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PREVENTIVE
OBSTETRICS
SUBMITTED TO
SUBMITTED BY
DRISYA.V.R.
1st year MSc Nursing
Asst.Professor
Govt.College of Nursing
Govt.College of Nursing
Alappuzha
Alappuzha
0
INDEX
Sl.
no:
CONTENT
Page no:
1.
INTRODUCTION
2.
3.
4-28
B. Intranatal Nursing
28-30
C. Postnatal Nursing
31-42
4.
RELATED RESEARCHES
43-47
5.
CONCLUSION
47-48
6.
BIBLIOGRAPHY
48
Central objective:
On completion of the class, the students acquire knowledge regarding
preventive obstetrics, appreciates its importance and use of this knowledge in the
areas of profession
Specific objective:
At the end of the class, the students are able to:
Define preventive obstetrics
Mention preventive obstetrics measures
Explain preventive obstetrics measures, antenatal nursing, Intranatalnursing,
postnatal nursing
INTRODUCTION
Preventive obstetrics is the concept of prevention or early detection ofparticular
health deviations through routine periodic examinations and screenings. The
concept of preventive obstetrics concerns with the concepts of the health and wellbeing of the mother and her baby during the antenatal, intranatal and postnatal
period. It aims to promote the well- being of mothers and babies and to support
sound parenting and stable families. Nursing care centered on health promotion and
health maintenance during pregnancy presents an excellent opportunity for nurses to
teach expectant mothers about normal changes expected and alert them to a variety
of risk factors.
PREVENTIVE OBSTETRICS
Preventive
Preventive is the term used to prevention or slowing the course of an illness or
disease. It is intended or used to prevent or hinder acting as an obstacle.
Obstetric
The branch of medicine that deals with the care of women during pregnancy,
childbirth and recuperative period following delivery is known as obstetric.
Preventive obstetric is the term for prevention of the complication that may
ariseduring antenatal, intranatal and postnatal period.
GOAL AND AIM
The goal of the preventive obstetrics is the delivery of a healthy infant by ahealthy
mother at the end of a healthy pregnancy. Pregnancy and child birth
normalphysiologic process that change from conception to delivery. The nurse has a
uniqueopportunity to reinforce the normal cycle of these processes and at the same
time, assessclient for problems that require intervention. Additionally, the nurse can
teach clientsabout the changes that are taking place and provide valuable guidance
for clients aboutwhen to seek guidance from health care providers.
The aim of preventive obstetrics is to ensure that through the pregnancy and
puerperium, the mother will have good health and that every pregnancy may
culminatein a healthy mother and a healthy baby.
Preventive Obstetric measure can be categorized into three main stages. Theyare as
follows:A. Antenatal Nursing
B. Intranatal Nursing
C. Postnatal Nursing
A.ANTENATAL NURSING
Antenatal care is the care during pregnancy. Antenatal care is essential even for
anormal and healthy, pregnant women for her own well- being and that of the baby
to beborn because no pregnancy and child birth is free from risk for both mother and
baby.
Ideally the care should start immediately after conception but practically as early
aspossible during the first trimester and should continue throughout the second and
thirdtrimesters.
OBJECTIVES OF ANTENATAL CARE
To promote, protect and maintain the health of the mother during pregnancy.
To detect high risk cases and give them special attention.
To foresee complications and prevent them.
To remove anxiety and dread associated with delivery.
To reduce maternal and infant mortality and morbidity.
To teach the mother elements of child care, nutrition, personal hygiene,
andenvironmental sanitation.
To sensitize the mother to the need for family planning, including advice
tocases seeking medical termination of pregnancy.
To detect and treat any abnormality found in pregnancy as early as possible.
Home visits are paid by the Female Health Worker or Public Health Nurse. If the
delivery is planned at home, several visits are required. The home visit will provide
opportunities to study the environmental and social conditions at home and to
provideprenatal advice. In the home environment, the woman will have more
confidence tomake an informed decision about home birth.
Immunization Against Tetanus
A pregnant woman must get two injections of Tetanus Toxoid during the period
between 16 36 weeks, at one month interval. These protect the mother and baby
bothfrom the risk of tetanus. The 2nd injection should preferably be given at least at
onemonth before delivery. If a woman is registered late then in that case even one
injectionwill do. If the woman is immunized earlier within three years of the
pregnancy, thenone booster dose will be enough.
Iron and Folic Acid and Vitamin A and D Supplementation
It is being found that 50-60 percent of pregnant women are anaemic due to iron
deficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to
take one tablet containing 60 mg of elemental iron and 500 mg of folic acid three
times dailyafter third month of pregnancy till 3 months after child birth if the mother
is foundhaving anaemia.
