Saturday, November 20, 2010

Maternal and Child Health Nursing Chapter 17

Chapter 17
High-Risk Pregnancy: A Woman with Special Needs
Mindy Carson, a 16-year-old girl, is 15 weeks pregnant. The father of Mindy's baby is a college student. He doesn't want Mindy to keep her baby after the birth because he doesn't want to get married until he finishes graduate school. Mindy insists she is old enough to be a parent and wants to keep her baby. Mindy's mother accuses the father of sharing methamphetamines with Mindy. She's worried Mindy has been working as a prostitute to support her drug habit. They both turn to you and ask you what you would recommend.
Typically, many women seen in a prenatal care setting do not fit the description of the average pregnant woman—a well young adult who maintains healthy patterns of living. Previous chapters discussed high-risk pregnancies for women who are ill when they become pregnant and for those who develop an illness while pregnant. This chapter presents information to add to your knowledge base about high-risk pregnancy in women with other special needs—very young adolescents and women who have waited until midlife to have their first child; those who are physically or cognitively challenged and those who are drug dependent.
Is Mindy old enough to be a parent? What qualities would you look for in her to discover if she is ready to parent? What type of referral does Mindy need?

Pregnancy and childbirth are leading causes of death in adolescents in developing countries (Mayor, 2004). In the United States, the adolescent pregnancy rate has decreased slightly to about 41/1,000 teenagers (NCHS, 2005). In contrast, the birth rate for women over age 40 is steadily increasing; it is currently about 10/1,000 (NCHS, 2005). Adolescents require special consideration during pregnancy because they are physically and psychosocially immature. Women over age 40 may need special consideration also because they can have difficulty adjusting psychosocially to a first pregnancy and the family changes that are required.
The pregnancy rate also is increasing among women who are physically or cognitively challenged, including those with conditions such as cerebral palsy that might have precluded pregnancy a few years ago. Physical and cognitive conditions present a challenge to childbearing and childrearing but do not necessarily prevent women from establishing their own families. Supportive nursing care that considers the limitations imposed by a particular disability, while focusing on the normal aspects of childbearing and childrearing and a woman's strengths, is vital.
Women who are drug dependent are yet another category of high-risk women who require a great deal of nursing support and care. Ideally, a woman would give up substance abuse for the health of a fetus, but that may not be possible. When this doesn't happen, every effort must be made to provide enough prenatal care and attention to protect the fetus in other ways.
These women with special needs have become a focus of attention, as evidenced by the National Health Goals (Box 17.1). The Department of Health and Human Services (DHHS) has initiated a special program to help reduce teenage pregnancy (
The Pregnant Adolescent
Adolescent pregnancy is not a new phenomenon; historically, it was common for women to marry at an early age and have a first baby during adolescence. In today's society, however, marriage and childbearing during the teenage years are not encouraged. New educational programs on the importance of delaying pregnancy have decreased the number of births in the United States to girls

under age 18 years from a rate of 117/1,000 to 41/1,000, but this number is still higher than that of other industrialized countries (Davis, 2003). Reasons for this high number include:
  • Earlier age of menarche in girls (many girls begin menstruating at age 10 and so are ovulating and able to conceive by age 11)
  • Increase in the rate of sexual activity among teenagers
  • Lack of knowledge about (or failure to use) contraceptives
  • Desire by young girls to have a child
In addition, some adolescents become pregnant as the result of rape or incest.
Failure of adolescents to obtain adequate knowledge of contraceptive measures is an issue that can be addressed by health care providers. Unfortunately, providing information does not always resolve the problem because adolescents often lack money to purchase protection such as birth control pills or a diaphragm. In addition, the egocentric phenomenon of adolescence makes a sexually active teenager believe she will not become pregnant: “It won't happen to me.” On the other hand, some adolescent girls actually plan pregnancy. They believe being pregnant will free them from an intolerable school or home situation and give them someone to love. This puts a tremendous responsibility on a newborn to furnish love and change a girl's life, and child abuse can occur when the newborn cannot meet such expectations.
At one time, pregnant unmarried girls were sent to a “secret” home or shelter where they would stay through the pregnancy, give birth, place the child for adoption, and return home as if nothing had happened to them. But something did happen, as much as the girl and her family wanted to pretend it did not. Often, the girl was affected psychologically, because she developed a relationship with the stranger inside her and then had to give the newborn away and never mention him or her again. Today, pregnant girls attend prenatal clinics or come to physicians' offices just as older women do. They deliver in birthing rooms at hospitals, and as many as 90% keep their babies (DHHS, 2000). Few give birth in alternative birth centers because adolescent pregnancies are considered high risk. Home birth is not recommended for the same reason. Offering increased guidance during pregnancy and for the following year can be an important nursing role (Koniak-Griffin et al., 2003).
Developmental Tasks of Adolescence
Adolescence is a vulnerable time for pregnancy because the developmental tasks of pregnancy are superimposed on those of adolescence. The developmental tasks of the average adolescent are fourfold: to establish a sense of self-worth or a value system, to emancipate from parents, to adjust to a new body image, and to choose a vocation (Erikson, 1963). A girl in the process of separating from her parents may be devastated by knowing that in less than a year someone will be dependent on her. When she realizes she is pregnant, she may have decreased ability to separate from her parents because she needs their financial help more than ever to obtain prenatal care and buy clothing for her new baby. If she must depend on her parent's health insurance, she may feel virtually trapped into dependence. Helping adolescents to make their own health care decisions at health care visits helps to foster a sense of independence in the middle of this forced dependency. Consider, for example, the decision that the adolescent must make about where to place a medication reminder chart: if it hangs in the kitchen, her mother may monitor it; in her bedroom or in her school locker, she alone will monitor it. An adolescent may not be able to choose when she comes for care (her mother has the car to drive her only on Tuesday afternoons), but during a visit she can do many things to feel independent, such as weigh herself, hold a mirror to view her pelvic examination, or be interviewed apart from her parent.
Parents may have difficulty allowing a daughter to make her own health care decisions this way. You may need to remind them that a pregnant adolescent is regarded as an emancipated minor—or a person capable of making health care decisions—and so may sign permission for her own care. Soon she will be caring for an infant, so she needs this practice in independence.
Pregnancy may interfere with the development of a healthy sexual relationship and cause difficulty in establishing future intimate relationships if the girl realizes that her current relationship has led to a situation detrimental to her. To prevent this, it is useful to help her view the pregnancy as a growth-producing experience. Most people can point to a day in their life when they “grew up” (perhaps a day a parent became ill or the day they left home for college). This pregnancy can be that “growing-up” revelation or a growth-producing experience for her.
Establishing a value system or sense of identity can be difficult if health care personnel treat a pregnant adolescent as though she were irresponsible. Encouraging her to continue school is crucial to her self-esteem and to her future, as well as to the future of her unborn child. Many schools have special programs that include aspects of prenatal care (Box 17.2).
Prenatal Assessment
Adolescents are considered high-risk clients because they have a high incidence of pregnancy-induced hypertension and iron-deficiency anemia. They also have a higher incidence of preterm birth, with low-birthweight infants, and a high rate of intimate partner abuse. Early and consistent prenatal care is essential to their health and the health of their baby.
Unfortunately, many adolescents do not seek prenatal care until late in their pregnancies. This may be due to a girl's denial of the pregnancy. Not seeking prenatal care is also a way of protecting the pregnancy—if she doesn't tell anyone, no one can suggest she terminate the pregnancy. After the 6th month, abortion is no longer a possibility, so she can feel free to come for care without being subjected to this pressure.
Other factors contributing to the lack of prenatal care include lack of knowledge of the importance of prenatal care and dependence on others for transportation. The girl may feel awkward in a prenatal setting (as an adult setting)

and frightened about her first pelvic examination. In addition, adolescents have a difficult time relating to authority figures. A primary nursing or case management approach that minimizes the number of health care providers a girl is exposed to may be the most effective method for providing care during the prenatal period for adolescents. Some adolescents do well in group prenatal care because it allows them to interact with a peer group (Box 17.3). Every community should have a facility designed especially for adolescents, but if this is not possible, all settings should accommodate adolescents' needs, eliminating this last reason for poor prenatal care.

