COLLEGE OF NURSING

Silliman University
Dumaguete City

Resource Unit: Care of Adolescent Pregnancy and

Pregnancy 35 years and above

Second Semester, SY 2007-2008

Level III

Submitted by:
Divinagracia, Eden Mae
Javier, Johanna
Nodado, Judee
C4

Submitted to:
Mrs. Kathleah S. Caluscusan

COLLEGE OF NURSING
Silliman University
Dumaguete City
 RESOURCE UNIT:

Vision: As a leading Christian Institution committed to total human development

for the well-being of society and environment.

Mission:
• Infuse into the academic learning the Christian faith
anchored on the gospel of Jesus Christ; provide an
environment where Christian fellowship and relationship
can be nurtured and promoted.
• Provide opportunities for growth and excellence in
every dimension of the University life in order to
strengthen character, competence and faith.
• Instill in all members of the University community an
enlightened social consciousness and a deep sense of
justice and compassion.
• Promoted unity among peoples and contribute to national
development.

COLLEGE OF NURSING
Silliman University
Dumaguete City

Resource Unit: Care of Adolescent Pregnancy and

Pregnancy 35 years and above
PLACEMENT: NCM-102 - C4 Ward Class
TIME ALLOTMENT: 2 HOURS
TOPIC DISCRIPTION: This topic deals with the care of adolescent pregnancy. This tackles on its developmental tasks,
causes of adolescent pregnancy, and the preventive measures and nursing care management. Also, this
topic entails the care of pregnant women over the age of 35. It embarks the various complications
associated with this pregnancy and the necessary nursing care interventions.
CENTRAL OBJECTIVE: At the end of 2-hour presentation, the learners shall be able to acquire comprehensive knowledge,
develop competent skills and transpire positive and desirable attitudes and values toward the care
of adolescent pregnancy and pregnancy over 35 years old, thereby promoting optimal well-being.

SPECIFIC CONTENT T-L EVALUATION

OBJECTIVES ACTIVITIES
At the end of
the discussion
PRAYER
and activities,
the learners
shall: INTRODUCTION:

• Be able to Socialized Able to

define at I. Definitions Of Related Terms discussion define the
least 8 of the related
related terms 1. Adolescent pregnancy terms basing
in their own Teen pregnancy is one serious consequence of early initiation of on ones
words sexual activity. Other serious consequences include an increased understandin
likelihood of late or no prenatal care, unattended births, reduced g with 75%
educational attainment, and decreased employment opportunities. competency.
Infants of teenage mothers are at greater risk of low birth weight
and increased infant mortality.

2. Placenta Previa
The placenta is implanted in the lower portion of the uterus;
painless uterine contraction; with dark red bleeding; usually occur
on the 24th weeks of gestation.

3. Low- Birth Weight

Infants born weighing significantly less than normal are considered
to be premature; their chances of survival and normal development are
considerably improved if they are fed special formula preparations to
meet their needs, rather than being breast-fed or fed normal infant
formula. The normal range of weight at birth is between 2.5 and 4.5 
kg.

4. Gestational Diabetes
If your blood sugar level is too high when you are pregnant, you have
gestational diabetes. It usually goes away after the baby is born.
High blood sugar can cause problems for you and your baby. Your baby
may grow too large, which can cause problems during delivery. Your
baby may also be born with low blood sugar. But with treatment, most
women with gestational diabetes are able to control their blood sugar
and give birth to healthy babies. Women who have had gestational
diabetes are more likely than other women to develop type 2 diabetes
later on. Once you have type 2 diabetes, you always have it. You may
be able to prevent type 2 diabetes if you stay at a healthy weight,
eat healthy foods, and exercise.

6. Pregnancy Over the Age of 35

Pregnancy at ages 35 and above with potential complications.
7. Pregnancy Induced Hypertension
Pre-eclampsia is a disease that only occurs during pregnancy. Pre-
eclampsia, pregnancy-induced hypertension (PIH), and toxemia are
essentially interchangeable terms used by your care provider for this
disease. This disease is characterized by swelling, high blood
pressure, and the presence of protein in the urine. Pre-eclampsia
occurs in 5 to 10 percent of all pregnancies. It can appear suddenly,
without warning, any time throughout your pregnancy, labor, or in the
early postpartum period. This disease can also be chronic, gradually
becoming worse over a period of time. It may be mild or severe. But,
no matter how ill you become with this disease, whether it's sudden
or gradual, the only cure is delivery of the baby. There are
medications and treatments to keep you from becoming more ill with
the disease, but no medications will make the disease go away
entirely.

Your care provider will begin to look for signs of pre-eclampsia

during your second trimester and continue through your postpartum
period. Sometimes, early treatment can prolong a pregnancy and lessen
complications for both mother and baby.

If you are diagnosed with pre-eclampsia before your baby's due date,
your care provider will occasionally want to prolong your pregnancy.
If you are close to your due date, your care provider will most
likely prepare you and the baby for delivery.

After delivery, the disease eventually goes away, and it is unlikely

that you will suffer any long-term effects of the disease.
Occasionally, there are complications that will require medical
attention for a time after you deliver. This may include taking blood
pressure medication and frequent follow-up visits with your care
provider.

8. Iron- deficiency Anemia

Iron deficiency anemia occurs when your body doesn't have enough
 iron. Iron is important because it helps you get enough oxygen
throughout your body. Your body uses iron to make hemoglobin.
Hemoglobin is a part of your red blood cells. Hemoglobin carries
oxygen through your body. If you do not have enough iron, your body
makes fewer and smaller red blood cells. Then your body has less
hemoglobin, and you cannot get enough oxygen.

9. Preterm Labor
Preterm labor is the start of labor between 20 and 37 weeks of
pregnancy. A full-term pregnancy lasts 37 to 42 weeks. In labor, the
uterus contracts to open the cervix. This is the first stage of
childbirth. Preterm labor is also called premature labor.

10. Cephalopelvic Disproportion Matching Game

A condition in which the fetus is unable to pass safely through the / Picture
pelvis during labor because of pelvic contraction, an unfavorable presentation
fetal position, or a large fetal head in relation to pelvic size.

II. Adolescent Pregnancy Socialized

• Be able to discussion Able to
discuss the A. Review of the Different Developmental recall the
different Task different
developmental development
task of 1. Physiologic Development task.
Adolescent
Pregnancy Puberty begins between the ages of 9 and 14, when the hormones
thoroughly. from the hypothalamus trigger the secretion of the hormones in the
pituitary gland. Pituitary hormones increase the production of
estrogen and progesterone by the ovaries. Although the sequence of
events is universal, the onset of puberty is influenced by many
factors, such as sex, genes, body type, nutrition and health. The
first sign of puberty is the growth spurt. This accelerated
growth, which occurs approximately 2 years earlier in females than
in males, continues over 3-year period. Changes in the appearance
of their bodies may make adolescents feel shy and awkward.
The development of secondary sex characteristics, such as breast
and pubic hair, has an impact on the adolescent’s new body image.
Primary sexual characteristics include maturation of the female
ovaries and male testes, thus leading to reproductive maturity.

Maturation of the ovaries and testes is marked by menarche in

girls and first ejaculation in boys. Menarche occurs in adolescent
females about 3 years after the growth spurt and occurs in about
half of all girls about age 12 1\2 years, but it may occur as
early as 10 years or as late as 16 years. As the brain matures in
the pubescent girl, stimulation of the hypothalamus leads to the
secretion of the gonadotropic-releasing hormone (Gn-RH). Gn-RH
stimulates the anterior pituitary to release gonadotropins, which
stimulates the gonads to mature and release ova in the female and
to produce sperms in the males. These physiologic changes enable
the adolescent to reproduce. The first menstrual cycle is usually
anovulatory, with regular ovulation not occurring for about a
year.

2. Cognitive Development
Socialized
As the body changes, the adolescent begins to look inward and discussion
become more egocentric. Adolescent egocentrism is a stage of
cognitive development in which teens consider their own
experiences to be unique. Egocentric thought prompts adolescent to
create imaginary audiences that allow them to think that other
people are watching them. The creation of the imaginary audience
explains the common feeling of self-consciousness among
adolescents. The invisibility fable that “It can’t happen to me”
is and extension of adolescent egocentrism.