During pregnancy, the mother requires extra iron and folic acid due to changes
takingplace in the body and growth of fetus in the womb. Therefore each mother is
given onetablet of iron and folic acid twice a day for at least 100 days to prevent
anaemia inmother and to promote proper growth of fetus.
Anemia is common in pregnancy and low income group. It is a major cause
ofmaternal and fetal mortality.
Prevention of Anemia
Avoidance of frequent of child birth: At least two years an interval between
pregnancies is most necessary to replace the lost iron during childbirth process
andlactation. This can be achieved by proper family planning guidance.
Supplementary iron Therapy: Iron supplementary should be a routine after
thepatient becomes free from nausea and vomiting. Daily 60mg iron with 1mg
folicacid is a quite effective prophylactic procedure.
Dietary Prescription: Well-balanced diet rich in iron and protein should
beadvised. The food rich in iron are liver, meat, egg, green vegetables, green pea
bean, whole wheat etc.
10
Maternal Malnutrition
The usual care after eating should continue. A dental check is advisable and any
dental carries should be treated. Use soft brush in this period.
o Personal Cleanliness and Bathing
During pregnancy sweet glands become more active so advice for bathing at least
oncea day, preferably twice but clean clothes should be used daily. The need to
bath everyday and to wear clean clothes should be explained. The hair should
also be kept cleanand tidy.
3. REST AND SLEEP
A pregnant woman needs sufficient rest. She should do less and lighter work. She
musthave 8-10 hours of sleep every night. She needs to take short nap during the
day. As thepregnancy advances, the mother requires more frequent short rests
during the day. Sheshould avoid strenuous work, carrying heavy loads or weights
e.g. bringing water fromlong distance, drawing of water from a well etc.
Rest is important for the maintenance of good health. She should need adequate
rest andrelaxation. Relaxation of the mind produces relaxation of the muscle and
a relaxedlower uterine segment and pelvic floor makes it easier for the baby to be
born.
4. PHYSICAL WORK
A job provides satisfaction, self-esteem and confidence, along with financial
peace ofmind. Women can continue working in pregnancy as long as they wish
and as long asthey and their baby remain well. Avoidance of exposure to
hazardous chemicals, Smoky environments, excessive lifting and exercise and at
least an 8- hour rest at nightis recommended.
5. EXERCISE
Exercise in pregnancy should be encouraged; through with advancing gestation
physicalconstraints may limit sporting activities. Exercise can improve
cardiovascular function,lower blood pressure and improve self- esteem and
confidence. Swimming is oftenhelpful throughout pregnancy especially with
advancing gestation as it is essentially anon-weight bearing exercise. It is
advisable however to avoid hyperthermia, dehydrationand exhaustion.
Consider decreasing weight bearing exercises like jogging, running and
concentrateon non-weight bearing activities such as swimming, cycling or
stretching. Advise her toavoid risky activities such as surfing, mountain climbing
and skydiving. Limit activityto shorter intervals. Exercise for 10 to 15 minutes; rest
for 2 to 3 minutes, then exercisefor another 10 to 15 minutes. The exercise should
be decrease as the pregnancy progresses.
6. COMFORTABLE CLOTHING AND SHOES
14
It is advisable to wear loose and comfortable cotton clothes, not too tight such as
blouseor cholo.Brassier which supports the breasts should be advised, but must
not be tootight so as to flatten the nipples but lift the breast well. A support for the
abdomen issometimes required, especially in a multigravida who has pendulous
abdomen so thepregnant mother should advise to support her whole abdomen with
a light belt.Pregnant should avoid high heeled shoes. She should wear flat shoes to
maintain centerof balance and to prevent backache to some extent.
7. SMOKING
It should be strongly discouraged in pregnancy. The target should be cessation
ofsmoking, but if not possible, then cutting down to as few as possible is
advisable.Smokers (especially those smoking > 20/day) have a slightly higher
incidence ofmiscarriage, a slightly higher perinatal death rate (20% increase in
20/day smokers, and35% increase if > 20/day) and babies of smokers are 150 to
300 gram lighter than babiesof nonsmokers. Furthermore, smoking is associated
with a three-fold increase in risk ofcleft palate. Smoking during pregnancy,
however, doesnt affect long term mental ormotor development. The mechanisms
involved include interference of carbon monoxidewith oxygen transfer, shifting the
oxygen dissociation curve to the left in both maternaland fetal hemoglobin and
reduced intervillous blood flow. Appropriate advice andsupport should be provided
for women who wish to try stopping smoking, with optimum benefits achieved if
smoking is stopped prior to conception.
Smoking should be cut down to a minimum, as heavy smoking by the mother can
resultin babies much smaller than average size due to placental insufficiency. The
perinatalmortality amongst babies whose mothers smoked during pregnancy is
between 10 to 40percent higher than in nonsmokers. Mothers who are moderate to
heavy drinkers(alcohol) become pregnant, have greater risk of pregnancy loss and if
they do not abort,their babies may have various physical and mental problems.
