Nursing Care of a Pregnant Family With
emancipated minor or a mature minor--a person
Special Needs
Ø Pregnant Adolescent
Ø Pregnant Woman Over Age 40
Ø Pregnant Woman Who Is Physically Or
Cognitively Challenged
Ø Woman Who Is Substance Dependent
Ø Woman Who Has Been Injured
Pregnant Adolescent
Adolescent pregnancy is not a new phenomenon.
Historically,it was common for women to marry
as early as age 12 or 13 and have their first baby
at age 15. In today’s society, however, marriage
and childbearing are life situations that are
thought of as belonging to later years. Teenage
pregnancies still continue, however.
Reasons for the high number of them include:
 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 able to conceive by age 11)
 Increase in the rate of sexual activity
among teenagers
 Lack of knowledge about (or failure to
use) contraceptives or abstinence
 Desire by young girls to have a child
Developmental Task Of Adolescence
The developmental tasks of the average
adolescent are fourfold:
(1) to establish a sense of self-worth or a value
system
(2) to emancipate from parents
(3) to adjust to a new body image
(4) and to choose a vocation
Pregnant adolescent is regarded as an
capable of making health care decisions--and so
may sign permission for her own care.
Prenatal Assessment
Many adolescents do not seek prenatal care until
late in their pregnancies as not seeking prenatal
care is a way of protecting the pregnancy--if she
doesn’t tell anyone, no one can suggest she
terminate the pregnancy. After the sixth month of
pregnancy, abortion is no longer a possibility,
Other factors contributing to the lack of prenatal
care include:
Ø Denial she is pregnant
Ø Lack of knowledge of the importance of
prenatal care
Ø Dependence on others for transportation
Ø Feeling awkward in a prenatal setting (an
adult setting)
Ø Fear of a first pelvic examination
Ø Difficulty relating to authority figures
q Health History
When interviewing adolescents, be certain to press
for the responses needed to assess safely. 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
A baby’s father may accompany a teenage girl
into the clinic or office to have the pregnancy
diagnosis established. Because he is not married
to her, he does not have a legal right to participate
in her decision concerning pregnancy, abortion, or
adoption, but he may not be devoid of feelings for
the girl or the baby.
they may need extra teaching to help them
become aware of common pregnancy symptoms
such as urinary frequency, fatigue, and breast
tenderness.
listen for signs of “nest-building” behavior during
a pregnancy history.
Family Profile
Be sure to ask a girl at prenatal visits where she is
living, what is the source of her income, and
whom she would call if she suddenly became ill.
Asking about home life may reveal a
dysfunctional family or an incest relationship as
the cause of the pregnancy. If the girl is under
legal age, incest is considered child abuse
Be certain to ask if the girl is planning to continue
with school.
Day History
Ask in particular about nutritional practices, sleep,
daily activity, use of drugs, and whether she has
friends who can support her through this
experience.
Be certain to include questions about her
medication history. Ask if she is taking anything
over the counter. Some adolescents take acne
medication that is potentially teratogenic, such as
tetracycline or isotretinoin (Accutane)
q Physical Examination
Obtain a baseline blood pressure at the first
prenatal visit and make a point of informing the
girl of her blood pressure reading to encourage
active health care participation in the future.
be certain that the girl has 15 minutes of rest
before you take a blood pressure or the recording
will be falsely high.
The specific gravity of water is 1.000, whereas
urine specific gravity ranges from 1.003 to 1.030.
Pregnancy Education
Many adolescents develop hemorrhoids during
pregnancy because the disproportion of their body
size to a fetus puts extra pressure on pelvic
vessels, causing blood to pool in rectal veins.
q Nutrition
Lack of good nutrition can result in preterm birth
and lowbirth-weight newborns.
The younger the girl is, the more likely she is to
have a low-birth-weight infant.
