no history of pica towards non food items with both her pregnancies.

However, she said that the pregnancy has made her like some of the foods she never liked like fresh fish. Mrs. Nkhata said that she does not eat pork based on religious ground as she is a Muslim but said that her culture does not restrict her from eating ant food. She explained that she has enough food in her house that is enough for her family all the times. She has good preparation and storage methods of food with some good storage principles like no relish remains to be used the next day, they only prepare enough food for the day.

P S! "#S!$!%&' ( H&S!"%) Mrs. N*hata is Para + with first delivery in ,--, and she was ,, years by then. #%$ *."/N !he first pregnancy way term with 0- weeks gestation by fundal height. !he baby was delivered at Ndirande Health 'entre and she delivered by Spontaneous 1ertex .elivery but sustained a tear which was sutured and healed without any complications. !he baby was 20--g at birth and was born without any congenital nor during birth complication. (abour had taken about +0 hours thus from 3 pm to 4am. Mrs. Nkhata has no history of ante5partum or intra5partum haemorrhage as well as Pre5eclampsia or eclampsia.

PS)'H"("6&' ( H&S!"%) Mrs. Nkhata said that the pregnancy that she has now was a planned one and also that the decision to have the pregnancy was made by both her and her husband such that they both were very happy for the pregnancy. She also said that she did not have any psychological problems due to both previous pregnancy as well as the current one except for the fear of labour pains. &MM7N&S !&"NS

Mrs. N*hata explained that she had received two doss of !etanus !oxoid 1accine with the first pregnancy and two doses with the current pregnancy. However, she expressed lack of knowledge on the fre8uency and number of doses of tetanus !oxoid 1accine she is expected to receive despite knowing the importance of the immuni9ations. $N1&%"NM$N! ( H&S!"%) "n environmental history, Mrs. N*hata said that she has a two bedroom house with a seat room which is occupied by three members of thee family, the husband, the first born child and herself. !he house is iron sheet roofed, cement floored and electrified. She said that she gets water from a 'ommunal /ater Point which is about :- metres from her house but she makes sure she has enough water all the time by keeping some in buckets knowing that there is a problem of water scarcity in her area at times. "n waste disposal, she said that there is a rubbish pit behind the house which is used for waste disposal and she keeps burning the waste in the pit to prevent it from being blown back to the house by wind when it;s full. S"'&"5$'"N"M&' H&S!"%) Mrs. Nkhata is a <orm four (eaver currently working with *7*7 Matches 'ompany as a Packer. Her husband is an electrician who is self employed. She said that her family is able to get their needs and necessities from the combined income that they get from their duties and they live happily. Mrs. Nkhata reported no exposure to increased workload for she is currently given light work by her bosses having understood her condition. Mrs. Nkhata does not smoke any kind of cigar nor drinks any kind of alcohol although the husband takes alcohol but in a reasonable manner. P%$S$N! "#S!$!%&' H&S!"%) Mrs. Nkhata is gravida , Para + mother (ast normal menstrual period = +:th >uly, ,-+-

$xpected date of delivery = 6estation by dates H&1 Status 1.%( = = =

,,nd pril, ,-++ 2- weeks, days Non5reactive Non5reactive

She is currently not on any medications except for the <errous Sulphate she is given when se visits antenatal clinic meant to help in the formulation of haemoglobin. $(&M&N !&"N Mrs. Nkhata has no any problem with either bowel movement or urination. However, she said that she had in the early days of pregnancy a problem of fre8uency micturation.

"#>$'!&1$ . ! Vital Signs !emperature #lood Pressure Pulse %ate %espiration %ate = = = = 2?.3@' +,-A3-mmHg 3- beats peer minute ,, breaths per minute

6$N$% ( PP$$ % N'$ Mrs Nkhata is a +?, cm tall woman, slim and light brown in complexion. She was wearing a red blouse and a black skirt with a pair of black slip5ons BshoesC. "n this day she weighed :D kilograms, gaining , kilograms from the weight during her booking visit which was :? kilograms. H$ .

