The Annals and Magazine of Natural History: Zoology, Botany, and Geology 1152307320, 9788131773451, 9789332514256, 1011031051, 9781011031054

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Midwifery and Obstetrical Nursing—Practical

Dr Sunita Lawrence Principal, Pragyan College of Nursing, Bhopal, Madhya Pradesh

Copyright © 2013 Dorling Kindersley (India) Pvt. Ltd. Licensees of Pearson Education in South Asia No part of this eBook may be used or reproduced in any manner whatsoever without the publisher’s prior written consent. This eBook may or may not include all assets that were part of the print version. The publisher reserves the right to remove any material in this eBook at any time. ISBN 9788131773451 eISBN 9789332514256 Head Office: A-8(A), Sector 62, Knowledge Boulevard, 7th Floor, NOIDA 201 309, India Registered Office: 11 Local Shopping Centre, Panchsheel Park, New Delhi 110 017, India

Dedicated to the mothers and newborns who died due to incompetent maternal practices

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About the Author

Dr Sunita Lawrence, B.Sc. (Nursing), M.Sc. (Maternity Nursing), Ph.D. (Nursing), M.A. (Sociology), RN, RM, is the Principal of Pragyan College of Nursing, Bhopal. She has authored many nursing books and is the Editorin-Chief of the Indian Journal of Holistic Nursing and Trends in Nursing Administration and Education, published from Bhopal. She is the President of Trained Nurses’ Association of India, Madhya Pradesh State Branch, since 2008 and is the advisor of the Society of Midwives India, Bhopal Chapter. Previously, she has served as the Assistant Director and as the Head of Department of Nursing and Health Sciences in the Madhya Pradesh Bhoj (Open) University and has also worked in various nursing institutions under the Government of Madhya Pradesh. Dr Sunita Lawrence is a nursing researcher, teacher, examiner, and guide for graduate, postgraduate, and doctoral students of various Indian universities. She is also a member of the nursing board of studies in various universities. She is the writer of numerous study materials for IGNOU, UNICEF, and Madhya Pradesh Bhoj (Open) University. Her scientific and research articles have been published in various national and international nursing journals. She has received the Best Nurse Arunachalam Award in 1997, Bhartiya Shiksha Ratna Award in 2008, Research Fellowship Award in 2010, and the Best Principal Award in 2011 for her contribution towards the nursing profession.

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Contents

About the Author Foreword Preface Acknowledgements

SECTION I 1. 2. 3. 4. 5.

SECTION II 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Intranatal Assessment and Care

Admission in Labour Room Nursing Care During Labour Preparing the Labour Room Assessment of Labour Progress Conducting Delivery Assessment and Management of the Third Stage of Labour Assessment and Management of the Fourth Stage of Labour Assessing the Placenta

SECTION IV 26. 27.

Prenatal Assessment and Care

Initial History Documentation of Antenatal Woman Determination of Expected Date of Delivery General Physical Examination Abdominal Examination and Application Breast Self-examination Vaginal Examination and Assessment of Pelvic Adequacy Prenatal Advices Prenatal Exercises Nutritional Advices Teaching Self-care Methods for Common Discomforts During Pregnancy Assessing Foetal Well-being Subsequent Prenatal Visits

SECTION III 18. 19. 20. 21. 22. 23. 24. 25.

Preconception Counselling: An Introduction

Preconception Education Genetic Counselling Preparation for Parenthood Teaching Self-care Methods of Determining Ovulation Assisted Artificial Reproductive Techniques

Postpartum Assessment

Postnatal Assessment Perineal Care

v ix xi xiii

1 3 7 11 17 21

25 27 33 36 41 47 50 54 57 73 77 80 98

101 103 105 107 109 115 121 123 125

129 131 136

viii

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28. 29. 30.

Contents

Assessing the Involution of the Uterus Postnatal Exercises Techniques of Breastfeeding

SECTION V 31. 32. 33. 34.

Assessment of the Newborn

155

Initial Assessment of the Newborn Weighing the Infant Newborn Resuscitation Assisting in Thermoregulation of the Newborn

157 169 171 178

SECTION VI 35. 36. 37. 38. 39. 40.

140 143 148

Assisting in Operative Procedures

181

Episiotomy Preparation for Medical/Surgical Induction Preparing the Woman for LSCS Preparation for Forceps Delivery Preparation for Tubectomy and Vasectomy Insertion of Intrauterine Contraceptive Device

183 186 191 194 196 200

Bibliography Index

203 205

Foreword

It gives me immense pleasure to write a foreword to the book Midwifery and Obstetrical Nursing— Practical written by Dr Sunita Lawrence. She has written the essential material needed for midwifery students and nurses in a clear and concise manner, in an easy and lucid style. In this edition, the practical text is presented in six sections, with Preconception counselling, Prenatal assessment and care, Intranatal assessment and care, Postpartum assessment, Assessment of the newborn, and Assisting in operative procedures being the topics discussed. Today, students and maternity nurses need to be empowered with professional knowledge, attitude and professional competency in the areas of maternal and child health care. This book will help them to be confident in carrying out their role by giving updated information. This book will also be useful for faculty in nursing, and I am sure that both the providers and consumers will be benefited.

Dr Alamelu Venketaraman

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Preface

As the 21st century is in progress, maternity care once again finds its role changing. In keeping with the changing times, clinical practice is adapting rapidly to keep up with new treatments, new technologies and newly identified problems. Professionals working for maternal care play a key role in enunciating the practice that is followed. It has long been recognized that guidelines for performing procedures in maternal care are essential. In light of this, I have developed the Midwifery and Obstetrical Nursing— Practical in lucid language with diagrams and photographs for the clarity of practical understanding. The practical manual is organized into six sections, namely Section 1: Preconception Counselling: An Introduction, Section 2: Prenatal Assessment and Care, Section 3: Intranatal Assessment and Care, Section 4: Postpartum Assessment, Section 5: Assessment of the Newborn and the last Section 6: Assisting in Operative Procedures. Overall, forty procedures of obstetrics and gynaecology are included in these six sections, although procedures of the protocol may vary from institution to institution. I believe that this practical manual will enable maternity nurses and students to position themselves as indispensable members of the health-care team. Dr Sunita Lawrence

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Acknowledgements

“Current best practices reflect the best understanding, at the present time, of the most effective interventions, if appropriately applied to the needs, to contribute to a reduction in maternal and newborn mortality and morbidity.” Susan Rae Ross, CARE, 1998 Global maternal mortality statistics reflect the widening gap between the developed and developing world. It has been observed that maternal mortality is high where proper practices are not followed while caring for women. At this juncture, I would like to thank Dr (Mrs) A. V. Raman, Director, Nursing Research and Education, WAHI, Thrissur, Kerala (Former Dean, Omayal Achi College of Nursing, Chennai, Tamil Nadu) for her support and guidance that she rendered during the writing of this book. I would like to thank Mr Rajesh Bagul for typing the matter and for the technical support he provided while preparing this manual. Deep appreciation is expressed to my family members for the support they provided for completing this practical manual. I hope that students and colleagues will find this publication useful during their practice in maternal units. Dr Sunita Lawrence

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Section i

Preconception Counselling: An Introduction Couples who choose to become pregnant generally want to do all they can to ensure that their child will be healthy. Consequently, they may seek advice about actions they can take to achieve a successful outcome. A relatively new concept, preconception counselling is as important to prenatal services as prenatal services itself. Preconception counselling is a care designed for health maintenance. It stresses healthy behaviour that promotes health of the woman and her potential foetus. Practical 1 of this section discusses the Preconception Education, an opportunity for couples to consider the risks that pregnancy or birth might pose. Practical 2: Genetic Counselling helps in identifying genetic problems, treatment options and medical and social support. Practical 3 deals with Preparation for Parenthood and approaches to parent education for healthy adoption of parenthood. Ovulation problems account for approximately 25% of female infertility and Practical 4: Teaching Self-care Methods of Determining of Ovulation aids to identify ovulation by simple methods. discusses psychological prepaOverall, this section will provide an opportunity to student nurses and midwives to discuss methods to have a healthier pregnancy.

PracticalS 1. Preconception Education 2. Genetic Counselling 3. Preparation for Parenthood 4. Teaching Self-Care Methods of Determining Ovulation

1 Preconception education

Preconception education is a process to assist eligible couples to be in good health by using approaches that are culturally acceptable and practicably possible to use by them.

oBJectiVeS 1. 2. 3. 4.

Establish lifestyle behaviour to maintain optimum health. Identify and treat risk factors before conception. Conceive a pregnancy without unnecessary risk factors. Prepare couples psychologically for pregnancy and the responsibilities that come with parenthood.

comPonentS for PreconcePtion education A B

Sr. no. 1.

Nurses should always divide preconception education into major components for a systematic approach. Nurses should always keep in mind to follow a teaching principle that is simple to complex. Use components for health promotion to build good rapport with the couples. Components

Rationale

Lifestyle and Social Life Assessment

Detailed history of issues related to lifestyle and social life is to be noted down as these issues could affect the optimal timing of conception.

a. Environmental Exposures

From hobbies, habits, home or environment, conditions associated with adverse reproductive outcomes should be identified and minimized in the preconception period. Exposure to organic solvents such as vinyl monomers used for plastic manufacturing, pesticides and heavy metals such as lead and mercury should be assessed. They lead to most common paediatric problems. If these are found in maternal blood in high levels, it may lead to retardation of foetal growth. If the above history is confirmed, blood test is ordered immediately and referral for proper management is made.

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b. Substance Use

Maternal use of alcohol, tobacco and other mood-altering substances is hazardous to the foetus. Alcohol is a teratogen and clear evidence of relationship between alcohol and foetal abnormalities like foetal alcohol syndrome (FAS) exists. Cocaine is a teratogen that causes prematurity, abruptio placentae and other complications such as maternal vasoconstriction, cardiac ischemia and premature rupture of membrane. Infants are born with the risk of neurobehavioural abnormalities. Use of tobacco leads to low birth weight (LBW). Caffeine consumption leads to spontaneous abortion and intrauterine growth retardation (IUGR). Use of opiates is associated with increased rate of stillbirth, foetal growth retardation and newborns with narcotic addiction. Frequent sharing of needles leads to human immunodeficiency virus (HIV) infection. Intensive preconception care should involve a multidisciplinary team of health-care providers, social services providers and psychologists to counsel regarding prenatal risk and couples should be screened for substance abuse.

c. Smoking

Carbon monoxide and nicotine are ingredients believed to be responsible for spontaneous abortion, abruptio placentae, placenta previa, preterm birth, LBW and sudden infant death syndrome. Smoking cessation 6 months prior to conception improves the conditions for pregnancy and for the foetus. Antismoking advices such as nicotine replacement therapy (chewing gum or transdermal patch insertion) are given. For women who smoke more than 20 cigarettes a day, therapy is used in USA.

d. Domestic Violence

Victims of domestic violence should be identified before they conceive, because they are likely to be abused during pregnancy. Physical abuse during pregnancy results in placental separation, antipartum haemorrhage, rupture of uterus, foetal fracture, etc. Information about available community and social and legal resources should be made available for dealing with abusive partner.

e. Financial Difficulties

The preconception period is an appropriate time to discuss financial resources that are provided under maternal care in Indian states. Working women should discuss the maternity financial benefits provided by employers during pregnancy and postnatal period. Assisting women to earn is a part of preconception care, as financial difficulties may lead to nutritional deficiencies.

