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  2. 2. MASTER PLANSUBJECT : OBSTETRIC AND GYNAECOLOGICAL NURSINGGENERAL OBJECTIVE: On completion of the seminar the students will beable to get adequate knowledge regarding preventive obstetrics and able toprevent obstetric complication by applying measures while practicing it.SPECIFIC OBJECTIVE: On completion of the seminar the students will be able to • Define preventive obstetrics • Mention preventive obstetrics measures • Explain preventive obstetric s measures, antenatal nursing, Intranatal nursing, postnatal nursing
  3. 3. SL.NO. CONTENT1 INTRODUCTION2 TERMMINOLOGIES3 CONTENT PREVENTIVE OBSTETRICS: Definition Preventive Obstetrics Measures A. Antenatal Nursing Objectives of Antenatal Care 1. Preconceptional Counseling and Care 2. Essential Antenatal Care Services 3. Specific Health Protection 4. Preparing for Confinement 5. Psychological Preparation of the Mother 6. Family Planning 7. Education for Self – Care 8. Hematological Investigations 9. Screening for Urinary Tract Infection 10. Minor Disorder of Pregnancy B. Intranatal Nursing Objectives of Intranatal Care 1. Domiciliary Care 2. Complications and Obstetrical Emergency during Intranatal Period C. Postnatal Nursing Objectives of Postnatal Care 1. Complications of the Postnatal Period 2. Restoration of Mother to Optimum Health 3. Breast Feeding 4. Respiratory Distress Syndrome and Neonatal Problems 5. Prevention of Injuries in the New Born Babies 6. Major Disorders of Newborn Baby 7. Family Planning 8. Health Education to Mother and Family4 CONCLUSION5 BIBLIOGRAPHY
  4. 4. PREVENTIVE OBSTETRICSINTRODUCTION Preventive obstetrics is the concept of prevention or early detection ofparticular health deviations through routine periodic examinations and screenings. Theconcept of preventive obstetrics concerns with the concepts of the health and well-beingof the mother and her baby during the antenatal, intranatal and postnatal period. It aimsto promote the well- being of mothers and babies and to support sound parenting andstable families. Nursing care centered on health promotion and health maintenanceduring pregnancy presents an excellent opportunity for nurses to teach expectantmothers about normal changes expected and alert them to a variety of risk factors. The goal of the preventive obstetrics is the delivery of a healthy infant by ahealthy mother at the end of a healthy pregnancy. Pregnancy and child birth normalphysiologic process that change from conception to delivery. The nurse has a uniqueopportunity to reinforce the normal cycle of these processes and at the same time, assessclient for problems that require intervention. Additionally, the nurse can teach clientsabout the changes that are taking place and provide valuable guidance for clients aboutwhen to seek guidance from health care providers. Early contact between the health care team and the pregnant client provides theopportunity to address the concepts of health promotion and health maintenance. Healthpromotion consists of education and counseling activities that help enhance andmaintain health which prevents from obstetrics. For the prevention of obstetricssystematic supervision (examination and advice) of a woman during pregnancy,antenatal care, preconceptional counseling and care are the major preventive measures. The aim of preventive obstetrics is to ensure that through the pregnancy andpuerperium, the mother will have good health and that every pregnancy may culminatein a healthy mother and a healthy baby. Although different parts of the world have different leading causes of maternaldeath attributable to pregnancy, in general, three major disorders have persisted for thelast 35 years like hypertensive disorders infection, and haemorrhage. The number ofmaternal deaths overall is small; however maternal mortality remains a significantproblem because a high proportion of deaths are preventable mainly through improvingthe access to a utilization of prenatal care services. Nurses can be instrumental ineducating the public about the importance of obtaining early and regular care duringpregnancy...
  5. 5. PREVENTIVE OBSTETRICDEFINITIONPreventive Preventive is the term used to prevention or slowing the course of an illness ordisease. It is intended or used to prevent or hinder acting as an obstacle.Obstetric The branch of medicine that deals with the care of women during pregnancy,childbirth and recuperative period following delivery is known as obstetric.Preventive Obstetric Preventive obstetric is the term for prevention of the complication that may ariseduring antenatal, intranatal and postnatal period. Preventive Obstetric measure can be categorized into three main stages. Theyare as follows:- A. Antenatal Nursing B. Intranatal Nursing C. Postnatal NursingA. ANTENATAL NURSING Antenatal care is the care during pregnancy. Antenatal care is essential even for anormal and healthy, pregnant women for her own well- being and that of the baby to beborn because no pregnancy and child birth is free from risk for both mother and baby.Ideally the care should start immediately after conception but practically as early aspossible during the first trimester and should continue throught the second and thirdtrimesters.Objectives of Antenatal Care To promote, protect and maintain the health of the mother during pregnancy. To detect “high risk” cases and give them special attention. To foresee complications and prevent them. To remove anxiety and dread associated with delivery. To reduce maternal and infant mortality and morbidity. To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation. To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy. To detect and treat any abnormality found in pregnancy as early as possible.
