Expectations of pregnant teenagers about nursing care in labor rooms

Expectativas de las adolescentes embarazadas sobre el cuidado de enfermería en salas de parto

Jenny Andrea Angarita Gómez; Mónica Paola Basto Montero; Islendy Noreña Acevedo; Myriam Patricia Pardo Torres

Research Division, Bogotá,Colombia. Universidad Nacional de Colombia.

ABSTRACT

Introduction: the settings of pregnant teenager’s labor moment have been largely unexplored. In the literature there is an emphasis on prenatal and puerperal care, so a deeper nursing care during this phase is clearly needed due to the particular conditions of the adolescence. Aims : identify main aspects that guide nursing care of pregnant teenager´s during labor and delivery trough evidence.
Methods : this study responds to an integrative review that allows us to join and synthesize available evidence of the research subject.
Results : there are four categories that guide nursing care in order to provide a human and differentiated attention to pregnant teenager´s during labor: Feelings and emotions, non pharmacological strategies, nursing role, pregnant teenager needs and rights.
Conclusions: the four categories of nursing care for pregnant teenagers in labor act as a guide for the elaboration of care protocols in labor rooms because they provide the four Meta-paradigmatic concepts of nursing: Health, person, nursing care, and environment.

RESUMEN

Introducción: las condiciones del parto en la adolescente gestante han sido poco exploradas, en la literatura se observa un énfasis en el cuidado prenatal y puerperal, por lo tanto se evidencia la necesidad de profundizar en el cuidado de Enfermería durante esta etapa de la gestación dadas las condiciones propias de la adolescencia. ]]> Objetivo: identificar los aspectos claves que orientan el cuidado de Enfermería de las gestantes adolescentes durante el trabajo de parto y parto a partir de la evidencia.
Métodos: el presente estudio corresponde a una revisión integrativa que permitió reunir y sintetizar las evidencias disponibles del tema investigado.
Resultados: surgen 4 categorías que orientan el cuidado de Enfermería para brindar una atención diferenciada y humana de la adolescente gestante durante el trabajo de parto y parto: Sentimientos y emociones, estrategias no farmacológicas, rol de Enfermería, necesidades y derechos de la adolescente gestante.
Conclusiones: las 4 categorías del cuidado de Enfermería para la adolescente gestante en trabajo de parto y parto, son una guía para la elaboración de protocolos de cuidado en salas de partos ya que aportan a los cuatro conceptos Meta-paradigmáticos de Enfermería: salud, persona, cuidado de Enfermería y entorno.

Keywords : Nursing Care; adolescent; pregnancy; labor.

INTRODUCTION

Teen pregnancy is a phenomenon with repercussions at a personal level (life project changes, incomplete scholar and professional formation), family level (separation from home, lack of support), and social level (stigmatization, difficult labor stability, poverty rising), whose rates have been growing, as reported in the world sanitary statistics of the World Health Organization:¹ In the 2000-2008 period the teen fertility rate (for 1000 women’s between 15 and 19 years old) in the Americas region ranks second in the world ranking with an average of 63 births, preceded by Africa who has the largest rate of all region´s with 117 births. After America we can find the rest of the region in the next order: South East Asia with 54 births, East Mediterranean Region with 41 births, European Region with 24 births, and West Pacific Region with 11 births.

Teen´s biological immaturity leads to complications during pregnancy such as: abortion, anemia, preeclampsia, premature rupture of membranes, and dystocia. Form the psychological point of view we can find self-esteem problems, frustration, anxiety, difficult adaptation to the mother role, distress for couple reject, post labor depression and fear. Teens inside their social context are stigmatized and discriminated for their pregnancy condition because it’s considered as an irresponsible act at their age and it can modify in a negative way their life project, which generates a reject attitude and the concealment of their condition.²

Nursing as the profession and discipline oriented to human beings care in the different stages of life starting from a humanized interpersonal relationship, try to respond to pregnant teenage physical, psychological, and socio-cultural needs, having clear that they are human beings with specific organics, functional, socials and emotional characteristics and which requires a differential care by the labor health care team.

