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Introduction
Prenatal care (care of the woman during pregnancy, before labour) is credited with the reduction of perinatal mortality over the last 55years. The earlier prenatal care is begun, the better. This provides an opportunity fro the health care provider to obtain baseline data on physical assessments and laboratory test results
Beckmann, Buford, and Witt (2000) found that the cost and length of time at an appointment were the major barriers to prenatal care. Anticipatory guidance ( providing information, teaching or guidance to a client in anticipation of an expected event) is probably the most important aspect of prenatal care. It is based on the assessment of the mother and fetus and knowledge of the normal process of pregnancy an possible complication. VAC1
Slide 3 VAC1
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Objectives
At the end of the theme the student should be able to: Define the key terms List the broad objectives and components of prenatal care Describe initial assessments- history, physical examination and risk assessment Calculate expected date of delivery ad gestational age Identify necessary laboratory tests fro risk assessments Discuss general health habits Describe the common discomforts of pregnancy and its management.
Communication
Nurse requires skilled communication techniques in order to promote sensitive exchange of information between members of the health team and the pregnant woman and her family. Listening skills involve attending to or focusing on what the woman is saying, considering the words, phrases and general content of what is said (Morrison & Burnard 1997) Non- verbal responses facial expression, body position, eye contact, proximity to the nurse and touch will affect the flow of information between the woman and nurse Promote communication by: gentle questioning, open ended statements and reflecting back key words from what is said to encourage and facilitate exploration of what is said (SteinParbury 1993)
First impressions
Nurses can gain much from the initial observation and assessment of a woman at the start of their first meeting Woman may be distressed at the: 1. Long wait 2. prospect of unpleasant experiences of previous booking visit 3. Failure of contraception unresolved anger may lead to unresponsive behavior Carry out assessment sensitively and enable the woman to express her concerns about this or previous experiences of pregnancy or birth
Initial history
Provides health care provider with the client s past and present health. 1. Personal information -age - education level - race or ethnic group -occupation -stability of living conditions - marital status
Economic level Housing Any h/o emotional or physical or physical deprivation (herself or children) Overuse or under use of health care systems Acceptance of pregnancy Personal preferences about the birth (expectations of both the woman and partner, presence of others and so on) Plans for care of child following birth.
Past pregnancies
no. of pregnancies no. of abortions, spontaneous or induced no. of living children h/o preceding pregnancies: length of pregnancy, length of labour and birth, type of birth Woman s perception of the experience, complications Perinatal status of previous children: apgar scores, birth weights, general development complications, feeding patterns Prenatal education classes
Occupational history Occupation Does she stand whole day? Any heavy lifting? Exposure to harmful substances Provision for maternity leaves Opportunity for regular breaks
Partners history Presence of genetic disease or conditions Significant health conditions Previous or present alcohol intake, drug use, tobacco use Occupation Education level Attitude towards pregnancy
Nurse must enquire about: The normal cycle and amount of bleeding in order to estimate the reliability of the calculation.
Calculating EDD by dates is sometimes confirmed by assessing uterine size, or more commonly by early ultrasound scan.