  6. 6. 1. Preconceptional Counseling and CareWhen couple is seen and counseled about pregnancy. Its course and outcome wellbefore the time of actual conception is called preconception counseling. It is a very newconcept. Objective is to ensure that a woman enters pregnancy with an optimal state ofhealth which would be safe both to herself and the fetus. Organogenesis is completed bythe 1st trimester. By the time the woman is seen first in the antenatal clinic it is often toolate to advice because all the adverse factors have already begun to exert their effect.In an ideal world antenatal care world commence at the preconception stage wherehealth education (general advice about nutrition, lifestyle, avoidance of teratogens, folicacid supplementation, etc) and risk assessment can be focused toward a plannedpregnancy. Preconception counseling is of much greater importance in two main groupsof women. Ones with underlying medical conditions that may be affected by or may influence the outcome of pregnancy. Examples of such conditions include diabetes, various endocrinopathies, hemostatic or thrombotic problem and cardiac disease. Patients following organ transplantation (kidney, liver, heart and lungs) are also now contributing to the ranks of these patients along with survivors of childhood malignancies. A multidisciplinary approach to optimize/ stabilize the underlying condition and planning care during the antenatal period is a key component to optimizing pregnancy outcome. Ones where there are identifiable factors that would suggest the couple are at a risk of fetal anomaly. Such identifiable factors may include a previous child affected by a single gene disorder or syndromic disorder, a family history of genetic disorder or history of parental chromosomal abnormality. Counseling is a major part of prenatal diagnosis. The majority of parents to be do not perceive themselves at risk and 95 percent of abnormalities do occur unexpectedly, in pregnancies not considered at risk. Preconceptional Counseling Permits Identification of high risk factors is done by detailed evaluation of medical, obstetric, family and personal history. Risk factors are assessed by laboratory tests, if required. Treatable factors like pre- existing chronic diseases (hypertension, diabetes, epilepsy) are stabilished in an optimal state by early intervention before pregnancy. Proper counseling to those with history of recurrent fetal loss or with family history of congenital abnormalities (genetic, chromosomal or structural), as there may be some untreatable factors. Overweight or under weight is to be corrected with proper dietary advice. Rubella and hepatitis immunization in a non – immune woman is to be offered. To record a base level health status including BP reading.
  7. 7. Folic acid supplementation (4mg a day) starting 4 weeks prior to conception up to 12 weeks of pregnancy is advised. Good understanding with the physician so that much of the problems and fear of the incoming pregnancy could be removed. The counseling should be done by primary health care providers. The help of obstetricians, physicians and geneticists may be required and should be extended.2. Essential Antenatal Care ServicesThe essential components of services during pregnancy include are:- Registration of Pregnant Women Antenatal Visits and Antenatal Care Immunization Against Tetanus Iron and Folic Acid and Vitamin A and D Supplementation Health education / prenatal advice during Pregnancy Registration of Pregnant WomenCare during pregnancy should be started as early as possible. The mother must beregistered within 20 weeks of pregnancy either at health centre/ antenatal clinic or athome by a nurse/health visitor/ female health worker (ANM) or trained person. Throughphysical and obstetrical check up should be done to screen for risk factors, makeassessment and give appropriate care for prevention and control of various healthproblems and complications. Antenatal Visits and Antenatal CareIdeally a woman should be seen and given care during pregnancy once a month duringthe first trimester or till seven months, once in fortnight during the second trimester ortill the eighth month and thereafter every week till confinement. But often these manyvisits are not feasible, neither for the mother nor for the health infrastructure available.The care should begin soon after conception and continue throughout pregnancy. Aschedule to follow for the mother is to attend the antenatal clinic once a month duringthe first seven months, twice a month during the next two months and thereafter once aweek if everything is normal. Therefore a minimum three visits one in each trimesterhave been recommended. The first visit should be done within 20 weeks or as early as the mother is registered. The second visit at 32 weeks of pregnancy. The third visit at 36 weeks of pregnancy.Further visits may be made if justified by the condition of the mother. At least one visitshould be paid in the home of the mother to make observation of actual conditions andaccordingly prepare the mother. The main purpose of contact during antenatal period isto make observations and assess general health, obstetrical health status, identify riskfactors and provide appropriate care.
  8. 8. The preventive services for mothers in the prenatal period are asfollows:-The first visit irrespective of when it occurs should include:- Taking Health HistoryIt includes recording history of menstruation, medical history, obstetrical history,socioeconomic history. Physical ExaminationIt includes recording of height, weight, blood pressure, temperature, pulse etc. generalobservations from head to toe. Obstetrical ExaminationIt includes general observations, examination of breasts, abdominal measurement,palpation and inspection, vaginal examination if necessary. Laboratory Investigations • Complete urine analysis • Stool examination • Complete blood count including Hbg estimation. • Serological examination. • Blood grouping and Rh determination. • Chest X- ray, if needed • Gonorrhea test, if neededOn subsequent visits • Physical examination including weight and blood pressure • Laboratory tests including urine examination and hemoglobin estimation • Iron and folic acid supplementation and medications as needed. • Immunization against tetanus • Group or individual teaching on nutrition, self care, family planning, delivery and parenthood • Home visiting by a female health worker or trained person ( trained traditional birth attendant) • Referral services, when necessaryRisk ApproachWhile continuing to provide appropriate care for all mothers, ‘high risk’ cases must beidentified as early as possible and arrangements to be made for skilled care. These casescomprise the following:- Women below 18 years of age or over 35 years in primigravida. Women who have had four or more pregnancies and deliveries. Short structured primigravida