Her head is ovoid in shape with long chemical made hair and there was neither dandruff nor presence of scars or masses on the scalp. < '$ !here were no signs of facial oedema on both inspection and palpation. !he face also did not have scars on inspection. $)$S !he eyes are symmetrical and ovoid in shape with no signs of peri5orbital oedema and had a pink conEunctiva. $ %S !he ears are symmetrical with the upper ears in line with the outer borders of the eyes. !here were no sore, no ear discharge, no lesions and no signs of inflammation on palpating the pre and post auricular lymph nodes. N"S$ Her nostrils are symmetrical with no any discharge. She has no history of epistaxis and did not have any polyps in the nostrils. M"7!H Her lips were smooth with no sores or cracks. Her tongue and oral mucosa were pink with no sore, no korpliks spots or signs of candidiasis. !here were neither decayed teeth nor gingivitis. She has neither cleft lip nor cleft palate. !he tonsilor, sub5 mandibular and sub mental lymph nodes were not enlarged. N$'* She has no problems with neck flexion as well as forward and backward neck bending. "n inspection, there were no obvious signs of distended Eugular veins, no sores, no obvious lesions. "n palpation, there were neither signs of enlarged thyroid gland nor enlarged deep cervical, sub5clavicle and infra 5clavicle lymph nodes.

'H$S! "n inspection, the chest did not have scars, lesions or signs of a pigeon chest with normal respiratory movements. "n auscultation, there were normal lung and heart sounds. #%$ S!S !he breasts are symmetrical in both si9e and shape and they both are light brown in colour with dark alleorae. !he breasts have no scars, scales, lesions, no sores, rashes, redness and no dimpling. "n breast palpation, no masses were felt except for the normal mammary gland. !he nipples are dark in colour, clean and not inverted. 7PP$% $F!%$M&!&$S !he arms are symmetrical with no signs of oedema on both inspection and palpation. She has a capillary refill of less than 2 seconds and has pink palms. However, Mrs. Nkhata reported having tingling sensation of the upper extremities. #."M$N "n inspection of the abdomen, there was a dark linea nigra, some striae gravidalum with no sores or scars. !he abdomen was ovoid in shape with a medium si9e. <oetal movements were also observed medially on inspection. (iver and spleen were not palpable indicating absence of organomegally. !he calculated gestation by dates was 2- weeks and Fundal height Pelvic, Lateral and Fundal Palpation <undal height <oetal Presentation = <oetal (ie <oetal Position = = = ,4 weeks

'ephalic (ongitudinal %ight "ccipital nterior

<oetal Heart %ate

+0, beats per minute

("/$% $F!%$M&!&$S !he lower extremities are symmetrical with no scars, varicose veins as well as signs of oedema on inspection. "n palpation, no tibial, ankle or pedal oedema was detected. No signs of 1aricose 1eins or .eep 1ein !hrombosis were detected on palpation of the cuff muscles. Howmans sign was not observed on flexion on the feet. 6$N&! (& 7pon inspection of the genitalia, no oedema, sores, warts, genital ulcers, abnormal vaginal discharge or signs of hematoma were observed. !here were no signs of varicose veins or genital mutilation or circumcision seen. !he vaginal discharge was mild, whitish and odourless.

P%"#($MS AN$$.S &.$N!&<&$.. *nowledge deficit on sexuality during intra and post partum periods related to inability set times on when to stop and resume sex. (ack of ade8uate information on immunisations related to limited information given on immunisations as evidenced by inability to outline the normal schedule for !etanus !oxoid 1accine. *nowledge deficit on <ocussed ntenatal 'are and its importance related to limited information given about focussed antenatal care as evidenced by late coming for initial visit. Possibily of not using family planning methods related to untrue speculations that .epo5 Provera is phasing out.

' %$ P%"1&.$.