Preconception Education

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5

f. Preconception Immunization

Preconception immunization of women to prevent diseases in their offspring is preferred. Immunization shots against measles, rubella, mumps, tetanus and hepatitis B are given, if not administered during childhood. Rubella infection during pregnancy leads to congenital infection in the baby, measles leads to high risk of spontaneous abortion and preterm birth and tetanus with transplacental transfer of toxin causes neonatal tetanus.

g. Nutritional Assessment

The body mass index (BMI, weight in kilograms/height in metres) is a preferred indicator of nutritional status. Both overweight and underweight women are at risk for poor pregnancy outcomes. Discuss eating habits, as proper breakfast, lunch and dinner are essential. Ask the type of diet that is followed by her. Plan a diet with proper calories and nutrition. Eating habits such as fasting, pica, eating disorders and the use of excess of vitamins should be discussed. Preconception intake of folic acid reduces the risk of neural tube defects.

h. Exercise

It is important for a woman to establish a regular exercise plan beginning at least 3 months before she plans pregnancy. Exercise improves the women’s blood circulation and general health and tones her muscles for easy and normal delivery.

2.

Family History

Assessment of family history for genetic risks offers a number of advantages.

3.

Medical Assessment

Preconception care for women with significant medical problems is very important. Potential problems that interfere with pregnancy such as cardiovascular problems, anaemia, pulmonary hypertension and diabetes mellitus increase the maternal and infant mortality rate and effect organogenesis and recurrent spontaneous abortion. These problems should be treated before women conceive to lessen the risk factors and to continue pregnancy with minimum risk and healthy outcome

4.

Screening for Infectious Diseases

Infectious diseases such as tuberculosis and toxoplasmosis and infection with hepatitis B, HIV, rubella and herpes simplex virus have an effect on the foetus and cause spontaneous abortion, IUGR and intrauterine foetal death. Counselling focuses on good hygiene and prevention of causes responsible for the above infectious diseases.

5.

Preconception Laboratory Tests Recommended for Women

Laboratory tests should be done to evaluate haemoglobin or hematocrit count, Rh factor, rubella infection; urine should be tested for sugar and albumin and screening should be done for HIV infection, hepatitis B virus infection and toxoplasmosis. Venereal Disease Research Laboratory and Pap smear tests should also be done. Early identification and intervention reduces the risks.

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6.

Medication Determination of Exposure

Anticonvulsant drugs increase the risk of congenital malformation. Anticoagulant substances increase the risk of haemorrhage and spontaneous abortion. Excess of aspirin also gives the same effect. Oral contraceptives should be stopped when planning conception and the woman should wait for a full menstrual cycle after discontinuation of the oral contraceptive. This allows the natural hormone cycle to set and facilitates planning subsequent pregnancy. Antithyroids and chemotherapeutic drugs also should be stopped before conception to reduce teratogenic effect.

7.

Reproductive History

Review of obstetric history when a woman is planning to conceive allows health-care professionals and couples to explore their fears, concerns and questions. Recording the menstrual history provides an opportunity to evaluate a woman’s knowledge of pregnancy and offers counselling about how she might use such knowledge to plan one. Diagnosis and treatment of conditions such as uterine malformations, maternal autoimmune diseases and genital infection may lessen the risk of recurrent pregnancy loss.

C D

Nurses should record all history carefully and advise on proper follow-up care. During subsequent visits, screening as above is required to promote healthy mother and healthy outcome.

2 Genetic counselling

Genetic counselling is a communication process in which the family is provided with the most complete and accurate information on the occurrence or the risk of recurrence of a genetic disease in the family.

oBJectiVeS 1. Allows families to make informed decisions about reproduction. 2. Helps families to assess the available treatments, consider appropriate alternatives to reduce risk and learn about the outcome of genetic diseases or abnormalities. 3. Deals with psychological and social implications that often accompany such problems. 4. Helps to reduce the incidence and impact of genetic diseases.

conditionS required for Genetic counSellinG A. Conditions in Parent or His/Her Family

Nurses who are aware of families at an increased risk of having a child with a genetic disorder are in an ideal position to make referrals. Genetic counselling is an appropriate course of action for any family wondering ‘Will it happen again?’ Genetic counselling is advised for any of the following conditions. a. Congenital Abnormalities Including Mental Retardation

Congenital malformation may be due to increased teratogenic substances, which can be avoided during pregnancy. If mental retardation of unidentified cause has occurred in a family, there may be an increased risk of recurrence.

b. Family Disorders

Families should be informed that certain diseases may have a genetic component and risk of their occurrence in a particular family may be higher than the general population. Disorders such as diabetes, cardiac problems, cancer, mental illness or chronic neurological or neuromuscular disorders fall under this category.

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Midwifery and Obstetrical Nursing—Practical

c. Known Inherited Diseases

Families should be educated about the nature of the inherited diseases. It is important to brief family members who are not at the risk of passing on a disorder, as should the family members who are at increased risk.

d. Metabolic Disorders

Any family at risk for having a child with metabolic disorder or biochemical defect should be referred. Most inborn errors of metabolism are autosomal recessive inherited ones. A family may not be identified as being at risk until the birth of an affected child. Carriers of the sickle cell traits can be identified before pregnancy begins and the risk of having an affected child can be determined. Prenatal diagnosis of an affected foetus should be made.

e. Chromosomal Abnormalities

Any couple who has had a child or any couple with a family history of a chromosomal abnormality may be at an increased risk of having another child similarly affected. This group would include families in which there is concern for a possible translocation, e.g. Down syndrome associated with trisomy 21, single gene.

f. Genetic Diseases

Exposure to mutagenic or teratogenic agents such as drugs and infection may lead to foetal and infant abnormalities. We have already discussed in practical 1 about the common teratogens such as drugs and chemicals, radiations, infections and maternal conditions and their effects.

B. Conditions in Mothers a. Reproductive Failure

If a woman has had three or more unexplained, consecutive, spontaneous first trimester losses, she has chances of reproductive failure. Maternal age 35 years or older leads to spontaneous abortion or stillbirth, foetal abnormalities or death before 1 month of age due to unknown causes.

b. Consanguinity

Marriages with blood relation or marriages within the family leads to many congenital malformation and blood disorders in the foetus, which can be screened during pregnancy.

c. Maternal Serum Alpha-Fetoprotein (AFP)

AFP is a foetal glycoprotein that is synthesized gradually. If it is high, it may lead to foetal haemolytic disorders, neural tube defects (spina bifida), oligohydramnios, low birth weight, foetal death, etc.

Genetic ScreeninG 1. 2. 3. 4. 5.

Chorionic villus sampling Genetic amniocentesis Percutaneous umbilical blood sampling for chromosomal diagnosis Maternal serum alpha-fetoprotein (MSAFP) Genetic ultrasonography

These tests are detailed in practical 8 of this book.

Genetic Counselling

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9

counSellinG Nurses are assuming an increasingly important role in counselling people about genetically transmit1. Identify families at risk for genetic problems. 3. 4. 5. 6. 7. 8. 9. 10.

Act as a liaison between family and medical doctors. Assist the family in understanding and dealing with information received. Help families in coping with this crisis. Provide information about known genetic factors. Assure continuity of nursing care to the family. Assist in suggested diagnostic procedures. Check that all the data have been carefully examined and analysed. On follow-up visit of family, give the couple all information like medical facts, diagnosis, probable cause of disorder and available management or alternatives for dealing with the risk of recurrence. 11. Take care not to assume a diagnosis, assume recurrence risk or provide genetic counselling without adequate information and training. Inadequate, inappropriate or inaccurate information may be misleading or harmful. childbearing or child adoption can be suggested. 13. Many genetic centres are available as government and non-governmental organizations where couples can be referred for proper guidance. 14. As the family returns to the daily aspects of living, the nurse can provide helpful information on day-to-day aspects of caring for the child, answer questions that arise and support parents in their decision and in referral. Based on sound knowledge about genetic problems, the nurse should prepare the family for counselling and act as a resource person during and after the counselling sessions.

SamPle queStionS for Prenatal Genetic ScreeninG 1. Are 35 years of age or older? 2. Have you, the baby’s father or anyone in either of your families ever had any of the following disorders? – Down syndrome (Mongolism) – Other chromosomal abnormalities – Haemophilia – Muscular dystrophy If yes, indicate the relationship of the affected person to you or to the baby’s father. 3. Do you or the baby’s father have a birth defect? If yes, who has the defect and what is it? 4. Do you or the baby’s father have any close relatives with mental retardation? If yes, indicate the relationship of the affected person to you or to the baby’s father.

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5. In any previous marriages, have you or the baby’s father had a child born dead or with a defect. 6. Do you, the baby’s father or a close relative in either of your families have a birth defect, any familial disorder or a chromosomal abnormality not listed in the previous questions? If yes, indicate the condition and the relationship of the affected person to you or to the baby’s father. 7. In any previous relationships, have you or the baby’s father had a stillborn baby or three or more 8. Have either of you had a chromosomal study? If yes, indicate the result. 9. Excluding iron and vitamins, have you taken any medication or recreational drugs since being pregnant or since your last menstrual period (LMP)? If yes, give the name of medication and time during pregnancy when the medication was taken. 10. Have you undergone radiation or chemotherapy in preconception or during pregnancy? If yes, mention the reason and name of drugs. 11. Have you been environmentally exposed to pesticides, lead or other harmful substance? If yes, when and the name of the substance. Many other questions may be asked related to each answer as required during recording.

3 Preparation for Parenthood

Parenthood is a turning phase in a couple’s life wherein pregnancy arrived as a transition period from

oBJectiVeS 1. Assist the expectant couple in the selection of best health-care setting within their reach. 2. Help the expectant couple to understand physiological changes, common discomfort and their management and prenatal care required during pregnancy. 3. Assist the expectant parents in the preparation of birth process. 4. Guide the expectant parents for postnatal adoption of the baby and for afterbirth care. 5. Help the family members and siblings in adjustment process with parent and newborn.

firSt SteP: aSSeSSinG the ParentS Sample questions given below can be asked while visiting parent or in clinic to identify their perception and acceptance of pregnancy. Sample Question

Area for Assessment I. Perception of complexities of mothering a. The baby is desired for itself Positive

1. Did you plan your pregnancy?

1. Feels positive about pregnancy

2. How do you feel about being pregnant?

Negative

3. Why do you want this baby?

1. Wants the baby to meet own needs such as someone to love her in the family b. Expresses concern about impact of mothering role on role as wife, career, school, etc.

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Positive 1. How do you think your life will be different after your baby is born?

1. Has realistic expectations of how the baby will affect job, career or personal goals.

2. How will the baby affect your relationship with your husband?

2. Shows interest in learning about childcare. Negative

3. Have you done any reading or prepared anything for the baby or contacted any health-care provider?

1. Feels pregnancy and the baby will affect her life 2. Has no insight for mothering role. c. Gives up routine habits that are not good for baby, e.g. quits smoking, adjusts time schedule. Positive

1. For your baby’s well-being, have you given up any routine habits that might affect your health?

1. Gives up routines that are not good for baby; quits smoking, adjusts eating habits, etc. Negative 1. Continues old routine. II. Attachment a. Strong feeling regarding sex of baby. Why? Positive

1. Why do you prefer a certain sex?

1. Verbalizes positive thoughts. Negative

2. Note comments woman makes about baby not being normal and why she feels this way.

1. Feels baby will be like negative aspects of herself and partner. b. Interested in data regarding foetus, e.g. growth and development, heart sound, etc. Positive

1. What did you think or feel when you first felt the baby move?

1. Is anxious to know the condition of the foetus. Negative 1. Shows no interest in foetal growth. 2. Shows negative feelings by rejecting counselling, not following diet, not resting adequately, not following proper hygiene measures, etc. c. Fantasises about baby Positive

1. Have you started preparing for the baby?

1. Follows cultural norms regarding preparation.

2. What do you think your baby will look like—what age do you see your baby at?

2. Shows behaviour appropriate to her history of pregnancy.

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Negative 1. Shows conditional bonding depending on sex of baby, delivery experience. 2. Considers only own needs. 3. Exhibits no attachment. 4. Fails to follow cultural norms regarding preparation. III. Acceptance of the child by significant others a. Acknowledges acceptance by significant others of the new responsibility inherent in the child. Positive 1. How does your partner feel about pregnancy?

