no relish remains to be used the next day, they only prepare enough food for the day.

PAST OBSTETRI A! "ISTOR# $rs. %&hata is Para ' (ith first deli)ery in *++* and she (as ** years by then. BREA&,O-% The first pregnan.y (ay term (ith /+ (ee0s gestation by fundal height. The baby (as deli)ered at %dirande "ealth entre and she deli)ered by Spontaneous 1ertex ,eli)ery but sustained a tear (hi.h (as sutured and healed (ithout any .ompli.ations. The baby (as 2/++g at birth and (as born (ithout any .ongenital nor during birth .ompli.ation. !abour had ta0en about '/ hours thus from 3 pm to 4am. $rs. %0hata has no history of ante5partum or intra5partum haemorrhage as (ell as Pre5e.lampsia or e.lampsia.

PS# "O!O6I A! "ISTOR# $rs. %0hata said that the pregnan.y that she has no( (as a planned one and also that the de.ision to ha)e the pregnan.y (as made by both her and her husband su.h that they both (ere )ery happy for the pregnan.y. She also said that she did not ha)e any psy.hologi.al problems due to both pre)ious pregnan.y as (ell as the .urrent one ex.ept for the fear of labour pains. I$$7%ISATIO%S $rs. %&hata explained that she had re.ei)ed t(o doss of Tetanus Toxoid 1a..ine (ith the first pregnan.y and t(o doses (ith the .urrent pregnan.y. "o(e)er, she expressed la.0 of 0no(ledge on the fre8uen.y and number of doses of tetanus Toxoid 1a..ine she is expe.ted to re.ei)e despite 0no(ing the importan.e of the immuni9ations. E%1IRO%$E%TA! "ISTOR#

On en)ironmental history, $rs. %&hata said that she has a t(o bedroom house (ith a seat room (hi.h is o..upied by three members of thee family, the husband, the first born .hild and herself. The house is iron sheet roofed, .ement floored and ele.trified. She said that she gets (ater from a ommunal -ater Point (hi.h is about :+ metres

from her house but she ma0es sure she has enough (ater all the time by 0eeping some in bu.0ets 0no(ing that there is a problem of (ater s.ar.ity in her area at times. On (aste disposal, she said that there is a rubbish pit behind the house (hi.h is used for (aste disposal and she 0eeps burning the (aste in the pit to pre)ent it from being blo(n ba.0 to the house by (ind (hen it;s full. SO IO5E O%O$I "ISTOR# ompany as a

$rs. %0hata is a <orm four !ea)er .urrently (or0ing (ith &7&7 $at.hes

Pa.0er. "er husband is an ele.tri.ian (ho is self employed. She said that her family is able to get their needs and ne.essities from the .ombined in.ome that they get from their duties and they li)e happily. $rs. %0hata reported no exposure to in.reased (or0load for she is .urrently gi)en light (or0 by her bosses ha)ing understood her .ondition. $rs. %0hata does not smo0e any 0ind of .igar nor drin0s any 0ind of al.ohol although the husband ta0es al.ohol but in a reasonable manner. PRESE%T OBSTETRI "ISTOR#

$rs. %0hata is gra)ida * Para ' mother !ast normal menstrual period = Expe.ted date of deli)ery = 6estation by dates "I1 Status 1,R! = = = ':th >uly, *+'+ **nd April, *+'' 2+ (ee0s, days %on5rea.ti)e %on5rea.ti)e

She is .urrently not on any medi.ations ex.ept for the <errous Sulphate she is gi)en (hen se )isits antenatal .lini. meant to help in the formulation of haemoglobin. E!I$I%ATIO% $rs. %0hata has no any problem (ith either bo(el mo)ement or urination. "o(e)er, she said that she had in the early days of pregnan.y a problem of fre8uen.y mi.turation.