Many adolescents enter pregnancy overweight or
obese. This can lead to macrosomia or overgrowth
in a fetus, a situation that leads to an increase in
the number of cesarean births
They may need frequent reminders that vitamin
and iron supplements intended to complement
nutrition during pregnancy must not only be
purchased but also must be taken. Be sure a girl
posts a medication reminder chart at home or in
her school locker to help increase adherence
q Activity and Rest
Assess a girl’s participation in sports and
determine which ones (if any) may have to be
discontinued during pregnancy (e.g., diving,
gymnastics, touch football).
Suggest ways to rest without compromising social
relationships (sitting, talking after school rather
than walking through the park).
q Physiologic Changes
All adolescent girls need substantial education on
the physiologic changes that occur during
pregnancy.
a girl may be unwilling to eat large meals during
pregnancy for fear of suffocating or drowning her
fetus.
Specific information about labor and delivery is
essential to counteract all the “scare stories” girls
may be hearing from their peers.
q Childbirth Preparation
Adolescents have a strong need for peer
companionship. When they become pregnant, they
often are cut off from fellow adolescents. This
makes them “ripe,” therefore, to join a class of
adolescents in preparation for childbirth
q Birth Decisions
Pelvic measurements should be taken early and
carefully in adolescent girls as cephalopelvic
disproportion is a real possibility because of the q Preterm Labor
girl’s incomplete pelvic growth
Complications
Adolescents of Adolescent
are at high Labor,
risk for preterm Birth,
labor,
When a cesarean birth must be scheduled because probably because
and thetheir uteruses arePeriod
Postpartum not fully
of cephalopelvic disproportion or poor fetal grown
growth, the information should be shared with the
girl and her parents as soon as possible.

q Plans for the Baby

Be certain they know all the options available to
them: keeping the baby, placing the baby in a
temporary foster home or adoption.
Adolescents, like all women, should be
Complications
encouraged of Adolescent Pregnancy
to breastfeed.
q Cephalopelvic Disproportion
Cephalopelvic disproportion is suggested by lack
of engagement at the beginning of labor, a
prolonged first stage of labor, and poor fetal
descent.
Graphing labor progress is a good way to detect
labor that is becoming abnormal.

q Pregnancy-Induced Hypertension
q Postpartum Hemorrhage
The best intervention for reducing an increasing
blood pressure during pregnancy is bed rest, Young adolescents are more prone to postpartum
preferably in a sidelying position. hemorrhage than the average woman because if a
girl’s uterus is not yet fully developed, it becomes
If the hypertension continues after a period of bed overdistended by pregnancy.
rest at home (or if the symptoms of pregnancy-
induced hypertension are advanced when they are
first discovered), a girl may be admitted to the
q Inability to Adapt Postpartally
hospital so bed rest can be better enforced. As
soon as the fetus is mature, labor will be induced Urge her to talk about labor and birth to make the
or a cesarean birth scheduled. happening real to her; otherwise, postpartum
depression is more apt to occur
q Lack of Knowledge About Infant Care
q Iron-Deficiency Anemia Pregnant Woman Over Age 40
Demonstrate bathing and changing the baby as
Deficiency is revealed by chronic fatigue, pale
appropriate. Model good parenting behaviors
mucous membranes, and a hemoglobin level less
whenever possible by being aware of how you
than 11 g/dL.
hold and care for the child.
Iron-deficiency anemia is associated with pica, or
the ingestion of inedible substances.
All pregnant women should take an iron and folic
acid supplement A woman over age 40 is more likely than a
younger woman to have a previously diagnosed
As soon as the body has iron, it will begin forming
condition, such as hypertension, varicosities, or
immature red blood cells (reticulocytes) rapidly.
hemorrhoids.
A reticulocyte count may be obtained in 2 weeks
to evaluate these levels and provide evidence that
the iron supplement is being taken. If the
reticulocyte count is not elevated by 2 weeks, it
implies a girl did not take the supplement.
 Developmental Tasks
The developmental challenge of the over-40 age
group is to expand their awareness or develop
generativity--that is, a sense of moving away from
themselves and becoming involved with the world
or community.
