Chapter 18
The Pregnant Adolescent and
Maternity Nursing in the Community
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Adolescent Pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
2
Objectives
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Define key terms listed.
Review the phases of adolescent
development.
Discuss the impact of pregnancy on the
development of the adolescent.
Examine the influence of pregnancy on
adolescent fathers.
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3
Objectives (cont.)
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Discuss the impact of unplanned adolescent
pregnancy on achieving the tasks of
pregnancy.
Explain the risks related to childbearing in
adolescents.
Outline the health education needs of the
adolescent.
Recognize two major risks for newborns of
adolescent mothers.
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4
Adolescent Pregnancy
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Rates of adolescent pregnancies, abortions,
and live births are significantly higher in the
United States than in most other developed
countries
Not prepared psychologically or economically
for parenthood
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5
Adolescent Development
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Adolescence—period of transition
Involves change, which can cause sense of
stress and anxiety
Specific ages
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Young or early: 10 to 13 years
Middle: 14 to 16 years
Late: 17 to 20 years
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Major Tasks of Adolescence
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Developing
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An identity
Autonomy and independence
Intimacy in a relationship
Comfort with one’s own sexuality
A sense of achievement
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Early Adolescence –
10 to 13 Years
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Rapid growth and development
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Physical changes in all body systems
Affects self-image
Exploratory behavior may occur
Thinking remains concrete
Rich fantasy life
Peer acceptance and conformity
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Middle Adolescence –
14 to 16 Years
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Development of secondary sexual
characteristics may be completed
Focus is on making self attractive
Use peers to share experiences and try roles
Can think more abstractly
May become increasingly self-centered and
feel invincible
Struggles for independence, challenges
family values and expectations
Wants to be treated like an adult
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9
Late Adolescence –
17 to 20 Years
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Ability to maintain stable, reciprocal
relationships
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Family more important, but independence from
them is a major developmental task
Has more realistic self-image
Sexual identity firmly established
Ability to solve problems, assess aspects of
life situations, delay immediate gratification
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Influences on Sexual Behavior
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Meaning is influenced by communication,
especially with parents, and visual images
Communication may be open or limited
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May avoid talking about sex with parents because
of parental response
Can confuse what is portrayed in media as
moral standards or publicly acceptable
behavior
School curricula may not be accurate or may
be superficial, leading to misinterpretation
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11
Peer Pressure

Many adolescent boys and girls become
sexually active, not because of sexual desire,
but because of the need to belong to a peer
group
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12
Community Influences
on Adolescents
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Changes from elementary school through
high school with new organization of classes
and new peers
Economic pressure and job availability
Availability of condoms and other barrier
control methods of contraception in public
leads adolescent to believe its okay to have
sex if they use them and they’re safe from
unintended pregnancy
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13
Prevention of Adolescent
Pregnancy

Federal law mandates sex education be
provided in the schools
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Federal funding pays for abstinence-only sex
education, omitting content related to
contraception, abortion, and safer sex practices
A study in 2006 showed that abstinence-only
programs did not delay sexual intercourse,
improve birth control, or decrease pregnancy
rates
Number of live births as of 2005: 40.4 per
1000 live births to adolescent parent
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14
Costs of Teen Pregnancy
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Taxpayer costs were $9.1 billion in 2004
Texas costs were $1 billion
Vermont costs were $12 million
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15
Preventing Adolescent
Pregnancy
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Anticipatory guidance
School education programs
Improved access to health care and counseling
Ready access to nurse or physician
Use of emergency contraceptives, as
appropriate
Choice of positive group membership
Choices and ability to use autonomy
Prevention of sexual abuse and date rape
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16
Confidentiality and the
Adolescent
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Laws vary from state to state
If health care worker cannot provide for
confidentiality, some teens will not seek
health care
Adolescents are at greater risk for
complications of pregnancy, yet are least
likely to seek early health care
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17
Medically Emancipated
Conditions

Many states do not require parental consent
for treatment for

Contraception
 Pregnancy
 Pregnancy-related care
 STIs
 Substance abuse
 Sexual assault
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18
Incidence of Adolescent
Pregnancy
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Sociodemographic factors strongly influence
birth rate
More than 1 million teenage girls become
pregnant each year
Most pregnancies are unplanned
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1 in 17 girls will become pregnant before the age
of 20 years
Many have had their first sexual encounter by age
14 years
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19
Health Consequences


Adolescents less likely to receive prenatal
care until later in pregnancy
Reasons

Not recognizing pregnancy
 Desiring to conceal it
 Not understanding value of prenatal care
 Not being able to afford or access care
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20
Termination of Education
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Pregnancy is the main cause of adolescent
girls dropping out of school
Those who have not completed at least high
school