  9. 9. Those who have practiced less than 2 years or more than 10 years of birth spacing. Those with cephalopelvic disproportion (CPD), genital prolapse. Malpresentations, e.g. breech, transverse lie etc. Antepartum hemorrhage, threatened abortion Preeclampsia and eclampsia Anemia Twins, hydramnios Previous stillbirth, intrauterine death, manual removal of placenta Elderly grandmultipara Those mother with blood Rh negative. Those with obesity and malnutrition. Prolonged pregnancy ( 14 days beyond expected date of delivery) Previous cesarean or instrumental delivery Pregnancy associated with medical conditions, e.g. cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease etc.The purpose of risk approach is to provide maximum services to all pregnant womenwith attention to those who need them most. Maximum utilization of all resources,including human resources is involved in such care. Services of traditional birthattendants, community health workers and women’s groups are utilized. The riskstrategy is expected to lead to improvements in both the quality and coverage of healthcare at all levels, particularly at primary health care level.Prevention• Administration of folic acid 5mg daily months before conception.• By improving pre- pregnancy health of woman.• Providing quality antenatal care.• Screening all pregnancies for high risk.• Provide appropriate clinical and technological care by specialist on time.• Prevent all kinds of infection.• Early diagnosis of malformation and termination.• Avoidance of medication (without physician’s prescription).• Health education on MCH and FP care.Maintenance of RecordsThe antenatal card is prepared at the first examination. It is generally made of thickpaper to facilitate filing. It contains a registration number, identifying data, previoushealth history, and main health events. The record is kept at the MCH/FP center. A linkis maintained between the Antenatal card, Postnatal card and under- fives card.Maintenance of records is essential for evaluation and further improvement of MCH/FPservices.Home VisitHome visits are paid by the Female Health Worker or Public Health Nurse. If thedelivery is planned at home, several visits are required. The home visit will provideopportunities to study the environmental and social conditions at home and to provide
  10. 10. prenatal advice. In the home environment, the woman will have more confidence tomake an informed decision about home birth. Immunization Against TetanusA pregnant woman must get two injections of Tetanus Toxoid during the periodbetween 16 – 36 weeks, at one month interval. These protect the mother and baby bothfrom the risk of tetanus. The 2nd injection should preferably be given at least at onemonth before delivery. If a woman is registered late then in that case even one injectionwill do. If the woman is immunized earlier within three years of the pregnancy, thenone booster dose will be enough. Iron and Folic Acid and Vitamin A and D SupplementationIt is being found that 50-60 percent of pregnant women are anaemic due to irondeficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to takeone tablet containing 60 mg.of elemental iron and 500 mg of folic acid three times dailyafter third month of pregnancy till 3 months after child birth if the mother is foundhaving anaemia.During pregnancy, the mother requires extra iron and folic acid due to changes takingplace in the body and growth of fetus in the womb. Therefore each mother is given onetablet of iron and folic acid twice a day for at least 100 days to prevent anaemia inmother and to promote proper growth of fetus.Anemia is common in pregnancy and low – income group. It is a major cause ofmaternal and fetal mortality.Prevention of Anemia Avoidance of frequent of child birth: At least two years an interval between pregnancies is most necessary to replace the lost iron during childbirth process and lactation. This can be achieved by proper family planning guidance. Supplementary iron Therapy: Iron supplementary should be a routine after the patient becomes free from nausea and vomiting. Daily 60mg iron with 1mg folic acid is a quite effective prophylactic procedure. Dietary Prescription: Well balanced diet rich in iron and protein should be advised. The food rich in iron are liver, meat, egg, green vegetables, green pea bean, whole wheat etc. Adequate treatment should be instituted to eradicate the illness likely to cause anemia. These are hookworm infestation, dysentery, and malaria, bleeding piles, urinary tract infection etc. Early detection of falling hemoglobin level is to be made. Hemoglobin level should be estimated at the first antenatal visit at the 28th and finally at 36th weeks. Avoid excessive blood loss during the 2nd stage of labour.
  11. 11. Health education / prenatal advice during PregnancyA major component of antenatal care is health education and prenatal advice. Themother is more receptive to advice concerning herself and her baby at this time than anyother time. A woman during pregnancy needs to know about her nutrition, personalhygiene, rest and sleep, exercise, use of drugs, warning signs etc.Pregnancy can be both an exciting and worrying time for the mother and her partner.Part of the role of the health care professionals (usually fulfilled by the communitymidwife and general practitioner) caring for the mother is the provision of informationabout everyday activities that may or may not be affected by or have an effect on thepregnancy. Diet during pregnancy Personal Hygiene Rest and Sleep Physical work Exercise Comfortable clothing and shoes Smoking Alcohol Breast Care Drugs Radiation Protections from infections and illnesses Sexual activities Travel Reporting of untowards signs and symptoms Child care Follow up visits Warning Signs Diet during pregnancyNutritional intake is an important factor in the maintenance of maternal health duringpregnancy and in the provision of adequate nutrients for embryonic/fetal development.Assessing nutritional status and providing nutritional information or referral to adietitian are part of the nurse’s responsibilities in prenatal care.Dietary extremes are associated with risks in pregnancy. Obesity is associated withgestational diabetes, hypertension and monitoring difficulties. Malnutrition is associatedwith maternal anemia and fetal growth restriction, while deficiency of certain vitaminspredispose to congenital abnormalities, folic acid deficiency is linked to the risk ofneural tube defects (NTDs). A balanced diet rich in fresh fruit and vegetable isrecommended. It is prudent to avoid unpasturized milk and cheeses and pâtés. Pregnantwoman should avoid eating liver due to its high vitamin A content. Vegans should haveIron and vitamin supplementation and ethnic groups lacking sunlight are advised tohave extra vitamin D.
  12. 12. A balanced and adequate diet is of utmost importance during pregnancy and lactation tomeet the increased needs of the mother, and to prevent nutritional stress. If maternalstores of iron are poor as may happen after repeated pregnancies and if adequate iron isnot available to the mother during pregnancy, it is possible that the fetus will lay downinsufficient iron stores.Relationship between Maternal and Foetal NutritionEnergyInadequate food intake and poor nutrient utilizationMaternal MalnutritionReduced blood volume expansionInadequate increase in cardiac outputDecreased blood and nutrient supply to the foetusReduced placental sizeReduced nutrient transferFoetal growth retardationThe increase in energy is to support the growth of the foetus, placenta, and maternaltissue and for the increase in basal metabolic rate due to additional work of growingfoetus and increase in maternal body size. Personal HygieneAdvice regarding personal hygiene is equally important. The need to bathe every dayand to wear clean clothes should be explained. About eight midday meals should beadvised. Constipation should be avoided by regular intake of green leafy vegetables,fruits and extra fluid. Purgatives such as caster oil to relieve constipation should beavoided. Light household work should be encouraged but manual physical labourduring pregnancy may adversely affect the fetus.