1. Acknowledges unconditional acceptance of pregnancy and baby by significant others.

2. How do your parents feel?

2. Partner accepts new responsibility inherent with the child. 3. Shares experience of pregnancy with parents. Negative 1. Significant others do not involve supportively. 2. Significant others show conditional acceptance of pregnancy depending on sex. 3. Partner does not take any responsibility. b. Concrete demonstration of acceptance of pregnancy/baby by significant others, e.g. significant others are involved in care of pregnancy. Positive

1. How do your family members and significant others feel about pregnancy?

1. Care for pregnant women. 2. Help woman financially, physically and emotionally. 3. Partner attends clinic with her. IV. Ensure physical well-being a. Concerns about having normal pregnancy, labour, delivery and baby. Positive

1. What have you heard about labour and delivery?

1. Woman prepares for labour and delivery and attends antenatal clinic.

2. Note data about woman’s reaction to prenatal class. 2. Woman is aware of danger signs of pregnancy. 3. Woman follows recommended care.

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Negative 1. Denial of signs and symptoms of complications of pregnancy. 2. Fails appointments, fails to follow instructions and refuses to attend antenatal clinic.

Second SteP: counSellinG the ParentS counselling the Parents parent to plan further counselling. 2. Both mother and father are required to counsel individually and together. – Antepartal education programmes are planned to provide counselling and to share information. – Promote woman to adopt maternal role, to accept pregnancy and to assimilate the pregnant state into her way to life. – Acceptance of baby is very important. Nurse should explain the importance of a child in married family life. A baby is required to complete a family. – Prepare mother psychologically to accept changes in her and her husband’s lives after the birth of the baby as a realistic fact. – Ask mother to read books related to baby’s arrival. If she cannot read, pictorial books can be arranged for her. – Teach mother in her early visits about a. Early gestational changes b. Self-care during pregnancy c. Foetal development and environmental danger for foetus d. Sexual activity during pregnancy e. Nutrition, rest and exercise g. Psychological changes during pregnancy h. Measures to be adopted to have a safe and healthy start to pregnancy. – Counsel her to give up some of the habits not good for baby’s health like smoking, bad eating habits, etc. This will help mother to feel about baby’s well-being. – Encourage mother to feel about baby and think about foetal growth and baby’s activities after birth. – Ask the woman’s husband to attend the clinic with her to understand the condition and to promote feeling of togetherness. – Help the couple to decide about the choice of birth setting. – Help to prepare for birth process and try to relieve fear and anxiety related to labour process. Teach relaxation techniques, breathing techniques and newborn safety measures.

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counselling the father Every father’s attitude is different in adjusting and accepting fatherhood. Some may be excited and pleased about the anticipated role of father. Nurses working with expectant fathers need to support fatherhood in four ways. – Emotional support: The primary support of father is for his partner or wife. This support would is imperative to permit nurturing the baby and to attend to his partner needs. – Instrumental support: Physical support is required from family members and friends during hospitalization of mother for delivery. – Informational support: The father needs to be updated on expert tips to solve immediate problems. Family members such as mother-in-law and grandmother are the experienced experts for giving tips. – Appraisal support: He needs guidance to perform fatherhood responsibilities.

counselling the Sibling – The older child often experiences a sense of loss or feels jealous on being ‘replaced’ by new baby and sharing the spotlight with a new brother or sister. – Parents should devote more time to maintain relationship with the child. – Father and the child should accompany the woman when she visits the antenatal clinic. Focus the child’s attention while listening to foetal heart sound and palpating abdomen. – Teach sibling through books, audiovisual materials, models and discussion. – Help parents with sibling preparation by helping them to understand the stresses the child may experience. – The child needs a supporting person during hospitalization of mother. The person should be well arrival of the baby. – Sibling response to pregnancy may vary with age and dependency need of the child. A formal sibling teaching class gives better adjustment.

counselling the family members

– – – –

etc. It is better to advise accompanying family members who will be with the woman during childbirth and postnatal period. Plan antenatal education for family members and others during each visit. Keep in mind that teaching duration should not be more than 15 minutes. Deal with important issues on antenatal, intranatal and postnatal periods during which woman needs support of the family members. It is also important to clarify the confusion, doubts and myths of family members during antenatal teaching. Teach and demonstrate important topics such as diet, exercise, preparation for birth, preparation for baby, breastfeeding technique and its importance, baby bath, postnatal diet, immunization of baby, weaning and family planning methods.

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– Expectant parents and their families have different interests and information needs as the pregnancy – Nurses can follow the below educational program in the preparation of parenthood of expectant parents and families. Early Pregnancy: The purpose of counselling is to provide fundamental information. A counselling session can be based on (1) early foetal development, (2) physiological and emotional changes, (3) human sexuality, (4) nutritional needs of the mother and foetus, (5) environmental hazards, (6) warning signs and (7) drugs and self-medication. Midpregnancy: Parents and family’s participation in care. Teach breastfeeding, infant care, basic hygiene, common discomfort and safe remedies, infant health and parenting. Late Pregnancy: Give emphasis on labour and birth. Teach methods of coping with labour pain, breathing relaxation, postnatal discomfort and pleasure. Parent educators must focus on building rapport, communicating clearly and reinforcing the positive and promoting changes in practices.

4 teaching Self-care methods of determining ovulation

Ovulation is the process of release of a mature ovum from the ovary due to the effect of various female hormones during the 14th day of the menstrual cycle every month. Teaching self-care methods of determining ovulation is the process by which a woman is taught easy methods to recognise the process of ovulation by herself at home.

oBJectiVeS 1. 2. 3. 4. 5.

Explore methods of assessment of ovulation process at home for testing infertility. Educate the couple about the normal body changes that occur during menstruation. Teach the couple signs and timing of ovulation for effective outcome. Help the couple to determine fertile period in case of irregular cycle. Help the couple to assess themselves prior to further hi-tech investigations.

teSt 1: BaSal Body temPerature (BBt) recordinG Observation: There is a ‘biphasic pattern’ of temperature variation in ovulatory cycle. If ovulation occurs, there is rise of temperature, which provides supportive evidence of ovulation a day after ovulation has Principle: The rise of temperature is secondary to progesterone output. The primary reason for the rise is the increase in production and secretion of norepinephrine, which is a thermogenic neural hormone. Teaching Plan: Sr. no.

Content

1.

Instruct the woman the purposes of recording BBT

2.

Explain the procedure to record BBT in chart.

Teaching Methods

Instruct the woman that the temperature chart has to be recorded

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3.

Instruct the woman to take her oral temperature at least for five minutes every morning before she gets out of bed and before starting any activity. At least 3 hours of sleep is needed for correct procedure.

Demonstrate temperature recording

4.

Instruct the women to use a BBT thermometer; otherwise, a clinical thermometer can be used to record the temperature.

Demonstrate the use of the thermometer

5.

Instruct the women to mark a round on the temperature chart every morning after taking temperature. Then ask her to connect that dot each day to reveal her pattern of baseline temperature reading as given in Figure 4.1 A and B

Demonstrate marking of dots

6.

Days when intercourse takes place should also be recorded on the chart for better evaluation. Ask the woman to record frequency of coital.

7.

Advice the woman to avoid situations which can disturb body temperature, like high intake of alcohol, sleeplessness, GI and other illnesses, immunization, warm or hot climate or use of electrical pads or blankets, etc.

Interpretation/Expected Findings: cycle increases by 0.5°−1°F (0.2°−0.5°C) following ovulation. The rise sustains throughout the second half of the cycle and falls 2 days prior to the next period called ‘biphasic pattern’. There may be a drop in temperature to about 0.5°F before the rise due to surging luteinizing hormone (LH) and with a peripheral level of progesterone to greater than normal. Clinical Importance: Maintaining the BBT chart during investigation is of help in determining ovulation and timing of postcoital test, endometrial biopsy, cervical mucus or vaginal cytology study for ovulation. It also helps the couple to determine the fertile period if the cycle is irregular.

teSt 2: cerVical mucuS method Observation: Alteration of the physiochemical properties of cervical mucus occurs due to the effect of oestrogen and progesterone. Principle: Disappearance of fern pattern beyond 22nd day of cycle that was present in the midcycle is suggestive of ovulation. Persistence of fern pattern beyond 22nd day suggests anovulation. Teaching Plan: 1. Explain the purpose of the procedure to the woman. 2. Instruct her to check the vagina each day when she uses the bathroom.

Hysterosalpingography

Postcoital exam

Coitus

Plasma progesterone test

Menses

Endometrial biopsy

Menses

figure 4.1 (A) A monophasic, anovulatory basal body temperature (BBT) chart. (B) A biphasic BBT chart illustrating ovulation, the different types of testing, and the time in the cycle that each would be performed.

Menses

Probable time of ovulation

/2 6/3 6/4 6/5 6/6 6/ 7 6/ 8 6/ 9 6/10 6/11 6/12 6/13 6/14 6/15 6/16 6/17 6/18 6/19 6/20 6/21 6/22 6/23 6/24 6/25 6/26 6/27 6/28 6/29 6/30 7/1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

6

Days of cycle

Coitus

Days of month C F 37.1 99.0 37.0 98.8 36.9 98.6 36.8 98.4 36.7 98.2 36.6 98.0 97.8 36.5 97.6 36.4 36.3 97.4 36.2 98.2 36.1 97.0

Menses

/5 4/6 4/7 4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28 4/29 4/30 5/1 5/2 5/3 5/4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

4

Days of cycle

Days of month C F 37.1 99.0 37.0 98.8 36.9 98.6 36.8 98.4 36.7 98.2 36.6 98.0 36.5 97.8 36.4 97.6 36.3 97.4 36.2 98.2 36.1 97.0

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3. Instruct her to check the vagina either by slight padding of tissue papers in vagina before voiding 4. Instruct her to note the wetness or presence of mucus and collect mucus. 5. Instruct her to observe the colour of mucus and its consistency (Figure 4.2). 7. Ask her to record several cycles of mucus changes before relying on this fertility method.

figure 4.2 Consistency of mucus.

Special Consideration: Presence and consistency of mucus is altered by vaginal infection, vaginal medications such as use of vaginal jelly, creams, lubricants, etc., or sometimes after sexual intercourse, semen can be confused with vaginal secretions.

5 assisted artificial reproductive techniques

by retrieving oocytes from the ovary or sperm from the testes or epididymis.

oBJectiVeS

3. Support the couple emotionally to overcome stress. 5. Explain the outcomes, which vary from person to person. 6. Help in follow-up visits.

methodS of art Method Intrauterine insemination

Definition

Indications

Process to bypass the endocervical canal, which is abnormal, and to place increased concentration of motile sperms close to the fallopian tubes by artificial insemination of either the husband’s sperms or a donor’s sperms

Hostile cervical mucus Cervical stenosis, oligospermia or asthenospermia Immune factor Impotency Male factor—anatomical defect (hypospadias) but normal ejaculation can be obtained

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In vitro fertilization Process by which fertilization and embryo is done in a laboratory and the transfer (IVF-ET) embryo is placed into the woman’s fallopian tube laparoscopically.

Tubal diseases Endometriosis Cervical hostility Failed ovulation induction Unexplained infertility

Gamete intrafallopian transfer

Sperm and the unfertilized oocytes Same as IVF-ET except there must be normal are transferred into the fallopian tube. tubal anatomy

Zygote intrafallopian transfer

Placement of zygote following 1 day of IVF into the fallopian tube either through abdominal ostium by laparoscopy or through uterine ostium under ultrasonic guidance.

Same as above

Intra-cytoplasmic sperm injection

Sperm is recovered from the ejaculated semen or retrieved by testicular sperm extraction or by microsurgical epididymal sperm aspiration procedures and injected directly into the cytoplasm of an oocyte by micropuncture of zona pellucida.