Are more likely to be unemployed
 Are employed in entry-level jobs
 Lack job security
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21
Adolescent Fathers
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1 in 15 boys fathers a child while a teenager
Tend to achieve less formal education
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Enter labor force earlier and with less education
Large number of fathers are at least 6 years older
than the girl
May be supportive initially, but support may wane
over time
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22
Nursing Care of the
Pregnant Adolescent
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Antepartum Care of Adolescents
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In planning effective prenatal care and
education, the nurse should obtain
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Knowledge of adolescent’s individual needs
Cultural preferences
Developmental level
Screening for STIs, substance abuse
Provide nutritional guidance
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24
Care of the Adolescent
During Labor and Delivery
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May be very modest
Low pain tolerance
Pain control and adequate coaching essential
Provide her support person with clear,
concrete, detailed suggestions, involving
specific directions and activities
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25
Care of the Postpartum
Adolescent
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May have inadequate or undeveloped coping
skills to manage transition to parenthood
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Issues of child care, finances, schooling, and
family dynamics need to be addressed
Nurse provides encouragement, support,
instruction

Perineal care, self-care, newborn care
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26
Adolescent Parenting
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May still have unmet needs in own phase of
development
Assuming role of parent separates them from
their peers
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Parenting programs in community
May find they have little social or financial
support
Tend to have repeated pregnancies, closely
spaced

Can create family instability, further impairing
good parenting
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27
Characteristic Adolescent
Parenting Practices
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Insensitivity to newborn behavioral cues
Pattern of limited nonverbal interaction
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May expect too much of child
Lack of knowledge of child development
Preference for aggressive behavior and physical
punishment
Limited learning in home environment
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28
STIs and Contraception
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29
Objectives



Name three specific sexually transmitted
infections that are increased in the
adolescent population.
List reasons for the high rate of contraceptive
failure in adolescents.
List the principles involved in counseling
adolescents.
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30
Objectives (cont.)


Discuss community approaches to pregnancy
prevention in adolescents.
Explain three ways to offer continuity of
follow-up care to families discharged early
from the hospital after childbirth.
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31
STIs in Adolescents
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Unprotected sex has two major
consequences in adolescence: unwanted
pregnancy and STI
People younger than 25 account for half of
new STIs in United States
1 in 4 adolescents will have contracted an STI
by high school graduation
Teens are biologically more susceptible due
to epithelium that is present on the cervix and
risk-taking behaviors
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32
Reasons Adolescents
Do Not Seek Health Care
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Limited access
Preference for nonbarrier birth control
methods
Involvement with multiple partners
Fear of lack of confidentiality
Lack of knowledge about free programs
Behavioral differences
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33
Teen Pelvic Examination
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
Key point is to fully inform the adolescent on
what to expect
Provide privacy
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34
Treatment Regimens
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
Single-dose therapy is available for some
STIs
Stress importance of completing treatment
regimen as instructed to prevent continued
infection or the development of a drugresistant strain
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35
Contraception and Adolescents
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Often do not use them correctly
Use or disuse linked to availability, cost, and
confidentiality
Some believe using birth control labels them
as a “bad girl”
Some teens believe they are protected from
pregnancy if the male withdraws before
ejaculating
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36
Teaching Adolescents
About Contraception

Nurse must consider

Maturity level
 Moral and religious beliefs
 Motivation to avoid pregnancy
 Frequency of intercourse
 Regularity of menses
 Knowledge of risks of contracting STIs
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37
Elective Abortion
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Not an easy decision for most teenagers
Conflicting religious and moral views
May not know where to seek services, learn
about other options
Parents may be involved in the decision as to
whether to carry the pregnancy to term
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38
Prenatal Programs
Available to Adolescents
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Three types of programs
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Clinic
Private medical services
School-based programs
Choice depends on accessibility and financial
circumstances
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39
Community Responsibility

