Other risk factors for pregnancy
- 1. PRESENTATION ON OTHER RISK FACTORS FOR PREGNANCY: ADOLESCENTS, ELDERLY, UNWED MOTHER & SEXUALLY ABUSED MOTHERS Under the Guidance of: Presented By: Mrs. Anugrah Milton Ms. Renu Prakash Sister Tutor M. Sc. Nursing(F), 3rd Semester RAKCON Obstetrics and Gynecology RAKCON (2019-2021)
- 2. Introduction to the Topic • Pregnancy and child birth is one of life’s major event • Every pregnancy carries its risks • Midwives are mainly concerned with normal pregnancy • pre-existing conditions and the Vulnerable groups • Pregnancy may be complicated by a variety of disorders and condition • midwife should have the knowledge of various major and other risk factors for a normal pregnancy
- 3. Risk Factors for Pregnancy Major Risk factorsfor pregnancy: ➢ Reproductiveabnormalities ➢ Age under 20 ➢ Age over 35 ➢ Weight ➢ Diabetes ➢ STIs ➢ Pre-existingconditions ➢ Multiplepregnancies ➢ Multiplebirths ➢ Previouscomplications Other Risk Factors for Pregnancy: • Adolescent/Teenagepregnancy • Pregnancyat elderage • Unwed Mothers • SexuallyAbused mothers
- 4. Other Risk Factors for Pregnancy 1. Pregnancy in Adolescent/Teenage 2. Elderly Pregnant Women 3. UNWED MOTHERS 4. SEXUAL ABUSE: A risk factor for Pregnancy
- 5. 1. Pregnancy in Adolescent/Teenage Introduction and Impact of adolescent period on Pregnancy: ❑ Teenage pregnancy is a global phenomenon. ❑ Complications of pregnancy and childbirth are the leading causes of mortality among women aged 15-19 in such areas. ❑ WHO’s contribution to meet the Millennium Development Goals (MDGs) ❑ Adolescent birth rate is one of the expanded indicators of Millennium Development Goal ❑ By WHO definition, the adolescent period covers the age of 10-19 years. ❑ Teen age constitutes a high-risk group requiring high priority services. ❑ A major problem for the pregnant teen relates to her own body ❑ There are high rates of spontaneous abortion, preterm delivery and low birth weight ❑ In addition to the increased maternal mortality rates, pregnancy can induce tremendous psychological stress on the adolescents
- 6. 1.3: Incidence of Adolescent Pregnancy: • Adolescent childbearing is an aged old problem in Nepal • Adolescents comprise of 23% of 23 million of Nepalese population. The median age at first marriage for ever married women in Nepal (age 15-49)is 16.6 years Nepal • 11% percent of the world’s teenage pregnancies happen in India. • India has one of the highest rates of early marriage in the world. The recent National Family Health Survey (NFHS) estimates that 27 percent of girls in India are married before their 18th birthday, that’s 1/3rd of all our young women India • The US has the highest adolescent birth rate of all developed countries • more than 40 percent of women become pregnant before they reach 20 years US
- 7. 1.4: Causes and Risk Factors 1. Poverty Growing up in a single parent household,havinga mother who was an adolescentmother, or havinga sister who has become pregnant are critical life events for becoming teen mother 2. Early Marriage • early age at marriage is the main reason for early pregnancy. • low age at marriage, poverty, low valueand self-esteem of girls, low level of educationand low levelof contraceptiveuse, early childbearing, sexual abuse and assault. 1.5: There are several predictors of sexual intercourse during the early adolescent years, including: Earlypubertal development A historyof sexual abuse Poverty Lack of attentive and nurturing parents Cultural and familypatterns of early sexual experience A lack of school or career goals Poor school performanceor droppingout of school
- 8. 1.6: Potential risk factors for a teenage girl to have early sexual behaviour and / or become pregnant include: Early dating and risky sexual behaviours Early use of alcohol and/or other substance use Dropping out of school and/ or low academic achievement Lack of a supportive environment Lack of involvement in school, family, or community activities Perceiving little or no opportunities for success Living in a community where early childbearing is common Growing up under impoverished conditions and poverty Having been a victim of sexual abuse or non- voluntary sexual experiences Having a mother who was aged 19 or younger when she first gave birth