Screening tests
Full blood count: -RBC/ WBC Hemoglobin (Hb) Blood type -A,B,AB or O RH factor:- positive or negative - If negative- do indirect coomb s test (repeat at 28wks and 32 weeks) Blood glucose for woman who: - Have family H/o diabetes - Had previous large babies b/weight> 4.0kg - H/o abortions, stillbirth - Have a weight of >80kg - Age of 35yrs>
VDRL (syphilis test) - Should be negative - Hepatitis B surface antigen - Positive state indicates either active hepatitis or carrier ( counsel mother)
HIV test should be negative Urinalysis: - note: color, ketones, albumin, glucose (use uristix)
Consider if the individual could be at risk: - Unprotected sex with an infected partner - Being transfused with blood or other blood products that have not been screened for HIV infection - Injected with used needles and syringes Post test counseling: - After results are back and patient is given the result
Negative result: does not necessarily mean she is negative if she feels she could have been exposed to the virus Positive result: a protocol to follow - HIV counselor/ nurse - Consultant/ senior registrar OBGYN - Pediatrician ( work as a team for subsequent follow up)
Nutritional needs
Dietary advice is usually given by: - Health educator/ nurse educator or dietician at initial visits and subsequent visits - Supplementary iron: Feso4 tablets and folic acid tablets which prevent neural defects in the fetus Advice woman to eat locally grown vegetables Avoid processed foods which have no nutritional value Need for adequate intake of foods reach in calcium- for healthy bones and teeth. Make suggestions for a more adequate dietary intake considering cultural and personal preferences
Prenatal care
Lecture 2
Objectives
At the end of this lecture, students would be able to: Discuss general health habits during pregnancy List common discomforts and management during pregnancy Discuss benefits of breastfeeding Perform physical examination and risk assessment
BREAST CARE
-Proper support is important whether woman is planning to breastfeed or bottlefeed. - Proper fitting maternity or nursing bra promotes comfort, retains breast shape, and prevents back strain if breasts are large. Cleanliness of breastsWash with water (soap removes the natural lubricant provided by the Montgomery s tubercles) Leaking breasts- advice woman to wear a nursing pad inside her bra Encourage woman to rub the leaking fluid onto the nipple to lubricate the skin
PERSONAL HYGIENE Daily bath is importantpregnant woman generally have increased perspiration and vaginal mucous. Douching not encouragedit changes the pH of the vagina and alters normal flora
CLOTHING An important aspect of the woman self image (in pregnancy ,the physical changes may have a negative impact on her self image) Clothes should be attractive, loose and nonconstricting Recommend low- heeled shoes ( higher heeled shoes aggravates backache) Edematous feet in late pregnancy- advice to wear a larger shoe size
1. 2. 3.
Regular physical activities e.g. walking, swimming, cycling Avoid fatigue Exercises in pregnancy contraindicated if the woman has: PIH Premature rupture of membrane Preterm labour during prior or present pregnancy
4. Incompetent cervix 5. Persistent second or third trimester bleeding 6. Fetal growth restriction *Adequate rest and sleep is very important ( especially during the first and last trimester.
EMPLOYMENT
How long to work depends on : The type of work done by the woman How the pregnancy is progressing Whether there are teratogenic hazards in the work environment If there are obstetrical or medical complications of pregnancy *Rest periods should be allowed during workday. If woman is subjected to physical strains or fatigue Maternity leave certificate: issued by a medical officer, usually 84 consecutive days, employer calculates resumption date. - Issued at not less than 6 weeks before EDD.
TRAVEL
-Need not be restricted if pregnancy is non complicated. Traveling by car: client to be encouraged to stop every 2 hours and walk around for 10 minutes or so Wear seat belt, both shoulder and lap, lap belt to be snugly below abdomen Advice woman to empty bladder (decreases possible bladder trauma in case of accident. For long trips- advice on travel by air (airlines and cruise ships need clearance by the OBGYN registrar if client is safe to travel by air< 35 weeks)
DENTAL CARE Regular oral hygiene should continue Dental care performed during pregnancy clearance is given by OBGYN registrar Oral health lectures facilitated by oral health team daily
SEXUAL ACTIVITY
In a healthy pregnancyno need to limit Contraindicated only: If women has history of preterm labour There is bleeding The membranes have ruptured barrier protection- to prevent sexually transmitted diseases Sexual desire- during the first trimester due to fatigue, nausea, vomiting and breast tenderness. in 2nd trimester-sexual desire is more than when not pregnant 3rd trimester due to discomforts of fatigue, dyspnoea, urinary frequency, painful pelvic ligaments
Preparation of environment
Large airy room (accommodate both mothers and partners) screens Thin mattresses for clients, covered (for at least 10 mothers) Extra draw sheets Hand-outs for mothers Mothers are given an orientation tour of the maternity facilities at the end of the birth preparation class.