Heavy drinking has beenassociated with fetal alcohol syndrome (FAS), which
includes intrauterine growthretardation and developmental delay. Advice should
also be given about dental care andsexual behavior during pregnancy. Sexual
intercourse should be restricted during thelast trimester of pregnancy.
8. ALCOHOL
An expectant mother should be advised to avoid drinking alcohol as drinking
alcohol isinjurious to the fetus and also to her own health. It leads to low birth
weight andretardation.
Pregnant women are advised to limit alcohol consumption and a consumption 20
gm. /week (2 units) appears to be generally safe. Heavy alcohol consumption
15
(greater than12 units or 120 gm. / day) is associated with the development of fetal
alcohol syndrome. The syndrome is characterized by growth retardation,
neurological and structural defects (facial, cardiac, joints). A lesser degree of
alcohol consumption but still greater than 8 units/day may also be associated with
fetal alcohol syndrome as well as other associated features such as increased risk of
miscarriage and reduced head circumference.
9. BREAST CARE
The mother should advice to clean her breast during bath. If the nipples are
anatomically normal, nothing is to be done beyond ordinary cleanliness. But if
nipples are retracted, correction should be done. For this mother is taught about
nipple care. She should wash her breast, with soap and water. To toughen the
nipples, it should be massaged by using soap and water and then roll them between
the forefinger and thumb and draw them out every day during the last two months.
This should be done three times a day. After massage, the nipples should be dried
and an oily substance applied to make them supple. Advise mother to wear a wellfitting and supportive brassiere.
10. DRUGS
The mother should be advised not to take any medicine unless it is prescribed by
thedoctor. As far as possible, medicine should be avoided for the three months
unless veryessential. The mother must inform to the doctor about pregnancy when
seeking anytreatment from the doctor or health personnel.
The use of drugs that are not absolutely essential should be discouraged. Certain
drugs taken by the mother during pregnancy may affect the fetus adversely and
cause fetalmalformations. The classical example is thalidomide, a hypotonic drug,
which causeddeformed hands and feet of the babies born. The drug proved most
serious when takenbetween 4 to 8 weeks of pregnancy. Other examples are LSD
which is known to causechromosomal damage, streptomycin which may cause 8th
nerve damage and deafness inthe fetus, iodine- containing preparations which may
cause congenital goiter in thefetus. Corticosteroids may impair fetal growth, sex
hormones may produce virilism, andtetracycline may affect the growth of bones
and enamel formation of teeth. Anestheticagents including pethidine administered
during labour can have depressant effort on thebaby and delay the onset of effective
respiration. Later still in the puerperium, if themother is breast- feeding, there are
certain drugs which are excreted in breast milk. Agreat deal of caution is required in
the drug intake by pregnant women.
11. RADIATION
16
14. TRAVEL
The mother should be instructed to avoid travel during the first three and last
twomonths of pregnancy especially long and tedious journey.If traveling for long
distances, periods of activity and rest should be scheduled. Whilesitting, the woman
can practice deep breathing, foot circling, and alternating contractingand relaxating
different muscle groups. Fatigue should be avoided.
15. REPORTING OF UNTOWARDS SIGNS AND SYMPTOMS
The expectant woman must be instructed to report to health personnel the
followingsigns and symptoms.
Unusual pain, bleeding from vagina.
Swelling in the feet, hands or face
Headache, dizziness, blurred vision at times. These symptoms indicate the
onset ofhigh blood pressure which is very dangerous and can prove fatal if
timely care is notgiven.
High fever
Babys movements not being felt.
Any other sigh or symptom which is considered unusual.
16. CHILD CARE
The mother should be educated on various aspects of child care. Mother craft
classescan be arranged if possible to train the mother regarding care during
pregnancy, childbearing, breast feeding, weaning and child nutrition, growth and
development of child,clothing, immunization, care during minor ailments, family
planning etc.Mothers attending antenatal clinics must be given mother craft
education that consistsof nutrition education, hygiene and childrearing, childbirth
preparation and familyplanning information.
17. FOLLOW UP VISITS
It is important that mother must be educated about the need for regular visits and
propercare during pregnancy. They must be convinced to pay follow up visit and
follow theinstructions regarding diet, personal hygiene, rest, physical work,
exercise, smoking,drinking, and protection from infections, sexual activities, and
travel etc.so as topromote health of both mother and the growing fetus.
18. WARNING SIGNS
The mother should be given instructions that she should report immediately, any of
thefollowing warning signals like swelling of the feet, convulsions, headache,
blurring ofthe vision, bleeding or discharge per vagina and any other unusual
symptoms.