Generally, adolescents who exhibit a high degree of egocentrism

 have not yet mastered formal operational thought. The logical and
abstract reasoning involved in formal operational thought allows
adolescents to speculate, form hypotheses, and imagine
possibilities. However, Piaget maintains that maturation of the
adolescent’s brain and body makes formal operational thought
possible, but not inevitable. Thus many adolescents continue to
use concrete operational thought and cannot imagine the future
consequences of their actions. Social interactions and education
are essential factors in enabling an individual to attain formal
operational thought.

3. Moral Development

As thought processes mature, so does moral reasoning. Cognitive

and psychosocial development allows adolescents to think more
abstractly and to question the moral views of their parents.
Social development exposes them to various ethical values.
Personal experiences force adolescents to make decisions on their
own and to consider moral questions more broadly than before.
According to Kohlberg, most young adolescents follows rules for
the purpose of gaining approval from other or to be a good citizen
(conventional level of morality). As late adolescents mature
cognitively and gain experiences with right and wrong, they
develop their own personal moral code (post conventional
morality). However, Kohlberg’s theory has been criticized for
being biased against women, who intend to see moral dilemmas
differently than men. According to Gilligan, men view moral
dilemmas in terms of the rights of others, whereas women are more
concerned with the needs of others.

4. Psychological Development
 The primary developmental task of adolescence is the search for Lecture-
identity, both as an individual and as a member of the larger discussion /
community. The ultimate goal is identity achievement, which occurs Matching game
when adolescents develop their own belief system and career goals.
Although adolescents strive to achieve individuality, they have self-
doubts and seek acceptance from their peers. In addition to the
search for independence, adolescents also depend on their parents for
financial and emotional support. Some adolescents achieve identity
prematurely, a process Erikson calls foreclosure. Others experience
identity diffusion with few commitments to goals, values, or society.
Some adolescents, unable to find alternative roles, rebel and adopt a
negative identity and become the opposite of what is expected of
them. Some adolescents postpone career and marriage decisions
(declaring a moratorium on identity formation) by attending college
or serving in the military.

• Clearly B. STD’s HIV in Adolescents

verbalize
understanding Vaginal, anal, and oral intercourse place young people at risk for Socialized Understand
on STD’s and HIV infection and other sexually transmitted diseases (STDs). Vaginal Discussion the causes
HIV in intercourse carries the additional risk of pregnancy. In the United if STD’s HIV
Adolescents States in
and its causes adolescent
• In 2005, 47% of high school students had ever had sexual pregnant
intercourse, and 14% of high school students had had four or more woman
sex partners during their life.1

• In 2005, 34% of currently sexually active high school students

did not use a condom during last sexual intercourse.1

• In 2002, 11% of males and females aged 15-19 had engaged in anal
sex with someone of the opposite sex; 3% of males aged 15-19 had
had anal sex with a male.2

• In 2002, 55% of males and 54% of females aged 15-19 had engaged
in oral sex with someone of the opposite sex.2
 • In 2004, an estimated 4,883 young people aged 13-24 in the 33
states reporting to CDC were diagnosed with HIV/AIDS,
representing about 13% of the persons diagnosed that year.3

• Each year, there are approximately 19 million new STD infections,

and almost half of them are among youth aged 15 to 24.4

• In 2000, 13% of all pregnancies, or 831,000, occurred among

adolescents aged 15-19.5

In addition, young people in the United States use alcohol and other
drugs at high rates.6 Adolescents are more likely to engage in high-
risk behaviors, such as unprotected sex, when they are under the
influence of drugs or alcohol. In 2005, 23% of high school students
who had sexual intercourse during the past three months drank alcohol
or used drugs before last sexual intercourse.1

Abstinence from vaginal, anal, and oral intercourse is the only 100%
effective way to prevent HIV, other STDs, and pregnancy. The correct
and consistent use of a male latex condom can reduce the risk of STD
transmission, including HIV infection.8,9 However, no protective method
is 100% effective, and condom use cannot guarantee absolute protection
against any STD or pregnancy.

HIV/STD prevention education should be developed with the active

involvement of parents, be locally determined, and consistent with
community values. It should address the needs of youth who are not
engaging in sexual intercourse and youth who are currently sexually
active, while ensuring that all youth are provided with effective
education to protect themselves and others from HIV/STD infection now
and lifelong.

• Cite the C. Causes of Adolescent Pregnancy

different Socialized Cited the
causes of Discussion different
adolescent The rate of adolescent pregnancy has steadily declined since reaching causes of
pregnancy an all-time high in 1990, mostly due to an increase in the use of adolescent
correctly. condoms. In fact, the birth rate among girls ages 10-14 has fallen to pregnancy
the lowest level in almost 50 years. through oral
questioning.
Since no form of contraception is completely effective, abstinence
(not having sexual intercourse) is the only sure way to prevent
pregnancy. A sexually active teenager who does not use contraception
has a 90% chance of becoming pregnant within a year.

Why teenagers have sex, and do so without effective methods of

contraception, is a topic of debate. Suggested reasons include:

• Adolescents become sexually mature (and fertile) approximately 4-

5 years before they reach emotional maturity.

• Adolescents today are growing up in a culture in which peers, TV

and movies, music, and magazines transmit subtle and obvious
messages that unmarried sexual relationships (specifically those
involving teenagers) are common, accepted, and even expected.
• Education about responsible sexual behaviour and specific, clear
information about the consequences of sexual intercourse
(including pregnancy, sexually transmitted diseases, and
psychosocial effects) are frequently not offered. Therefore, much
of the "sex education" that adolescents receive filters through
misinformed or uninformed peers.

When compared with other industrialized nations, the United States has
the highest rates of pregnancy, abortion, and childbirth among
teenagers, despite similar or higher rates of sexual activity in the
other countries.
 Teens are more likely to become pregnant if they:

• Begin dating early (dating at age 12 is associated with a 91%

chance of being sexually involved before age 19, and dating at
age 13 is associated with a 56% probability of sexual involvement
during adolescence)
• Use alcohol and/or other drugs, including tobacco products
• Drop out of school
• Have no support system or have few friends
• Lack involvement in school, family, or community activities
• Think they have little or no opportunity for success
• Live in a community or attend a school where early childbearing
is common and viewed as normal rather than as a cause for concern
• Grow up in poverty
• Have been a victim of sexual abuse or assault
• Have a mother who was 19 or younger when she first gave birth
• Be able to Socialized
correctly Discussion
identify the B. Preventive Measures and Nursing Care Management
preventive Actively
measures and 1. Primary Prevention of Adolescent High Risk Sexual Behaviour participate
Nursing care and Pregnancy in the
Management. matching
game about
Adolescent Sexual Behaviour preventive
measures
that
The average for initiation of sexual intercourse is 16.2 years for focuses on
females and 15.7 years for males. The proportion of Caucasian the
adolescent women who had ever had sexual intercourse steadily assessment,
increased between 1980 and 1988, with 41.4% reporting having had nursing
premarital sexual intercourse in 1980.43.1% in 1985,and 59.6% in diagnosis,
1988.The trend for adolescent African-American women was somewhat expected
different .The proportion African-American women having ever had outcomes
sexual intercourse was 58.1% in 1980,declined to 55.4% in 1985,and and the
increased to 58.8% in 1988(CDC,1991 a,;1991 b). Although African – plan of
 American girls tend to initiate sexual intercourse at younger ages care and
than do European –American girls, racial differences are beginning implementat
to narrow because of the increased in ion
Premarital sexual intercourse among Caucasian teens (AGI, 1994;Leigh
et all ,1994).

In addition to racial differences, other demographic and

physiological factors have been linked with adolescent premarital
sexual intercourse .Demographic factors such as older age (Lock and
Vincent ,1995;Newcomer and Baldwin ,1992),low socioeconomic status
(Rabin and Hayward , 1993),single –parent family (lock Vincent ,1995 ;
young 1990 ) have been correlated with an increased incidence of
adolescent premarital sexual intercourse .the influence of parent –
adolescent communication is a strong predictor of sexual intercourse
,but others have found no relationship (Pirkens,1991).

Perceptions that their friends are sexually active (Lock and

Vincent ,1995;National institute of child health and human Development
,1991, Yawn and Yawn ,1993) lows educational goals (Dry
foots,1990)have been also associated premarital sexual intercourse
,most researches have not found a consistent relationship (Yawn and
Yawn ,1993 ;cabin and Hayward, `1993).