- 9. Symptoms of Pregnancy in Teenagers/Adolescents Missedperiod Fatigue Breasttenderness Distentionof abdomen Nausea/ vomiting Light-headedness or actual fainting The adolescentmay or may not admit to being involvedsexually
- 10. Symptoms of Pregnancy in Teenagers/Adolescents cont… There are usually weightchanges Examination may show increasedabdominal girth Pelvicexaminationmay reveal bluish or purple colorationof vaginal walls Bluish or purple colorationand softening of the cervix UPT and/or serum HCG is usually positive An obstetricscan confirms accurate dates for pregnancy
- 11. Consequences of Teenage Pregnancy Higher rates of Morbidity and Mortality Hampers further education of female adolescents Greater riskof socioeconomic disadvantage Medical complications Health complications STI, Substance abuse and Accidents
- 12. Consequences of Teenage Pregnancy Cont…. Malnutrition Low birth Weight babies Recourse to Abortion including unsafe abortion Infant Death, Blindness, Deafness, mental retardation and Cerebral Palsy High Perinatal risk Other medical problems
- 13. Consequences of Teenage Pregnancy Cont…. Combination of biological and social factors Psychosocial problems Spontaneous abortion Nutritional anaemia Incidence of contracted pelvis is higher Caesarean section rate
- 14. Complications of Adolescent Pregnancy • There are variouspublic health implications. • Early and adequateprenatalcare is crucial for detecting pregnancy risksThe public health implications • Smoking, alcohol use, or drug abuse; poor and inconsistent nutrition; or multiple sexualpartners. Teenage mothers are more likely to demonstrate behaviours • These childrenhave an increased risk of developmentaldelay,academic difficulties, behavioural disorders,substance abuse, and becoming adolescent parentsthemselves. The children of adolescent mothers do not fare • Have poor academicperformance, higher school drop-out rates, limited financialresources, and reduced income potential. Adolescentfathers are similar to adolescentmothers •Children born to single teenage mothers are more likely to drop out of school,to give birth out of wedlock, to divorce or separate, and to become dependent on welfare •Teen pregnancyresults in huge publiccost to the society. There are multiple societal implications of teen pregnancy
- 15. Available options and Management of Adolescent Pregnancy Abortion Giving up infants for adoption after delivery Smoking, alcohol use, and drug abuse should be strongly discouraged Close antenatal check-ups Adequate Nutrition Correction of anaemia Early detection of pre-eclampsia More rest to avoid premature births Appropriate exercise and adequate sleep Access to effective contraceptive Appropriate and adequate counselling
- 16. Prevention of Adolescent Pregnancy Aims for programs addressing teen pregnancy • directed at delaying the initiation of sexual activities and early marriages • directed at preventing pregnancy for sexually active adolescents • directed at ensuring the well- being of adolescent parents Approach •To create awareness •Clinic-focused program •delaying early marriage •subsequent pregnancies should be discouraged •Prevention of marriage at teenage •Adolescent sex education •effective and successful sex education programs •Family planning services Key principles •Parents,guardians and other members of society must play key roles •The primary messages of prevention programs should be on abstinence and personal responsibility •Adolescents must be given clear pathways •work together to develop comprehensive strategies for prevention of teen pregnancy. Various Education Programmes • 1. Abstinence education programs • 2. Peer counselling programs • 3. Family planning program Effectiveness and success of implementedprograms • multiple approaches to the problem • Primary prevention (first pregnancy) and secondary prevention (repeat pregnancy) • A successful prevention program - Modified from American academy of paediatrics, Committee on Adolescence
- 17. Factors associated with a delay in the initiation of sexual intercourse include Factors associated with increased consistent contraceptive use among sexually active youth include Adolescents who choose to be sexually active are frequently limited in their contraceptive options