Heartburn
Prenatal exercises
FEAR- TENSION PAIN SYNDROME (proposed by Dr. Grantly DICK-READ Classes based on the physiology of birth, exercises for: the abdomen& perineal muscles,& relaxation techniques. Classes also focus on teaching the woman to visualize what is happening inside her body, and to use abdominal breathing and not chest breathing.
Dr. Robert Bradley ( focused on environmental variables) - Husband or partner support is most important
In labour: diversionary activities are encouraged 1. When not walking tailor sit or sim s position 2. During contraction: woman is to close her eyes and relax with slow deep abdominal breathing. 3. Husband is to be supportive, touch the laboring woman, and put a hand on her abdomen during contractions.
combined controlled muscle relaxation and breathing techniques. The pregnant woman is taught to contract specific group of muscles and relax the rest of her body. ( this conditions her to relax when her uterus contracts Abdominal effleurage, light stroking of abdomen used to relieve mild pain. Back pain can be relieved by putting pressure on the sacrum
Benefits of breastfeeding
BABY: Optimum growth and development Initiates bonding between mother and baby Nutritionally optimum A laxative for baby MOTHER: Prevents excessive bleeding during and after birth Lowers risk of ovarian cancer Helps mother to return to pre-pregnancy weight
Screening tests: During the initial visit, screening tests are performed to determine the mother s health and to have baseline data with which to compare subsequent test results Return visits: For an uncomplicated pregnancy generally are: Every 4 weeks for the first 28 weeks Every 2 weeks during weeks 29- 36 Every week from 36 weeks> till birth
Dizziness Fever over 37.8 C and chills Pain or cramping in abdomen Irritating vaginal discharge Dysuria Noticeable reduction or absence of fetal movement
Subjective data: The following subjective data should be collected at each return visit: How the client is feeling Any discomforts, concerns, or question the client may have Any body changes noticed by the client How developmental tasks are being met
Objective data: The following is collected on each return visit and compare to the previous visits: Blood pressure- any increase of 30mmHg systolic or 15mmHg diastolic from one visit to the next- report to the healthcare provider. If there is no previous BP to compare to, a blood pressure of 140/90 should be reported
Weight: Total weight gain should be approximately (25 -35 lbs) distributed as follows: Weeks 1 to 12 2 to 4 lbs Weeks 13 to 40 - 1 lb/week Uterine size: the fundal height in centimeters indicates the weeks of gestation between 18 and 30 weeks.
Edema: A small amount of dependent edema is often present in the last few weeks of pregnancy. Edema of the hands and face should be reported. Small amounts of edema is difficult to detect so ask the client if her rings are tighter or if she has had to remove her rings.
Abdominal palpations
Fetal position: Assessment of fetal position is performed using the Leopold s maneuvers, a series of specific palpations of the pregnant uterus to determine fetal position and presentation. Positioning of client: supine with knees bent, examiner stands at client s right side facing her head.
Leopold s maneuver
First ,the examiner palpates to determine
which fetal part is in the fundus. Generally it is the buttocks Second, the examiner moves hands to the side of the uterus and determines on which side of the mother lies the fetal back is located. Third, the examiner's right hand is placed above the symphysis to note whether the head or breech is near the pubis symphysis.( this should correlate with the first maneuver). Fourth, the examiner changes position to face the client s feet, and palpate the sides of the abdomen to determine on which side the cephalic prominence presents.
Referencing
White. L, (2005). Foundations of Maternal & pediatric nursing.(2nd ed.). Thomson, Delmar learning Fraser, D. M, Cooper, A. (2003). Myles text book for Midwives (14th ed).Churchill Livingston, Elsevier. Olds, London, Ladewig.(1992).Maternal- Newborn Nursing A family- centered approach.(4th ed.).Addison Wesley. Redwood City.
Tutorial activity
Divide into 4 groups: Choose a health education topic from the following: -minor disorders of pregnancy (at least 5) -Benefits of breastfeeding -birth preparation class -danger signs during pregnancy and labour You will use the remainder of the group as your audience of pregnant mothers ( do not forget the presence of partners/ husbands) Tutorial leaders will assess the health talk
Pre- reading
on the types of exercises pregnant women do