Health History
Take a detailed health history at the first prenatal visit to establish individual risks. This is best done without the girl's parents present. The girl needs practice in being responsible for her own health, and having to account for her health practices helps her do this. It also helps prevent her from fabricating an answer to please a parent.
Some adolescents come to a facility with concerns such as “weight gain” or “feeling tired all the time” rather than saying they are pregnant, hoping health care providers will think of pregnancy as a possible reason for their symptoms. This is part denial and part pregnancy protection. Always be alert to the possibility of pregnancy when an adolescent describes symptoms that are vague and hard to define. If the importance of what she is saying when she mentions feeling “tired” or “nauseated” is missed, she may ask if someone will feel her stomach. If told this is not necessary for any of the symptoms she has mentioned, she may describe bigger symptoms, such as “terrible stomach pain.” Think of possible pregnancy when you hear such a “growing” history.
Many adolescents believe their world is totally separate from the adult world and, to keep it separate, they do not voluntarily share information with adults. When interviewing adolescents, be certain to press for the responses needed to assess safely. Do not accept statements such as “I eat okay” as a nutrition history or “I'm a very active person” as a history of rest and activity.
If an adolescent delayed seeking health care, ask for the reason for this at her first prenatal visit. Acknowledge that “protecting” the pregnancy is a desirable motive, but that continuing with prenatal care is much more beneficial.
If a parent does accompany a girl, ask the parent separately what, if any, concerns he or she wishes to discuss. A young adolescent is still a daughter, and a parent may be as concerned about her health during this pregnancy as he or she was at health visits when the girl was being seen for a cold or injury.
A baby's father may accompany a girl into the clinic or office to have the diagnosis established. Because he is not married to the adolescent, he does not have a legal right to participate in the girl's decision concerning pregnancy, abortion, or adoption, but he may not be devoid of feelings for the girl or the baby. If he is an adolescent, he may feel sorrow that because of his age he cannot provide adequately for the girl and baby. If a complication occurs, he may feel genuine grief. Assuming that the boy is irresponsible reveals a lack of understanding of human behavior, especially that of adolescents. Allowing him to offer support in the current pregnancy helps him to better define his role (Bunting & McAuley, 2004). Be sure he receives compassionate education on preventing further pregnancies until he is more mature.
Often, adolescent girls have not been exposed to many pregnant women, so they may need extra teaching to help them become aware of common pregnancy symptoms such as urinary frequency, fatigue, and breast tenderness. Asking what symptoms an adolescent is having, and reassuring her they are part of a normal pregnancy, can help prevent her from attempting to treat them with potentially teratogenic over-the-counter medications.
As pregnancy progresses, listen for signs of “nest-building” behavior during a pregnancy history. An adolescent girl may not have the financial resources to buy clothing or a baby bed. She may reveal nest-building feelings by asking an increasing number of questions about newborns. Offer suggestions, such as making one article of clothing for the baby or saving her own money for one article—activities that promote active involvement in the pregnancy and provide a measure of nest-building behavior (the girl who, week after week, spends her money on something else is probably not as involved in the pregnancy as the girl who puts away even one dollar each week toward a pair of baby shoes).
Some adolescents have difficulty telling their parents about the pregnancy. Role-playing or simulation may be an effective technique for helping them prepare to do this. Some girls report on a second visit that their parents were not nearly as angry as they had anticipated. Instead, their parents reacted as if they had been waiting to hear this news, having accepted it as inevitable months before.

Family Profile
Adolescents may leave home if their family disapproves of the pregnancy, joining the ranks of homeless or adolescent runaways. Others do not leave home, but separate themselves emotionally from their family. Trying to manage by themselves leaves young girls with tremendous financial strain and a devastating sense of loneliness. Be sure to ask a girl at prenatal visits where she is living, what is the source of her income, and whom she would call if she suddenly became ill.
Asking about home life may reveal a dysfunctional family or an incest relationship as the cause of the pregnancy. If the girl is under legal age, incest is considered child abuse. Know your local and state laws on this topic and make the necessary report.
Because of family relationship problems, a girl may need help in making arrangements for the next few months of her pregnancy and for child care afterward. Will her parents allow her to live at home during the pregnancy? If not, is there a relative she may go to? What kind of financial support does she need? Family and social supports for pregnant adolescents have been shown to be important influences on the maintenance of a healthy pregnancy lifestyle and help prevent low birthweight in their children.
Ask also if the girl is planning to continue with school. Pregnancy is an egocentric time when outside interests do not always seem important. Help her to see that the months of pregnancy will go faster if she is busy. Doing well in school is a way of keeping busy. It also is important in preparing an adolescent for the future, because a high school education is necessary to obtain marketable skills to support herself and her baby. Once she has given birth, returning to school may be difficult because she may have child care problems and because she may feel she is more mature than the other girls (or the other girls may make her feel this way). Any school that obtains federal money cannot discriminate against students because they are physically challenged. Many states interpret pregnancy as physically challenging, so in those states a girl cannot be forced to leave school (or even asked to go to an alternate school) because of pregnancy. You may need to advocate for a girl with a school committee for a proper school placement.
Day History
An adolescent is often unwilling to provide a detailed day history unless its purpose is well explained. Tell her the purpose of the history is to learn more about her as a whole person, not to discover if she is doing things during the day she should not do. Adolescents are private people; to allow you to walk through their adolescent world for a day is a breach of adolescent philosophy.
Ask in particular about nutritional practices, sleep, daily activity, use of drugs, and whether she has friends who can support her through this experience.
Be certain to include questions about her medication history. Ask if she is taking anything over the counter. Some adolescents take acne medication that is potentially teratogenic, such as tetracycline or isotretinoin (Accutane). Some take frequent doses of over-the-counter cold remedies. Impress upon adolescents the importance of not taking any medication—even nonprescription—without prior approval from their physicians or nurse-midwives during pregnancy.
Physical Examination
Physical examination procedures with pertinent adolescent findings are discussed in Chapter 33. Be certain to explain procedures as you do the exam. A statement such as “Oh, you're starting to have colostrum,” a positive finding of pregnancy, may be frightening to an adolescent who does not know what colostrum is. A better way to phrase such a finding might be “Your breasts are healthy. You're already beginning to produce early breast milk. Later on we'll talk about the importance of breast milk for newborns.” This kind of feedback makes the health examination a learning experience; relieves anxiety for adolescents, who tend to be very concerned about body appearance; and provides a way of encouraging healthy behavior patterns.
Adolescents are at an increased risk for pregnancy-induced hypertension, probably due to immature blood vessels (Moldenhauer & Sibai, 2003). Few adolescents are told the results of blood pressure determinations at health maintenance visits, so they will not know what their typical finding is. Obtain a baseline blood pressure at the first prenatal visit and make a point of informing the girl of her blood pressure reading to encourage active health care participation in the future. Adolescents are often active in a waiting room—walking to get a magazine, returning it, looking out the window; be certain that the girl has 15 minutes of rest before you take a blood pressure or the recording will be falsely high.
Use a Doppler technique to obtain fetal heart tones, if possible, because hearing the fetal heart helps an adolescent acknowledge the reality of her pregnancy. For the same reason, make a point of assessing fundal height from visit to visit to show the baby is growing.
Adolescents who use drugs may be reluctant to supply a urine specimen for testing because they are afraid you are secretly looking for evidence of drug use. In this instance, you may receive a cupful of water in place of a urine specimen. If in doubt as to the substance you are testing, check the specific gravity. The specific gravity of water is 1.000, whereas urine specific gravity ranges from 1.003 to 1.030.
Many adolescents like to weigh themselves at prenatal visits as weight gain in early pregnancy is proof they are pregnant. It is good practice to make a note of the clothing the girl is wearing the first time she is weighed (eg, jeans, T-shirt) so later weight determinations can be compared accurately. Be certain she knows a healthy weight gain is important for fetal growth and this weight can be lost afterward.

