Professional Documents
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PREVENTIVE OBSTETRICS
MASTER PLAN
SUBJECT
able to get adequate knowledge regarding preventive obstetrics and able to prevent obstetric complication by applying measures while practicing it.
Define preventive obstetrics Mention preventive obstetrics measures Explain preventive obstetric s measures, antenatal nursing, Intranatal nursing, postnatal nursing
SL.NO. 1 INTRODUCTION
CONTENT
TERMMINOLOGIES
CONTENT
PREVENTIVE OBSTETRICS: Definition Preventive Obstetrics Measures A. Antenatal Nursing Objectives of Antenatal Care 1. Preconceptional Counseling and Care 2. Essential Antenatal Care Services 3. Specific Health Protection 4. Preparing for Confinement 5. Psychological Preparation of the Mother 6. Family Planning 7. Education for Self Care 8. Hematological Investigations 9. Screening for Urinary Tract Infection 10. Minor Disorder of Pregnancy B. Intranatal Nursing Objectives of Intranatal Care 1. Domiciliary Care 2. Complications and Obstetrical Emergency during Intranatal Period C. Postnatal Nursing Objectives of Postnatal Care 1. Complications of the Postnatal Period 2. Restoration of Mother to Optimum Health 3. Breast Feeding 4. Respiratory Distress Syndrome and Neonatal Problems 5. Prevention of Injuries in the New Born Babies 6. Major Disorders of Newborn Baby 7. Family Planning 8. Health Education to Mother and Family
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CONCLUSION BIBLIOGRAPHY
PREVENTIVE OBSTETRICS
INTRODUCTION
Preventive obstetrics is the concept of prevention or early detection of particular health deviations through routine periodic examinations and screenings. The concept of preventive obstetrics concerns with the concepts of the health and well-being 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. The goal of the preventive obstetrics is the delivery of a healthy infant by a healthy mother at the end of a healthy pregnancy. Pregnancy and child birth normal physiologic process that change from conception to delivery. The nurse has a unique opportunity to reinforce the normal cycle of these processes and at the same time, assess client for problems that require intervention. Additionally, the nurse can teach clients about the changes that are taking place and provide valuable guidance for clients about when to seek guidance from health care providers. Early contact between the health care team and the pregnant client provides the opportunity to address the concepts of health promotion and health maintenance. Health promotion consists of education and counseling activities that help enhance and maintain health which prevents from obstetrics. For the prevention of obstetrics systematic supervision (examination and advice) of a woman during pregnancy, antenatal care, preconceptional counseling and care are the major preventive measures. 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 culminate in a healthy mother and a healthy baby. Although different parts of the world have different leading causes of maternal death attributable to pregnancy, in general, three major disorders have persisted for the last 35 years like hypertensive disorders infection, and haemorrhage. The number of maternal deaths overall is small; however maternal mortality remains a significant problem because a high proportion of deaths are preventable mainly through improving the access to a utilization of prenatal care services. Nurses can be instrumental in educating the public about the importance of obtaining early and regular care during pregnancy.
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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
Preventive obstetric is the term for prevention of the complication that may arise during antenatal, intranatal and postnatal period. Preventive Obstetric measure can be categorized into three main stages. They are 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 a normal and healthy, pregnant women for her own well- being and that of the baby to be born 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 as possible during the first trimester and should continue throught the second and third trimesters.
Folic acid supplementation (4mg a day) starting 4 weeks prior to conception up to 12 weeks of pregnancy is advised. Good understanding with the physician so that much of the problems and fear of the incoming pregnancy could be removed. The counseling should be done by primary health care providers. The help of obstetricians, physicians and geneticists may be required and should be extended.
The preventive services for mothers in the prenatal period are as follows:The first visit irrespective of when it occurs should include:Taking Health History It includes recording history of menstruation, medical history, obstetrical history, socioeconomic history. Physical Examination It includes recording of height, weight, blood pressure, temperature, pulse etc. general observations from head to toe. Obstetrical Examination It includes general observations, examination of breasts, abdominal measurement, palpation and inspection, vaginal examination if necessary. Laboratory Investigations Complete urine analysis Stool examination Complete blood count including Hbg estimation. Serological examination. Blood grouping and Rh determination. Chest X- ray, if needed Gonorrhea test, if needed
On subsequent visits
Physical examination including weight and blood pressure Laboratory tests including urine examination and hemoglobin estimation Iron and folic acid supplementation and medications as needed. Immunization against tetanus Group or individual teaching on nutrition, self care, family planning, delivery and parenthood Home visiting by a female health worker or trained person ( trained traditional birth attendant) Referral services, when necessary
Risk Approach
While continuing to provide appropriate care for all mothers, high risk cases must be identified as early as possible and arrangements to be made for skilled care. These cases comprise the following:Women below 18 years of age or over 35 years in primigravida. Women who have had four or more pregnancies and deliveries. Short structured primigravida
Those who have practiced less than 2 years or more than 10 years of birth spacing. Those with cephalopelvic disproportion (CPD), genital prolapse. Malpresentations, e.g. breech, transverse lie etc. Antepartum hemorrhage, threatened abortion Preeclampsia and eclampsia Anemia Twins, hydramnios Previous stillbirth, intrauterine death, manual removal of placenta Elderly grandmultipara Those mother with blood Rh negative. Those with obesity and malnutrition. Prolonged pregnancy ( 14 days beyond expected date of delivery) Previous cesarean or instrumental delivery Pregnancy associated with medical conditions, e.g. cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease etc. The purpose of risk approach is to provide maximum services to all pregnant women with attention to those who need them most. Maximum utilization of all resources, including human resources is involved in such care. Services of traditional birth attendants, community health workers and womens groups are utilized. The risk strategy is expected to lead to improvements in both the quality and coverage of health care at all levels, particularly at primary health care level. Prevention Administration of folic acid 5mg daily months before conception. By improving pre- pregnancy health of woman. Providing quality antenatal care. Screening all pregnancies for high risk. Provide appropriate clinical and technological care by specialist on time. Prevent all kinds of infection. Early diagnosis of malformation and termination. Avoidance of medication (without physicians prescription). Health education on MCH and FP care.