Assess couples by history and observation to
determine if childbearing appears to be timed
correctly for them. If not, they may need extra
time to accept a pregnancy and adapt to becoming
parents.
Women who have a child after age 40 fall into one
of two groups: those who are having their final
child and those who have delayed childbearing
because of education or a career and are having
their first child
Prenatal Assessment
q Health History
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.
Ask if she has been taking any medication or
herbal remedies to relieve reported symptoms,
such as nausea or fatigue.
Family Profile
Identify a woman’s source of income.
Evaluate how many people are financially or
emotionally dependent on her
Day History
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.
Identify personal habits, such as cigarette smoking
and alcohol consumption,
q Physical Examination
Inspect her lower extremities thoroughly for
varicosities, because these are more common in
women over age 40.
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
Assess a woman’s breasts for any abnormalities,
as women over age 40 are in a higher-risk group
for breast cancer than are younger women.
q Chromosomal Assessment
Women over 35 are offered a triple-screen (alpha-
fetoprotein [AFP], human chorionic gonadotropin,
and unconjugated estriol levels) drawn on blood
serum at the 15th week of pregnancy to detect
whether an open spinal cord or chromosomal
defect could be present in the fetus, because their
risk for Down syndrome is so much higher than it
is in younger Pregnancy
women Education
q Nutrition
Assess the number of meals a woman eats outside
her home each week, including those she packs
for lunch or eats in restaurants.
Urge her to substitute a caffeine-free soft drink in
place of an alcoholic beverage.
q Prenatal 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.
 Complications of Pregnancy for a Woman
Over Age 40
q Pregnancy-Induced Hypertension
At any age, the best way to reduce the symptoms
of pregnancy-induced hypertension is for a
woman to rest for a good portion of each day.
Complications of Labor, Birth, and the
Postpartum Period for a Woman Over Age 40
q Failure to Progress in Labor
Labor in an older primipara may be prolonged
because cervical dilatation may not occur as
spontaneously as in a younger woman.
Graphing labor progress is a good method to use
to determine when labor is becoming prolonged.
q Difficulty Accepting the Event
Review plans for child care and 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.
q Postpartum Hemorrhage
She may be more prone to perineal-anal tears
because her perineum is less subtle
Be sure to assess the amount of her lochial flow to
detect this complication.
Pregnant Woman Who Is Physically Or
Cognitively Challenged
In the past, women with conditions such as vision,
hearing, cognitive, neurologic, or orthopedic
challenges were sheltered by their families to such
an extent that women with even moderately
physically challenging conditions could not meet
potential sexual or marriage partners and so did
not become pregnant. In addition, most people
believed these individuals should not become
pregnant.
Rights of the Physically or Cognitively
Challenged Person
By federal law, physically disabled persons must
have freedom of access to public buildings by
means of ramps or handrails
Under the same law, a hospital cannot deny care
to a person with a disability even though the
disabling condition complicates treatment
considerably, possibly requiring extra personnel
and time.
A woman with a disability has full rights to her
child, so the baby cannot be taken from her at
birth without her full consent.
Modifications for Pregnancy
q Safety Measures to Explore
Safety is a key area of concern when caring for a
pregnant woman who is physically or cognitively
challenged.
Emergency Contacts.
Evaluate the client’s ability to contact someone in
case of pregnancy-related emergency.
Transportation. Assess a client’s ability to come
for prenatal care.
Mobility. All women who use wheelchairs are
taught to press with their hands against the
armrests and lift their buttocks up off the
wheelchair seat for 5 seconds every hour. This
prevents the formation of pressure ulcers on the
buttocks and posterior thighs. Encourage a
pregnant woman to continue to perform this
maneuver during pregnancy as the increased
weight of a fetus increases her risk for pressure
ulcer formation from compression.
Elimination. Encourage a high fluid intake and
frequent voiding, however, to prevent urinary tract
infections.