Prenatal Health Teaching
Adolescents need a great deal of health teaching during pregnancy because they do not know many common measures of care that an older woman has learned from experience. They are often unwilling to follow health care advice, however, that makes them different in any way from their peers. On the other hand, adolescents often do not have well-established health practices, so they are adaptable.
Adolescent girls may respond to health teaching that is directed to their own health more than to that of a fetus inside them: “Eat a high-protein diet because protein makes your hair shiny (or prevents split fingernails)” often leads to better adherence than a statement such as “Protein is good for your baby.” “Taking the iron supplement should make you feel less tired” is better than “It will help build the baby's blood supply,” for the same reason. These are truthful statements and they appeal to an adolescent's preoccupation with self. In addition, this type of health teaching is the only form to which an adolescent who is denying her pregnancy can respond.
Be certain to include information on the effects of drugs on fetal welfare, including over-the-counter medications, herbal preparations, and recreational drugs. Pregnancy can become an important growth experience if it provides the motivation some adolescents need to withdraw from recreational drug use.
Adolescents also need instructions about possible discomforts and changes associated with pregnancy, and measures to relieve them. (See Chapter 11 for a complete discussion.) Many adolescents develop hemorrhoids during pregnancy because the disproportion of their body size to a fetus puts extra pressure on pelvic vessels, causing blood to pool in rectal veins. Reassure girls that this is a pregnancy-related phenomenon that will resolve when the pregnancy is over.
Adolescents may also develop many striae across the sides of their abdomens because so much stretching of the abdominal skin occurs. Assure them again that, because of skin elasticity, these marks will probably fade after pregnancy. Chloasma, excess pigment deposition on the face and neck, appears at the same rate in adolescents as in older women. Adolescents, however, may be more conscious of this pigment because overall they are more conscious and concerned about their facial appearance. Suggesting a cover makeup and offering reassurance the pigmentation will fade after pregnancy may help.
Good nutrition is a major problem during adolescent pregnancy because many girls enter pregnancy with poor nutritional stores from years of eating a less-than-optimal diet. Lack of good nutrition can result in low-birthweight newborns and preterm births. The younger the girl is, the more likely she is to have a low-birthweight infant. To prevent these complications, the girl's diet must be sufficient to allow for the growth of a fetus and also provide for the needs of her own growing body. This means she may need to gain more weight than the mature woman does during pregnancy. Protein, iron, folic acid, and vitamin A and C deficiencies may become acute. Besides eating larger amounts of food, a pregnant adolescent should be sure to eat proper foods, possibly abandoning the food fads she has been following. Some girls are so peer-oriented they balk at substituting a glass of orange juice for a cola beverage because no one else they know drinks orange juice. The best you may be able to accomplish is to secure her agreement to switch to non-caffeinated soft drinks.
Many adolescent girls eat poorly during pregnancy because they simply do not know what constitutes a good diet. Some girls have little choice in what foods are prepared at home. To change a dietary pattern, you may have to talk to the person who does the cooking in the family.
Many adolescents eat at least one meal a week at a fast-food restaurant. Remember that if the girl is attending school, she eats at least one meal away from home each day. If she travels by school bus, she may have to leave by 6:00 or 7:00 in the morning, so she needs suggestions on how to construct a quick but healthy breakfast. If she leaves home this early, she will have a long wait until lunchtime. Suggest midmorning snacks, such as fruit, that are not just empty calories. Be certain nutrition education includes how to “brown-bag” or buy a nutritious cafeteria lunch (type A school lunches are discussed in Chapter 31).
Adolescents traditionally do not take medicine conscientiously, so they may need frequent reminders that vitamin and iron supplements during pregnancy must not only be purchased but also must be taken. Be sure a girl posts a medication reminder chart at home or in her school locker to help increase adherence.
Activity and Rest
Adolescents vary greatly in their preferred level of activity. Assess a girl's participation in sports and determine which ones (if any) should be discontinued during pregnancy (diving, gymnastics, touch football). Many girls practice sports not for the enjoyment of the sport but for the feeling of “team” or companionship. You may need to suggest alternative activities (joining the drama or language club, inviting friends over once a week to watch a movie) so they don't suffer from the loss of companionship.

Adolescent girls may not plan enough rest time during pregnancy, especially if they are acting as if nothing is happening to them. It may help to explore a typical day and suggest ways to rest without compromising social relationships.
Pregnancy Information
A young girl may have distorted beliefs about her body. Despite all the health information given to children in school, it is not uncommon to find an adolescent who thinks her baby is growing in her stomach. Such a girl may be unwilling to eat large meals during pregnancy for fear of suffocating the fetus. All adolescent girls need substantial education on the physiologic changes that occur during pregnancy. In addition, specific information about labor and delivery is essential to counteract all the “scare stories” they may be hearing from their peers. Gaining knowledge is another way that pregnancy can be a growth experience. At the end of the pregnancy, this adolescent will know a great deal more about her body and her ability to monitor her health than her average classmate.
Childbirth Preparation
Adolescents have a strong need for peer companionship. When they become pregnant, they often are cut off from fellow adolescents. This makes them “ripe,” therefore, to join a class of adolescents in preparation for childbirth. They are excellent students because being a student is age-appropriate for them. They have enough childish magical belief operating that they are not skeptical about whether prepared childbirth will work. In fact, believing that prepared childbirth will work is an important component in a successful prepared childbirth experience, so this becomes a self-fulfilling prophecy.
Birth Decisions
Pelvic measurements should be taken early and carefully in adolescent girls as cephalopelvic disproportion is a real possibility because of the girl's incomplete pelvic growth. Most girls who are told their baby will have to be born by cesarean birth respond well to the news, and many are relieved, because surgery seems controlled and simple compared with the agonies of labor they imagine. The decision on the method of birth should be shared with the girl and her parents when the health care team first reaches it. This is part of being honest with the girl. Adolescents, for the most part, want to know the truth. They tend to regard the withholding of information not as protection but as an indication they are being treated as children.
Plans for the Baby
Adolescents may need additional time at prenatal visits to talk to a good listener about how they feel about being pregnant and becoming a mother. Scared? Bewildered? Numb? Happy? Be certain they know all the options available to them: keeping the baby, or placing the baby in a temporary foster home or for adoption. Adolescents, like all women, should be encouraged to breast-feed (Sikorski et al., 2005). Breast tissue matures with pregnancy, so even the very young adolescent is physically capable of breast-feeding.
Complications of Adolescent Pregnancy
Adolescent pregnancy carries an increased incidence of pregnancy-induced hypertension, iron-deficiency anemia, preterm labor, and cephalopelvic disproportion (Box 17.4). Cephalopelvic disproportion leads to an increased incidence of cesarean birth. Fortunately, with conscientious prenatal care, these complications can be minimized.
Pregnancy-Induced Hypertension
Because adolescents are more prone to pregnancy-induced hypertension than the average woman (see Chapter 15), establishing a baseline blood pressure is important. This is particularly important if an adolescent has not had her blood pressure measured since a preschool or school-age checkup as long as 10 years earlier.
The best intervention for reducing an increasing blood pressure during pregnancy is bed rest, preferably in a side-lying position. Bed rest may be difficult for a teenager because she easily grows bored and being confined to bed limits her interactions with peers and school activities. Many girls on bed rest at home may rest better

if they are lying on the living room couch, where they can be aware of household activity, rather than in an upstairs bedroom where they have to get up time and again to see what is happening. Also, it is easier for a parent to encourage bed rest if a girl is within eyesight. If called too many times to the distant bedroom for small tasks, a parent tends to say, “Get up and get it yourself this time.”
Help to establish a specific routine of bed rest—does it mean being strictly confined to bed or sitting up part of the day in a lounge chair with legs elevated? Can she take a shower once a day? Use the bathroom? Knowing the exact rules from the beginning helps prevent misunderstandings and hurt feelings.
Girls on bed rest need activities to keep them busy. These can include homework or listening to music. If the end of the pregnancy is near, a girl may be able to have a friend bring her homework assignments. If the bed rest period will be longer than 2 weeks, however, she may need to make arrangements for home tutoring. You may need to advocate for her with the school system for this service (remembering that only rarely can it be denied on the basis of pregnancy). “Assignments” from the health care agency, such as reading about appropriate toys and games for infants, is also a way to occupy time. Frequent telephone calls from the health care facility show concern and offer an opportunity to enforce health teaching points. Be certain a girl does not interpret being placed on bed rest as being ill. This can cause her to reduce her nutritional intake or to curtail body hygiene.
Low-dose aspirin therapy may be prescribed to help reduce symptoms of hypertension of pregnancy. Keep in mind adolescents often are not reliable at taking daily medicine, particularly if it seems as unimportant as aspirin. Help a girl make a medicine reminder chart to promote adherence to this aspect of care.
If the hypertension continues after a period of bed rest at home (or if the symptoms of pregnancy-induced hypertension are acute when they are first discovered), a girl may be admitted to the hospital so bed rest can be better enforced. As soon as the fetus is mature, labor is induced.
Iron-Deficiency Anemia
Many adolescent girls are deficient in iron because their low protein intake cannot balance the amount of iron lost with menstrual flows. Deficiency is revealed by chronic fatigue, pale mucous membranes, and a hemoglobin level less than 11 g/dL. As if the girl's body has identified a mineral lack, iron-deficiency anemia is associated with pica, or the ingestion of inedible substances. Cravings for ice cubes or candy bars may develop because of this.
A pregnancy compounds iron-deficiency anemia because a girl must now supply enough iron for fetal growth and her increasing blood volume. All pregnant women should take an iron and folic acid supplement (folic acid is important for red blood cell growth and prevention of neural tube defects). This is especially important for the adolescent.
Help a girl plan a daily time for taking her iron supplement. Review with her how many iron-rich foods she needs to eat daily in addition to this. An iron supplement is not a supplement until her dietary intake is already strong in iron-rich foods.
As soon as the body has iron, it will begin forming immature red blood cells (reticulocytes) rapidly. A reticulocyte count may be obtained in 2 weeks to evaluate these levels and provide evidence that the iron supplement is being taken. If the reticulocyte count is not elevated by 2 weeks, it implies a girl did not take the supplement. Taking a stool swab and assessing it for the black tinge of an iron supplement or reassessing her serum iron level are other methods of assessing for adherence.
Preterm Labor
Adolescents are at 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 that labor contractions begin as only a sweeping contraction no more intense than menstrual cramps. Also, any vaginal bleeding is suspicious of labor and should be reported. Adolescent girls have gained much of their knowledge of labor from television (where a woman suddenly announces she is in labor and within 15 minutes gives birth). Therefore, they may dismiss light contractions as simple discomfort, not realizing they might be the start of labor. Adolescents who recognize labor contractions early on can seek care to have premature labor halted.
Complications and Concerns of Labor, Birth, and the Postpartum Period
Cephalopelvic Disproportion
Because their own development is still immature, adolescents are prone to cephalopelvic disproportion. Cephalopelvic disproportion is suggested by lack of engagement at the beginning of labor, a prolonged first stage of labor, and poor fetal descent. Adolescent labor does not differ from labor in the older woman if cephalopelvic disproportion is absent. Graphing labor progress is a good way to detect labor that is becoming abnormal. Be certain the adolescent has a support person with her in labor so she can relax and breathe effectively with contractions. If this person is also an adolescent, you may need to serve as the true support person, or at least spend considerable time coaching so he or she can support the girl in labor.
Postpartum Hemorrhage
Young adolescents are more prone to postpartum hemorrhage than the average woman because if a girl's uterus is not yet fully developed, it becomes overdistended by pregnancy. An overdistended uterus does not contract as readily as a normally distended uterus in the postpartum period. Adolescents also may have more frequent or deeper perineal and cervical lacerations than 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 for adequate