Maintenance of Records
The antenatal card is prepared at the first examination. It is generally made of thick paper to facilitate filing. It contains a registration number, identifying data, previous health history, and main health events. The record is kept at the MCH/FP center. A link is maintained between the Antenatal card, Postnatal card and under- fives card. Maintenance of records is essential for evaluation and further improvement of MCH/FP services.
Home Visit
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 provide
prenatal advice. In the home environment, the woman will have more confidence to make an informed decision about home birth.
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 and lactation. This can be achieved by proper family planning guidance. Supplementary iron Therapy: Iron supplementary should be a routine after the patient becomes free from nausea and vomiting. Daily 60mg iron with 1mg folic acid is a quite effective prophylactic procedure. Dietary Prescription: Well balanced diet rich in iron and protein should be advised. The food rich in iron are liver, meat, egg, green vegetables, green pea bean, whole wheat etc. Adequate treatment should be instituted to eradicate the illness likely to cause anemia. These are hookworm infestation, dysentery, and malaria, bleeding piles, urinary tract infection etc. Early detection of falling hemoglobin level is to be made. Hemoglobin level should be estimated at the first antenatal visit at the 28th and finally at 36th weeks. Avoid excessive blood loss during the 2nd stage of labour.
A balanced and adequate diet is of utmost importance during pregnancy and lactation to meet the increased needs of the mother, and to prevent nutritional stress. If maternal stores of iron are poor as may happen after repeated pregnancies and if adequate iron is not available to the mother during pregnancy, it is possible that the fetus will lay down insufficient iron stores.
Maternal Malnutrition
Foetal growth retardation The increase in energy is to support the growth of the foetus, placenta, and maternal tissue and for the increase in basal metabolic rate due to additional work of growing foetus and increase in maternal body size.
Personal Hygiene
Advice regarding personal hygiene is equally important. The need to bathe every day and to wear clean clothes should be explained. About eight midday meals should be advised. Constipation should be avoided by regular intake of green leafy vegetables, fruits and extra fluid. Purgatives such as caster oil to relieve constipation should be avoided. Light household work should be encouraged but manual physical labour during pregnancy may adversely affect the fetus.
This is here in abundance and most women are in the open air for a large part of the day and it is good for them but advice regarding their sleeping arrangements should be given. The bowels
The bowel action should occur daily and without the use of laxatives. Drinking glass of warm water on getting up each morning and drinking plenty of fluids during the day can encourage this. Plenty of roughage in the diet is also helpful.Constipation should be avoided by regular intake of green leafy vegetables, fruits and extra fluids.Purgatives like caster oil should be avoided to relieve constipation. Care of Teeth
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. Personal Cleanliness and Bathing
During pregnancy sweet glands become more active so advice for bathing at least once a day, preferably twice but clean clothes should be used daily.The need to bath every day and to wear clean clothes should be explained. The hair should also be kept clean and tidy.
Physical work
A job provides satisfaction, self esteem and confidence, along with financial peace of mind. Women can continue working in pregnancy as long as they wish and as long as they and their baby remain well. Avoidance of exposure to hazardous chemicals, Smokey environments, excessive lifting and exercise and at least an 8- hour rest at night is recommended.
Exercise
Exercise in pregnancy should be encouraged; through with advancing gestation physical contraints may limit sporting activities. Exercise can improve cardiovascular function, lower blood pressure and improve self- esteem and confidence. Swimming is often helpful throughout pregnancy especially with advancing gestation as it is essentially a non weight bearing exercise. It is advisable however to avoid hyperthermia, dehydration and exhaustion. Consider decreasing weight bearing exercises like jogging, running and concentrate on non weight bearing activities such as swimming, cycling or stretching. Advise her to avoid risky activities such as surfing, mountain climbing and skydiving. Limit activity to shorter intervals. Exercise for 10 to 15 minutes; rest for 2 to 3 minutes, then exercise for another 10 to 15 minutes. The exercise should be decrease as the pregnancy progresses.
