Risk factors in pregnancy

Other risk factors in pregnancy: adolescence, elderly, substance abuse & sexual violence

1. OTHER RISK FACTORS IN PREGNANCY- AGE : ADOLESCENT, ELDERLY, UNWED MOTHERS, SEXUAL & SUBSTANCE ABUSE PRESENTED BY : NISHA SAIJU

2. INTRODUCTION 200 million pregnancies every year. ↑ risks for certain populations: adolescents, older women, HIV  women, substance abuse or sexual abuse. Pregnancy experience is unique & personal. Many go through confusion & isolation. Desperately need help!!!!!!!!!!!!!!!!!!

3. THE PREGNANT ADOLESCENT Time: onset of puberty to the cessation of physical growth. Roughly 11 – 19 yrs Oscillate between being children & adults. Need to adjust to the physiological changes in their bodies. Dependence on parents.

4. DEVELOPMENTAL TASKS OF ADOLESCENCE Seeking economic & social stability. Developing a personal value system Building meaningful relationship with others Becoming comfortable with their changing bodies Working to become independent.

5. Parents may have difficulty allowing a teenage daughter to make health decisions. Nurse needs to remind that pregnant adolescent is an “ emancipated minor ”: a person capable of making health decisions. Healthcare providers should communicate with adolescents in a manner they understand & respect them as individuals.

6. Risk factors Adolescent pregnancy is a complex issue with many reasons for concern. Kids age 12 - 14 years old are more likely than other adolescents to have unplanned sexual intercourse . They are more likely to be talked into having into sex. Up to two-thirds of adolescent pregnancies occur in teens aged 18 - 19 years old.

7. Risk factors contd …… Early menarche Peer pressure to become sexually active Sexual abuse as a child Lack of information regarding contraception Poverty Culture / ethnicity Low self esteem Strong need for someone to love Early dating without supervision

8. Symptoms Pregnancy symptoms include: Abdominal distention Breast enlargement and breast tenderness Fatigue Light-headedness or actual fainting Missed period Nausea/vomiting Frequent urination

9. Signs and tests The adolescent may or may not admit to being involved sexually. If the teen is pregnant, there are usually weight changes (usually a gain, but there may be a loss if nausea and vomiting are significant). Examination may show increased abdominal girth, and the health care provider may be able to feel the fundus (the top of the enlarged uterus).

10. Pelvic examination may reveal bluish or purple coloration of vaginal walls, bluish or purple coloration and softening of the cervix, and softening and enlargement of the uterus. A pregnancy test of urine and/or serum HCG are usually positive. A pregnancy ultrasound may be done to confirm or check accurate dates for pregnancy.

11. IMPACT OF PREGNANCY ON ADOLESCENTS ‣ Negative impact in terms of health & social impact. ‣ 7 out of 10 adolescents will drop out of school. ‣ Children of adolescent mothers are at a greater risk of preterm birth, LBW, child abuse, neglect, poverty & death…. ‣ Greater psycho-social impact

12. Treatment All options made available to the pregnant teen should be considered carefully, including abortion, adoption, and raising the child with community or family support. Discussion with the teen may require several visits with a health care provider to explain all options in a non-judgmental manner and involve the parents or the father of the baby as appropriate.

13. Early and adequate prenatal care, preferably through a program that specializes in teenage pregnancies, ensures a healthier baby. Pregnant teens need to be assessed for smoking, alcohol use, and drug use, and they should be offered support to help them quit.

14. Prognosis Having her first child during adolescence makes a woman more likely to have more children overall. Teen mothers are about 2 years behind their age group in completing their education. Women who have a baby during their teen years are more likely to live in poverty

15. Teen mothers with a history of substance abuse are more likely to start abusing by about 6 months after delivery. Teen mothers are more likely than older mothers to have a second child within 2 years of their first child.

16. Infants born to teenage mothers are at greater risk for developmental problems. Girls born to teen mothers are more likely to become teen mothers themselves, and boys born to teen mothers have a higher than average rate of being arrested and jailed.

17. Complications Pregnancy induced hypertension Iron- deficiency Anemia Preterm Labor Cephalo- pelvic Disproportion Postpartum Hemorrhage Inability to adapt Post- partally Knowledge Deficit about Infant care.

