FNP LECTURE THEME 2

Pre natal care Lecture 1 Presenter :Ms Aliti Qarikau

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.

Aims of prenatal care

Developing a partnership with the woman Providing a holistic approach to the woman s care that meets her individual needs Promoting an awareness of the public health issues for the woman and the family Exchanging information with the woman and her family and enabling them to make informed choices about pregnancy and birth.

Aims of prenatal care cont:

Being an advocate for the woman and her family during her pregnancy, supporting her right to choose care that is appropriate for her own needs and those of her family Recognizing complications of pregnancy and appropriately referring women within the multidisciplinary team Facilitating the woman and her family in their preparations to meet the demands of birth, and make a birth plan Facilitating the woman to make an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision. Offering education for parenthood within a planned programme or an individual basis Working in partnership with other pertinent organizations

Initial Assessment (Booking)

Purpose: to introduce the woman to the maternity service where information will be shared between the woman and nurse in order to discuss , plan and implement care for the duration of the pregnancy, the birth and postnatally.

Initial visit cont:

often quite lengthy nurse has the first contact with the pregnant woman who require: a comfortable/ supportive environment open communication positive nurse s attitude - will help put the woman at ease at the initial visit and sets the tone for the remainder of the visit. complete history is recorded to identify factors that may negatively affect the pregnancy physical examination is performed

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

Observation of physical characteristics

Posture and gait can indicate back problems or previous trauma to the pelvis Woman may be lethargic which indicates extreme tiredness, anemia, malnutrition and or depression

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

Current medical history

Weight General health including nutrition, exercises etc Present medication (Including non- prescription drugs) Previous or present use of alcohol, tobacco, caffeine (ask specifically amount consumed daily) Drug allergies and other allergies Presence of disease conditions e.g. diabetes, hypertension, cardiovascular disease, renal problem etc Immunization record Presence of any abnormal conditions

Past medical history

Childhood diseases Past treatment for any diseases. Any hospitalization? ( hepatitis, rheumatic fever, pyelonephritis) Surgical procedures Presence of bleeding disorders ( has she received blood transfusion?)

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

Determination of due date

Families generally want to know the due date or date around the childbirth Commonly known as EDD estimated date of delivery It is 40weeks from the first day of the woman s LNMP Calculated by adding 9 months and 7 days to the first day of the woman s LNMP This method assumes that : the last period of bleeding was true menstruation (implantation of the ovum may cause slight bleeding)

 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)

Pretest and post test counseling

The discovery by an individual that she is infected with HIV will have profound effects on her psychologically, socially and economically. For complex social reasons it is a uniquely stigmatized infection Pretest counseling: Decision making about HIV testing may be more complex in pregnancy, because the woman will need to consider the implications not only on herself, but socially & on the family relationships Information about the nature of the infection Meaning of test results Why the need for testing Get consent for test ( some voluntarily come for testing )

 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)

Factors placing woman at risk for nutritional inadequacy:

Adolescence: -due to demands for own growth and pregnancy: possible poor dietary habits, and possibility of trying to hide pregnancy Inadequate nutritional intake Pica Low income Smoking, alcohol use, or drug addiction Short interval between pregnancies- no time to replenish maternal stores. Medical conditionsdiabetes or kidney problems depression

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

Get ready for class activity!!

Calculate the EDD for: 1- Suzy who had her last normal period on 12/10/09 2- Esther who said that the first day of the last period was the 26th of September 2009

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

General health habits Self care:

Physical care during pregnancy generally involves minor adjustments in or moderation of normal habits. 1. Breast care 2. Personal hygiene 3. Activity and rest 4. Clothing 5. Employment 6.Travel 7. Dental care 8. Sexual activity

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

ACTIVITY & REST

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

Sexual activity cont:

Advice woman not to lie Men change in desire. (related to their feelings flat on back during about partner s intercourse after the 4th changing appearance, month. (supine concern about hurting hypotension syndrome). her or the fetus) Pillow should be placed under the hip to displace the uterus or use an alternate position.

CHILBIRTH EDUCATION (Birth preparation classes)

Usually recommended for pregnant women above 28 weeks of gestation Woman to undergo at least 2-3 sessions Helps women to understand what is happening in her body-has less fear and is less tensed, be more relaxed during labour, and will be able to help more effectively during the birth process. Facilitated by the Physiotherapist and/or nurse educator. 28wks -35wks-excercises for relieving backaches, cramps, stretching exercises, relaxation postures, correcting postures, perineal muscle excercises,deep breathing 35weeks>- labour preparation classes

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.

Management of common discomforts cont:

Hemorrhoids Prevent constipation, apply ice packs, use topical anesthetic ointments, take sitz bath, gently push hemorrhoids back into rectum Dorsiflex when prolonged standing or resting necessary, elevate legs when sitting or resting, increase number of rest periods Rest with feet and legs elevated, avoid crossing legs, standing still, restrictive clothing, wear support hose Get adequate rest, use proper posture, use proper body mechanics, wear low heeled shoes. Ankle edema

Varicose veins (legs) Backache

Management of common discomforts

Discomfort Nausea and vomiting intervention Limit fluid intake at meals & upon walking Small frequent meals Avoid fried, spicy, odorous, or gas forming foods Avoid overeating Sit up for 1 hour after eating, take antacid only with Dr s approval Empty bladder when urge is felt, do not restrict fluid intake Wear well fitting bra Eat small meals, omit gas forming foods from diet, have regular elimination Increase activity and fluid intake Increase fiber in diet (raisins, fresh vegetables and fruits)

Heartburn

Urinary frequency Breast tenderness Flatulence Constipation

Minor discomforts cont:

Dyspnea Lie on either side, sleep in semi- fowlers position, maintain proper posture Evaluate diet for adequate calcium and phosphorous intake, pull toes up towards knee, rest with legs elevated Lie on either side, not on back, arise slowly, avoid standing in warm area, practice slow, deep respirations, drink orange juice for fast-acting sugar. Bath or shower daily, avoid douching, wear absorbent cotton underwear. Use lotion on skin, change soap, rinse well. Drink more fluids. Leg cramps

Dizziness and fainting

Vaginal discharge . Itchy skin

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.

DR. Fernand Lamaze (psycho prophylaxis- mental & physical preparation)

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

Physical examination and risk assessment

Begins with measuring the client s height and weight and vital signs. A head to toe examination is performed by the health care provider Special attention is given to the assessment of the heart, lungs, pelvis, breasts and nipples. Pelvic examination is performed last The external genitalia are examined for scars, lesions, or infections, a pap smear is done if appropriate

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

Warning signs during pregnancy

Vaginal bleeding (any), bloody or show Sudden gush of fluid from vagina Persistent vomiting Severe continuous headache Swelling of face , hands and feet when arising in the morning Visual disturbances: blurred vision, double vision, flashes of light, spots before eyes

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.

Measuring fundal height

From symphysis pubis to height of fundus

Palpating for the position of the presenting part

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