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A SEMINAR ON PREVENTIVE OBSTETRICS SUBMITTED TO SUBMITTED BY MRS.MEERA MRS.Aneesa.S ASST.proffessor 1st year Msc Nursing VNSS COLLEGE OF NURSING kollam
MASTER PLAN SUBJECT : OBSTETRIC AND GYNAECOLOGICAL NURSING GENERAL OBJECTIVE: On completion of the seminar the students will be able to get adequate knowledge regarding preventive obstetrics and able to prevent obstetric complication by applying measures while practicing it. SPECIFIC OBJECTIVE: On completion of the seminar the students will be able to • Define preventive obstetrics • Mention preventive obstetrics measures • Explain preventive obstetric s measures, antenatal nursing, Intranatal nursing, postnatal nursing
SL.NO. CONTENT 1 INTRODUCTION 2 TERMMINOLOGIES 3 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 4 CONCLUSION 5 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. . .
PREVENTIVE OBSTETRIC DEFINITION Preventive Preventive is the term used to prevention or slowing the course of an illness or disease. It is intended or used to prevent or hinder acting as an obstacle. Obstetric The branch of medicine that deals with the care of women during pregnancy, childbirth and recuperative period following delivery is known as obstetric. Preventive Obstetric 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. Objectives of Antenatal Care To promote, protect and maintain the health of the mother during pregnancy. To detect “high risk” cases and give them special attention. To foresee complications and prevent them. To remove anxiety and dread associated with delivery. To reduce maternal and infant mortality and morbidity. To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation. To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy. To detect and treat any abnormality found in pregnancy as early as possible.
1. Preconceptional Counseling and Care When couple is seen and counseled about pregnancy. Its course and outcome well before the time of actual conception is called preconception counseling. It is a very new concept. Objective is to ensure that a woman enters pregnancy with an optimal state of health which would be safe both to herself and the fetus. Organogenesis is completed by the 1st trimester. By the time the woman is seen first in the antenatal clinic it is often too late to advice because all the adverse factors have already begun to exert their effect. In an ideal world antenatal care world commence at the preconception stage where health education (general advice about nutrition, lifestyle, avoidance of teratogens, folic acid supplementation, etc) and risk assessment can be focused toward a planned pregnancy. Preconception counseling is of much greater importance in two main groups of women. Ones with underlying medical conditions that may be affected by or may influence the outcome of pregnancy. Examples of such conditions include diabetes, various endocrinopathies, hemostatic or thrombotic problem and cardiac disease. Patients following organ transplantation (kidney, liver, heart and lungs) are also now contributing to the ranks of these patients along with survivors of childhood malignancies. A multidisciplinary approach to optimize/ stabilize the underlying condition and planning care during the antenatal period is a key component to optimizing pregnancy outcome. Ones where there are identifiable factors that would suggest the couple are at a risk of fetal anomaly. Such identifiable factors may include a previous child affected by a single gene disorder or syndromic disorder, a family history of genetic disorder or history of parental chromosomal abnormality. Counseling is a major part of prenatal diagnosis. The majority of parents to be do not perceive themselves at risk and 95 percent of abnormalities do occur unexpectedly, in pregnancies not considered at risk. Preconceptional Counseling Permits Identification of high risk factors is done by detailed evaluation of medical, obstetric, family and personal history. Risk factors are assessed by laboratory tests, if required. Treatable factors like pre- existing chronic diseases (hypertension, diabetes, epilepsy) are stabilished in an optimal state by early intervention before pregnancy. Proper counseling to those with history of recurrent fetal loss or with family history of congenital abnormalities (genetic, chromosomal or structural), as there may be some untreatable factors. Overweight or under weight is to be corrected with proper dietary advice. Rubella and hepatitis immunization in a non – immune woman is to be offered. To record a base level health status including BP reading.
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. 2. Essential Antenatal Care Services The essential components of services during pregnancy include are:- Registration of Pregnant Women Antenatal Visits and Antenatal Care Immunization Against Tetanus Iron and Folic Acid and Vitamin A and D Supplementation Health education / prenatal advice during Pregnancy Registration of Pregnant Women Care during pregnancy should be started as early as possible. The mother must be registered within 20 weeks of pregnancy either at health centre/ antenatal clinic or at home by a nurse/health visitor/ female health worker (ANM) or trained person. Through physical and obstetrical check up should be done to screen for risk factors, make assessment and give appropriate care for prevention and control of various health problems and complications. Antenatal Visits and Antenatal Care Ideally a woman should be seen and given care during pregnancy once a month during the first trimester or till seven months, once in fortnight during the second trimester or till the eighth month and thereafter every week till confinement. But often these many visits are not feasible, neither for the mother nor for the health infrastructure available. The care should begin soon after conception and continue throughout pregnancy. A schedule to follow for the mother is to attend the antenatal clinic once a month during the first seven months, twice a month during the next two months and thereafter once a week if everything is normal. Therefore a minimum three visits one in each trimester have been recommended. The first visit should be done within 20 weeks or as early as the mother is registered. The second visit at 32 weeks of pregnancy. The third visit at 36 weeks of pregnancy. Further visits may be made if justified by the condition of the mother. At least one visit should be paid in the home of the mother to make observation of actual conditions and accordingly prepare the mother. The main purpose of contact during antenatal period is to make observations and assess general health, obstetrical health status, identify risk factors and provide appropriate care.
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 women’s 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 physician’s 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. Immunization Against Tetanus A pregnant woman must get two injections of Tetanus Toxoid during the period between 16 – 36 weeks, at one month interval. These protect the mother and baby both from the risk of tetanus. The 2nd injection should preferably be given at least at one month before delivery. If a woman is registered late then in that case even one injection will do. If the woman is immunized earlier within three years of the pregnancy, then one booster dose will be enough. Iron and Folic Acid and Vitamin A and D Supplementation It is being found that 50-60 percent of pregnant women are anaemic due to iron deficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to take one tablet containing 60 mg.of elemental iron and 500 mg of folic acid three times daily after third month of pregnancy till 3 months after child birth if the mother is found having anaemia. During pregnancy, the mother requires extra iron and folic acid due to changes taking place in the body and growth of fetus in the womb. Therefore each mother is given one tablet of iron and folic acid twice a day for at least 100 days to prevent anaemia in mother and to promote proper growth of fetus. Anemia is common in pregnancy and low – income group. It is a major cause of maternal and fetal mortality. Prevention of Anemia Avoidance of frequent of child birth: At least two years an interval between pregnancies is most necessary to replace the lost iron during childbirth process 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.