OB>E TI1E ,ATA Vital Signs Temperature Blood Pressure Pulse Rate Respiration Rate = = = = 2?.3@ '*+A3+mm"g 3+ beats peer minute ** breaths per minute

6E%ERA! APPEEARA% E $rs %0hata is a '?* .m tall (oman, slim and light bro(n in .omplexion. She (as (earing a red blouse and a bla.0 s0irt (ith a pair of bla.0 slip5ons BshoesC. On this day she (eighed :D 0ilograms, gaining * 0ilograms from the (eight during her boo0ing )isit (hi.h (as :? 0ilograms. "EA, "er head is o)oid in shape (ith long .hemi.al made hair and there (as neither dandruff nor presen.e of s.ars or masses on the s.alp. <A E There (ere no signs of fa.ial oedema on both inspe.tion and palpation. The fa.e also did not ha)e s.ars on inspe.tion.

E#ES The eyes are symmetri.al and o)oid in shape (ith no signs of peri5orbital oedema and had a pin0 .onEun.ti)a. EARS The ears are symmetri.al (ith the upper ears in line (ith the outer borders of the eyes. There (ere no sore, no ear dis.harge, no lesions and no signs of inflammation on palpating the pre and post auri.ular lymph nodes. %OSE "er nostrils are symmetri.al (ith no any dis.harge. She has no history of epistaxis and did not ha)e any polyps in the nostrils. $O7T" "er lips (ere smooth (ith no sores or .ra.0s. "er tongue and oral mu.osa (ere pin0 (ith no sore, no 0orpli0s spots or signs of .andidiasis. There (ere neither de.ayed teeth nor gingi)itis. She has neither .left lip nor .left palate. The tonsilor, sub5 mandibular and sub mental lymph nodes (ere not enlarged. %E & She has no problems (ith ne.0 flexion as (ell as for(ard and ba.0(ard ne.0 bending. On inspe.tion, there (ere no ob)ious signs of distended Eugular )eins, no sores, no ob)ious lesions. On palpation, there (ere neither signs of enlarged thyroid gland nor enlarged deep .er)i.al, sub5.la)i.le and infra 5.la)i.le lymph nodes. "EST On inspe.tion, the .hest did not ha)e s.ars, lesions or signs of a pigeon .hest (ith normal respiratory mo)ements. On aus.ultation, there (ere normal lung and heart sounds. BREASTS

The breasts are symmetri.al in both si9e and shape and they both are light bro(n in .olour (ith dar0 alleorae. The breasts ha)e no s.ars, s.ales, lesions, no sores, rashes, redness and no dimpling. On breast palpation, no masses (ere felt ex.ept for the normal mammary gland. The nipples are dar0 in .olour, .lean and not in)erted. 7PPER EFTRE$ITIES The arms are symmetri.al (ith no signs of oedema on both inspe.tion and palpation. She has a .apillary refill of less than 2 se.onds and has pin0 palms. "o(e)er, $rs. %0hata reported ha)ing tingling sensation of the upper extremities. AB,O$E% On inspe.tion of the abdomen, there (as a dar0 linea nigra, some striae gra)idalum (ith no sores or s.ars. The abdomen (as o)oid in shape (ith a medium si9e. <oetal mo)ements (ere also obser)ed medially on inspe.tion. !i)er and spleen (ere not palpable indi.ating absen.e of organomegally. The .al.ulated gestation by dates (as 2+ (ee0s and Fundal height Pelvic, Lateral and Fundal Palpation <undal height <oetal Presentation = <oetal !ie <oetal Position <oetal "eart Rate = = = = *4 (ee0s ephali. !ongitudinal Right O..ipital Anterior '/* beats per minute

!O-ER EFTRE$ITIES The lo(er extremities are symmetri.al (ith no s.ars, )ari.ose )eins as (ell as signs of oedema on inspe.tion. On palpation, no tibial, an0le or pedal oedema (as dete.ted. %o signs of 1ari.ose 1eins or ,eep 1ein Thrombosis (ere dete.ted on palpation of the .uff mus.les. Howmans sign (as not obser)ed on flexion on the feet.

