Judgemental approach should be avoided&girl should be treated with dignity with assurance of confidentiality,avoiding criticism at any step.
Important issues are 1)social deprivation,isolation,depressionbecause of negative attitude towards pregnancy& foetus.
2)drug abuse -close association & ivdrug abuse associated with increasedrisk of infections ,such as HIV, HEPATITIS( both have effect on pregnancy & its mode of management).so screening for the same should be offered.
3)sexual history to include history of partner,history of sexual abuse(sensitive approach,associated psychological problems need to be addressed,such as fear of examination& delivery).History of STDs,such as chlamydia & gonnorrhoea& screening for the same with endocervical swabs.Positive results require referral to GUM clinic for treatment & contact tracing.
4)Advise against alcohol & smoking.Offer smoking cessation programme &provide support to help with stopping or reducing the qty.Tell that both ( alcohol & smoking are associated with fetal problems such as IUGR,fetal alcohol syndrome)
5)Folic acid supplementation whether commenced or not,if not to be commenced along with iron & protein supplementation for correction of nutritional deficiencies as this group is at risk of malnurition.
6)Assess rubella immune status by doing antibodies ,if not immune advise immunisation in the postpatum period.
7)Assess knowledge of contraception &any history of use .Provide updated information along with leaflets.
Problems during antenatal care are dating problems ,irregular visits ,hypertension, infection( HIV,HEPATITIS),fetalgrowth restriction,premature labour,obstructed labour, dystocia,perineal tears,increasedoperative intervention, including operative delivery& poorresponse to labour analgesia( because of anxiety &tolerance if drug abuse).
Postnatal problems are postnatal depression,lactation problems( failure to breast feed or continue with it),postpartum haemorrhage ( because of increased intervention),lack of contraception ,leading to second unplanned pregnanycyadding to extra burden.
Modification in antenatal care will involve care in a dedicated unit at tertiary centre if possible with involvement of obstetrician with special interest midwiife ,neonatologist &anaesthetist).Keeping the girl in the health care so that she gets benefits& social support in case of need .Mother should be involved in the care which can ensure regular visits& proper intake of medicines .
Early booking scan because of dating problems( to ensure correct gestational age)& all otherbooking investigations, including blood group & Rh type,VDRL,FBC,URINALYSIS,HIV,HEP-B),uterine artery doppler& anomaly scanat 18-20 wks for prediction of pre-ecclampsia&anomalies respectively.
Serial monitoring of BP ,urine for proteinuria& USG for fetal growth at regular intervals.
Encourage girl to attend antenatal classes, so as to develop positive attitude towards pregnancy.
Consutant should be called for delivery.Presence of partner or mother during labour will help in giving support .No indication for induction or caesrean section , unless for obstetric reasonsor infection.No contraindication for labour analgesia,butneed for higher doses should be discussed beforehand.Active management of third stage of labour ( use of oxytocin drip &methyl ergometrine).
Encourage bonding with baby & breast feeding.
Ensure to give contraceptive advice before discharge as well as at the time of folloup to avoid next unplanned pregnancy.
