200 million pregnancies every year.
↑ risks for certain populations: adolescents, older
women, HIV women, substance abuse or sexual
Pregnancy experience is unique & personal.
Many go through confusion & isolation.
Desperately need help!!!!!!!!!!!!!!!!!!
THE PREGNANT ADOLESCENT
Time: onset of puberty to the cessation of
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
Seeking economic & social stability.
Developing a personal value system
Building meaningful relationship with others
Becoming comfortable with their changing
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.
Adolescent pregnancy is a complex issue with many
reasons for concern. Kids age 12 - 14 years old are more
likely than other adolescents to have unplanned sexual
intercourse . They are more likely to be talked into
having into sex.
Up to two-thirds of adolescent pregnancies occur in
teens aged 18 - 19 years old.
Risk factors contd……
Peer pressure to become sexually active
Sexual abuse as a child
Lack of information regarding contraception
Culture / ethnicity
Low self esteem
Strong need for someone to love
Early dating without supervision
Pregnancy symptoms include:
Breast enlargement and breast tenderness
Light-headedness or actual fainting
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
A pregnancy ultrasound may be done to confirm or
check accurate dates for pregnancy.
IMPACT OF PREGNANCY ON
‣ Negative impact in terms of health & social
‣ 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
All options made available to the pregnant teen should be
considered carefully, including
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 non-
judgmental 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.
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
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
Girls born to teen mothers are more likely to become
teen mothers themselves, and boys born to teen
mothers have a higher than average rate of being
arrested and jailed.
1. Imbalanced nutrition : less than body requirements
related to insufficient intake
2. Risk for injury : maternal & fetal related to inadequate
prenatal care & screening.
3. Social Isolation related to body image changes
4. Interrupted family processes related to adolescent
5. Disturbed body image related to situational crisis of
6. Risk for impaired parenting related to immaturity &
lack of experience
Cheryl Anderson & Michelle Mccarley : Psychological
Birth trauma in adolescents experiencing an early
birth. Maternal & Child Nursing. May/Jun 13
Cross- sectional descriptive study compared 2 groups
of adolescents(delivering prior to 38 weeks & between
38 – 42 weeks) for PBT.
Results: single Primigravida over 16 yrs of age.
Adolescents delivering before 38 weeks though LSCS
reported symptoms of depression & were at highest
risk for PBT. Additionally they lacked pain control &
unsupportive caregivers in Labor.
Does Watching Sex on Television Predict
-Anita Chandra, DrPH, Steven C. Martino, PhD
Data from a national longitudinal survey of teens (12–17
years of age, monitored to 15–20 years of age) were used to
assess whether exposure to televised sexual content
predicted subsequent pregnancy for girls or responsibility
for pregnancy for boys. We measured experience of a teen
pregnancy during a 3-year period.
RESULTS: Teens who were exposed to high levels of
television sexual content were twice as likely to experience
a pregnancy in the subsequent 3 years, compared with
those with lower levels of exposure
Depression and Teenage Pregnancy
By Jane Collingwood
Analysis showed that teenage mothers had higher
levels of depression than other teenagers or adult
mothers, but the experience of teenage childbearing
did not appear to be the cause. “Rather, teenage
mothers’ depression levels were already higher than
their peers’ before they became pregnant, and they
remained higher after childbearing and into early and
Results suggest that the combination of poverty and
existing distress was a good predictor of teen
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.
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
Mixed emotions among mothers.
Parents must prepare a safe & nurturing environment
during pregnancy 7 after birth.
Must integrate child into an established family system.
Number of 1st time pregnancies has increased
significantly over last 3 decades.
Reasons for delaying pregnancy include:
Desire for advanced education
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 &
↑ 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 &
Ambivalent feeling towards pregnancy.
Need help to cross 2 simultaneous phases of life :
becoming involved with the world & concentrating on
the baby inside her.
Pre natal Assessment
Begin prenatal care early
Fortunately women in this age group are well –
Few may attribute lack of menstruation to menopause.