3.Specific Health Protection
18
21
trisomy-21 andsevere neural tube defects. Women aged 35 years and above, and
those who alreadyhave an afflicted child are at high risk.
4.Preparing for Confinement
The preparation for safe delivery is very important. It should be done well in
advance toavoid any type of difficulty or emergency which might occur at the time
of delivery.The health personnel discuss with the couple and may be other members
of the familyabout the alternative suitable place for confinement which includes
home, health centreor hospital. The decision will depend upon the health status of
both mother and thefetus, risk factors and environmental conditions at home.High
risk mother must be delivered at primary health center, first referral unit orhospital
at the discretion of doctor. However a normal healthy mother may be deliveredat
home. But she must be delivered by a trained birth attendant, female health worker
(ANM),health supervisor ( LHV) to protect the life of both mother and the baby
andprevent them from any infection especially tetanus. It is important to arrange
transportin advance for transportation of mother to hospital or first referral unit
duringemergency, if any. The following preparation should be done for delivery at
home.
Preparation of the room or some place for confinement: The room or some place in the room should be clean, ventilated and well
lighted. Itshould be kept ready beforehand.
Preparation of the articles include:
Washed and sun-dried sufficient old clothes.
Washed and sun-dried bed sheet, blanket and mat.
Stove/gas burner, match box.
Large vessel with lid, bucket and a mug, a parat and a tasla.
A lantern and a torch
A new razor blade, clean cotton
A plastic sheet to be placed over the mattress to protect it from fluid
andblood.
Washed and sun dried linens or towel to wrap the baby.
Arrangements to burn or deep bury the placenta.
The trained Dai should be ready with her own kit for delivery. It should have
thefollowing articles:
a) Enema can two bowels and one kidney tray, torch, a pair of scissors.
b) Clean gauze pieces, cord ligatures, mucus sucker and baby weighing spring
balance.
c) Drugs and antiseptic like injection methergin, methylated spirit.
22
Antenatal care in the first trimester starts with a visit to the GP after a missed
period andconfirmation of pregnancy. It also provides an ideal opportunity for the
woman todiscuss any anxieties she may have.
8. Hematological Investigations
These include hemoglobin estimation and a complete blood picture if indicated.
Bloodgroup determination and antibody screen is also performed to identify rhesus
negativewomen who will need prophylaxis against rhesus isoimmunization.
Full blood count
This is the most commonly performed hematological investigation in
pregnancy.Pregnancy is associated with a physiological dilutional anemia due to
greater increasein plasma volume than red cell mass and therefore the lower limit
for a normal Hemoglobin is10.5 g/dl in pregnancy as opposed to 11.5g/dl in the
non-pregnant female. Many womenenter pregnancy with a low iron reserve and
therefore if anemia is detected inpregnancy it should be appropriately investigated
by assessment of ferritin, total ironbinding capacity (TIBC), serum and red cell
folate and B12 levels based on the bloodpicture. The most common cause of
anemia in pregnancy is iron deficiency anemia. FBC estimation is performed 4 8
weekly in the second half of pregnancy and low hemoglobin on admission in
labour is an indication for sending a specimen to the lab for group and save in case
of intrapartum or postpartum bleeding.
Blood grouping and screening for antibodies
Blood grouping at booking, enables the determination women who are rhesus
negativeand therefore may be at risk of rhesus isoimmunization. The incidence of
rhesus diseasehas dramatically fallen over the last thirty years the introduction of
anti Dadministration. Despite screening at 28 and 34 weeks or after any potential
sensitizingevent and administration of prophylactic anti D at these times, a small
number of RhDnegative women still develop anti-D antibodies because of small
silent hemorrhagespredominantly in the third trimester or because of failure of
timely administration ofanti D immunoglobulin. Screening for red cell antibodies
should be repeated in allwomen in early pregnancy in subsequent pregnancies,
even if rhesus positive, as theremay be other clinically significant antibodies as a
consequence of previous pregnancyor blood transfusion. An antibody screen is
performed to detect the presence ofantibodies that may put the baby at risk of
hemolytic disease or result in difficultieswith cross- matching blood for the mother
if required at any age of pregnancy, labour orpostnatally. If antibodies are detected,
the titer is determined and subsequent samplestaken for further estimation at
appropriate time interval.
24
Constipation
Itching
Leg Cramp
Morning Sickness ( Nausea and Vomiting)
Nausea and vomiting especially in the morning, soon after getting out of bed,
areusually common in primigravida. It may due to emotional factors, fatigue,
andcarbohydrate metabolism. So it is important to prevent it from getting worse
ashyperemesis gravidarum may occur.
Prevention
Identify the particular odour of foods that are most upsetting and avoid the
odour ofcertain foods, because women are very sensitive to smells.