The pregnant teenage is living two experiences at the same time: the building of a new corporal image, from the physical and psychological changes of puberty, and the adaptation process to the pregnancy-puerperal cycle that also implies a series of changes at corporal, physiological, affective and relational levels.³

The setting of the labor moment in the pregnant teenage have been largely unexplored because is generally focus on the prenatal and puerperal care. Therefore is necessary to deeply explore in the nursing care during this stage of the reproductive process given the specific conditions of adolescence recognizing labor and delivery as an intimate moment experienced in a familiar space which support and love received allows the natural development of the birth of a new human being. However, there is a huge barrier imposed by medicalized labor where there´s no evidence of a holistic assistance model because women´s in the majority of hospitals remain separated from their families, coexisting in rare environments, with stressed health care staff, along with interventions that cause pain, discomfort and loneliness.⁴

By this is necessary to identify de key aspects that guide nursing care in pregnant teenagers during labor and delivery starting from the evidence.

METHODS

This study responds to an integrative review that Alcala⁵ refers as a research method that allows to join and synthesize available evidences about a research subject. Is the only method that bring together the research of the past and the present with different methodological approximations (quantitative, qualitative), with the purpose of extract general conclusions of this body of literature about a particular subject.

The six stages proposed by Alcala⁵ for an integrative review were used in the development of this study in the following way:

2. Search of literature or sampling: the research process bring together articles found on databases such as DOAJ, Ovid Nursing, Scielo, Medline, Ovid Journals, Science Direct, Pub Med, Academic Search Complete, LILACS; Master degree thesis, Undergraduate thesis, textbooks, and articles bibliographic lists.

The search was focused on research articles of the last ten years period using the following search words: pregnant teenager, labor, nursing, humanization, and human care in Spanish, English and Portuguese language.

3. Study of categorization: in this stage a bibliographic chart ,proposed by the Trabajo Final subject of the maternal perinatal specialization at Universidad Nacional de Colombia, was used to resume each one of the articles highlighting the study identification, objectives, main concepts, results, conclusions, suggestions and observations from which was made a critical valuation to determine the level of evidence in each article and the contribution in the creation of categories that constitutes the mains aspects found in the review.

4. Valuation of found studies: the studies were valuated according to the criteria of authenticity, methodological quality, information relevance and representativeness for the investigation.

5. Results interpretation: after reading and analyzing the content of each one of the articles included in the review and complement the information with the theoretical contributions on maternal perinatal care, the next step is to classify the articles according to the level of evidence proposed by the Secretaria de Salud de Bogotá,⁶ allowing us to allocate the research articles in levels of evidence 2 and 3.

6. Presentation of integrative review.

RESULTS AND DISCUSSION

Category 1: Feelings and emotions of the pregnant teenager during labor and delivery

During the labor central and peripheral nervous systems intervene with a series of signs and symptoms that are manifested by mothers, such as the perception of feelings like pressure, pain and pushing,⁷ feelings that make mothers feels incapable of satisfactorily finish their labor as a way of a ineffective coping of the process.

Other psychological, cognitive and emotional factors and facing the crisis of a judged maternity that origin a low self esteem level for being a mother in an early age can contribute to that ineffective labor in pregnant teenagers.

To Bethea,⁸ feelings of pregnant women´s vary in the labor. Some of them can see it as a welcome act that ends a large waiting period for a child. Others consider it as a proof of strength or as a terrible suffering from which they can no escape

All this new experiences causes a series of characteristic feelings in pregnant teenagers that are described next

Fear: Trough history has been observed that women’s are predisposed to the labor moment, especially those women´s that belong to the western culture due to de religious cults that lead in this region came from Old Testament that stated “in pain you shall bring forth children”.⁹ Therefore, is more than conditioned in women´s psychology the pain at labor and that intensifies the fear of the child birth. In the eastern culture we found a different scenario. Women´s doesn’t experiment labor as a disease or as a painful process but as something usual in the women life cycle, reducing fear of it.¹⁰

Cultural context that have been tissue around labor makes that increasingly appears more reasons to be afraid of; there is a factor that causes fear along pregnancy and during labor and it is the condition of the unborn child or the possible complications that can occurs that affects in some way the fetal or newly born well being.¹¹

Added to the previous, different experiences that has to be experienced in a labor room are fully unknown for pregnant teenagers raising their insecurity that appear for not knowing what to do or how to act during labor, in some cases because of their condition of being mothers for the first time, being afraid of been pointed for not doing the right things as the health team expects.¹¹

The role that plays the health team for reducing fear that experiments the pregnant teenager along labor and delivery is essential being that they are persons that have more contact with her and also can reduce her fears trough communication and physical contact. Nevertheless, evidence shows that is the health team who instills fear the most; McCallum and cols study¹² refers that teenagers expressed verbal abuse from the health team and impertinence in the comments making feel them guilty of the situation they were living.