Health education / prenatal advice during Pregnancy A major component of antenatal care is health education and prenatal advice. The mother is more receptive to advice concerning herself and her baby at this time than any other time. A woman during pregnancy needs to know about her nutrition, personal hygiene, rest and sleep, exercise, use of drugs, warning signs etc. Pregnancy can be both an exciting and worrying time for the mother and her partner. Part of the role of the health care professionals (usually fulfilled by the community midwife and general practitioner) caring for the mother is the provision of information about everyday activities that may or may not be affected by or have an effect on the pregnancy. Diet during pregnancy Personal Hygiene Rest and Sleep Physical work Exercise Comfortable clothing and shoes Smoking Alcohol Breast Care Drugs Radiation Protections from infections and illnesses Sexual activities Travel Reporting of untowards signs and symptoms Child care Follow up visits Warning Signs Diet during pregnancy Nutritional intake is an important factor in the maintenance of maternal health during pregnancy and in the provision of adequate nutrients for embryonic/fetal development. Assessing nutritional status and providing nutritional information or referral to a dietitian are part of the nurse’s responsibilities in prenatal care. Dietary extremes are associated with risks in pregnancy. Obesity is associated with gestational diabetes, hypertension and monitoring difficulties. Malnutrition is associated with maternal anemia and fetal growth restriction, while deficiency of certain vitamins predispose to congenital abnormalities, folic acid deficiency is linked to the risk of neural tube defects (NTDs). A balanced diet rich in fresh fruit and vegetable is recommended. It is prudent to avoid unpasturized milk and cheeses and pâtés. Pregnant woman should avoid eating liver due to its high vitamin A content. Vegans should have Iron and vitamin supplementation and ethnic groups lacking sunlight are advised to have extra vitamin D.
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. Relationship between Maternal and Foetal Nutrition Energy Inadequate food intake and poor nutrient utilization Maternal Malnutrition Reduced blood volume expansion Inadequate increase in cardiac output Decreased blood and nutrient supply to the foetus Reduced placental size Reduced nutrient transfer 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.
• Fresh air and sunshine 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. Rest and Sleep A pregnant woman needs sufficient rest. She should do less and lighter work. She must have 8-10 hours of sleep every night. She needs to take short nap during the day. As the pregnancy advances, the mother requires more frequent short rests during the day. She should avoid strenuous work, carrying heavy loads or weights e.g. bringing water from long distance, drawing of water from a well etc. Rest is important for the maintenance of good health. She should need adequate rest and relaxation. Relaxation of the mind produces relaxation of the muscle and a relaxed lower uterine segment and pelvic floor makes it easier for the baby to be born. 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. Comfortable clothing and shoes It is advisable to wear loose and comfortable cotton clothes, not too tight such as blouse or cholo.Brassier which supports the breasts should be advised, but must not be too tight so as to flatten the nipples but lift the breast well. A support for the abdomen is sometimes required, especially in a multigravida who has pendulous abdomen so the pregnant mother should advise to support her whole abdomen with a light belt. Pregnant should avoid high heeled shoes. She should wear flat shoes to maintain center of balance and to prevent backache to some extent. 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, doesn’t 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. Protections from infections and illnesses Infections in pregnancy are responsible for significant morbidity and mortality. The direct financial costs of disease can be as starting and are much more difficult to measure. Some consequences of maternal infection last a life time. Education and counseling are important aspects of care for the prevention of maternal infections. Adolescents mothers are at high risks because of earlier partners. The recent trend of exchanging sex for drugs is contributing to a rise in infection rates, especially among poor, and minority women. The prevention of disease and the reduction of maternal and neonatal effects continue to be monumental challenges. An expectant mother must be instructed to protect herself from the risk of any infection especially measles, German measles and syphilis because these infections can cause spontaneous abortion, malformation, mental retardations, still-birth, perinatal death etc. The child may develop congenital syphilis. If the mother is found having syphilis she must get herself treated by the trained health personnel especially from health center/hospital. 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. Reporting of untowards signs and symptoms • The expectant woman must be instructed to report to health personnel the following signs and symptoms. • Unusual pain, bleeding from vagina. • Swelling in the feet, hands or face • Headache, dizziness, blurred vision at times. These symptoms indicate the onset of high blood pressure which is very dangerous and can prove fatal if timely care is not given. • High fever • Baby’s movements not being felt. • Any other sigh or symptom which is considered unusual. 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.
3. Specific Health Protection Specific protection for pregnant women’s health is an essential aspect of prenatal care. This is because 50 to 60% of women, belonging to low socio-economic groups are anemic in the last trimester of pregnancy. The major causative factors are iron and folic acid deficiencies. Anaemia is known to be associated with high incidence of premature births, postpartum haemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother. Anaemia Surveys in different parts of India indicate that about 50 to 60 percent of women belonging to low socio- economic groups are anemic in the last trimester of pregnancy. The major aetiological factors being iron and folic acid deficiencies. It is well known that anaemia per se is associated with high incidence of premature births, postpartum haemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother. Other Nutritional Deficiencies Protection is required against other nutritional deficiencies that may occur during pregnancy such as protein, vitamin and mineral deficiencies. So Vitamin A and D capsules should be supplied for the pregnant mother. Toxemias of Pregnancy The presence of albumin in urine and increase in blood pressure indicates toxemias of pregnancy. Their early detection and management are indicated. Efficient antenatal care minimizes the risk of toxemias of pregnancy. Diabetes This plays an important role for presentational diabetes. To prevent early pregnancy loss and congenital anomalies, medical care should begin before conception. A complete assessment of the diabetic status and associated complications is done to find out if she is fit to go through pregnancy. Evaluation of thyroid function is also recommended in type 1 diabetes as hypothyroidism is frequently encountered in these women. Those on oral hypoglycemic agents should be switched to insulin therapy preferably before conception. Tetanus Protection If the mother was not immunized earlier, two doses of tetanus toxoid should be given, the first dose at 16th to 20th week and the second dose at 20th to 24th week of pregnancy. For a woman who has been immunized earlier, one booster dose will be sufficient. When such a booster dose is given, it will provide necessary cover for subsequent pregnancies for the next five years.
