INTRODUCTION 200 million pregnancies every year. ↑ risks for certain populations: adolescents, older women, HIV women, substance abuse or sexual abuse. Data show that pregnant teenagers in the Philippines are mostly 17 to 19 years old. They live with their mothers, parents, or relatives. The father of the child is, in most cases, a teenage boy. According to the 2014 Young Adult Fertility and Sexuality (YAFS) study, around 14 percent of Filipino girls aged 15 to 19 are either pregnant for the first time or are already mothers According to Josefina Natividad, YAFS coordinator and director of the University of the Philippines Population Institute, young Filipinos have limited access to sex education and ASRH- (Adolescent sexual and reproductive health services) especially if they are underage and unmarried. Recent (2014) data from the Philippine Statistical Authority (PSA) reveal that every hour, 24 babies are delivered by teenage mothers. Pregnancy experience is unique & personal. Many go through confusion & isolation. Desperately need help!!!!!!!!!!!!!!!!!! THE PREGNANT ADOLESCENT Time: onset of puberty to the cessation of physical growth. Roughly 11 – 19 yrs Oscillate between being children & adults. Need to adjust to the physiological changes in their bodies. Dependence on parents. DEVELOPMENTAL TASKS OF ADOLESCENCE Seeking economic & social stability. Developing a personal value system Building meaningful relationship with others Becoming comfortable with their changing bodies Working to become independent. Parents may have difficulty allowing a teenage daughter to make health decisions. Nurse needs to remind that pregnant adolescent is an “emancipated minor”: a person capable of making health decisions. Healthcare providers should communicate with adolescents in a manner they understand & respect them as individuals. Risk factors Early menarche Peer pressure to become sexually active Sexual abuse as a child Lack of information regarding contraception Poverty Culture / ethnicity Low self esteem Strong need for someone to love Early dating without supervision Symptoms Pregnancy symptoms include: Abdominal distention Breast enlargement and breast tenderness Fatigue Light-headedness or actual fainting Missed period Nausea/vomiting Frequent urination Signs and tests The adolescent may or may not admit to being involved sexually. If the teen is pregnant, there are usually weight changes (usually a gain, but there may be a loss if nausea and vomiting are significant). Examination may show increased abdominal girth, and the health care provider may be able to feel the fundus (the top of the enlarged uterus). Pelvic examination may reveal bluish or purple coloration of vaginal walls, bluish or purple coloration and softening of the cervix, and softening and enlargement of the uterus. A pregnancy test of urine and/or serum HCG are usually positive. A pregnancy ultrasound may be done to confirm or check accurate dates for pregnancy. IMPACT OF PREGNANCY ON ADOLESCENTS ‣ Negative impact in terms of health & social impact. ‣ 7 out of 10 adolescents will drop out of school. ‣ Children of adolescent mothers are at a greater risk of preterm birth, LBW, child abuse, neglect, poverty & death…. ‣ Greater psycho-social impact Treatment All options made available to the pregnant teen should be considered carefully, including adoption, and raising the child with community or family support. Discussion with the teen may require several visits with a health care provider to explain all options in a nonjudgmental manner and involve the parents or the father of the baby as appropriate. Early and adequate prenatal care, preferably through a program that specializes in teenage pregnancies, ensures a healthier baby. Pregnant teens need to be assessed for smoking, alcohol use, and drug use, and they should be offered support to help them quit. Prognosis Having her first child during adolescence makes a woman more likely to have more children overall. Teen mothers are about 2 years behind their age group in completing their education. Women who have a baby during their teen years are more likely to live in poverty Teen mothers with a history of substance abuse are more likely to start abusing by about 6 months after delivery. Teen mothers are more likely than older mothers to have a second child within 2 years of their first child. Infants born to teenage mothers are at greater risk for developmental problems. Complications Pregnancy induced hypertension Iron- deficiency Anemia Preterm Labor Cephalo- pelvic Disproportion Postpartum Hemorrhage Inability to adapt Post-partally Knowledge Deficit about Infant care. NURSING MANAGEMENT Prenatal Assessment Health History Family profile Physical examination NURSING DIAGNOSES 1. 2. 3. 4. 5. 