativity—that is, a
Tasks and sense of moving away from
Pregnancy themselves and becoming
involved with the world or
community (Erikson, 1963).
  A woman over age 40, like all women,
should begin prenatal care early in
pregnancy.
 Women of this age group are well
informed about the advisability of early
prenatal care and have adequate
Prenatal health insurance, so they do seek an
early appointment.
Assessment
 A few mistakenly believe their lack of
menstruation is the result of early
menopause so do not seek an early
health care consultation.
 Ask women in this age group about
their present symptoms of
pregnancy, how they feel about
the pregnancy, and how it fits into
their lifestyle.
Health History  If a woman did not realize she was
pregnant, she may have self-
medicated.
Ask if she has been taking any
medication or herbal remedies to
relieve reported symptoms, such as
nausea or fatigue.
 Because a woman is functioning
well in a business world does not
mean she has a healthy
pregnancy lifestyle.
Health History Do not accept answers such as
“I drink socially” or “I take the
usual drugs” without exploring
what those phrases mean
specifically.
 Some women over age 40 who
are pregnant for the first time
have recently changed their life
pattern (married or became
Family Profile involved in a long-term sexual
relationship) or have decided to
have a child, perhaps through in
vitro fertilization, without a spouse
before they are no longer able to
conceive.
  Whereas a younger woman often
waits a while after marrying to
become pregnant, a woman over
age 40 often plans to become
pregnant immediately after marriage
because she senses her reproductive
Family Profile time clock ticking.
 Because of this, she may find herself
making many adjustments at once
(not only to a new life partner, house
or apartment, and perhaps
community, but also to a pregnancy).
  Ask specifically about a woman’s job and
estimate the amount of walking or back
strain it entails.
 Ask about recent diet or exercise programs.
 If a woman belongs to a health club,
Day History remind her that the use of saunas and hot
tubs for longer than 10 minutes at a time is
contraindicated during pregnancy
because of possible hyperthermia and
teratogenic effects of extreme heat on a
developing fetus.
  Identify personal habits, such as
cigarette smoking and alcohol
consumption, that may be
Family Profile detrimental to a fetus to
determine if counseling to halt or
decrease these habits could be
effective
 Physical Examination

A woman over age 40 needs

a thorough physical
Inspect her lower extremities
examination at her first
thoroughly for varicosities,
prenatal visit to establish her
because these are more
general health and to identify
common in women over age
any problems, particularly
40
circulatory disturbances she
may have.
  Obtain a urine specimen and test it for
specific gravity, glucose, and protein to
evaluate overall renal function and the
possibility of gestational or type 2 diabetes,
because older women are more prone than
younger women to develop these conditions.
 Assess a woman’s breasts for any
Physical abnormalities, as women over age 40 are in a
higher-risk group for breast cancer than are
Examination younger women.
 Ask if she has had yearly mammograms. In
addition, assess for fetal heart sounds and
fetal movement at prenatal visits because
gestational trophoblastic disease
(hydatidiform mole) is also more common in
women over age 40
 Women over 35 are offered a
triple-screen (alpha-fetoprotein
[AFP], human chorionic
gonadotropin, and
Chromosomal unconjugated estriol levels)
Assessment drawn on blood serum at the
15th week of pregnancy to
detect whether an open spinal
cord or chromosomal
 Elevate your legs.
 Be certain your diet includes
Tips on vitamin C, because this is
Preventing important to strengthen vein walls.