6E%ITA!IA 7pon inspe.tion of the genitalia, no oedema, sores, (arts, genital ul.ers, abnormal )aginal dis.harge or signs of hematoma (ere obser)ed. There (ere no signs of )ari.ose )eins or genital mutilation or .ir.um.ision seen. The )aginal dis.harge (as mild, (hitish and odourless.

PROB!E$S A%EE,S I,E%TI<IE,. &no(ledge defi.it on sexuality during intra and post partum periods related to inability set times on (hen to stop and resume sex. !a.0 of ade8uate information on immunisations related to limited information gi)en on immunisations as e)iden.ed by inability to outline the normal s.hedule for Tetanus Toxoid 1a..ine. &no(ledge defi.it on <o.ussed Antenatal )isit. Possibily of not using family planning methods related to untrue spe.ulations that ,epo5 Pro)era is phasing out. are and its importan.e related to limited

information gi)en about fo.ussed antenatal .are as e)iden.ed by late .oming for initial

ARE PRO1I,E, <o.us Antenatal are loo0s at .omprehensi)e .are gi)en to a pregnant (oman (ith spe.ified type of .are per ea.h )isit of the four expe.ted )isits that the (oman attends antenatal .lini.. It loo0s at 8uality of .are and not 8uantity of the number of )isits. <o.used Antenatal are emphasises on treating e)ery mother as an indi)idual or uni8ue person (ith indi)idual problems and needs. The .are that (as gi)en to $rs. %0hata (as based on the problems and needs that she had as (ell as spe.ifi. .are a..ording to hergestation age.

On this day, $rs. %0hata (as treated .omprehensi)ely starting (ith history ta0ing to fill in gaps follo(ed by "I1 and Syphilis tests then full physi.al assessment (hi.h in)ol)ed using all the four modalities of inspe.tion, palpation, aus.ultation and per.ussion. I made sure that the .lient;s .are (as pro)ided in a )ery .ondu.i)e en)ironment, thus ensuring pri)a.y as (ell as .leanliness. I made sure that she felt (ell ta0en .are of and (el.ome to the .lini. by being respe.tful, a..ommodati)e and letting her as0 8uestions and express fears than loo0ing at the .are as a burden throughout the pro.edures. E%1IRO%$E%T ,uring the filling in of gaps, .olle.tion of important information that (as missed out on the boo0ing day, an en)ironment that ensured pri)a.y and .omfort (as ensured. The data (as .olle.ted at an en.losed pla.e (here no one else .ould listen to (hat (as being dis.ussed and this made the .lient to be more open and to gi)e the information that (as re8uired. !i0e(ise, during the physi.al examination, a .ubi.al (as used to promote pri)a.y .onsidering that pro.edures in)ol)ed this time in.lude exposure of sensiti)e areas li0e the .hest, abdomen and genitalia. <I!!I%6 I% O< 6APS 7pon re)ie( of the Antenatal .ardApage for $rs. %0hata se)eral areas that re8uired to be filled in (ere realised. In addition to that, some more areas in the health passport (ere identified (hi.h also needed filling in. The health did not ha)e information on her family medi.al history and her medi.al and surgi.al history (hi.h is supposed to be filled o the first and se.ond pages of the health passport and this is also (here some important personal data is do.umented. See Appendix...... sho(ing the pages after filling in. %ot only that but also blood group and rhesus fa.tor (ere not tested but still more being an important information espe.ially (hen it .omes to emergen.ies li0e anaemia, I still referred her go also go for the tests (hen she goes for the other tests.