Eat dry crackers or bread 15 minutes before getting up from the bed in the
morning.
Advice to consume small frequent meal (every 2 hours if possible).
Avoiding spicy and greasy food and consuming protein snack at night
Advice to take light and dry snacks instead of heavy meal.
Avoid brushing after eating.
Keep room well ventilated for fresh air.
Indigestion
Indigestion often occurs after eating too much of heavy or greasy food or
drinking toomuch of alcohol. It is characterized by discomfort or a burning
feeling in the mid chest or stomach.
Prevention
Avoid fatty, greasy and spicy foods
Eat small frequent meals instead of the usual three meals.
Avoid alcohol, coffee and cigarettes.
Eat boiled foods.
Varicose veins
Varicose veins are enlarged superficial veins on the legs; vulva and anus varicose
veinsare disorder of the second and third trimesters. It is due to increased
maternal age,excessive weight gain large foetus and multiple pregnancies etc.
Prevention
Exercise regularly and avoid tight clothes.
Avoid standing for long time and sitting with feet hanging down.
Lift the legs up with extra pillows while sitting, resting or sleeping.
Avoid crossing legs at the knees because it provides the pressure on her
veins.
{
{
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26
Backache
This is common problem during pregnancy especially in the third trimesters.
Slightbackache may be due to faulty posture and is more common in
multigravida. It may bedue to fatigue, by lifting heavy objectives and poor
postures, fatigue.
Prevention
Take adequate rest in proper position and posture.
Wear supportive shoes with low heels, avoid high heels shoes.
Do prenatal exercise and do not gain more weight.
Avoid excessive twisting, bending, stretching and also excessive standing
orwalking.
Fainting ( Syncope)
It is the disorder common in second and third trimester. Many pregnant
womenoccasionally fall to faint, especially in warm and crowed areas. It is due to
anemia,sudden changes of position, standing for long periods in warm and crowd
areas.
Prevention
Avoid prolonged standing.
Rest in side lying position in left lateral to prevent supine hypotension.
Eat regularly iron containing food and plenty of liquid.
Advice to be alert for safety.
Heartburn
Heartburn is a burning sensation in the mediastinal region due to back flow
(regurgitation) of acid contents into the esophagus often accompanied by bad test
inthe mouth.
Prevention
Avoids foods known to cause gastric upset.
Avoid greasy, fried foods, coffee, alcohol and cigarettes.
Advice to take small frequent meal, but eat slowly.
Take adequate rest in sleeping with more pillows on propped position.
Explain that this is related to pregnancy and the problem disappears after
pregnancy.
Constipation
Constipation is a condition of infrequent, irregular and difficulty in passing stool
or thepassing of hard stool. It is common during pregnancy. It is due to lack of
physicalactivity or exercise, decrease fluids, oral iron supplement, pressure of
enlarging uteruson intestine.
27
Prevention
Encourage to maintain bowel habit, going to toilet at same time every day
and toiletwhen having the urge.
Encourage to drinking adequate liquid ( of least 200ml per day)
Advice to eat in regular schedule.
Encourage eating fruits, vegetables, gains and roughage in the diet.
Advice to do regular daily exercise.
Itching
Itching is an unpleasant cutaneous sensation that provokes a desire to scratch the
skin. Itmay be due to poor personal hygiene, heat rash, minor skin disease.
Prevention
Advice to take daily bath.
Advice to wear non- irritating clothes, cotton panty.
Leg Cramps
Leg Cramps are painful muscle spasm in the muscles. They occur most
frequently atnight but may occur at other times. Leg cramps are more common in
the third trimester.
Prevention
Advice to take enough calcium ( milk, green leafy vegetables)
Advice to take warm bath to improve the circulation.
Advice to do exercise regularly.
Strengthen the legs, point or pull toes upward towards the knees
B. INTRANATAL NURSING
Childbirth is a normal physiological process, but complications may arise.
Septicemiamay result from unskilled and septic manipulations, and tetanus
neonatorum from the use of unsterilized instruments. The need for effective
intranatal care is therefore indispensable, even if the delivery is going to be a normal
one. The emphasis is on thecleanliness. It entails clean hands and fingernails, a
clean surface for delivery, cleancutting and care of the cord, and keeping birth canal
clean by avoiding harmfulpractices. Hospitals and health centers should be equipped
for delivery with midwiferykits, a regular supply of sterile gloves and drapes,
towels, cleaning materials, soap andantiseptic solution, as well as equipment for
sterilizing instruments and supplies.
Objectives of Intranatal Care
1. To delivery with minimum injury to the newborn and mother.
28
The prolonged labour may occur due to fault in power, fault in passage and fault in
passenger etc. so the preventive measures should be done before the delivery.