Varicose  Rest in a side-lying position with

your body tipped slightly forward
Veins (Sims’ position). This allows leg
veins to drain and empty.
  Avoid long periods of standing in one
place by taking “walk breaks”; active
muscle contraction helps venous
return.
Tips on  Avoid sitting with your legs crossed.
Preventing  Do not wear anything constricting,
such as knee-high stockings, on your
Varicose lower legs.
Veins  If you wear support hose, put them
on before you get out of bed in the
morning, before veins become
swollen, for best results.
  Childbirth education classes oriented
toward the older woman provide
important information on pregnancy and
bring these women and their support
people together.
 A woman over age 40, like any other
pregnant woman, needs access to
Pregnancy health care personnel who can supply
her with factual information during a
Education pregnancy.
 She also needs additional support while
she works through this role change in her
life.
  A pregnant woman over age 40 may be unique in her
circle of friends, she may feel shut out of her usual group
because of the pregnancy.
 This makes her ready, therefore, to join a childbirth

Prenatal preparation or prenatal exercise class where she is “one

of the group”

Classes  Be certain a woman plans (or the couple plans together)

to set aside a specific time every day to do breathing
exercises in preparation for labor.
 a busy woman may never find time to get to them and
will be unprepared in labor
 Assess the number of meals a
woman eats outside her home
each week, including those she
packs for lunch or eats in
restaurants.
 She may need tips on how to
Nutrition adjust pregnancy nutrition so she
can obtain the same nutrition
whether she prepares meals at
home or eats them at an office or
community function.
  Urge her to substitute a caffeine-free
soft drink in place of an alcoholic
beverage. In some offices, large
amounts of coffee are consumed.
 Urge her to substitute milk or juice or
decaffeinated coffee.
 Many women this age normally drink
Nutrition little milk.
 Rather than getting used to milk
again, a woman may appreciate
suggestions on other ways to ingest
calcium, such as puddings or yogurt.
Complications Complications that occur with a
of Labor, Birth, woman over age 40 related to
and the birth or the immediate period
Postpartum after birth also are the results of
Period for a a body that may not be as
Woman Over elastic as it was when the
Age 40 woman was younger.
  Women who delay childbearing
until age 40 may need additional
Complications discussion time at prenatal visits to
of Labor, Birth, help them incorporate a pregnancy
and the into their lifestyle.
Postpartum They may need reminders to save
Period for a time during the day for rest,
Woman Over particularly if at risk for pregnancy-
Age 40 induced hypertension or varicosities.
 hypertension of pregnancy,
preterm or post term birth,
Complications and cesarean birth—
of Pregnancy ❖These are related to the fact that
for a Woman the woman’s circulatory system
Over Age 40 may not be as competent as when
she was younger or her body tissues
may not be as elastic as they were
once
 A woman over age 40 may have a
higher incidence of pregnancy-
induced hypertension than a
younger woman, possibly related
1. Pregnancy- to blood vessel inelasticity or
because hypertension tends to
Induced occur more frequently in nulliparas
Hypertension than in multiparas as well as those
with already elevated blood
pressure
 Labor in an older primipara may
be prolonged because cervical
dilatation may not occur as
Failure to spontaneously as in a younger
Progress in woman.
Labor Graphing labor progress is a good
method to use to determine when
labor is becoming prolonged.
 Many women this age may need a
cesarean birth if labor is overly
Failure to prolonged and places a fetus at risk.
Progress in Encourage a woman to verbalize
Labor how she is feeling about her
progress throughout labor to allow
for reassurance and prompt
intervention should problems arise.
  Women over age 40 may begin to
have second thoughts about
childbearing this late in life as the
reality of a new baby registers with
Difficulty them during the intrapartal and
postpartum periods.
Accepting  Review plans for child care and
the Event postpartum rest, with an emphasis on
helping women learn to balance their
lives, especially if they are planning on
returning to work soon after the birth.
  the cervix may not dilate as readily
during an older woman’s labor, the
uterus may not contract as readily in the
postpartum period because of
inelasticity.
Postpartum  Therefore, an older woman may be at
Hemorrhage higher risk for postpartum hemorrhage
 She may be more prone to perineal-
anal tears because her perineum is less
subtle
 Women who are physically or
cognitively challenged may need help
in adjusting their usual regimen to
pregnancy.
Be certain they are aware of how to
contact help in an emergency.
Ensure that all medications they are
taking for their primary disorder are safe
for use during pregnancy.
Women who is Substance
Dependent
  Substance dependence is a growing
health problem in women of
childbearing age, so its incidence
during pregnancy is increasing.
Women who
 As many as 10% to 20% of pregnant
is Substance women use illegal drugs during
Dependent pregnancy
 The use of cocaine, amphetamines,
and multiple drugs has increased
dramatically in recent years.
 Adolescents have an increased rate
of inhalant abuse and binge drinking.
 is defined as the inability to meet
major role obligations, an
increase in legal problems or risk-
Substance taking behavior, or exposure to
abuse hazardous situations because of
an addicting substance.
 A person is substance
dependent when he or she has
withdrawal symptoms following
Substance
discontinuation of the
abuse substance, combined with
abandonment of important
activities,
  Recreational drugs commonly used in pregnancy
are those commonly used by women in their