<ocus ntenatal 'are looks at comprehensive care given to a pregnant woman with specified type of care per each visit of the four expected visits that the woman attends antenatal clinic. &t looks at 8uality of care and not 8uantity of the number of visits. <ocused ntenatal 'are emphasises on treating every mother as an individual or uni8ue person with individual problems and needs. !he care that was given to Mrs. Nkhata was based on the problems and needs that she had as well as specific care according to hergestation age. "n this day, Mrs. Nkhata was treated comprehensively starting with history taking to fill in gaps followed by H&1 and Syphilis tests then full physical assessment which involved using all the four modalities of inspection, palpation, auscultation and percussion. & made sure that the client;s care was provided in a very conducive environment, thus ensuring privacy as well as cleanliness. & made sure that she felt well taken care of and welcome to the clinic by being respectful, accommodative and letting her ask 8uestions and express fears than looking at the care as a burden throughout the procedures. $N1&%"NM$N! .uring the filling in of gaps, collection of important information that was missed out on the booking day, an environment that ensured privacy and comfort was ensured. !he data was collected at an enclosed place where no one else could listen to what was being discussed and this made the client to be more open and to give the information that was re8uired. (ikewise, during the physical examination, a cubical was used to promote privacy considering that procedures involved this time include exposure of sensitive areas like the chest, abdomen and genitalia. <&((&N6 &N "< 6 PS 7pon review of the ntenatal cardApage for Mrs. Nkhata several areas that re8uired to be filled in were realised. &n addition to that, some more areas in the health passport were identified which also needed filling in.

!he health did not have information on her family medical history and her medical and surgical history which is supposed to be filled o the first and second pages of the health passport and this is also where some important personal data is documented. See ppendix...... showing the pages after filling in. Not only that but also blood group and rhesus factor were not tested but still more being an important information especially when it comes to emergencies like anaemia, & still referred her go also go for the tests when she goes for the other tests. "n the antenatal page as well, gravidity and parity of the mother were not indicated during the first visit but got documented on this visit. TESTS <ocused ntenatal recommends mothers undergoing several different tests at different visits and different gestation ages. Such tests are like H&1, Syphilis, haemoglobin level, urine protein and '.0 count in case of those who are H&1 positive but not on antiretroviral therapy. H&1, 1.%( and Haemoglobin level are the tests that are expected to be done on booking so as to have a baseline data for some of them like H&1 and haemoglobin are tested again after sometime i.e. H&1 is tested again after 2 months while haemoglobin level is retested at 2? weeks. 7rine protein is expected to be tested every visit from first to fourth visit but unfortunately none of these were done on the first visit "n this visit & played a role of helping Mrs. Nkhata get tested for H&1 and Syphilis whose results came out negative as indicated on the antenatal card B ppendix.....C after filling in the gaps. However, & referred the client to Gueen $li9abeth 'entral Hospital for the tests which could not be done at Ndirande ntenatal 'linic due to lack of materials like the haemacue kits and protein dipsticks. !he referral was done after Ndirande Health 'entre also reported not having the materials PH)S&' ( $F M&N !&"N

s indicated in thee obEective data, during physical assessment, no specific problems were presented or detected from Mrs. Nkhata and all the findings were documented on the antenatal card and were also communicated to the client. See ppendix...... showing the antenatal card with findings of the abdominal assessment. M$.&' !&"NS Most of medications at the ntenatal 'linic are given according to gestation ages of the mothers and most of them are given for prophylactic purposes i.e. SP is given to prevent a mother from malaria, <errous Sulphate is given to prevent anaemia whilst benda9ole is given to combat worms infestation. SP is given every four weeks between the gestations of +? to 2? weeksH <errous Sulphate is given at every visit throughout pregnancy whilst benda9ole is given Eust once and at first visit. SP is given in such a way to prevent the tetratonegic effects that the sulphur may have on the foetus. "n this visit, Mrs. Nkhata, having the gestation age of 2- weeks, she was given both SP tablets B2C as well as <errous Sulphate B2- tabletsC. SP was given after confirming that 0 weeks had passed since the last dose was taken. M&./&<$%) ' %$

N ()S&S "< ' %$ lot of things and care were done during Mrs. Nkhata;s booking antenatal visit. & should sincerely give credit to the care provider who handled Mrs. Nkhata on the first visit for the good Eob for most things expected to be done on booking especially data needed to be filled on the antenatal card was filled. However, not every bit of information was collected and documentedH for example, no information was documented indicating gravidity and parity on the antenatal card. !his information is very important to every midwife who would come into contact with the client for it gives a picture of the kind of client one is dealing with i.e. prim5gravida, multigravida or grand multipara. !hese also determine the kind of care that a client will get.