Preventive Measures
Antenatal and early intranatal detection of the factors likely to produce
prolongedlabour and then to institute its appropriate management.
Use partograph to record fetal, maternal and labour condition and maintain
itmeticulously which help in early detection
Selective and judicious augmentation of labour can be employed by low rupture
ofthe membranes followed by the oxytocin drip.
Keep vigilant during labour and appropriate management should promptly
beinstituted if the first is delayed as evidence from the cervicograph and there
istendency of slow descent in the second stage.
Abnormal Uterine Contraction
Abnormal uterine contraction may be due to obstructed labour due to contracted
pelvic,congenital malformation of fetus like hydrocephalus, brow presentation,
neglectedtransverse lie etc.
Preventive Measures
Periodic and careful antenatal visits.
Early detection of factors affecting labour, such as passage or passenger
duringantenatal or early intranatal period to place an appropriate method of
delivery.
Careful and constant observation of the mature of uterine contraction and
keeprecord meticulously in partograph
Obstructed Labour
The obstructed labour may be due to contracted pelvis, cephalopelvic
disproportion,congenital malformation of the fetus etc.
Preventive Measures
1. Antenatal
Risk assessment in the antenatal clinic:
Past medical and obstetrical history of obstructed labour.
Assessment of pelvis for bony and soft passage anomalies.
Abdominal examination for engagement.
Ultrasonography is employed to assess fetal anomalies.
Refer the mother in an appropriate place or hospital where the choice of
safedelivery is contemplated
2. Intranatal
Keep continuous vigilance by using partograph.
30
32
The three important factors i. e. trauma, sepsis and anemia should be prevented and
tobe treated effectively after detection. Dehydration during delivery should be
promptlycorrected.Leg exercise and early ambulation are encouraged especially
following operativedelivery.
Postpartum Hemorrhage
Postpartum hemorrhage is the condition of excessive bleeding from the genital tract
atany time following the babys birth up to 6 weeks after delivery. It may occur at
anytime that is during third stage of labour, within 24 hours or after 24 hours of
labour.
PREVENTIVE MEASURES OF PPH
SL.N
1.
2.
3.
4.
5.
Antenatal Period
Intranatal Period
Ensure regular
antenatal care
Postnatal Period
6.
7.
third
stagee.g.
Immediate oxytocin
Control Cord Traction
Uterine Massage
In all cases of the
induced or augmented
labour byoxytocin
should be kept
oncontinuous
oxytocininfusion for
at least onehour after
delivery.
Examine the
placenta and
membranes and cord
carefully
Encourage and
assistto empty the
bladderperiodically
and forambulation.
with thenew mother role especially in the first pregnancy. Body image changes and
unconsciousintrapsychic conflicts related to pregnancy, childbirth, and motherhood
becomeactivated. It is no wonder that 25% to %0% of the pregnant women develop
mildpsychological symptoms in the puerperal period. The commonest type is the
milddepression and irritability known as the postnatal blues.
Prevention
Advice to the family and relatives to deal properly with the postnatal situation
of thepostnatal mother.
Help her to feed the baby and assist her in domestic duties.
Advice to provide sufficient rest, balance diet and to give love and care.
2.Restoration of mother to optimum health
The second objective of postnatal care is to provide care whereby, the woman
canrecuperate physically and emotionally from her experience of delivery. The broad
areasof this care fall into three divisions:
a) Physical
Postnatal Examinations
Soon after delivery, the health checks-ups must be frequent, i.e., twice a day during
thefirst 3 days, and subsequently once a day till the umbilical cord drops off. At each
ofthese examinations, the health personnel should checks temperature, pulse
andrespiration, examines the breasts, checks progress of normal involution of the
uterus,examines lochia for any abnormality, checks urine and bowels and advises or
perinealtoilet including care of the stitches, if any. The immediate postnatal
complications, puerperal sepsis, thrombophlebitis, secondary haemorrhage should be
kept in mind. Atthe end of 6 weeks, an examination is necessary to check up
involution of the uteruswhich should be complete by then. Further visits should be
done once a month during the 6 months and thereafter once in 2 or 3 months tills the
end of one year.
In rural areas only limited postnatal care is possible. Efforts should be made by
theFHWs to give at least 3 to 6 postnatal visits. The common conditions found
onexamination during the late postnatal period are sub involution of uterus,
retroverteduterus, prolapse of uterus and cervicitis. Postnatal examination offers an
opportunity todetect and correct these defects.
Anemia
Routine hemoglobin examination should be done during postnatal visits, and
whenanemia is discovered, it should be treated. In some cases it may be necessary
tocontinue treatment for a year or more.