- 18. Nursing Care of Pregnant Adolescents Assessment/Analysis 1. Personal and family health;menstrual history 2. Nutritional status 3. Drug/alcoholabuse 4. Developmentallevel 5. Support system; financial status 6. Potentialrole of infant’s father 7. Attitude about pregnancy Planning/Implementation 1. Establisha trusting relationship 2. Refer to appropriate agencies and resources 3. Promote problem-solving abilities 4. Involvefather, if desired 5. Provide prenatal education;encourage consistent prenatalcare 6. Nursing Care of Women during Uncomplicated Pregnancy, Labor, Childbirth, and the Postpartum Period. Evaluation/Outcomes 1. Woman Arrives at decisionsregarding pregnancy 2. She Keeps prenatal appointmentsand attends child-care classes 3. She Involvessignificant others in planningduring pregnancy and for the future
- 19. RESEARCH ARTICLES 1. An Update on Teenage Pregnancy: Internet scientific publications The Internet Journal of Gynecology and Obstetrics: Volume 5 Abstract • Teenage pregnancy, which is detrimental to the health of mother and child, is a common public health problem worldwide. It is one of the key issues concerning reproductive health of women not only in developing but also in developed countries. There is a growing awareness that early child bearing has multiple consequences in terms of maternal health, child health and over all well-being of society. Although prevention of unwanted teenage pregnancy is our primary goal, many adolescents continue to become pregnant. The purpose of this article is to review current trends and issues on adolescent pregnancy to update the practitioners. The readers are provided with more recent data on adolescent sexuality, contraceptive use, and childbearing as well as suggestionsfor addressing the challenges of teenage pregnancy.
- 20. 2. Childhood Sexual Abuse and Adolescent Pregnancy: A Meta-analytic Update Objective: Recent increases in adolescent pregnancies have sparked a renewed impetus to identify risk factors, such as childhood sexual abuse (CSA), associated with adolescent pregnancy. Given mixed evidence regarding the strengthof the relationship between CSA and adolescent pregnancy, the objective of the meta- analysis was to provide an estimate of the effect size of this relationship using updated literature and meta-analytic techniques. Methods: Meta-analyses of 21 studies were conductedusing a random effects model of binary outcomesto determine aggregate effect-size estimates controlling for study heterogeneity. Results: CSA significantly increased the odds of experiencing an adolescent pregnancy by 2.21-fold. A supplementalanalysis suggested that 4.5 out of 10 pregnant adolescents may have a prior history of CSA. Conclusions: CSA places females at increased risk for subsequent adolescent pregnancy. Addressing conditions associated with CSA might impact the overall adolescent pregnancy rate.
- 21. 2. Elderly Pregnant Women Introduction • First-time mothers over 35 years are often called as “elderly primigravidae” and considered as “at risk,” • changes in the demographics of childbearing 1. rising trends in age at first marriage, 2. postponing childbearing until later reproductive years, and 3. increasing proportion of mothers at advanced ages as well as primigravidae at advanced age • In the United States, the percentage of first births for women 35–39 years of age increased by 24% and that for women 40–44 years of age increased by 35% between 2000 and 2012. Definition • The elderly primigravidais a patient going through her 1st pregnancy at or over the age of 35years • Elderly Multipara is a patient going through her consecutive pregnancy at or above the age of 35years because of secondary infertility or any other cause
- 22. Two groups of Elderly pregnant women have emerged Multiparous Women • may have never used contraceptives • may have used contraceptives successfully during childbearing years but have an additional child during the menopausal period Primiparous women (Elderly Primigravida) • Women having their first pregnancy at or above the age of 30 years • 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.