Therefore it’s proposed that health personal that works in labor rooms orientate their job toward the search of empathy with the teenagers in order to reduce their fear.

Pain at labor: is a unpleasant sensorial and emotional experience causes buy a real or potential tissue injury;¹⁴ depends on the socio cultural characteristics and physical (age, parity, cervix conditions, relation between fetal size and birth canal, fatigue, tiredness, etc) and psychological factors (fear, anxiety, lack of information, undesired pregnancy) that can increase the painful sensation.¹⁵

During labor the practice of pelvic bimanual exams repeatedly increases the pain that experiments pregnant teenagers. In McCallum and cols study ¹² mothers said that the fact that women´s in labor share spaces without separating curtains in labor rooms make them to watch other women´s experiences increasing their fear and also intensifying their pains, response explained by Read Theory.¹⁶

According to Read fear and pain to the unknown create a set of protective tensions in women´s body. These tensions are allocated in their mind and physically in some muscular groups that at fear moments inhibit and create a uterine resistance that cause pain. Therefore Read highlight in her theory tree obstacles for labor that are fear, tension and pain.

Loneliness: is one of the main feelings that women´s experiments at labor and delivery in obstetrical rooms of those institutions that as in our context doesn’t allow the entry of companion; feeling expressed by teenagers in Bravo¹⁷ and Villamizar¹¹ studies. There is loneliness feelings when the teenage pregnant is in an environment different to her daily life, with health staff that doesn’t understand her concern and pain manifestations. In this way nursing plays an important role in reducing this feeling, because nurses are with this women´s during labor not only to inform but to support labor and satisfy the process needs, such as the need of company.¹⁷

Satisfaction : During labor women´s can experiment feelings as joy and satisfaction because labor represents a paradoxical experience between the best things that could happens to women´s after pregnancy and the painful event that test their femininity and personal competences, limiting the control they can have over their physiology.

To Pacheco and cols¹⁸ the mother´s that have experimented labor said that is a moment characterized by a mix of pain, joy and pleasure.

Satisfaction is a relevant feeling in the speech of teenage mother´s because the birth leads them to a peace and contact period with their sons. ¹⁸ Contact is one of the most expected moments for mother´s because that moment is when a mother-son link is established; is the most pleasant moment and the more regarding. Klaus and Kennel¹⁹ defines the first hours after the birth as a “sensitive maternal period”. Reciprocal interaction between the newly born and the mother makes that every moment they spent together cause a stronger attachment.

Category 2: Non pharmacological strategies to apply during labor and delivery

Within the most used techniques to provide well being, security and comfort to women´s in labor and their son to be born are:

- Massage: the use of massages during labor produce relaxation, reduce anxiety and pain by improving the blood circulation and the tissues oxygenation.^{20, 21} Some studies such as Brown²² and Barbosa²³ reinforce massages utility as a valuable strategy.

- Breath control: breathing is important in labor because the uterus is contracting in a demanding way. If muscles don’t receive oxygen contractions increase the pain and cramps can be produced. When the mother breath correctly controls contractions and benefits the process. ^{20, 24-26}

- Musicoterapy: one of the common uses of musicoterapy is the regulation of the mood because music can cause relaxing effects due to its capacity of change humor, reduce stress and encourage positive thoughts. It can be used as a detonating factor of relaxation or breathing response. ^{24, 27}

- Aromatherapy: the massage with essential oils is an important treatment that combines the effects of oil with the contact of the caring nurse and the pregnant teenager.

The adequate technique using these oils is to gently rub the belly or the sacral lumbar region from the beginning of labor depending of the women preferred and more favorable position for the labor.¹³

- Freedom of movement: the possibility of free movement during labor helps women´s to deal with the painful situation.

Between more favorable positions for pain reductions that are referee in the literature we can find left lateral decubitus, following by the lotus flower. This last one is the most used in the labor latent stage.^{13, 28}

On the other hand there´s evidence about the advantages that physiological labor in vertical or squatting position. Balaskas²⁶ and Schilling²⁸ said that the birth canal surface can be increased to 30 % when the women change form lying down position to squatting position.