6. Imbalanced nutrition : less than body requirements related to insufficient intake Risk for injury : maternal & fetal related to inadequate prenatal care & screening. Social Isolation related to body image changes Interrupted family processes related to adolescent pregnancy Disturbed body image related to situationalcrisis of pregnancy Risk for impaired parenting related to immaturity & lack of experience The teenage mother should be encouraged to Seek prenatal care early in pregnancy Eat a nutritious diet, Take prescribed vitamins and iron supplements Engage in healthy physical activity. Though a supportive family can help the teenage mother cope with her new responsibilities, social service agencies may be needed to help her find ways to finish school and seek employment. NURSING MANAGEMENT OF ELDERLY PREGNANT WOMEN 2 groups of women have emerged: Multiparous women : have an additional child during the menopausal period Primiparous women : deliberate delay of childbearing (May seek information about pregnancy from books, friends & internet.) Multiparous Women Some may have never used contraceptives Some may have used contraceptives successfully during childbearing years. As menopause approaches, they cease menstruating or stop use of contraceptives & consequently become pregnant. Mixed emotions among mothers. Primiparous women Number of 1st time pregnancies has increased significantly over last 3 decades. Reasons for delaying pregnancy include: Desire for advanced education Career priorities Use of better contraceptives Result of fertility therapies Dilemma: pregnancy has positive & negative effects Select right time for pregnancy Partners share the preparation for parenthood. Outcomes of Pregnancy in elderly women Adverse peri-natal outcomes more common. More likely to have LBW Infants, premature births & multiple births. ↑ risk for maternal mortality due to hemorrhage, infection, embolism, hypertensive disorders of pregnancy, cardiomyopathy & strokes. ↑ maternal age leads to infertility & spontaneous abortions, GDM , PIH, chromosomal abnormalities, genetic disorders, placenta previa, Preterm labor & surgical births Developmental Tasks & Pregnancy Developmental challenge over 40: expand their awareness or develop Generativity. “Sandwich Generation” : caring for aging parents & growing children. Ambivalent feeling towards pregnancy. Need help to cross 2 simultaneous phases of life : becoming involved with the world & concentrating on the baby inside her. Nursing Management Pre natal Assessment Begin prenatal care early Fortunately women in this age group are well – informed Few may attribute lack of menstruation to menopause. Health History Ask about present symptoms of pregnancy. How they feel about pregnancy Enquire about any self medication. Family Profile : source of income Physical Examination Thorough physical examination at 1st prenatal visit to establish general health & identify problems Inspection of lower extremities for varicosities. Urine specimen : glucose, protein Assessment of breast Assessment of FHR & Fetal movements. Chromosomal assessment: triple screen ( AFP. HCG & Unconjugated estriol level) COMPLICATIONS Hypertension, Pre-term or Post-term birth & Caesarean birth Related to the fact that women’s circulatory system may not be as competent as when she was younger. Tissues may not be elastic as before Pregnancy – Induced Hypertension : Best way for reduction- rest for good proportion of time. Plan activities that can be done on bed rest. Complications related to Labor, childbirth & Postpartum period Failure to progress in labor : cervix does not dilate as spontaneously due to ↓ elasticity in cells Difficulty in accepting the event : second thoughts about childbearing during labor & childbirth Postpartum Hemorrhage : uterus may not contract readily due to inelasticity NURSING CARE First Trimester Anxiety related to deficient knowledge as evidenced by women’s question & concerns Imbalanced Nutrition : less than body requirements related to nausea & vomiting as evidenced by women’s reports & weight loss. Fatigue related to hormonal changes in the first trimester as evidenced by woman’s complaints Second Trimester Constipation related to progesterone effect on the Gastro-intestinal tract as evidenced by woman’s report of altered patterns of elimination Third Trimester Fear related to deficient knowledge regarding onset of labor & processes of labor related to inexperience as evidenced by woman’s questions & concerns. INTRAPARTUM CARE Risk for injury: maternal & fetal due to complications associated with elderly pregnancy. Pain related to labor process. Knowledge deficit related to labor processes Postpartum care Pain related to episiotomy or caesarean birth . Knowledge deficit related to neonate care related to lack of experience. Risk for interrupted family processes related to inclusion of new family member. UNWED MOTHERS Lady who becomes pregnant without legal justification of physical intimacy between man & woman. In traditional societies like India, becoming pregnant before marriage is considered a sin. The psychosocial impact of becoming an unwed mother is very stressful & depressive. Factors associated with Unwed Pregnancy Poverty Prostitution Teenage mistake Improper Sex Education Contraceptive failure Consequences of being an Unwed mother For the mother Not socially acceptable Considered a curse. Brings a lot of personal disorganization Lack of support from family & society Difficult life ahead For Family Also bears the brunt of negative consequences. May suffer boycott from community Isolation Psychological trauma Health problems Both mother & child at risk Due to lack of support unsafe delivery practices conducted at unhygienic conditions to hide pregnancy Improper guidance for rearing of child Legal rights of an Unwed Mother Establish Paternity : raise the matter in court against the man expected to be the father of her child. Support to Child : can demand support in the form of money or some other form from the father once paternity is established, Custody of the child : still has the right to undertake custody of the child even after paternity has been established. Prevention of Unwed Pregnancy Peer education Sex education Supply of contraceptives Abolition of Prostitution Factors influencing care