- 23. Complications of delayed pregnancy During pregnancy • Abortion; • preeclampsia; • Abruptio placentae; • Uterine fibroid; • Medical Complications • Tendency of post maturity and • Intrauterinegrowth restriction. During labor • preterm labor; • prolonged labor: • uterine inertia (occipito-posterior); • impaired joint mobility & • inelasticity of the soft tissues of the birth canal. • Maternal and fetal distress appears early; • Increased caesarean delivery and • Retained placenta. • Difficulty in accepting the event Fetal risks • Preterm birth and prematurity either iatrogenicor spontaneous,IUGR, fetal congenital malformation (aneuploidy). Puerperium • (1) Increased morbidity due to operative interference and failinglactation. • (2) Postpartum Haemorrhage: uterus may not contract readilydue to inelasticity
- 24. Management of Elderly pregnant women Preconception counselling: • Preconceptual phase is the time to identify any risk factor that could potentially affect the perinatal outcome adversely. • Objective is to ensure that a woman enters pregnancy with an optimal state of health which would be safe both for herself and the fetus. • The woman is informed about the risk factor and at the same time care is provided to reduce or to eliminate the risk factor in an attempt to improve the pregnancy outcome. • Considering the risks involved in pregnancy and labor, the patients are considered “high risk”.
- 25. Nursing Care of elder Pregnant Women Assessment/Analysis • Health history; gynaecologic/obstet ric history (fibroids; nulliparous;grand multipara);family health history • 2. Genetic history, counselling,and testing • 3. Nutritional status • 4. Prescribed/over- the-counter medicationsand supplements Planning/Implementation • Refer for genetic counselling • Provide prenatal care with emphasis on pre-existing conditionsand immunizations • Allow for verbalization of plans regarding work, changing responsibilities,and altered lifestyle Evaluation/Outcomes • Expresses feelings regarding expectationsof body changes • 2. Uses appropriate agencies for risk assessment • 3. Makes appropriateplans for role change during pregnancy and after birth
- 26. Prognosis • The maternal morbidity is high and the maternal mortality is slightly increased due to the increased complications and operative interference. • The perinatal mortality is increased due to prematurity, increased congenital malformation (trisomy 21) and operative interference. Outcomes of Pregnancy in elderly women • Adverse peri-natal outcomesmore common. • More likely to have LBW Infants, premature births & multiple births. • ↑ risk for maternal mortality due to haemorrhage, infection, embolism, hypertensive disorders of pregnancy, cardiomyopathy & strokes. • ↑ maternal age leads to infertility & spontaneousabortions, GDM, PIH, chromosomal abnormalities, genetic disorders, placenta previa, Preterm labor & surgical births. •
- 27. Research Articles • 1. M.A. Sajjad et all, “FIVE YEAR STUDY OF ELDERLY PRIMIGRAVIDA AT AMIN HOSPITAL” (Iranian Journal of Public Health) • 2. Pregnancy outcomein elderly primigravida: Department of Obstetricsand Gynecology, Veer Surendra Sai Institute of Medical Science and Research, Burla, Odisha, India (2019) • 3. Pregnancy outcomein elderly primi gravidas: Vibha Moses, Nilesh Dala • 4. The outcome of pregnancy in elderly primigravidas: Haifa A Al-Turki, (Saudi medical journal)
- 28. ABSTRACT • Background: Incidence of elderly primigravida has increased now days, due to rising education level, effective means of birth control and high carrier goals. The women who conceived in advanced age more than 35 years for first time is defined as elderly primigravida who are high risk for maternal & foetal complication and outcome. • Methods: This is a prospective hospital-based study done from October 2016 to November 2018. • Results: The incidence of elderly primigravida was 2.51% but majority (84.76%) are married early and conceived late. Most of them are belongs to high socioeconomic group (62.86%). ❖The commonest complications which were seen more frequently in elderly primigravida than young primigravida during pregnancy were: Anaemia- 28.57%, fibroid- 5.71%, Pre-eclampsia- 18.09%, eclampsia- 3.81%, IUGR- 12.38% and twin pregnancies- 5.72%. ❖The complications which were developed during labour ( in 55.24% cases): foetal distress- 33.33%, PPH- 3.81%, retained placenta- 2.86%, caesarean section- 29.52%, and congenital anomaly- 8.15%. • Conclusions: Elderly primigravida are high-risk for several complications like spontaneous abortion, preterm labour, prolonged labour, foetal distress, high caesarean rate, PPH, congenital anomaly and increased incidence of perinatal mortality.
