The Childbearing Family with Special Needs
Learning Objectives
After studying this chapter, you should be able to:
• Discuss the incidence and factors that contribute to teenage pregnancy.
• Identify the effects of pregnancy on the adolescent mother, her infant, and the family.
• Describe the role of the nurse in the prevention and management of teenage pregnancy.
• Relate the major implications of delayed childbearing to maternal and fetal health.
• Describe the effects of substance abuse on the mother, fetus, and newborn.
• Examine the role of the nurse when the mother places her infant for adoption.
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All families must make major changes as they adapt to pregnancy and childbirth. For some families, however, the changes are particularly difficult. Those families have special needs related to parents’ age, substance abuse, birth of an infant with congenital abnormalities, perinatal loss, relinquishment, or intimate partner violence. Perinatal nurses have an opportunity to make a difference in the lives of these families.
Adolescent Pregnancy
Incidence of Teenage Pregnancy
In 2009, there were 39.1 births per 1000 women ages 15 to 19 years in the United States, the lowest rate ever recorded. Approximately 410,000 teens gave birth. The birth rates for Hispanic and African-American teenagers were more than twice as high as the birth rate for non-Hispanic white teens (Centers for Disease Control and Prevention [CDC], 2011d). Asian/Pacific Islander adolescents have the lowest rate of teen pregnancy (Kochanek, Kirmeyer, Martin, et al., 2012).
Approximately 3 out of 10 girls in the United States become pregnant by age 20, and approximately 750,000 teen pregnancies occur each year (National Campaign to Prevent Teen and Unplanned Pregnancy [NCPTUP], 2010a). The pregnancy and birth rates for teenagers in the United States are higher than those in other developed countries (Alan Guttmacher Institute, 2011). A Healthy People 2020 goal is to reduce the rate of pregnancy for women 15 to 17 years of age to 36.2 pregnancies per 1000. Another goal is to reduce the pregnancy rate for women 18 to 19 years of age to 105.9 per 1000 (U.S. Department of Health and Human Services [USDHHS], 2010).
Factors Associated with Teenage Pregnancy
Approximately 82% of teen pregnancies are unintended. Seventy percent of adolescents report that they have had sex by age 19 years (Alan Guttmacher Institute, 2011). The high level of sexual activity and inconsistent or lack of contraceptive use among adolescents are directly related to the incidence of teenage pregnancies in the United States.
Adolescents often fail to recognize their vulnerability and believe that pregnancy cannot happen to them. Some risk pregnancy and parenthood as a means of gaining or maintaining a love relationship. They may see themselves as lacking power in their relationships and defer to their partner’s wishes. Other teens see pregnancy as a means to gain independence (Box 24-1).
Adolescents who give birth are more likely to be low income, which may mean they have less access to contraception and abortion. These teenagers may not believe finishing their education and obtaining good jobs are possibilities for them and may see little reason to postpone pregnancy. Most pregnant adolescents are pregnant for the first time. However, 19% of pregnant adolescents have had one or more previous births (Alan Guttmacher Institute, 2011) (Figure 24-1).
Sex Education
Sex education for teenagers should help them clarify their own values and beliefs about sexuality, understand how to set limits on sexual activity, and learn effective measures to prevent pregnancy and sexually transmitted diseases (STDs) when they decide to become sexually active (see Chapter 31). Gonorrhea and chlamydial infection are particularly prevalent during these years, and these diseases can be transmitted to the infant and affect the eyes and lungs.
Learning how to set limits on sexual behavior is particularly important for younger teenagers, who may be pressured to become sexually active before they have developed the maturity to deal responsibly with intercourse, contraception, or unplanned pregnancy. They need advice about how to handle pressure so they can postpone sexual intercourse until they are emotionally and physically ready.
When providing sex education, nurses must keep in mind that adolescent males and females mature at different rates and may be more comfortable learning in separate groups. In talking with teenagers, nurses should use simple but correct language such as uterus, testicles, penis, and vagina.
Preconception Counseling
Because adolescents are often seen by a health care provider for various reasons before they become pregnant, counseling to improve health for a future pregnancy should be offered them during any health care visit. Smoking cessation, attaining optimum weight, folic acid intake, and screening for violence are all topics that should be discussed with all young women so that a future pregnancy has the most positive outcome (Heavey, 2010).