National Campaign to Prevent Teen
Pregnancy began in 1996

Involves adolescents in planning programs
 Provides role models from same cultural and
racial background
 Long-term and intensive programs
 Focuses on adolescent needs
 Provides nonjudgmental counselors who
understand the developing adolescent
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40
Risks of Adolescent Pregnancy
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41
Risks
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
A delay in revealing the pregnancy may limit
the options available to the adolescent
The longer an adolescent waits to make
decisions on her pregnancy, the higher the
risk of negative outcomes (e.g., too late to
have elective abortion, failure to obtain
appropriate prenatal care early in the
pregnancy)
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42
Home Care
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43
Objectives
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Describe a prenatal home visit.
Outline postpartum teaching that may be
provided in the home.
Identify two high-risk newborn conditions that
may be followed at home.
Discuss legal liability and home care.
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44
Objectives (cont.)
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
Review the nurse’s role in home care of new
mothers and newborns.
Review and discuss the Healthy People 2020
objectives related to maternal-infant care.
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45
Overview of Issues in Home Care
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If they meet certain criteria, both low- and
high-risk pregnant women and newborns can
be monitored or treated at home
Essential teaching and competencies
Include written instructions
Documentation is used as basis of
reimbursement for care provided in home
setting
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46
Home Care Settings
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Health promotion and disease prevention
Fill gap made by hospital stay, coordinate
multidisciplinary care, and make referrals
Can take place in home, short- or long-term
care, foster care, and hospice care
Information can be obtained by phone,
Internet, electronic monitoring
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Protocols and Tools
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Emphasis placed on identifying learning
needs and skills essential in peripartum
Written materials, help or advice phone lines,
Internet
Nurse assists in teaching, caregiving, and
preparing woman and family for discharge
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Legal Issues
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Two types of legal liability
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Negligence
Violation of state licensing laws
Reduce risk of legal liability by
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Informed consent and clear documentation
Interventions with sound scientific basis and
backed by evidence-based practice
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Alternative Health Care Practices
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Nurse is able to observe cultural practices
and alternative treatments being used in the
home setting
It is important for the nurse to clearly
document what is being used or done in the
medical record and also to state what forms
of information, education, or training were
provided to the patient or caregiver
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Home Pregnancy Tests
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Now commonly sold over-the-counter in most
stores
Considered reliable if performed correctly
If positive, woman should arrange prenatal
care as soon as possible
The urine pregnancy test only confirms the
presence of human chorionic gonadotropin
(hCG); it does not confirm a uterine
pregnancy
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51
Prenatal Home Care

Teaching includes

Physiologic and psychological changes
 Compliance with prenatal visits
 Use of monitors or other special instructions
 Common discomforts of pregnancy
• Including body mechanics
 Home safety and medications
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52
Prenatal Care
for Low-Risk Pregnancies

For women with difficulty accessing health
care


Transportation, family responsibilities, job
The nurse


Takes a health history
Performs screenings typically conducted in clinic
• Fetal heart rate, vital signs, urine screen, weight, fundal
height


Provides teaching
Documents all assessments
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53
Prenatal Care
for High-Risk Pregnancies


Set standards and criteria must be met for
woman to qualify for this type of prenatal care
and monitoring
Home care allows for more normal
environment, while minimizing family disruption


Nurse discusses importance of rest and determines
if any barriers exists
Nurse reviews teachings such as signs of
preterm labor, how to place monitoring
devices, and need for communication
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54
Postpartum Home Care
for Low-Risk Mothers



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Sometimes depends on needs of family
Mother is assessed to determine level of
recovery and if any complications have arisen
Newborn assessment is also performed
Documentation should include findings,
interventions, teaching provided
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55
Teaching in Home Care Setting
for Low-Risk Mothers




Common postpartum discomforts
Optimal rest periods
Family planning
Home care nurse able to see home situation
and can use observations for means of
making appropriate community referrals
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Guidelines for
Postpartum Home Visit
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


Previsit preparation
In-home interventions
In-home end of visit
Postvisit activities
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57
Home Care
for Low-Risk Newborns

Nurse observes and demonstrates

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Newborn positioning and carrying
Home facilities
Household safety
Condition of cord and circumcision site
Provides information on

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Growth and development
Safety needs
Immunizations
Follow-up care
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Jaundice
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Assessment should include




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Degree of jaundice
Stool patterns
Newborn behavior
Mother-newborn interaction
If infant appears jaundiced, nurse may
perform heel stick to test for bilirubin levels
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Home Phototherapy

Bilirubin in skin absorbs light and changes it
into water-soluble product




Excreted in feces and urine
Teach parents how to use equipment
Review how infant should be clothed during
treatments
Instruct parents to not use ointments,
because they could cause blistering of
infant’s skin
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60
Breastfeeding

Breast milk provides proteins, carbohydrates,
and fats for the newborn



Provides immunologic protection against infection
Facilitates early bonding between mother and
infant
In-home teaching usually needs 1 or 2 visits
for mother to be successful
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61
The Homeless
Mother and Newborn



Lack of permanent home
Often have difficulty accessing care; receive
care from multiple sites and health care
providers; incomplete medical records
Health problems typically include

Respiratory and nutritional disorders, lack of
preventive care, development or continuation of
high-risk behavior, mental disorders
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The Homeless
Mother and Newborn (cont.)



Follow-up difficult
Essential to determine whether mother and
baby have a place to go before discharge
Nurse can


Facilitate community referrals
Provide self-care education
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63
Cost of Early Discharge
and Home Care


Hospital costs have decreased with earlier
discharges
Need for home care services has increased



Includes follow-up visits by health care provider or
home care nurse
Amount of actual savings has not been
examined
Continued research in this area is needed
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64
Healthy People 2020

Some goals related to maternal-infant care
include




Increase the number of women with appropriate
weight gain during pregnancy
Increase the number of pregnant women
protected against vaccine-preventable disease
Reduce maternal-child obesity
Increase worksite lactation programs
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65
Audience Response System
Question 1
What is one of the most common home health
treatments provided to high-risk newborns?
A. Physical therapy
B. Phototherapy
C. Nutritional monitoring
D. Jaundice monitoring
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Review Key Points
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67