- 29. 3. UNWED MOTHERS Introduction • Unwed mothers remain a challenge in obstetric practice • fairly common occurrencein the western countries • regarded as a threat to the family • Changing Trend Definition • Lady who becomes pregnant without legal justification of physical intimacy between man & woman is known as “Uwed Mother” • In traditional societies like India, becoming pregnant beforemarriage or becoming mother before marriage is considered a sin. The psychosocial impact of becoming an unwed mother is very stressful & depressive.
- 30. Research Article: Regarding Incidence in India Rising incidence of unwed mothers in India; associated social parameters & institutional guidelines for managing them Department of Obstetrics & Gynaecology, Cama and Albless Hospital, Mumbai, MH, India Background: Globally the incidence of unwed mothers is rising which is higher in western countries, developing countries like India are soon catching up. Methods: It’s a retrospective study from Jan. 2009 to Dec. 2013 analysed 51 cases of unwed mothers Aims and objectives: • To study the changing trends in the incidence of unwed mothers in the institute over the years. • To study the social and family backgroundsof unwed mothers Results: The study showed a 50% rise in the incidence of unwed mothers in that institute over the years with a majority (49%) of them being teenaged girls. 68% unwed mothers were uneducated or had only primary education & 58.9% unwed mothers had some predisposing factor which might have contributed to the pregnancy. 52% unwed mothers (who delivered) opted for institutional admission till term and 35.4% of these underwent a caesarean section at term (higher than institute LSCS rates). 21.5% unwed mother united with father with social worker intervention. Conclusions: Social and demographic parameters play a significant role in the incidence of unwed mothers.
- 31. Cause/Factors associated with unwed mother Poverty Prostitution Teen age mistake Improper sex education Contracept ive failure
- 32. Consequences of being an Unwed mother • Social Non-acceptable • Considered as curse • Personaldisorganization • Not get enough support from their familiesand the society. Being mother before marriage, A mother has to face great consequences • Societyboycott the family of unwed mother and familyloose their relationship with the society.Consequences for the family • Unwed mother lacks support from familyand society,therefore she faces great economicproblems. • Face great difficultiesin taking care of herself and the baby. Economic problems • Both mother and child are at greatrisk of serious health problems. • Unsafe deliverypracticeswhich are usually conducted at unhygienicplaces to hide unwanted pregnancy from society. Health problems
- 33. Legal rights of an Unwed Mother Establish Paternity Support to Child Custody of the child
- 34. Prevention of Unwed Pregnancy Peer Education Sex Education Supply of Contraceptives Abolition of Prostitution
- 35. Factors influencing care of unwed mothers Age of the mother Family support Financial stability Approach towards pregnancy Social and cultural background
- 37. 4. SEXUAL ABUSE: A risk factor for Pregnancy Introduction to sexual abuse in pregnancy Many types of sexual abuse Offender Incest It can occur at any time Trauma of sexual abuse can last a lifetime Woman suffered abuse as a child Accidental Intentional Disclosure of Sexual Abuse
- 38. Triggers, Signs & Symptoms, & Best practices/intervention for sexually abused mother Triggers Signs Symptoms Best practices/ intervention
- 39. Triggers for sexual Abuse • Any occurrence that makes a woman feel as if she has no control over what is happening to her by someone, she perceives to be in a position of power has the potential to instill feelings of fear. • The abuse cycle relies on this imbalance of power, and whether it is real or perceived a woman can be triggered and experience flashbacks, uncontrollable emotions, and stress related symptoms. • She may feel that the Doctor or other Medical Professionals have all the power as they are in positions of authority; • she may feel that she has lost complete control of her body and her right to privacy; and she may feel immense fear, shame and guilt for being scared of unknown procedures and exams and view this as evidence that she is not a good person that will impact her self-image as a mother.