Options When Pregnancy Occurs
An adolescent who becomes pregnant must choose one of three options: (1) terminate the pregnancy, (2) continue the pregnancy and place the infant for adoption, or (3) keep the infant. Some pregnant teens choose abortion, but this is not an acceptable option for others. Teenagers who might consider termination may not acknowledge the pregnancy or seek care until it is too late for abortion.
Only 2% to 4% of unmarried adolescents relinquish their newborns for adoption (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2007). Those who do may have complicated feelings of grief, relief that a “bad” experience is over, and anger at parents who were unwilling to provide assistance and thus make adoption the only realistic option. For some pregnant adolescents, the autonomous decision to place the infant for adoption “for the child’s good” may be an important step toward maturity.
Adolescents who choose abortion or adoption receive less assistance in dealing with their experience than those who keep their infants. They need help in coping with their feelings about their decision (see Adoption, p. 568).
Socioeconomic Implications of Teenage Pregnancy
The medical expenses of adolescent pregnancy often are not covered by the family’s health insurance, and public services become necessary. The public cost of teenage pregnancy in the United States is approximately $9 billion each year (CDC, 2011c). Costs include funds for Temporary Assistance for Needy Families (TANF), Medicaid, food stamps, payment to care providers, and administrative costs. Teenage mothers are more likely than older mothers to be nonwhite, poor, less educated, and unmarried, and many of the problems of early childbearing are related to these factors (SmithBattle, 2009). They are more likely to have larger families at an earlier age, resulting in more children to feed and clothe on an already inadequate income.
Although the financial cost of teenage pregnancy is enormous, the cost in human terms is often tragic. The developmental tasks of adolescence, such as achieving independence from parents and establishing a lifestyle that is personally satisfying, may be interrupted. Instead of becoming independent, they often become more dependent on parents or a boyfriend as a result of pregnancy. Educational goals may be curtailed for some young mothers, limiting employment opportunities and resulting in reliance on the welfare system. Parenthood is a leading cause of school drop out for adolescent girls. Only 51% of teen mothers obtain a high school diploma, and less than 3% attain a college degree by age 30 years (NCPTUP, 2010c).
Children born into this situation do not escape unscathed. They may show a higher incidence of impaired intellectual functioning and poor school adjustment. The negative cycle is often repeated: daughters of teenage mothers are three times more likely to become teen mothers than daughters of older mothers (NCPTUP, 2010b). As a result, children of adolescent parents are often among the poorest people in the United States.
For some adolescents, however, pregnancy motivates a desire to do well in school so they can provide for their infants. Pregnancy and birth may have a stabilizing effect in adolescents who change past poor lifestyle choices and become more goal directed than they had previously been. They may become more determined to get an education to enable them to get jobs that allow them to provide for their children. Mothering may provide a new sense of purpose and reduced risk-taking that may enhance teen parenting abilities (SmithBattle, 2009).
Implications for Maternal Health
Most pregnant teens have no medical complications during their pregnancy. However, they are at increased risk for anemia, preeclampsia, and preterm birth. They also have an increased risk for being victims of violence during pregnancy. After birth they are more likely to have infection and depression (Cunningham, Leveno, Bloom, et al., 2010; Elfenbein & Felice, 2011). The high incidence of STDs among pregnant teenagers is another concern.
The reason for the incidence of complications among teenagers is unclear. It may be caused by inconsistent prenatal care and economic or sociocultural problems rather than by age (Wildschut, 2011). Delayed prenatal care may result from denial of the pregnancy, lack of knowledge of how to get care, or a negative view of health care providers. Seven percent of pregnant adolescents have late or no prenatal care (Alan Guttmacher Institute, 2011).
Implications for Fetal-Neonatal Health
Prematurity and low birth weight (less than 2500 g or 5.5 lb) are more likely to occur in infants born to adolescent mothers. These infants also have a higher infant mortality rate (Wildschut, 2011). Preterm infants are more likely to have low birth weight and the added risks associated with immature organs. The cause of low birth weight may be fetal growth restriction (FGR), the failure of the fetus to grow as expected. This condition may result from a variety of causes, such as poor placental perfusion, which occurs during preeclampsia, or the underdeveloped vasculature of the uterus in young primigravidas. Cigarette smoking is another cause of low birth weight. Teens are more likely to smoke during pregnancy than other maternal age-groups (Grassley, 2011b).