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. 4. Preparing for Confinement The preparation for safe delivery is very important. It should be done well in advance to avoid any type of difficulty or emergency which might occur at the time of delivery. The health personnel discuss with the couple and may be other members of the family about the alternative suitable place for confinement which includes home, health centre or hospital. The decision will depend upon the health status of both mother and the fetus, risk factors and environmental conditions at home. High risk mother must be delivered at primary health center, first referral unit or hospital at the discretion of doctor. However a normal healthy mother may be delivered at home. But she must be delivered by a trained birth attendant, female health worker (
ANM),health supervisor ( LHV) to protect the life of both mother and the baby 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. 5. Psychological preparation of the mother Psychological preparation of the mother is important during pregnancy and delivery. The expectant mother, especially the primary Para mother has fear and anxiety about child birth, its outcome, and complications etc.It is very important to discuss various aspects of pregnancy and delivery .This helps in overcoming their fears and anxietes.Sufficient time and opportunity must be given to expectant mothers to have free and frank talk on all aspects of pregnancy and delivery. The “mother craft” classes at the MCH centers help a great deal in removing their fears and in gaining confidence.
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. 7. Education for Self – Care Health maintenance is an important aspect of prenatal care. Patient participation in the care ensures prompt reporting of untoward responses to pregnancy. Patient as symptom of responsibility of health maintenance is prompted by understanding of maternal adaptations to the growth of the unborn child and a readiness to learn. Nurses in their role of teacher provide patients with the information necessary for compliance with health care measures. The expectant mother needs information about many subjects. During the initial health assessment, the woman may have indicated a need to learn self care activities such as prevention of urinary tract infection. Supportive maternity brassiere with pads to absorb discharge may be worn at night, wash with warm water and keep dry, see maternal physiology and sexual counseling. Both partners need reassurance and support, support significant other who can reassure woman about her attractiveness, etc improved communication with her partner, family and others, refer to social worker, if needed or supportive services ( financial assistance, food stamps) 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. 9. Screening for Urinary Tract infection Urinary tract infections may be asymptomatic. Whether symptomatic or not, urinary tract infections present a risk to both mother and fetus. Prevention of these infections is essential. The woman’s understanding and use of general hygiene measures are assessed. Before developing a plan of care, the nurse needs to elicit feelings or ideas concerning cultural, ethnic, religious, or other factors affecting health practices. The rationale being that some cases asymptomatic bacteriuria and a lower urinary tract infection may lead to complications of the advanced stages of the disease. The woman may need to learn that every woman should always wipe from front to back after urinating or moving her bowels and use a clean piece of toilet paper for each wipe. Wiping from back to front may carry bacteria from the rectal area to the urethral opening and increase risk of infection. Soft, absorbent toilet tissue, preferably white and unscented, should be used because harsh, scented or printed toilet paper may cause irritation. Women need to change panty shields or sanitary napkins often. Bacteria can multiply on soiled napkins. Women need to wear underpants and pantyhose with a cotton crotch. They should avoid wearing tight – fitting slacks or jeans or panty shields for long periods. Some women don’t have an adequate fluid and food intake. After eliciting her food preferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12 glasses) of liquid a day.
10. Minor Disorder of Pregnancy Most pregnant women do suffer from minor disorders during pregnancy. Minor disorder is a condition caused by pregnancy, which is not present in the prepregnant state. It should be solved in correct time to prevent complication offering minor treatment and proper explanation for the reduction of these problems and anxiety. The exact cause of minor disorders are still unknown but it could be due to increasing level of hormone especially progesterone in the blood. The common minor disorders are Morning Sickness ( Nausea and Vomiting) Indigestion Varicose veins Backache Fainting Heartburn Constipation Itching Leg Cramp Morning Sickness ( Nausea and Vomiting) Nausea and vomiting especially in the morning, soon after getting out of bed, are usually common in primigravida. It may due to emotional factors, fatigue, and carbohydrate metabolism. So it is important to prevent it from getting worse as hyperemesis gravidarum may occur. 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. Objectives of Intranatal Care To delivery with minimum injury to the newborn and mother. To be readiness to deal with complications such as prolonged labour, haemorrhage, convulsions, malpresentations, prolapse of the cord etc. To do care of the baby at delivery like resuscitation, care of the cord, care of the eyes etc. To prevent infection. To detect and deal with any complications.e.g. Antepartum and postpartum haemorrhage, prolonged labour, malpresentation, prolapse cord etc. To resuscitate the baby and to provide immediate care to baby. 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.” Advantages of the domiciliary midwifery service The mother delivers in the familiar surroundings of her home and this may tend to remove the fear associated with delivery in a hospital, The chances for cross infection are generally fewer at home than in the nursery/ hospital, and The mother is able to keep an eye upon her children and domestic affairs; this may tend to ease her mental tension Most deliveries will have to take place in the home with the aid of Female Health Workers or trained dais. Domiciliary out reach is a major component of intranatal health care: The Female Health Worker, who is a pivot of domiciliary care, should be adequately trained to recognize the ‘danger signals’ during labour and seek immediate help in transferring the mother to the nearest Primary Health Centre or Hospital. The danger signals are: Sluggish pains or no pains after rupture of members.
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 2. Complications and obstetrical emergency during intranal period Prolonged Labour The prolonged labour may occur due to fault in power, fault in passage and fault in passager etc. so the preventive measures should be done before the delivery. 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. Abnormal Uterine Contraction Abnormal uterine contraction may be due to obstructed labour due to contracted pelvic, congenital malformation of fetus like hydrocephalus, brow presentation, neglected transverse lie etc. 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 post- partal 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.
