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NO TIME OBJECTIVES

CONTENT ADOLESCENT PREGNANCY Over one million teenage girls in united states become pregnant annually about 9% of sexually active 14 years old. A teenage pregnancy is defined as pregnancy in women less than 18 years. In India marriage between age group 13-16 years is seen in rural areas and hence conception in early age occurs. Pregnancy in early teens is associated with an adverse effect on maternal nutrition, birth weight and survival of offspring. Most of the teenage births are the result of unintended pregnancies. The risk for problems during pregnancy & child birth is greatest in the pregnant adolescent girl younger than 15 years. The incidence of low-birth weight infants & spontaneous abortion, as well as infant mortality are two to three times higher for girls in the age group than they are for women older than 25 years. The very young pregnant adolescent is at higher risk for each of the confounding variables associated with poor pregnancy outcomes & for those conditions associated with a first pregnancy Effect on mother: there are increased chances of lower maternal body weight gain, lower pregnancy weight gain, high prevalence of anemia, pregnancy induced hypertension. There is chance of CPD and obstructed labour due to inadequately sized pelvis. Effect on baby: there is increased chance of prematurity, low birth weight, birth asphyxia and care during delivery. Proper antenatal check up is a must. They should receive iron and folic acid with calcium supplementation.

STUDENT TEACHER ACTIVITY

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EVALUATION

Prevention of sexually transmitted diseases and counseling is a must. They should be considered a high risk group and institutional delivery is must. Assessment Interview: The interview at the initial prenatal visit for pregnant adolescent is similar to that for the adult pregnant woman. A thorough health history that includes a review of systems & sexual history is warranted Nutritional assessment Nutritional assessment includes: The girls history (medical, obstetric, lifestyle, psychosocial) A dietary assessment Anthropometric measurements Laboratory testing Clinical evaluation The effect of maternal on gestational weight gain is unclear because in most studies other factors influencing. Gestational weight gain are: Alcohol use Parity Smoking Inadequate weight gain early in pregnancy is linked to the birth of small for gestational age infants. However, an adequate early weight gain may be difficult for her to achieve because of the girls body image, poor pre pregnancy nutritional status & poor diet during pregnancy. A late inadequate weight gain linked to perform birth & small for gestational age infants. The adolescent is at greater nutritional risk because of the high fat content of food served at school cafeterias and the consumption of large amounts of fast foods common among teenagers. Her beverage intake also should be assessed because adolescents may inadvertently consume excessive amounts of caffeine in soft drinks & other

beverages. Besides finding out about the foods & beverages she consumes, lifestyle behaviours such as frequent dieting, alcohol consumption, smoking & substance abuse also affect her nutritional status & should be assessed well. Nutritional needs of young adolescents are greater than those of women whose growth has been completed. The hematocrit values found in adolescents show them to be at particular risk for nutritional anemia. Adolescents diet tend to be inadequate, particularly iron & folic acid. Health care providers should use specific, reliable procedures for obtaining and recording weight & height & should implement them consistently in classifying women according to weight for height, setting weight gain goals & monitoring weight gain during pregnancy. Psychological status Psychological screening includes an assessment of girls response to pregnancy including whether she is depressed or suicidal. The nurse should also assess their perceived learning, literacy, problem solving ability, time orientation, body image, dependency & peer & partner relationships Pregnant teenagers should also be assessed for evidence of previous sexual abuse. Recent studies have shown that adolescent females who have been sexually abused are at increased risk for becoming pregnant as teenagers. Support systems Emotional support, particularly that from the teenagers family, is extremely important to pregnant adolescent because the people in the support systems, particularly be parents, boy friend or husband can give significant influence on the pregnancy outcome. Many pregnant teenagers come from socially & economically deprived families. The nurse can assist those adolescents at risk to begin to change their behaviours so that their use of health care delivery system & its resources enhances their health & well being & those of the child. Physical examination The physical assessment of pregnant teenagers is same as that of adult