In every young sexually experienced adolescent ,sexual abuse

must suspected .In one study investigating the relationship between
sexual abuse the adolescent pregnancy ,researches found that 66% of
the 535 pregnant of parenting adolescent females had experienced no
voluntary sexual intercourse (Boyer and fine ,1992). The father of
the baby is often an adult.

Able to cite
3 or more
 nursing
Nursing Care Management assessment,
interventions
When adolescent choices include engaging in sexual activity, the and
adolescent is a risk for virus health problems. The nurse can work evaluations
affectivity with the sexual experienced adolescent to achieve optimal at 75%
health outcomes. The nursing process can be used to accomplish this competency.
goal.

a. Assessment

A thorough health history interview (including menstrual, sexual

and dietary factors )with review of systems ,complete physical
examination (including breast and pelvic examination ), and
laboratory test should be conducted .In addition ,assessment of the
psychosocial (e.g. sexual identity ,body image ,self-concept ),
cognitive –development stage , and support systems is essential
.the health is needed to identify learning and care needs ,.then
health history interview should be conducted in a quite ,private
room the adolescent fully clothed .An unhurried , non-judgemental
attitude will facilitate patient relaxation .The interview with no
threatening question.
After rapport is established with the patient, more sensitive
question may be asked. The nurse should be aware of culturally
unacceptable verbal non verbal responses. The nurse should be use
direct language, such as “sexual intercourse,”not” making love “.

i. Physical examination

A thorough physical examination is essential. The nurse should be

alert possibilities
Of sexual abuse of the young adolescent because the young adolescent
has little experience with what normal body functions are, STDs
may go unnoticed and unreported to health care providers to
treatment. heavy menstrual bleeding or other abnormal bleeding in
adolescent may be related abortion ,trauma endocrine diseases
,infection, or other causes ,such as taking oral contraceptives
incorrectly or even correctly (Hilliard and Rebar ,1990).

A pelvic examination is recommended for any teenage woman who sexually

active for those considering oral contraceptives. During puberty the
vaginal epithelium is thin .Therefore it is more vulnerable to
irritation and infection .contact vagina can result from performed
soap. Powders, sprays, and tight jeans or other garments.

Adolescent girls are modest and usually tense during the pelvic
examination. Instruction in relaxation techniques is helpful.
Lidocaine ointment may be used as a lubricant .the anxious
adolescent client may feel more comfortable using a mirror so she
can participate in the examination too painful and is truly unable
to cooperate, an examination under anesthesia may be necessary
(Hilliard and Rebar ,1990).

Although true breast disease is uncommon in adolescent girls ,

anxiety about symptoms such as welling is common .Breast examination
findings in teens commonly

b. Nursing Diagnosis

After a review of assessment findings from the interview,

physical examination, and laboratory /diagnostic test, appropriate
nursing diagnoses are formulated. Examples of nursing diagnoses that
may apply include the following :

-Body-image disturbance related to puberty.

-Decisional conflict related to unclear personal values or beliefs

regarding premarital sexual intercourse.

-Lack of experience with sexual decision making.

-Lack of relevant information.

Health-seeking behaviours: contraceptive use related to desire to

avoid pregnancy.

Non-compliance: contraceptive regimen related to lack of information

on correct contraceptive regimen unplanned sexual encounter side
effect of contraceptives.
.Health-seeking behaviour; safer sexual practices related to desire to
avoid sexual transmitted diseases.

c. Expected outcomes

A nursing care plan is based on the adolescent’s health care

needs. The expected outcomes for care, mutually determined by the
adolescent and the nurse, are stated-centered terms. Examples of
possible excepted outcomes include the following. adolescent will:

1. Demonstrate acceptance of changes in body as a result of puberty

(e.g., posture, grooming, and dress).
2. Verbalize personal values and beliefs about premarital sexual
intercourse .
3. Verbalize alternatives to sexual intercourse for expressing
feelings.
4. Verbalize that she and her partner are practicing safer
sexual behaviour.
5. Verbalize consequences associated with unsafe sexual
practices.
6. Verbalize /demonstrate correct method of using contraceptive
of choice.
7. Not contract an STD.

8.Not become pregnant.

 d. Plan of care and Implementation

i. Sexual education
Sexuality education. In review of school-based sexuality education
programs, Kirby (1992) described the evolution of sexuality education
programs. Initially, sexuality education programs focused on
knowledge about Ricks and consequences of pregnancy, values
clarification, and development of decision-making and not
accelerate or delay the initiation of sexual intercourse .Those who
were concerned that sexuality education be value-free developed
abstinence-only programs. Evolution of abstinence –only programs has
shown that they are effective in changing attitudes about premarital
sexual intercourse but have had little effect on sexual behaviour.
Early evaluation of HIV/AIDS education programs have indicated an
increase in knowledge, but few studies have measured the effect on
sexual behaviour (Kirby et al ,1994).

More recently, sexuality education programs have been based on

theoretical models such as social learning theory. Preliminary
evaluation of programs based on social learning theory suggests that
they are effective in delaying sexual intercourse and reducing
unprotected sexual intercourse.

Parents may not involve themselves in sexuality education for

several reasons (1) they may not have adequate information;(2) they
may be uncomfortable with the topic of sex ;and (3) adolescent may
be un comfortable when parents find it difficult to acknowledge
that their ‘child ‘is a sexual person with sexual feelings and
behaviours .
Parental refusal to discuss sexual behaviour may cause the adolescent
to keep sexual activity secret and may interfere with the adolescent’s
efforts to seek help. National survey of parent reveal greater support
for inclusion of comprehensive sex education in school curricula and
at earlier ages for today’s youth (CDC, 1991a, 1991b).

Sexuality education programs should begin before puberty (some

suggest As Early as kindergarten ) and provide adolescent with
experience in personal decision making practice in applying the
information to their lives .Programs should address how to handle
peer pressure, focus on both females and males ,and involve parent to
enhance parent adolescent communication and to strengthen family
ties. Community institutions (e. g., churches, local lay groups ,and
professionals groups) should also be involved to lend financial or
volunteer support to the programs.

Health education to the primary prevention level includes providing

information about good hygiene, prevention of STDs contraceptive use.
Health education strategies needs to be creative and developmentally.
Culturally, educationally, and language appropriate. Education should
be appropriate for low-risk groups, high-risk groups, and parent or
partners of low- risk groups.

Nurses should promote school-based sexuality education for early

ages. In addition, since teachers report a lack of training sexuality
education (cabins and Hayward, 1993), nurses should take a more active
role in training sexuality concepts in school. Nurse can Facilitate
the development of peer counseling groups, with peer providing
information and counseling to other adolescent.

2. Secondary Prevention with Pregnant Adolescents

Teenage childbearing has been associated with unfavourable

consequences for mother, child, and society. After the birth of a
child the mother is at high risk for low educational attainment, low
SES, and dependency on public welfare. Teenager pregnancy remains the
major reason female adolescents terminate their education prematurely.
Leaving school early is associated with unemployment and poverty. Thus
adolescent parents often fail to complete their basic education, have
fewer opportunities for employment and career advancement, and have
limited earning potential. Younger mothers than older mothers live in
families with annual incomes near the poverty level.
 Pregnancy puts the adolescent and her baby at risk nutritionally.
Poor nutritional status can lead to inadequate weight gain during
pregnancy, which contributes to low birth weight in the infant. In
additional, mother younger than 15 years old are twice as likely to
deliver preterm or low- birth- weight infants. Pregnancy adolescents
are also at increased risk for iron deficiency anemia, which has been
associated with prematurity and low birth weight.

The incidence of abandonment, abuse, separated, and divorce is 2

to 4 times higher among adolescents married in their teens than among
those married in their 20s. In addition to the stress of the
transition to marriage, this family instability is related to other
variables, including low level of education, low level of employment,
and lack of support systems.

The Very Young Pregnant Adolescent

The pregnant adolescent younger than 15 years of age is most at

risk for problems I pregnancy and childbirth. The incidences of LBW
infants, infant mortality, and abortion are 2 to 3 times higher in
this age group than for women older than 25 years.