The Teenage Expectant Father
The majority of adolescent mothers have partners within 2 years of their age, but some have partners 6 or more years older. These men may accept responsibility for the child, or they may become “phantom fathers,” who are absent or rarely involved in raising the child.
Almost all adolescent expectant fathers indicate that they are not ready for fatherhood. Many are depressed as they grapple with the conflicting roles of adolescence and fatherhood. Although some express interest in learning about childbirth and child care, those who do not want to be fathers are less likely to be supportive. Some do not wish to be involved with the infant, leaving the pregnant girl to seek support elsewhere. Others are involved in some degree during the pregnancy and early years of the child’s life but become less involved over time. Many adolescent mothers perceive that support from their partners is inadequate.
A disproportionate number of teenage expectant fathers are from environments of poverty and lack job skills or educational preparation. Many need job training before they can earn enough money to contribute to the support of their children.
Impact of Teenage Pregnancy on Parenting
Adolescent mothers are at risk of becoming non-nurturing parents. Whether this risk results from adolescence per se, the higher incidence of premature births, the lower socioeconomic status, or the particular home environment is difficult to determine. Having to focus on an infant at a time when most teenagers are absorbed in their own thoughts and activities may make parenting difficult. Teens tend to respond in a less sensitive manner to their infants (Grassley, 2011b). Their own immature coping mechanisms may cause young adolescents to use immature or punitive measures toward the infant when the source of the mother’s stress is other factors such as social isolation or inadequate financial resources.
Adolescent parents are likely to be surprised and dismayed at how difficult and time-consuming parenting can be. They may have little understanding of the expected growth and development of infants. For example, they may expect that the infant will sleep through the night, smile, or be toilet trained before it is possible for infants to do these things.
Preparing for parenthood is important. Although pregnant adolescents may want to be good mothers, they often do not actively seek information about infant care and development. The mother’s relationship with the father of the baby may affect her parenting abilities. A close and satisfying relationship with the baby’s father may increase attachment behaviors in the mother. Thus the father should be included, when appropriate, in care of the mother and baby. However, many adolescent mothers do not have a good relationship with the father of their baby and will need support in coping.
Nursing Care
The Pregnant Teenager
Assessment
Physical Assessment
Assessment of pregnant teenagers is similar to that of older women in many respects. At the initial visit, obtain a thorough health and family history to determine whether conditions such as diabetes or infectious diseases increase the risk for the mother and fetus. Monitor closely for signs of iron deficiency anemia, preeclampsia, or STDs. Attempt to identify behavioral risk factors, such as poor nutrition, smoking, alcohol or drug use, or unprotected sex, that could harm the mother or fetus. Screen for physical or sexual abuse, which is more common in pregnant teenagers.
Structure the interview so that questions can be interspersed in a more general conversation that explores the teenager’s likes and concerns. This approach helps establish rapport and gain a better understanding of the teenager.
Cognitive Development
Determine the teenager’s cognitive development and ability to absorb health counseling. The three most important areas of cognitive development are:
Knowledge of Infant Needs
Assess knowledge of infant needs and parenting skills. How does the teenager plan to feed the infant? What will she do when the infant cries? How will she know when the infant is ill and should be taken to a pediatrician? Does she know how much the infant should sleep? What plans have been made to provide for the safety needs of the infant?
Family Assessment
Begin assessment of the family unit by determining the degree of participation by the father of the infant. Fathers may plan to marry the expectant mother, participate in the pregnancy and rearing of the child without marriage, or be totally uninvolved.
It is important to assess the adolescent without the presence of her parents, but it is also crucial to determine the availability and amount of family support. Families respond in a variety of ways. A family member (usually the girl’s mother) may take over the mothering role, or all infant care may be performed by the teenager. In other families, care and responsibilities are shared. This arrangement allows the adolescent to complete the developmental tasks of adolescence as well as learning the mother role.
The pregnant teenager’s mother is particularly important when assessing the family. She may feel that she has “failed” as a mother, or she may resent the new cycle of child care in which the pregnancy involves her. Many pregnant adolescents live with their mothers who provide various levels of support. If the family is unable or unwilling to provide care for an adolescent with an infant, what other social support can be located? In some situations, the family of the baby’s father may be of assistance.