Azoospermia, severe oligospermia Obstruction of efferent duct system (male) Failure of fertilization in IVF Unexplained infertility Women with premature ovarian failure

Embryo or oocyte donation

Process by which a donated embryo/oocyte is transferred into the uterus of an infertile woman at the appropriate time of normal cycle.

Women whose ovaries have been removed Older women Failure to respond with super-ovulation regimen Genetic diseases

Adoption: point of management must be realistically understood. Adoption is an alternative for many couples.

nurSinG reSPonSiBilitieS Psychological Preparation

2. A nurse needs to be constantly aware of the emotional needs, irrational thoughts and fears and provide emotional support and inform the couple about alternative options available. 3. Assess individual couples for stress and support accordingly. 4. Prepare couples psychologically to adopt a child from a registered agency, if they cannot

or adoption, as it is essential to prevent couples from societal embarrassment. -

Assisted Artificial Reproductive Techniques

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23

ethical consideration in art 1. The methods of resolving infertility raise many ethical questions including

– Financial and moral responsibilities for a child born with congenital defects – Issue of donor selection 2. Thoughtfully assess the values of the couple and identify any clinical situation in which they feel they could not function. 3. Act in the clients’ best interest and not for their personal interest or of the hospital’s interest. Client needs a series of explanations to accept the procedure. 4. Provide assistance in resolving the dilemma.

action and reason behind it and the possible results of the proposed action. the clients, health-care agency and the health-care professionals involved. 7. Outline various courses of actions and present alternative solutions to the problem. 8. Determine the possible outcome of course of actions suggested to client. 9. Determine who ‘owns’ the problem in family and who should make the decision. The factors to be considered include who will be affected by the decision, for whom the decision is made, whose moral and legal responsibilities are being affected and what degree of consent is needed from those involved in the procedure.

Pre-art care 1. 2. 3. 4.

Explain the procedure to the couple, discuss in detail and solve their queries. Obtain consent from couple after informing them the details. Prepare client’s part as prepared in other surgeries. Prepare all the reports regarding the investigations done before sending the client into the operation theatre. Check both client and donor for infectious diseases.

6. Maintain proper temperature for oocyte, sperm, embryo, zygote, etc. 7. Shift client to operation theatre after premedication administration. 8. Ensure that the procedure is done at the appropriate time of the woman’s menstrual cycle for positive effect.

Postsurgery care 1. Advice rest to release physical and emotional stress. 2. Advice to take prescribed medication regularly.

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| Midwifery and Obstetrical Nursing—Practical

Advice to avoid sexual intercourse until the advice of the doctor. Instruct to inform any uneasiness immediately. Ask to avoid psychological stress and anxiety to prevent failure or loss of pregnancy. Ensure that the whole pregnancy is progressing under medical supervision. Make efforts to prevent complications. Follow-up the woman until she is due for delivery.

Section ii

Prenatal Assessment and Care The prenatal period is a preparatory one, both physically in terms of foetal growth and mentally in terms of maternal preparation. Ideally, health care before the advent of pregnancy has been adequate and prenatal care is a continuation of that established care. Prenatal health supervision permits diagnosis and treatment of maternal disorders that may develop during pregnancy. Healthy outcome of pregnancy depends on good prenatal care. This section discusses the measures that should be adopted for a healthy pregnancy and healthy outcome. Practical 6 explains Initial History Documentation of Antenatal Woman. Practical 7 guides in calculating due date of delivery under the title Determination of Expected Date of Delivery. Practical 8: General Physical Examination explains the methods of complete and systematic examination of the pregnant woman to assess her general health. Practical 9 discusses the Abdominal Examination and Application and Practical 10: Breast Self-examination, which is very important, details the methods that the pregnant woman should follow while self-examining her breasts, which should start from the prenatal period. The pelvic region accommodates the foetus and provides a passage for delivery. Practical 11 deals with Vaginal Examination and Assessment of Pelvic Adequacy. Prenatal Advices and Prenatal Exercises are subsequently dealt with in Practical 12 and Practical 13, respectively. A nutritious diet plays an important role in foetal growth, and diet guidance is discussed in Practical 14: Nutritional Advices. During pregnancy, the woman may undergo some discomforts that can be prevented and treated at home. Practical 15 offers an opportunity for the pregnant women by Teaching Self-care for Common Discomforts During Pregnancy. Intrauterine growth assessment of the foetus will be learnt in Practical 16: Foetal Well-being. Practical 17: Subsequent Prenatal Visits will review the subsequent prenatal examination at each visit until pregnancy reaches full term. On completion of section 2, student nurses will be able to learn complete prenatal assessment and assist the pregnant woman for a healthy outcome.

PracticalS 6. Initial History Documentation of Antenatal Woman 7. Determination of Expected Date of Delivery 8. General Physical Examination 9. Abdominal Examination and Application 10. Breast Self-Examination 11. Vaginal Examination and Assessment of Pelvic Adequacy 12. Prenatal Advices 13. Prenatal Exercises 14. Nutritional Advices 15. Teaching Self-Care Methods for Common Discomforts During Pregnancy 16. Assessing Foetal Well-Being 17. Subsequent Prenatal Visits

6 initial History Documentation of antenatal Woman

Documentation of the history of an antenatal woman is a process of systematic collection of information to determine the adequacy of pregnant state.

oBJectiVeS 1. 2. 3. 4.

Assess general health of pregnant woman Identify possible health problems Plan antenatal care (ANC) for woman Monitor progress of pregnancy

articleS reQUireD 1. Antenatal card or history sheet 2. Pen

PreParation For initial HiStorY DocUMentation 1. Establish good rapport with the antenatal woman by ensuring a comfortable environment for communication. 2. Maintain privacy when recording history. 3. Proceed from informal to formal and simple data to complex data. 4. Be active and patient while listening. 5. Be a guide when documenting history. 6. To get more comprehensive data, use a more detailed approach.

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ProceDUre

1. Personal Information

2. Partner’s History

3. Current Medical History

4. Medical History

Initial History Documentation of Antenatal Woman

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29

5. Family Medical History culosis, pre-eclampsia, eclampsia or pregnancy-induced hypertension (PIH)

6. Current Pregnancy

7. Past Pregnancies

8. Gynaecological History

The nurse can use the initial interview to observe the woman’s non-verbal communications and interactions between the woman and her support person.

Prenatal HiGH-riSK FactorS Factor

Maternal Implication

Foetal/Neonatal Implication

Social and Personal Low income/low educational level

Poor ANC

Low birth weight

Poor nutrition

IUGR

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| Midwifery and Obstetrical Nursing—Practical

Poor diet

Inadequate nutrition

Foetal malnutrition

↑ Risk of anaemia

Prematurity

↑ Risk of antepartum haemorrhage or postpartum haemorrhage (PPH)

Foetal death

Weight < 40 kg

Poor nutrition Prolonged labour

IUGR Hypoxia with difficult birth

Age < 18 years

Poor nutrition

Low birth weight

Poor ANC

↑ Foetal demise

Multiparity > 3

Anaemia

↑ Risk of pre-eclampsia ↑ Risk of cephalopelvic disproportion (CPD) Age > 35 years

Smoking one pack of cigarettes or more a day

↑ Risk of pre-eclampsia

↑ Risk of congenital birth

↑ Risk of caesarean birth

↑ Risk of chromosomal anomalies

↑ Risk of hypertension

↓ Placental perfusion

↑ Risk of cancer

↓ O2 and nutrients

↓ Oxygen-carrying capacity

Low birth weight IUGR Preterm birth ↑ Risk of sudden infant death syndrome (SIDS)

Substance abuse

↑ Risk of poor nutrition ↑ Risk of infection with IV drugs

↑ Risk of congenital anomalies

↑ Risk of acquired immunodeficiency virus (HIV)

↓ Risk of serum bilirubin

↑ Risk of low birth weight ↑ Risk of abruptio placentae

Alcohol consumption

↑ Risk of poor nutrition Potential for hepatic effects

Short height < 140 cm

↑ Risk of foetal alcoholic syndrome ↑ Risk of foetal distress and IUGR

↑ Risk of caesarean birth

↑ Risk of foetal distress and IUGR

↑ Risk of pre-eclampsia, hypertension

Low birth weight

Episodes of hypoglycaemia and hyperglycaemia

Macrosomia

Pre-existing Medical Disorders Diabetes mellitus

Initial History Documentation of Antenatal Woman

↑ Risk of caesarean birth

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31

Neonatal hypoglycaemia ↑ Risk of congenital anomalies ↑ Risk of respiratory distress syndrome

Cardiac diseases

Cardiac decompensation

↑ Risk of foetal demise

Strain on mother’s body

↑ Perinatal mortality

↑ Maternal death rate Anaemia, haemoglobin < 9 g/dl

Hypertension

Iron deficiency anaemia

Foetal death

Low energy level

Prematurity

↓ Oxygen carrying capacity

Low birth weight

↑ Vasospasm

↓ Placental perfusion

↑ Risk of central nervous system (CNS) irritability, convulsion

Low birth weight

↑ Risk of cerebrovascular accident

Preterm birth

↑ Risk of renal damage Thyroid disorders

↑ Infertility

↑ Spontaneous abortion ↑ Risk of congenital goitre

Hypothyroidism

Hyperthyroidism Renal disease

↓Basal metabolic rate, goitre, myxoedema

Mental retardation

↑Risk of PPH

↑ Preterm birth

↑ Risk of pre-eclampsia

Cretinism

Danger of thyroid storm

↑ Tendency of thyrotoxicosis

↑ Renal failure

↑ Risk of IUGR ↑ Risk of preterm delivery

Diethylstilbestrol exposure

↑ Infertility, spontaneous abortion

Stillborn

↑ Emotional/psychological distress

↑ Risk of preterm birth

↑ Cervical incompetence ↑ Risk of IUGR ↑ Risk of preterm birth

Habitual abortion

↑ Emotional/psychological distress

↑ Risk of abortion

Caesarean birth

↑ Probability of repeat caesarean birth

↑ Preterm birth

Rh or blood group sensitization

↑ Financial expenditure for investigation and treatment

↑ Risk of respiratory distress ↑ Risk of hydrops fetalis Icterus gravis Neonatal anaemia Kernicterus Hypoglycaemia

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Large baby

↑ Risk of caesarean birth

Birth injury

↑ Risk of gestational diabetes

Hypoglycaemia

Current Pregnancy Rubella in first trimester

Congenital heart disease Cataracts Nerve deafness Bone lesions Prolonged virus shedding

Rubella in second trimester Herpes virus

Hepatitis Thrombocytopenia Severe discomfort

Foetal infection

Possibility of caesarean birth

Neonatal herpes virus Neurological defect

Syphilis

↑ Incidence of abortion

↑ Foetal demise

Abruptio placentae or placenta previa

↑ Risk of haemorrhage

Foetal/neonatal anaemia

Long hospitalization

Intrauterine haemorrhage

Congenital syphilis

↑ Foetal demise PIH Multiple gestation

As described in hypertension ↑ Risk of PPH

↑ Risk of preterm birth

↑ Risk of caesarean birth Spontaneous premature rupture of membrane

↑ Uterine infection

↑ Preterm birth ↑ Foetal demise ↑ Risk of sepsis

7 Determination of expected Date of Delivery

The process of calculating the probable date of childbirth is called expected date of delivery (EDD). is a trend in literature to avoid it, instead referring to it as estimated date of delivery (EDD). Childbirth refer the due date as the estimated date of birth (EDB).

oBJectiVeS 1. Calculate the gestational age of pregnancy 3. Assess foetal growth 4. Prevent postmaturity complications

articleS reQUireD 1. Woman’s antenatal card or record 3. Draping sheet 4. Hand washing articles

ProceDUre 1. Maintain privacy during interview and gestational examination

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| Midwifery and Obstetrical Nursing—Practical

First Method Nagele’s rule: This is the most common method use to determine EDD. To use this method, begin

= August 21 Add 7 days August 21 + 7 days = August 28 = EDD OR

November 21 + 7 days = November 28 Subtract 3 months = August 28 = EDD OR

Subtract 3 months = August 21, 1994 Add 7 days August 21, 1994 + 7 days = August 28, 1994 Add 1 year August 28, 1994 + 1 year = August 28, 1995 = EDD

Second Method From the date of quickening: gives the EDD (Figure 7.1).

third Method From the height of the uterus: (Figure 7.2) and the duration of pregnancy is calculated by the following formula a. Height of the fundus in cm ! b. Height of the fundus in cm !