On the antenatal page as (ell, gra)idity and parity of the mother (ere not indi.ated during the first )isit but got do.umented on this )isit. TESTS <o.used Antenatal re.ommends mothers undergoing se)eral different tests at different )isits and different gestation ages. Su.h tests are li0e "I1, Syphilis, haemoglobin le)el, urine protein and ,/ .ount in .ase of those (ho are "I1 positi)e but not on antiretro)iral therapy. "I1, 1,R! and "aemoglobin le)el are the tests that are expe.ted to be done on boo0ing so as to ha)e a baseline data for some of them li0e "I1 and haemoglobin are tested again after sometime i.e. "I1 is tested again after 2 months (hile haemoglobin le)el is retested at 2? (ee0s. 7rine protein is expe.ted to be tested e)ery )isit from first to fourth )isit but unfortunately none of these (ere done on the first )isit On this )isit I played a role of helping $rs. %0hata get tested for "I1 and Syphilis (hose results .ame out negati)e as indi.ated on the antenatal .ard BAppendix.....C after filling in the gaps. "o(e)er, I referred the .lient to Gueen Eli9abeth tests (hi.h .ould not be done at %dirande Antenatal entre also reported not ha)ing the materials P"#SI A! EFA$I%ATIO% As indi.ated in thee obEe.ti)e data, during physi.al assessment, no spe.ifi. problems (ere presented or dete.ted from $rs. %0hata and all the findings (ere do.umented on the antenatal .ard and (ere also .ommuni.ated to the .lient. See Appendix...... sho(ing the antenatal .ard (ith findings of the abdominal assessment. $E,I ATIO%S $ost of medi.ations at the Antenatal lini. are gi)en a..ording to gestation ages of the mothers and most of them are gi)en for prophyla.ti. purposes i.e. SP is gi)en to pre)ent a mother from malaria, <errous Sulphate is gi)en to pre)ent anaemia (hilst entral "ospital for the lini. due to la.0 of materials li0e

the haema.ue 0its and protein dipsti.0s. The referral (as done after %dirande "ealth

Abenda9ole is gi)en to .ombat (orms infestation. SP is gi)en e)ery four (ee0s bet(een the gestations of '? to 2? (ee0sH <errous Sulphate is gi)en at e)ery )isit throughout pregnan.y (hilst Abenda9ole is gi)en Eust on.e and at first )isit. SP is gi)en in su.h a (ay to pre)ent the tetratonegi. effe.ts that the sulphur may ha)e on the foetus. On this )isit, $rs. %0hata, ha)ing the gestation age of 2+ (ee0s, she (as gi)en both SP tablets B2C as (ell as <errous Sulphate B2+ tabletsC. SP (as gi)en after .onfirming that / (ee0s had passed sin.e the last dose (as ta0en. $I,-I<ER# ARE

A%A!#SIS O<

ARE

A lot of things and .are (ere done during $rs. %0hata;s boo0ing antenatal )isit. I should sin.erely gi)e .redit to the .are pro)ider (ho handled $rs. %0hata on the first )isit for the good Eob for most things expe.ted to be done on boo0ing espe.ially data needed to be filled on the antenatal .ard (as filled. "o(e)er, not e)ery bit of information (as .olle.ted and do.umentedH for example, no information (as do.umented indi.ating gra)idity and parity on the antenatal .ard. This information is )ery important to e)ery mid(ife (ho (ould .ome into .onta.t (ith the .lient for it gi)es a pi.ture of the 0ind of .lient one is dealing (ith i.e. prim5gra)ida, multigra)ida or grand multipara. These also determine the 0ind of .are that a .lient (ill get. Se.ondly, the data do.umented on the antenatal .ard for abdominal assessment seem to ha)e been ta0en for granted by the .are pro)ider during the pre)ious )isit. "a)ing been gi)en the date for the last normal menstrual period, there (as no reason heAshe .ould not .al.ulate the gestation by dates for this day 0no(ing its importan.e. The .al.ulated gestation by dates is )ery important to a mid(ife for it gi)es a base .omparison (ith the fundal height done by tape measure or finger breadths. It also seems that the mid(ife (ho .ared for $rs. %0hata during the first )isit does not 0no( (hat it means (hen (e say presentation by abdominal assessment for sheAhe

