Age-Related Concerns

1 Identify the risks of childbearing that are related to adolescents.

2 Identify the risks of childbearing that are related to advanced maternal age.

3 Distinguish between the risks that can be attributed solely to biologic age factors and the risks that can be attributed to sociocultural and economic factors.

4 Select interventions that correspond to the developmental level of a pregnant adolescent.

5 Design and implement health education that reflects a sensitivity to the specialized needs of younger expectant parents and older expectant parents

INTRODUCTION

Pregnancy that occurs at the two age extremes (younger than 19 and older than 35 years) of a woman’s childbearing years places the expectant mother and the fetus at risk for age-related complications. The maternal mortality risk for adolescents younger than 17 years has been reported to be twice that of adult pregnant women (Klein, 2005). However, the increased risks of age extremes might be related more to sociocultural and economic factors than to the biologic factors of age. Many of these risks can be minimized through the use of current technology, education, and consistent prenatal care. Certainly, preexisting biologic conditions might require management by a high-risk team, regardless of the age of the woman (Suplee, Dawley, & Bloch, 2007).

Pregnancy in women 35 years and older who deliver in settings in which current technology is available might be at no higher risk for an adverse outcome than pregnancy in younger women. The trend toward technology to treat infertility has led to the possibility of childbirth in women of any age (Suplee, Dawley, & Bloch, 2007). Using surrogacy or egg donors, women well into the menopausal years can have children.

Each year more than 750,000 adolescents become pregnant in the United States (American College of Obstetricians and Gynecologists [ACOG], 2007a). For the first time in 15 years, the teen birth rate rose in 2006 by 3%. This followed a 14-year downward trend in which teen births steadily fell 34% from the 1991 peak (Hamilton, Martin, & Ventura, 2007). In 2007 the birth rate among teens 15 to 19 years old was 45.2% (Hamiton, Martin & Ventura, 2007). The United States continues to have the highest teen pregnancy rate among all developed countries (ACOG, 2007b). Once an adolescent has had an infant, she is at increased risk for another teen pregnancy (Ladewig, London, & Davidson, 2010). Approximately 25% of adolescents giving birth had a previous birth (Klein, 2005). With early and thorough prenatal care, adolescents older than the age of 15 years experience no greater risks than those of the general pregnant population (Ladewig, London, & Davidson, 2010). Although the incidence of certain complications might be higher because of age extremes, the diagnoses, interventions, and evaluations remain relatively unchanged from those for the general pregnant population with the same complications.

CLINICAL PRACTICE

Adolescence

A Assessment

1. History (specifics to add related to the adolescent’s age)

a. Age at menarche

(1) Several of the first menstrual cycles are anovulatory and irregular, making gestational dating difficult.

(2) Long bone growth is incomplete until approximately 2 years after menarche, and the pelvis does not reach adult size until 1 to 3 years after menarche; there is an increased risk of cephalopelvic disproportion (CPD) among young adolescents because of lack of pelvic maturity (Davidson, London, & Ladewig, 2008).

b. Number of sexual partners

(1) Having multiple sexual partners increases the risk of concurrent sexually transmitted diseases; adolescents will frequently have serial monogamous relationships (i.e., one short-term monogamous relationship that is followed by another, and then another).

(2) Each year young adults who are 15 to 24 years old account for 48% of all newly reported cases of sexually transmitted diseases in the United States (Guttmacher Institute, 2006).

c. Knowledge about how conception occurs

d. Planned or unplanned pregnancy: more than 90% of teens described their pregnancies as unintended (Klein, 2005)

e. Previous pregnancies

(1) Term or preterm

(2) Spontaneous abortions

(3) Therapeutic abortions

f. Contraceptive use: although statistics indicate an increased use of condoms among the adolescent population, adolescents are still inconsistent contraceptive users (Ladewig, London, & Davidson, 2010). The majority of sexually active teens (74% of females and 82% of males) used contraceptives the first time they had sex (Guttmacher Institute, 2006) and 62.8% reported using a condom during their last sexual intercourse (Ladewig, London, & Davidson, 2010).

(1) Is frequently inadequate in adolescents; there is a high incidence of pregnancy-related, iron deficiency anemia in pregnant adolescents who are younger than 17 (Davidson, London, & Ladewig, 2008)

(2) Caloric restriction can occur when the pregnant adolescent attempts to “not get fat,” to control abdominal protrusion, or to deny the pregnancy to herself and others (Davidson, London, & Ladewig, 2008).

(3) Overeating might occur to mask the body’s changes of pregnancy.

(4) Overweight and obesity prior to pregnancy: 17.4% of the adolesent population is overweight (National Center for Health Statistics, 2006). There are significant health risks and implications for prepregnant maternal obesity for mother and child (Stothard, Tennant, Bell, & Rankin, 2009)

(5) The incidence of eating disorders might be high among adolescents as a group (Ladewig, London, & Davidson, 2010).

(6) Good maternal weight gain during an adolescent pregnancy improves fetal growth and reduces mortality (Ladewig, London, & Davidson, 2010).