Objectives of postnatal care To prevent complications of the post-partal period. To restore, promote and maintain health of the mother and baby. To promote breast feeding. To establish good nutritious of the baby. To check the adequacy of breast feeding. To prevent infection and identify any health problem/disorder in the baby. To support and strengthen the parents confidence and their role within their family and cultural environment. To provide family planning instructions and services. To provide basic health education to mother and family on various aspects of mother and child care.. 1. Complications of the postnatal period Certain complications may arise during the postnatal period which is be recognized early and dealt with promptly. These are as follows: 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. Deep vein Thrombosis It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence of infection. 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 baby’s 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. Preventive measures of PPH SL.N Antenatal Period Intranatal Period Postnatal Period 1. • Ensure regular • Judiciously administer • Continue to monitor antenatal care sedative, analgesic and vital signs oxytocin 2. • Maintain Hb level as • Avoid hasty delivery of the • Observe the lochia, near as normal baby. type, amount and • One should take at least 2- consistency. 3 minutes to deliver the trunk after the head is born. • Baby should be pushed out by the retracted uterus and not be pulled out. 3. • Check blood • Prevent the labour being • Check Hb level if grouping and typing prolonged needed 4. • Identify high risk • Avoid fiddling and • Prevent infection mothers ( twins, kneading of the uterus or hydramnios, APH, pulling the cord before the grand multipara etc) placental separation and deliver in a well equipped hospital 5. • Strict application of active • Observe the mother management of third stage for two hours after e.g. Immediate oxytocin delivery and ensure Control Cord Traction that the uterus is hard Uterine Massage and contracted enough. 6. • In all cases of the induced • Encourage the mother or augmented labour by for breast feeding. oxytocin should be kept on continuous oxytocin infusion for at least one hour after delivery. 7. • Examine the placenta and • Encourage and assist membranes and cord to empty the bladder carefully periodically and for ambulation.
Inversion of the uterus The uterus is said to be inverted if it rums inside – out partially or completely during delivery of the placenta. Preventive measures Don’t 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. Urinary tract infection and incontinence of urine It is one of the common causes of puerperal pyrexia, the incidence being 15 % of all deliveries. It is due to frequent catheterization either during labour or in early puerperium to relieve retention of urine, recurrence of previous pyelitis, poor personal hygiene and vaginal hygiene, trauma following instrumental delivery, poor fluid intake. It is extremely important to look for these complications in the postnatal period and prevent or treat them promptly. Postnatal Blues Pregnancy and puerperium are highly stressful periods in a woman’s 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. 2. Restoration of mother to optimum health The second objective of postnatal care is to provide care whereby, the woman can recuperate physically and emotionally from her experience of delivery. The broad areas of this care fall into three divisions:
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 one’s 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 child’s 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. 4. Respiratory Distress Syndrome and Neonatal Problems Asphyxia Neonatorum Asphyxia neonatorm is defined as failure to initiate and maintain spontaneous respiration within one minutes of birth. It may due to traumatic forceps or vaccum delivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine hypoxia due to placental insufficiency APH, and premature separation of placenta. Prevention • Antenatal screening of high risk patients. • Complete fetal monitoring, particularly in high risk pregnancy group to ensure early detection of fetal distress • Intrapartum fetal monitoring. Respiratory Distress syndrome Respiratory distress syndrome almost always occurs in preterm babies. It may be due to prematurely, maternal anemia, pre- eclampsia, diabetes, APH after 28 weeks of gestation, intrauterine hyposia etc.
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. 5. Prevention of Birth Injuries Intracranial injury and haemorrhage The intracranial injury and haemorrhage is due to trauma, rapid compression as in breech delivery, face presentation, instrumental delivery. 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. Prevention of injuries in the new born babies Comprehensive antenatal and intranatal care is the key to success in reduction of birth trauma and consequently in the reduction of perinantal mortality and neonatal morbidity. Antenatal period Screen out the risk babies. Employ liberal use of C/S and episiotomy. Contracted pelvis, CPD, malpresentation should be included and manage accordingly. Intranatal period During normal delivery Continuous fetal monitoring to detect fetal distress, extract baby before he become compromised. This can prevent traumatic cerebral anoxia.
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 shouldn’t 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. Vaginal Breech Delivery To prevent intracranial injuries: - The crucial period in breech delivery is during delivery of the after- coming head. Never be in haste during delivery of the head which find little time to mould. Episiotomy should be done as a routine to minimize head compression. Controlled delivery of the head by forceps is preferable. To prevent spinal injury: - Acute bending at the neck is to be prevented while forceps are being applied to the after coming head or delivery of the head. To prevent fracture: - The limbs are delivered in a manner described in breech delivery. 6. Major Disorders of Newborn Baby Ophthalmia Neonatorum Ophthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks of life which is characterized by purulent discharge, swelling and redness of affected eyes. Prevention • Any suspicious vaginal discharge during the antenatal period should be treated and the strict aseptic technique should maintain at birth. • The newborn baby’s 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 baby’s 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. Skin Infection ( pemphigus neonatorum) The unhygienic environments, cross infection or carrier are the source of infection. • The baby bath should be given 24 hours offer delivery. • The carriers or sources of infection are to be sought for and appropriate measure to be taken. 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. 8. Health Education to Mother and Family Health education during the postnatal period should cover the following areas:
• 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 neonate’s 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 baby’s napkin where contamination by urine or faces may occur.
• Bathing the baby 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 infant’s 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 infant’s 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, “Park’s 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
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OBG

  • 1. A SEMINAR ON PREVENTIVE OBSTETRICS SUBMITTED TO SUBMITTED BY MRS.MEERA MRS.Aneesa.S ASST.proffessor 1st year Msc Nursing VNSS COLLEGE OF NURSING kollam
  • 2. MASTER PLAN SUBJECT : OBSTETRIC AND GYNAECOLOGICAL NURSING GENERAL OBJECTIVE: On completion of the seminar the students will be able to get adequate knowledge regarding preventive obstetrics and able to prevent obstetric complication by applying measures while practicing it. SPECIFIC OBJECTIVE: On completion of the seminar the students will be able to • Define preventive obstetrics • Mention preventive obstetrics measures • Explain preventive obstetric s measures, antenatal nursing, Intranatal nursing, postnatal nursing
  • 3. SL.NO. CONTENT 1 INTRODUCTION 2 TERMMINOLOGIES 3 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 4 CONCLUSION 5 BIBLIOGRAPHY
  • 4.