During dilatation period a bath can reduce anxiety stimulating endorphin production, improve uterine perfusion, shorten dilatation period and increase the sensation of pain control and satisfaction.²⁵

Category 3: Nursing role in labor and delivery

From nursing the pregnant teenagers phenomenon demands the discovery of the kinds of interactions that they have with the environment, the level of environment complexity in where they are immersed, the way they see the world trough their believes and the cultural influence that impacts their teenage behaviors, attitudes and feelings.³⁰

The demands of attention of the nurse staff from the patient are orientated principally to count with the presence of a professional that bring them human warmth, orientation and security bases on the knowledge.³

The health care of pregnant teenager in labor offer by health team professionals need to have as a goal the accomplishment of the well being in consideration of the different human beings dimensions.

In this order of ideas, nursing care of pregnant teenagers in labor have to be coated of a technical and scientific competence, a commitment characterized by the authentic presence and a human behavior that take into account the woman as another human being with an self care potential but at the same time as someone who need the satisfaction of a set of needs during labor and delivery.³¹

Consequently, the satisfaction of women´s during labor is given essentially by the relational component developed by nurses that gives a transpersonal care characterized by the moral commitment of the nurse to protect and enhance the human dignity

From the received accompanying the nurse humanize the attention during labor and delivery being attentive and giving response to the needs and expectation of the teenager, orientating and answering her questions,⁵ providing emotional support, advocating to avoid every form of violence against the woman and the infringement of her rights, respecting her intimacy and autonomy, giving support, human warmth and comfort.^{29, 31}

For the role of the nurse in the health team stands out is important for her to be committed to her assignments and validate her knowledge and criteria over the specific needs of the pregnant teenager, avoiding the supremacy of biological attention focused on medical attention. In this way the work will be done by a multi professional team in which the space of each one is respected and the priority has to be first of all the situation of the pregnant teenager in an integral way.^{31, 32}

Category 4: Pregnant teenager’s needs and rights

Pregnant teenager´s during labor and delivery have some specific needs that have to be identified and some rights that have to be respected by the health professionals that are involved during this process in order to provide a differentiated attention based on constant information, affectivity, trust, respect and confidentiality.³

To identify the needs of pregnant teenager´s the nursing professional have to know the morphological, physiological, and emotional changes, and the social and cultural environment that surrounds the teenage pregnancy, that in most of the cases constitutes a problem because it is accompanied by events such as school abandon, partner abandon, familiar and social groups relationships deterioration and economic problems.³³

Accordingly to the findings of the integrative review, between the need that presents teenagers in labor and delivery and from which nursing care must be orientated we can find:

- Need of a direct care of the nursing professional: nursing care of the pregnant teenager doesn’t have to be centered only on the strict surveillance of clinical pathological aspects that characterize labor in a biological dimension, but also with the same level of importance attention is demanded on psycho affective, cultural and social aspects related to maternity, advice in the rights of women´s in pregnancy attention, labor and delivery, constant information and timely education of pregnant teenagers.

In addition, the nursing professional have to provide continuous support during labor and delivery, moment when women´s can be particularly vulnerable to the environmental influences;³³ complementing this support with the maintenance of a warmth environment, comfortable, with respect and confidentiality, ensuring a human attention; all the above with the intention of complying with the Calidad de atención en Enfermería stated by the article 19 of the law 266/1996 of the Colombian Congress³⁴ through a scientific quality, technique, social, human and ethic nursing care

- Respect for pregnant teenager´s rights: from the review of WHO policies, Secretaria Distrital de Salud de Bogotá and authors such as Tornquist,³⁵ Castro,³² Pacheco¹⁸ a compilation of the rights that should be informed and ensured to pregnant teenager´s was made:

o Right to respect of privacy, security, comfort, physical and psychological well being of the pregnant teenager

o Right to respect of feminine physiology and avoid unnecessary procedures

o Right to recognizition and respect of cultural beliefs of the pregnant teenagers

o Right to continuous companion during the whole labor process

o Right to express emotions, feelings and take her own decisions

o Right to respect of autonomy and central role during the labor process

- Psycho social needs: in a human attention model in the labor and delivery process the pregnant and her companion must be treated with respect and empathy, always considering their opinions, preferences and needs.¹⁸

In order to satisfy the specific needs of pregnant teenager´s is essential to know their actual situations because not in every case pregnancy is undesired, a mistake or a negative fact for their life’s. In the study made by Ajoulat and cols³⁶ the participants perceive the baby as a support for their self esteem related with a greater sense of maturity, responsibility and pride. Also they considered that having a son could end their loneliness and emptiness feelings. This same study contemplates pregnancy as a strategy to escape from an insupportable situation or to recover control over their own life and body.