Fourth Method

= duration of pregnancy in months =

Determination of Expected Date of Delivery

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35

or 3 months. Palpating the edge of the fundus with one hand, the height of the uterus can be palpated

cavity.

January

Feb rua r

y

No ve mb e

r

ber cem De

October

rch Ma

36 40 32

April

26

Ma y

er mb pte e S

20 16 12 10

e Jun

July

Au gu st

Figure 7.1 Estimated date of birth wheel.

6. Convey the EDD to the woman and her family.

Figure 7.2 Estimating the date of delivery using height of the uterus.

8 General Physical examination

Systematic assessment of a pregnant woman from head to foot is called general physical examination.

oBJectiVeS 1. Assessing any abnormality in the body that interferes with pregnancy. 2. Identifying any abnormality in the body that can have an effect on pregnancy and the outcome of pregnancy.

articleS reQUireD 1. Draping sheet 2. Articles of physical examination

ProceDUre 1. Arrange the physical examination room. Keep the physical examination tray ready. 2. Explain the activities of physical examination to the woman to reduce curiosity and fear. Also explain the importance of physical examination during pregnancy.

6. As you are examining, explain the procedure and give appropriate instructions before each step. 7. Do the following examinations.

General Physical Examination

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37

Vital SiGnS recorDinG a. Blood pressure (BP) : renal disease, apprehension or anxiety, etc. BP > for medical management. b. Pulse Increased rate may be due to excitement or anxiety, cardiac disorders, infections, etc. Advise rest and counsel to relieve anxiety. Refer major problems to doctors. c. Respiration degree of hyperventilation. Assess for respiratory abnormalities. d. Temperature Infection may increase temperature. Assess for any infection and if it continues refer to doctor.

Weight Varies from individual to individual. > < For women with weight < sel for healthy diet. In case of sudden weight gain, assess for PIH, and in case of diabetes, assess for

Skin Absence of edema, sometimes slight edema in extremities, absence of lesion or rashes. Pigmentation changes normal, e.g. linea nigra, striae gravidarum, chloasma.

veins, decreased circulation). Refer for various investigations and medical consultation in case of abnormalities. Striae, chloasma and linea nigra are normal manifestations of pregnancy due to physiological changes.

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| Midwifery and Obstetrical Nursing—Practical

eyes Conjunctiva is pallor in anaemia and yellowish in jaundice. ance of medical advice.

nose Nasal mucosa is redder than oral mucosa. In pregnancy, nasal mucosa is oedematous

Refer to physician for olfactory loss.

Mouth Sometimes hypertrophy of gingivitis tissues because of oestrogen may be noted. Assess for haemoglobin, advice to maintain oral hygiene and consult dentist.

neck Sometimes small mobile non-tender nodes are found. In thyroid, small, smooth lateral lobes palpable on either side of trachea. Slight hyperplasia is noted by the third month of pregnancy. due to hypothyroidism. question woman about dietary habits.

chest and lungs Chest: Symmetrical, with smaller anteroposterior (AP) diameter than transverse Inspection and palpation: No retraction or bulging Percussion: Bilateral symmetry in tone. Auscultation: tory and inspiratory phases. Chest: Increased AP diameter, funnel chest, Pigeon chest (emphysema, asthma, chronic obstructive pulmonary disease (COPD)). Ribs: diameter. Ribs

Percussion: Flatness of percussion, which may be Auscultation: Abnormal sound heard over any other area of chest. Chest/Ribs: Evaluate for asthma. COPD Percussion: Evaluate for pleural effusions, consolidation of the lung or tumour. Auscultation: Refer to doctor.

General Physical Examination

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39

Heart Normal rate, rhythm and heart sounds. Pregnancy-related changes include the folmurmurs that increase in held expiration are normal due to increased volume. extra sounds. Complete initial assessment, refer to physician if needed.

Breasts Please refer practical 10 of section 2 of this practical guide.

abdomen Please refer practical 9 of section 2 of this practical guide.

extremities

Evaluate for other symptoms of heart disease. Initiate follow-up if woman men-

Spine Normal spine curves are concave cervical, convex thoracic and concave lumbar. In pregnancy, lumbar spinal curve may be accentuated. Shoulders and iliac crests should be even.

reflexes Normal and symmetric. Hyperactivity in PIH. Evaluate for other symptoms of PIH.

Pelvic area and its Measurements Please refer practical 11 of section 2 of this practical guide

anus and rectum

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| Midwifery and Obstetrical Nursing—Practical

Counsel about appropriate prevention and relief measures. Refer to physician for further evaluation.

Postexamination Procedure

5. Maintain antenatal record properly and advise woman to come for follow-up visits.

9 abdominal examination and application

It is the process of identifying the foetal condition and favourable birth passage.

oBJectiVeS 1. Observe the lie, presentation and position of foetus as to assess the relationship between foetal head and pelvic brim. 2. Assess foetal growth. 4. Arrange for referral in case of any deviations from normal.

articleS reQUireD 1. Draping sheet 3. Measuring inch tape 5. Patient’s chart

PreParation anD PrecaUtionS An abdominal examination is carried out during every antenatal visit. Before the examination remember to follow the below procedures. quent visit. 2. Explain the purpose and procedure of examination. 3. Provide privacy and comfortable position. 5. As far as possible, dress her with a loose gown during examination.

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| Midwifery and Obstetrical Nursing—Practical

7. Ensure that your hands are clean and warm. 8. Proceed systematically and gently. 9. Avoid palpation and count the foetal heart rate (FHR) reading during contraction.

MeaSUreMent oF UterUS Measure the abdominal height. A measuring tape or a pelvimeter may be used to measure the fundal height.

be performed by measuring from the upper border of the symphysis pubis to the upper border of the fundus. McDonald’s rule is used to calculate fundal height. Height of fundus (cm) ! = duration of pregnancy in lunar months. Height of fundus (cm) ! = duration of pregnancy in

bilicus in an average woman (Figure 9.1).

36 40 32 26 20 16 12 10

Figure 9.1 Approximate height of the fundus at various weeks of pregnancy.

Abdominal Examination and Application

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43

Measuring Fundal Height by Weeks Refer to the fourth method of determining EDD in practical 7 of section 2 Fundal Height/Abdominal Girth More Than Normal

Fundal Height/Abdominal Girth Less Than Normal

Mistaken date Hydramnios Multiple pregnancy Large baby Fibroids in utero Obesity Concealed bleeding

Mistaken date IUGR Transverse/oblique lie Bicornuate uterus Intrauterine foetal death Missed abortion

inSPection Silver striae or purple striae may be present especially in multipara women. Diastasis of

Observe whether shape of uterus is longitudinally ovoid or transversely ovoid.

PalPation (leoPolD’S ManoeUVreS) Abdominal palpation is a systematic way to evaluate the maternal abdomen.

Fundal Palpation: breech is felt in normal pregnancy. Spine is in the form of soft irregular parts. This indicates that the presentation is cephalic, and lie is longitudinal.

the upper border of the uterus.

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| Midwifery and Obstetrical Nursing—Practical

Figure 9.2 Fundal palpation (grip)

Lateral Palpation:

the uterus and push the foetus over towards the examining hand.

Figure 9.3 Lateral palpation

Pelvic Palpation: Pelvic palpation is done to feel the cephalic prominence, which will decide the presenting parts and which indicates cephalic presentation. If two poles are felt along with limbs, sinciput is felt. Along the

Abdominal Examination and Application

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45

Figure 9.4 Deep pelvic palpation

Pawlik’s Palpation: (Figure 9.5). It indicates whether the presenting part is moving (non-engaged) or not moving (engaged).

then on the left.

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| Midwifery and Obstetrical Nursing—Practical

Figure 9.5 Pawlik’s palpation (grip)

Ballottement tapped sharply. Absence of ballottement indicates oligohydramnios. Auscultation beats per minute. Heart rate more than 160 beats per minute or less than 100 beats per minute indicates foetal distress.

muscles and locating the FHR will be easy. rior position and umbilicus and right joint in the right occipito anterior position.

Foetal Movements (Kick Counts) to count foetal movements every day.

lateral position after a meal and count the foetal movements.

10 Breast Self-examination

A woman can examine her breast following the systematic methods outlined below.

oBJectiVeS

PreParation oF articleS 2. Poster with pictures showing methods of breast self-examination

ProceDUre 1. Explain the purposes of breast self-examination. 2. Provide privacy. 3. Describe and demonstrate the correct method of examination.

side, both arms stretched above her head and both hands placed on her hips while leaning forward (Figure 10.1).

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| Midwifery and Obstetrical Nursing—Practical

Figure 10.1 Position for inspection of breasts

and record the following characteristics for each position. a. Size and symmetry of the breasts 1. There may be variations in breasts, but the variations should remain constant during the rest b. Shape and direction of the breasts 1. The shape of the breasts can be round or pendulous with some variation between the breasts. 2. The breasts should be pointing slightly laterally. c. Colour, thickening, oedema and venous patterns of increased blood supply due to tumour. Symmetric venous patterns are considered normal. d. Surface of the Breasts together or against her hips suggests malignancy. e. Nipple size, shape, direction, rashes, ulceration and discharge 3. Instruct the woman to palpate (feel) her breast as detailed below.

breast.

bloody).

Breast Self-examination

(a)

(c)

(b)

(d)

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49

Figure 10.2 Breast self-examination

Breast Examination During Pregnancy

Pregnancy changes

2. Breasts become nodular during pregnancy. heaviness.

6. Note appearance of striae. 7. Feel tubercles of Montgomery enlarge. mary areola.

11 Vaginal examination and assessment of Pelvic adequacy

It is the examination of external and internal vagina to detect normal birth process.

oBJectiVeS 1. Detect external vaginal abnormality. 3. Decide cervical dilatation and effacement. 4. Detect second stage of labour.

PreParation oF articleS A sterile tray containing

PreParation oF WoMan 1. Bladder should be empty before examination. 3. Perineal area should be clean before internal vaginal examination.

Vaginal Examination and Assessment of Pelvic Adequacy

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51

4. Vaginal examination is restricted after membrane rupture. 5. Do not do vaginal examination in case of antepartum haemorrhage or placenta previa.

ProceDUre 1. Explain the procedure to the woman. 3. Encourage her to relax during the procedure. 4. Assist the woman to get to the lithotomy position, raise the woman’s head slightly using pillows and drape her with a draping sheet. 5. Facilitate open communication to help the woman to relax.

external inspection maturity. -

5. During the examination review the history such as burning sensation during micturition and pain in the perineum.

swelling, discharge and pain.

internal examination 1. Wash hands and wear sterile gloves.

left hand (Figure 11.1). 4. Never touch the labia minora with sterile hand.

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8. Note measurement of the pelvic inlet sacral promontory) 9. Note pelvic mid dimension vergence of the walls of the pelvis

A

C

B

Figure 11.1 Manual measurement of inlet and outlet. (A) Estimation of diagonal conjugate which extends from lower border of symphysis pubis to sacral promontory. (B) Estimation of anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. (C) Methods that may be used to check manual estimation of anteroposterior measurements.

10. Pelvicoutlet

12. Remove the draping sheet.

Vaginal Examination and Assessment of Pelvic Adequacy

after care 1. Replace instruments after washing and send for autoclaving.

