In 2002, there were nearly half a million births in the United States to adolescent girls 19 or younger.1 Although nurses strive diligently to provide culturally competent care to women of differing ethnic backgrounds, sometimes nurses can forget that developmentally competent care is also essential for providing optimal care to adolescents.
A review of the literature found few studies documenting adolescent responses to labor and birth. Thurman and Hulsey2 documented adolescents' preferences for and use of labor pain management and found that significantly less primiparous adolescents choose regional anesthesia compared to older primiparous women, but the researchers could not explain why. Low et al3 contrasted adolescents' experiences of childbirth with the experiences reported by adults. They found that adolescents put limited time into planning for their birth, have a greater focus on planning for the baby, and use the media as a significant source of information. Work has been done on providing social support to teens during pregnancy, but little research has been published on providing support to adolescents during labor and birth.
Everyone who cares for adolescents should be aware of the conflicting views society has regarding teen sexuality. The media and entertainment industries portray sexuality as fun, carefree, and without consequences. Eggermont4 found that as 15-year-olds watched more television, their expectations of peers' sexual activities increased. When adolescents do become pregnant, there are many negative attitudes toward the pregnancy among adolescents and their families, including feelings of embarrassment, foolishness, and futility.5 Adolescent males are viewed by many as predatory and irresponsible in their sexuality.6 Fordham and Obgu7 found that assumptions that adolescents are troublesome and that low-income minority youth are incapable and not motivated affects the support given to this subset of teens. Fessler8 described the American cultural belief that early childbearing almost always has negative outcomes, and she concluded that this belief contributes to a sense of discomfort that many healthcare providers feel while caring for pregnant and laboring adolescents.
The labor and delivery nurse needs to be aware of the developmental stages of adolescence when caring for the teen girl in labor and during the postpartum period. Although major physical changes occur in both adolescent males and females, physical maturity does not demonstrate cognitive development. Early adolescents are concrete thinkers and must progress into individuals who are able to reason abstractly and anticipate future consequences. Adolescents are risk takers, as a consequence of the lack of future planning. Risk-taking has developmental benefits, enabling adolescents to try out new skills and test limits. However, risk-taking and lack of future planning also lead to unintended consequences such as pregnancy for the adolescent.
The psychosocial stages of adolescence are key components to be included in the plan of care for teens. Early adolescents, aged 11-13, have poor futurity orientation but do have early formal operational thinking. These girls may be narcissistic and egocentric. They may need more direction and fewer choices and may seem more like children than older adolescents. The mother or other adult support persons can be recruited to participate in the care and support of the teen, while being cognizant that family members might hold conflicting views about the pregnancy. Often, mothers of pregnant teens were teen mothers themselves and are aware of the difficulties ahead for their daughters.
Middle adolescence, ages 14-17, is marked by the peak of conflict with parents and other adults and an increase in testing behaviors. For these girls, autonomy is a chief concern. These girls may wish to exert their independence from their support systems and may be perceived by their caregivers to be demanding and unreasonable. Nurses caring for these girls need to understand that adolescents in this state of development may seem irrational to adults. Adolescents in this age group look to others for validation and react strongly to their perceived lack of respect by adults.
Older adolescence, ages 18 and 19, brings more formal operational thinking with the formation of more realistic, future-oriented goals. These older girls have reactions that are associated more closely with adult behavior. However, at times of stress, such as labor, they may regress to an earlier stage of development. Again, even if the physical development is more like that of an adult, the psychological development may be more like that of a child.
The nurse is neither a surrogate parent nor a member of the girl's peer group. The adolescent needs to develop a trusting relationship with the caregiver in a short period of time. A nonjudgmental relationship can be maintained and is crucial to a birth experience that is safe and satisfying for the adolescent and her family. This relationship will enable the nurse to assist the adolescent with the tasks of early parenthood, such as attachment, breast-feeding, and family planning. The nurse can explore with the teen future goals such as school attendance and healthcare in the postpartum period.
The trend in labor and delivery units is toward facilitating unlimited attendance of family members and friends during labor and birth, according to the wishes of the mother. The nurse may have a room full of adolescents, including the father of the baby and the girlfriends of the laboring teen. Setting limits is essential while respecting the right of the laboring girl to the birth experience she would like to have. The nurse can attempt to engage the father of the infant and attempt to include other family members in labor support, acknowledging that family structure may be different than the structure the nurse is most familiar with.
Low et al3 emphasize that the effects of judgmental treatment of adolescents create stress that adult women do not experience. In their study, adolescents described a level of tension brought about by the negative treatment by healthcare providers, including nurses, that affected the entire experience of birth and had an impact on the confidence the girl felt in her ability to become a parent.
Nurses caring for women during labor, birth, and the postpartum period are usually careful to develop cultural competence and respect for these women of other backgrounds or beliefs. Providing care for adolescents during this stressful, yet potentially empowering time, also presents challenges. Developmental competence should be a part of the education offered to all providers caring for teens and a component of the care plan for these girls.
Jackie Tillett ND, CNM
Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wis, Director, Nurse-Midwifery Center at Aurora Sinai Medical Center, Milwaukee, Wis
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