Ask about present symptoms of pregnancy.
How they feel about pregnancy
Enquire about any self medication.
Family Profile : source of income
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)
Hypertension, Pre-term or Post-term 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
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
Social, genetic & environmental factors need to be
considered & appropriate interventions planned!!!!!
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
Constipation related to progesterone effect on the
Gastro-intestinal tract as evidenced by woman’s report
of altered patterns of elimination
Fear related to deficient knowledge regarding onset of
labor & processes of labor related to inexperience as
evidenced by woman’s questions & concerns.
Risk for injury: maternal & fetal due to complications
associated with elderly pregnancy.
Pain related to labor process.
Knowledge deficit related to labor processes
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.
M.A. Sajjad et all, “FIVE YEAR STUDY OF ELDERLY PRIMIGRAVIDA AT AMIN
HOSPITAL” Iranian Journal of Public Health 1977;6(3) : 121-134
In a period of 5 years there were 30000 deliveries at Amin hospital, among
them, 355 deliveries of primigravidas over 35 years of age who were included in
this retrospective study. Comparison with the same number of primigravidas
under 30 years of age indicate a much higher rate of fetal and neonate mortality
as well as other minor and major complications in the older group.
Incidence of breech presentation and twins was high,
Duration of pregnancy, first and second stage of labor also was longer
Operative deliveries including forceps and vacuum deliveries were more
frequent and the rate of cesarean-section was high (19.4% comparing with 5.5%
in control group).
Toxemia of pregnancy, hyper tension, ante partum and
postpartum, hemorrhage, fetal and neonatal mortality showed an increased'
frequency in the studied group
Distribution of congenital malformations were found to be equal except that a
case of Down syndrome was recorded in the studied group.
The outcome of pregnancy in elderly primigravidas.
Haifa A Al-Turki, Saudi medical journal(impact factor: 0.52). 11/2003; 24(11):1230-3
To investigate the effect of advancing age of 35 years and more on the outcome of pregnancy in
nulliparous women and to compare the type of complications observed in this group of women to those
in the age of 20-34 years.
This was a retrospective analysis of 2517 primigravidas delivered at King Fahd Hospital of the
University, Al-Khobar, Kingdom of Saudi Arabia between 1996-2000.
The data were collected from the records of the labor room and the medical records were screened for
maternal age, antenatal complications, gestational age, birth-weight of the neonate, sex of the neonate
and the Apgar score.
Between age of 20-34 years (Group A) there were 1950 patients with the mean age of 24.79 years
(range 20-34) and in women over the age of 35 years (Group B) there were 205 patients with the mean
age of 38.72 years (range 35-48 years).
Group B had significantly less number of normal deliveries 59.9 compared to group A 81% with p value
of <0.001. Diabetes mellitus was common in group B as compared to group A and was statistically
significant at p value <0.001.
The gestational age in group B was 36.06 weeks and in group A it was 38.84 weeks (p value was
markedly significant at <0.001).
Women in group B had more deliveries by cesarean section (CS) 23.8% as in group A 12.6%, a significant
p value <0.001. The birth-weight in group B was less compared to group A, p value of <0.002.
Childbearing in elderly primigravidas does have higher rates of complications due to diseases such as
diabetes mellitus and preeclamptic toxemia. They are liable to have more deliveries by CS than by other
methods, in spite of lower gestational age and birth weight. The overall outcome however does not
appear grim, as was once believed. This study suggests that women in the age group of >35 years should
be informed of their pregnancy expectations and outcomes.
Lady who becomes pregnant without legal
justification of physical intimacy between man &
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
Improper Sex Education
Consequences of being an Unwed
For the mother
Not socially acceptable
Considered a curse.
Brings a lot of personal disorganization
Lack of support from family & society
Difficult life ahead
Also bears the brunt of negative consequences.