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12 Prenatal Advices

Prenatal advices are informal and formal health education methods to the childbearing mother and family members are detailed in this practical.

oBJectiVeS 1. Promote safe and healthy pregnancy. 3. 4. 5. 6.

Impart education regarding care of pregnancy. Demonstrate antenatal exercise. Prepare mother for childbirth. Ensure normal and safe delivery.

ProceDUre 1.

Nutritional Education Encourage sufficient amount of food during breakfast, lunch and dinner. Advice the woman to take one glass of milk at bedtime. Encourage intake of green leafy vegetables and fruits.

For getting the required amount of nutrients. Milk provides calcium required for foetal bone growth. Green leafy vegetables are rich in fibre and prevent constipation and provide micronutrients.

Iron-rich food is adviced.

Prevents anaemia in pregnancy.

Instead of having a bigger portion at a time, advice taking food in small portions. (Detail discussed in practical 14) 2.

Frequent diet helps to prevent nausea and vomiting.

Hygiene Maintenance Daily bath is required.

Helps in increasing blood circulation throughout the body.

Care of teeth and oral cavity is important.

Dental caries, gingivitis or any other infection should be treated immediately.

Prenatal Advices

3.

Breast hygiene, clean nipple and areola

Check colostrum secretion

Teach perineal hygiene

Prevents infection during pregnancy

May precipitate premature rupture of membrane and thus pre-term delivery. Avoid vaginal bleeding during early pregnancy and premature uterine contraction in late pregnancy

Substance Abuse Avoid smoking and alcohol. Avoid drugs without the physician’s order especially during the first trimester of pregnancy

9.

It prevents tetanus in mother and the child.

Sexual Intercourse To be avoided during early and late pregnancy.

8.

This is to prevent supine hypotension syndrome, as to prevent obstruction in blood flow towards foetal circulation.

Travel Avoid frequent and long-distance travel during mid and late pregnancy.

7.

Rest and sleep are required to gain weight and for relaxation of the body.

Immunization Two doses of tetanus toxoid injection are given. The first dose is given as soon as pregnancy is confirmed and the second dose is given after an interval of 1 month.

6.

This makes the woman feel comfortable and promotes blood circulation. As pregnancy progresses, the size of the uterus and abdomen increases, and it is essential to wear clothes that are loose around the abdomen.

Rest and Sleep Ensure at least 1 hour of rest during the afternoon. Minimum 8 hours of night sleep is necessary. Advice to adopt left lateral position while lying down.

5.

55

Clothing Clothing should be loose, light and comfortable especially loose around the waist and abdomen.

4.

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It interferes with the normal development of the foetus.

Educating Mothercraft Advice mother and significant others to prepare clothes for baby with soft clothes.

It prepares the mother mentally to receive the baby and promotes bonding with baby.

Teach breastfeeding techniques and prepare the nipple by rolling and pulling upwards.

It reduces apprehension of breastfeeding after delivery.

Demonstrate baby care such as baby bath, changing nappies, holding baby, etc.

This will also help mother to relieve anxiety and fear of baby care.

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10. Preparation of Childbirth Provide information about childbirth process; and breathing and relaxation techniques during childbirth.

This will relieve anxiety and fear of labour pain. Helps to beardown process in labour.

Teach to keep things required ready when it is time to be admitted in hospital.

This is for reducing effort and time wasted during admission when the woman is in labour pain.

11. Motivation for Use of Family Planning Methods Provide detailed information regarding family planning methods.

This helps to prepare the woman and her family to plan the number of children.

Encourage primi woman to use contraceptive devices (e.g. Copper T)

Helps to maintain interval between two children and keep mother and baby healthy.

Advice for permanent methods to multipara woman.

This helps to keep mother and baby healthy and helps in proper family maintenance.

13 Prenatal Exercises

Prenatal exercises are muscle activities that strengthen the pelvic and perineal regions for the preparation of birth process and promote rapid restoration of muscle tone after birth.

OBJECTIVES 1. 2. 3. 4. 5. 6.

Increases blood circulation throughout the body. Strengthens the tone of the muscles in the pelvic and perineal regions. Reduces fatigue. Encourages relaxation during labour. Promotes physical comfort and correct posture. Promotes good body mechanics.

PRECAUTIONS 1.

Consult doctor prior to exercise.

Discuss the current regimen and obstetrics condition to continue exercise.

2.

Seek help.

Determine your limits of tolerance.

3.

Consider decreasing weight-bearing exercises.

Concentrate on non-weight-bearing activities, such as walking instead of running.

4.

Avoid risky activities such as mountain climbing, skydiving, racquet ball, etc.

Activities requiring precise balance and coordination may be dangerous. Avoid exercises that require holding breath.

5.

Exercise can be done regularly at least three times in a week as long as mother is healthy.

This will help in maintaining stamina and reducing undue strain on muscles.

6.

Limit activity to shorter intervals.

Exercise 10–15 minutes, rest for 2–3 minutes, then exercise for another 10 minutes.

7.

Decrease the exercise level as pregnancy progresses.

The normal alterations of advancing pregnancy, such as decreased cardiac reserve and increased respiratory effort, may produce physiologic stress if you exercise strenuously for a long time.

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8.

Note down pulse every 10–15 minutes when exercising.

If it is more than 140 beats per minute, slow down until it returns to a maximum of 90 beats per minute.

9.

Avoid becoming overheated.

It is best not to exercise for more than 35 minutes, especially in hot, humid weather. As body temperature rises, the heat is transmitted to the foetus. Prolonged or repeated foetal temperature elevation may result in birth defect. Body temperature should not exceed 100.4°F.

10.

Warm-up and stretching exercises.

Avoid strenuous exercises that strain the joints and avoid stretching. No exercise should be performed while lying down flat on back after the fourth month of gestation.

11.

A cool-down period.

Mild activities involving legs after an exercise will help to bring respiration, heart and metabolic rates back to normal.

12.

Rest for 10 minutes after exercise.

Lying on left side take rest then rise gradually from the floor to avoid feeling dizzy or faint (orthostatic hypotension).

13.

Drink two or three glasses of water.

After exercise, to replace the body fluids lost through perspiration.

14.

Increase calorie intake.

It is to replace the calorie burned during exercise and to provide the extra energy needs of pregnancy.

15.

Exercise at a comfortable pace.

This is not the time to be competitive, long time can be taken for exercise.

16.

Wear supportive brassiere.

As breast size and weight increase, changes in posture may occur and give pressure on the ulnar nerve.

17.

Wear supportive shoes.

As the uterus grows, centre of gravity shifts and women compensate with arching back. These natural changes make a woman feel off balance and she is more likely to fall.

18.

Stop exercising.

Stop exercising if shortness of breath, dizziness, numbness, tingling, pain of any kind, more than four uterine contractions per hour, decreased foetal activity or vaginal bleeding is experienced.

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SOME SIMPLE EXERCISES Grounding

Figure 13.1

Purpose: This exercise helps to correct the posture in the sitting position. It also helps in keeping the woman calm and quiet and helps her to concentrate before she starts exercising. Method: 1. Sit cross-legged on a firm surface, be it a carpet, dhurrie or sheet. As you sit cross-legged, become aware of the areas of your body that are touching the ground. 2. Gradually stretch both the hands towards and above the head without raising your chin and head. 3. Breath in slowly and deeply. Stop your breath for a while and exhale it. 4. Do this three times.

Neck Exercises Purpose: This exercise is helpful in mobilizing and strengthening the neck and shoulder muscles. It also helps to relieve the tension in the neck and shoulder muscles.

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Method: 1. Sit cross-legged with the back straight. Keep the head and neck in one straight line. 2. Incline the head slightly downward so that the chin moves towards the chest. 3. Straighten the head again and take it backwards with your mouth open, so that you are looking at the ceiling. Close your mouth for a few seconds. Bring the head back to the starting position. 4. Do this three times.

Shoulder Rotation: Purpose: Shoulder rotation helps to relieve pain in the upper back and nape of the neck. Method: 1. 2. 3. 4. 5. 6. 7.

Sit cross-legged with the back straight. Keep the head and neck in a straight line. Bring the shoulders forward. Raise the shoulders up to your ears. Thrust shoulders backwards so that chest goes outwards. Bring shoulders back to the starting position. Repeat these movements in a circular motion. Make circular motions in the opposite direction. Do three circular motions in each direction.

Deep Breathing Exercises Purpose: It provides a lot of oxygen to your body. Besides, when you breathe in, the diaphragm presses on the abdominal organs, massaging and invigorating them. Method: 1. 2. 3. 4. 5.

Sit cross-legged with the back straight and keep the head and neck in a straight line. Take a short breath and then exhale slowly through pursed lips, to the maximum. Let your lungs naturally fill up with air when exhalation is complete. Breathe normally for about three breaths. Repeat the first three steps. Do this three times.

Best time to do this exercise is early in the morning, in the open at sunrise so that you can also get vitamin D.

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Bust Exercise

Figure 13.2

Purpose: This exercise is for the pectoral muscles and helps to lift and firm the breasts. Method: 1. Sit cross-legged with the back straight and keep your head and neck in a straight line. 2. Join both palms together under the breasts like a ‘namaste’ away from the body in a flat position, that is, with the fingertips pointing straight ahead. 3. Press the palms firmly together and hold to a count of 10. 4. Release the pressure on both palms. 5. Repeat this three times. 6. Join both palms together like a ‘namaste’, in front of the breasts, away from the body, in a slanting position. 7. Press the palms firmly together and hold to a count of 10. 8. Release the pressure on both palms. 9. Repeat this three times. 10. Join both palms together like a namaste, with the fingertips pointing to your chin, yet not touching your body. 11. Press palms firmly together and hold to a count of 10. 12. Release the pressure on both palms. 13. Repeat this three times.

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Pelvic Floor Exercise

Figure 13.3

Purpose: Pelvic muscles support the womb. They help to hold the extra weight of the growing uterus in pregnancy. Exercising these muscles helps to strengthen them and maintains their shape. Method: 1. Sit cross-legged; this exercise can also be done in a standing or lying position. Start with Exercise A. After 3 days start Exercise B. After 3 more days do Exercise C. Exercise A 1. Exhale and leave your pelvic floor absolutely relaxed, as when passing urine. 2. Now imagine that you interrupt or stop the flow of urine for a while, by a slight contraction of the muscles. 3. Repeat the above steps three times. Exercise B 1. Exhale and relax the pelvic floor. 2. Imagine that you want to pass urine badly, but you are at a public toilet and have to wait in the queue; and as you wait, you have to control the passing of urine by a strong contraction of your muscles. 3. Hold the contraction until a count of six and release. Exhale and repeat the contraction twice. Exercise C 1. Exhale gradually. 2. Contract your pelvic floor muscles a little bit and count to six.

Prenatal Exercises

3. 4. 5. 6. 7.

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Contract your pelvic floor muscles a little more and count six. Contract your pelvic floor muscles the maximum you can and count six. Exhale slowly and gently release or let go of your pelvic floor muscles, while you exhale. Breath normally for three to four breaths. Repeat. Do this exercise five times.

Ankle Movement Purpose: It relieves the strain of extra weight of pregnancy carried by this area of the body. Method: 1. Sit with one leg outstretched, the other leg bent at the knee and the lower part of the bent leg just above the ankle resting on the thigh of the outstretched leg. Rest your back against the wall if you like. 2. Hold the bent leg just above the ankle with one hand, and with the other hand rotate the foot from the ankle. 3. Rotate the foot five times clockwise and five times anticlockwise.

Figure 13.4

Cobbler Pose (Shoe Repairer Position) Purpose: This exercise relaxes and stabilizes the pelvis and pelvic joint and also stretches the inner thigh and the pelvic floor muscles. Method: 1. Sit on the ground. 2. Bring the soles of your feet together in front of you, so that you form a ‘namaste’ with your feet. 3. Now with your hands hold the soles of your feet together and drag them inwards along the floor towards your body. You will feel stretch on your inner thighs. 4. Do once and stay in position for as long as you comfortably can.