Nursing Diagnosis and Planning
Many adolescents wait until the second or third trimester to seek prenatal care because they either do not realize that they are pregnant, continue to deny that they are pregnant, or want to hide the pregnancy. They may not know where to go for care and may fear the results of the pregnancy on their lives and relationships. Teenagers often have little information about physiologic demands, such as an increased need for nutrients, that pregnancy imposes on their bodies. As a result, they may have a pattern of sporadic prenatal care and missed appointments (see Nursing Care Plan). One of the most relevant nursing diagnoses is:
Expected Outcomes
The expectant mother will keep scheduled prenatal appointments and follow health care instructions given throughout pregnancy. She will communicate her concerns throughout pregnancy. The family will verbalize emotions and concerns and maintain functional support of the expectant mother and her infant.
Interventions
Eliminating Barriers to Health Care
Two major barriers to health care are scheduling conflicts and negative attitudes of some health care workers. Help the adolescent locate the clinic closest to her that offers appointments when she (and her partner, if they wish) is available. Provide information about public transportation to that location, if necessary.
Pregnant women of all ages state that the negative attitude of some health care workers can discourage them from obtaining regular prenatal care. Nurses can be instrumental in finding ways to overcome these negative attitudes, thus encouraging pregnant women, including teenagers, to return for needed follow-up care. Nurses can acknowledge that frustration and
NURSING CARE PLAN
An Adolescent’s Responses to Pregnancy and Birth
Focused Assessment
Ann, 16 years old, comes to the prenatal clinic during the 20th week of her pregnancy. She lives with her parents, who both work, and a younger sister. She sees her boyfriend sporadically but is unsure if he will be involved with the baby. She remains in school but discusses her concern about how she looks: “How much bigger am I going to get?” “Why is my face so blotchy?”
Nursing Diagnosis
Disturbed Body Image related to perceived negative effects of pregnancy, as evidenced by verbalized concern about appearance.
Planning
Expected Outcomes
Interventions and Rationales
1. Allow time at each prenatal visit for Ann to express concerns about weight gain and other physiologic changes of pregnancy, such as hyperpigmentation and stretch marks.
An adolescent is often ashamed and uncomfortable with her pregnant body. She feels more comfortable if she can share these feelings and be reassured they are a normal part of pregnancy.
2. Initiate interaction about body changes by asking open-ended questions such as “How do you feel about your weight gain?”
Adolescents may be intimidated by health care professionals and may think their own feelings are not important enough to discuss.
3. Provide anticipatory guidance about normal changes, such as the pattern of weight gain during pregnancy and weight loss after childbirth.
Most adolescents do not know what to expect during pregnancy. Anticipatory guidance reduces fear and provides needed information.
4. Explain the reason for changes that are most troublesome at each prenatal visit (weight gain, hyperpigmentation, stretch marks, breast changes).
Knowing that some changes are temporary and that increasing weight indicates that the fetus is growing and developing is helpful. This may become a source of pride for the teenager.
5. Involve Ann in scheduling prenatal appointments and classes and making plans for childbirth.
Participation in decision making promotes a positive sense of self.
6. Promote a positive self-image by praising grooming, posture, and responsible behavior such as keeping prenatal appointments and following recommendations: “You have never missed an appointment, and your baby is growing very well.”
Positive reinforcement is particularly important to help the adolescent meet the developmental tasks of developing a sense of identity and self-worth.
Evaluation
Ann discusses her concerns about how she looks and begins to make positive statements about herself at each prenatal visit.
Focused Assessment
Ann reveals that her father says she has “shamed the family.” She discusses her fears that her friends, none of whom have been pregnant, will reject her because she is pregnant. She tearfully confides that she will have to “drop out of everything” and feels guilty for “putting my family through this.”
Nursing Diagnosis
Situational Low Self-Esteem related to feelings of rejection by family and friends, as manifested by statements indicating guilt and uncertainty about future support for herself and her infant.
Planning
Expected Outcomes
Interventions and Rationales
1. Use therapeutic communication techniques to help her continue to express her feelings.
Listen to her to help Ann see her feelings as important and help the nurse prioritize interventions.
2. Help Ann identify what she can do to overcome anxiety about rejection from her family and friends.
a. Suggest that she talk to family members about her guilt for the unhappiness she is causing them and fear they will not assist her through the pregnancy and birth.
Although they seek independence, family values are important to adolescents. Rejection by the family would lead to great stress.
3. Assist her in locating and joining the school-age mothers’ program if available through her school district.
Teenagers in the same situation often replace the pregnant teenager’s previous peer group.
4. Encourage Ann to discuss her economic needs as well as her plans for continuing school when the infant is born.
Planning provides some sense of control and increases feelings of competency.