Common childbearing years:

✓ Cocaine
Substances ✓ Amphetamines

Abused ✓ Marijuana
✓ phencyclidine
During ✓ inhalants
Pregnancy ✓ Opiates
✓ alcohol.
  Cocaine is derived from Erythroxylum coca,
a plant grown almost exclusively in South
America.
 When sniffed into the nose or smoked in a
pipe, cocaine is absorbed across the
Cocaine mucous membranes to affect the central
nervous system.
 As a result, sudden vasoconstriction occurs.
 Respiratory and cardiac rates and blood
pressure increase rapidly in response to the
vasoconstriction. Immediate death may
result from cardiac failure.
  Methamphetamine (speed) has a
pharmacologic effect similar to cocaine.
 Its use is becoming more common
because it is easily and cheaply
manufactured
Amphetamines  Ice, a rock type of methamphetamine
that is smoked, can produce high
concentrations of drug in the maternal
circulation.
 Newborns whose mothers used the drug
show jitteriness and poor feeding at birth
and may be growth restricted.
  Both marijuana and hashish are
obtained from the hemp plant,
cannabis.
 When smoked, they produce
tachycardia and a sense of well-
being.
Marijuana  Although not advised, some women
use marijuana to counteract nausea
and Hashish in early pregnancy.
 These drugs are frequently part of
polydrug abuse, so their effects on
fetal development are not well
documented
  Phencyclidine (PCP) is an animal
tranquilizer that is a frequently used
street drug in polydrug abuse.
 It causes increased cardiac output
and a sense of euphoria. It has the
Phencyclidine potential for causing long-term
hallucinations (flashback episodes).
 PCP tends to leave the maternal
circulation and concentrate in fetal
cells, so it may be particularly injurious
to a fetus.
 Narcotic agonists, used for the
treatment of pain (e.g.,
morphine or meperidine
Narcotic [Demerol]) and cough
Agonists suppression (codeine), are also
widely abused because of their
potent analgesic and euphoric
effect.
  Inhalant abuse refers to the “sniffing” or “huffing” of
aerosol drugs.
 Frequently abused substances include airplane glue,
cooking sprays, and computer keyboard cleaner.
Inhalants  Most of these substances contain freon as a propellant
and can lead to severe respiratory and cardiac
irregularities.
 The respiratory depression they can cause could be
enough to limit the fetal oxygen supply to a serious level.
  Although alcohol can be legally purchased
and is served generously at social functions, it
is just as detrimental to fetal growth as illegal
drugs.
 Excessive use tends to occur in women with
impulsive personalities
Alcohol  There is little documentation regarding how
much alcohol must be ingested before fetal
alcohol syndrome, a syndrome with significant
facial features, possible cognitive challenges
and memory deficits, occurs, so women are
advised to drink no alcohol during pregnancy
  A fetus of a woman who is substance
dependent is at high risk because of
the direct effects of the drug and the
woman who indirect effects of an unhealthy
is substance lifestyle.
 Women should be encouraged to join
dependent drug reduction maintenance
programs if possible to reduce fetal
risk.
 Results from sources such as
violence, automobile accidents,
and falls. Women with traumatic
Trauma in injuries need to be carefully
pregnancy assessed to determine if intimate
partner abuse was the cause of
the trauma.
TRAUMA IN PREGNANCY