18. NURSING MANAGEMENT Prenatal Assessment Health History Family profile Physical examination

19. NURSING DIAGNOSES Imbalanced nutrition : less than body requirements related to insufficient intake Risk for injury : maternal & fetal related to inadequate prenatal care & screening. Social Isolation related to body image changes Interrupted family processes related to adolescent pregnancy Disturbed body image related to situational crisis of pregnancy Risk for impaired parenting related to immaturity & lack of experience

20. Journal Articles Cheryl Anderson & Michelle Mccarley : Psychological Birth trauma in adolescents experiencing an early birth . Maternal & Child Nursing. May/Jun 13 Cross- sectional descriptive study compared 2 groups of adolescents(delivering prior to 38 weeks & between 38 – 42 weeks) for PBT. Results: single Primigravida over 16 yrs of age. Adolescents delivering before 38 weeks though LSCS reported symptoms of depression & were at highest risk for PBT. Additionally they lacked pain control & unsupportive caregivers in Labor.

21. Does Watching Sex on Television Predict Teen Pregnancy?  -Anita Chandra, DrPH, Steven C. Martino, PhD Data from a national longitudinal survey of teens (12–17 years of age, monitored to 15–20 years of age) were used to assess whether exposure to televised sexual content predicted subsequent pregnancy for girls or responsibility for pregnancy for boys. We measured experience of a teen pregnancy during a 3-year period. RESULTS: Teens who were exposed to high levels of television sexual content were twice as likely to experience a pregnancy in the subsequent 3 years, compared with those with lower levels of exposure

22. Depression and Teenage Pregnancy By Jane Collingwood Analysis showed that teenage mothers had higher levels of depression than other teenagers or adult mothers, but the experience of teenage childbearing did not appear to be the cause. “Rather, teenage mothers’ depression levels were already higher than their peers’ before they became pregnant, and they remained higher after childbearing and into early and middle adulthood”. Results suggest that the combination of poverty and existing distress was a good predictor of teen pregnancy.

23. NURSING MANAGEMENT OF ELDERLY PREGNANT WOMEN 2 groups of women have emerged: Multiparous women : have an additional child during the menopausal period Primiparous women : deliberate delay of childbearing May seek information about pregnancy from books, friends & internet.

24. Multiparous Women Some may have never used contraceptives Some may have used contraceptives successfully during childbearing years. As menopause approaches, they cease menstruating or stop use of contraceptives & consequently become pregnant. Mixed emotions among mothers. Parents must prepare a safe & nurturing environment during pregnancy 7 after birth. Must integrate child into an established family system.

25. Primiparous women Number of 1 st time pregnancies has increased significantly over last 3 decades. Reasons for delaying pregnancy include: Desire for advanced education Career priorities Use of better contraceptives Result of fertility therapies Dilemma: pregnancy has positive & negative effects Select right time for pregnancy Partners share the preparation for parenthood.

26. Outcomes of Pregnancy in elderly women Adverse peri-natal outcomes more common. More likely to have LBW Infants, premature births & multiple births. ↑ risk for maternal mortality due to hemorrhage, infection, embolism, hypertensive disorders of pregnancy, cardiomyopathy & strokes. ↑ maternal age leads to infertility & spontaneous abortions, GDM , PIH, chromosomal abnormalities, genetic disorders, placenta previa, Preterm labor & surgical births

27. Developmental Tasks & Pregnancy Developmental challenge over 40: expand their awareness or develop Generativity. “Sandwich Generation” : caring for aging parents & growing children. Ambivalent feeling towards pregnancy. Need help to cross 2 simultaneous phases of life : becoming involved with the world & concentrating on the baby inside her.

28. Nursing Management Pre natal Assessment Begin prenatal care early Fortunately women in this age group are well – informed Few may attribute lack of menstruation to menopause. Health History Ask about present symptoms of pregnancy. How they feel about pregnancy Enquire about any self medication. Family Profile : source of income

29. Physical Examination Thorough physical examination at 1 st prenatal visit to establish general health & identify problems Inspection of lower extremities for varicosities. Urine specimen : glucose, protein Assessment of breast Assessment of FHR & Fetal movements. Chromosomal assessment: triple screen ( AFP. HCG & Unconjugated estriol level)

30. COMPLICATIONS Hypertension, Pre-term or Post-term birth & Caesarean birth Related to the fact that women’s circulatory system may not be as competent as when she was younger. Tissues may not be elastic as before Pregnancy – Induced Hypertension : Best way for reduction- rest for good proportion of time. Plan activities that can be done on bed rest.