The very young adolescent is at particular risk because she enters

prenatal care later than do older adolescents and women. Late entry
into prenatal care may result from late recognition of pregnancy,
denial of pregnancy, or confusion about available. Late presentation
for care may result in inadequate time before the birth to attend to
correctable problems. The very young pregnant adolescent is at higher
risk for each of the confounding variables associated with poor
pregnancy outcomes and for those conditions associated with first
pregnancy. When prenatal care is given early and consistently and
confounding variables are accounted for, very young pregnant
adolescent are at no greater risk than older pregnant women. The role
of the nurse in reducing the risk and consequences of adolescent
pregnancy is thus twofold: first, to encourage early and continued
prenatal care and second, to refer the adolescent, if necessary social
support services, which can help reverse a negative socioeconomic
 environment.
• Properly
discuss and Identified
establish Development Tasks of Pregnancy the
deeper developmental
knowledge of The pregnant adolescent faces the same development tasks of pregnancy tasks of
the as the pregnant adult. These tasks include the following: pregnant
developmental 1Accepting the biologic reality of pregnancy. Most adolescent do not clients above
task of expect to become pregnant. They may deny it until the signs are 35 years at
pregnant woman so obvious they can no longer be ignored by family members. It id 75%
over the age common for teens to diet and wear constricting clothes to hide their competency.
of 35. condition and to succeed in concealing the pregnancy until it is
quite high.

2Accepting the reality of the unborn child. The adolescent may

accept only the fantasy of having a cute, happy, healthy baby to
dress up and play with like a doll. The idea of the infant’s growth
and development into an older child may not be a reality to the
adolescent.

3Accepting the reality of parenthood. Being a parent implies being

loving, concerned, and capable of providing the nurturing care an
infant needs. Although there usually is the desire to be a good
mother, young adolescent parents have limited life experiences,
their own need to grow and develop, and little ability to cope with
abstractions and to solve problems. The amount and type of support
available to adolescent can significantly influence the
accomplishment of these tasks.
Culture Influences

The pregnancy rate for poor and low-income minority adolescents

is high. Poverty and societal racism have a harmful affect on family
and community life. The lack of social and family support, nurturance,
and supervision of the adolescent (as may occur in single-family
household)- coupled with fewer opportunities to accomplish social and
educational goals- places these individual at high risk for pregnancy.
The availability of social support varies across ethnic groups.
In addition, cultural differences exist in adolescent’s knowledge
of sexuality and in their beliefs about pregnancy and prevention.
Nurses must be aware of differences in cultural beliefs if open
communication is to occur. When these beliefs are assessed and
incorporated into a plan of care, more effective programs for
pregnancy prevention may result and more appropriate care may be
provided.

Cited 3 or
Family Reactions to Adolescent Pregnancy more risks
and
One of the most difficult tasks of the pregnant adolescent is telling complications
he parents that she is pregnant. The adolescent may not talk about her of adolescent
pregnancy until it is obvious. Her mother usually is the first to find pregnancy /
out and may attempt to prevent the adolescent’s father from 35 years old
discovering his daughter’s pregnancy. The usual initial reactions of pregnant
grandparents-to-be to the news are shocks, anger, shame, guilt, and mothers at
sorrow. The nurse must assess any disharmony that is occurring in the 75%
family and assist family members in adapting to the pregnancy (or competency.
other options).

Satisfactoril
y discussed
the suitable
Nursing Care Management nursing
Many interacting biologic and social factors affect the quality of management to
human reproduction, and these in turn are influenced by the pregnant
preconception, maternal, and neonatal care that is made available. The clients above
adolescent and her offspring are particularly vulnerable to the risks 35 years of
inherent in pregnancy and parenthood. This result from circumstances age.
characteristic of her age group, such as cognitive-development level,
psycho logic immaturity, economic dependency, delayed medical care,
and lack of political power and influence. The multifaceted and
complex needs of the adolescent are most effectively addressed by
means of a multidisciplinary team of nurses, physicians, registered
dietitians, and social workers

a. Assessment

i. Interview
The interview for the initial prenatal visit for the pregnant
adolescent is similar to that for an adult pregnant woman. A through
health history, with a review of systems and sexual history, is
warranted. Cultural considerations should be aware that before
pregnancy the very young adolescent usually has received care only
from a pediatric health care provider and may be apprehensive about an
unfamiliar health care provider. In addition to obtaining a health
history from the pregnant adolescent, the nurse should elicit
information about the health of the baby’s father.

ii. Nutritional assessment

. Nutrition assessment id essential and includes the following
components: history (medical, obstetric, life-style, psychosocial).
Dietary assessment, anthropometric measurement, laboratory testing,
and clinical evaluation. The effect of maternal age on gestational
weight gain is unclear because most studies have not controlled for
other factor influencing gestational weight gain, such as parity, prep
regnant weight for height, ethnicity, alcohol use, and smoking. Except
for very young teens, there id little evidence that maternal age
influences weight gain when other factors are controlled.
Inadequate weight gain early in pregnancy is linked to small-for-
gestational-age (SGA) infants. Early weight gain may be difficult
because of body image, poor prepregnancy nutritional status, and poor
diet during pregnancy. Late inadequate weight gain is linked to
preterm birth and SGA infants. Availability of nutrients to the fetus
depends on whether the teenager mother continues to grow while
pregnant. Fetal growth restriction in teens still growing may result
from competition for nutrients. If the teenage woman experienced early
menarche, she may have an increased rate of growth for a longer period
of time post menarche.
Health care provider should use specific, reliable procedures for
obtaining and recording weight and height and should them consistently
in classifying women according to weight for height, setting weight
gain goals, and monitoring weight gain over the course of pregnancy

iii. Psychosocial status

Psychosocial screening includes assessment for response to pregnancy,
depression, or suicide. The nurse should also assess the adolescent's
cognitive-developmental level, literacy, problem-solving ability, time
orientation, body image, dependency, and peer and partner
relationships.
In addition to body changes associated with puberty, the body
image. For adult women, body changes associated with pregnancy reflect
growth and survival of the infant. Pregnant teens may be ambivalent
about the pregnancy. They may deny the pregnancy, which can have a
negative influence on body image and may lead to decreased nutritional
intake to limit weight gain.

iv. Knowledge base and perceive need

The adolescent is assessed for her knowledge of sexuality and
reproduction, prenatal development, process of labor and delivery, and
pain management during labor. Basic knowledge of these factors is
important to help the pregnant adolescent understand more readily the
additional changes that occur during pregnancy. The nurse should refer
the pregnant adolescent to childbirth classes to prepare for labor and
birth. Assessment of perceived learning needs reveals valuable
information that may be used as the basis for planning and
intervention.
 v. Support systems
Emotional support, particularly from the family of origin, is
extremely important to the pregnant adolescent. Persons in the support
system, particularly the parents, boyfriend, or husband, can
significantly influence pregnancy outcome. The nurse must assess how
the pregnant adolescent perceives her role and the roles and level of
support from others in her support from others in her support system.
Many pregnant adolescents come from socially and economically
deprived families. Appropriate use of health care resources and
compliance with preventive health care measures may not be part of
their health value system. The nurse can assist those adolescents at
risk to begin to change their own behaviour so that use of the health
care delivery system and its resources enhance health and well-being

vi. Physical examination

Physical assessment is the same as for the pregnant woman. Careful

determination of baseline blood pressure is necessary because
adolescents have lower systolic and diastolic pressures than do older
women. An adolescent could be in serious jeopardy for eclampsia with a
blood pressure reading of 140/90 mm Hg.

vii. Laboratory tests

Screenings are similar to those for the adult pregnant woman and
should include hemoglobin and hematocrit level., white blood celland
differential count, blood type, RH factor, and antibody screen;
rubella titer; serologic test for syphilis; urinalysis and urine
culture; Papsmear; and vaginal or rectal smear for Neisseria
gonorrhoeae, B-streptococcal, and chlamydial infections, A 1-hour
glucose tolerance test should be obtained at 28 weeks' gestation to
screen for gestational diabetes. HIV testing, tuberculin skin testing,
and sickle cell screening may also be recommended for patient at risk.
 b. Nursing Diagnosis
The information gathered during the assessment, along with laboratory
data, is analyzed and provides the basis for formulating nursing
diagnoses. Nursing diagnoses relevant to the pregnant adolescent might
include the following:

