[Type text] Running Head: PRENATAL CARE

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Prenatal Care for Adolescents Sara B. Dayon University of Wyoming

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Adolescents do not plan to get pregnant, however many do. Teen pregnancies come with many risks to the mother and the baby. Adolescents often do not receive timely prenatal care, either they are in denial about being pregnant or they are afraid to come forward. The physical health risks include, but are not limited to; pregnancy induced hypertension, anemia, preterm delivery, and low weight gain during pregnancy. Pregnancy during adolescence also affects mental health as well and she may have feelings are depression, guilt, anger, and guilt. Pregnant adolescents are more likely to drop out of high school and have increased risks to domestic violence. There are also risks to the infant as well. Many infants born to adolescent mothers who do not receive proper prenatal care have a low birth weight, leading to underdeveloped organs. Adolescents are also more likely to smoke, drink and are less likely to take prenatal vitamins. These children also suffer from increased behavioral problems, developmental delays and learning disabilities. Studies have shown that early and frequent prenatal care can help to prevent maternal complications and fetal death. Education for this population is one of the best ways to increase prenatal care. Often times, the pregnant adolescent does not know whom they can turn to, or she is afraid to come forward. Many different programs are being developed for pregnant adolescents and this teaching plan will discuss the research that is being done and what type of environment/program pregnant adolescents can benefit from.

History of Prenatal Care Prenatal care was developed in the beginning of the 1900s. Doctors began to realize that even though they were doing a lot for the mothers and babies during the labor and birth, there was still a high mortality and morbidity from congenital defects, multiple births

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and fetal diseases. Dr. J.W. Ballantyne made the connection between maternal exposures to alcohol, nicotine and lead, and infectious diseases, such as syphilis and tuberculosis, as major fetal hazards and began promoting specific antenatal treatments to reduce their impact on pregnancy outcomes (Moos, 2003, pg. 286). Ballantynes ideas on prenatal care influenced programs in 1907 in the United States. The first prenatal programs begin in the seventh month of gestation, however, by the 1920s programs were implemented that involved seeing the mother sooner and more often. Home visits by nurses were very common in implementing these programs. At these visits, nurses inquired about danger signs, checked the patient s blood pressure and urine, assessed fetal heart tones and provided advice about diet, hygiene, exercise, and preparation for infant care (Moos, 2003, pg. 279). Public health nurses were the main providers of prenatal care because it was their responsibility to seek out pregnant women and develop a relationship that would foster a healthy pregnancy through prenatal care. By 1929, the United States developed the basic framework of prenatal care that we currently use today: 1st obstetric visit by 16 weeks, with subsequent visits at 24 weeks, every 2 weeks starting at 28 weeks, and weekly beginning at 36 weeks (Moos, 2003, pg. 279). Benefits of Prenatal Care There are many benefits of prenatal care to the mother and the baby and studies have shown the sooner it is implemented the better. women who receive prenatal care during the 1st trimester have better pregnancy outcomes than women with little or no prenatal care (Moos, 2003, pg.280). Since prenatal care became implemented, it has prevented many infant deaths through preventing possible complications. Prenatal care provides numerous secondary prevention opportunities, such as Rhogam to prevent isoimmunization, maternal antibiotic treatment to prevent congenital syphilis, maternal antiviral drugs to diminish the risk of vertical

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transmission of HIV, and maternal influenza vaccine to prevent pregnancy complications (Moos, 2003, pg. 281). Pregnant women are under constant surveillance to help detect pregnancy induced hypertension early, detection of intrauterine growth restriction, identify fetal distress, and other complications that may arise. Because of this surveillance, interventions can be implemented to increase the survivability of the fetus. Prenatal care continues to be studied and new programs are implemented and new tests are developed to ensure that the mother and the baby are healthy from antepartum to postpartum. Adolescent Prenatal Care Every year approximately 1 million adolescents become pregnant(Montgomery, 2003, pg.250). The majority of adolescents do not plan to get pregnant and when they do, they are often scared, and do not know what to do, or who to turn to. Adolescents begin prenatal care late more often than other age groups (Montgomery, 2003, pg. 250). There are many reasons for this, one being they may not have any idea that they are pregnant. They may not know the signs of pregnancy. Studies have shown that, more adolescents than adults reported early 1st trimester vaginal bleeding that they attributed to menses, which may have contributed to their delay in seeking prenatal care (Montgomery, 2003, pg.251). Many adolescents will try to hide their pregnancy because they do not want the father of the baby to know about the pregnancy or they do not want their parents to know they are engaging in sexual activity. An adolescent also may fear that she will lose her job or friends, be removed from school or home, or suffer other negative consequences. In addition, she may fear the stigmatization that often occurs among adolescents who become pregnant (Montgomery, 2003, pg.251). For all adolescents this period of their life is a very emotional time. When an adolescent becomes pregnant she may have feelings of guilt, denial, fear, and be overwhelmed. These feelings may contribute to seeking