5. Point out and praise any positive actions she takes, such as keeping prenatal appointments or eating a nutritious diet.
Sincere praise helps reinforce a positive self-image.
Evaluation
Ann makes plans to talk with her family and at her next visit reports relationships are somewhat improved. She enters a school-age mothers’ program and is very pleased. She states her best friend has been very supportive.
Focused Assessment
Ann has a normal vaginal birth of a 6-lb, 3-oz girl at 38 weeks of gestation. She does not want to breastfeed because she feels uncomfortable with it. She will live at home, and her parents have agreed to pay for child care for the infant while she is in school. She seems unsure how to respond when the infant cries and handles her only during feedings.
Nursing Diagnosis
Risk for Impaired Parenting related to lack of knowledge of infant needs and little confidence in her ability to care for the infant, as evidenced by uncertain responses to the infant.
Planning
Expected Outcomes
Interventions and Rationales
2. Demonstrate how to respond when the infant cries, and emphasize the importance of promptness and gentleness. Explain that infants develop a sense of trust when needs are met promptly and that crying does not indicate the infant is spoiled.
Modeling the way to respond to the infant helps Ann see what to do so she can respond in a like manner.
3. Include the grandparents and the infant’s father (if involved) in as many demonstrations as possible.
This will help promote consistency of care.
4. Emphasize the importance of touch and verbal stimulation, and point out reciprocal bonding behaviors, such as the infant following Ann with the eyes. Teach her the signs her infant is being overstimulated and needs a period of rest.
Newborns have many behaviors that stimulate attachment between parent and child. Recognition of overstimulation and the need for rest enhances caregiving ability.
5. Instruct Ann in early growth and development of the infant (how often newborns need to eat, how much they sleep, behaviors to expect).
Anticipatory guidance helps parents have realistic perceptions of the infant.
6. Encourage Ann to continue in the school-age mothers’ program and to attend parenting classes along with other teenagers.
Learning along with her peers will help her increase her parenting skills and provides a continuing peer support group.
7. Discuss Ann’s future plans for her education and avoiding another pregnancy before she is ready. Provide information about contraceptives and refer her to her primary care provider.
Helping the teen make realistic plans for her future is important. Providing information about avoiding pregnancy may help her meet her goals.
Evaluation
Ann responds quickly and gently when her infant cries. She gives basic care as taught and discusses what to expect in early growth and development of her baby. She makes frequent positive comments about her daughter.
Additional Nursing Diagnoses to Consider
staff burnout may occur when health care workers provide care for families with multiple problems. Allowing providers to see the same families consistently may help increase caring relationships and positive attitudes.
Applying Teaching or Learning Principles
Arrange for the pregnant teenager to participate in small groups with common concerns. Being with peers may help her feel comfortable in asking questions and voicing concerns. Specific needs that might be addressed are the benefits of prenatal care or help in eliminating any unhealthy habits. Near the end of pregnancy, preparations for labor and delivery and infant care become the priorities.
Repetition is an important method of teaching and clarifying misinformation. Allow ample time for discussion. Although teenagers often do not read or benefit from printed materials to the same degree that older parents do, written materials prepared especially for adolescents may be helpful. Teens often respond well to audiovisual aids.
It is particularly important that the nurse does not sound like a parent when working with adolescents. Avoid using the words “should” or “ought” or making decisions for the teenagers.
Counseling
Allow time to counsel teenagers about their specific problems, such as nutrition, stress reduction, and infant care.
Nutrition
Counseling about nutrition is one way to help reduce the incidence of low-birth-weight infants. Determine the adolescent’s general nutritional status, and assess for eating disorders that would reduce caloric intake and possibly affect fetal growth. Emphasize that she is still growing and her intake must be adequate for her own growth as well as that of the fetus. Discuss nutrition during lactation, pointing out the advantages for both mother and baby. Tailor information to the individual adolescent’s likes and peer group habits. Nutrition education must be socially and culturally appropriate. (See Chapter 14 for suggestions on nutrition for adolescents.)
Refer the teen to food stamp providers, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), surplus food distributors, and food banks, if necessary. Many teenagers have limited access to food and lack the ability to store or prepare it.