Smoking
It should be strongly discouraged in pregnancy. The target should be cessation of smoking, 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 of miscarriage, a slightly higher perinatal death rate (20% increase in 20/day smokers, and 35% increase if > 20/day) and babies of smokers are 150 to 300 gm lighter than babies of non smokers. Furthermore, smoking is associated with a three-fold increase in risk of cleft palate. Smoking during pregnancy, however, doesnt affect long term mental or motor development. The mechanisms involved include interference of carbon monoxide with oxygen transfer, shifting the oxygen dissociation curve to the left in both maternal and fetal hemoglobin and reduced intervillous blood flow. Appropriate advice and support 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 result in babies much smaller than average size due to placental insufficiency. The perinatal mortality amongst babies whose mothers smoked during pregnancy is between 10 to 40 percent higher than in non smokers. 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 been associated with fetal alcohol syndrome (FAS), which includes intrauterine growth
retardation and developmental delay. Advice should also be given about dental care and sexual behavior during pregnancy. Sexual intercourse should be restricted during the last trimester of pregnancy.
Alcohol
An expectant mother should be advised to avoid drinking alcohol as drinking alcohol is injurious to the fetus and also to her own health. It leads to low birth weight and retardation. Pregnant women are advised to limit alcohol consumption and a consumption 20 gm/ week (2 units) appears to be generally safe. Heavy alcohol consumption (greater than 12 unts 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.
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 everyday 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 well fitting and supportive brassiere.
Drugs
The mother should be advised not to take any medicine unless it is prescribed by the doctor. As far as possible, medicine should be avoided for the three months unless very essential. The mother must inform to the doctor about pregnancy when seeking any treatment 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 fetal malformations. The classical example is thalidomide, a hypotonic drug, which caused deformed hands and feet of the babies born. The drug proved most serious when taken between 4 to 8 weeks of pregnancy. Other examples are LSD which is known to cause chromosomal damage, streptomycin which may cause 8th nerve damage and deafness in the fetus, iodine- containing preparations which may cause congenital goiter in the fetus. Corticosteroids may impair fetal growth, sex hormones may produce virilism, and tetracycline may affect the growth of bones and enamel formation of teeth. Anaesthetic agents including pethidine administered during labour can have depressant effort on the baby and delay the onset of effective respiration. Later still in the puerperium, if the
mother is breast- feeding, there are certain drugs which are excreted in breast milk. A great deal of caution is required in the drug intake by pregnant women.
Radiation
Exposure to radiation is a positive danger to the developing fetus. The most common source of radiation is abdominal X-ray during pregnancy. Studies have shown that mortality rates from leukemia and other neoplasm were significantly greater among children exposed to intrauterine X-ray. Congenital malformations such as microcephaly are known to occur due to radiation. Hence, X-ray examination in pregnancy should be carried out only for definite indications.
Sexual activities
Patient inhibition to ask and failure to address the issue by health professionals has resulted in considerable misconceptions. In general with an uncomplicated pregnancy, there are no contraindications to coitus or other form of sexual enjoyment in pregnancy including cunnilingus and masturbation. There is no evidence that these have a damaging influence on the fetus or risk inducing premature labour. With advancing gestation certain coital positions may be physically awkward. There may be decline in some women in sexual desire and activity in early pregnancy toward the end of pregnancy. Coitus may be avoided with premature rupture of membranes and where there have been recurrent episodes of APH and in the presence of a placenta previa major. The mother should be advised to avoid coitus during the first three months and the last two months. In the first three months it increases the risk of abortion. The risk of abortion is more in mothers who have previous history of abortion. In late pregnancy it predisposes to infection.
Travel
The mother should be instructed to avoid travel during the first three and last two months of pregnancy especially long and tedious journey. If traveling for long distances, periods of activity and rest should be scheduled. While sitting, the woman can practice deep breathing, foot circling, and alternating contracting and relaxating different muscule groups. Fatigue should be avoided.
Child care
The mother should be educated on various aspects of child care. Mother craft classes can be arranged if possible to train the mother regarding care during pregnancy, child bearing, 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 consists of nutrition education, hygiene and childrearing, childbirth preparation and family planning information.
Follow up visits
It is important that mother must be educated about the need for regular visits and proper care during pregnancy. They must be convinced to pay follow up visit and follow the instructions regarding diet, personal hygiene, rest, physical work, exercise, smoking, drinking, and protection from infections, sexual activities, and travel etc.so as to promote health of both mother and the growing fetus.
Warning Signs
The mother should be given instructions that she should report immediately, any of the following warning signals like swelling of the feet, convulsions, headache, blurring of the vision, bleeding or discharge per vagina and any other unusual symptoms.
