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Case study: unusual or difficult clinical cases

Why is specialist nursing care pivotal in managing under-age pregnancy?

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Nurses are constantly dealing with new and challenging situations in their day-to-day practice. Case studies are a way of sharing these experiences and offering possible solutions

An unplanned pregnancy

We were informed of the admission of a young girl, Adele*, aged about 12, who was referred via her local hospital with an unplanned, mid-trimester pregnancy. She had recently moved to the UK and was being cared for by a female guardian. Adele’s father lived abroad and her mother’s whereabouts were unknown.

Adele was said to have conceived following alleged ‘consensual’ sex with a juvenile. However, under the Sexual Offences Act (2003) all sexual activity with children under the age of 13 is illegal, as consent cannot be legally obtained (Home Office, 2004). In 13-16-year-olds the law focuses mainly on sexual activity with people aged 18 and over. In this case the likelihood of prosecution was small as the boy was also underage.

Accompanied by her guardian, Adele presented to her local A&E with abdominal pains a few weeks before admission into our unit. Clinical examination and investigations confirmed that she was pregnant.

Adele’s guardian had concealed the pregnancy; it transpired that, since her arrival in the UK, Adele had not attended school and her legal status in the country was uncertain. The local child protection team and social services became involved in her care. The woman’s legal status as guardian was not verified, which had implications in terms of consent.

Issues to consider

The primary concern was managing the pregnancy appropriately. After specialist counselling and consultation, Adele was clear she did not want to continue the pregnancy and was able to give informed consent for medical termination. Admission was arranged into the gynaecology ward at her local hospital. However, a failure in communication resulted in the ward refusing to accept Adele on the day of admission. The community gynaecologist then immediately referred her to our team.

A multidisciplinary meeting was held to prepare for her arrival, with representatives from gynaecology, paediatrics, child protection and the police. Despite her age, it was inappropriate to nurse Adele on the paediatric ward. Following discussion with our lead nurse and the community gynaecologist, it was decided that, as a senior member of staff, I would be Adele’s principal carer, with assistance from a named staff nurse with whom Adele could bond.

I appreciated the extra support, as I envisaged the care process would be emotionally demanding. Assured that the staff nurse felt informed and confident, we agreed she would manage her own workload but also play an active role in caring for Adele when necessary.

The paediatric team offered excellent support and clinical expertise as required and the modern matron for paediatrics liaised with me regularly.

Points of care

A mid-trimester termination is medically induced via administration of vaginal and oral prostaglandins. The process can take hours, culminating in the delivery of the foetus, followed by eventual expulsion of the placenta. The process is safe, however, the psychological effects of labouring in such circumstances should not be underestimated.

On admission, my priority was to establish a rapport with the girl. I needed her to trust me; without this, I believe her care would have been severely compromised. Adele was mature and articulate but her interaction with the play specialist served as a reminder that she was only a child, and she displayed typical signs of anxiety.

I felt that the issue of whether to address Adele as a child or an adult was irrelevant. To get her to respond positively, I needed to relate to her as an intelligent yet vulnerable young person with complex needs.

I also knew it was imperative to gain the guardian’s trust and cooperation. While she remained guarded, she was not an obstacle in care delivery, allowing us to make an unpleasant experience as manageable for Adele as possible. Throughout the day, Adele was polite, compliant, and showed gratitude for her care. Importantly, she showed she was clear she had made the right decision; she expressed relief and thanks for helping her through a difficult process.

Once the pregnancy had been passed, the police arrived to collect specimens for forensic evidence, and take my statement. For continuity, Adele was discharged into the care of her local services – the PCT, social services, child protection and police.

Conclusion

The provision of care for women having a mid-trimester medical termination challenges our ability to appropriately manage potentially difficult and sensitive issues. Unplanned, underage pregnancy presents exceptional circumstances that require gynaecology nurse specialists to coordinate a collaborative effort of care in the child’s best interests.

*The patient’s name and certain details have been changed to protect identities.

Author: MS, is education/practice development nurse in gynaecology at a London NHS trust.

 

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