Self-Care
Provide the same teaching about self-care that would be given to an older woman (see Chapter 13). In addition, emphasize prevention of STDs by using a condom even though she is pregnant. Counsel the adolescent about lifestyle changes, such as smoking or substance abuse cessation, that will benefit her and the fetus, and refer her to resources to help her with these problems. One Internet resource for smoking cessation that is designed for pregnant adolescents is www.smashoutcigarettes.org. The site uses pictures, video, and information to show the immediate effects of smoking on the teen and her baby (Comer & Grassley, 2011).
Stress Reduction
Identify the stressors in the adolescent’s life. Stress may be related to basic needs such as food, shelter, and health care. Fear of labor and delivery and fear of being single, alone, and unsupported all create stress. Meeting the developmental tasks of adolescence while working on the developmental tasks of pregnancy is another stressor.
A variety of measures may be used to reduce stress, depending on the teenager’s age, situation, and available support. Refer adolescents with chronic life stress to a social worker to achieve stability. If the girl is very young or if the pregnancy occurred as a result of rape or incest, social service and law enforcement agencies must become involved to provide protection and assistance.
The pregnant teenager often experiences stress because she has not told her parents or the father of the infant about the pregnancy. Role-play the encounter with her to help her work out a plan for breaking the news. Although there is strain on the relationship when the teen first tells her parents, her relationship with her parents may improve over time if her parents are supportive.
Teens who experience high levels of stress during pregnancy and postpartum may spend less time on infant care activities, feel less competent as parents, and have a more difficult time adjusting to being mothers than teens with lower levels of stress during pregnancy and postpartum (Holub, Kershaw, Ethier, et al., 2007). Therefore interventions to reduce stress in pregnant adolescents affect the infant as well as the mother.
Help the teen think ahead to how her life will change as a result of the pregnancy and what might interfere with the mother role. Help her identify possible solutions to the problems presented. Assistance with resolving conflict with support persons and identifying new sources of support are other important interventions.
Attachment to the Fetus
Because attachment begins during pregnancy, helping the adolescent begin this process is important. Seeing the fetus move during an ultrasound often changes any pregnant woman’s perceptions about the fetus. Hearing the fetal heartbeat and feeling the baby move may also increase attachment. Looking at illustrations of the fetus at different gestational ages increases the mother’s interest. A heightened awareness of the fetus may make her more likely to follow suggestions that will enhance fetal well-being. Discussion of fetal changes month to month may lead to discussion of the capabilities and needs of the neonate.
Breastfeeding
Adolescents who decide to breastfeed their infants need much support in their endeavor. Adapt teaching to the mother’s level of understanding. Encourage questions as they may have much misinformation. Privacy is important to adolescents as they often feel embarrassed to breastfeed in front of others. Provide help with correct positioning and latching the infant. Show her how to drape a blanket to cover her breast and the nursing infant. Check on the mother frequently during feedings to identify any problems and intervene appropriately in a timely manner. Discuss problems that may occur so she has a realistic understanding of them and knows when and where to seek help, if necessary. Offer praise liberally. Success in latching the baby onto the breast and seeing the infant gain weight may be very rewarding for the mother.
Promoting Family Support
The pregnant teenager needs encouragement to include her family in her decision making and problem solving. Discuss topics such as who will care for the infant, whether the teenager will return to school, and what financial assistance is available from the family and the infant’s father. Adolescent mothers who have adequate emotional support are more likely to learn appropriate parenting techniques.
If, however, the family has multiple problems such as substance abuse or domestic violence, involving family members may be inappropriate. The teenager should be encouraged to communicate with a family friend or other trusted adult instead.
Providing Support during Labor
The needs of the pregnant adolescent during labor are similar to those of the older woman. They need to feel respected and that the nurse cares about them. Help with pain management is particularly important. They also want to feel their support persons were supported by the nurse. Younger teens respond to praise while older teens may focus on receiving information from the nurse (Sauls, 2010).
Providing Referrals
Make referrals to conveniently located community and national resources for pregnant adolescents. Include well-baby clinics offered by public health services, programs for school-age mothers offered by many school districts, TANF, and WIC. Church and community organizations may also provide needed assistance.
Evaluation
Delayed Pregnancy
An increasing number of women become pregnant relatively late in their reproductive lives. In 2009, the birth rate for women aged 40 to 44 years increased to 10.1 per 1000 women (Kochanek, et al., 2012). Advances in contraception and improved infertility treatment allow women more options in childbearing.