- 40. Signs Flashbacks • re-experience of something that has happened in the past, it is so powerful and involuntary that the individual feels that they have ‘relived’ the experience SleepDisturbances • either sleeping too much or too little, particularly so if flashbacks are returning in the form of dreams. Food Intake: uncontrollable hunger or the opposite, extreme lack of appetite. MoodChanges: the memories may provoke mood changes, such as increased irritability, anxiety or depression Physical Pain • Headaches, and body aches such as back or neck pain with no reasonable cause.
- 41. Symptoms • Mistrust toward the caregiver, bondingfailure, PTSD, eating disorders, obesity, desire to change one’s name, failure to remove one’s clothes when appropriate,nervousnessabout being watched Psycho-social problems • Fear of pain. Phobia of needles, pelvic exams or other invasive procedures. Dreams and nightmares, dissociation disorders, anger issues, rigid control of thought process, poor self-imaging, blocking all early childhood memories Mental problems Physical problems Sexual problems • Fear of being ‘ripped apart’ during birth, inability to breastfeed or having difficulties, hyperemesis gravidarium, threatened premature labour, may hold the labour at a certain point to protect genital area or the baby, fear of losing control Problems during pregnancy, childbirth and postpartum Sexual addiction, inability to achieve orgasm, prostitution, pregnant teens Infertility, migraines, severe PMS, swallowing and gagging sensitivity
- 42. Best practices/interventions for sexually abused mother Provide opportunities for her active participation Recognizeand accept that some fears and concerns make sense Try to separate her pregnancy experience fromher past abuse Respect her right to privacy Discuss whether or not to disclose her abuse history Openly discuss fears and concerns the expectant mother may be experiencing Assist her in identifying where she is experiencing the most significantimbalance of power,control and fear
- 43. Best practices/interventions for sexually abused mother cont…. Educate her on recognizing and preparing for triggers Ensure that other members of her pregnancy medical team are aware that she is the sexual abuse survivor Develop a birth plan that is flexible and clearly stated Having a loved one close during times of stress Role of the midwife as her birthing assistant
- 44. Bring extra support and care during her labour stages Established a bond Ensuring continuity in communicati ons Be the consistent member Continue to reassure her and maintain eye contact Consistently provide reassurance, validate her feelings and emotions Role of the midwife as her birthing assistant
- 45. The impact of Sexual Abuse on Breastfeeding There are a wide range of reactions to sexual abuse regarding breastfeeding • Some women cannot tolerateeven the thought of breastfeeding • others may haveneutral feelings Early Post-Partum • She may havefelt psychologically traumatizedand reminded of the sexual abuse • She may not have enough time to bond and get comfortable with her new role Night-time Feeding A new mother may associate night feeding with her memories of her past, Some mothers find that it is easier to express milk and use a bottle for night feedings Older Infants Older infants smile, giggle, pull away from the nipple, and maytry be playful during feeding times, it maymake her feel uncomfortable
- 46. Role of a Midwife Explain the facts of breastfeeding and infant development Be prepared! Get breastfeeding literature and information, seek resources Develop a plan for the mother to control the environment
- 47. Summary/Conclusion “Midwives need to be vigilant and sensitive to the individual needs of vulnerable women” Good practice, All midwives must be sensitivetothe issues of vulnerable populations Communication Adolescent Mothers, Unwed Mothers
- 48. Bibliography: BOOKS: • Fraser D M, Cooper M A. Myles Textbook for midwives. (15th ed). Edinburg: Elbs. 2009, page no: 27 • DC Dutta, textbook of obstetrics including perinatology and contraception,18th edition. Jaypee brother’s medical publishers (P) LTD. INDIA (2015), page no: 320 • Mayes' midwifery,14th edition, Baillière Tindall, an imprint of Elsevier Ltd (2011), • page no-227 & 267, • Mosby’s Comprehensive Review of Nursing; Patricia M. Nugent, RN,EdD & Sharon Souter, PhD, RN, CNE; an imprint of Elsevier; 20th edition; page no-551
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