perineal stretching. If a laceration does occur, it usually heals readily without complication.
Inability to Adapt Postpartally
The immediate postpartum period may be an almost unreal time for an adolescent. Giving birth is such a stress and a major crisis that all women have difficulty integrating it into their life. It may be particularly difficult for the adolescent. The girl may “block out” the hours of labor as if they didn't happen. If she was particularly frightened by labor, she may have received a narcotic, so her memory of the labor hours may not be clear. Urge her to talk about labor and birth to make the happening real to her; otherwise, postpartum depression can occur.
Lack of Knowledge About Infant Care
Adolescents show the same positive bonding behavior with their infants as their more mature counterparts (Fig. 17.1). They may, however, lack knowledge of infant care. Although they may consider themselves to be knowledgeable in child care because they baby-sat for a neighbor's child or a younger sibling, they can be overwhelmed in the postpartum period to realize that when the baby is their own, child care is not as simple as it once seemed. When the child cries, they cannot hand it to someone else; at the end of 4 hours, when they are tired of caring for the baby, they cannot leave and walk away. Although these things were most likely discussed with an adolescent during pregnancy, these feelings may not arise until the child is actually born. Spend time with a girl observing how she handles her infant. Demonstrate bathing and changing the baby as appropriate. Model good parenting behaviors whenever possible by being aware of how you hold and care for the child.
Unfortunately, most adolescent mothers do not breast-feed. This is related to their perception of breast-feeding as something that will “tie me down” and the reality (in many instances) that they will be returning to school full-time soon after birth. Education about the importance of breast-feeding and tips for how to incorporate it into a busy lifestyle can increase the number of adolescents who breast-feed (see Chapter 25). Help young mothers who do not choose to breast-feed to find a feeding method that is satisfying to them and safe for the infant.
FIGURE 17.1 A new adolescent mother begins to bond with her infant. (Photo by John Gallagher, with permission of University of Pennsylvania Medical Center, Philadelphia, PA.)
The Pregnant Woman Over Age 40
The incidence of women delaying their first pregnancy until their late 30s or early 40s is increasing (Box 17.5). Eight percent of births in the United States today are to women over age 35; 3% to 4% are to women over age 40 (NCHS, 2005). In the past, it was assumed a woman of this age was past the optimal age for childbearing and was at risk for many complications. Today, with the exception of a greater incidence of chromosomal abnormality, there is little evidence of increasing complications in women older than age 35 as long as prenatal care is begun early in the pregnancy.
A woman over age 40 is more likely than a younger woman to have a previously diagnosed condition, such as hypertension, varicosities, or hemorrhoids. In addition, by age 40 a woman usually has a major role change to undertake during pregnancy, because she often is well established in a career or has an accustomed routine at home or in her community. She needs to think through how this

pregnancy and childrearing are going to fit into and change her life. Although she may feel rich in the number of support people she perceives around her, she may discover she has few “pregnancy support” people because she does not have many friends her age who are also having babies—some may be close to becoming grandmothers. The only things these friends remember of pregnancy and labor are their particular highs and lows, and the care they received may not reflect current practice. This may leave a woman without access to the daily “shop talk” of other pregnant women, or someone to turn to with questions such as whether the backache she is experiencing or frequent need to urinate is normal. On the other hand, because many women delay childbearing today, she may be one of a sizable group of women in the community experiencing pregnancy at this stage of life.
Childbirth education classes oriented toward the older woman provide important information on pregnancy and can bring these women and their support people together. A woman over age 40, like any other pregnant woman, needs access to health care personnel who can supply her with factual information during a pregnancy. She also needs additional support while she works through this role change in her life.
Developmental Tasks and Pregnancy
The developmental challenge of the over-40 age group is to expand their awareness or develop generativity—that is, a sense of moving away from themselves and becoming involved with the world or community (Erikson, 1963). Some people assume that once they reach adulthood, the way they are is the way they will always be. They are amazed to find that their bodies change (e.g., men may lose their hair; women and men both gain weight) and so do their interests. They find themselves joining committees and clubs, coaching Little League teams, or organizing fundraising or community events.
A woman in this age group who is pregnant may begin to feel ambivalent during pregnancy, because she may want to continue with community activities, yet also wants to concentrate on the baby inside her. You may need to help her balance her life so she can manage crossing two life phases this way.
Many adults over the age of 40 are caring for aging parents. This additional responsibility may make it difficult for a woman to complete the psychological work of pregnancy. It also may create extra strain on her finances and time.
Prenatal Assessment
A woman over age 40, like all women, should begin prenatal care early in pregnancy. Fortunately, most women of this age group are well informed about the advisability of early prenatal care and have adequate health insurance, so they do seek an early appointment. A few mistakenly believe their lack of menstruation is the result of early menopause and do not seek an early health care consultation.
Health History
Ask women in this age group about their present symptoms of pregnancy, how they feel about the pregnancy, and how it fits into their lifestyle. If a woman did not realize she was pregnant, she may have self-medicated. Ask if she has been taking any medication or herbal remedies to relieve reported symptoms, such as nausea or fatigue. Because a woman is functioning well in a business world does not mean she has a healthy pregnancy lifestyle. Don't accept answers such as “I drink socially” or “I take the usual drugs” without exploring what those phrases mean specifically.
Family Profile
Some women over age 40 who are pregnant for the first time have recently changed their life pattern (married or became involved in a long-term sexual relationship) or have decided to have a child, perhaps through in vitro fertilization, without a spouse before they are no longer able to conceive. Whereas a younger woman often waits a while after marrying to become pregnant, a woman over age 40 often plans to become pregnant immediately after marriage because she senses her reproductive years are running out. Because of this, she may find herself making many adjustments at once (not only to a new life partner, house or apartment, and perhaps community, but also to a pregnancy).
Identify a woman's source of income. If she has a well-paying job, stopping work because of a pregnancy complication may reduce her family's income greatly. Also evaluate how many people are financially or emotionally dependent on her (such as children from a former marriage, elderly parents, an elderly neighbor, or fellow workers who count on her). During pregnancy, when a woman often needs extra emotional support, feeling responsible for so many people can be difficult (Box 17.6).
Day History
Ask specifically about a woman's job and estimate the amount of walking or back strain it entails. Ask about recent diet or exercise programs. If a woman belongs to a health club, remind her that the use of saunas and hot tubs for longer than 10 minutes at a time is contraindicated during pregnancy because of possible hyperthermia and teratogenic effects of extreme heat on the developing fetus. Identify personal habits, such as cigarette smoking and alcohol consumption, that may be detrimental to a fetus to determine if counseling to halt or decrease these habits could be effective.
Physical Examination
A woman over age 40 needs a thorough physical examination at her first prenatal visit to establish her general health and to identify any problems, particularly circulatory disturbances. Inspect her lower extremities thoroughly for varicosities, because these are more common in women over age 40. Obtain a urine specimen and test it for specific gravity, glucose, and protein to evaluate overall renal function and the possibility of gestational or type 2 diabetes, because older women are more prone than younger women to develop these conditions.
Assess a woman's breasts for any abnormalities, as women over age 40 are in a higher-risk group for breast cancer than are younger women. Ask if she has had yearly mammograms. In addition, assess for fetal heart sounds