(a) Young pregnant adolescents should strive for a weight gain at the upper end of the range for an adult pregnant woman.

(b) Young pregnant adolescents should consume as much as 50 kcal/kg of nutrition per day, if active.

h. Prenatal care

(1) Some adolescents have no prenatal care, might not have known they were pregnant, deny their pregnancy, or are confused about available prenatal services (Corbett, 2007).

(2) Prenatal care is frequently started in middle to late pregnancy (ACOG, 2007b; Ladewig, London, & Davidson, 2010).

(3) Sporadic prenatal care and missed appointments are prevalent.

(4) Adolescents who lack adequate and early prenatal care have an increased incidence of pregnancy complications and tend to give birth to low-birthweight babies (ACOG, 2007b). Among this age group, prenatal care is the critical factor that has the most influence on the pregnancy outcome (Ladewig, London, & Davidson, 2010).

i. Risk taking behaviors

(1) Adolescents between the ages of 15 and 19 have a high incidence of sexually transmitted infections (STIs) including genital herpes, gonorrhea, syphilis, and chlamydia (Ladewig, London, & Davidson, 2010).

(2) Alcohol, tobacco, and illicit drug use

(3) Tattooing and piercing

j. Social support system plays an important part in transitioning the teen to the role of mother (Logsdon & Koniak-Griffin, 2005).

(1) Financial

(a) Having a child at an early age is a strong predictor that the the adolescent’s children will live in poverty.

(b) Adolescent mothers tend to fail at establishing a stable family at such a young age (Ladewig, London, & Davidson, 2010).

(2) Emotional: father of child

(a) An adolescent father is usually not prepared (maturational or psychologic) to deal with the consequences of pregnancy.

(b) Studies indicate that between 16% to 37% of pregnant adolescents experience domestic violence (Ladewig, London, & Davidson, 2010).

(3) Marital status; majority of adolescent marriages end in divorce

(4) Parents’ awareness of and attitude toward their teenage daughter’s pregnancy

k. Attendance at prenatal classes

2. Developmental assessment

a. The overall developmental tasks of an adolescent are:

(1) Acceptance of and comfort with one’s body image

(2) Internalization of a sexual identity and role

(3) Development of a personal value system

(4) Development of a sense of productivity

(5) Identification of a life’s work

(6) Achievement of a sense of independence

(7) Development of an adult identity

b. The early-adolescent girl (younger than 15 years)

(1) Is a concrete thinker

(2) Usually has some degree of discomfort with normal body changes and body image

(3) Usually has only a minimal ability to foresee the consequences of her behavior and see herself in the future

(4) Usually has an external locus of control

c. The middle-adolescent girl (15 to 17 years)

(1) Is prone to experimentation and challenges

(a) Drugs and alcohol

(b) Tattoos and piercings

(d) Feeling invulnerable

(2) Seeks independence and frequently turns to her peer group for support, information, and advice; pregnancy at this age can force a parental dependency and interfere with her striving for independence (Ladewig, London, & Davidson, 2010)

(3) Is capable of formal operational thought and abstract thinking, but might have difficulty anticipating the long-term implications of her actions

d. The late-adolescent girl (17 to 19 years)

(1) Is developing individuality

(2) Is capable of thinking abstractly and anticipating consequences

(3) Is capable of problem solving and decision making

(4) Can picture herself in control

3. Physical findings (specifics related to the adolescent girl’s age)

a. Bone growth is still incomplete in early adolescence.

(1) If pregnancy occurs before bone growth is complete, it can interfere with or arrest further bone growth.

(a) The first 4 years after menarche carry the highest risk (Ladewig, London, & Davidson, 2010).

(b) An increase of estrogen during this time, caused by pregnancy, can lead to the early closure of the epiphysis.

(2) Pelvic bones have not reached adult female dimensions: the incidence of cephalopelvic disproportion, leading to cesarean section, is increased (Davidson, London, & Ladewig, 2008).

b. Signs of hypertensive disorders in pregnancy; preeclampsia is primarily a disease of first pregnancies and maternal age extremes (Peters, 2008). (See Chapter 19 for a complete discussion of hypertensive disorders in pregnancy.)

c. Signs of intrauterine growth restriction

(1) Morbidity in babies of adolescents might be attributed to two common causes: prematurity and low birthweight (Klein, 2005).

(2) Adolescents have a higher incidence of low-birthweight infants, especially very young girls ages 14 or younger (Klein, 2005).

(3) Fundal height and gestational age discrepancy might be noted.

(4) Inadequate nutritional status might be evidenced by low weight gain; nutritional needs include:

(a) Additional amounts of protein, iron, and calcium needed to support the adolescent’s growth and fetal development (Ladewig, London & Davidson, 2010).

(b) Folic acid supplementation (Ladewig, London, & Davidson, 2010)

(5) Signs of infection (see Chapter 20 for a complete discussion of intrauterine infection and Chapter 17 for a discussion of congenital infections of the neonate)