- Body-image disturbance related to pregnancy

- Post-trauma response related to Physical or sexual abuse
- Altered family processes related to Birth of infant to teenage mother
-Risk for altered nutrition: less than body requirements related to
Combined nutritional demands of teenage pregnancy and growth in
the very young adolescent. Low socioeconomic
- Altered growth and development related to
Loss of independence and disruption of peer relationships
secondary to pregnancy.
- Decisional conflict related to
Parenthood
Adoption
Abortion
- Altered health maintenance related to
Low socioeconomic status
Lack of access and availability of health care services
- Noncompliance with therapeutic regimen related to
- Inadequate knowledge
- Lack of social support
- Knowledge deficit: ante partum, intrapartum, postpartum, newborn
care related to
- Lack of experience

c. Expected outcome
The plan of care reflects the adolescent mother’s need increased
surveillance with health care measures, and feeling of personal and
social integrity. The care begins as early as possible in the prenatal
period and extends through the formative period of the new family.
Whenever possible, expected outcomes for care mutually
determined. These expected outcomes may include the following. The
adolescent will:

1. Demonstrate acceptance of changes in the body as a result of

pregnancy (e.g, posture, grooming, dress)
2. Demonstrate clear communication with her family and will
effectively resolve problems
3. Express her fears, anger, and guilt about previous sexual abuse
and will identify and will identify and contact appropriate
support persons/resources
4. Have adequate weight gain with hemoglobin level >11.0g/dl
5. Seek prenatal care in the first trimester
6. Demonstrate behavior appropriate to her developmental level.
7. Keep appointments for prenatal and postpartum care
8. Give birth to an infant whose birth weight is appropriate for
gestational age
9. Identify and contact support system in her community
10.Verbalize understanding of teaching related to antepartum,
intrapartum, postpartum, and newborn care
11.Demonstrate appropriate self-care and newborn care

d. Plan of Care and Implementation

Health care professional who work with pregnant adolescents must
come to terms with their own sexuality so they can maintain a non
judgment approach. They should be genuinely interested in the
adolescent- enthusiastic, warm, caring individuals able to view
adolescent as young people worthy of respect and dignity. Nurses must
be able to listen and respond with honest answer.

Nurses must be adept in using various teaching strategies. Group

discussions meet the adolescent’s strong need for peer contact and
acceptance. Anonymous question and pre-tests can be used to identify
knowledge deficits or beliefs in myths. Demonstrations by the nurse
with return demonstrations by the teen facilitate assessment of the
adolescent’s abilities. It is important to use simple, concrete,
direct language. Using correct terminology for body parts and giving
direct answer to questions communicates respect. Because young
adolescents have short attention spans, educational sessions should be
short-15 minutes or less. In addition of more than one of the senses
by using multimethod approaches and active participation by the
adolescent are helpful. For example, the use of visual models, films,
charts, and role playing helps to reinforce learning and fits with the
concrete cognitive style of young adolescents. Written instructional
materials such as brochures and visual teaching aids should be
attractive, bright in color, and contain more pictures than words. The
comic book format may appeal to the very young adolescent.

i. Prenatal care
Risk factors, such as pre-eclampsia and poor nutritional status, have
been linked with inadequate prenatal care. Those who received
inadequate care were also more likely to think that prenatal care was
unimportant, to have negative attitudes toward physicians, to have
late recognition of pregnancy, and to rely on their families for
prenatal advice. In addition, the teenage mothers who received
inadequate prenatal care placed more importance on an “adolescent
only” clinic than did other teens.
Attracting teens to prenatal care may improve maternal and
infant outcomes. Teens who were referred to a special teenage clinic
initiated prenatal care earlier and have more visit than teens who
attended a traditional clinic.

Adolescents are likely to obtain more adequate care if the prenatal

site is attractive and inviting and if special efforts are made to
register and retain them in care.
Maternal adaptation during pregnancy should be discussed, using
concrete examples of “what to do” and “what not to do”. Prenatal
education requires creativity, Flexibility, humor, and at times, ego
strength. The nurse should avoid treating the adolescent as a child
 ii. Support and information group
The prenatal care services already discussed are offered predominantly
in clinics or in hospitals. In addition to these services, various
self-help groups are available for pregnant teens and their families.
The programs vary in structure and content, depending on the
organization or agency sponsoring the program. Example of group types
include those that focus on the pregnant adolescent and her self-care,
those addressing teenage parenting (which teens and their infants may
attend together) , and support groups for parents (of the pregnant
adolescent) who learn how to cope and adapt to the experience.

iii. Nutritional counselling

The purpose of nutrition counseling is to increase the adolescent’s
knowledge of nutrients and ability to plan, select, and prepare
optimally nutritive foods for herself and her family (table 12-1). The
nutritional needs of the mature (15 years and older) pregnant
adolescent approach those pregnant adults. Additional amounts of
vitamins, minerals, and calories are needed to meet the growth needs
of the pregnant adolescent and her fetus and to correct deficiencies
resulting from inadequate intake of nutrients before, during, and
after pregnancy. Iron supplements are needed to provide for the
growing muscle mass and blood volume increase in the pregnant
adolescent (story,1990). Most adolescent females consume at least one
snack per day, with a range of one to seven. Snacks contribute more
than “empty calories”. Nutrients found in many of the snacks eaten by
adolescent females contribute approximately half the RDA of
riboflavin, vitamin C, and thiamine. Pregnant adolescent should be
encouraged to eat nutritious snacks such as peanut butter crackers,
cheese, fruits and juice.

iv. Newborn feeding

Many adolescent initially respond negatively to the idea of
breastfeeding. Fear of permanent alteration in the breasts, a view of
breastfeeding as “dirty”, other misconceptions, and a lack of role
models all contribute to the failure to choose breastfeeding as an
option. Peer reactions or negative responses from the spouse or
boyfriend are other factors. Thus bottle-feeding is often the feeding
method chosen. The nurse may help the adolescent weigh the realities
of breastfeeding, such as 24-hour commitment, against the realities of
continuing her education. For successfully breastfeeding the
adolescent’s family and school must work together.
All teens needs much support for breastfeeding, especially after
leaving the hospital. When identified counseling needs are beyond the
nurse’s scope, the adolescent is referred to a counselor who deals
effectively with adolescent.

v. Labor and birth

The very young adolescent may be frightened of needles, pelvic
examination, noises from other women in labor or from equipment, and
birth rooms. Single, private rooms should be provided when possible.
The adolescent in labor should have the support of a knowledgeable
coach, perhaps her husband, friend, parent, or nurse many teenage
women come to labor lacking preparation; they are fearful and often
alone. If they are admitted early in the first stage, teaching about
relaxation with contractions, ambulation, side-lying positions, and
comfort measures can be accomplished. The adolescent may be more
concerned with how the baby will get out than with fetal well-being.
Even though she may show an intense response to the contractions, the
adolescent is trusting and will follow suggestions. Anticipatory
guidance and explanation of all procedures before they are
administered should always be a component of the nurse’s care.
Adolescents are usually responsive to staff members sharing in their
delight about the infant. For these young parents, efforts to promote
parent-child attachment are particularly important.

vi. Postpartum care

Physically the adolescent mother requires the same care as any woman
who has given birth. Explicit directions for self-care and infant care
are required. Most adolescent view the care of the infant as their
primary area of concern. The need for continued assessment of the new
mother’s parenting abilities during the postbirth period is essential.
In addition, continued support should be provided by involving
grandparents (Fig.12-4) or other family members through home visits
and group session for discussion of infant care and parenting
problems. Outreach programs concerned with self-care, parent- child
interactions, child injuries, and instances of failure to thrive, as
well as those that provide prompt and effective community
intervention, prevent more serious problems

vii. Adoption
The adolescent will need to support if she is contemplating adoption
for her child. Health professionals must avoid using phrases that give
negative connotations to the adoption process. Phrases such as “put up
for adoption” and “give up for adoption” imply a callous, uncaring,
insensitive biological parent. Neither should the terms “real or
natural parents” be used exclusively for generic parents. The adoptive
parents are the “real parents” because they care for the child.
Neutral language such as “arranging for an adoption”, “biologic
parents” or” birth mother” and” adoptive parent” are preferred.

viii.Grief
Grief result from change or actual or perceived loss. The adolescent
may experience grief brought to a preterm infant who may be in the
intensive care unit, or the death of the infant. The nurse can help
the birth mother move through the grieving process. Intensive teaching
and continuous support programs are essential if the young mother and
her vulnerable infant are not to be estranged.