and fetal movement at prenatal visits because gestational trophoblastic disease (hydatidiform mole) is more common in women over age 40 (see Chapter 15).
Chromosomal Assessment
Women over 40 are offered a triple-screen (alpha-fetoprotein [AFP], human chorionic gonadotropin, and unconjugated estriol levels) drawn on blood serum at the 15th week of pregnancy to detect whether an open spinal cord or chromosomal defect could be present in the fetus, because their risk for Down syndrome is so much higher than it is in younger women (Egan et al., 2004). If this test is positive, an amniocentesis will be scheduled at the 16th week of pregnancy. Be certain a woman is prepared for these studies and receives support during them. Alert her about the possibility of false-positive results with AFP testing. Many women of this age group do not begin nest-building until these tests confirm that the child will be healthy.
Assess the number of meals a woman eats outside her home each week, including those she packs for lunch or eats in restaurants. She may need tips on how to adjust pregnancy nutrition so she can obtain the same nutrition whether she prepares meals at home or eats them at an office or community function. Urge her to substitute a caffeine-free soft drink in place of an alcoholic beverage. In some offices, large amounts of coffee are consumed. Urge her to substitute milk or juice or decaffeinated coffee. Many women this age normally drink little milk. Rather than getting used to milk again, a woman may appreciate suggestions on other ways to ingest calcium, such as puddings or yogurt.
Prenatal Classes
Because a pregnant woman over age 40 may be unique in her circle of friends, she may feel shut out of her usual group because of the pregnancy. This

makes her ready, therefore, to join a childbirth preparation or prenatal exercise class where she is “one of the group” (Fig. 17.2).
Be certain a woman plans (or the couple plans together) to set aside a specific time every day to do breathing exercises in preparation for labor. Otherwise, a busy woman may never find time to get to them and will be unprepared in labor.
FIGURE 17.2 Exercise classes during pregnancy provide women with an opportunity to interact with other pregnant women while benefiting from a carefully monitored work-out. (© Kathy Sloane.)
Complications of Pregnancy for a Woman Over Age 40
The complications of pregnancy most likely to occur in a woman over age 40—hypertension of pregnancy, preterm or post-term birth, and cesarean birth—are related to the fact that the woman's circulatory system may not be as competent as when she was younger or her body tissues may not be as elastic as they once were (Box 17.8; Malee, 2003; Porter & Scott, 2003).
Pregnancy-Induced Hypertension
A woman over age 40 may have a higher incidence of pregnancy-induced hypertension than a younger woman, possibly related to blood vessel inelasticity or because hypertension tends to occur more frequently in nulliparas than multiparas or those with already elevated blood pressure. At any age, the best way to reduce the symptoms of

pregnancy-induced hypertension is for a woman to rest for a good portion of each day. If a woman works full-time, stopping work may be difficult or impossible for her, not only because she believes she may miss out on a promotion or risk losing her job, but also because her income is important to her family and she is used to being productive, not merely resting all day. To allow her to rest effectively, you may need to help her plan activities she can accomplish on bed rest, such as reworking a school course outline, restructuring her office filing system, or working at a hobby she has wanted to pursue but never had time for before.
Complications and Concerns of Labor, Birth, and the Postpartum Period
Complications that occur with a woman over age 40 related to birth or the immediate period after birth also are the results of a body that may not be as elastic as it was when the woman was younger.
Failure to Progress in Labor
Labor in an older primipara may be prolonged because cervical dilatation may not occur as spontaneously as in a younger woman, probably because of decreased elasticity in cells. Graphing labor progress is a good method to use to determine when labor is becoming prolonged. Many women this age may need a cesarean birth if labor is overly prolonged and places the fetus at risk. Encourage a woman to verbalize how she is feeling about her progress throughout labor to allow for reassurance and prompt intervention should problems arise. Urge her support person to be present for the birth to offer needed support. Keep in mind that some older men may not be as comfortable in a birthing room as their younger counterparts would be.
Difficulty Accepting the Event
Women over age 40 may begin to have second thoughts about childbearing this late in life as the reality of a new baby registers with them during the intrapartal and postpartum period. Although they may have read a great deal about babies during pregnancy, they may wish they had read more or were as confident with this phase of their life as they are about other areas such as their home, office, or classroom. Review plans for child care and postpartum rest, with an emphasis on helping women learn to balance their lives. They most likely will need this help, especially if they are planning on returning to work soon after the birth. They might appreciate help making child care arrangements. You can assure them that day care for preschool children has positive socialization results (Zoritch, Roberts, & Oakley, 2005).
Postpartum Hemorrhage
Just as the cervix may not dilate as readily during an older woman's labor, the uterus may not contract as readily in the postpartum period due to inelasticity. Therefore, an older woman is at higher risk for postpartum hemorrhage. Close observation is essential. Because a woman over age 40 may be an independent woman who is interested in self-care, she may ask for little help. Be sure to assess the amount of lochial flow to detect this complication.
The Pregnant Woman Who Is Physically or Cognitively Challenged
In the past, women with conditions such as vision, hearing, cognitive, spinal cord, or orthopedic challenges were sheltered by their families to such an extent that women with even moderately physically challenging conditions did not meet potential sexual or marriage partners and so did not become pregnant. In addition, most people believed these individuals should not become pregnant. Today, women with varying degrees of disability attend public schools, work in offices, join community organizations, establish sexual relationships, marry, and plan pregnancies. Because these women (and in some instances their support persons also) face special problems related to their conditions, nursing care during pregnancy must be designed with these special concerns in mind so a woman's and family's problems and needs can be addressed and met.
TABLE 17.1 lists general areas of care that are important in planning for the physically or cognitively challenged woman who is pregnant.
Rights of the Physically or Cognitively Challenged Person
There are always ethical considerations related to women with disabilities and pregnancy (Scott, 2005). By federal law, physically disabled persons must have freedom of access to public buildings by means of ramps or handrails. All public health care facilities must be in compliance with these laws both in terms of physical facilities and in the true spirit of the law: that is, people should be made to feel psychologically welcome as well as physically able to reach the inside of the building. Under the same law, a hospital cannot deny care to a person with a disability even though the disabling condition complicates treatment considerably, possibly requiring extra personnel and time. A woman with a disability has full rights to her child, so the baby cannot be taken from her at birth without her full consent. Likewise, she cannot be forced to terminate the pregnancy or undergo sterilization unless that is her informed decision.
TABLE 17.1 Areas of Planning With Physically or Cognitively Challenged Women During Pregnancy
Area Assessment and Planning Guidelines
Transportation Ask if a woman has transportation for prenatal care and for emergencies.
Pregnancy counseling Assess the special modifications of care that will need to be made depending on a woman's special challenge. Use additional visual or auditory aids to make your teaching points clear.
Support person Determine who is the woman's support person. In some instances, a woman's condition requires so much assistance during pregnancy that one support person will not be enough. If necessary, contact community agencies to lend additional support, with her consent.
Health Don't lose track of a woman's primary health problem. For example, a woman with cerebral palsy needs to continue an active muscle exercise program during pregnancy for her primary illness.
Work Assess whether a woman works outside her home and, if work is discontinued during pregnancy, what she could substitute for a social contact activity. Women with physical or cognitive challenges may be lonely because they do not have a wide range of friends or social contacts.
Recreation Assess whether her level of activity is adequate, and make concrete suggestions within her limitations for increasing it. Many women with a physically challenging condition lead a rather sedentary life (partly because they do not have many social contacts).
Self-esteem Assess a woman's level of self-esteem: it may be low because of repeated failures in her life. Give praise at prenatal visits and help her make pregnancy a growth experience.