31. Complications related to Labor, childbirth & Postpartum period Failure to progress in labor : cervix does not dilate as spontaneously due to ↓ elasticity in cells Difficulty in accepting the event : second thoughts about childbearing during labor & childbirth Postpartum Hemorrhage : uterus may not contract readily due to inelasticity

32. NURSING CARE Social, genetic & environmental factors need to be considered & appropriate interventions planned!!!!! First Trimester Anxiety related to deficient knowledge as evidenced by women’s question & concerns Imbalanced Nutrition : less than body requirements related to nausea & vomiting as evidenced by women’s reports & weight loss. Fatigue related to hormonal changes in the first trimester as evidenced by woman’s complaints

33. Second Trimester Constipation related to progesterone effect on the Gastro-intestinal tract as evidenced by woman’s report of altered patterns of elimination Third Trimester Fear related to deficient knowledge regarding onset of labor & processes of labor related to inexperience as evidenced by woman’s questions & concerns.

34. INTRAPARTUM CARE Risk for injury: maternal & fetal due to complications associated with elderly pregnancy. Pain related to labor process. Knowledge deficit related to labor processes

35. Postpartum care Pain related to episiotomy or caesarean birth . Knowledge deficit related to neonate care related to lack of experience. Risk for interrupted family processes related to inclusion of new family member.

36. Journal Article M.A. Sajjad et all, “FIVE YEAR STUDY OF ELDERLY PRIMIGRAVIDA AT AMIN HOSPITAL” Iranian Journal of Public Health 1977;6(3) : 121-134 In a period of 5 years there were 30000 deliveries at Amin hospital, among them, 355 deliveries of primigravidas over 35 years of age who were included in this retrospective study. Comparison with the same number of primigravidas under 30 years of age indicate a much higher rate of fetal and neonate mortality as well as other minor and major complications in the older group. Incidence of breech presentation and twins was high, Duration of pregnancy, first and second stage of labor also was longer Operative deliveries including forceps and vacuum deliveries were more frequent and the rate of cesarean -section was high (19.4% comparing with 5.5% in control group). Toxemia of pregnancy, hyper tension, ante partum and postpartum, hemorrhage , fetal and neonatal mortality showed an increased' frequency in the studied group Distribution of congenital malformations were found to be equal except that a case of Down syndrome was recorded in the studied group.

37. The outcome of pregnancy in elderly primigravidas . Haifa A Al- Turki , Saudi medical journal(impact factor: 0.52). 11/2003; 24(11):1230-3 To investigate the effect of advancing age of 35 years and more on the outcome of pregnancy in nulliparous women and to compare the type of complications observed in this group of women to those in the age of 20-34 years. This was a retrospective analysis of 2517 primigravidas delivered at King Fahd Hospital of the University, Al- Khobar , Kingdom of Saudi Arabia between 1996-2000. The data were collected from the records of the labor room and the medical records were screened for maternal age, antenatal complications, gestational age, birth-weight of the neonate, sex of the neonate and the Apgar score. Between age of 20-34 years (Group A) there were 1950 patients with the mean age of 24.79 years (range 20-34) and in women over the age of 35 years (Group B) there were 205 patients with the mean age of 38.72 years (range 35-48 years). Group B had significantly less number of normal deliveries 59.9 compared to group A 81% with p value of <0.001. Diabetes mellitus was common in group B as compared to group A and was statistically significant at p value <0.001. The gestational age in group B was 36.06 weeks and in group A it was 38.84 weeks (p value was markedly significant at <0.001). Women in group B had more deliveries by cesarean section (CS) 23.8% as in group A 12.6%, a significant p value <0.001. The birth-weight in group B was less compared to group A, p value of <0.002. Childbearing in elderly primigravidas does have higher rates of complications due to diseases such as diabetes mellitus and preeclamptic toxemia . They are liable to have more deliveries by CS than by other methods, in spite of lower gestational age and birth weight. The overall outcome however does not appear grim, as was once believed. This study suggests that women in the age group of >35 years should be informed of their pregnancy expectations and outcomes.