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prenatal care later in pregnancy. Adolescents may not know where to turn to for prenatal care. At this time, they are also trying to figure out how to pay for such services. She may not know where to go for care or that programs exist for adolescents who cannot afford to pay. Pregnant adolescents who sought prenatal care early were more likely to have adequate family support, were not afraid to tell their parents about the pregnancy, and had more knowledge about pregnancy than those who delayed entry into prenatal care (Montgomery, 2003, pg.252). A nutritional assessment should be completed during the prenatal period. Often times, adolescents are very worried about body image and this may put them at risk for decreased nutritional intake. Pregnant adolescents also should receive a thorough nutritional assessment and follow-up counseling to improve their nutritional intake. The nutritional assessment should include dietary assessment, weight and height evaluation, and laboratory testing (Montgomery, 2003, pg. 253). Adolescents are also at higher risk for some pregnancy complications, such as, risk for pregnancy-induced hypertension, preeclampsia, and intrauterine growth restriction, preterm delivery and low birth weight and inadequate weight gain (Montgomery, 2003, pg. 253). Pregnant Adolescents Prenatal Needs The pregnant adolescent has different needs than the adult pregnant woman. Adolescents often require more support and need more teaching during their pregnancy and postpartum. When a pregnant adolescent steps forward for prenatal care, she is accepting the beginning of her new life. The adolescent she be praised for taking this step. During the visit the importance of taking care of herself and the importance of prenatal care should be emphasized. Emotional support and prenatal care content must be tailored to the individual adolescents needs; developmental level; and individual, racial, or cultural preferences (Montgomery, 2003, pg.

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252). It is important to remember that age does not necessarily represent maturity level. A thorough assessment of the adolescents developmental level is very important in providing appropriate care. Individualized prenatal nursing care for the adolescent client that incorporates developmental needs and health education with prenatal needs has the potential to contribute positively to prenatal, intrapartal, and postpartal outcomes. While caring for the adolescent it is important to remember that the adolescent may have many questions but be afraid to ask them or not know how to ask them due to their lack of communication skills at this stage. It is also important to remember that each adolescent is trying to figure out who they are at this stage and they are all different. As a heterogeneous group, adolescents have varying beliefs, value systems and experiences, and represent different cultural and religious groups. All of these characteristics must be taken into consideration when caring for adolescents, pregnant or not (Montgomery, 2003, pg. 253). Pregnant Adolescents Educational Needs Education for the adolescent in the early prenatal period should focus on eating well during pregnancy, normal fetal growth and development, body changes associated with pregnancy, common ailments and how to resolve or treat them safely during pregnancy, and general safety during pregnancy (Montgomery, 2003, pg.253). It is important to address any questions the adolescent may have, even if it is about the labor and delivery, without answering these questions it may be difficult for her to concentrate on the information being given to her. The best way to present information to the adolescent is with written material that can be reviewed as necessary. The information given should be presented at the adolescents developmental level that they can understand. It is important to note that studies show, Adolescents who participated in a study about prenatal nutrition education noted that they

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preferred adolescent actresses in electronic or video mechanisms to written materials (Montgomery, 2003, pg. 253). Ways to promote prenatal care is using community health programs. Educational and community-based programs are additional mechanisms to provide health promotion content to pregnant adolescents. Adolescents may delay prenatal care because they dont feel comfortable seeing a provider or dont personally know where to find a provider (Montgomery, 2003, pg. 254). Community education can be a way to encourage the adolescent to keep prenatal appointments, and the importance of continued prenatal care can be stressed in the community setting. Another way community education programs promote prenatal care is allowing adolescents to be surrounded by other adolescents that are in the same situation as they are. Many adolescents prefer group activities, using the support of their network of friends. Community groups that offer classes geared toward pregnant adolescents can help to meet these needs and provide information to adolescents (Montgomery, 2003, pg. 255). Adolescents may not be aware of the types of assistance that is available to them. Community programs can provide information about these programs, such as, Women, Infants, and Childrens (WIC) programs. Web sites, the local library and the newspaper can be resources for adolescents to locate information or services they may need. Part of providing information and content to pregnant adolescents is also empowering them to be better consumers of health care (Montgomery, 2003, pg. 254). Communicating With the Pregnant Adolescent While caring for the pregnant adolescent it is important for the nurse to put aside their feelings and judgments. Nurses must be cautious and avoid personal biases that might taint treatment with a disrespectful or judgmental overtone (King-Jones, 2008, pg. 1). The way