indi.ated that it (as a )ertex presentation of (hi.h )ertex .an not be determined by pel)i. palpation but )aginally. SheAhe (ould rather indi.ate .ephali. for presentation and a position i.e. Right O..ipital Anterior, !eft O..ipital Anterior or other positions. Blood Pressure is on of the important )ital signs in pregnant (omen and unfortunately, it (as not done on the boo0ing day. #es its true there .ould be no a sphygmomanometer but still more a referral to %dirande only for a blood pressure .he.0 (ould be helpful. Pregnant (omen are at a ris0 of de)eloping pre5e.lampsia (hi.h is high blood pressure in pregnan.y and .an only be diagnosed if blood pressure if .he.0ed at e)ery )isit. 7rine protein test is also )ital in the (ay that presen.e of protein in urine is indi.ati)e of pre5e.lampsia $rs. %0hata had .ome for boo0ing at a gestation age of *? (ee0s by fundal height and this .learly sho(s la.0 of 0no(ledge on fo.used antenatal .are as (ell as its importan.e. $rs. %0hata being a Para one (ith birth of first born in *++3 (hen fo.used antenatal (as already under implementation, it (as expe.ted she must ha)e already been exposed to su.h type of .are. 7nfortunately, the mother .ame at *? (ee0s gestation follo(ing the old routine antenatal system. -hen i as0ed her, she said .oming at *+ (ee0s and abo)e (as (hat she 0ne(. This mother la.0ed information on fo.used antenatal and its importan.e (hi.h refle.ts that she (as not gi)en enough information about it during her first pregnan.y. EFPE TE, <I%,I%6S <OR T"E %EFT 1ISIT $rs. %0hata had .ome for her se.ond antenatal )isit at a gestation age of *4 (ee0s, ho(e)er, a..ording to fo.used antenatal, by this time she (as supposed to be.oming for her third )isit (hi.h is supposed to bee bet(een *D (ee0s and 2* (ee0s. In this .ase $rs. %0hata (ill ha)e her third and final normal )isit at 2? (ee0s though at this time a mother is normally expe.ted to be .oming for a fourth )isit. -hen $rs. %0hata .omes at 2? (ee0s (hi.h (ould be on ............., she (ill undergo se)eral assessments some that are routine li0e )itals signs (hilst some (ill base on her .ondition as being in third trimester or ha)ing a 2? (ee0s gestation. Some of thee .are (ill also base of the gaps that the mid(ife (ill identify as being left out during the

pre)ious )isit. On the next )isit the mid(ife (ill ha)e to .he.0 on the .are gi)en on the pre)ious )isit, e)aluate and then ha)e a basing for planning hisAher .are and this (ill also depend on the .urrent problems and the unmet needs of the .lient. The mid(ife (ill .olle.t some information from the .lient to fill in the gaps that are not filled during this )isit. She (ill also .he.0 on the progress of pregnan.y by as0ing $rs. %0hata on ho( she fairing (ith her pregnan.y. Some of the 8uestions she may as0 are the presen.e of foetal mo)ements and minor disorders of pregnan.y for this (ill help the mid(ife to isolate the problems that the .lient has at present. $rs. %0hata (ill also ha)e to undergo se)eral tests (hi.h (ill be due by this time i.e. haemoglobin le)el and urine protein. "aemoglobin le)el is .he.0ed on boo0ing and in third trimester, at 2? (ee0s to be spe.ifi. (hilst for urine protein is .he.0ed at e)ery )isit to the antenatal .lini.. 1ital signs are another aspe.t that (ill ha)e to be .he.0ed by the mid(ife as part of monitoring progress of pregnan.y. Any abnormality in the )ital signs is indi.ati)e of a problem in the pregnant (oman. <or exampleH high blood pressure .ould be indi.ati)e of pre5e.lampsia, fe)er .ould indi.ate a systemi. infe.tion and in.reased respiratory rate .ould mean diffi.ulty breathing, though, it is thought to be normal at 2? (ee0s. Physi.al assessment (ill also be done in.luding general assessment as (ell as abdominal assessment. 6eneral assessment (ill in)ol)e a head to assessment and no abnormality is expe.ted from it. The abdominal assessment (ill in)ol)e inspe.tion, palpation and aus.ultation of the abdomen to .he.0 si9e and shape of abdomen, fundal height, lie, presentation and position of foetus as (ell as foetal heart rate. The abdomen is inspe.ted for s.ars, linea nigra, striae gra)idalum, si9e and shape, foetal mo)ements, bladder fullness and )isible organomegally. Thee fundal height (ill be measured using a tape measure of finger breadths so as to determine the age of pregnan.y. Then the pel)is (ill be palpated for presentation (hi.h is normally, lateral palpation (ill be done to note the lie and position of the foetus.