May suffer boycott from community
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
Prevention of Unwed Pregnancy
Supply of contraceptives
Abolition of Prostitution
Factors influencing care of unwed
Age of the mother
Approach towards pregnancy
Social and cultural background
Role of a Nurse
As an :
Ms Jeevitha, 26 yr old unmarried woman presented to casualty
0n 23/07/13 with complaints of severe headache & GTCS, one
episode of vomiting & unconsciousness on 23/07/13
H/o severe anemia before 2 months, transfused 2 pints of
B.P.- 220/180 mmhg
Alleged to have LMP 7 days back.
Diagnosed as ? Hypertensive of young & seizure disorder.
Shifted to I ward, confided LMP was 26/01/13.
Scan showed fetal movement & fetal heart ve
Final diagnosis : Unmarried Primi @ 25 3 weeks of
gestation with Eclampsia.
Termination of pregnancy advised.
Induced : expelled fresh still born baby boy @ 3;40 pm
TPR stable, B.P- 130/90 mmhg
Patient feels guilty of being pregnant.
Cries occasionally, feeling shy to face parents now
Few family members told about actual diagnosis :
supportive of the mother.
Patient now wants to do her parent’s will for her
whatever it may be!!!!!!!!!!
Social problem affecting all societies.
1 out of 4 US women have been physically & sexually
assaulted by an intimate partner.(NVAWS)
1 women being battered every 12 sec in US (Penny
2 types of violence : intimate partner violence & sexual
THE CYCLE OF VIOLENCE
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 &
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
Threatening to kill the victim
Forcing victim to perform humiliating acts
Making demeaning remarks about victim
Hitting, grabbing, pushing, choking , kicking or causing
physical harm to victim
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
Female Genital Mutilation
Childhood Sexual Abuse
Any type of exploitation that involves a child younger
than 18 yrs of age.
disrobing, nudity, masturbation, fondling, digital
penetration & intercourse.
Lifelong impact on survivors.
Early abuse : lowers self esteem & ability to protect
Influences the way victims live their lives & form
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.
It is an act of violence
Legal rather than a medical term
Denotes penile penetration of the female or male
Statutory Rape : sexual activity between an adult & a
person under 18 despite the willingness of the
Acquaintance Rape : involves someone being forced
to have sex by a person he or she knows.
Date Rape : sexual assault which occurs within dating
Drugs used : “club drugs”; Rohypnol, Ketamine etc
Phases of Rape Recovery
Acute Phase : shock, fear , disbelief , anger , shame
, guilt, feelings of un-cleanliness, insomnia &
Outward Adjustment Phase : appears outwardly
composed & returns to work or school ; refuses to
discuss the assault & denies need for counseling
Re-organization Phase : survivor attempts to make
life adjustments by moving or changing jobs.
Female Genital Mutilation
Also called “female circumcision”.
Cultural practice followed in Africa, Middle- East &
Definition - Procedure involving the partial or total
removal or other injury to the female genital
organs, whether for cultural or other non- therapeutic
More than 140 million girls estimated to have
2 million at risk annually.
Reasons for performing
Ideology & cultural value of each community.
Rite of passage into womanhood
Means of preserving virginity
Performed when girl is between 4 and 10 yrs old ; age
when she cannot give informed consent for a
procedure with life-long health consequences.
Untrained village practitioners using no form of
anesthesia perform the operation.
Cutting instruments : broken glass, knives, tin
lids, scissors, unspecialized razors & crude
Types of FGM Procedures
Type 1 Excision of Prepuce
Type 2 Excision of Clitoris & part or all of the Labia Minora
Type 3 Excision of all or part of the external genitalia & stitching of vaginal
Type 4 Pricking or Piercing or incision of the clitoris or Labia
Cauterizing by burning the clitoris & surrounding tissue
Scraping or cutting vaginal orifice
Introduction of corrosive substance into vagina
Placing herbs into vagina to narrow it.
Health Risks Associated with FGM
Intense pain & dysmenorrhea
Damage to urethra, vagina & anus
↑ morbidity & mortality during childbirth
Modern form of slavery
Women & children are held captive & forced to have
sexual intercourse with numerous people.