36
Nutrition
Though a malnourished mother is able to secrete as much breast milk as wellnourishedone, she does it at the cost of her own health. The nutritional needs of the
mother mustbe adequately met. Often the family budget is limited, the mother
should be shown themeans how she can eat better with less money.
Postnatal Exercises
Postnatal exercises are necessary to bring the stretched abdominal and pelvic
musclesback to normal as quickly as possible. Gradual resumption of normal house
holdduties may be enough to restore ones figure.
b) Psychological
The next big area of postnatal care involves a consideration of the psychological
factorspeculiar to the recently delivered woman. One of the psychological problems
is fearwhich is generally borne of ignorance. Other problems are timidity and
insecurityregarding the baby. If a woman is to endure cheerfully the emotional
stresses ofchildbirth, she requires the support and companionship of her husband.
Fear andinsecurity may be eliminated by proper prenatal instruction. The so called
postpartumpsychosis is perhaps precipitated by birth, and it is rather uncommon.
c) Social
It has been said that the most important thing a woman can do is to have a baby. This
isonly part of the truth. The really important thing is to nurture and raise the child in
awholesome family atmosphere. She, with her husband, must develop her own
methods.
3.Breast feeding
Postnatal care offers an excellent opportunity to find out how the mother is
gettingalong with her baby, particularly with regard to feeding. For many children
breast milkprovides the main source of nourishment in the first year of life. In some
societies,lactation continues to make an important contribution to the childs
nutrition for 18thmonths or longer.
Postnatal care includes helping the mother to establish successful breast-feeding.
Formany babies breast milk provides the main source of nourishment in the first
year oflife. When the standard of environmental sanitation is poor and education
low, thecontent of feeding bottle is likely to be as nutritionally poor as it is
bacteriologicallydangerous. It is therefore very important to advise mothers to
provide exclusive breastfeeding in the initial months.
4.Respiratory Distress Syndrome and Neonatal Problems
Asphyxia Neonatorum
37
Pregnancy spacing
Mother and family members should be advised about the importance of
pregnancy spacing. There should be at least the gap of 2 years of pregnancy
spacing.
Health checkup for mother and baby
Regular health checkup and follow up for mother and baby is very important
with in puerperium period.
Prevention of infection in the baby
Midwives have an important role to play in creating a safe environment that
decreases the chance of infant acquiring infection after birth.
Encouraging and assisting the mother for breast feeding thus increasing
infantsimmune protection.
Ensuring careful and frequent hand washing by all careers; the
simpleprocedure remains the single most important method of preventing
the spread of infection in infants.
Rooming in the infants with his/ her mothers.
Adequately spacing costs when infants are in the nursery with other infants.
Always use individual equipment for each infant.
Avoiding any irritation or trauma to the infants skin and mucous membrane,
asintact skin provides a barrier against infection.
Controlling extra visitor.
Birth registration
RELATED RESEARCHES
1. Care during labor and birth for the prevention of intrapartum-related
neonatal deaths: a systematic review and Delphi estimation of mortality
effect.
Lee AC1, Cousens S, Darmstadt GL, Blencowe H, Pattinson R, Moran NF, Hofmeyr
GJ, Haws RA, Bhutta SZ, Lawn JE.
Abstract
BACKGROUND:
Their objective was to estimate the effect of various childbirth care packages on
neonatal mortality due to intrapartum-related events ("birth asphyxia") in term
babies for use in the Lives Saved Tool (LiST).
METHODS:
They conducted a systematic literature review to identify studies or reviews of
childbirth care packages as defined by United Nations norms (basic and
43
comprehensive emergency obstetric care, skilled care at birth). They also reviewed
Traditional Birth Attendant (TBA) training. Data were abstracted into standard
tables and quality assessed by adapted GRADE criteria. For interventions with low
quality evidence, but strong GRADE recommendation for implementation, an
expert Delphi consensus process was conducted to estimate cause-specific
mortality effects.
RESULTS:
They identified evidence for the effect on perinatal/neonatal mortality of
emergency obstetric care packages: 9 studies (8 observational, 1 quasiexperimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasiexperimental). Studies were of low quality, but the GRADE recommendation for
implementation is strong. Our Delphi process included 21 experts representing all
WHO regions and achieved consensus on the reduction of intrapartum-related
neonatal deaths by comprehensive emergency obstetric care (85%), basic
emergency obstetric care (40%), and skilled birth care (25%). For TBA training
they identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1
quasi-experimental, 5 observational). There was substantial between-study
heterogeneity and the overall quality of evidence was low. Because the GRADE
recommendation for TBA training is conditional on the context and region, the
effect was not estimated through a Delphi or included in the LiST tool.