  • 5. 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. . .
  • 6. PREVENTIVE OBSTETRIC DEFINITION Preventive Preventive is the term used to prevention or slowing the course of an illness or disease. It is intended or used to prevent or hinder acting as an obstacle. Obstetric The branch of medicine that deals with the care of women during pregnancy, childbirth and recuperative period following delivery is known as obstetric. Preventive Obstetric 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. Objectives of Antenatal Care To promote, protect and maintain the health of the mother during pregnancy. To detect “high risk” cases and give them special attention. To foresee complications and prevent them. To remove anxiety and dread associated with delivery. To reduce maternal and infant mortality and morbidity. To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation. To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy. To detect and treat any abnormality found in pregnancy as early as possible.
  • 7. 1. Preconceptional Counseling and Care When couple is seen and counseled about pregnancy. Its course and outcome well before the time of actual conception is called preconception counseling. It is a very new concept. Objective is to ensure that a woman enters pregnancy with an optimal state of health which would be safe both to herself and the fetus. Organogenesis is completed by the 1st trimester. By the time the woman is seen first in the antenatal clinic it is often too late to advice because all the adverse factors have already begun to exert their effect. In an ideal world antenatal care world commence at the preconception stage where health education (general advice about nutrition, lifestyle, avoidance of teratogens, folic acid supplementation, etc) and risk assessment can be focused toward a planned pregnancy. Preconception counseling is of much greater importance in two main groups of women. Ones with underlying medical conditions that may be affected by or may influence the outcome of pregnancy. Examples of such conditions include diabetes, various endocrinopathies, hemostatic or thrombotic problem and cardiac disease. Patients following organ transplantation (kidney, liver, heart and lungs) are also now contributing to the ranks of these patients along with survivors of childhood malignancies. A multidisciplinary approach to optimize/ stabilize the underlying condition and planning care during the antenatal period is a key component to optimizing pregnancy outcome. Ones where there are identifiable factors that would suggest the couple are at a risk of fetal anomaly. Such identifiable factors may include a previous child affected by a single gene disorder or syndromic disorder, a family history of genetic disorder or history of parental chromosomal abnormality. Counseling is a major part of prenatal diagnosis. The majority of parents to be do not perceive themselves at risk and 95 percent of abnormalities do occur unexpectedly, in pregnancies not considered at risk. Preconceptional Counseling Permits Identification of high risk factors is done by detailed evaluation of medical, obstetric, family and personal history. Risk factors are assessed by laboratory tests, if required. Treatable factors like pre- existing chronic diseases (hypertension, diabetes, epilepsy) are stabilished in an optimal state by early intervention before pregnancy. Proper counseling to those with history of recurrent fetal loss or with family history of congenital abnormalities (genetic, chromosomal or structural), as there may be some untreatable factors. Overweight or under weight is to be corrected with proper dietary advice. Rubella and hepatitis immunization in a non – immune woman is to be offered. To record a base level health status including BP reading.
  • 8. 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. 2. Essential Antenatal Care Services The essential components of services during pregnancy include are:- Registration of Pregnant Women Antenatal Visits and Antenatal Care Immunization Against Tetanus Iron and Folic Acid and Vitamin A and D Supplementation Health education / prenatal advice during Pregnancy Registration of Pregnant Women Care during pregnancy should be started as early as possible. The mother must be registered within 20 weeks of pregnancy either at health centre/ antenatal clinic or at home by a nurse/health visitor/ female health worker (ANM) or trained person. Through physical and obstetrical check up should be done to screen for risk factors, make assessment and give appropriate care for prevention and control of various health problems and complications. Antenatal Visits and Antenatal Care Ideally a woman should be seen and given care during pregnancy once a month during the first trimester or till seven months, once in fortnight during the second trimester or till the eighth month and thereafter every week till confinement. But often these many visits are not feasible, neither for the mother nor for the health infrastructure available. The care should begin soon after conception and continue throughout pregnancy. A schedule to follow for the mother is to attend the antenatal clinic once a month during the first seven months, twice a month during the next two months and thereafter once a week if everything is normal. Therefore a minimum three visits one in each trimester have been recommended. The first visit should be done within 20 weeks or as early as the mother is registered. The second visit at 32 weeks of pregnancy. The third visit at 36 weeks of pregnancy. Further visits may be made if justified by the condition of the mother. At least one visit should be paid in the home of the mother to make observation of actual conditions and accordingly prepare the mother. The main purpose of contact during antenatal period is to make observations and assess general health, obstetrical health status, identify risk factors and provide appropriate care.
  • 9. 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
  • 10. 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 women’s 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 physician’s 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
  • 11. prenatal advice. In the home environment, the woman will have more confidence to make an informed decision about home birth. Immunization Against Tetanus A pregnant woman must get two injections of Tetanus Toxoid during the period between 16 – 36 weeks, at one month interval. These protect the mother and baby both from the risk of tetanus. The 2nd injection should preferably be given at least at one month before delivery. If a woman is registered late then in that case even one injection will do. If the woman is immunized earlier within three years of the pregnancy, then one booster dose will be enough. Iron and Folic Acid and Vitamin A and D Supplementation It is being found that 50-60 percent of pregnant women are anaemic due to iron deficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to take one tablet containing 60 mg.of elemental iron and 500 mg of folic acid three times daily after third month of pregnancy till 3 months after child birth if the mother is found having anaemia. During pregnancy, the mother requires extra iron and folic acid due to changes taking place in the body and growth of fetus in the womb. Therefore each mother is given one tablet of iron and folic acid twice a day for at least 100 days to prevent anaemia in mother and to promote proper growth of fetus. Anemia is common in pregnancy and low – income group. It is a major cause of maternal and fetal mortality. Prevention of Anemia Avoidance of frequent of child birth: At least two years an interval between pregnancies is most necessary to replace the lost iron during childbirth process 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.