Modifications for Pregnancy
Most women with some degree of challenge need modifications of their care during pregnancy. Explore with them at a first prenatal visit the exact nature of their disability and their general self-image. Some women who are physically or cognitively challenged maintain high self-esteem despite severe limitations and are able to modify, grow, and learn with a pregnancy, whereas others have a poor sense of self-esteem that will make this particularly difficult for them. For many of them, pregnancy will become a special event, a 9-month announcement to everyone that, despite their seeming limitations, they are equal to other women and capable of participating in one of life's miracles (McKay-Moffat, 2003).
Safety Measures to Explore
Safety is a key area of concern when caring for the pregnant woman who is physically or cognitively challenged. Be sure to assess areas such as emergency contact persons, suppliers of transportation, and individual considerations such as mobility, elimination, and possible autonomic responses.
Emergency Contacts
Evaluate the client's ability to contact someone in case of an emergency. Does a woman have a telephone she can reach readily? Does she know how to activate the emergency medical system (911) in her community? If a woman's speech is not clear, evaluate whether she will be understood while using the telephone to call for help in an emergency. Some women with limited mobility, such as those with spinal cord injury or cerebral palsy, have a specially designed telephone contact system in their home that connects to a paramedic or hospital emergency service through a beeper system. Check that they intend to maintain this throughout pregnancy. Women who are hearing challenged use a specially equipped telephone (a TDD device) that prints out messages for them.
Assess a client's ability to come for prenatal care. If a woman depends on a support person for transportation to a health care facility, appointments may have to be arranged according to that person's schedule to prevent missed appointments. If a woman does not drive, who would transport her if a pregnancy emergency should occur? Women with cognitive or vision challenges, for example, may not qualify for a driver's license and so may need someone, such as a family member or friend, to drive. Women with spinal cord injury may have difficulty transferring into the specially equipped, hand-controlled car they usually drive as pregnancy progresses.
All women who use wheelchairs are taught to press with their hands against the armrests and lift their buttocks up off the wheelchair seat for 5 seconds every hour. This prevents the formation of pressure ulcers on the buttocks and posterior thighs. Encourage the pregnant woman to continue to perform this maneuver during pregnancy as the increased weight of a fetus increases her risk for pressure ulcer formation from compression. In addition, severe hip flexion from sitting in a wheelchair limits venous return from the lower extremities. For at least 1 hour every morning and afternoon, encourage women who ambulate by wheelchair to decrease the sharp bend at the knees that results from sitting in the chair, to promote venous return and help prevent varicosities and thrombi formation. Adjusting the footrests of the wheelchair so a woman's legs are not sharply bent at the knees is helpful.
If balance is a problem, a woman may need reevaluation at the midpoint of pregnancy as the weight of her abdomen increases. This may necessitate the use of crutches if she did not use them before, or use of a wheelchair if

she was ambulatory with crutches or a walker before pregnancy. Keep in mind that a woman who is physically challenged achieved the degree of ambulation that she first presents with usually after years of physical therapy and strengthening of leg and arm muscles. Help her see that reducing her degree of independence during pregnancy is not a step backward for her but a step forward, allowing her to have a safe pregnancy without the danger of falling (Fig. 17.3).
When mobility is an effort, a woman may not drink as much as usual or use a bathroom as frequently as she would if those actions were effortless. Encourage a high fluid intake and frequent voiding to prevent urinary tract infections. Women with spinal cord injury who use an indwelling catheter are at especially high risk for contracting urinary tract infections during pregnancy. Women who perform self-catheterization or change their own indwelling catheter may be unable to continue to do this late in pregnancy because the increasing size of their abdomen interferes with their ability to see or reach the perineum comfortably. If this happens, it may be necessary for her to arrange for a support person, a home care nurse, or a home health aide to do this for her.
Autonomic Responses
In a woman who has a high spinal cord injury (cervical or high thoracic), observe for autonomic dysreflexia during pregnancy, labor, and the immediate postpartum period. This is an exaggerated autonomic response to stimuli. Any irritating condition, such as a distended bladder, increasing uterine size, labor contractions, or breast-feeding, may initiate the response (Malee, 2003). Without upper motor neuron control to reverse the phenomenon, extreme symptoms such as severe hypertension (300/160 mm Hg), throbbing headache, flushing of the skin and profuse diaphoresis above the level of the spinal lesion, nausea, and bradycardia may occur. Immediate action is necessary to protect against cerebrovascular accident or intraocular damage. Elevate a woman's head to reduce cerebral pressure and locate the irritating stimulus (usually a distended bladder or bowel). If bladder distention is the cause, remove the bladder pressure by catheterization if an indwelling catheter is not in place. If a catheter is in place, check to see why it is not draining, then encourage it to drain by unkinking or flushing to allow urine to flow freely again. Anticipate the need for an antihypertensive agent to alleviate the extreme hypertension, although as soon as the source of irritation is removed, symptoms typically fade quickly.
FIGURE 17.3 During pregnancy, a woman who is physically challenged may need to use a wheelchair to help safeguard against injury. Assure her that she may still enjoy her independence and daily activities, such as caring for an older child. (© Keith/Custom Medical Stock Photo.)
Prenatal Care Modifications to Meet Specific Needs
The physical examination may need to be modified depending on individual circumstances. Although women with disabilities have been followed by health care providers most of their life, they may never have had a pelvic examination before and so need clear instructions about why it is needed and what it will consist of. Many obstetric examining tables are built for the comfort of the examiner and are too high for a woman to transfer to from a wheelchair by simply sliding onto the table. To help a woman move to the table, a ramp from the physical therapy department may be necessary so the wheelchair can be elevated to the level of the table. Woman with spinal cord injury or cerebral palsy may be unable to maintain their legs in a lithotomy position because of either hip flexion contracture or laxness of leg support. This means a dorsal recumbent, rather than a lithotomy, position may be required for a pelvic examination.
Women who are cognitively challenged may not be aware how they became pregnant. If a woman became pregnant because she was taken advantage of sexually, she may need some time to talk and work through this experience before she can allow a pelvic examination.
If a visually challenged woman brings a guide dog with her to a health care visit, remember that although the dog's chief function is to offer direction, its instinct causes it to become a woman's protector. In this role, the dog may feel threatened by people who try to pet it. Petting a guide dog also distracts it from safeguarding its owner. When interviewing or teaching visually challenged women, do not use your hands to illustrate points (“I'll need a urine sample of at least this much urine [measured with your fingers]”). Do not use colors as descriptions of objects (“put on the blue gown”). Use demonstration aids that allow a woman to feel or touch. When helping with or performing physical assessment, let the woman know you are closing the door or drawing a curtain to ensure privacy. Always alert a woman when you are going to touch her, so as not to startle her. Otherwise, you may find yourself facing a growling guide dog that rises to protect her.
If a woman is hearing impaired, she may not be able to see the examiner's face during a pelvic examination. This means any question asked of her during this time will not be understood because she cannot see the examiner's lips to lip read (Josiah, 2004).
Pregnancy Education
Modify health teaching to meet a woman's specific needs. As stated previously, avoid references to colors or using

your hands when explaining something to a visually challenged woman. Enlist the aid of her other senses, such as touch (McGuire, 2003). For a woman who is cognitively challenged, instructions about pregnancy may need to be limited to those few items crucial for safety, such as “do not drink alcohol or take any medicine.”
If a woman and her support person are both visually challenged, pamphlets about pregnancy care will not be useful. If the support person can see, offer the pamphlets to him or her, suggesting he or she read them to her as a shared activity. This will be helpful for her and also makes the partner a more informed support person. Many visually challenged women have tape recorders supplied by Recording for the Blind and Dyslexic (, a national, nonprofit, voluntary organization. Telephone the local association and ask if they have any material already recorded on pregnancy or breast-feeding they could supply. If not, make a tape recording of any information you particularly want a woman to remember or she seems concerned about. Supply the health care facility telephone number at the beginning of the tape for an easy reminder in an emergency, and perhaps the date of her next visit as well.
Plan nutritional education based on each client's specific challenges and usual routine. Ask what a woman normally eats. A visually challenged woman or one who ambulates by wheelchair, for example, may prepare her own breakfast and lunch, meals that may not require a stove. The only hot meal a woman may eat is one a support person cooks in the evening. Nutrition counseling for two meals daily, therefore, needs to center on foods that can be prepared without cooking.
Activity and exercise, important for any pregnant woman, are crucial for a woman who is physically challenged. Evaluate the amount of exercise a woman gets daily. If mobility is a concern, exercise can be very reduced in bad weather. In this case, be sure a woman understands that walking around her home or apartment can provide the same level of exercise as if she were walking around the block or exercising in a health club.
Although labor and the child's birth may be modified somewhat because of a woman's physical condition, gaining general knowledge about labor and birth and participating in a shared experience with her partner are still valuable. Urge women who are challenged in some way to attend childbirth preparation classes. If a woman is not working outside her home, she may have more time than others to practice breathing exercises and enter labor more adept at using such a method to control pain in labor than other women.
If a woman is severely hearing challenged, she may not have heard the many spot television announcements on not smoking or drinking alcohol during pregnancy; she may need more time at prenatal visits so this can be discussed. In addition, lip reading is a difficult skill to learn, so many hearing-challenged persons cannot do this with ease. Even if a woman is skilled at this, she may not be able to decipher new words such as amniotic, gestation, or edema. Show her the printed words so she can see what your lip motion represents when presenting new pregnancy terms. If a woman uses sign language, she may bring an interpreter with her to translate. Be certain to talk to her, not the interpreter, when interviewing.
Modifications for Labor and Birth Preparation
Women who are physically or cognitively challenged will need adaptations in preparation for labor and birth. Helpful suggestions are:
  • A woman with a spinal cord injury may not be able to feel uterine contractions. Late in pregnancy, she will need to palpate her abdomen periodically for tightening or the presence of contractions so she is aware of beginning labor.
  • Women with muscle spasticity or spinal cord injury may not be able to push effectively for the second stage of labor and so may need cesarean birth or forceps birth.
  • If a woman cannot assume a lithotomy position because of hip contracture, vaginal delivery from a Sims' or dorsal recumbent position can be used.
  • Braille watches used by visually challenged persons may not have second hands. They may need to time the length of contractions by counting rather than timing them by a watch.
  • During labor, the hearing-challenged woman cannot hear information on how she is progressing if you are not directly facing her. If she needs to communicate with her support person in sign language, act as an advocate to keep her hands unencumbered by equipment such as intravenous lines. Remember she cannot hear the infant cry at birth. Hand the infant to her as soon as possible after birth so she can see and feel the baby is crying and breathing well.
  • Be certain to identify the usual sounds of birthing rooms (the beeping of a monitor, the swish of a central supply routing system, and so forth) for the visually challenged woman. Hearing sounds and not being able to identify them is frightening.
Modifications for Postpartum Care
After birth, be sure to assess and teach.
  • Ask whether a woman desires contraceptive information.
  • Support her attempts to breast-feed.
  • Be certain a woman has a return appointment for both herself and her infant for follow-up care and that the arrangements are within her capabilities, transportation, and understanding.
Modifications for Planning Child Care
Allow for extra time during the first days after birth for mother–child interaction. For example, after birth, a woman who is cognitively challenged may need extra time to understand the transition from “being pregnant” to “having a baby.” She may have difficulty learning to judge when her infant is hungry. She may need extra supervision to be certain she doesn't leave the baby unprotected on a bed. A woman with a spinal cord disability may be