Secondly, the data documented on the antenatal card for abdominal assessment seem to have been taken for granted by the care provider during the previous visit. Having been given the date for the last normal menstrual period, there was no reason heAshe could not calculate the gestation by dates for this day knowing its importance. !he calculated gestation by dates is very important to a midwife for it gives a base comparison with the fundal height done by tape measure or finger breadths. &t also seems that the midwife who cared for Mrs. Nkhata during the first visit does not know what it means when we say presentation by abdominal assessment for sheAhe indicated that it was a vertex presentation of which vertex can not be determined by pelvic palpation but vaginally. SheAhe would rather indicate cephalic for presentation and a position i.e. %ight "ccipital nterior, (eft "ccipital nterior or other positions. #lood Pressure is on of the important vital signs in pregnant women and unfortunately, it was not done on the booking day. )es its true there could be no a sphygmomanometer but still more a referral to Ndirande only for a blood pressure check would be helpful. Pregnant women are at a risk of developing pre5eclampsia which is high blood pressure in pregnancy and can only be diagnosed if blood pressure if checked at every visit. 7rine protein test is also vital in the way that presence of protein in urine is indicative of pre5eclampsia Mrs. Nkhata had come for booking at a gestation age of ,? weeks by fundal height and this clearly shows lack of knowledge on focused antenatal care as well as its importance. Mrs. Nkhata being a Para one with birth of first born in ,--3 when focused antenatal was already under implementation, it was expected she must have already been exposed to such type of care. 7nfortunately, the mother came at ,? weeks gestation following the old routine antenatal system. /hen i asked her, she said coming at ,- weeks and above was what she knew. !his mother lacked information on focused antenatal and its importance which reflects that she was not given enough information about it during her first pregnancy. $FP$'!$. <&N.&N6S <"% !H$ N$F! 1&S&!

Mrs. Nkhata had come for her second antenatal visit at a gestation age of ,4 weeks, however, according to focused antenatal, by this time she was supposed to becoming for her third visit which is supposed to bee between ,D weeks and 2, weeks. &n this case Mrs. Nkhata will have her third and final normal visit at 2? weeks though at this time a mother is normally expected to be coming for a fourth visit. /hen Mrs. Nkhata comes at 2? weeks which would be on ............., she will undergo several assessments some that are routine like vitals signs whilst some will base on her condition as being in third trimester or having a 2? weeks gestation. Some of thee care will also base of the gaps that the midwife will identify as being left out during the previous visit. "n the next visit the midwife will have to check on the care given on the previous visit, evaluate and then have a basing for planning hisAher care and this will also depend on the current problems and the unmet needs of the client. !he midwife will collect some information from the client to fill in the gaps that are not filled during this visit. She will also check on the progress of pregnancy by asking Mrs. Nkhata on how she fairing with her pregnancy. Some of the 8uestions she may ask are the presence of foetal movements and minor disorders of pregnancy for this will help the midwife to isolate the problems that the client has at present. Mrs. Nkhata will also have to undergo several tests which will be due by this time i.e. haemoglobin level and urine protein. Haemoglobin level is checked on booking and in third trimester, at 2? weeks to be specific whilst for urine protein is checked at every visit to the antenatal clinic. 1ital signs are another aspect that will have to be checked by the midwife as part of monitoring progress of pregnancy. ny abnormality in the vital signs is indicative of a problem in the pregnant woman. <or exampleH high blood pressure could be indicative of pre5eclampsia, fever could indicate a systemic infection and increased respiratory rate could mean difficulty breathing, though, it is thought to be normal at 2? weeks. Physical assessment will also be done including general assessment as well as abdominal assessment.

6eneral assessment will involve a head to assessment and no abnormality is expected from it. !he abdominal assessment will involve inspection, palpation and auscultation of the abdomen to check si9e and shape of abdomen, fundal height, lie, presentation and position of foetus as well as foetal heart rate. !he abdomen is inspected for scars, linea nigra, striae gravidalum, si9e and shape, foetal movements, bladder fullness and visible organomegally. !hee fundal height will be measured using a tape measure of finger breadths so as to determine the age of pregnancy. !hen the pelvis will be palpated for presentation which is normally, lateral palpation will be done to note the lie and position of the foetus. <undal palpation will also be done to rule out multiple gestation or presentation in a situation where the head is not located in the pelvic. <oetal heart rate will also have to bee auscultated using a fetalscope to confirm wellbeing of the foetus.