of unwed mothers Age of the mother Family support Financial stability Approach towards pregnancy Social and cultural background Role of a Nurse As an : Educator Advocate Helper Researcher SEXUAL ABUSE INTRODUCTION Social problem affecting all societies. One in twenty five women age 15-49 who have ever had sex ever experienced forced first sexual intercourse One in ten women age 15-49 ever experienced sexual violence 2 types of violence : intimate partner violence & sexual abuse. THE CYCLE OF VIOLENCE Tension Building Abusive Incident Honeymoon Phase Tension Building : 1st phase. Tension escalates between the couple. Excessive drinking, jealousy & other factors may lead to hostility & friction. Abusive Incident : explosion of violence .Victim is assaulted. Batterer loses control both physically & emotionally. Honeymoon Phase: period of calm, loving, contrite behavior on the part of the batterer. He may be genuinely sorry for the pain he caused to his partner. Attempts to make up his behavior & believe he can never hurt the woman he loves. Violence during Pregnancy Pregnancy often start or escalation of violence. Pregnant women are vulnerable at this time. Factors leading to battery: Inability of couple to cope up with stressors of pregnancy. Doubt about partner’s fidelity. Perception of baby as a competitor Financial burden related to expenses of pregnancy. Stress of role transition Insecurities & jealousy of pregnancy. Types of Abuse Mental : Threatening to kill the victim Forcing victim to perform humiliating acts Making demeaning remarks about victim Physical: Hitting, grabbing, pushing, choking , kicking or causing physical harm to victim Sexual : Forcing woman to have vaginal, oral or anal intercourse against her will. Biting victim’s breast or genitals Forcing victim to perform sexual acts with other people Types of Sexual Violence Childhood sexual abuse Incest Rape Statutory Acquaintance Date Childhood Sexual Abuse Any type of exploitation that involves a child younger than 18 yrs of age. Includes disrobing, nudity, masturbation, fondling, digital penetration & intercourse. Early abuse : lowers self esteem & ability to protect themselves. Influences the way victims live their lives & form relationships Incest Sexual exploitation between blood relatives or surrogate relatives before victim reaches 18 yrs of age. Victims often tricked, coerced or manipulated. Perpetrators often threaten their victims so they are afraid to disclose the abuse. Rape It is an act of violence Legal rather than a medical term Denotes penile penetration of the female or male without consent Statutory Rape : sexual activity between an adult & a person under 12 despite the willingness of the underage person. Acquaintance Rape : involves someone being forced to have sex by a person he or she knows. Date Rape : sexual assault which occurs within dating relationship Drugs used : “club drugs”; Rohypnol, Ketamine etc SUBSTANCE ABUSE IN PREGNANCY Introduction Most pregnant women reluctant to reveal substance abuse. Use of drug ↑ risk of medical complications in mother & baby. Placenta acts as an active transport mechanism. Critical determinants of effect of drug on fetus : drug, dosage, route of administration, timing of exposure. Common substances abused during pregnancy Alcohol Caffeine Nicotine Cocaine Marijuana Narcotics Sedatives Substances Effect on Pregnancy 1. Alcohol Spontaneous abortion, LBW, IUGR 2. Caffeine Vasoconstriction & mild diuresis in mother, fetal stimulation 3. Nicotine Vasoconstriction, ↓ utero-placental flow, LBW, Abortion 4. Cocaine Vasoconstriction, GHTN, Abruptio Placentae, snow baby syndrome, CNS Defects, IUGR 5. Marijuana Anemia, ↓ weight gain, Amotivational syndrome, newborn tremors, prematurity & IUGR. 6. Narcotics Maternal & Fetal withdrawal, Abruptio placentae, preterm labor, PROM, asphyxia, newborn sepsis, intellectual impairement, malnutrition 7. Sedatives CNS Depression, newborn withdrawal , maternal seizures in labor, newborn abstinence syndrome, delayed lung maturity Alcohol related effects No amount of alcohol consumption is safe during pregnancy. FAS →Fetal Alcohol Spectrum Disorder (FASD) FASD (Fetal alcohol spectrum disorders) includes; Craniofacial dysmorphia - Set of malformations that occur in the early bony fusion of one or more sutures, causing abnormal growth of the craniofacial skeleton. IUGR - Intrauterine growth restriction Microcephaly Limb & Cardiac anomalies Characteristic Features (FASD) Small head circumference Short palpebral fissures & small eye openings - it refers to the opening between the eye lids. Thin upper lip Receding jaw Low nasal bridge Skin folds at corner of eyes Small, flat midface area Cognitive & Behavioral problems Attention Deficit / hyperactivity Disorder Inability to foresee consequences Inability to learn from previous experiences Lack of organization Learning difficulties Poor abstract thinking Poor impulse control Speech & language problems. NURSING MANAGEMENT Emphasizes screening & prevention to reduce the high incidence of obstetric & medical complications among users as well as their passively addicted infants Assessment History Screening questionnaires Urine toxicology screening NURSING INTERVENTIONS Education about effects of substance exposure of fetus Interventions to improve mother – child attachment & improve parenting. Psychosocial support Referral to outreach programs Follow – up of children born to dependent mothers. Dietary counseling More frequent prenatal visits Support systems & vocational assistance.