Uribe³⁷ in her study stated that the pregnant needs can be attended transmitting tranquility, trust, information about labor, confidentiality, continuous presence, respect. Those elements are interpretated by mother´s as psycho social and physical well being, bringing them to have a more peaceful labor and to give it a positive meaning.

According to studies made by Hoffmeryr and Nikdem,³⁸ and the review made by Langer A³⁹ women´s that count with a companion support have shorter labor periods, have more possibility of a vaginal spontaneous labor, surgical labors decrease and newly born have less possibility of present lower APGAR punctuations.

In our setting is common in labor rooms not to involucrate the father inside these processes and is perceived as a possible obstacle or spy of the professional work and not as a main character or protective element in the maternal perinatal health care.⁴⁰ The study made by Komura and cols ⁴¹ shows the experience of professionals that works in labor rooms where the presence of companion was positive in several aspects of the labor assistance: favorable evolution of labor, increase of endorphin levels that contributes to reduce pain and stress. A companion meets the needs that a professional can not comply because the continuous presence make possible the quick detection of problems, satisfy demands of attention and guarantee security for the mothers and professional in their practice.

Between benefits of the adequate companion of the labor we can find: decrease of cesarean births, analgesic use, oxitocics use, forceps use, increase of interaction level between the baby and his parents, strengthening the link through the beginning of early maternal lactation.

One of the inconvenient for the realization of an adequate companion is the lack of nursing staff with knowledge in the area and with human warmth due to the financial deficit of health institutions in the developing countries.⁴² Health institutions should recognized that is cost-effective to count with capable nursing professionals that can anticipate the events, avoiding complications that lead to the increase of maternal perinatal morbimortality and in turn promotes normal labor decreasing the demand of high cost interventions.

The differentiated and integral attention that nurse professionals offers it characterized by the focus on the four Meta paradigmatic concepts that guides their care such as: person, environment, nursing and health.

This is how centering on a vulnerable population, in this case pregnant teenagers, approach to their reality and determine their needs to facilitate the passage of the teenager trough the gestational period, with the implications that has for her in every dimension of the human being.

From the integrative review it can be determined the guidelines that orientate and promote the pregnant teenager well being in labor and delivery.

So it is guaranteed that the teenager has a positive and unique experience in one of the most significant moments for a woman: give birth, and even more when for an adolescent it have been difficult to face, build and assume de mother role.

Actually in the labor room services is perceived a medicalized environment that offers a standardized attention centered on a biologist vision where the woman lost the main role of this natural process and is subject to the health care team decisions without taking into account her physical and psycho emotional characteristics, and her autonomy.

With the contributions suggested in the categories: feelings and emotions of pregnant teenagers during labor and delivery, non pharmacological strategies during labor and delivery, needs and rights of the pregnant teenager a contribution is made to the professional practice of nursing with the finality of improve the maternal health trough quality attention that implies the knowledge about the pregnancy experience and delivery for the teenager assuming it is a union of body, mind and spirit and which understanding can be made through active listening and feelings interpretation to find the meaning they build to the process they are experiencing and is associated with their believes and expectations, without forgetting the importance that deserves to have in count their support network.

In turn is important to propose and materialize public policies like the case of the Modelo de Servicios de Salud Amigables para Adolescentes y Jovenes proposed by the Fondo de Poblacion de las Naciones Unidas (UNFPA) that guide and prioritize the health processes to protect and promote health and well being of pregnant teenagers and their newly born sons.

Those policies has to be spread to all the health workers with the objective of find mechanisms for their implementation and therefore make more human and qualified the attention to persons depending on the life cycle in where they are.

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Recibido: 19 de octubre de 2012. ]]> Aprobado: 7 de febrero de 2015.

Jenny Andrea Angarita Gómez. Dirección: Calle 75 N°20B- 19, Bogotá- Colombia. Tel: 3118869292. E-mail: jaangaritag@unal.edu.co