$FP$'!$$. <&N.&N6S <undal height <oetal Presentation = <oetal (ie <oetal Position <oetal Heart %ate = = = = 2? weeks

'ephalic (ongitudinal %ight "ccipital nteriorA(eft "ccipital nterior +0- I +?- beats per minute

!he above expected findings are thee normal expected finding in the absence of possibility of having abnormal findings .%76S "n this visit Mrs. Nkhata will only be provided with <errous Sulphate as a drug to supplement iron for haemoglobin formation. SP will not be given because it is believed

to have a teratonic effect on the fetus when given at the gestation of 2? weeks and above. $FP$'!$. .&S"%.$%S #y this time the expected disorders that Mrs. Nkhata may have are difficulty breathing, fre8uent micturation, headache, constipation, backache, oedema varicosities, haemorrhoids and cramps for these are the common disorders that usually come in third trimester. MANAGEMENT OF THE E PE!TE" M#N#$ "#SO$"E$S HEA$T%&$N !his is a burning, irritating sensation in the oesophagus also known as gastric reflux B<raser, 'ooper and Nolte, ,--?C. 6astric reflux commonly occurs as a result of delayed gastric emptying, decreased intestinal motility, and decreased lower oesophageal sphincter tone. &f it happens that Mrs. Nkhata develops heartburn, education and counseling on li'est(le
)odi'ication will be provided and will include awareness of posture i.e. Maintaining upright positions Bespecially after mealsC, sleeping in a propped up position and dietar( )odi'ications Be.g. small fre8uent meals, eating slowly, reduction of high5fat foods and caffeineC.

S*ELL#NG+E"EMA s the growing uterus puts pressure on the veins that return blood from feet and legs, swollen feet and ankles may become an issue. t the same time, swelling in legs, arms or hands may place pressure on nerves, causing tingling or numbness. <luid retention and dilated blood vessels may leave the face and eyelids puffy, especially in the morning. !o reduce swelling, the client will be advised to use cold compresses on the affected areas. (ying down or using a footrest may relieve ankle swelling. She might even elevate her feet and legs while she sleeps which will also minimise the swelling by gravity.

",SPNEA !his is a common symptom between the gestation of 20 and 2? weeks. &t is as a result of the pressure by the growing uterus on the diaphragm B<raser, 'ooper and Nolte, ,--?C. &f Mrs. Nkhata happens to develop dyspnoea, she will be educated of the physiology of the problem for her to understand what;s happening. She will also be advised on sleeping in semi5fowlers position so as to be increasing the area for lung expansion hence improved respiratory condition. She will also be encouraged to have periods and resting to reduce the body need for oxygen. !ONST#PAT#ON 'onstipation in pregnancy especially third trimester is usually caused by reduced motility of large intestine which comes due to the muscle laxative effect of the hormone progesterone which is produced in large amounts this period, &ncreased water re5 absorption from large intestine due to hormone aldosterone effect, Pressure on the pelvic colon by the pregnant uterus and sedentary life during pregnancy . if the client will come with the problem of constipation, she will advised on drinking plenty of fluids, high fibre foods and get plenty of exercise. !hese help in softening the bowels hence reduced risk of constipation. %A!-A!HE .uring pregnancy, ligaments become softer and stretch to prepare for labour. !his can put a strain on the Eoints of the lower back and pelvis, which can result in backache. !o overcome this problem Mrs. Nkhata will be advised to avoid heavy lifting, bend her knees and keep her back straight when lifting or picking up things from the ground, move her feet when turning and avoid sudden twisting movements, /ork at a surface high enough to prevent her from stooping and to sit with her back straight and well5 supported. nother advice will be that she should make sure she gets enough rest, particularly later in pregnancy.