Evaluation
The nurse can be reasonably assured that care has been effective if
the expected outcomes have been achieved; that is, if the adolescent:

• Demonstrates acceptance of changes in body as a result of

 pregnancy (e.g..posture, grooming, dress)

• Demonstrates behaviour appropriate to developmental level

• Give birth to an infant whose birth weight is appropriate for

gestational age

3. Tertiary Prevention with Adolescent Parents

Adolescent’s ability to function in mothering role is affected
by the level of stress she is experiencing. They are exposed to
many stresses as they undertake the task and responsibilities of
parenthood, a role that is best assumed by the adults who are
financially and educationally secured.

a. Assessment
Assessment of Parenting abilities include the following:
• Ability to emphasize with the child
• Her self-concept
• Her definition of an identification with the maternal role
• Ability to solve problem and consider the child within the
context of the future
• Support system
• Ability to perform care giving task

b. Nursing Diagnosis
• Altered family process related to Adaptation to teen parenthood
• Risk for altered parent/infant attachment related to decreased
communication with the infant
• Altered role performance related to lack of knowledge of
maternal role

c. Expected Outcome
• The adolescent’s family will communicate effectively and provide
 support
• The adolescent will demonstrate the appropriate interactions with
the baby
• The adolescent will demonstrate appropriate role performance

d. Plan of Care and Implementation

• Nurse must demonstrate to the adolescent that she is still
important
• Before discussing about the care of the infant, the nurse should
inquire about the adolescent and her friend, school, social life
and allow her to discuss feelings and responses to the labor and
birth
• The nurse physical assessment skills can be taught to the
adolescent parent so that she becomes more knowledgeable about
her child’s needs.

• Discuss the
different III. Pregnant Woman Over the Age of 35
complications
of pregnant
woman above 35
years
satisfactorily
What you need to know:
Healthy women from age 35 into their 40s usually have healthy
pregnancies. If problems do arise, they can usually be
successfully treated.

Women over age 35 have an increased risk of:

• Fertility problems
• High blood pressure
• Diabetes
• Miscarriage
• Placenta previa, a condition in which the placenta is in
the wrong place and covers the cervix
• Cesarean section
• Premature delivery
• Stillbirth
• A baby with a genetic disorder

Because of these increased risks for women over 35, prenatal

care is especially important.

What you can do:

No matter what your age, see your health care provider before
trying to get pregnant. This is especially important if you:

• Have a chronic medical condition, such as diabetes, a

seizure disorder or high blood pressure
• Are on long-term medication

If not under control, some medical conditions can cause risks

for you and your baby.

If you are older than 35 and don�t get pregnant after trying
for six months, see your health care provider.
 A Mommy After 35
Most healthy women from age
35 into their 40s have
healthy pregnancies. Most
women over 35 are in good
health. Good prenatal care
and healthy habits can help you reduce
certain risks. If problems do arise for
women over 35, they can usually be
successfully treated.

No matter what your age, see your health

care provider before trying to get
pregnant if you:

• Have a chronic medical condition,

such as diabetes, a seizure
disorder or high blood pressure
• Are on long-term medication

If not under control, some medical

conditions can cause risks for you and
your baby.

If you are older than 35 and don’t get

pregnant after trying for six months,
see your health care provider. Older
women may find it harder to get pregnant
than younger women because fertility
declines with age. In many cases,
infertility can be treated.

Prenatal Care Is Important

Prenatal care is especially important
for women over 35 because:

• They�re more likely to get high

IV. Complications Pregnant woman over 35 years

A. Pregnancy Induced Hypertension

*Pregnancy induced hypertension is a hypertensive state that appears

during pregnancy and disappears after the birth of the fetus.
Hypertensive disease in pregnancy is one of the major causes of
maternal death and is responsible for a large number of perinatal
deaths. It occurs, by definition, after 20 wks. Gestation. It is
defined by the presence of an increase in blood pressure of 30 mm Hg
systolic or 15 mm Hg diastolic or greater over baseline levels on two
occasions at least 6 hours apart; or is defined by the presence of
blood pressure of 140/90 mm hg or greater.

** The cause of PIH is still the subject of much research; no known

theory accounts for all symptoms. The following observations have been
made:
--- It is known that PIH is related to physiologic changes of
pregnancy, because it disappears after pregnancy.

--- PIH is much more likely to develop in the woman exposed to

chorionic villi for the first time (primigravida ) or in those who are
exposed to a superabundance of chorionic villi, as with twins or a
hydatiform mole.

--- PIH seems to be a disease of the extremes - weight (underweight

or overweight), age (adolescents or the elderly primigravida)

--- PIH occurs most frequently in women who have a predisposition

to hypertensive disease (family history), or previous PIH.
PATHOPHYSIOLOGY IN PIH - The basic pathophysiologic alteration that
occurs in preeclampsia is widespread vasospasm in the body, which is
thought to be the result of an abnormal sensitivity of the woman's
vascular smooth muscle to blood vessel constrictor hormones produced
in her body.This vascular constriction in various parts of the body
leads to :

A. decreased delivery of oxygen and glucose to all tissues of the

body.
B. shift of fluids (especially plasma) from inside the circulatory
system to the tissues, resulting in a decreased intravascular
volume--- edema, large, sudden weight gain.
C. hemoconcentration within the circulatory system as the plasma
content is decreased; elevation in blood pressure--- elevated or
rising hematocrits; blood pressure elevation.
D. thrombocytopenia--- decreasing platelets (< 50,000); increased risk
for intracranial hemorrhage.
E. spilling of protein into the urine due to a loss of efficiency in
the filtering process of the kidney. This results in hypoalbuminemia
and is an important indicator of severity of the disease. ---
proteinuria.
F. spasm of the blood vessels and edema in the brain or the optical
vascular bed--- visual disturbances: blurred vision, scotomata;
dizziness, headache.
G. spasm of the blood vessels with small hemorrhages in the capsule
covering the liver---epigastric pain (RUQ)-a late symptom.
H. irritation of the central nervous system--- hyperactive
reflexes/clonus,convulsions.
I. decreased blood supply to the placental vascular bed, thus reducing
uteroplacental blood flow--- inadequate placental growth and function,
thus compromising the fetus (IUGR, fetal distress, prematurity).
 Able to
B. THE ANEMIAS OF PREGNANCY recall and
supply
IRON DEFICIENCY, FOLIC ACID DEFICIENCY, SICKLE CELL ANEMIA fitting
information’s
* Anemia is a decrease in circulating red blood cells and consequently to the care
a decrease in the capacity to carry oxygen to vital organs in the of adolescent
mother and the fetus. Anemia may be caused by pregnancy, as with iron pregnant
deficiency, or it may be a preexisting condition such as sickle-cell woman and
anemia. Anemia may cause severe maternal and fetal complications. pregnant
Anemia may be an indicator of nutritional, social, and/or woman above
environmental problems that affect pregnancy. The hemoglobin level of 35 years at
most iron-sufficient pregnant women is usually 11 g/dL or higher. The 75%
incidence of all types of anemia during pregnancy is variable competency.
depending on whether supplemental iron or other supplements are taken.

IRON DEFICIENCY
Iron deficiency anemia is a common medical disorder of pregnancy,
affecting at least 15-30% of pregnant women. Those especially at risk 15-item Quiz
include adolescents, poorly nourished clients, followers of fad diets,
women with multiple gestations, or women whose pregnancies are closely
spaced. Women with anemia have a higher incidence of infection than
women with normal hematological values. The incidence of small for
gestational age babies and stillbirths are increased with severe
anemia due to the limited amount of oxygen available for fetal
oxygenation.
Assessment of iron deficiency anemia begins with health and
nutritional histories. About 25% of women with anemia practice pica
(The ingestion of non food items with no nutritional value such as
dirt, starch, clay, ice cubes). The causes of pica are attributed to a
variety of reasons and may be engaged in by children as well as
pregnant women and other adults. Pica may be a psychologic response, a
cultural phenomenon, the body's response to needed nutrients or a
response to hunger. Controversy exists as to whether the iron
deficiency is the cause or effect of the anemia. Research findings
have shown that interference with absorption of necessary nutrients
occurs when clay is eaten. Physical signs of anemia include pallor
(although this may not be the case due to hyperemia of the skin during
pregnancy), weight loss, complaints of being tired and feeling
listless.