38. UNWED MOTHERS

39. Lady who becomes pregnant without legal justification of physical intimacy between man & woman. In traditional societies like India, becoming pregnant before marriage is considered a sin. The psychosocial impact of becoming an unwed mother is very stressful & depressive.

40. Factors associated with Unwed Pregnancy Poverty Prostitution Teenage mistake Improper Sex Education Contraceptive failure

41. Consequences of being an Unwed mother For the mother Not socially acceptable Considered a curse. Brings a lot of personal disorganization Lack of support from family & society Difficult life ahead

42. For Family Also bears the brunt of negative consequences. May suffer boycott from community Isolation Psychological trauma Health problems Both mother & child at risk Due to lack of support unsafe delivery practices conducted at unhygienic conditions to hide pregnancy Improper guidance for rearing of child

43. Legal rights of an Unwed Mother Establish Paternity : raise the matter in court against the man expected to be the father of her child. Support to Child : can demand support in the form of money or some other form from the father once paternity is established, Custody of the child : still has the right to undertake custody of the child even after paternity has been established.

44. Prevention of Unwed Pregnancy Peer education Sex education Supply of contraceptives Abolition of Prostitution

45. Factors influencing care of unwed mothers Age of the mother Family support Financial stability Approach towards pregnancy Social and cultural background

46. Role of a Nurse As an : Educator Advocate Helper Researcher

47. Case Presentation Ms Jeevitha , 26 yr old unmarried woman presented to casualty 0n 23/07/13 with complaints of severe headache & GTCS, one episode of vomiting & unconsciousness on 23/07/13 H/o severe anemia before 2 months, transfused 2 pints of blood, B.P.- 220/180 mmhg Alleged to have LMP 7 days back. Diagnosed as ? Hypertensive of young & seizure disorder. Shifted to I ward, confided LMP was 26/01/13. Scan showed fetal movement & fetal heart  ve Final diagnosis : Unmarried Primi @ 253 weeks of gestation with Eclampsia.

48. Termination of pregnancy advised. Induced : expelled fresh still born baby boy @ 3;40 pm on 24/07/13. TPR stable, B.P- 130/90 mmhg Patient feels guilty of being pregnant. Cries occasionally, feeling shy to face parents now Few family members told about actual diagnosis : supportive of the mother. Patient now wants to do her parent’s will for her whatever it may be!!!!!!!!!!

49. SEXUAL ABUSE

50. INTRODUCTION Social problem affecting all societies. 1 out of 4 US women have been physically & sexually assaulted by an intimate partner.(NVAWS) 1 women being battered every 12 sec in US (Penny 2004) 2 types of violence : intimate partner violence & sexual abuse.

51. THE CYCLE OF VIOLENCE

52. Tension Building : 1 st phase. Tension escalates between the couple. Excessive drinking, jealousy & other factors may lead to hostility & friction. Abusive Incident : explosion of violence .Victim is assaulted. Batterer loses control both physically & emotionally. Honeymoon Phase : period of calm, loving, contrite behavior on the part of the batterer. He may be genuinely sorry for the pain he caused to his partner. Attempts to make up his behavior & believe he can never hurt the woman he loves.

53. Violence during Pregnancy Pregnancy often start or escalation of violence. Pregnant women are vulnerable at this time. Factors leading to battery: Inability of couple to cope up with stressors of pregnancy. Doubt about partner’s fidelity. Perception of baby as a competitor Financial burden related to expenses of pregnancy. Stress of role transition Insecurities & jealousy of pregnancy.