F$E.&ENT M#!T&$AT#ON

s the baby moves deeper into your pelvis towards term of pregnancy, a woman feel more pressure on your bladder and may find herself urinating more often, even during the night. !his extra pressure may also cause her to leak urine J especially when she laughs, coughs or snee9es. &n this case the client will Eust have to be assured that this is normal with a good explanation of the cause. She will also have to be advised on perineal care to prevent ascending infections. !$AMPS 'ramp is a sudden, sharp pain, usually in calf muscles or feet. &t is most common at night, but nobody really knows what causes it. !he woman will be oriented to skills she will have practice to combat the problem for exampleH pulling up of toes hard up towards the ankle, or rub the muscle hard. 6entle exercise in pregnancy, particularly ankle and leg movements, which can improve blood circulation and may help to prevent cramp occurring and plenty of calcium rich foods Bleafy green vegetables, dairy products, sunflower seeds, salmon and dried beansC and magnesium rich foods Bnuts, dates and figs, yellow corn, green vegetables and applesC in her diet. FEA$ s the pregnancy draws near term most women become afraid of the labour pains, fears about childbirth may become more persistent. How much will it hurtK How long will it lastK How will they copeK &f Mrs. Nkhata happens to come with such a problem, she will be advised on the importance of hospital delivery where pain relief mechanisms are available. She will also be asked to have time with other women who have had positive experience of labour and this will help in relieving her fears.

$.7' !&"N N. '"7NS$((&N6 .uring the assessment, several areas were identified that needed education and counselling to Mrs. Nkhata. < M&() P( NN&N6

Mrs. Nkhata indeed knows what family planning is as well as the available family planning methods in Malawi but has problems with choice of family planning method according to her reproductive goals. Mrs. Nkhata expressed that she wants to use inEectable contraceptives B.epo5ProveraC as her family planning methods of choice. However, she also expressed fears that she had heard that the method is phasing out soon. (ooking at her reproductive goals, & felt that Mrs. Nkhata could also benefit from other family methods that are long term like &ntrauterine 'ontraceptive .evice and >adelle than the methods she had chosen & discussed with her of all the methods on the positives, negatives and availability of the methods with much emphasis on >adelle which is the best method for her basing on her goals as she wants to have a space of five years before gets pregnant again so the same with the method as it is made to last for : years. & also commented on the speculation that inEectable contraceptives are phasing out by telling her that it is not true. & also explained to her that the best time to start family planning is six weeks after delivery for it is believed that by this time a woman;s fertility has returned and also her body has returned to her pre5pregnant state and can resume sex B<amily Planning Handbook, ,--4C &MM7N&S !&"NS #ased on the information that she had received only two doses of !etanus !oxoid 1accine with the first pregnancy and two with the current one, & felt she needed more information on the right expected schedule the mothers are need to follow to complete all the five doses for !!1. "n this day, an explanation on the normal vaccination schedule was given to Mrs. Nkhata so that as she has already started with the two doses, should finish the remaining three doses. <inishing the doses will help in reducing the risk of the baby from getting tetanus. /e together planned on how she was going to get the other doses. !he third dose will be given on 3ADA++, the fourth dose will be given on 3ADA+, and the last dose will de given on 3ADA+2. S$F7 (&!)

Mrs. Nkhata did not have knowledge on when to stop sex before delivery and when resume after delivery. "n this day, oriented her to the right time as to when she can stop sex as well as when to resume. & told her that there is no limitation as to when they can stop sex thus they can have sex until term of pregnancy as far as they are comfortable. & also explained to her that they can resume sex as early as ? weeks as far as she feels that her body is ready for sex. #&%!HH P( N N. '"MP(&' !&"N P%$P %$.N$SS %ealising that Mrs. Nkhata was afraid of labour pains, & took sometime counselling her on normal processes of pregnancy until labour and delivery so as to alley her anxiety. &i put emphasis on the need and importance of delivering at the hospital where measures of managing labour pains are used. & also advised her on the need to associate and learn from mothers who had undergone the same experience several times who can help her prepare for her labour and delivery. <"'7S$. N!$N ! ( ' %$ #asing on the time that she had started antenatal visits, it showed that she did not have enough or no knowledge on focused antenatal care and its importance. & therefore planned to educate her on what focused antenatal is, and its importance. Mrs. Nkhata was told what is done at the clinic where focused antenatal system is followed and also what if expected of women undergoing focused antenatal care especially when to start attending antenatal and how fre8uent. /e also discussed on the importance of attending all the expected normal four visits of antenatal care. M&N"% .&S".$%S "< P%$6N N') &n addition to these education and counselling sessions, Mrs. Nkhata was also prepared for the expected minor disorders that may develop as the pregnancy progresses especially in the third trimester. Minor disorders like dyspnoea, heartburn, constipation and backache are some of the common disorders that occur to mother in their third trimesters. So she was told of the disorders so as when they happen she should not be anxious but accept them as things that happen normally.

.ate for the next visit.