GOALS OF NURSING CARE:

1. Prevention of anemia - Ideally nutritional status should be

improved prior to pregnancy. 2. Increase iron intake by daily
supplements - The primary function of iron is to combine with protein
to produce hemoglobin, that blood component which transports oxygen to
all living cells. Iron enhances the quality of the blood and thereby
increases an individual's resistance to stress and disease. There is
an increased need for iron during pregnancy because of the maternal
expanding blood volume, the demands of the fetus and placenta, and the
blood losses during childbirth. A physiological anemia exists in early
pregnancy due to the increase in plasma volume. The hematocrite
decreases by 7%. This is pseudoanemia. The total daily iron
requirement for the pregnant woman is usually not met by the usual
American diet or by existing iron stores of many women. The
recommended dosage is 300 mg of supplemental iron during the second
half of pregnancy. Additional doses up to 3x a day are prescribed when
the Hgb falls below 10-11 mg. Parenteral iron may be prescribed in
severe cases. Iron is usually not given in the first trimester because
the effects on the fetus are not known, and iron tends to further
aggravate nausea and vomiting which is a problem for a large portion
of women. 3. Modification of the diet to increase foods high in iron
content - Foods rich in iron include organ meats, especially liver and
egg yolks, seafood, dark green leafy vegetables, dried fruits,
enriched cereals and grains and molasses. Iron absorption is enhanced
in the presence of vitamins C and E.

FOLIC ACID DEFICIENCY

* In the United States, megaloblastic anemia beginning during

pregnancy almost always results from folic acid deficiency.
Megaloblastic anemia is a disorder of the red blood cell production
that demonstrates as an alteration in cell morphology. In the absence
of folic acid, red blood cells fail to divide, become enlarged and are
fewer in number. Folic acid deficiency is usually found in pregnant
women who consume neither fresh vegetables nor foods with a high
content of animal protein.
The increased red blood cell production during pregnancy and fetal
demand for iron can result in folic acid or folacin deficiency. Folic
acid deficiency , when present, usually accompanies iron deficiency.

* Folic acid deficiency may be assessed by using various methods.

- Nutritional assessment - Overcooking destroys as much as 80% of
available folic acid in food.
- Signs and symptoms - Nausea, vomiting, pallor, anorexia, soreness
of the tongue, and stomatitis.
- Laboratory values - Mean corpuscular volume is elevated, smears
indicate macrocytes (immature form of red blood cells), and a folate
level less than 5 mg/mL.

* Treatment of folic acid deficiency includes an oral folic acid

supplement of 1 mg daily and nutritional counseling. Good sources of
folic acid are green leafy vegetables, fish, meat, poultry, eggs,
milk, and legumes.

C. Preterm Labor

Adolescents are high risk for preterm labor, probably because their
uteruses are not fully grown. Review the signs of labor with them by
the 3rd month of pregnancy. Stress the labor contractions no more
intense than menstrual cramps. Also, vaginal bleeding is suspicious of
the labor and should be reported.

D. Cephalopelvic Disproportion

They are prone to cephalopelvic disproportion because their own

development is still immature. This is suggested by lack of engagement
at the beginning of the labor, a prolonged first stage of labor, and
poor fetal descent.

E. Failure to Progress in Labor

Labor in older primipara maybe prolonged because cervical dilatation
may not occur as spontaneously as in younger women, probably because
of elasticity in cells. Many women in this age may need a caesarean
birth both if labor is becoming is overly prolonged and places the
fetus at risk. Encourage a woman to verbalize how is she feeling about
her progress throughout labor to allow for reassurance and prompt
intervention should problem arise.

F. Postpartum Hemorrhage

More prone than the average woman because if a girl’s uterus is not
fully developed, it becomes over distended by pregnancy. An over
distended uterus does not contract as readily as a normally distended
uterus in the postpartum period. Adolescent may have more frequent or
deeper perineal and cervical lacerations than the older women because
of the size of the infant in relation to their body. On the other
hand, young adolescents are generally healthy and have supple body
tissue that allows more adequate perineal stretching.

G. Gestational Diabetes

The risk to your baby from gestational diabetes is not as severe as

the risk to your baby if you have diabetes prior to getting pregnant.
Because your baby is done forming by the time gestational diabetes
begins, birth defects are not probable, but there are other problems
that may occur. As glucose can go through the placenta to the baby it
gives an excess energy supply to your baby. Since your baby doesn't
need the extra energy, the energy from the glucose is changed into
fat, which results in a large birth weight for your baby. Having an
overweight baby at birth can lead to problems when it travels down the
birth canal, including possible shoulder injuries, and breathing
problems. It can also lead to overweight children, and children who
develop type 2 diabetes as adults.

V. Nursing Interventions / Health Education

A. Prenatal Health teaching

What you need to know:

Prenatal care is the care you get while you are pregnant. This care
can be provided by a doctor, midwife or other health care professional.

The goal of prenatal care is to monitor the progress of a pregnancy

and to identify potential problems before they become serious for
either mom or baby.

All mothers-to-be benefit from prenatal care. Women who see a health
care provider regularly during pregnancy have healthier babies, are
less likely to deliver prematurely, and are less likely to have other
serious problems related to pregnancy.

During prenatal visits, the health care provider:

• Teaches the woman about pregnancy

• Monitors any medical conditions she may have (such as high blood
pressure)
• Tests for problems with the baby
• Tests for health problems in the woman (such as gestational
diabetes)
• Refers the woman to services such as support groups, the WIC
 program or childbirth education classes

What you can do:

As soon as you think you are pregnant, call your health care provider
to find out when you should come in for your first prenatal care
appointment.

During your pregnancy, make sure you attend all of your prenatal care
appointments, even if you’re feeling fine.

Sometimes getting to an appointment may be difficult or it may seem

like a waste of time. For the sake of your baby, though, make getting
prenatal care a priority.

Ideally, it's best to see your provider before you become pregnant.
This is called a preconception visit. This visit can address concerns
and issues before you get pregnant.

All women need prenatal care. Women who see a health care provider
regularly during pregnancy have healthier babies, are less likely to
deliver prematurely, and are less likely to have other serious
problems related to pregnancy.

A typical prenatal care schedule for a low-risk woman with a normally

progressing pregnancy is:

• Weeks 4 to 28: 1 visit per month (every 4 weeks)

• Weeks 28 to 36: 2 visits per month (every 2 to 3 weeks)
• Weeks 36 to birth: 1 visit per week

A woman with a chronic medical condition or a �high-risk� pregnancy

may have to see her health care provider more often. Make sure you go
to all your prenatal care appointments, even if you’re feeling fine.
What Happens at a Prenatal Care Visit?
During your first prenatal care visit, your provider will ask you a
lot of questions and do some tests. Most of your other visits will be
much shorter.

At the first visit your health care provider will:

• Ask you about your health, your partner’s health and the health of
your close family members. Don’t worry if you don’t know all the
answers.
• Identify medical problems.
• Discuss with you any medications you are taking.
• Do a physical exam and a pelvic (internal) exam.
• Weigh you.
• Check your blood pressure.
• Check a urine sample for infection.
• Do some blood tests to check for anaemia and see if you have had
certain infections. You will be asked if you want a test for HIV,
the virus that causes AIDS.
• Do a pap smear to check for cervical cancer and other tests for
vaginal infections
• Figure out your due date: an estimate of the day your baby will
be born. Most babies are born within two weeks (before or after)
their due date.
• Make sure you're taking a prenatal vitamin with folic acid.

During later prenatal visits your provider will:

• Weigh you.
• Check your blood pressure.
• Measure your belly to see how the baby is growing (middle and
late pregnancy).
• Check your hands, feet and face for swelling.
• Listen for the baby’s heartbeat (after the 12th week of
pregnancy).
 • Feel your abdomen to assess the baby’s position (later in
pregnancy).
• Do any tests that are needed, such as blood tests or ultrasound.
• Ask you if you have any questions or concerns. It’s a good idea to
write down your questions and bring a list with you so you don’t
forget.

Remember, the things you tell your health care provider are
confidential. That means that he or she can’t tell anyone else what you
say without your permission. So don’t be afraid to talk about issues
that might be uncomfortable or embarrassing. It’s OK to tell your
provider if you smoke, drink alcohol or take any drugs, or if your
partner hurts or scares you. Your provider needs to know all about you
and your lifestyle so that he or she can give you and your baby the
best care.