<undal palpation (ill also be done to rule out multiple gestation or presentation in a situation (here the head is not lo.ated in the pel)i.. <oetal heart rate (ill also ha)e to bee aus.ultated using a fetals.ope to .onfirm (ellbeing of the foetus.

EFPE TEE, <I%,I%6S <undal height <oetal Presentation = <oetal !ie <oetal Position <oetal "eart Rate = = = = 2? (ee0s ephali. !ongitudinal Right O..ipital AnteriorA!eft O..ipital Anterior '/+ I '?+ beats per minute

The abo)e expe.ted findings are thee normal expe.ted finding in the absen.e of possibility of ha)ing abnormal findings ,R76S On this )isit $rs. %0hata (ill only be pro)ided (ith <errous Sulphate as a drug to supplement iron for haemoglobin formation. SP (ill not be gi)en be.ause it is belie)ed to ha)e a teratoni. effe.t on the fetus (hen gi)en at the gestation of 2? (ee0s and abo)e. EFPE TE, ,ISOR,ERS By this time the expe.ted disorders that $rs. %0hata may ha)e are diffi.ulty breathing, fre8uent mi.turation, heada.he, .onstipation, ba.0a.he, oedema )ari.osities, haemorrhoids and .ramps for these are the .ommon disorders that usually .ome in third trimester. MANAGEMENT OF THE E PE!TE" M#N#$ "#SO$"E$S HEA$T%&$N

This is a burning, irritating sensation in the oesophagus also 0no(n as gastri. reflux B<raser, ooper and %olte, *++?C. 6astri. reflux .ommonly o..urs as a result of delayed gastri. emptying, de.reased intestinal motility, and de.reased lo(er oesophageal sphin.ter tone. If it happens that $rs. %0hata de)elops heartburn, edu.ation and .ounseling on li'est(le
)odi'ication (ill be pro)ided and (ill in.lude a(areness of posture i.e. $aintaining upright positions Bespe.ially after mealsC, sleeping in a propped up position and dietar( )odi'ications Be.g. small fre8uent meals, eating slo(ly, redu.tion of high5fat foods and .affeineC.

S*ELL#NG+E"EMA As the gro(ing uterus puts pressure on the )eins that return blood from feet and legs, s(ollen feet and an0les may be.ome an issue. At the same time, s(elling in legs, arms or hands may pla.e pressure on ner)es, .ausing tingling or numbness. <luid retention and dilated blood )essels may lea)e the fa.e and eyelids puffy, espe.ially in the morning. To redu.e s(elling, the .lient (ill be ad)ised to use .old .ompresses on the affe.ted areas. !ying do(n or using a footrest may relie)e an0le s(elling. She might e)en ele)ate her feet and legs (hile she sleeps (hi.h (ill also minimise the s(elling by gra)ity. ",SPNEA This is a .ommon symptom bet(een the gestation of 2/ and 2? (ee0s. It is as a result of the pressure by the gro(ing uterus on the diaphragm B<raser, ooper and %olte, *++?C. If $rs. %0hata happens to de)elop dyspnoea, she (ill be edu.ated of the physiology of the problem for her to understand (hat;s happening. She (ill also be ad)ised on sleeping in semi5fo(lers position so as to be in.reasing the area for lung expansion hen.e impro)ed respiratory .ondition. She (ill also be en.ouraged to ha)e periods and resting to redu.e the body need for oxygen. !ONST#PAT#ON