Rubella Rubella infection suffered by the mother, especially in early pregnancy can have devastating consequences for the fetus. In an attempt to reduce the incidence of congenital rubella defects, vaccination has been undertaken. HIV Screening Pregnant women are ethically obligated to seek reasonable care during pregnancy and to avoid causing harm to the fetus. Maternity nurses should be advocates for the fetus, but not at the expense of the pregnant woman. Incidence of perinatal transmission from an HIV positive mother to her fetus ranges from 25% to 35%. Methods of preventing maternal fetal transmission ad fetal treatment currently are not available. Until there is change in technology that alters the diagnosis or treatment of the fetus, testing of the pregnant woman should be voluntary. Health care providers have an obligation to make sure the pregnant woman is well informed about HIV symptoms and testing. HIV may pass from an infected mother to her fetus through the placenta or to her infant during delivery or breast feeding. About one third of the children of HIV positive mothers infected through this routine. The risk of transmission is higher if the mother is newly infected or if she has already developed AIDS. Prenatal testing for HIV infection should be done as early in pregnancy as possible for pregnant women who are at risk ( if they or their partners have multiple sexual partners, have sexually transmitted disease or use illicit injectable drugs). Universal confidential voluntary screening of pregnant women in high prevalence areas may allow infected woman to choose therapeutic abortion, make an informed decision on breast feeding or receive appropriate care. Hepatitis B Screening for hepatitis B aims to determine whether the patient has ever been exposed to the virus, and whether is immune to the virus or whether she is a potential risk of transmitting the infection to the neonate, her partner and to health care professionals. A combined course of active and passive immunization can then be undertaken in the neonate at risk after birth. The importance of preventing hepatitis B infection in the neonate is that while in the adult patient the virus is cleared within 6 months in 90 percent of infected individuals, in neonates 90 percent become chronic carriers with the risk of post infective hepatitis cirrhosis and hepatocellular carcinoma. Syphilis Screening for syphilis should be performed for the prevention of congenital syphilis in the neonate. Treatment confers benefits to mother too, by preventing development of cardiovascular and neurological complications of the advanced stages of the disease. Syphilitic infection in the woman is transmissible to the fetus, especially when she is suffering from primary or secondary stages after the 6th month of pregnancy. Neurological damage with mental retardation is one of the most serious complications. Blood should be tested for syphilis (VDRL) at the first visit and late in pregnancy.
It is routine procedure in antenatal clinics to test blood for syphilis at the first visit. Since the mother can subsequently get infected with syphilis, the ideal procedure would be to test blood for syphilis both early and late in pregnancy. Congenital syphilis is easily preventable. Ten daily injections of procaine penicillin ( 600,000 units) are almost always adequate. German Measles Rubella infection contracted during the first 16 weeks of pregnancy can cause major defects such as cataract, deafness and congenital heart diseases. Vaccination of all women of child bearing age, who are seronegative, is desirable. Before vaccinating, it is desirable that pregnancy is ruled out and effective contraception be maintained for eight weeks after vaccination because of possible risk to the fetus from the virus, should the mother become pregnant. Rh Status It is a routine procedure in antenatal clinics to test the blood for Rhesus type in early pregnancy. If the woman is Rh- negative and the husband is Rh-positive, she is kept under surveillance for determination of Rh- antibody levels during antenatal period. The blood is further examined at 28th week and 34th to 36th week of gestation for antibodies. Rh anti D immunoglobulin should be given at 28th week of gestation so that sensitization during the first pregnancy can be prevented. If the baby is Rh positive, the Rh anti-D immunoglobulin is given again within 72 hours of delivery. It should also be given after abortion. Post maturity should be avoided. Whenever there is evidence of hemolytic process in fetus in utero, the mother should be shifted to an equipped center specialized to deal with Rh problems. The incidence of hemolytic disease due to Rh factor in India is estimated to be approximately one for every 400-500 live births. Prenatal Genetic Screening Screening for genetic abnormalities and for direct evidence of structural anomalies is performed in pregnancy in order to make the option of therapeutic abortion available when severe defects are detected. Typical examples are screening for trisomy-21 and severe neural tube defects. Women aged 35 years and above, and those who already have an afflicted child are at high risk.
ANM),health supervisor ( LHV) to protect the life of both mother and the baby and prevent them from any infection especially tetanus. It is important to arrange transport in advance for transportation of mother to hospital or first referral unit during emergency, 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. It should 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 and blood. 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 the following 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. d. Hand washing articles. These equipments and articles must be kept ready by the mother and family so that there is no problem at the time of delivery. The instructions must be given to another regarding these. Similarly the trained dais and health workers should be ready with their delivery kit for conduct of delivery at home.
6. Family Planning
Family planning is related to every phase of the maternity cycle. Educational and motivational efforts must be initiated during the antenatal period. If the mother has had two or more children, she should be motivated for puerperal sterilization. The mother should be educated and motivated for small family norm and spacing of children.
First Trimester
Antenatal care in the first trimester starts with a visit to the GP after a missed period and confirmation of pregnancy. It also provides an ideal opportunity for the woman to discuss any anxieties she may have.