CONCLUSION:
Evidence quality is rated low, partly because of challenges in undertaking RCTs for
obstetric interventions, which are considered standard of care. Additional
challenges for evidence interpretation include varying definitions of obstetric
packages and inconsistent measurement of mortality outcomes. Thus, the LiST
effect estimates for skilled birth and emergency obstetric care were based on expert
opinion. Using LiST modelling, universal coverage of comprehensive obstetric
care could avert 591,000 intrapartum-related neonatal deaths each year. Investment
in childbirth care packages should be a priority and accompanied by
implementation research and further evaluation of intervention impact and cost.
2. Pelvic floor exercises during and after pregnancy: a systematic review of
their role in preventing pelvic floor dysfunction.
Harvey MA1.
Abstract
OBJECTIVE:
To review the literature on the origin, anatomical rationale, techniques, and
evidence-based effectiveness of peripartum pelvic floor exercises (PFEs) in the
44
prevention of pelvic floor problems including urinary and anal incontinence, and
prolapse.
DATA SOURCES:
Literature was reviewed for background information. MEDLINE, EMBASE,
CINAHL, and proceedings of scientific meetings were searched for evidencebased data. A comprehensive literature search was performed to find all studies
that involved the use of antepartum and/or postpartum PFEs. For the MEDLINE
(1966 to 2002) and CINAHL (1980 to 2002) searches, the following key words
were used: urinary incontinence (prevention and control, rehabilitation, therapy),
fecal incontinence, exercise or exercise therapy, Kegel, muscle contraction,
muscle tonus, muscle development, pelvic floor, pregnancy, puerperium, puerperal
disorders. For the EMBASE (1980 to 2002) search, the following key words were
used: micturition disorder (prevention, rehab, disease management, therapy), fecal
incontinence, labour complication, pregnancy disorder, puerperal disorder,
antepartum care, pregnancy, kinesiotherapy, exercise, pelvic floor, bladder. A
manual search was performed of available abstracts presented at the annual
scientific meetings of the International Continence Society (1997, 1999 to 2002),
American Urogynecologic Association (1997 to 1998, 2000 to 2002), and
International Urogynecological Association (1997, 1999 to 2002). Twelve studies
evaluating the role of antepartum PFE were found, of which 3 randomized
controlled trials (RCTs) comparing PFEs for the prevention of urinary
incontinence to controls were included. Twelve studies evaluating postpartum
PFEs for prevention of urinary incontinence were reviewed, of which 4 RCTs
were included. Five studies evaluating postpartum PFEs for the prevention of anal
incontinence were reviewed, of which 4 RCTs were included. Participants in the
studies were primiparous women. DATA
RESULTS:
Antepartum PFEs, when used with biofeedback and taught by trained health
care personnel, using a conservative model, does not result in significant shortterm (3 months) decrease in postpartum urinary incontinence, or pelvic floor
strength. Postpartum PFEs, when performed with a vaginal device providing
resistance or feedback, appear to decrease postpartum urinary incontinence and to
increase strength. Reminder and motivational systems to perform "Kegel"
exercises are ineffective in preventing postpartum urinary incontinence.
Postpartum PFEs do not consistently reduce the incidence of anal incontinence.
CONCLUSION:
45
CONCLUSION
Preventive obstetrics is the concept of prevention or early detection of
particularhealth deviations through routine periodic examinations and
screenings. The concept ofpreventive obstetrics concerns with the concepts of
the health and well-being of themother and her baby during the antenatal,
intranatal and postnatal period. It aims topromote the well- being of mothers and
babies and to support sound parenting andstable families. Nursing care centered
on health promotion and health maintenanceduring pregnancy presents an
excellent opportunity for nurses to teach expectantmothers about normal
changes expected and alert them to a variety of risk factors.Preventive Obstetric
measure can be categorized into three main stages. They are asfollows: Antenatal Nursing
Intranatal Nursing
Postnatal Nursing
BIBILIOGRAPHY.
Lowdermilk & PerryCashion (2006); MATERNITY NURSING,
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Hiralal Konar (2011); D.C. DUTTAS TEXTBOOK OF OBSTETRICS;
7th edition; NCBA publication;PP :95-113
Basavanthappa
B.T;ESSENTIALS
OF
MIDWIFERY
&
OBSTETRICAL, Jaypee Publications (New Delhi);PP: 130-228.
Krishna Kumari Gulani (2005); COMMUNITY HEALTH NURSING
(PRINCIPLES AND PRACTICES), 1st Edition, Maternal and Child
Health, Kumar Publishing House, page no.: 354 366.
K.Park (2007) PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL
MEDICINE; 21stedition; Bhanot publication;PP: 415 422.
Susan Scott Ricci (2013); ESSENTIALS OF MATERNITY, NEWBORN
AND WOMENS HEALTH NURSING; 3rdedition; Lippincott
publication; PP: 38-52.
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www.cinhal.com
www.medline.com
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