Autonomic Responses. Observe for autonomic
dysreflexia during pregnancy, labor, and the
immediate postpartum period. This is an
exaggerated autonomic response to stimuli.
Elevate a woman’s head to reduce cerebral
pressure and locate the irritating stimulus (usually
a distended bladder or bowel).
q Prenatal Care Modifications to Meet
Specific Needs
Woman with spinal cord injury or cerebral palsy
may be unable to maintain their legs in a
lithotomy position because of either hip flexion
contracture or laxness of leg support. This means
a dorsal recumbent, rather than a lithotomy,
position may be required for a pelvic examination.
When interviewing or teaching visually
challenged women, be certain not to use your
hands to illustrate points (“I’ll need a urine sample
of at least this much urine [measured with your
fingers]”). Do not use colors as descriptions of
Modifications for gown”).
Labor and
objects (“put on the blue Use Birth
demonstration aids that allow a woman to feel or
touch instead.
Women who are physically or cognitively
challenged will need adaptations in preparation
for labor and birth. Helpful suggestions are:
· A woman with a spinal cord injury may not be
able to feel uterine contractions. Late in
pregnancy, she will need to palpate her abdomen
periodically for tightening or the presence of
contractions so she is aware of beginning labor.
· Women with muscle spasticity or spinal cord
injury may not be able to push effectively for the
second stage of labor and so may need cesarean or
forceps birth.
· If a woman cannot assume a lithotomy position
because of hip contracture, vaginal delivery from
a Sims’ or dorsal recumbent position is best.
· Braille watches used by visually challenged
persons may not have second hands. They may
need to time the length of contractions by
counting rather than timing them by a watch.
· During labor, the hearing-challenged woman
cannot hear information on how she is progressing
if you are not directly facing her. If she needs to
communicate with her support person in sign
language, act as an advocate to keep her hands
unencumbered by equipment such as intravenous
lines. Remember she cannot hear her infant cry at
birth. Hand the infant to her as soon as possible
after birth so she can see and feel the baby is
crying and breathing.
· BeModifications forthe
certain to identify Postpartum
usual soundsCare
of
birthing rooms (the beeping of a monitor, the
swish of a central supply routing system, and so
forth) for the visually challenged woman. Hearing
sounds and not being able to identify them can be
frightening.
After birth, be sure to assess and teach:
· Whether a woman desires contraceptive
information.
· Whether she needs additional support to be
successful at breastfeeding.
· Whether she has a return appointment for both
herself and her infant for follow-up care and that
the arrangements are within her capabilities,
transportation, and understanding
q Modifcations for Planning Child Care
Urge a visually challenged woman to make eye
contact when talking to her infant.
Encourage a woman to develop a habit of turning
on Woman
lights after
Whodinner
Is because her infant
Substance will need
Dependent
light to develop vision.
hearing-impaired woman is not able to hear her
baby crying. Help her plan to bring the infant’s
crib or bassinet close to her bed so she can feel the
vibration of the baby’s stirring and waking.
Substance abuse is defined as the inability to
meet major role obligations, an increase in legal
problems or risk-taking behavior, or exposure to
hazardous situations because of an addicting
substance.
A person is substance dependent when he or she
Commonsymptoms
has withdrawal Substances Abused During
following
discontinuation of the Pregnancy
substance, combined with
abandonment of important activities, spending
increased time in activities related to substance
use, using substances for a longer time than
planned, or continued use despite worsening
problems because of substance use.
q Narcotic Agonists
q Cocaine
Cocaine is derived from Erythroxylum
coca, a plant grown almost exclusively in
South America.
Sudden vasoconstriction occurs.
(Respiratory and cardiac rates and blood
pressure increase rapidly). Immediate
death may result from cardiac failure.
extreme vasoconstriction that occurs can
severely compromise placental circulation,
leading to premature separation of the
placenta, which then results in preterm
labor or fetal death.
q Amphetamines
Methamphetamine (speed) has a
pharmacologic effect similar to cocaine.