8. Hematological Investigations
These include hemoglobin estimation and a complete blood picture if indicated. Blood group determination and antibody screen is also performed to identify rhesus negative women 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 increase in plasma volume than red cell mass and therefore the lower limit for a normal Hb is 10.5 g/dl in pregnancy as opposed to 11.5g/dl in the non pregnant female. Many women enter pregnancy with a low iron reserve and therefore if anemia is detected in pregnancy it should be appropriately investigated by assessment of ferritin, total iron binding capacity (TIBC), serum and red cell folate and B12 levels based on the blood
picture. 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 negative and therefore may be at risk of rhesus isoimmunization. The incidence of rhesus disease has dramatically fallen over the last thirty years the introduction of anti D administration. Despite screening at 28 and 34 weeks or after any potential sensitizing event and administration of prophylactic anti D at these times, a small number of RhD negative women still develop anti-D antibodies because of small silent hemorrhages predominantly in the third trimester or because of failure of timely administration of anti D immunoglobulin. Screening for red cell antibodies should be repeated in all women in early pregnancy in subsequent pregnancies, even if rhesus positive, as there may be other clinically significant antibodies as a consequence of previous pregnancy or blood transfusion. An antibody screen is performed to detect the presence of antibodies that may put the baby at risk of hemolytic disease or result in difficulties with cross- matching blood for the mother if required at any age of pregnancy, labour or postnatally. If antibodies are detected, the titer is determined and subsequent samples taken for further estimation at appropriate time interval.
Prevention
o Identify the particular odour of foods that are most upsetting and avoid the odour of certain foods, because women are very sensitive to smells. o Eat dry crackers or bread 15 minutes before getting up from the bed in the morning. o Advice to consume small frequent meal (every 2 hours if possible). o Avoiding spicy and greasy food and consuming protein snack at night o Advice to take light and dry snacks instead of heavy meal. o Avoid brushing after eating. o Keep room well ventilated for fresh air.
Indigestion
Indigestion often occurs after eating too much of heavy or greasy food or drinking too much 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 veins are 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.
Backache
This is common problem during pregnancy especially in the third trimesters. Slight backache may be due to faulty posture and is more common in multigravida.It may be due 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 or walking.
Fainting ( Syncope)
It is the disorder common in second and third trimester. Many pregnant women occasionally 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 oesophagus often accompanied by bad test in the 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 the passing of hard stool. It is common during pregnancy. It is due to lack of physical activity or exercise, decrease fluids, oral iron supplement, pressure of enlarging uterus on intestine.
Prevention
Encourage to maintain bowel habit, going to toilet at same time everyday and toilet when 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. It may 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 at night but may occur at other times.Leg cramps are more common in the third trimester.
Prevention
Advice to take enough calcium ( milk, greenleafy 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. Septicemia may 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 the cleanliness. It entails clean hands and fingernails, a clean surface for delivery, clean cutting and care of the cord, and keeping birth canal clean by avoiding harmful practices. Hospitals and health centers should be equipped for delivery with midwifery kits, a regular supply of sterile gloves and drapes, towels, cleaning materials, soap and antiseptic solution, as well as equipment for sterilizing instruments and supplies.
1. Domiciliary Care
Mothers with normal obstetric history may be advised to have their confinement in their own homes, provided the home conditions are satisfactory. In such cases, the delivery may be conducted by Health Worker Female or trained Dai. This is known as domiciliary midwifery service.
Good pains for an hour after rupture of members, but no progress Prolapse of the cord or hand Meconium stained liquor or a slow irregular or excessively fast fetal heart Excessive show or bleeding during labour Collapse during labour A placenta not separated within half an hour after delivery Postpartum haemorrhage or collapse
Preventive Measures
Antenatal and early intranatal detection of the factors likely to produce prolonged labour and then to institute its appropriate management. Use partograph to record fetal, maternal and labour condition and maintain it meticulously which help in early detection Selective and judicious augmentation of labour can be employed by low rupture of the membranes followed by the oxytocin drip. Keep vigilant during labour and appropriate management should promptly be instituted if the first is delayed as evidence from the cervicograph and there is tendency of slow descent in the second stage.
Preventive Measures
Periodic and careful antenatal visits. Early detection of factors affecting labour, such as passage or passenger during antenatal or early intranatal period to place an appropriate method of delivery. Careful and constant observation of the mature of uterine contraction and keep record meticulously in partograph
Obstructed Labour
The obstructed labour may be due to contracted pelvis, cephalopelvic disproportion, congenital malformation of the fetus etc.
Preventive Measures
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 safe delivery is contemplated Intranatal Keep continuous vigilance by using partograph. Careful assessment of the progress of labour. Timely intervention of a prolonged labour and prompt action need to be taken with mothers who likely to develop obstructed labour.
C. POSTNATAL NURSING
Care of the mother and newborn after delivery is known as postnatal or postpartal care. Following delivery, the mother and baby are visited daily for ten days. During each of these visits the midwife/ FHW checks temperature, pulse and respirations of the mother, examines her breasts, checks the progress of normal involution of uterus, examines lochia for any abnormality, checks urine and bowels and advices on perineal toileting. The immediate postnatal complications such as puerperal sepsis, throbophlebitis and secondary haemorrhage must be kept in mind. At the end of the 6th week, the woman needs an examination by the physician in the health center to check up involution of the uterus, which should be complete by then. Further visits should be done once a month during the first six months and thereafter once in 2 to 3 months until the end of one year. In rural areas, where only limited care is possible, efforts should be made by the FHW to give at least 3 to 6 postnatal visits. The common conditions found during the late postnatal period are sub involution of uterus, prolapse of uterus and cervicitis. Postnatal examination offers an opportunity to detect and correct these defects. Anemia if presents need to be treated. Health education regarding affordable nutritious diet and postnatal exercises to restore the stretched abdominal and pelvic muscles must be provided to enable the mother have a normal post- partum period. The psychological aspect of postnatal care needs to be addressed based on a needs assessment. New mothers may have timidity and fears due to ignorance and insecurity regarding the care of the baby. In order to endure the emotional stress of childbirth, she requires the support and companionship of her husband as well as encouragement and assistance of family. Fear and insecurity may be eliminated by proper prenatal instructions, postnatal enforcing and supportive care.