  13. 13. • Fresh air and sunshineThis is here in abundance and most women are in the open air for a large part of the dayand it is good for them but advice regarding their sleeping arrangements should begiven.• The bowelsThe bowel action should occur daily and without the use of laxatives. Drinking glass ofwarm water on getting up each morning and drinking plenty of fluids during the day canencourage this. Plenty of roughage in the diet is also helpful.Constipation should beavoided by regular intake of green leafy vegetables, fruits and extra fluids.Purgativeslike caster oil should be avoided to relieve constipation.• Care of TeethThe usual care after eating should continue. A dental check is advisable and any dentalcarries should be treated. Use soft brush in this period.• Personal Cleanliness and BathingDuring pregnancy sweet glands become more active so advice for bathing at least oncea day, preferably twice but clean clothes should be used daily.The need to bath everyday and to wear clean clothes should be explained. The hair should also be kept cleanand tidy. Rest and SleepA pregnant woman needs sufficient rest. She should do less and lighter work. She musthave 8-10 hours of sleep every night. She needs to take short nap during the day. As thepregnancy advances, the mother requires more frequent short rests during the day. Sheshould avoid strenuous work, carrying heavy loads or weights e.g. bringing water fromlong distance, drawing of water from a well etc.Rest is important for the maintenance of good health. She should need adequate rest andrelaxation. Relaxation of the mind produces relaxation of the muscle and a relaxedlower uterine segment and pelvic floor makes it easier for the baby to be born. Physical workA job provides satisfaction, self esteem and confidence, along with financial peace ofmind. Women can continue working in pregnancy as long as they wish and as long asthey and their baby remain well. Avoidance of exposure to hazardous chemicals,Smokey environments, excessive lifting and exercise and at least an 8- hour rest at nightis recommended.
  14. 14. ExerciseExercise in pregnancy should be encouraged; through with advancing gestation physicalcontraints may limit sporting activities. Exercise can improve cardiovascular function,lower blood pressure and improve self- esteem and confidence. Swimming is oftenhelpful throughout pregnancy especially with advancing gestation as it is essentially anon weight bearing exercise. It is advisable however to avoid hyperthermia, dehydrationand exhaustion.Consider decreasing weight – bearing exercises like jogging, running and concentrateon non weight bearing activities such as swimming, cycling or stretching. Advise her toavoid risky activities such as surfing, mountain climbing and skydiving. Limit activityto shorter intervals. Exercise for 10 to 15 minutes; rest for 2 to 3 minutes, then exercisefor another 10 to 15 minutes. The exercise should be decrease as the pregnancyprogresses. Comfortable clothing and shoesIt is advisable to wear loose and comfortable cotton clothes, not too tight such as blouseor cholo.Brassier which supports the breasts should be advised, but must not be tootight so as to flatten the nipples but lift the breast well. A support for the abdomen issometimes required, especially in a multigravida who has pendulous abdomen so thepregnant mother should advise to support her whole abdomen with a light belt.Pregnant should avoid high heeled shoes. She should wear flat shoes to maintain centerof balance and to prevent backache to some extent. SmokingIt should be strongly discouraged in pregnancy. The target should be cessation ofsmoking, but if not possible, then cutting down to as few as possible is advisable.Smokers (especially those smoking > 20/day) have a slightly higher incidence ofmiscarriage, a slightly higher perinatal death rate (20% increase in 20/day smokers, and35% increase if > 20/day) and babies of smokers are 150 to 300 gm lighter than babiesof non smokers. Furthermore, smoking is associated with a three-fold increase in risk ofcleft palate. Smoking during pregnancy, however, doesn’t affect long term mental ormotor development. The mechanisms involved include interference of carbon monoxidewith oxygen transfer, shifting the oxygen dissociation curve to the left in both maternaland fetal hemoglobin and reduced intervillous blood flow. Appropriate advice andsupport should be provided for women who wish to try stopping smoking, withoptimum benefits achieved if smoking is stopped prior to conception.Smoking should be cut down to a minimum, as heavy smoking by the mother can resultin babies much smaller than average size due to placental insufficiency. The perinatalmortality amongst babies whose mothers smoked during pregnancy is between 10 to 40percent higher than in non smokers. Mothers who are moderate to heavy drinkers(alcohol) become pregnant, have greater risk of pregnancy loss and if they do not abort,their babies may have various physical and mental problems. Heavy drinking has beenassociated with fetal alcohol syndrome (FAS), which includes intrauterine growth
  15. 15. retardation and developmental delay. Advice should also be given about dental care andsexual behavior during pregnancy. Sexual intercourse should be restricted during thelast trimester of pregnancy. AlcoholAn expectant mother should be advised to avoid drinking alcohol as drinking alcohol isinjurious to the fetus and also to her own health. It leads to low birth weight andretardation.Pregnant women are advised to limit alcohol consumption and a consumption 20 gm/week (2 units) appears to be generally safe. Heavy alcohol consumption (greater than12 unts or 120 gm/ day) is associated with the development of fetal alcohol syndrome.The syndrome is characterized by growth retardation, neurological and structuraldefects (facial, cardiac, joints). A lesser degree of alcohol consumption but still greaterthan 8 units/day may also be associated with fetal alcohol syndrome as well as otherassociated features such as increased risk of miscarriage and reduced headcircumference. Breast CareThe mother should advice to clean her breast during bath. If the nipples areanatomically normal, nothing is to be done beyond ordinary cleanliness. But if nipplesare retracted, correction should be done. For this mother is taught about nipple care. Sheshould wash her breast, with soap and water. To toughen the nipples, it