particularly interested in inspecting her baby's back. A visually challenged woman will probably want to reassure herself her baby can see. Be sure to give the baby to her as soon as possible so she can touch the baby and feel for intact body parts. If the birthing room is cold, explain to her that you want to rewrap the baby to prevent chilling, not because her touching is wrong or because you are trying to hide an imperfection in the baby.
Breast-feeding has special advantages for women who are physically or cognitively challenged because it is the method of feeding that is not only best for the baby, but also requires the least preparation effort on the mother's part. For a woman who is visually challenged and unable to read printed instructions, for example, breast-feeding eliminates formula errors. For a woman who uses a wheelchair, it eliminates trips to the refrigerator. However, breast-feeding may not be possible for a woman with muscle spasticity because the let-down reflex, which depends on muscle relaxation, may not occur. Be certain that women who are cognitively challenged understand they need to feed until the infant is satisfied, not until they are tired of feeding.
Encourage women to think through what baby care equipment will be best for them. Some infant crib rails lower by pressure on a foot pedal. Others use a waist-high lever. A woman who ambulates by wheelchair usually finds the waist-high lever most convenient because she can reach this most easily. Also review with a woman any special steps she will need to use for safe child care. Many women need a referral for home care follow-up and possibly the use of a home health aide for child care.
If a woman has difficulty with mobility, ask how she anticipates carrying her infant. Using an anterior baby sling is usually effective with a wheelchair. Women who are mobile by crutches or a walker can place the baby in a small wagon and pull it. Some women lie on their back on the floor, place the baby on their chest, and scoot across the floor. The important point is not how a woman carries her baby, but that she has thought through a safe and comfortable way to do this.
Urge a visually challenged woman to make eye contact when talking to her infant. Many visually challenged people do not turn on lights in their home because they do not perceive the difference between light and dark. Encourage a woman to develop a habit of turning on lights after dinner because her infant will need light to develop vision. If her support person also is visually challenged, suggest she check with a close friend or neighbor monthly to see that light bulbs have not burned out.
One of the biggest worries for the hearing-impaired woman is that she will not be able to hear her baby crying. Help her plan to bring the infant's crib or bassinet close to her bed so she can feel the vibration of the baby's stirring and waking. Urge her to talk to the infant as she gives care so the infant is introduced to sounds and words. Some women whose speech is severely affected by their hearing disorder are reluctant to speak to strangers. Assure her that her infant is not a stranger and will quiet readily to the sound of her voice. The child may develop her speech pattern because of this. Being spoken to and sung to during the first year is important for overall development, however, so this is still preferable to living in a world of silence.
Some women who are cognitively challenged may have been raised in a group home and only recently moved to their own apartment. Unlike those raised at home, these women may have unusual difficulty making plans for child care because they have never seen the care of young children. You have a legal obligation to investigate whether a newborn will receive safe care before hospital discharge. Be certain to ask enough questions so that you are sure a woman who is severely cognitively challenged, for example, has a responsible friend or partner to help her with child care.
A Woman Who Is Substance Dependent
Substance dependence is a growing health problem in women of childbearing age, so its incidence during pregnancy is increasing. As many as 10% to 20% of pregnant women use illegal drugs during pregnancy (DHHS, 2000). The use of cocaine, amphetamines, and multiple drugs has increased dramatically in recent years. Adolescents have an increased rate of inhalant abuse and binge drinking.
Substance abuse is defined as the inability to meet major role obligations, legal problems, or an increase in risk-taking behavior or exposure to hazardous situations because of an addicting substance. A person is substance dependent when he or she has withdrawal symptoms following discontinuation of the substance, combined with abandonment of important activities, spending increased time in activities related to substance use, using substances for a longer time than planned, and continued use despite worsening problems due to substance use (Jaffe & Anthony, 2005).
Typically, substance-dependent women are thought to be in the younger age group, as the overall incidence of drug use is highest in this group. However, any woman could be substance dependent. Therefore, all pregnant women need to be assessed for the possibility of substance abuse.
A mark of a woman with a substance abuse problem is that she may come late in the pregnancy for prenatal care because she is afraid her drug use will be discovered and she will be reported to authorities (Brady et al., 2003). She may have difficulty following prenatal instructions for proper nutrition because although she may desire to eat well, she may lack sufficient money for both drugs and nutritious food, and choosing drugs will make her nutrition inadequate. She may not have money for supplemental vitamins or iron preparations for the same reason. If she

is using a drug that sustains her for only a few hours, she cannot wait long at a health care facility to be seen for an appointment.
Illicit drugs tend to be of small molecular weight, so they cross the placenta readily. As a result, a fetus of an addicted mother has a drug concentration of about 50% that of the mother. Because this can lead to fetal effects, drug abuse can account for fetal abnormalities or preterm birth (Higley & Morin, 2004). If a woman uses injected drugs, the risk for hepatitis B or human immunodeficiency virus (HIV) infection increases. Additionally, a woman may earn money to buy drugs through prostitution, which increases the risk for sexually transmitted infection and poses an additional threat to a fetus.
Drugs Commonly Used During Pregnancy
Recreational drugs commonly used in pregnancy are those commonly used by women in their childbearing years: cocaine, amphetamines, marijuana, phencyclidine, inhalants, opiates, and alcohol.
Cocaine is derived from Erythroxylum coca, a plant grown almost exclusively in South America. When sniffed into the nose or smoked in a pipe, cocaine is absorbed across the mucous membranes, affecting the central nervous system. As a result, sudden vasoconstriction occurs. Respiratory and cardiac rates and blood pressure increase rapidly in response to the vasoconstriction. Immediate death may result from cardiac failure. Alkaloidal cocaine (crack), a concentrated mixture, produces an even more rapid and intense “high” when inhaled.
Cocaine has become one of the most frequently abused drugs during pregnancy, and its use is exceptionally harmful during pregnancy because the extreme vasoconstriction that occurs can severely compromise placental circulation, leading to abruptio placentae, or a tearing loose of the placenta, which then results in preterm labor or fetal death (Box 17.9). Infants born to cocaine-dependent women may suffer the immediate effects of intracranial hemorrhage and a withdrawal syndrome of tremulousness, irritability, and muscle rigidity. Long-term effects are not well documented, but learning defects are suspected (Higley & Morin, 2004; Lewis et al., 2004).
Counseling women to discontinue cocaine use during pregnancy is often disappointing. The effects of the drug are so intense that it is difficult for addicted women to withdraw. Cocaine use can be detected by urinalysis because the metabolites of cocaine can be detected in urine up to 1 week after use.
Methamphetamine (speed) has a pharmacologic effect similar to cocaine. Its use is becoming more common because it is easily and cheaply manufactured. Ice, a rock type of methamphetamine that is smoked, can produce high concentrations of drug in the maternal circulation. Newborns whose mothers used the drug show jitteriness and poor feeding at birth and may be growth restricted (Smith et al., 2003).
Marijuana and Hashish
Both marijuana and hashish are obtained from the hemp plant, cannabis. When smoked, they produce tachycardia