Puerperal sepsis
This is infection of the genital tract within 3 weeks after delivery. This is accompanied by rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in lower abdomen, etc. Puerperal sepsis can be prevented by attention to asepsis, before and after delivery. This is particularly important in domiciliary midwifery service.
Prevention
Puerperal sepsis is to a great extent preventable. Certain measure should be taken under before, during and following labour. Antenatal Detect and eradicate the septic focus especially located in the teeth, gums, tonsils, middle ears etc. Maintain and improve the health of status of the patient especially to raise Hb level, prevent eclampsia, early treatment of any abnormalities. Vaginal examination during pregnancy especially in the last months should be kept in a minimum and should be carried out with strict surgical asepsis. Intercourse should be avoided during the last two months to prevent introduction of organisms like streptococcus. The patient should avoid contact with persons suffering from infectious disease. The patient should take care of personal hygiene. Intranatal The nurse, doctor and other personnel entering into labour room should wear mask, gown and cap to prevent the infection of personnel spread to labour room. The delivery should be conducted taking full surgical asepsis.
Members should be kept preserved as long as possible. Well management on every step of labour which prevents possibility of infection. Avoid prolonged labour and mother from exhaustion. Traumatic vaginal delivery should preferable be avoided and intrauterine manipulation if required should be done by maintaining strict surgical asepsis. After placenta delivery, explore the vagina to determine if there are any pieces of membranes or blood clots retained in uterus. Enema should be given in first stage of labour to prevent the contamination of stool in 2nd stage of labour. Dust should be avoided in the labour room. Laceration of the genital tract should be repaired promptly. Excessive blood loss during delivery should be replaced promptly by blood transfusion to improve the general body resistance. Postnatal Period Aseptic precaution should be taken for at least one week following delivery until the open wound the uterus and the genital tract injury, if any, are healed up. Nurse should take aseptic precaution and wear mask while giving perineal care. Restrict too much visitors in ward. Sterilized sanitary pad should be used and changed frequently to prevent lochia to decompose and become offensive on the pad. Clean the vulval area with antiseptic solution after each urination and defecation. Isolation as well as barrier nursing measure for infected patient and infants is imperative. Advise to avoid sexual intercourse for 4-6 weeks after delivery.
Thrombo phlebitis
This is an infection of the veins of the legs, frequently associated with varicose veins. The leg may become tender, pale and swollen. So the mother should be encouraged to do the leg exercise to increase the muscle tone.
Prevention
The three important factors i. e. trauma, sepsis and anemia should be prevented and to be treated effectively after detection. Dehydration during delivery should be promptly corrected. Leg exercise and early ambulation are encouraged especially following operative delivery.
Postpartum Hemorrhage
Postpartum hemorrhage is the condition of excessive bleeding from the genital tract at any time following the babys birth up to 6 weeks after delivery. It may occur at any time that is during third stage of labour, with in 24 hours or after 24 hours of labour.
Antenatal Period
Ensure regular antenatal care Maintain Hb level as near as normal
Intranatal Period
Judiciously administer sedative, analgesic and oxytocin Avoid hasty delivery of the baby. One should take at least 23 minutes to deliver the trunk after the head is born. Baby should be pushed out by the retracted uterus and not be pulled out. Prevent the labour being prolonged Avoid fiddling and kneading of the uterus or pulling the cord before the placental separation
Postnatal Period
Continue to monitor vital signs Observe the lochia, type, amount and consistency.
2.
3. 4.
5.
Check blood grouping and typing Identify high risk mothers ( twins, hydramnios, APH, grand multipara etc) and deliver in a well equipped hospital
Strict application of active management of third stage e.g. Immediate oxytocin Control Cord Traction Uterine Massage In all cases of the induced or augmented labour by oxytocin should be kept on continuous oxytocin infusion for at least one hour after delivery. Examine the placenta and membranes and cord carefully
6.
Observe the mother for two hours after delivery and ensure that the uterus is hard and contracted enough. Encourage the mother for breast feeding.
7.
Encourage and assist to empty the bladder periodically and for ambulation.
Preventive measures
Dont employ any method to expel the placenta when the uterus is relaxed. Avoid pulling cord simultaneously with fundal pressure. Attempt proper technique to deliver the placenta and of manual removal of placenta. Pay visilant observation for separation of placenta.
