FNP LECTURE THEME 2

Pre natal care Lecture 1 Presenter :Ms Aliti Qarikau

Introduction
Prenatal care (care of the woman during pregnancy, before labour) is credited with the reduction of perinatal mortality over the last 55years. The earlier prenatal care is begun, the better. This provides an opportunity fro the health care provider to obtain baseline data on physical assessments and laboratory test results

 Beckmann, Buford, and Witt (2000) found that the cost and length of time at an appointment were the major barriers to prenatal care. Anticipatory guidance ( providing information, teaching or guidance to a client in anticipation of an expected event) is probably the most important aspect of prenatal care. It is based on the assessment of the mother and fetus and knowledge of the normal process of pregnancy an possible complication. VAC1

Slide 3 VAC1
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Objectives
At the end of the theme the student should be able to: Define the key terms List the broad objectives and components of prenatal care Describe initial assessments- history, physical examination and risk assessment Calculate expected date of delivery ad gestational age Identify necessary laboratory tests fro risk assessments Discuss general health habits Describe the common discomforts of pregnancy and its management.

Aims of prenatal care

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

Aims of prenatal care cont:

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

Initial Assessment (Booking)

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

Initial visit cont:

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

Communication
Nurse requires skilled communication techniques in order to promote sensitive exchange of information between members of the health team and the pregnant woman and her family. Listening skills involve attending to or focusing on what the woman is saying, considering the words, phrases and general content of what is said (Morrison & Burnard 1997) Non- verbal responses facial expression, body position, eye contact, proximity to the nurse and touch will affect the flow of information between the woman and nurse Promote communication by: gentle questioning, open ended statements and reflecting back key words from what is said to encourage and facilitate exploration of what is said (SteinParbury 1993)

First impressions
Nurses can gain much from the initial observation and assessment of a woman at the start of their first meeting Woman may be distressed at the: 1. Long wait 2. prospect of unpleasant experiences of previous booking visit 3. Failure of contraception unresolved anger may lead to unresponsive behavior Carry out assessment sensitively and enable the woman to express her concerns about this or previous experiences of pregnancy or birth

Observation of physical characteristics

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

Initial history
Provides health care provider with the client s past and present health. 1. Personal information -age - education level - race or ethnic group -occupation -stability of living conditions - marital status

 Economic level Housing Any h/o emotional or physical or physical deprivation (herself or children) Overuse or under use of health care systems Acceptance of pregnancy Personal preferences about the birth (expectations of both the woman and partner, presence of others and so on) Plans for care of child following birth.

Past pregnancies
no. of pregnancies no. of abortions, spontaneous or induced no. of living children h/o preceding pregnancies: length of pregnancy, length of labour and birth, type of birth Woman s perception of the experience, complications Perinatal status of previous children: apgar scores, birth weights, general development complications, feeding patterns Prenatal education classes

Current medical history

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

Past medical history

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

Occupational history Occupation Does she stand whole day? Any heavy lifting? Exposure to harmful substances Provision for maternity leaves Opportunity for regular breaks

Partners history Presence of genetic disease or conditions Significant health conditions Previous or present alcohol intake, drug use, tobacco use Occupation Education level Attitude towards pregnancy

Determination of due date

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

 Nurse must enquire about: The normal cycle and amount of bleeding in order to estimate the reliability of the calculation.

Calculating EDD by dates is sometimes confirmed by assessing uterine size, or more commonly by early ultrasound scan.

Screening tests
Full blood count: -RBC/ WBC Hemoglobin (Hb) Blood type -A,B,AB or O RH factor:- positive or negative - If negative- do indirect coomb s test (repeat at 28wks and 32 weeks) Blood glucose for woman who: - Have family H/o diabetes - Had previous large babies b/weight> 4.0kg - H/o abortions, stillbirth - Have a weight of >80kg - Age of 35yrs>

 VDRL (syphilis test) - Should be negative - Hepatitis B surface antigen - Positive state indicates either active hepatitis or carrier ( counsel mother)

HIV test should be negative Urinalysis: - note: color, ketones, albumin, glucose (use uristix)

Pretest and post test counseling

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

 Consider if the individual could be at risk: - Unprotected sex with an infected partner - Being transfused with blood or other blood products that have not been screened for HIV infection - Injected with used needles and syringes Post test counseling: - After results are back and patient is given the result

 Negative result: does not necessarily mean she is negative if she feels she could have been exposed to the virus Positive result: a protocol to follow - HIV counselor/ nurse - Consultant/ senior registrar OBGYN - Pediatrician ( work as a team for subsequent follow up)

Factors placing woman at risk for nutritional inadequacy:

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

Nutritional needs
Dietary advice is usually given by: - Health educator/ nurse educator or dietician at initial visits and subsequent visits - Supplementary iron: Feso4 tablets and folic acid tablets which prevent neural defects in the fetus Advice woman to eat locally grown vegetables Avoid processed foods which have no nutritional value Need for adequate intake of foods reach in calcium- for healthy bones and teeth. Make suggestions for a more adequate dietary intake considering cultural and personal preferences

Get ready for class activity!!

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