pregnant women. However, careful determination of their baseline blood pressure is necessary because teenagers have lower systolic & diastolic pressures than the older women For eg: a pregnant teenager with a blood pressure of 140/90 mm Hg could be at serious risk for preeclampsia Laboratory tests Laboratory tests done for pregnant adolescents are similar to those done for adult pregnant women & should include a determination of the hematocrit levels, a white cell count & differential blood typing. Rh factor determination, an antibody screen, determination of the rubella titer, serologic test for syphilis, urinalysis urine culture, papsmear & vaginal or rectal smears to screen for gonorrheal, beta streptococcal & clamedia infection. Glucose tolerance test for gestational diabetes. HIV testing tuberculin skin testing & sickle cell screening for clients at risk. ELDERLY PRIMIGRAVIDA Women having their first pregnancy at or above age of 30-35 years are called elderly primigravida. These cases who have conceived long after marriage at more risk. Types: One with high fecundity A woman married late but conceives soon after the marriage One with low fecundity Women married early but conceives long after marriage. This type is prognostically more unfavourable. Moreover, because of low fecundity chance of future progressive are remote. Complications Mother: During pregnancy

there is increased chance of abortion, pre eclampsia- because of increased association of hypertension, abruption placenta of pre-eclampsia & folic acid deficiency intra uterine growth retardation. Uterine fibroid medical complications related with advancing age like hypertension, diabetes, organic heart lesion. Tendency of post maturity During labor there is increased chance of premature labour prolonged labour due to uterine inertia caused by anxiety or mal position (occipito posterior), impaired joint mobility inelasticity of soft tissues of birth canal. Maternal & fetal distress appears early Chances of operative intervention are increased chance of retained placenta is increased due to uterine atony & increased association of fibroid puerperium increased morbidity due to operative interference failing lactation Fetal : there is increased chance of congenital malformation (trisomy 21) due to age, thus Perinatal morbidity is increased. If necessary triple test should be done at 14-16 weeks. Prognosis The maternal morbidity is high & the maternal mortality, is increased due to prematurity, increased congenital malformation (trisomy21) & operative

interference Management: Considering the risk involved in pregnancy & labour, the women are considered high risk. They require meticulous antenatal supervision & should have a mandatory hospital delivery. Since induction is unsatisfactory caesarean section is the preferred alternative. The following principles are followed: Result of induction is unsatisfactory & as such caesarean section is a preferred alternative Sonography or straight X-ray is to be done prior to cesarean section to exclude bony congenital malformations of the fetus. GRAND MULTIPARA A grand multipara, relates to a pregnant mother has got previous four or more viable births. The incidence has been gradually declining over the couple of decades due to acceptance of small family norm but it still constitutes to about one-tenth of the hospital population and accounts for one third of the maternal deaths in the developing countries. Complications Pregnancy: There is increased incidence of Abortion: spontaneous & induced Inherent: obstetric hazard such as a. Malpresentation due to pendulous abdomen & lumbar lordosis, b. multiple pregnancy, c. placenta previa Medical complications associated with increasing age including anaemia (Iron deficiency) hypertension, cardiac problems, diabetes, haemorrhoids, varicose veins, hernia. During labor there is chance of obstructed labor due to

Obstructed labour-due to malposition, Malpresentation, CPD cord prolapse due to increasing size of fetus secondary contracted pelvis which is mostly related to ill nourished mothers and forward projection of the sacrum due to sublaxation of sacroiliac joints there by diminishing the inlet conjugate rupture uterus-if obstruction remains undetected & left uncased for PPH are increased due to anemia, uterine atony, increased association of adherent placenta or due to increased collagen deposit in between muscle fibres. Shock due to ill health, hemorrhage or unrecognized uterine rupture. There is increased operative interference because of complications. After delivery also there are chances of subinvolution & falling lactation. Puerperium 1. increased morbidity due to in intranatal 2. subinvolution 3. failing lactation Management The cases are considered as high risk. As such they require adequate antenatal care should have a mandatory hospital delivery. During labour the following guidelines are prescribed. 1. pelvic assessment should be done as a routine. 2. Presentation & position are to be checked 3. Undue delay in progress should be viewed with concern 4. Vigilant observation against PPH