Postnatal Blues
Pregnancy and puerperium are highly stressful periods in a womans life. The person is threatened by various changes such as physiological changes, and endocrine changes occurring in ones body, as she is in reorganization of psyche in accordance with the new mother role especially in the first pregnancy. Body image changes and unconscious intrapsychic conflicts related to pregnancy, childbirth, and motherhood become activated. It is no wounder that 25% to %0% of the pregnant womrn develop mild psychological symptoms in the puerperal period. The commonest type is the mild depression and irritability known as the postnatal blues. Hein Roth 2006
Prevention
Advice to the family and relatives to deal properly with the postnatal situation of the postnatal 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.
Physical
Postnatal Examinations Soon after delivery, the health checks-ups must be frequent, i.e., twice a day during the first 3 days, and subsequently once a day till the umbilical cord drops off. At each of these examinations, the health personnel should checks temperature, pulse and respiration, examines the breasts, checks progress of normal involution of the uterus, examines lochia for any abnormality, checks urine and bowels and advises or perineal toilet including care of the stitches, if any. The immediate postnatal complications, puerperal sepsis, thrombophlebitis, secondary haemorrhage should be kept in mind. At the end of 6 weeks, an examination is necessary to check up involution of the uterus which 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 the FHWs to give at least 3 to 6 postnatal visits. The common conditions found on examination during the late postnatal period are sub involution of uterus, retroverted uterus, prolapse of uterus and cervicitis. Postnatal examination offers an opportunity to detect and correct these defects. Anemia Routine hemoglobin examination should be done during postnatal visits, and when anemia is discovered, it should be treated. In some cases it may be necessary to continue treatment for a year or more.
Nutrition Though a malnourished mother is able to secrete as much breast milk as well nourished one, she does it at the cost of her own health. The nutritional needs of the mother must be adequately met. Often the family budget is limited, the mother should be shown the means how she can eat better with less money. Postnatal Exercises Postnatal exercises are necessary to bring the stretched abdominal and pelvic muscles back to normal as quickly as possible. Gradual resumption of normal house hold duties may be enough to restore ones figure.
Psychological
The next big area of postnatal care involves a consideration of the psychological factors peculiar to the recently delivered woman. One of the psychological problems is fear which is generally borne of ignorance. Other problems are timidity and insecurity regarding the baby. If a woman is to endure cheerfully the emotional stresses of childbirth, she requires the support and companionship of her husband. Fear and
insecurity may be eliminated by proper prenatal instruction. The so called postpartum psychosis is perhaps precipitated by birth, and it is rather uncommon.
Social
It has been said that the most important thing a woman can do is to have a baby. This is only part of the truth. The really important thing is to nurture and raise the child in a wholesome 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 getting along with her baby, particularly with regard to feeding. For many children breast milk provides 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 18th months or longer. Postnatal care includes helping the mother to establish successful breast-feeding. For many babies breast milk provides the main source of nourishment in the first year of life. When the standard of environmental sanitation is poor and education low, the content of feeding bottle is likely to be as nutritionally poor as it is bacteriologically dangerous. It is therefore very important to advise mothers to provide exclusive breast feeding in the initial months.
Prevention Administration of dexamethasone in patients anticipating preterm delivery especially before 34 weeks for lung maturity. Assessment of lung maturity before premature induction of labour and induction of labour and to delay the induction as much as possible without any risk to the fetus. Prevent fetal hypoxia in diabetic mothers. Avoid smoking, anemia, pre- eclampsia, APH and other complication during pregnancy. Suction immediately after birth to patent the airway.
Prevention
Comprehensive intranatal and antenatal care is the key to success in the reduction of intracranial injuries. Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal monitoring. Episiotomy and use of forceps to deliver the premature baby minimize the intracranial disturbance. Avoid traumatic vaginal delivery in preference to caesarean section. Difficult forceps should be avoided. In vaccum delivery, traction is made only after proper cephalic application. Avoid prolonged and difficult labour.
Episiotomy is to be done carefully after placing two fingers in between the head and the stretched perineum- to prevent injury to the scalp. The neck shouldnt be unduly stretched while delivering the shoulders to minimize injuries to the brachial plexus or steromastoid Special care in preterm delivery Prevent anoxia Avoid strong sedation. Liberal episiotomy and use of forceps to minimize intracranial compression. Administer vitamin k 1 mg intramuscularly to prevent or minimize haemorrhage from the traumatized area.
Forceps Delivery
Difficult forceps are to be withheld in preference to the safer caesarean section. Never apply traction unless the application is a correct one
Ventouse Delivery
It is relatively less traumatic, but it should be avoided in preterm babies.
Prevention
Any suspicious vaginal discharge during the antenatal period should be treated and the strict aseptic technique should maintain at birth. The newborn babys closed eyes and face with sterile water and swab at bath times to avoid infection of the eye.
The midwife and mother should always wash her hand before touching the babys face.
Neonatal Tetanus
Neonatal Tetanus is a dreadful infection with a high mortality rate.
Prevention
Mother should be given tetanus toxoid during pregnancy. While cutting the cord, instrument for cord cutting should be boiled and cord should be cut under aseptic precaution. The room should be kept clean. Cord care should be done daily.
Omphalitis
Acute omphalitis is an infection of umbilical stump. It is usually mild as present as a scanty purulent discharge.