Maternal and Fetal Implications of Delayed Pregnancy
When the mature woman decides to conceive, she may experience a delay in becoming pregnant, particularly after the age of 35 years. This is because of the normal aging of the ovaries and the increased incidence of reproductive tract disorders. (See “Infertility” in Chapter 31.)
Although most pregnancies in mature women are normal, there is an increased risk of complications associated with pregnancy. The risks may be genetic, a result of preexisting medical conditions, or from obstetric complications. Advanced maternal age is associated with an increased risk for fetal chromosome abnormalities such as trisomy 21 (Down syndrome). Genetic abnormalities also increase when the father is older than 55 years (Johnson, Gregory, & Niebyl, 2007).
The most common examples of preexisting diseases that can cause maternal or fetal jeopardy are hypertension and diabetes mellitus. Uterine myomas (fibroids) occur with greater frequency in women older than 35 years and may be associated with postpartum hemorrhage. The older woman is also at increased risk for obstetric complications such as spontaneous abortion, gestational diabetes, cesarean birth, preterm delivery, stillbirth, preeclampsia, multifetal gestation, placenta previa, abruptio placentae, and low-birth-weight infants (Bayrampour & Heaman, 2010; Cunningham et al., 2010; Lu, Williams, & Hobel, 2010; March of Dimes, 2009).
Most women who have delayed pregnancies have few problems and deliver healthy infants. Those who develop complications can often have a successful pregnancy with good medical and nursing care.
Advantages of Delayed Childbirth
Mature primigravidas come to the parenting role with a range of personal resources: psychosocial maturity, self-confidence, and a sense of control over their lives. In addition, they are capable of solving complex problems and are often adept at maintaining interpersonal relationships. Many have made a conscious decision to wait until they are older to start their families. Because they are more likely to be financially secure, they can afford good care for their infants. They are experienced at setting priorities and developing plans. They are usually able to manage stress and will seek support and assistance when needed. They are often more accepting and feel less conflict in the parenting role (von Kohler, 2011) (Figure 24-2).
Disadvantages of Delayed Childbirth
Pregnancy complications that the woman did not expect may occur causing a need for activity restrictions or missed work. After childbirth, mature primiparas need more time to recover and have less energy than their younger counterparts. They may find child care an exhausting experience for the first few weeks, particularly if they had a cesarean birth or other complications of pregnancy.
Peer support may be less available for mature primigravidas. Some older women have chosen to have a child without a partner and lack the support that women with partners have (Mandel, 2010). Many of their friends have teenage children and no longer relate to the concerns of a new mother. Younger mothers have some of the same concerns, but they often do not share the perspective of older mothers.
Family support may also be lacking for the older woman. Her parents are usually in their 60s or 70s and may not be able to assist with child care to the extent that younger grandparents can.
Nursing Considerations
Preconception Care
Preconception care is particularly important for the older woman planning to become pregnant. A visit to the nurse-midwife, nurse practitioner, or obstetrician can identify risk factors and correct them, whenever possible. The preconception visit is essentially the same as for a younger woman but pays particular attention to any medical conditions more likely to occur in the older woman (see “Preconception Care” in Chapter 13).
Reinforcing and Clarifying Information
Because the fetus of a mature woman is at increased risk for chromosomal anomalies, information about available diagnostic tests will be provided (see Chapter 15). The tests most often recommended are multiple marker screening, chorionic villus sampling, amniocentesis, and ultrasonography. The family’s beliefs and attitudes about abortion may determine whether the woman will have the recommended tests. The woman who would not consider abortion regardless of the condition of the fetus may refuse diagnostic studies or have them to help prepare them for the problems that will occur at birth. Nurses must respect the decision of each woman and acknowledge that it may have been difficult to make.
Facilitating Expression of Emotions
Several days or weeks may pass between the performance of some diagnostic studies and receipt of the results. This is a particularly difficult time for many expectant parents, and nurses often assist the couple to express their concerns and emotions (see Chapter 15).
Mature gravidas also worry about complications that may affect the fetus or their own health. They are aware that they may not have another opportunity for pregnancy because of their age. They may also be concerned about their ability to balance their careers with increased family responsibilities.
Providing Parenting Information
Nurses often help the mature primipara prepare for effective parenting. Anticipatory guidance about measures that will help conserve energy after childbirth is very useful. Such measures include meal planning and setting realistic housekeeping goals. In addition, many older mothers need to mobilize all available support so that they can reserve their energy for infant care.