should bemassaged by using soap and water and then roll them between the forefinger and thumband draw them out everyday during the last two months. This should be done threetimes a day. After massage, the nipples should be dried and an oily substance applied tomake them supple. Advise mother to wear a well fitting and supportive brassiere. DrugsThe mother should be advised not to take any medicine unless it is prescribed by thedoctor. As far as possible, medicine should be avoided for the three months unless veryessential. The mother must inform to the doctor about pregnancy when seeking anytreatment from the doctor or health personnel.The use of drugs that are not absolutely essential should be discouraged. Certain drugstaken by the mother during pregnancy may affect the fetus adversely and cause fetalmalformations. The classical example is thalidomide, a hypotonic drug, which causeddeformed hands and feet of the babies born. The drug proved most serious when takenbetween 4 to 8 weeks of pregnancy. Other examples are LSD which is known to causechromosomal damage, streptomycin which may cause 8th nerve damage and deafness inthe fetus, iodine- containing preparations which may cause congenital goiter in thefetus. Corticosteroids may impair fetal growth, sex hormones may produce virilism, andtetracycline may affect the growth of bones and enamel formation of teeth. Anaestheticagents including pethidine administered during labour can have depressant effort on thebaby and delay the onset of effective respiration. Later still in the puerperium, if the
  16. 16. mother is breast- feeding, there are certain drugs which are excreted in breast milk. Agreat deal of caution is required in the drug – intake by pregnant women. RadiationExposure to radiation is a positive danger to the developing fetus. The most commonsource of radiation is abdominal X-ray during pregnancy. Studies have shown thatmortality rates from leukemia and other neoplasm were significantly greater amongchildren exposed to intrauterine X-ray. Congenital malformations such as microcephalyare known to occur due to radiation. Hence, X-ray examination in pregnancy should becarried out only for definite indications. Protections from infections and illnessesInfections in pregnancy are responsible for significant morbidity and mortality. Thedirect financial costs of disease can be as starting and are much more difficult tomeasure. Some consequences of maternal infection last a life time.Education and counseling are important aspects of care for the prevention of maternalinfections. Adolescents mothers are at high risks because of earlier partners. The recenttrend of exchanging sex for drugs is contributing to a rise in infection rates, especiallyamong poor, and minority women. The prevention of disease and the reduction ofmaternal and neonatal effects continue to be monumental challenges.An expectant mother must be instructed to protect herself from the risk of any infectionespecially measles, German measles and syphilis because these infections can causespontaneous abortion, malformation, mental retardations, still-birth, perinatal death etc.The child may develop congenital syphilis. If the mother is found having syphilis shemust get herself treated by the trained health personnel especially from healthcenter/hospital. Sexual activitiesPatient inhibition to ask and failure to address the issue by health professionals hasresulted in considerable misconceptions. In general with an uncomplicated pregnancy,there are no contraindications to coitus or other form of sexual enjoyment in pregnancyincluding cunnilingus and masturbation. There is no evidence that these have adamaging influence on the fetus or risk inducing premature labour. With advancinggestation certain coital positions may be physically awkward. There may be decline insome women in sexual desire and activity in early pregnancy toward the end ofpregnancy. Coitus may be avoided with premature rupture of membranes and wherethere have been recurrent episodes of APH and in the presence of a placenta previamajor.The mother should be advised to avoid coitus during the first three months and the lasttwo months. In the first three months it increases the risk of abortion. The risk ofabortion is more in mothers who have previous history of abortion. In late pregnancy itpredisposes to infection.
  17. 17. TravelThe mother should be instructed to avoid travel during the first three and last twomonths of pregnancy especially long and tedious journey.If traveling for long distances, periods of activity and rest should be scheduled. Whilesitting, the woman can practice deep breathing, foot circling, and alternating contractingand relaxating different muscule groups. Fatigue should be avoided. Reporting of untowards signs and symptoms• The expectant woman must be instructed to report to health personnel the following signs and symptoms.• Unusual pain, bleeding from vagina.• Swelling in the feet, hands or face• Headache, dizziness, blurred vision at times. These symptoms indicate the onset of high blood pressure which is very dangerous and can prove fatal if timely care is not given.• High fever• Baby’s movements not being felt.• Any other sigh or symptom which is considered unusual. Child careThe mother should be educated on various aspects of child care. Mother craft classescan be arranged if possible to train the mother regarding care during pregnancy, childbearing, breast feeding, weaning and child nutrition, growth and development of child,clothing, immunization, care during minor ailments, family planning etc.Mothers attending antenatal clinics must be given mother craft education that consistsof nutrition education, hygiene and childrearing, childbirth preparation and familyplanning information. Follow up visitsIt is important that mother must be educated about the need for regular visits and propercare during pregnancy. They must be convinced to pay follow up visit and follow theinstructions regarding diet, personal hygiene, rest, physical work, exercise, smoking,drinking, and protection from infections, sexual activities, and travel etc.so as topromote health of both mother and the growing fetus. Warning SignsThe mother should be given instructions that she should report immediately, any of thefollowing warning signals like swelling of the feet, convulsions, headache, blurring ofthe vision, bleeding or discharge per vagina and any other unusual symptoms.