  • 12. Health education / prenatal advice during Pregnancy A major component of antenatal care is health education and prenatal advice. The mother is more receptive to advice concerning herself and her baby at this time than any other time. A woman during pregnancy needs to know about her nutrition, personal hygiene, rest and sleep, exercise, use of drugs, warning signs etc. Pregnancy can be both an exciting and worrying time for the mother and her partner. Part of the role of the health care professionals (usually fulfilled by the community midwife and general practitioner) caring for the mother is the provision of information about everyday activities that may or may not be affected by or have an effect on the pregnancy. Diet during pregnancy Personal Hygiene Rest and Sleep Physical work Exercise Comfortable clothing and shoes Smoking Alcohol Breast Care Drugs Radiation Protections from infections and illnesses Sexual activities Travel Reporting of untowards signs and symptoms Child care Follow up visits Warning Signs Diet during pregnancy Nutritional intake is an important factor in the maintenance of maternal health during pregnancy and in the provision of adequate nutrients for embryonic/fetal development. Assessing nutritional status and providing nutritional information or referral to a dietitian are part of the nurse’s responsibilities in prenatal care. Dietary extremes are associated with risks in pregnancy. Obesity is associated with gestational diabetes, hypertension and monitoring difficulties. Malnutrition is associated with maternal anemia and fetal growth restriction, while deficiency of certain vitamins predispose to congenital abnormalities, folic acid deficiency is linked to the risk of neural tube defects (NTDs). A balanced diet rich in fresh fruit and vegetable is recommended. It is prudent to avoid unpasturized milk and cheeses and pâtés. Pregnant woman should avoid eating liver due to its high vitamin A content. Vegans should have Iron and vitamin supplementation and ethnic groups lacking sunlight are advised to have extra vitamin D.
  • 13. 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. Relationship between Maternal and Foetal Nutrition Energy Inadequate food intake and poor nutrient utilization Maternal Malnutrition Reduced blood volume expansion Inadequate increase in cardiac output Decreased blood and nutrient supply to the foetus Reduced placental size Reduced nutrient transfer 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.
  • 14. • Fresh air and sunshine 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. Rest and Sleep A pregnant woman needs sufficient rest. She should do less and lighter work. She must have 8-10 hours of sleep every night. She needs to take short nap during the day. As the pregnancy advances, the mother requires more frequent short rests during the day. She should avoid strenuous work, carrying heavy loads or weights e.g. bringing water from long distance, drawing of water from a well etc. Rest is important for the maintenance of good health. She should need adequate rest and relaxation. Relaxation of the mind produces relaxation of the muscle and a relaxed lower uterine segment and pelvic floor makes it easier for the baby to be born. 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.
  • 15. 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. Comfortable clothing and shoes It is advisable to wear loose and comfortable cotton clothes, not too tight such as blouse or cholo.Brassier which supports the breasts should be advised, but must not be too tight so as to flatten the nipples but lift the breast well. A support for the abdomen is sometimes required, especially in a multigravida who has pendulous abdomen so the pregnant mother should advise to support her whole abdomen with a light belt. Pregnant should avoid high heeled shoes. She should wear flat shoes to maintain center of balance and to prevent backache to some extent. 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, doesn’t 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
  • 16. 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
  • 17. 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. Protections from infections and illnesses Infections in pregnancy are responsible for significant morbidity and mortality. The direct financial costs of disease can be as starting and are much more difficult to measure. Some consequences of maternal infection last a life time. Education and counseling are important aspects of care for the prevention of maternal infections. Adolescents mothers are at high risks because of earlier partners. The recent trend of exchanging sex for drugs is contributing to a rise in infection rates, especially among poor, and minority women. The prevention of disease and the reduction of maternal and neonatal effects continue to be monumental challenges. An expectant mother must be instructed to protect herself from the risk of any infection especially measles, German measles and syphilis because these infections can cause spontaneous abortion, malformation, mental retardations, still-birth, perinatal death etc. The child may develop congenital syphilis. If the mother is found having syphilis she must get herself treated by the trained health personnel especially from health center/hospital. 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.
  • 18. 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. Reporting of untowards signs and symptoms • The expectant woman must be instructed to report to health personnel the following signs and symptoms. • Unusual pain, bleeding from vagina. • Swelling in the feet, hands or face • Headache, dizziness, blurred vision at times. These symptoms indicate the onset of high blood pressure which is very dangerous and can prove fatal if timely care is not given. • High fever • Baby’s movements not being felt. • Any other sigh or symptom which is considered unusual. 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.
  • 19. 3. Specific Health Protection Specific protection for pregnant women’s health is an essential aspect of prenatal care. This is because 50 to 60% of women, belonging to low socio-economic groups are anemic in the last trimester of pregnancy. The major causative factors are iron and folic acid deficiencies. Anaemia is known to be associated with high incidence of premature births, postpartum haemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother. Anaemia Surveys in different parts of India indicate that about 50 to 60 percent of women belonging to low socio- economic groups are anemic in the last trimester of pregnancy. The major aetiological factors being iron and folic acid deficiencies. It is well known that anaemia per se is associated with high incidence of premature births, postpartum haemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother. Other Nutritional Deficiencies Protection is required against other nutritional deficiencies that may occur during pregnancy such as protein, vitamin and mineral deficiencies. So Vitamin A and D capsules should be supplied for the pregnant mother. Toxemias of Pregnancy The presence of albumin in urine and increase in blood pressure indicates toxemias of pregnancy. Their early detection and management are indicated. Efficient antenatal care minimizes the risk of toxemias of pregnancy. Diabetes This plays an important role for presentational diabetes. To prevent early pregnancy loss and congenital anomalies, medical care should begin before conception. A complete assessment of the diabetic status and associated complications is done to find out if she is fit to go through pregnancy. Evaluation of thyroid function is also recommended in type 1 diabetes as hypothyroidism is frequently encountered in these women. Those on oral hypoglycemic agents should be switched to insulin therapy preferably before conception. Tetanus Protection If the mother was not immunized earlier, two doses of tetanus toxoid should be given, the first dose at 16th to 20th week and the second dose at 20th to 24th week of pregnancy. For a woman who has been immunized earlier, one booster dose will be sufficient. When such a booster dose is given, it will provide necessary cover for subsequent pregnancies for the next five years.