Newborns whose mothers used the drug
show jitteriness and poor feeding at birth
and may be growth restricted.
q Marijuana and Hashish
Both are obtained from the hemp plant,
cannabis.
When smoked, they produce tachycardia
and a sense of well-being.
A frequent user may not be able to
breastfeed because of reduced milk
production and the risk to the newborn
from excretion of the drug in the milk.
q Phencyclidine
q Inhalants
It 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 potential for
causing long-term hallucinations
(flashback episodes).
It tends to leave the maternal circulation
and concentrate in fetal cells, so it may be
particularly injurious to a fetus.
used for the treatment of pain (e.g.,
morphine or meperidine [Demerol]) and
cough suppression (codeine),
Widely abused because of their analgesic
and euphoric effect.
Heroin, a raw opiate, is the main opiate
used recreationally to the point of
dependence,
It may be administered intradermally
(“skin popping”), through inhalation
(“snorting”), or intravenously (“shooting”)
Pregnancy complications related to its use
include pregnancy-induced hypertension
and, because narcotics are often injected
with shared needles, phlebitis, subacute
bacterial endocarditis, and hepatitis B and
HIV infection.
Withdrawal symptoms include nausea,
vomiting, diarrhea, abdominal pain,
hypertension, restlessness, shivering,
insomnia, body aches, and muscle jerks. It
may begin as soon as 6 hours after the last
drug dose and can continue for several
days.
Can result in fetal opiate dependence and
severe withdrawal symptoms in the infant
after birth. Infants of opiate-abusing
women tend to be small for gestational age
and have an increased incidence of fetal
distress and meconium aspiration.
They will have the same withdrawal
symptoms after birth as the mother would
if she abruptly stopped taking the drug.
Inhalant abuse refers to the “sniffing” or
“huffing” of aerosol drugs.
Frequently abused substances include
airplane glue, cooking sprays, and
computer keyboard cleaner.
Most of these substances contain freon as a
propellant and can lead to severe
respiratory and cardiac irregularities.
 q Alcohol urine) may reveal bleeding or bladder rupture
best.
Although alcohol can be legally purchased
and is served generously at social
Assessment
functions, it is just as detrimental to fetal
growth as illegal drugs.
There is little documentation regarding q Health History
how much alcohol must be ingested before
Document the circumstances of the
fetal alcohol syndrome, a syndrome with
trauma: what happened, the time of the
significant facial features, possible
injury, signs and symptoms of injury she is
cognitive challenges and memory deficits,
experiencing, and actions she has taken to
occurs, so women are advised to drink no
counteract these.
alcohol during pregnancy
Evaluate whether a woman’s degree of
binge drinking (five or more alcohol
injury is in proportion to the history.
drinks on one occasion)

Trauma and Pregnancy q Physical Examination

Trauma (injury by force) is a phenomenon that
seems remote from pregnancy because pregnant
women usually take extra safety precautions to
protect their body.
Physiologic Changes in Pregnancy That
Affect Trauma Care
A primary rule to remember is that after a
traumatic injury, a woman’s body will maintain
her own homeostasis at the expense of the fetus.
A woman’s total plasma volume increases during
pregnancy from approximately 2600 mL to 4000
mL at term
Central venous pressure (normal is 0 to 5 cm H2O
in a nonpregnant state) is increased to 2 to 7 cm
H2O.
Leukocyte count rises (to 20,000 mm3 at term)
Central venous pressure (normal is 0 to 5 cm H2O
in a nonpregnant state) is increased to 2 to 7 cm
H2O.
Culdocentesis, or needle aspiration through the
posterior vaginal fornix into the peritoneal cavity,
may be done instead of needle paracentesis, to
assess bleeding.
Peritoneal Lavage (the process of inserting a
peritoneal dialysis catheter into the abdominal
cavity, adding a quantity of an isotonic solution,
aspirating it again, and analyzing it for blood or
All women who receive a blow to their
abdomen need to be evaluated for
complications such as premature
separation of the placenta.