and a sense of well-being. Some women have begun to use marijuana to counteract nausea in early pregnancy (Westfall, 2004). These drugs are frequently part of polydrug abuse, so their effects are not well documented. They are associated with loss of short-term memory and an increased incidence of respiratory infection in adults. A frequent user may not be able to breast-feed because of reduced milk production and the risk to the newborn from excretion of the drug in the milk.
Phencyclidine (PCP) is an animal tranquilizer that is a frequently used street drug in polydrug abuse. It causes increased cardiac output and a sense of euphoria. It has the potential for causing long-term hallucinations (flashback episodes). PCP tends to leave the maternal circulation and concentrate in fetal cells, so it may be particularly injurious to a fetus.
Narcotic Agonists
Narcotic agonists, used for the treatment of pain (e.g., morphine or meperidine [Demerol]) and cough suppression (codeine), are also widely abused because of their potent analgesic and euphoric effect. Heroin, a raw opiate, is the main opiate used recreationally to the point of dependence, and its use is increasing in incidence in young adults. A short-acting narcotic, heroin is inactive until it crosses the blood–brain barrier (which it does more quickly than morphine). It may be administered intradermally (“skin popping”), through inhalation (“snorting”), or intravenously (“shooting”). It produces an immediate and short-lived feeling of euphoria followed by sedation. Pregnancy complications related to its use include pregnancy-induced hypertension and, because narcotics are often injected with shared needles, phlebitis, subacute bacterial endocarditis, and hepatitis B and HIV infection.
Withdrawal symptoms include nausea, vomiting, diarrhea, abdominal pain, hypertension, restlessness, shivering, insomnia, body aches, and muscle jerks. Withdrawal symptoms may begin as soon as 6 hours after the last drug dose and can continue for several days. Their severity and duration depend on the amount of drug used daily and the length of the dependence period.
Heroin abuse in the pregnant woman can result in fetal opiate dependence and severe withdrawal symptoms in the infant after birth. Infants of opiate-abusing women tend to be small for gestational age and have an increased incidence of fetal distress and meconium aspiration. They will have the same withdrawal symptoms after birth as the mother would if she abruptly stopped taking the drug.
Because a fetus is exposed to drugs that must be processed by the liver during pregnancy, the fetal liver is forced to mature faster than normal. For this reason, newborns of substance-abusing women seem better able to cope with bilirubin at birth than other babies; hyperbilirubinemia is therefore rarely a problem. Fetal lung tissue also appears to mature more rapidly than normal, apparently from the stress of intrauterine drug exposure. Therefore, although the infant is born preterm, the chance that he or she will develop a condition such as respiratory distress syndrome is less than average.
If possible, an opiate-dependent woman should be enrolled in a methadone maintenance program during pregnancy. Infants of women taking methadone do not escape withdrawal symptoms, and some infants appear to have more severe reactions to methadone withdrawal than to heroin withdrawal (Berghella et al., 2003). Because a woman is being provided an oral drug legally, however, a fetus is at least ensured better nutrition, better prenatal care, and less exposure to pathogens such as hepatitis B and HIV. If a methadone program is not available, women may be treated with buprenorphine (Comer & Annitto, 2004). Drug withdrawal symptoms of the newborn and accompanying nursing care are discussed in Chapter 26.
Inhalant abuse refers to the “sniffing” or “huffing” of aerosol drugs. Frequently abused substances include airplane glue, cooking sprays, or computer keyboard cleaner. Most

of these substances contain Freon as a propellant and can lead to severe respiratory and cardiac irregularities. The effect of these drugs during pregnancy is not well documented, but the respiratory depression they can cause could be enough to limit the fetal oxygen supply to a serious level.
Although alcohol can be legally purchased and is served generously at social functions, it is just as detrimental to fetal growth as illegal drugs. There is little documentation as to how much alcohol must be ingested before fetal alcohol syndrome, a syndrome with significant facial features and cognitive challenge, occurs, so women are advised to drink no alcohol during pregnancy (Burd, Klug, & Martsolf, 2004). When discussing alcohol ingestion with young adults, be certain to talk about binge drinking (five or more alcohol drinks on one occasion) to be certain a woman doesn't believe this type of occasional drinking is safe during pregnancy (Bailey et al., 2004).
Key Points
Adolescent pregnancy is a major concern, because although it is decreasing in incidence, it still occurs at a high rate and can interfere with the development of both an adolescent and fetus. Nursing care needs to be individualized to meet the prepartal, intrapartal, and postpartum needs of this age group. Helping adolescents view a pregnancy as a growth experience can help them mature in their ability to parent.
Women who delay childbearing until age 40 may need additional discussion time at prenatal visits to help them incorporate a pregnancy into their lifestyle. They may need reminders to save time during the day for rest, particularly if at risk for pregnancy-induced hypertension or varicosities.
Women who are physically, cognitively, visually, or hearing challenged or who have a spinal cord injury are apt to have special needs during pregnancy that must be addressed by health care providers. Providing time for discussion early in pregnancy so these needs can be identified and anticipated is an important role for nurses.
Women who are physically or cognitively challenged may need help in adjusting their usual regimen to pregnancy. Be certain they are aware of how to contact help in an emergency. Ensure that all medications they are taking for their primary disorder are safe for use during pregnancy.
A woman who is substance dependent presents a unique challenge during pregnancy. Encouraging her to decrease or halt her drug intake to safeguard the health of a fetus is a short-term goal. Addressing her need to decrease drug intake for the remainder of her life so she can be a quality parent is a long-term goal.
A fetus of a woman who is substance dependent is at high risk because of the direct effects of the drug and the indirect effects of an unhealthy lifestyle. Women addicted to opiates should be encouraged to join drug reduction maintenance programs if possible to reduce fetal risk.
Critical Thinking Exercises
  • Mindy, the 16-year-old girl you met at the beginning of the chapter who is 15 weeks pregnant, tells you she is old enough to be a responsible parent and plans to keep her baby. What clues would you look for to see if her self-evaluation is correct?
  • Mindy makes friends with Clara, a 44-year-old woman, at the prenatal clinic. Clara works at a desk job as a stockbroker. She eats most of her meals at restaurants. Mindy lives at home and attends school. Both have inactive lifestyles. How would your teaching to prevent pregnancy complications differ for these two clients?
  • Mindy is dependent on methamphetamine. You suspect she supports her drug habit by prostitution. Describe modifications to her plan of care that would be necessary to ensure consistent prenatal care. What specific advice would you want to stress with her to avoid complications of pregnancy?
  • Examine the National Health Goals related to women with special needs. Most government-sponsored money for nursing research is allotted based on these goals. What would be a possible research topic to explore pertinent to these goals that would be applicable to the Carson family and also advance evidence-based practice?
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Burd, L., Klug, M., & Martsolf, J. (2004). Increased sibling mortality in children with fetal alcohol syndrome. Addiction Biology, 9 (2), 179–186.
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Suggested Readings
Crow, L. (2003). Viewpoint. Invisible and centre stage: a disabled woman's perspective on maternity services. RCM Midwives Journal, 6 (4), 158–161.
Gomez, C., et al. (2005). Expired air carbon monoxide concentration in mothers and their spouses above 5 ppm is associated with decreased fetal growth. Preventive Medicine, 40 (1), 10–15.
Hughes, R. B. et al. (2005). Stress and women with physical disabilities: identifying correlates. Women's Health Issues, 15 (1), 14–20.
Kovalesky, A. (2004). Women with substance abuse concerns. Nursing Clinics of North America, 39 (1), 205–217.
Low, L. K., et al. (2003). Adolescents' experiences of childbirth: contrasts with adults. Journal of Midwifery & Women's Health, 48 (3), 192–198.
Merewood, A., & Philipp, B. L. (2003). Promoting breastfeeding in an inner-city hospital: how to address the concerns of the maternity staff regarding illicit drug use. Journal of Human Lactation, 19 (4), 418–420.
Marcellus, L. (2003). Critical social and medical constructions of perinatal substance misuse: truth in the making. Journal of Family Nursing, 9 (4), 438–452.
Prilleltensky, O. (2003). A ramp to motherhood: the experiences of mothers with physical disabilities. Sexuality and Disability, 21 (1), 21–47.
Russell, S. T., & Lee, F. C. H. (2004). Practitioners' perspectives on effective practices for Hispanic teenage pregnancy prevention. Perspectives on Sexual and Reproductive Health, 36 (4), 142–149.
Saewyc, E. M., Magee, L. L., & Pettingell, S. E. (2004). Teenage pregnancy and associated risk behaviors among sexually abused adolescents. Perspectives on Sexual and Reproductive Health, 36 (3), 98–105.
Savage, C. (2003). Screening for alcohol use in women of childbearing age. Journal of Addictions Nursing, 14 (2), 63–64.
Spear, H. J. (2004). Personal narratives of adolescent mothers-to-be: contraception, decision making, and future expectations. Public Health Nursing, 21 (4), 338–346.

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