  18. 18. 3. Specific Health ProtectionSpecific protection for pregnant women’s health is an essential aspect of prenatal care.This is because 50 to 60% of women, belonging to low socio-economic groups areanemic in the last trimester of pregnancy. The major causative factors are iron and folicacid deficiencies. Anaemia is known to be associated with high incidence of prematurebirths, postpartum haemorrhage, and puerperal sepsis and thromboembolic phenomenain the mother. AnaemiaSurveys in different parts of India indicate that about 50 to 60 percent of womenbelonging to low socio- economic groups are anemic in the last trimester of pregnancy.The major aetiological factors being iron and folic acid deficiencies. It is well knownthat anaemia per se is associated with high incidence of premature births, postpartumhaemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother. Other Nutritional DeficienciesProtection is required against other nutritional deficiencies that may occur duringpregnancy such as protein, vitamin and mineral deficiencies. So Vitamin A and Dcapsules should be supplied for the pregnant mother. Toxemias of PregnancyThe presence of albumin in urine and increase in blood pressure indicates toxemias ofpregnancy. Their early detection and management are indicated. Efficient antenatal careminimizes the risk of toxemias of pregnancy. DiabetesThis plays an important role for presentational diabetes. To prevent early pregnancyloss and congenital anomalies, medical care should begin before conception. Acomplete assessment of the diabetic status and associated complications is done to findout if she is fit to go through pregnancy.Evaluation of thyroid function is also recommended in type 1 diabetes ashypothyroidism is frequently encountered in these women. Those on oral hypoglycemicagents should be switched to insulin therapy preferably before conception. Tetanus ProtectionIf the mother was not immunized earlier, two doses of tetanus toxoid should be given,the first dose at 16th to 20th week and the second dose at 20th to 24th week of pregnancy.For a woman who has been immunized earlier, one booster dose will be sufficient.When such a booster dose is given, it will provide necessary cover for subsequentpregnancies for the next five years.
  19. 19. RubellaRubella infection suffered by the mother, especially in early pregnancy can havedevastating consequences for the fetus. In an attempt to reduce the incidence ofcongenital rubella defects, vaccination has been undertaken. HIV ScreeningPregnant women are ethically obligated to seek reasonable care during pregnancy andto avoid causing harm to the fetus. Maternity nurses should be advocates for the fetus,but not at the expense of the pregnant woman. Incidence of perinatal transmission froman HIV – positive mother to her fetus ranges from 25% to 35%. Methods of preventingmaternal – fetal transmission ad fetal treatment currently are not available. Until there ischange in technology that alters the diagnosis or treatment of the fetus, testing of thepregnant woman should be voluntary. Health care providers have an obligation to makesure the pregnant woman is well informed about HIV symptoms and testing.HIV may pass from an infected mother to her fetus through the placenta or to her infantduring delivery or breast feeding. About one third of the children of HIV positivemothers infected through this routine. The risk of transmission is higher if the mother isnewly infected or if she has already developed AIDS. Prenatal testing for HIV infectionshould be done as early in pregnancy as possible for pregnant women who are at risk (if they or their partners have multiple sexual partners, have sexually transmitted diseaseor use illicit injectable drugs). Universal confidential voluntary screening of pregnantwomen in high prevalence areas may allow infected woman to choose therapeuticabortion, make an informed decision on breast feeding or receive appropriate care. Hepatitis BScreening for hepatitis B aims to determine whether the patient has ever been exposedto the virus, and whether is immune to the virus or whether she is a potential risk oftransmitting the infection to the neonate, her partner and to health care professionals. Acombined course of active and passive immunization can then be undertaken in theneonate at risk after birth. The importance of preventing hepatitis B infection in theneonate is that while in the adult patient the virus is cleared within 6 months in 90percent of infected individuals, in neonates 90 percent become chronic carriers with therisk of post infective hepatitis cirrhosis and hepatocellular carcinoma. SyphilisScreening for syphilis should be performed for the prevention of congenital syphilis inthe neonate. Treatment confers benefits to mother too, by preventing development ofcardiovascular and neurological complications of the advanced stages of the disease.Syphilitic infection in the woman is transmissible to the fetus, especially when she issuffering from primary or secondary stages after the 6th month of pregnancy.Neurological damage with mental retardation is one of the most serious complications.Blood should be tested for syphilis (VDRL) at the first visit and late in pregnancy.