onstipation in pregnan.y espe.ially third trimester is usually .aused by redu.ed motility of large intestine (hi.h .omes due to the mus.le laxati)e effe.t of the hormone progesterone (hi.h is produ.ed in large amounts this period, In.reased (ater re5 absorption from large intestine due to hormone aldosterone effe.t, Pressure on the pel)i. .olon by the pregnant uterus and sedentary life during pregnan.y . if the .lient (ill .ome (ith the problem of .onstipation, she (ill ad)ised on drin0ing plenty of fluids, high fibre foods and get plenty of exer.ise. These help in softening the bo(els hen.e redu.ed ris0 of .onstipation. %A!-A!HE ,uring pregnan.y, ligaments be.ome softer and stret.h to prepare for labour. This .an put a strain on the Eoints of the lo(er ba.0 and pel)is, (hi.h .an result in ba.0a.he. To o)er.ome this problem $rs. %0hata (ill be ad)ised to a)oid hea)y lifting, bend her 0nees and 0eep her ba.0 straight (hen lifting or pi.0ing up things from the ground, mo)e her feet (hen turning and a)oid sudden t(isting mo)ements, -or0 at a surfa.e high enough to pre)ent her from stooping and to sit (ith her ba.0 straight and (ell5 supported. Another ad)i.e (ill be that she should ma0e sure she gets enough rest, parti.ularly later in pregnan.y.

F$E.&ENT M#!T&$AT#ON As the baby mo)es deeper into your pel)is to(ards term of pregnan.y, a (oman feel more pressure on your bladder and may find herself urinating more often, e)en during the night. This extra pressure may also .ause her to lea0 urine J espe.ially (hen she laughs, .oughs or snee9es. In this .ase the .lient (ill Eust ha)e to be assured that this is normal (ith a good explanation of the .ause. She (ill also ha)e to be ad)ised on perineal .are to pre)ent as.ending infe.tions. !$AMPS ramp is a sudden, sharp pain, usually in .alf mus.les or feet. It is most .ommon at night, but nobody really 0no(s (hat .auses it. The (oman (ill be oriented to s0ills she

(ill ha)e pra.ti.e to .ombat the problem for exampleH pulling up of toes hard up to(ards the an0le, or rub the mus.le hard. 6entle exer.ise in pregnan.y, parti.ularly an0le and leg mo)ements, (hi.h .an impro)e blood .ir.ulation and may help to pre)ent .ramp o..urring and plenty of .al.ium ri.h foods Bleafy green )egetables, dairy produ.ts, sunflo(er seeds, salmon and dried beansC and magnesium ri.h foods Bnuts, dates and figs, yello( .orn, green )egetables and applesC in her diet. FEA$ As the pregnan.y dra(s near term most (omen be.ome afraid of the labour pains, fears about .hildbirth may be.ome more persistent. "o( mu.h (ill it hurtK "o( long (ill it lastK "o( (ill they .opeK If $rs. %0hata happens to .ome (ith su.h a problem, she (ill be ad)ised on the importan.e of hospital deli)ery (here pain relief me.hanisms are a)ailable. She (ill also be as0ed to ha)e time (ith other (omen (ho ha)e had positi)e experien.e of labour and this (ill help in relie)ing her fears.