During the first weeks after childbirth the mother may experience feelings of social isolation, particularly if her friends have children who are much older. If she is accustomed to the mental stimulation of a job, she may miss it while staying at home. If she elects to return to work, she is likely to experience guilt and grief because she must leave her infant.
Older gravidas are more likely to seek out information they need from a variety of sources. First-time mothers older than 35 years are especially receptive to prenatal classes. Classes provide an opportunity to meet other older expectant parents with whom they have much in common. Women may have special concerns about the risks they face and may have many questions. They often adopt health-promoting activities such as improving nutrition and eliminating harmful substances. Printed materials that can be used to reinforce teaching are often helpful.
Substance Abuse
The use of legal substances, such as alcohol and tobacco, use of illicit drugs, and abuse of prescription drugs increase the risk for medical complications in the mother and poor birth outcomes in the infant. Approximately 5.1% of pregnant women reported using illicit drugs during the preceding month in a government study (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009).
Incidence
Although tobacco, alcohol, and marijuana are the most commonly abused substances, the use of opioids, cocaine, and amphetamines has had a major impact on health care for pregnant women and their offspring. A Healthy People 2020 goal is to increase abstinence in pregnant women to 98.3% for alcohol, 98.6% for cigarette smoking, and 100% for use of illicit drugs (USDHHS, 2010).
Maternal and Fetal Effects
When a pregnant woman uses a substance, the fetus experiences the same systemic effects as the expectant mother but often more severely and for a longer time. A drug that causes intoxication in the woman causes it for prolonged periods in the fetus. The fetus cannot metabolize drugs efficiently and will experience the effects long after they have abated in the woman. Maternal, fetal, and neonatal effects of commonly abused substances are summarized in Table 24-1.
TABLE 24-1
MATERNAL AND FETAL OR NEONATAL EFFECTS OF COMMONLY ABUSED SUBSTANCES
| SUBSTANCE | MATERNAL EFFECTS | FETAL OR NEONATAL EFFECTS |
| Caffeine (coffee, tea, cola, chocolate, cold remedies, analgesics) | Stimulates CNS and cardiac function, causes vasoconstriction and mild diuresis; half-life triples during pregnancy | Crosses placental barrier and stimulates fetus; teratogenic effects are undocumented |
| Tobacco | Decreased placental perfusion, abruptio placentae, anemia, PROM, preterm labor, spontaneous abortion | Prematurity, LBW, neurodevelopmental problems, increased incidence of SIDS |
| Alcohol (beer, wine, mixed drinks, after-dinner drinks) | Spontaneous abortion, abruptio placentae | Fetal demise, FGR, fetal alcohol spectrum disorders, FAS (facial and cranial anomalies, developmental delay, intellectual impairment, short attention span) |
| Marijuana (“pot” or “grass”) | Often used with other drugs: alcohol, cocaine, tobacco; exact effects undetermined | Unclear, more study needed, may be related to neurobehavioral problems; increased risk of anomalies or mortality unproven |
| Cocaine (“crack”) | Hyperarousal state, euphoria, generalized vasoconstriction, hypertension, tachycardia, increased STDs, increased spontaneous abortion, abruptio placentae, preeclampsia, PROM, preterm labor, precipitous delivery | Tachycardia, stillbirth, prematurity, irritability, sleep followed by agitation, poor response to comforting or interaction, possible attention and language problems |
| Amphetamines and methamphetamines (“speed,” “crystal,” or “ice”; ecstasy) | Vasoconstriction, tachycardia, hypertension, spontaneous abortion, preterm labor, abruptio placentae, preeclampsia, and retroplacental hemorrhage | Increased risk for FGR, prematurity, cleft palate, abnormal sleep patterns, agitation, poor feeding, vomiting |
| Antidepressants such as selective serotonin reuptake inhibitors | Relief of anxiety and depression, risk of anomalies with paroxetine, small risk of anomalies for other antidepressants | Transient respiratory distress, irritability, poor tone, persistent pulmonary hypertension |
| Opioids (heroin, methadone, morphine) | Malnutrition, anemia, increased incidence of STDs, HIV exposure, hepatitis, thrombosis, cardiac disease, spontaneous abortion, preterm labor | FGR, LBW, perinatal asphyxia, meconium aspiration syndrome, neonatal abstinence syndrome, fetal or neonatal death, SIDS, child abuse and neglect, long-term developmental effects unclear |
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