No one knows exactly why women who get early and regular prenatal care
have healthier pregnancies and healthier babies. But we do know it
works. So go. Do it for yourself and your baby.

Remember: In addition to prenatal care, be sure to have a dental

checkup early in pregnancy to help your mouth remain healthy. You may
even want to see your dentist more often than usual.

B. Nutrition
What you need to know:
You don’t have to give up all the foods you love when you’re pregnant.
You just need to eat smart and make sure that most of your choices are
healthy ones. You only need 300 extra calories per day to support your
baby’s growth and development.

What you can do:

Follow the serving recommendations. And watch your portions’ you may be
eating more than you think! Avoid too much sugar and fat in your diet.
Your Healthy Diet During Pregnancy
Eating healthy foods can help you have a healthy baby. But sometimes
it's hard to know what foods to eat. This article will help. How much
should you eat each day when you're pregnant? Follow these food
guidelines.

Fruit
Eat 2 to 4 fruit servings each day. One fruit serving is:

• 1/2 cup fresh, frozen or canned fruit

• 1 medium whole fruit (orange, apple, banana)
• 3/4 cup fruit juice (avoid unpasteurized juices)

Vegetables
Eat 3 to 5 vegetable servings each day. One vegetable serving is:

• 1/2 cup raw or cooked vegetables

• 1 small baked potato
• 3/4 cup vegetable juice (avoid unpasteurized juices)

Grains
Eat 6 to 11 serving each day. One grain serving is:

• 1 slice bread
• 1 cup dry cereal
• 1/2 cup cooked rice, pasta or cereal
• 1 small pancake
• 1 small tortilla
Proteins
Eat 2 to 3 protein servings each day. One protein serving is:

• 2 ounces lean meat, poultry or fish (For more information on

fish, see Food-borne Risks in Pregnancy.)
• 2 tablespoons peanut butter
• 1/2 cup dried or cooked beans
• 2 eggs

Milk Products
Eat 2 to 3 milk servings each day. (Low-fat or skim is best.) One
milk serving is:

• 1 cup milk
• 1 cup yogurt
• 2 1-inch cubes cheese (Avoid soft cheeses such as feta, brie, Camembert,
Roquefort, blue-veined, queso blanco, queso fresco or Panela, unless the cheese
is label as made with pasteurized milk.)

You may find that your interest in food changes during pregnancy. You
may not be very hungry during the first months. But you may want to
eat all the time during the later months! Every woman is different.
The important thing is to eat healthy foods that you like all during
your pregnancy.

To learn more about healthy eating during pregnancy, listen to the

March of Dimes Podcast with Marion Nestle, professor of nutrition

Don't Eat That!

The articles Food Safety and Food-borne Risks in Pregnancy provide
information about foods that are not safe to eat during pregnancy.

Not Too Much

You can eat up to 12 ounces a week of fish that have small amounts of
mercury. The 12 ounces can include:
 • Shrimp, salmon, pollock, catfish and canned light tuna.
• Albacore (white tuna). Don't eat more than 6 ounces of this tuna
in one week.

Drink no more than one 12-ounce cup of coffee each day. Remember, the
amount of caffeine in coffee varies, depending upon the type of
coffee, how it is prepared, and the amount of coffee used. Caffeine
can also be found in soft drinks, medications and other foods. Try
coffees and teas that are decaffeinated (they don't have caffeine in
them). Read labels on food, drinks and medicine to know how much
caffeine you're getting.

C. Activity and Rest

Before you go out and run a marathon, it’s important that you
discuss your exercise plans with your health care provider. Not all
pregnant women should exercise, especially if they are at risk of
preterm labor or suffer from any kind of serious ailment, such as
heart or lung disease. So check with your health care provider
before you start an exercise program.

Next, decide what type of exercise you will do. Pick things you
think you will enjoy. You may want to try several things. For
example, brisk walking for 30 minutes or more is an excellent way
to get the aerobic benefits of exercise, and you don’t need to join
a health club or buy any special equipment. You could also run,
hike or dance, if you like. Swimming is another sport that is
especially good for pregnant women. The water simultaneously
supports the weight of your growing body and provides resistance
that helps bring your heart rate up. You can also look around for
aerobics and yoga classes designed specifically for pregnant women.
You may find that a variety of activities helps keep you motivated
to continue exercising throughout your pregnancy and beyond.
 You do need to be careful when choosing a sport. Avoid any
activities that put you at high risk for injury, such as horseback
riding or downhill skiing. Similarly, pregnant women should also
stay away from sports in which you could get hit in the abdomen,
such as ice hockey, kickboxing or soccer. Especially after the
third month, it is important to avoid exercises that require you to
lie flat on your back. Lying on your back can restrict the flow of
blood to the uterus and endanger your baby. Finally, pregnant women
should never scuba dive, because this sport may result in the
dangerous formation of gas bubbles in the baby’s circulatory system.

When you exercise, pay attention to your body and how you feel.
Don’t overdo it try to build up your level of fitness gradually. If
you have any serious problems, such as vaginal bleeding, dizziness,
headaches, chest pain, decreased fetal movement or contractions,
stop exercising and contact your health care provider immediately.

So with a little bit of caution, you can achieve or maintain a

level of fitness that would shock your grandmother. You’ll feel and
look better, and yes, you can still put your feet up after you’ve
come back from your walk.

Conditions That Make Exercise Dangerous During Pregnancy

If you have any of the conditions below, do not exercise. Check with
your health care provider.

• Heart disease
• Lung disease
• Incompetent cervix: The cervix is the narrow, outer end of the
uterus. If it is weak, it cannot hold the fetus in the uterus.
• Preterm labor (before 37 completed weeks of pregnancy)
 • Multiple pregnancy (twins, triplets or more) at risk for preterm
labor
• Frequent bleeding from the vagina during months 4-9 of pregnancy
• Placenta previa: The placenta connects the baby’s blood supply to
the mother’s blood. Attached to the mother’s uterus, it is an
unborn baby’s lifeline. Placenta previa is a low-lying placenta
that covers part or all of the cervix. This can block the baby’s
exit from the uterus.
• Hypertension

D. Childbirth preparation /Childbirth Educational Class

Childbirth classes help expectant parents learn about and
prepare for labor and birth. There are several kinds to choose
from. Two of the most popular are Lamaze and Bradley, named
after their developers. Most childbirth education classes use
one of these two approaches. Many borrow elements from each.

Both Lamaze and Bradley teach women how to cope with labor pain.
Both approaches encourage the woman�s partner to participate in
the labor and delivery process.

Other childbirth education techniques include the Alexander

technique, HypnoBirthing, Birthing From Within, and Birthworks.
Learn as much as you can about each technique until you find an
approach that seems right for you.

The Lamaze Method

Lamaze teaches simple coping strategies for labor, including focused
breathing, moving and positioning, massage, relaxation techniques,
and labor support. Women receive information about medical procedures
and pain relief during labor so that they can make informed choices.
For more information, visit the Lamaze Web site.

The Bradley Method

Bradley teaches natural childbirth in the absence of medical
complications. It emphasizes exercise, nutrition and deep-breathing
techniques. For more information, visit the Bradley Web site.

Creating a Birth Plan

Some childbirth education classes help women create a birth plan. This
is a written document in which you express your preferences about
labor and delivery. Topics covered include where you want to deliver,
who your support people will be, and the pain medications you want (if
any). If you do create a birth plan, be sure to share it with your
provider ahead of time. He or she needs to be aware of your wishes and
discuss them with you well in advance.

VI. Educational Game

VII. Giving of Prizes

VIII. Open Forum

 IX. Evaluation

BIBILIOGRAPHY

Beers, M. (2003). The Merick manual of medical information. (2nd ed). New York: Simon and Schuster, Inc.

Kozier, B. et al. (2004). Fundamentals of nursing concepts, process and practice. (7th ed.). Upper Saddle River,
New Jersey: Pearson Education Inc.

Pillitteri, A.(2007). Maternal and child health nursing: Care of the childbearing and childbearing family.
(5th ed.). Philadelphia :Lippincott Willimans & Wilkins.

Smeltzer, S. et al. (2007). Brunner & Suddarth’s textbook of medical surgical nursing. (11th ed.). Philadephia:
Lippincott Williams & Wilkins.

Wong, D. & Perry, S. (1998). Maternal child nursing care. (2nd ed.). St. Louis, Missouri : Mosby -Year Book Inc.