E,7 ATIO% A%,

O7%SE!!I%6

,uring the assessment, se)eral areas (ere identified that needed edu.ation and .ounselling to $rs. %0hata. <A$I!# P!A%%I%6 $rs. %0hata indeed 0no(s (hat family planning is as (ell as the a)ailable family planning methods in $ala(i but has problems (ith .hoi.e of family planning method a..ording to her reprodu.ti)e goals. $rs. %0hata expressed that she (ants to use inEe.table .ontra.epti)es B,epo5Pro)eraC as her family planning methods of .hoi.e. "o(e)er, she also expressed fears that she had heard that the method is phasing out soon. !oo0ing at her reprodu.ti)e goals, I felt that $rs. %0hata .ould also benefit from other family methods that are long term li0e Intrauterine than the methods she had .hosen ontra.epti)e ,e)i.e and >adelle

I dis.ussed (ith her of all the methods on the positi)es, negati)es and a)ailability of the methods (ith mu.h emphasis on >adelle (hi.h is the best method for her basing on her goals as she (ants to ha)e a spa.e of fi)e years before gets pregnant again so the same (ith the method as it is made to last for : years. I also .ommented on the spe.ulation that inEe.table .ontra.epti)es are phasing out by telling her that it is not true. I also explained to her that the best time to start family planning is six (ee0s after deli)ery for it is belie)ed that by this time a (oman;s fertility has returned and also her body has returned to her pre5pregnant state and .an resume sex B<amily Planning "andboo0, *++4C I$$7%ISATIO%S Based on the information that she had re.ei)ed only t(o doses of Tetanus Toxoid 1a..ine (ith the first pregnan.y and t(o (ith the .urrent one, I felt she needed more information on the right expe.ted s.hedule the mothers are need to follo( to .omplete all the fi)e doses for TT1. On this day, an explanation on the normal )a..ination s.hedule (as gi)en to $rs. %0hata so that as she has already started (ith the t(o doses, should finish the remaining three doses. <inishing the doses (ill help in redu.ing the ris0 of the baby from getting tetanus. -e together planned on ho( she (as going to get the other doses. The third dose (ill be gi)en on 3ADA'', the fourth dose (ill be gi)en on 3ADA'* and the last dose (ill de gi)en on 3ADA'2. SEF7A!IT# $rs. %0hata did not ha)e 0no(ledge on (hen to stop sex before deli)ery and (hen resume after deli)ery. On this day, oriented her to the right time as to (hen she .an stop sex as (ell as (hen to resume. I told her that there is no limitation as to (hen they .an stop sex thus they .an ha)e sex until term of pregnan.y as far as they are .omfortable. I also explained to her that they .an resume sex as early as ? (ee0s as far as she feels that her body is ready for sex. BIRT"" P!A% A%, O$P!I ATIO% PREPARE,%ESS

Realising that $rs. %0hata (as afraid of labour pains, I too0 sometime .ounselling her on normal pro.esses of pregnan.y until labour and deli)ery so as to alley her anxiety. Ii put emphasis on the need and importan.e of deli)ering at the hospital (here measures of managing labour pains are used. I also ad)ised her on the need to asso.iate and learn from mothers (ho had undergone the same experien.e se)eral times (ho .an help her prepare for her labour and deli)ery. <O 7SE, A%TE%ATA! ARE

Basing on the time that she had started antenatal )isits, it sho(ed that she did not ha)e enough or no 0no(ledge on fo.used antenatal .are and its importan.e. I therefore planned to edu.ate her on (hat fo.used antenatal is, and its importan.e. $rs. %0hata (as told (hat is done at the .lini. (here fo.used antenatal system is follo(ed and also (hat if expe.ted of (omen undergoing fo.used antenatal .are espe.ially (hen to start attending antenatal and ho( fre8uent. -e also dis.ussed on the importan.e of attending all the expe.ted normal four )isits of antenatal .are. $I%OR ,ISO,ERS O< PRE6%A% # In addition to these edu.ation and .ounselling sessions, $rs. %0hata (as also prepared for the expe.ted minor disorders that may de)elop as the pregnan.y progresses espe.ially in the third trimester. $inor disorders li0e dyspnoea, heartburn, .onstipation and ba.0a.he are some of the .ommon disorders that o..ur to mother in their third trimesters. So she (as told of the disorders so as (hen they happen she should not be anxious but a..ept them as things that happen normally.

,ate for the next )isit.