  • 20. 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.
  • 21. 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. 4. Preparing for Confinement The preparation for safe delivery is very important. It should be done well in advance to avoid any type of difficulty or emergency which might occur at the time of delivery. The health personnel discuss with the couple and may be other members of the family about the alternative suitable place for confinement which includes home, health centre or hospital. The decision will depend upon the health status of both mother and the fetus, risk factors and environmental conditions at home. High risk mother must be delivered at primary health center, first referral unit or hospital at the discretion of doctor. However a normal healthy mother may be delivered at home. But she must be delivered by a trained birth attendant, female health worker (
  • 22. 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. 5. Psychological preparation of the mother Psychological preparation of the mother is important during pregnancy and delivery. The expectant mother, especially the primary Para mother has fear and anxiety about child birth, its outcome, and complications etc.It is very important to discuss various aspects of pregnancy and delivery .This helps in overcoming their fears and anxietes.Sufficient time and opportunity must be given to expectant mothers to have free and frank talk on all aspects of pregnancy and delivery. The “mother craft” classes at the MCH centers help a great deal in removing their fears and in gaining confidence.
  • 23. 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. 7. Education for Self – Care Health maintenance is an important aspect of prenatal care. Patient participation in the care ensures prompt reporting of untoward responses to pregnancy. Patient as symptom of responsibility of health maintenance is prompted by understanding of maternal adaptations to the growth of the unborn child and a readiness to learn. Nurses in their role of teacher provide patients with the information necessary for compliance with health care measures. The expectant mother needs information about many subjects. During the initial health assessment, the woman may have indicated a need to learn self care activities such as prevention of urinary tract infection. Supportive maternity brassiere with pads to absorb discharge may be worn at night, wash with warm water and keep dry, see maternal physiology and sexual counseling. Both partners need reassurance and support, support significant other who can reassure woman about her attractiveness, etc improved communication with her partner, family and others, refer to social worker, if needed or supportive services ( financial assistance, food stamps) 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
  • 24. 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. 9. Screening for Urinary Tract infection Urinary tract infections may be asymptomatic. Whether symptomatic or not, urinary tract infections present a risk to both mother and fetus. Prevention of these infections is essential. The woman’s understanding and use of general hygiene measures are assessed. Before developing a plan of care, the nurse needs to elicit feelings or ideas concerning cultural, ethnic, religious, or other factors affecting health practices. The rationale being that some cases asymptomatic bacteriuria and a lower urinary tract infection may lead to complications of the advanced stages of the disease. The woman may need to learn that every woman should always wipe from front to back after urinating or moving her bowels and use a clean piece of toilet paper for each wipe. Wiping from back to front may carry bacteria from the rectal area to the urethral opening and increase risk of infection. Soft, absorbent toilet tissue, preferably white and unscented, should be used because harsh, scented or printed toilet paper may cause irritation. Women need to change panty shields or sanitary napkins often. Bacteria can multiply on soiled napkins. Women need to wear underpants and pantyhose with a cotton crotch. They should avoid wearing tight – fitting slacks or jeans or panty shields for long periods. Some women don’t have an adequate fluid and food intake. After eliciting her food preferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12 glasses) of liquid a day.
  • 25. 10. Minor Disorder of Pregnancy Most pregnant women do suffer from minor disorders during pregnancy. Minor disorder is a condition caused by pregnancy, which is not present in the prepregnant state. It should be solved in correct time to prevent complication offering minor treatment and proper explanation for the reduction of these problems and anxiety. The exact cause of minor disorders are still unknown but it could be due to increasing level of hormone especially progesterone in the blood. The common minor disorders are Morning Sickness ( Nausea and Vomiting) Indigestion Varicose veins Backache Fainting Heartburn Constipation Itching Leg Cramp Morning Sickness ( Nausea and Vomiting) Nausea and vomiting especially in the morning, soon after getting out of bed, are usually common in primigravida. It may due to emotional factors, fatigue, and carbohydrate metabolism. So it is important to prevent it from getting worse as hyperemesis gravidarum may occur. 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
  • 26. 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
  • 27. 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.
  • 28. 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. Objectives of Intranatal Care To delivery with minimum injury to the newborn and mother. To be readiness to deal with complications such as prolonged labour, haemorrhage, convulsions, malpresentations, prolapse of the cord etc. To do care of the baby at delivery like resuscitation, care of the cord, care of the eyes etc. To prevent infection. To detect and deal with any complications.e.g. Antepartum and postpartum haemorrhage, prolonged labour, malpresentation, prolapse cord etc. To resuscitate the baby and to provide immediate care to baby. 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.” Advantages of the domiciliary midwifery service The mother delivers in the familiar surroundings of her home and this may tend to remove the fear associated with delivery in a hospital, The chances for cross infection are generally fewer at home than in the nursery/ hospital, and The mother is able to keep an eye upon her children and domestic affairs; this may tend to ease her mental tension Most deliveries will have to take place in the home with the aid of Female Health Workers or trained dais. Domiciliary out reach is a major component of intranatal health care: The Female Health Worker, who is a pivot of domiciliary care, should be adequately trained to recognize the ‘danger signals’ during labour and seek immediate help in transferring the mother to the nearest Primary Health Centre or Hospital. The danger signals are: Sluggish pains or no pains after rupture of members.
  • 29. 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 2. Complications and obstetrical emergency during intranal period Prolonged Labour The prolonged labour may occur due to fault in power, fault in passage and fault in passager etc. so the preventive measures should be done before the delivery. 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. Abnormal Uterine Contraction Abnormal uterine contraction may be due to obstructed labour due to contracted pelvic, congenital malformation of fetus like hydrocephalus, brow presentation, neglected transverse lie etc. 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.