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Figure 13.5

Pelvic Lift Purpose: This exercise strengthens the back muscles and relieves lower backache or feeling of congestion in the groin. Method: 1. 2. 3. 4.

Lie down flat on your back. Bend both legs at knees and place the feet on the floor. Now put your weight on both feet and raise your hips off the floor. Once raised, stay in position for at least to a count of ten. Gently lower yourself back to the floor. Do once or twice.

Figure 13.6

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Knee-Chest Position

Figure 13.7

Purpose: This exercise helps to shift the weight of pregnant uterus away from the pelvic floor and spine, thus it relieves backache and radiation pains in the hips and legs. This exercise also helps to reduce gastric problems. Method: 1. Kneel on the floor with knees slightly apart. Then go forwards on all fours (limbs) by placing your palms on the floor in front of you directly under your shoulder joints. Keep your head down and back straight, keep your head down all the while. Raising the head will encourage the hollowing or caving in of the back. If the back is allowed to hollow, it can give rise to backache. Stay for a while in this position. 2. Go down, putting your elbows in place of your palms, and point palms towards opposite elbows. 3. Rest your head in your arms. If your stomach pushes against the thighs, separate your knees further, so that your stomach fits in the hollow between your thighs. Secondly, guard against hollowing of the back. If hollowing occurs, correct it by gently pulling in your stomach. 4. Stay in position as long as you comfortably can. Breathe normally, while in position you will feel a rush of blood towards your face, which will make your face warm. Do not worry. This exercise is to be done once.

Leg Lift Purpose: This exercise helps to prevent varicose veins by assisting the blood to flow back towards the heart through the groin area. It soothes the legs. Method: 1. Lie on your side with one arm stretched outwards under your head, and the palm of the other arm placed in front of you. Place a pillow between your abdomen and the floor. 2. Raise the upper leg higher than your hip. 3. Hold for a count of six. 4. Gently bring your legs back to the starting position. 5. Repeat three to four times with each leg.

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Figure 13.8

Curling Leaf Purpose: This reduces the strain in the back while getting up and also lessens the possibility of backache. Method: 1. Lie flat on your back. Bend the left leg at the knee, placing the foot next to the knee of the outstretched leg. Stretch the right arm behind your head. 2. Put the weight of your body on the foot of the bent left leg. 3. Roll your body in the opposite direction, that is to the right. 4. Simultaneously, as you roll on to the right side, bring your left palm to rest on the floor, in front of your abdomen. 5. Now straighten your left leg and rise up supporting your weight on both palms. 6. Repeat with the other leg. Practice four times.

Figure 13.9

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Figure 13.10

Leg Swing Purpose: This exercise helps to make pelvic joints flexible. Method: 1. Stand with your hands on your hips and feet placed normally. Exercise A 1. Tilt very slightly to the left side and swing the right leg forward and then backward four times. 2. Repeat with the other leg. Exercise B 1. 2. 3. 4.

Stand with hands on hips. Swing one leg outward sideway and bring back to the starting position. Repeat three times. Repeat with the other leg.

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Pelvic Tilting Purpose: This exercise relieves lower backache and also helps to retain abdominal tone, after delivery, the abdomen will tone up faster and more easily. Method: Exercise A 1. 2. 3. 4.

Stand straight normally. Exhale. Bend slightly at the knees. Contract and tighten your bottom as if you are holding something in your bottom. As you tighten your buttocks and stretch the muscles there, the pubic area in the front will be thrust forward and up towards your umbilical. Your abdomen will be tilted backwards towards your backbone. At the same time the curve in the middle of your back will straighten.

Figure 13.11

Prenatal Exercises

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Figure 13.12

5. Hold this position for a count of six. 6. Release and get back to the starting position. 7. Repeat this three to five times. Exercise B 1. 2. 3. 4. 5. 6. 7. 8. 9.

Lie down flat on your back. Flex the knee and place feet flat on the floor. Place a folded hand towel or napkin in hollow of your back. Exhale. Tighten the buttock muscles and draw in the lower abdomen. Simultaneously flatten the hollow of your back against the floor and press on the folded towel. Hold for a count of six. Release and breathe normally. Repeat this exercise three to five times.

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Figure 13.13

Walking on Toes and Heels Purpose: This exercise promotes blood circulation to the lower limbs. This helps to prevent cramps of legs. Method: 1. 2. 3. 4.

Stand normally in a place where you have about six feet of open space to walk. Walk across the six feet space on your toes. Walk back on your heels. Walk on outer side of both your feet across the six feet space. Do once every day before going to bed.

Figure 13.14

Squatting Purpose: Squatting helps in keeping the pelvic joints and muscles flexible. In squatting, pelvic inlet, outlet and sacrum are at their widest. Do squatting frequently. If you have squatting-type toilet, use this toilet instead of doing this exercise. Squatting also prevents constipation.

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Method: 1. Squat as when using a squatting-type toilet. If the pregnancy is well advanced with a big stomach, follow these steps. 2. Stand normally, with your bottom touching the wall. 3. Raise your toes. 4. Go down into a squat. 5. Do not go into a complete squat; remain in a slightly raised position. 6. Rest your lower back against the wall and spread your knees as wide apart as you can. 7. Stay for at least two minutes in this position. 8. Now go forward on your hands and then your knees to come out of the squatting position. In the ninth month when the foetus is in a head-down position, in order to encourage the fixing or the engagement of the foetus’ head instead of squatting one could sit with knees bent and a couple of cushions on one’s calves. This position would cause the pelvic structure to be raised to above the level of the knees, with a forward tilt it helps the angle to become perfect for the foetus to enter the pelvic inlet. Precaution: This exercise should not be done by women who have had stitches at the os of cervix, placenta previa and previous episiotomy.

Figure 13.15

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Relaxation

Figure 13.16

It is important for a woman to remain relaxed. A good time to practice relaxation is when all your work is finished, when you are not expected to be called or to be made to answer telephone or door bell. Method: 1. Lie down quietly and allow your mind and body 5–10 minutes to quieten down. 2. Find a comfortable position to relax, use cushions, pillows, sheets or blankets as required. 3. Once you are settled in a comfortable position, close your eyes and allow thoughts about your baby to flow as you are watching her/him. 4. Do not judge your thoughts, just watch for 10–15 minutes. 5. Lie down with your eyes closed and relax your body. 6. After relaxation, do not get up suddenly. Slowly move your hands, feet and body and rise gently.

14 Nutritional Advices

Good prenatal nutrition is a prime requisite for successful outcome of pregnancy.

OBJECTIVES 1. 2. 3. 4. 5.

Promotes foetal growth. Meets nutritional need of woman and foetus during pregnancy. Prevents intrauterine growth retardation of foetus. Promotes immunity in mother and foetus. Prevents nutritional deficiency in mother and foetus.

POINTS TO REMEMBER 1. It is not essential to eat for two people during pregnancy, but a balanced diet as per the requirement of the pregnant woman is required. 2. Diet is always planned according to the need of the individual pregnant woman.

Nutritional Requirement and Rationale Nutrients

Recommended Dietary Allowances

Rationale

Sources

Calorie

Extra 300 kcal/day during the I trimester, 2200 kcal/day during the II trimester and 2500 kcal/day during the III trimester

To meet ↑energy needs for foetal growth, mother needs for milk production.

Carbohydrate, fat, protein

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Protein (g)

65

Synthesis of the products of conception—foetus, amniotic fluid, placenta; growth of maternal tissues: uterus, breasts, red blood cells (RBCs), plasma protein, secretion of milk protein in lactation.

Meat, eggs, milk, cheese, legumes (dry beans, peas, peanuts), pulse, soyabean, fish, etc.

Minerals

175 (125 mg)

Increased maternal metabolic rate.

Iodized salt, sea food, milk and milk products

Calcium (g)

1.2

Foetal skeleton and tooth bud formation. Maintenance of maternal bone and tooth mineralization.

Milk, cheese, yoghurt, fish, deep-green leafy vegetables, beans, drumstick, all roots and tubers

Phosphorus (g)

1.2

Foetal skeleton and tooth bud formation. Maintenance of maternal bone and tooth mineralization.

Milk cheese, yoghurt, meat, wholegrains, nuts, legumes

Iron (mg)

30

Increased maternal haemoglobin Liver, meat, fish, whole formation, foetal liver iron or enriched breads storage, placental growth. and cereals, deepgreen leafy vegetables, legumes, dried fruits, pomegranates, jaggery, roots

Zinc (mg)

15

Component of numerous enzyme systems; important in preventing congenital malformations

Liver, fish, meat, milk, wholegrains, roots

Magnesium (mg)

450

Involved in energy and protein metabolism, tissue growth, muscle action

Nuts, legumes, meat, wholegrain, fish, roots

Selenium (mg)

65

Antioxidant, protects cell membranes and teeth

Seafood, wholegrains, meat, legumes

Iodine (g)

175 (125 mg)

Increased maternal metabolic rate

Iodized salt, seafood, milk and milk products

6000

Essential for cell development, formation of tooth bud, development of enamel-forming cells in gum tissues, growth of bone and epithelial tissues

Deep-green leafy, dark yellow vegetables and fruits, papaya, mango, carrot, milk, butter, cheese, egg, liver, fish

Fat-Soluble Vitamins Vitamin A (IU)

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Vitamin D (IU)

400

Involved in absorption of calcium Milk, egg yolk, butter, and phosphorus, improves liver, seafood mineralization

Vitamin E (IU)

15

Antioxidant (protects cell membrane from damage), especially important for preventing haemolysis of RBCs

Vegetable oils, green leafy vegetables, wholegrains, liver, nuts, cheese, sprouted pulses

Vitamin C (mg)

400

Tissue formation and integrity, formation of connective tissues, enhancement of iron absorption

Citrus fruits, strawberries, tomatoes, raw deepgreen leafy vegetables, broccoli

Vitamin B1 (Thiamine) (mg)

1.5

Involved in energy metabolism

Wholegrains, legumes, liver, green vegetables

Vitamin B2 (mg) (Riboflavin)

1.8

Involved in energy and protein metabolism

Milk, liver, enriched grains, deep green and yellow vegetables

Vitamin B6 (mg) (Pyridoxine)

0.3

Involved in protein metabolism

Milk, liver, wholegrains, green vegetables

Vitamin B12 (mg) 0.4 (Cyanocobalamin)

Production of nucleic acids and proteins, especially important in the formation of RBCs and prevention of megaloblastic or macrocytic anaemia in foetus.

Milk, egg, meat liver, cheese, green leafy vegetables

Folic acid (mg)

300

Increased RBC formation, prevention of macrocytic or megaloblastic anaemia

Green leafy vegetables, oranges, broccoli, asparagus, liver

Niacin (mg)

17

Involved in energy metabolism

Meat, fish, poultry food, liver, wholegrains, peanuts

Water-Soluble Vitamins

DIET IN PREGNANCY (ITEMS REQUIRED DAILY) Items

Vegetarian Diet

Non-vegetarian Diet

Cereals

360 g

360 g

Pulses

90 g

90 g

Green leafy vegetables

120 g

120 g

Roots and tubers

90 g

90 g

Yellow and red vegetables

90 g

90 g

Butter and ghee

45 g

45 g

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Milk Meat and fish Eggs

900 g

600 g

—

90 g

1–4 per week

Groundnuts

90 g

—

Citrus fruits and tomatoes

120 g

120 g

Note: Intake of milk is to be increased as pregnancy advances. Salads should also be included in diet.

15 Teaching Self-care Methods for Common Discomforts During Pregnancy Common discomforts during pregnancy result from physiological and anatomical changes and are specific to each trimester.