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adolescents are treated is related to the whether they seek, or continue to seek health care. Adolescents often note that excessive waiting times and inappropriate staff behavior contribute to delay in seeking prenatal care (Montgomery, 2003, pg. 253). The majority of education for the pregnant adolescent comes from the nurse. The nurse is viewed as someone they can confide in and trust, because of this the nurse is at an advantage. If the trust is lost, communication between the adolescent and nurse will be diminished and the chance of effective prenatal care lost as well. The pregnant adolescent will often lash out or rebel against parents, nurses and other authority figures that threaten autonomy and independence (King-Jones, 2008, pg.3). When caring for a pregnant adolescent, the nurse has to be mindful of talking less and listening more. Often, the delivery of information supersedes information gathering for the nurse pressed to complete designated tasks in a limited amount of time. The pregnant adolescent may perceive this tendency as inattentiveness and may believe that shes not afforded the time to express her needs (King-Jones, 2008, pg. 5). The nurse must realize that caring for a pregnant adolescent is unlike caring for a pregnant adult. Their needs, concerns and aspirations are as varied as their cultural, socioeconomic and educational backgrounds. This heterogeneity demands nursing practice that is respectful of differences, sensitive to intricacies of social contexts and family worlds and focused on the way it is, rather than the way it should be (King-Jones, 2008, pg. 6). Interventions for the Pregnant Adolescent Adolescents are very dependent upon their peers for support. As an adolescent matures, parents become less influential and peers become increasingly influential (Montgomery, 2003, pg. 1). Often times, their peers will be a source of encouragement and, in some instances adolescents do receive positive validation for their pregnancy from peers (Montgomery, 2003, pg. 2). An adolescents own mother can be a positive influence when it comes to seeking and

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continuing prenatal care. Adolescent mothers who participated in a prenatal and parenting program with their own mothers were less likely to drop out of school and had better self-esteem when compared with those not in the program (Montgomery, 2003, pg. 5). Healthy people 2010 set up goals for health promotion of pregnant adolescents. These include: Access to quality health care services, educational and community-based programs injury and violence prevention, maternal infant and child health (Montgomery, 2003, pg. 4). Prenatal care not only improves the health of the mother and baby during the antepartum period, it also continues to improve the health of both mother and baby post partum. Adolescents who received more intensive prenatal education from trained community volunteers experienced fewer premature labors and/or births, more often returned for postpartum care, were more likely to use contraception post pregnancy and were more likely to return for an annual family planning visit (Montgomery, 2003, pg. 6). Adolescents lack of prenatal care is often related to lack of education about what they are supposed to eat and do to encourage a healthy pregnancy. With counseling, its easy for most adolescents to understand the connection between eating good and having a positive pregnancy outcome (Montgomery, 2003, pg. 6). A possible nursing diagnosis to focus on for pregnant adolescents includes knowledge deficit regarding pregnancy process, individual needs, and future expectations. This may be related to lack of information, unfamiliarity with resources, lack of interest in learning, information misinterpretation. This can be evidenced by request for information, and development of complications. Another nursing diagnosis is: altered nutrition, less than body requirements related to intake insufficient to meet metabolic demands. This is evidenced by lack of information, insufficient weight gain during pregnancy, anemia, and inappropriate uterine/fetal growth. Interventions should be centered around these diagnoses.

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There have been many research studies that support the interventions and importance of prenatal care in pregnant adolescents. A study performed by Derbyshire, E. compared the dietary habits of pregnant adolescents and non-pregnant adolescents found that pregnant adolescents do have better dietary habits when compared to their non-pregnant counterparts. It can be concluded that pregnant teenagers seem to follow a similar trend to that reported in adult studies; pregnant mothers have a better dietary profile when compared against non-pregnant individuals (Derbyshire, 2009, pg. 496). However, it is also states that pregnant girls continued to fall below UK guidelines for several key nutrients (Derbyshire, 2009, pg. 496). Studies have been done to determine what factors caused late entry into prenatal care. According to Wiemann et al. (1997) risk factors for late entry into prenatal care showed that adolescents who no longer had contact with the father of the baby, adolescents with no history of abortion, adolescents who had not used alcohol in the last 30 days and those who were unemployed. Another study by Flynn et al.(2008) looked at how home visits by a nurse improved prenatal care. During the study, teens received a monthly visit by a public health nurse and one by a medical social worker. The nurse and social work helped the teens to set up prenatal appointments, select a provider, they were also provided transportation to these appointments. The results of the study were positive. The teens made more visits to their prenatal care appointments than teens that did not receive home visits. Teaching Plan Nursing diagnosis: Knowledge deficit related to lack of information, unfamiliarity with resources, information misinterpretation. Goals: Patient will verbalize understanding of condition, patient will discuss and adhere to components of adequate prenatal diet

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Objectives: Patient will attend at least 90% of prenatal appointments, patient will create a list of at least 6 available resources Outcome: Patient will have an increased understanding of the importance of prenatal care and resources available Nursing diagnosis: Altered nutrition, less than body requirements related to intake insufficient to meet metabolic demands Goals: Patient will eat a nutritionally adequate diet, gain prescribed weight, take daily iron/vitamin supplements Objectives: Patient will create and maintain a daily food diary, patient will gain weight as prescribed during all trimesters of pregnancy, patient will create a list of 10 nutritional foods and 10 non-nutritional foods, patient will create a list of 5 risk factors associated with decreased nutritional intake.