54. Types of Abuse Mental : Threatening to kill the victim Forcing victim to perform humiliating acts Making demeaning remarks about victim Physical : Hitting, grabbing, pushing, choking , kicking or causing physical harm to victim Sexual : Forcing woman to have vaginal, oral or anal intercourse against her will. Biting victim’s breast or genitals Forcing victim to perform sexual acts with other people

55. Types of Sexual Violence Childhood sexual abuse Incest Rape Statutory Acquaintance Date Female Genital Mutilation Human Trafficking

56. Childhood Sexual Abuse Any type of exploitation that involves a child younger than 18 yrs of age. Includes disrobing, nudity, masturbation, fondling, digital penetration & intercourse. Lifelong impact on survivors. Early abuse : lowers self esteem & ability to protect themselves. Influences the way victims live their lives & form relationships

57. Incest Sexual exploitation between blood relatives or surrogate relatives before victim reaches 18 yrs of age. Victims often tricked, coerced or manipulated. Perpetrators often threaten their victims so they are afraid to disclose the abuse.

58. Rape It is an act of violence Legal rather than a medical term Denotes penile penetration of the female or male without consent Statutory Rape : sexual activity between an adult & a person under 18 despite the willingness of the underage person. Acquaintance Rape : involves someone being forced to have sex by a person he or she knows. Date Rape : sexual assault which occurs within dating relationship Drugs used : “club drugs”; Rohypnol, Ketamine etc

59. Phases of Rape Recovery Acute Phase : shock, fear , disbelief , anger , shame , guilt, feelings of un-cleanliness, insomnia & nightmare Outward Adjustment Phase : appears outwardly composed & returns to work or school ; refuses to discuss the assault & denies need for counseling Re-organization Phase : survivor attempts to make life adjustments by moving or changing jobs.

60. Female Genital Mutilation Also called “female circumcision”. Cultural practice followed in Africa, Middle- East & Asia. Definition - Procedure involving the partial or total removal or other injury to the female genital organs, whether for cultural or other non- therapeutic purposes.(WHO) More than 140 million girls estimated to have undergone FGM 2 million at risk annually.

61. Reasons for performing Ideology & cultural value of each community. Rite of passage into womanhood Means of preserving virginity Performed when girl is between 4 and 10 yrs old ; age when she cannot give informed consent for a procedure with life-long health consequences. Untrained village practitioners using no form of anesthesia perform the operation. Cutting instruments : broken glass, knives, tin lids, scissors, unspecialized razors & crude instruments.

62. Types of FGM Procedures Types Procedure Type 1 Excision of Prepuce Type 2 Excision of Clitoris & part or all of the Labia Minora Type 3 Excision of all or part of the external genitalia & stitching of vaginal opening Type 4 Pricking or Piercing or incision of the clitoris or Labia Cauterizing by burning the clitoris & surrounding tissue Scraping or cutting vaginal orifice Introduction of corrosive substance into vagina Placing herbs into vagina to narrow it.

63. Health Risks Associated with FGM Intense pain & dysmenorrhea Pelvic infections Hemorrhage HIV infection Damage to urethra, vagina & anus Recurrent vaginitis UTI’s Incontinence Vulvar abscess Dyspareunia ↑ morbidity & mortality during childbirth

64. Human Trafficking Modern form of slavery Women & children are held captive & forced to have sexual intercourse with numerous people. Victims : lack education, employment Traffickers promise victims employment as nannies, maids, models etc. Traffickers transport victim from their countries to unfamiliar destinations. Once captive, traffickers coerce them using rape, torture, starvation, imprisonment into prostitution, pornography, sex trade or forced labor - Violence Protection Act, 2000

65. Impact of Sexual Violence Devastating short & long term effects. Women experience psychological, physical & cognitive symptoms. Posttraumatic Stress Disorder : develops when an event outside the range of normal human experience occurs that produces marked distress in the person. Intrusion : re-experiencing the trauma, includes nightmares, flashbacks, recurrent thoughts. Avoidance : avoiding trauma related stimuli, social withdrawal, emotional numbing. Hyper-arousal: increased emotional arousal, exaggerated startle response, irritability.

66. Nursing Management Deficient Knowledge related to understanding the cycle of violence & availability of resources. Fear related to possibility of severe injury to self or child during cycle of violence. Low self – esteem related to feelings of worthlessness. Hopelessness related to prolonged exposure to violence. Compromised individual & family coping related to persistence of victim-abuser relationship.