  20. 20. It is routine procedure in antenatal clinics to test blood for syphilis at the first visit.Since the mother can subsequently get infected with syphilis, the ideal procedure wouldbe to test blood for syphilis both early and late in pregnancy. Congenital syphilis iseasily preventable. Ten daily injections of procaine penicillin ( 600,000 units) arealmost always adequate. German MeaslesRubella infection contracted during the first 16 weeks of pregnancy can cause majordefects such as cataract, deafness and congenital heart diseases. Vaccination of allwomen of child bearing age, who are seronegative, is desirable. Before vaccinating, it isdesirable that pregnancy is ruled out and effective contraception be maintained for eightweeks after vaccination because of possible risk to the fetus from the virus, should themother become pregnant. Rh StatusIt is a routine procedure in antenatal clinics to test the blood for Rhesus type in earlypregnancy. If the woman is Rh- negative and the husband is Rh-positive, she is keptunder surveillance for determination of Rh- antibody levels during antenatal period. Theblood is further examined at 28th week and 34th to 36th week of gestation for antibodies.Rh anti – D immunoglobulin should be given at 28th week of gestation so thatsensitization during the first pregnancy can be prevented. If the baby is Rh positive, theRh anti-D immunoglobulin is given again within 72 hours of delivery. It should also begiven after abortion. Post maturity should be avoided. Whenever there is evidence ofhemolytic process in fetus in utero, the mother should be shifted to an equipped centerspecialized to deal with Rh problems. The incidence of hemolytic disease due to Rhfactor in India is estimated to be approximately one for every 400-500 live births. Prenatal Genetic ScreeningScreening for genetic abnormalities and for direct evidence of structural anomalies isperformed in pregnancy in order to make the option of therapeutic abortion availablewhen severe defects are detected. Typical examples are screening for trisomy-21 andsevere neural tube defects. Women aged 35 years and above, and those who alreadyhave an afflicted child are at high risk.4. Preparing for ConfinementThe preparation for safe delivery is very important. It should be done well in advance toavoid any type of difficulty or emergency which might occur at the time of delivery.The health personnel discuss with the couple and may be other members of the familyabout the alternative suitable place for confinement which includes home, health centreor hospital. The decision will depend upon the health status of both mother and thefetus, risk factors and environmental conditions at home.High risk mother must be delivered at primary health center, first referral unit orhospital at the discretion of doctor. However a normal healthy mother may be deliveredat home. But she must be delivered by a trained birth attendant, female health worker (
  21. 21. ANM),health supervisor ( LHV) to protect the life of both mother and the baby andprevent them from any infection especially tetanus. It is important to arrange transportin advance for transportation of mother to hospital or first referral unit duringemergency, if any. The following preparation should be done for delivery at home.Preparation of the room or some place for confinement:- The room or some place in the room should be clean, ventilated and well lighted. It should be kept ready beforehand. Preparation of the articles include: Washed and sun-dried sufficient old clothes. Washed and sun-dried bed sheet, blanket and mat. Stove/gas burner, match box. Large vessel with lid, bucket and a mug, a parat and a tasla. A lantern and a torch A new razor blade, clean cotton A plastic sheet to be placed over the mattress to protect it from fluid and blood. • Washed and sun dried linens or towel to wrap the baby. • Arrangements to burn or deep bury the placenta.The trained Dai should be ready with her own kit for delivery. It should have thefollowing articles: a. Enema can two bowels and one kidney tray, torch, a pair of scissors. b. Clean gauze pieces, cord ligatures, mucus sucker and baby weighing spring balance. c. Drugs and antiseptic like injection methergin, methylated spirit. d. Hand washing articles.These equipments and articles must be kept ready by the mother and family so thatthere is no problem at the time of delivery. The instructions must be given to anotherregarding these. Similarly the trained dais and health workers should be ready with theirdelivery kit for conduct of delivery at home.5. Psychological preparation of the motherPsychological preparation of the mother is important during pregnancy and delivery.The expectant mother, especially the primary Para mother has fear and anxiety aboutchild birth, its outcome, and complications etc.It is very important to discuss variousaspects of pregnancy and delivery .This helps in overcoming their fears andanxietes.Sufficient time and opportunity must be given to expectant mothers to havefree and frank talk on all aspects of pregnancy and delivery. The “mother craft” classesat the MCH centers help a great deal in removing their fears and in gaining confidence.
  22. 22. 6. Family PlanningFamily planning is related to every phase of the maternity cycle. Educational andmotivational efforts must be initiated during the antenatal period. If the mother has hadtwo or more children, she should be motivated for puerperal sterilization. The mothershould be educated and motivated for small family norm and spacing of children.7. Education for Self – CareHealth maintenance is an important aspect of prenatal care. Patient participation in thecare ensures prompt reporting of untoward responses to pregnancy. Patient as symptomof responsibility of health maintenance is prompted by understanding of maternaladaptations to the growth of the unborn child and a readiness to learn. Nurses in theirrole of teacher provide patients with the information necessary for compliance withhealth care measures.The expectant mother needs information about many subjects. During the initial healthassessment, the woman may have indicated a need to learn self care activities such asprevention of urinary tract infection.Supportive maternity brassiere with pads to absorb discharge may be worn at night,wash with warm water and keep dry, see maternal physiology and sexual counseling.Both partners need reassurance and support, support significant other who can reassurewoman about her attractiveness, etc improved communication with her partner, familyand others, refer to social worker, if needed or supportive services ( financial assistance,food stamps)First TrimesterAntenatal care in the first trimester starts with a visit to the GP after a missed period andconfirmation of pregnancy. It also provides an ideal opportunity for the woman todiscuss any anxieties she may have.8. Hematological InvestigationsThese include hemoglobin estimation and a complete blood picture if indicated. Bloodgroup determination and antibody screen is also performed to identify rhesus negativewomen who will need prophylaxis against rhesus isoimmunization. Full blood countThis is the most commonly performed hematological investigation in pregnancy.Pregnancy is associated with a physiological dilutional anemia due to greater increasein plasma volume than red cell mass and therefore the lower limit for a normal Hb is10.5 g/dl in pregnancy as opposed to 11.5g/dl in the non pregnant female. Many womenenter pregnancy with a low iron reserve and therefore if anemia is detected inpregnancy it should be appropriately investigated by assessment of ferritin, total ironbinding capacity (TIBC), serum and red cell folate and B12 levels based on the blood
  23. 23. picture. The most common cause of anemia in pregnancy is iron deficiency anemia.FBC estimation is performed 4 – 8 weekly in the second half of pregnancy and lowhemoglobin on admission in labour is an indication for sending a specimen to the labfor group and save in case of intrapartum or postpartum bleeding. Blood grouping and screening for antibodiesBlood grouping at booking, enables the determination women who are rhesus negativeand therefore may be at risk of rhesus isoimmunization. The incidence of rhesus diseasehas dramatically fallen over the last thirty years the introduction of anti – Dadministration. Despite screening at 28 and 34 weeks or after any potential sensitizingevent and administration of prophylactic anti – D at these times, a small number of RhDnegative women still develop anti-D antibodies because of small silent hemorrhagespredominantly in the third trimester or because of failure of timely administration ofanti D immunoglobulin. Screening for red cell antibodies should be repeated in allwomen in early pregnancy in subsequent pregnancies, even if rhesus positive, as theremay be other clinically significant antibodies as a consequence of previous pregnancyor blood transfusion. An antibody screen is performed to detect the presence ofantibodies that may put the baby at risk of hemolytic disease or result in difficultieswith cross- matching blood for the mother if required at any age of pregnancy, labour orpostnatally. If antibodies are detected, the titer is determined and subsequent samplestaken for further estimation at appropriate time interval.9. Screening for Urinary Tract infectionUrinary tract infections may be asymptomatic. Whether symptomatic or not, urinarytract infections present a risk to both mother and fetus. Prevention of these infections isessential. The woman’s understanding and use of general hygiene measures areassessed. Before developing a plan of care, the nurse needs to elicit feelings or ideasconcerning cultural, ethnic, religious, or other factors affecting health practices. Therationale being that some cases asymptomatic bacteriuria and a lower urinary tractinfection may lead to complications of the advanced stages of the disease.The woman may need to learn that every woman should always wipe from front to backafter urinating or moving her bowels and use a clean piece of toilet paper for each wipe.Wiping from back to front may carry bacteria from the rectal area to the urethralopening and increase risk of infection. Soft, absorbent toilet tissue, preferably white andunscented, should be used because harsh, scented or printed toilet paper may causeirritation. Women need to change panty shields or sanitary napkins often. Bacteria canmultiply on soiled napkins. Women need to wear underpants and pantyhose with acotton crotch. They should avoid wearing tight – fitting slacks or jeans or panty shieldsfor long periods.Some women don’t have an adequate fluid and food intake. After eliciting her foodpreferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12 glasses)of liquid a day.