OBJECTIVES 1. Identify reasons for discomfort during pregnancy. 2. Teach self-care measures to pregnant woman.

SELF-CARE MEASURES FOR COMMON DISCOMFORTS DURING PREGNANCY Educate pregnant woman and significant others on the following. Discomfort

Influencing Factors

Self-Care Measures

FIRST TRIMESTER Nausea and vomiting

Increased levels of human chorionic gonadotropin, changes in carbohydrate metabolism, emotional factors, fatigue.

Avoid strong odours or causative factors. Eat glucose biscuits or toast before arising out of the bed in the morning.

Urinary frequency

Pressure of uterus on bladder in both the first and third trimesters.

Void when urge is felt. Increase fluid intake during day. Decrease fluid intake during evening to decrease nocturia.

Breast tenderness

Increased levels of oestrogen and progesterone.

Wear well-fitting supportive brassiere.

Increased vaginal discharge

Hyperplasia of vaginal mucosa and increased production of mucus by the endocervical glands due to the increase in oestrogen levels.

Follow cleanliness by bathing daily. Avoid douching and nylon panties; cotton panties are more absorbent. Powder can be applied in panty to absorb mucus.

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Constipation (in III trimester also)

Increased level of progesterone causes general bowel sluggishness (I trimester). Pressure of enlarged uterus on intestine. Intake of iron tablet. Lack of exercise and decreased fluid intake (III trimester).

Increase fluid intake, increase fibre in diet and exercise. Develop regular bowel habits. Use stool softner if advised.

Nasal stuffiness and epistaxis

Elevated oestrogen levels.

May be unresponsive, but cool air vaporizer may help; avoid use of nasal sprays and decongestants.

Ptyalism

Specific causative factors unknown

Use mouthwashes, chew gum or suck on chocolates or lozenges.

SECOND AND THIRD TRIMESTERS Heart burn (pyrosis)

Increased production of progesterone; decreased gastrointestinal motility and increased relaxation of cardiac sphincter, displacement of stomach by enlarging uterus; thus regurgitation of acidic/ gastric contents into the oesophagus.

Eat small and more frequent meals. Use low-sodium antacids. Avoid overeating, fatty and fried foods, lying down after meals and also avoid use of sodium bicarbonate.

Ankle oedema

Prolonged standing or sitting. Increased level of sodium due to hormonal influence. Circulatory congestion of lower extremities. Increased capillary permeability leads to varicose vein.

Practice frequent dorsiflexion of feet when prolonged sitting or standing is necessary. Elevate legs when sitting or resting. Avoid tight or restrictive bands around legs.

Varicose veins

Elevate legs frequently. Wear Venous congestion in the lower veins that increases with pregnancy. Hereditary supportive hose. factors such as weakening of valves of veins, increased age and weight gain.

Flatulence

Decreased gastrointestinal motility leading to delayed emptying time. Pressure of growing uterus on large intestine; air swallowing.

Avoid gas-forming foods. Chew food thoroughly. Exercise daily. Maintain normal bowel habits.

Haemorrhoids

Constipation, increased pressure from gravid uterus on haemorrhoidal veins

Avoid constipation. Apply ice packs, topical ointments or anaesthetic agents; warm soaks or sitz baths can also be helpful; consult physician.

Backache

Increased curvature of the lumbosacral vertebrae as the uterus enlarges. Increased levels of hormones, which cause softening of cartilage in body joints. Fatigue and poor body mechanics.

Use proper body mechanics. Practice the pelvic tilt exercise, Avoid uncomfortable working heights, high-heeled shoes, lifting heavy loads and fatigue.

Leg cramps

Imbalance of calcium/phosphorus ratio. Increased pressure of uterus on nerves. Poor circulation to lower extremities. Pointing the toes.

Practice dorsiflexion of feet in order to stretch the affected muscles. Increase calcium in diet. Apply heat to the affected muscles. Arise slowly from resting position.

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Faintness

Postural hypotension. Sudden change of position causes venous pooling in dependent veins. Standing for long periods in warm area. Faintness could be due to anaemia.

Avoid prolonged standing in warm or stuffy environment. Evaluate hematocrit.

Dyspnoea

Decreased vital capacity from pressure of enlarging uterus on the diaphragm.

Use proper posture when sitting and standing. Sleep propped up with pillows for relief if problem occurs at night.

Carpal tunnel syndrome

Compression of median nerve in carpal tunnel of wrist. Aggravated by repetitive hand movements.

Avoid aggravating hand movements. Use splint as prescribed. Elevate the affected arm.

Note: Ask the woman to consult physician if any discomfort aggravates.

16 Assessing Foetal Well-being

Continuous foetal monitoring during the total course of pregnancy is known as assessment of foetal well-being.

OBJECTIVES 1. 2. 3. 4.

Assess foetal health status. Count FHR. Identify foetal anomalies. Assess foetal maturity and growth.

METHODS OF FOETAL ASSESSMENT 1. 2. 3. 4.

Auscultation of FHR Recording biophysical profile (BPP) of the foetus Biochemical assessment of foetus Electronic foetal monitoring (EFM)

1. AUSCULTATION OF FHR FHR is checked on routine visits. It can be heard at 12 weeks using a Doppler device and 18–20 weeks onwards using a fetoscope.

Equipment: 1. Fetoscope/Doppler device/Pinard’s fetoscope/stethoscope 2. Draping sheet

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Procedure: 1.

Prepare the woman.

2.

Explain the procedure and the information that will be obtained.

Explanation of the procedure decreases anxiety and increases relaxation.

3.

Drape with sheet and open only the abdominal area.

Privacy is required.

LSA LOP RSA LOA ROP ROA Location of FHT in left occipito anterior position

4.

Place the fetoscope on the woman’s abdomen at possible area identified by Leopold’s manoeuvres as shown in the figure.

Fetoscope is an older assessment tool and can be used during visit at home. Now ultrasound Doppler is preferred.

5.

Usually the fetoscope is placed halfway between the umbilicus and the symphysis pubis in the midline.

The FHR is most likely to be heard in this area.

6.

Without touching the fetoscope, listen to the FHR carefully.

Touching with finger, the nurse’s own pulse beats or the sound made by the wristwatch could be mistaken to be foetal heartbeat.

7.

To use Doppler ultrasound, place ultrasonic gel on the diaphragm of Doppler.

Sound may be controlled with a volume knob.

8.

Place diaphragm on the woman’s abdomen halfway from umbilicus to symphysis pubis and midline. Listen carefully for FHR.

Ensure the FHR and not the woman’s pulse is being heard.

9.

For both the methods check the woman’s pulse against the sounds heard; if the rates are not similar, count the FHR.

If foetal heartbeat is not heard, move the fetoscope from this area in a circle and try to hear the FHR.

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10.

Report and record findings.

Provides record during whole pregnancy and labour

11.

If parents like they can also hear FHR.

Increases enthusiasm in parents

12.

Make the woman comfortable.

2. RECORDING BPP OF THE FOETUS BPP is a non-invasive dynamic assessment of a foetus and its environment using ultrasonography scanning.

Purposes: 1. Assess foetus at risk (surveillance of foetus) especially to assess hypoxemia of CNS. 2. Immediate management of risk.

Procedure: 1.

Prepare the woman

2.

Explain the procedure and indications for assessment of BPP.

Accurate information regarding the procedure is imperative to allay anxiety.

3.

Ask the woman to come with full bladder.

It supports the uterus in position for imaging.

4.

Position her comfortably in the supine position with small pillows under her head and knees.

This will help to prevent supine hypotension.

5.

Position woman so that she can also observe images if she desires.

Helps to create enthusiasm.

6.

Do/help in ultrasonography for BPP.

BPP scoring is given below. BPP Variables

Normal (Score = 2)

Abnormal (Score = 0)

Foetal breathing movements

One or more episodes in 30 minutes, each lasting for >30 seconds.

Episodes absent or no episode of >30 seconds within 30 minutes.

Gross body movements

Three or more discrete body/limb movements in 30 minutes (episodes of active continuous movements considered as a single movement)

Less than three episodes of body/limb movement within 30 minutes.

Foetal tone

One or more episodes of active extension with return to flexion of foetal limbs or trunk; opening and closing of hands considered normal tone.

Slow extension with return to flexion; movement of limb in full extension or foetal movement absent.

Reactive FHR

Two or more episodes of acceleration of >15 beats/minute lasting for >15 seconds associated with foetal movements within 20 minutes

Less than two episodes of acceleration or acceleration of 1 cm in two perpendicular planes.

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Pockets absent or pocket measuring 10%

Gestational age >34 weeks

Osmolality

Decline after 20 weeks of gestation

Advancing non-specific gestational age

Dependent on cell cultured for karyotype and enzymatic activity

Counselling may be required

Amniotic fluid analysis Colour Lung profile

Genetic disorders Sex-linked Chromosomal Metabolic

Procedure (Common for Biochemical Assessment of Foetus) Prepare Equipment 1. Collect supplies: 22-gauze spinal needle with stylet, 10 ml and 20 ml syringes 2. Aspiration needle as per individual procedure

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3. 4. 5. 6. 7.

| Midwifery and Obstetrical Nursing—Practical

3–6 sterile 10-ml test tubes Ultrasonogram/endoscopy equipment/CT scan machine as required. Ultrasonic gel Cotton swabs, sponge holder and antiseptic lotion. Draping sheet

Method 1.

Explain the procedure and reassure the woman.

Information will decrease anxiety.

2.

Take signature on consent form

Informed consent indicates woman’s awareness of risks and consent to procedure.

3.

Ask the woman to empty her bladder if asked by physician.

Emptying the bladder decreases the risk of bladder perforation.

4.

Monitor vital signs; obtain baseline data of mother’s BP, pulse, respiration and FHR monitor.

Continuous maternal and foetal assessment is essential.

5.

Locate the foetus and placenta. Give assistance to Real-time ultrasound is used to identify foetal physician in palpating for foetal position. Assist with parts and placenta and locate pockets of real-time ultrasound. amniotic fluid, umbilical cord, and chorionic villus as per the requirement of investigation.

6.

Clean the maternal abdomen (vagina in case of transvaginal) with antiseptic lotion and drape with sheet.

Infection is prevented, and privacy of patient is kept in mind.

7.

After collecting specimen in test tubes, take the test tubes from the physician and provide correct identifications; send to laboratory with appropriate laboratory slips. Essential precaution is taken continuously during the procedure.

Ensure foetus is not inadvertently punctured.

8

Reassess vital signs; determine woman’s BP, pulse and respiration and FHR; palpate fundus to assess for uterine contractions; monitor woman with external foetal monitor for 20–30 minutes after procedure. Ask woman to rest on left.

Uterine contractions may ensue following procedure; treatment course should be determined to counteract any supine hypotension and to increase venous return and cardiac output.

9.

Maintain client’s complete record. Record type of procedure done, date, time, name of the physician who performed the test, maternal foetal response and disposition of specimens.

Records maintained help in managing mother.

10.

Reassure woman; instruct her to report any of the following side effects

Client will know how to recognize side effects or conditions that warrant further treatment.

Unusual foetal hyperactivity or lack of movement. Vaginal discharge—clear drainage or bleeding Uterine contractions or abdominal pain Fever or chills

Assessing Foetal Well-being

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Electronic Foetal Monitoring Electronic foetal monitoring provides a visual assessment to FHR.

Purpose: 1. 2. 3. 4.

Trace continuous FHR. Determine intrauterine environment support to foetus. Determine time of birth. Identify uteroplacental insufficiency.

Indications for EFM If one or more of the following factors are present, EFM is suggested. 1. Previous history of a stillborn baby at 38 or more weeks of gestation. 2. Presence of maternal complications such as PIH, placenta previa, abruptio placentae, multiple gestation. 3. Induction of labour (introducing pitocin). 4. Preterm labour (gestation