To implement the teaching plan I would start in the schools. There are many adolescents who are afraid to come forward and if I went into the schools, they would be more likely to come to me. Studies have shown that adolescents do better within a group of their peers. I feel that a group approach with adolescents would work in the beginning. 1.I would ask former pregnant adolescents to come in and tell their stories, what they would have done differently and wish they might have done. Adolescents look to their peers for support and encouragement and this would foster that. 2.At the end of the session I would ask each to individually sign up for a one on one session with me where we could discuss their personal concerns and answer any other questions they may have on the individual level.

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3.I would also encourage attendance at the bi-weekly support group. The adolescents can talk about how their pregnancy is going and ask their peers questions. 4. At these meetings I would provide information about different stages of pregnancy and information about nutritional intake and how important it is for the baby. 5. During these meetings I would have different speakers in to either talk about their experiences or professionals that are familiar with the pregnant adolescent. To evaluate their learning, at the private sessions I would ask them questions pertaining to weekly discussions at the meetings and use this to determine further areas of teaching. I would also ask them to name one thing that they learned or thought was useful during the group meetings. To determine what the adolescents are most interested in learning about I would ask for weekly suggestions by way of a secret box. I would try to let the adolescents lead the group with me providing information for them to think about and discuss. Materials used For the group I would use posters created specifically for adolescents development stage, videos, and speakers. I would not use power points because I do not feel a power point would hold the adolescents attention. Adolescents need to be interested in the material being presented and it should be presented in a way that will hold their attention. Adolescents tend to be more responsive to other adolescents so speakers and videos would work well. I would also incorporate age appropriate written materials that they can look back on for references. I would also ask the adolescents to bring in anything that they have found helpful during their pregnancy to share with the group. In conclusion, in order to teach this population about prenatal care it has to be presented in a way that interests them. It should not be taught in a preaching, authoritative way, but rather

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as an equal, someone who is there to help. Studies have shown that adolescents respond well when in peer groups, which is why I feel that a group discussion would foster education. If an adolescent sits in a classroom all day, the last thing they want is to be talked to like a teacher. However, if they are placed in a laid back setting, the nurse may get more information from them and to them. Studies have shown that adolescents do want to learn, and the majority does want to have healthy babies. The problem is that adolescents perceive themselves as infallible. If they are taught risk factors and consequences of not receiving prenatal care they may be more likely to keep appointments. They need to be faced with the facts that if they do not receive good prenatal care and take care of themselves, it could mean life long consequences for their baby.

[Type text] Appendix- Evaluation Tool

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1. Did you find this group discussion useful to your situation?

2. If you could change anything about the group session what would it be?

3. Name 3 things that you learned

4. Do you feel that the information presented was in an organized, easy to understand way?

5. Did the instructor demonstrate knowledge in the subject?

6. Do you feel the private session was useful?

[Type text] References:

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1. Budd, Marilyn and Flynn Linda. (2008). Enhancing Resource Utilization Among Pregnant Adolescents. Public Health Nursing, 25, 140-148. 2. Derbyshire, E. (2009). Dietary Habits of Pregnant and Non-Pregnant Adolescents. Journal of Nutrition and Food Science, 39, 1-10. 3. Frye, Barbara and Barham, Barbara. (1975). Reaching Out to Pregnant Adolescents. The American Journal of Nursing, 75, 1-4 4. Hueston, William; Geesey, Mark; Diaz, Vanessa. (2007). Prenatal Care Initiation Among Pregnant Teens in the United States: An Analysis Over 25 Years. Journal of Adolescent Health, 42, 243-248. 5. King-Jones, Tammy. (2008). Pregnant Adolescents Perils and Pearls of Communication. AWHONN Lifelines, 10, 1-7. 6. Montgomery, Kristen.(2003). Nursing Care for Pregnant Adolescents. Journal of Obstetric, Gynecological, and Neonatal Nursing, 32, 249-257. 7. Montgomery, Kristen. (2003). Health Promotion for Pregnant Adolescents. AWHONN Lifelines, 7, 1-13. 8. Moos, Merry-K.(2006). Prenatal Care: Limitations and Opportunities. Journal of Obstetric, Gynecological, and Neonatal Nursing, 35,278-285. 9. Wiemann, Constance; Berenson, Abbey; Garcia-del Pino, Leticia; McCombs, Sharon. (1997). Factors Associated with Adolescents risk for late entry into prenatal care. Family Planning Perspectives, 29, 273.