Prevention
Maintain strict sterile technique during good cutting and cord dressing. Keep the environment clean as far as possible. Identification of pathogen by umbilical culture and isolate the baby.
7. Family Planning
Every attempt should be made to motivate mothers when they attend postnatal clinics or during postnatal contacts to adopt a suitable method for spacing the next birth or for limiting the family size as appropriate. Contraceptives that will not affect lactation may be prescribed immediately following delivery after a physical examination.
Hygiene- personal and environmental Breast Care Breast Feeding of infant. Care of the Newborn baby Care of the umbilical cord Bathing the baby Nutritious diet for the mother Postnatal Exercise Rest, sleep and activity Pregnancy spacing Health check up for mother and baby Prevention of infection in the baby Birth registration Hygiene- personal and environmental
Maternal and neonates personal hygiene should be maintained to prevent infection. Vulval care and daily bathing should be done as lochia drainage occurs. Cleanliness helps her to fresh and activates energy to care.Perineal care should be done to observe the amount, colour, odour and consistency of the lochia, to keep the stitch clean, dry and help in fast healing, to prevent local and ascending infection. Breast Care
Breast care is very important for both mother and baby because it prevents from infection, so the mother should advised to clean her breast before and after each feed with clean water and hand washing too. Advice to wear clean brassiere. Breast Feeding of infant
Breast milk has anti infective properties that protect the infant from infection in the early months. It is a complete food and provides all nutrients needed to infant in the first few months. So encourage mother to feed the breast feeding for her baby. Care of the Newborn baby
The care of the newborn baby is very important to make sure baby is thriving and to detect early sign of illness and abnormalities and treat it accordingly. Care of the umbilical cord
Cleanliness of the umbilical cord is essential. The cord is to be inspected once more for evidence of slipping of ligature. Dressing with bland power and cord binder are not favoured in places where the baby is placed in a clean environment. However the cord should be cleaned at least twice a day and should be observed if there is bleeding from the site of the cord. And also advice the mother and family members not to enclosed within the babys napkin where contamination by urine or faces may occur.
Bathing the baby is also very important to keep clean and comfortable for the baby, to maintain blood circulation, to prevent from infection, to detect any abnormalities or infection and treat it accordingly. Nutritious diet for the mother
It is the most essential basic needs of everybody but especially for lactating mother. Without nutrition, the mother cannot get energy and decrease the secretion of milk, so mother should eat highly nutritious foods and soups high in protein and carbohydrate e.g. Jawno KO soup, meat soup, Dal soup, chaku etc. Postnatal Exercise
Postnatal exercise is the exercise done after delivery in postnatal period which is very important to improve blood circulation, to help in involution of reproductive organs, to prevent thrombosis and thrombophlebitis, to promote well being of the postnatal mother, to restore the tone of the abdominal the pelvic muscles, for proper drainage of lochia. So advice mother to do postnatal exercise. Rest, sleep and activity
Mother should have 1o hours rest at night and 1-2 hours at afternoon till 40-60 days of delivery. Heavy working, heavy lifting should be avoided in puerperium because it predispose to uterine prolapse. 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 check up for mother and baby
Regular health check up 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 infants immune protection. Ensuring careful and frequent hand washing by all careers; the simple procedure 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, as intact skin provides a barrier against infection. Controlling extra visitor. Birth registration
CONCLUSION
Preventive obstetrics is the concept of prevention or early detection of particular health deviations through routine periodic examinations and screenings. The concept of preventive obstetrics concerns with the concepts of the health and well-being 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 Obstetric measure can be categorized into three main stages. They are as follows: Antenatal Nursing Intranatal Nursing Postnatal Nursing
BIBILIOGRAPHY. Lowdermilk & Perry Maternity Nursing, 6th edition Published by Mosby (Philadelphia), , page no: 123-167. Dutta D.C Text book of Obstetrics Including perinatology and Contraception,6th Edition (2004), New central book Agency ( Culkatta) Pg. No.95-113 Maya Devi Subedi, Manual of Midwifery A, 1st Edition, Chapter 11, Antenatal Advice, Books and Stationers, 2005, page no.: 157 - 165. Basavanthappa B.T Essentials of Midwifery & Obstetrical, Japee Publications (New Delhi) Pg.No.130-228 .. Krishna Kumari Gulani, Community Health Nursing (Principles and Practices), 1st Edition, Chapter-11, Maternal and Child Health, published by Kumar Publishing House, 2005, page no.: 354 366. K Park, Parks Textbook of Preventive and Social Medicine, 19th Edition, Chapter 9, Preventive Medicine in Obstetrics, Pediatrics and Geriatrics, published by M/s Banarsidas Bhanot, 2007, page no.: 415 422. LYNETTE A. AMENT, Professional Issues In Midwifery, Chapter 13, Historical Perspectives on Research and the ACNM, published by Jones and Bartlett Publishers, 2007, page no.: 263 266. Gloria Hoffmann Wold, Contemporary Maternity Nursing, 1st Edition, Chapter 1, Overview of Maternity Nursing, published by Mosby, 1996, page no.: 4 24. Http// Industrial relations.naukrihub.com