  • 30. 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 post- partal 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.
  • 31. Objectives of postnatal care To prevent complications of the post-partal period. To restore, promote and maintain health of the mother and baby. To promote breast feeding. To establish good nutritious of the baby. To check the adequacy of breast feeding. To prevent infection and identify any health problem/disorder in the baby. To support and strengthen the parents confidence and their role within their family and cultural environment. To provide family planning instructions and services. To provide basic health education to mother and family on various aspects of mother and child care.. 1. Complications of the postnatal period Certain complications may arise during the postnatal period which is be recognized early and dealt with promptly. These are as follows: 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.
  • 32. 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. Deep vein Thrombosis It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence of infection. 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
  • 33. Postpartum hemorrhage is the condition of excessive bleeding from the genital tract at any time following the baby’s 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. Preventive measures of PPH SL.N Antenatal Period Intranatal Period Postnatal Period 1. • Ensure regular • Judiciously administer • Continue to monitor antenatal care sedative, analgesic and vital signs oxytocin 2. • Maintain Hb level as • Avoid hasty delivery of the • Observe the lochia, near as normal baby. type, amount and • One should take at least 2- consistency. 3 minutes to deliver the trunk after the head is born. • Baby should be pushed out by the retracted uterus and not be pulled out. 3. • Check blood • Prevent the labour being • Check Hb level if grouping and typing prolonged needed 4. • Identify high risk • Avoid fiddling and • Prevent infection mothers ( twins, kneading of the uterus or hydramnios, APH, pulling the cord before the grand multipara etc) placental separation and deliver in a well equipped hospital 5. • Strict application of active • Observe the mother management of third stage for two hours after e.g. Immediate oxytocin delivery and ensure Control Cord Traction that the uterus is hard Uterine Massage and contracted enough. 6. • In all cases of the induced • Encourage the mother or augmented labour by for breast feeding. oxytocin should be kept on continuous oxytocin infusion for at least one hour after delivery. 7. • Examine the placenta and • Encourage and assist membranes and cord to empty the bladder carefully periodically and for ambulation.
  • 34. Inversion of the uterus The uterus is said to be inverted if it rums inside – out partially or completely during delivery of the placenta. Preventive measures Don’t 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. Urinary tract infection and incontinence of urine It is one of the common causes of puerperal pyrexia, the incidence being 15 % of all deliveries. It is due to frequent catheterization either during labour or in early puerperium to relieve retention of urine, recurrence of previous pyelitis, poor personal hygiene and vaginal hygiene, trauma following instrumental delivery, poor fluid intake. It is extremely important to look for these complications in the postnatal period and prevent or treat them promptly. Postnatal Blues Pregnancy and puerperium are highly stressful periods in a woman’s 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. 2. Restoration of mother to optimum health The second objective of postnatal care is to provide care whereby, the woman can recuperate physically and emotionally from her experience of delivery. The broad areas of this care fall into three divisions:
  • 35. 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 one’s 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
  • 36. 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 child’s 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. 4. Respiratory Distress Syndrome and Neonatal Problems Asphyxia Neonatorum Asphyxia neonatorm is defined as failure to initiate and maintain spontaneous respiration within one minutes of birth. It may due to traumatic forceps or vaccum delivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine hypoxia due to placental insufficiency APH, and premature separation of placenta. Prevention • Antenatal screening of high risk patients. • Complete fetal monitoring, particularly in high risk pregnancy group to ensure early detection of fetal distress • Intrapartum fetal monitoring. Respiratory Distress syndrome Respiratory distress syndrome almost always occurs in preterm babies. It may be due to prematurely, maternal anemia, pre- eclampsia, diabetes, APH after 28 weeks of gestation, intrauterine hyposia etc.
  • 37. 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. 5. Prevention of Birth Injuries Intracranial injury and haemorrhage The intracranial injury and haemorrhage is due to trauma, rapid compression as in breech delivery, face presentation, instrumental delivery. 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. Prevention of injuries in the new born babies Comprehensive antenatal and intranatal care is the key to success in reduction of birth trauma and consequently in the reduction of perinantal mortality and neonatal morbidity. Antenatal period Screen out the risk babies. Employ liberal use of C/S and episiotomy. Contracted pelvis, CPD, malpresentation should be included and manage accordingly. Intranatal period During normal delivery Continuous fetal monitoring to detect fetal distress, extract baby before he become compromised. This can prevent traumatic cerebral anoxia.
  • 38. 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 shouldn’t 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. Vaginal Breech Delivery To prevent intracranial injuries: - The crucial period in breech delivery is during delivery of the after- coming head. Never be in haste during delivery of the head which find little time to mould. Episiotomy should be done as a routine to minimize head compression. Controlled delivery of the head by forceps is preferable. To prevent spinal injury: - Acute bending at the neck is to be prevented while forceps are being applied to the after coming head or delivery of the head. To prevent fracture: - The limbs are delivered in a manner described in breech delivery. 6. Major Disorders of Newborn Baby Ophthalmia Neonatorum Ophthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks of life which is characterized by purulent discharge, swelling and redness of affected eyes. Prevention • Any suspicious vaginal discharge during the antenatal period should be treated and the strict aseptic technique should maintain at birth. • The newborn baby’s closed eyes and face with sterile water and swab at bath times to avoid infection of the eye.
  • 39. • The midwife and mother should always wash her hand before touching the baby’s 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. Skin Infection ( pemphigus neonatorum) The unhygienic environments, cross infection or carrier are the source of infection. • The baby bath should be given 24 hours offer delivery. • The carriers or sources of infection are to be sought for and appropriate measure to be taken. 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. 8. Health Education to Mother and Family Health education during the postnatal period should cover the following areas:
  • 40. • 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 neonate’s 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 baby’s napkin where contamination by urine or faces may occur.
  • 41. • Bathing the baby 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 infant’s 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.
  • 42. Avoiding any irritation or trauma to the infant’s 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, “Park’s 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