67. Interventions Goal : enable victim gain control of her life. Key : good, non- judgmental communication. Primary : aimed at breaking the abuse cycle through community educational initiatives by health worker. Secondary : deals with victims & abusers in early stages with goal of preventing progression of abuse. Tertiary : activities geared toward helping severly abused women & children recover & become productive members of society. Rehabilitating abusers to stop the cycle of violence.

68. JOURNAL ARTICLES “Rape and Abortion” by Fr. Frank A. Pavone International Director Priests for Life The woman who has been raped has undergone a terrible trauma and injustice. Will an abortion help her? First of all, the abortion will not un-rape the woman Second, abortion brings a trauma of its own. In rape, the trauma is "Someone hurt me." In abortion, the trauma is "I hurt and killed someone else -- my child."  Abortion is never the answer. Let's not add violence to violence. When it comes to the woman who carries a baby conceived by rape, let's choose to love them both!

69. Women Who Became Pregnant Through Sexual Assault Say, “Ask Us” Of the respondents, 164 were victims of rape and 28 were victims of incest (sexual assault involving a family member). Overall, 69 percent continued the pregnancy and either raised the child or made an adoption plan, 29 percent had abortions and 1.5 percent had miscarriages. Nearly 80 percent of the women who aborted the pregnancy reported that abortion had been the wrong solution. Most women who had abortions said that abortion only increased the trauma they were experiencing. In many cases, the victim faced strong pressure or demands to abort. 43 percent of rape victims who aborted said they felt pressured or were strongly directed by family members or health workers to abort. In almost every case where an incest victim had an abortion, it was the girl’s parents or the perpetrator who made the decision and arrangements for the abortion, not the girl herself. More than 80 percent of the women who carried their pregnancies to term said that they were happy that they had continued the pregnancy. None of the women who gave birth to a child conceived in sexual assault expressed regret or wished they had aborted instead.

70. SUBSTANCE ABUSE IN PREGNANCY

71. Introduction Most pregnant women reluctant to reveal substance abuse. Use of drug ↑ risk of medical complications in mother & baby. Placenta acts as an active transport mechanism. Many drugs : Teratogenic effects. Critical determinants of effect of drug on fetus : drug, dosage, route of administration, timing of exposure.

72. Common substances abused during pregnancy Alcohol Caffeine Nicotine Cocaine Marijuana Narcotics Sedatives

73. Substances Effect on Pregnancy Alcohol Spontaneous abortion, LBW, IUGR, FAS, ARBD, MR Caffeine Vasoconstriction & mild diuresis in mother, fetal stimulation Nicotine Vasoconstriction, ↓ utero -placental flow, LBW, Abortion Cocaine Vasoconstriction, GHTN, Abruptio Placentae, snow baby syndrome, CNS Defects, IUGR Marijuana Anemia, ↓ weight gain, Amotivational syndrome, newborn tremors, prematurity & IUGR. 6. Narcotics Maternal & Fetal withdrawal, Abruptio placentae, preterm labor, PROM, asphyxia, newborn sepsis, intellectual impairement , malnutrition Sedatives CNS Depression, newborn withdrawal , maternal seizures in labor, newborn abstinence syndrome, delayed lung maturity

74. Alcohol related effects No amount of alcohol consumption is safe during pregnancy. FAS → Fetal Alcohol Spectrum Disorder (FASD) FASD includes; Craniofacial dysmorphia IUGR Microcephaly Limb & Cardiac anomalies

75. Characteristic Features (FASD) Small head circumference Short palpebral fissures & small eye openings. Thin upper lip Receding jaw Low nasal bridge Skin folds at corner of eyes Small, flat midface area

76. Cognitive & Behavioral problems Attention Deficit / hyperactivity Disorder Inability to foresee consequences Inability to learn from previous experiences Lack of organization Learning difficulties Poor abstract thinking Poor impulse control Speech & language problems.

77. NURSING MANAGEMENT Emphasizes screening & prevention to reduce the high incidence of obstetric & medical complications among users as well as their passively addicted infants Assessment History Screening questionnaires Urine toxicology screening

78. NURSING INTERVENTIONS Education about effects of substance exposure of fetus Interventions to improve mother – child attachment & improve parenting. Psychosocial support Referral to outreach programs Follow – up of children born to dependent mothers. Dietary counseling More frequent prenatal visits Support systems & vocational assistance.

79. Thank You