A Foley catheter is inserted to assess urine
output and to rule out a ruptured bladder
(blood would return or urine would be
blood-tinged if bleeding were occurring).
To prevent supine hypotension syndrome,
be certain a woman does not lie supine for
an examination.
Therapeutic Management
If respirations are not present or are ineffective,
cardiopulmonary resuscitation (CPR) should
begin.
If she does not respond, assess whether her airway
is obstructed by holding your cheek next to her
nostrils and assessing for air exchange. Look in
her mouth for a foreign object.
If she is not breathing, pull her chin forward and,
using a resuscitation bag, administer two breaths.
Assess cardiovascular function by palpating the
carotid pulse.
If this is not palpable or the pupils are fixed,
heart function must also be supplemented. Begin
external heart massage at a rate of two breaths to
every 15 heart compressions (one rescuer) or one
breath to every 5 heart compressions for two
rescuers (the same as for all adults).
if there has been blood loss, a central line may be
inserted and lactated Ringer’s or another isotonic
solution infused to restore fluid volume or provide
an open line for emergency medication.
Ephedrine is the drug of choice with a pregnant
woman to restore blood pressure in an emergency
situation because it has a minimal peripheral
vasoconstrictive effect.
Dopamine in low doses is a second drug that can
be used.
q Open Wounds
 Lacerations - Halt bleeding by putting
pressure on the edges of the laceration
(this is difficult to achieve in the lower
extremities because venous pressure is
greatly increased in pregnancy).
For sutures to be used, a local anesthetic
such as lidocaine (Xylocaine) is necessary.
 Puncture Wounds - To determine the depth
and extent of a wound, a fistulogram may
be done.
celiotomy or an exploratory surgical
procedure into the abdominal cavity may
be performed, if there is a suspicion of
bleeding into the abdominal cavity.
 Animal or Snake Bites - If the dog cannot
be located or is proved to be rabid after 48
hours of observation, a woman must be
administered rabies immune globulin and
vaccine.
q Blunt Abdominal Trauma
To assess if there is abdominal bleeding, a
diagnostic peritoneal lavage may be done
by introducing a small amount of normal
saline by a syringe into the peritoneum and
then withdrawing it to see if blood is
evident.
Ultrasound may also be used.
Traumatic blow to the abdomen could
cause dislodgement of the placenta
(abruptio placentae) or preterm labor.
A tocolytic such as terbulaline can be
administered to halt preterm labor if it has
been demonstrated that the uterine
environment is still intact
q Gunshot Wounds
Assessment of the wound includes
inspection for the point where the bullet
entered the body and the point where it
exited (the entry wound is small but the
exit wound is large because as a bullet
slows, it begins to tumble, enlarging the
space it occupies).
Ampicillin, a drug that is safe to
administer during pregnancy, is frequently
prescribed.
q Poisoning
activated charcoal is the drug of choice to
neutralize stomach poison.
q Choking
If a pregnant woman chokes on a piece of
meat or any foreign object blocks her
airway, attempting to dislodge the object
with a sudden upward thrust to the upper
abdomen is difficult.
Late in pregnancy, therefore, a rescuer
might use successive chest thrusts instead.
q Orthopedic Injuries
wrist injury (Colles fracture)
Apply ice to the area to decrease swelling
as an immediate first-aid measure.
a radiograph may be necessary to
determine whether a fracture is present.
q Burns
 Burns are dangerous in the pregnant
woman not only because of the thermal
injury that occurs but because of inhalation
of carbon monoxide gases from the fire,
which could lead to extreme fetal hypoxia
as carbon monoxide crosses the placenta in
placePostmortem
of oxygen. Cesarean Birth
In response to a severe trauma such as a
burn, prostaglandins are produced,
possibly causing preterm labor.

This is usually attempted if the fetus is past 24

weeks and less than 20 minutes has passed since
the mother died.
Infant survival is best in these circumstances if no
more than 5 minutes has passed.
A classic cesarean incision is used.