Victims : lack education, employment
Traffickers promise victims employment as
nannies, maids, models etc.
Traffickers transport victim from their countries to
Once captive, traffickers coerce them using
rape, torture, starvation, imprisonment into
prostitution, pornography, sex trade or forced labor
- Violence Protection Act, 2000
Impact of Sexual Violence
Devastating short & long term effects.
Women experience psychological, physical & cognitive
Posttraumatic Stress Disorder : develops when an
event outside the range of normal human experience
occurs that produces marked distress in the person.
Intrusion: re-experiencing the trauma, includes
nightmares, flashbacks, recurrent thoughts.
Avoidance: avoiding trauma related stimuli, social
withdrawal, emotional numbing.
Hyper-arousal: increased emotional
arousal, exaggerated startle response, irritability.
Deficient Knowledge related to understanding the
cycle of violence & availability of resources.
Fear related to possibility of severe injury to self or
child during cycle of violence.
Low self – esteem related to feelings of worthlessness.
Hopelessness related to prolonged exposure to
Compromised individual & family coping related to
persistence of victim-abuser relationship.
Goal : enable victim gain control of her life.
Key : good, non- judgmental communication.
Primary : aimed at breaking the abuse cycle through
community educational initiatives by health worker.
Secondary : deals with victims & abusers in early
stages with goal of preventing progression of abuse.
Tertiary : activities geared toward helping severly
abused women & children recover & become
productive members of society. Rehabilitating abusers
to stop the cycle of violence.
“Rape and Abortion” by Fr. Frank A. Pavone
International Director Priests for Life
The woman who has been raped has undergone a
terrible trauma and injustice.
Will an abortion help her? First of all, the abortion will
not un-rape the woman
Second, abortion brings a trauma of its own.
In rape, the trauma is "Someone hurt me." In abortion,
the trauma is "I hurt and killed someone else -- my
Abortion is never the answer. Let's not add violence to
violence. When it comes to the woman who carries a
baby conceived by rape, let's choose to love them both!
Women Who Became Pregnant Through Sexual Assault Say, “Ask Us”
Of the respondents, 164 were victims of rape and 28 were victims of incest
(sexual assault involving a family member). Overall, 69 percent continued
the pregnancy and either raised the child or made an adoption plan, 29
percent had abortions and 1.5 percent had miscarriages.
Nearly 80 percent of the women who aborted the pregnancy reported that
abortion had been the wrong solution.
Most women who had abortions said that abortion only increased the trauma
they were experiencing.
In many cases, the victim faced strong pressure or demands to abort. 43
percent of rape victims who aborted said they felt pressured or were
strongly directed by family members or health workers to abort.
In almost every case where an incest victim had an abortion, it was the girl’s
parents or the perpetrator who made the decision and arrangements for the
abortion, not the girl herself.
More than 80 percent of the women who carried their pregnancies to term
said that they were happy that they had continued the pregnancy.
None of the women who gave birth to a child conceived in sexual assault
expressed regret or wished they had aborted instead.
Most pregnant women reluctant to reveal substance
Use of drug ↑ risk of medical complications in mother
Placenta acts as an active transport mechanism.
Many drugs : Teratogenic effects.
Critical determinants of effect of drug on fetus :
drug, dosage, route of administration, timing of
Common substances abused
Alcohol related effects
No amount of alcohol consumption is safe during
FAS →Fetal Alcohol Spectrum Disorder (FASD)
Limb & Cardiac anomalies
Characteristic Features (FASD)
Small head circumference
Short palpebral fissures & small eye openings.
Thin upper lip
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
Poor abstract thinking
Poor impulse control
Speech & language problems.
Emphasizes screening & prevention to reduce the high
incidence of obstetric & medical complications among
users as well as their passively addicted infants
Urine toxicology screening
Education about effects of substance exposure of fetus
Interventions to improve mother – child attachment &
Referral to outreach programs
Follow – up of children born to dependent mothers.
More frequent prenatal visits
Support systems & vocational assistance.