  24. 24. 10. Minor Disorder of PregnancyMost pregnant women do suffer from minor disorders during pregnancy. Minordisorder is a condition caused by pregnancy, which is not present in the prepregnantstate. It should be solved in correct time to prevent complication offering minortreatment and proper explanation for the reduction of these problems and anxiety. Theexact cause of minor disorders are still unknown but it could be due to increasing levelof hormone especially progesterone in the blood.The common minor disorders are Morning Sickness ( Nausea and Vomiting) Indigestion Varicose veins Backache Fainting Heartburn Constipation Itching Leg Cramp Morning Sickness ( Nausea and Vomiting)Nausea and vomiting especially in the morning, soon after getting out of bed, areusually common in primigravida. It may due to emotional factors, fatigue, andcarbohydrate metabolism. So it is important to prevent it from getting worse ashyperemesis gravidarum may occur.Preventiono Identify the particular odour of foods that are most upsetting and avoid the odour of certain foods, because women are very sensitive to smells.o Eat dry crackers or bread 15 minutes before getting up from the bed in the morning.o Advice to consume small frequent meal (every 2 hours if possible).o Avoiding spicy and greasy food and consuming protein snack at nighto Advice to take light and dry snacks instead of heavy meal.o Avoid brushing after eating.o Keep room well ventilated for fresh air. IndigestionIndigestion often occurs after eating too much of heavy or greasy food or drinking toomuch of alcohol. It is characterized by discomfort or a burning feeling in the mid –chest or stomach.Prevention Avoid fatty, greasy and spicy foods
  25. 25. Eat small frequent meals instead of the usual three meals. Avoid alcohol, coffee and cigarettes. Eat boiled foods. Varicose veinsVaricose veins are enlarged superficial veins on the legs; vulva and anus varicose veinsare disorder of the second and third trimesters. It is due to increased maternal age,excessive weight gain large foetus and multiple pregnancies etc.Prevention Exercise regularly and avoid tight clothes. Avoid standing for long time and sitting with feet hanging down. Lift the legs up with extra pillows while sitting, resting or sleeping. Avoid crossing legs at the knees because it provides the pressure on her veins. BackacheThis is common problem during pregnancy especially in the third trimesters. Slightbackache may be due to faulty posture and is more common in multigravida.It may bedue to fatigue, by lifting heavy objectives and poor postures, fatigue.Prevention Take adequate rest in proper position and posture. Wear supportive shoes with low heels, avoid high heels shoes. Do prenatal exercise and do not gain more weight. Avoid excessive twisting, bending, stretching and also excessive standing or walking. Fainting ( Syncope)It is the disorder common in second and third trimester. Many pregnant womenoccasionally fall to faint, especially in warm and crowed areas. It is due to anemia,sudden changes of position, standing for long periods in warm and crowd areas.Prevention Avoid prolonged standing. Rest in side lying position in left lateral to prevent supine hypotension. Eat regularly iron containing food and plenty of liquid. Advice to be alert for safety. Heartburn
  26. 26. Heartburn is a burning sensation in the mediastinal region due to back flow(regurgitation) of acid contents into the oesophagus often accompanied by bad test inthe mouth.Prevention Avoids foods known to cause gastric upset. Avoid greasy, fried foods, coffee, alcohol and cigarettes. Advice to take small frequent meal, but eat slowly. Take adequate rest in sleeping with more pillows on propped position. Explain that this is related to pregnancy and the problem disappears after pregnancy. ConstipationConstipation is a condition of infrequent, irregular and difficulty in passing stool or thepassing of hard stool. It is common during pregnancy. It is due to lack of physicalactivity or exercise, decrease fluids, oral iron supplement, pressure of enlarging uteruson intestine.Prevention Encourage to maintain bowel habit, going to toilet at same time everyday and toilet when having the urge. Encourage to drinking adequate liquid ( of least 200ml per day) Advice to eat in regular schedule. Encourage eating fruits, vegetables, gains and roughage in the diet. Advice to do regular daily exercise. ItchingItching is an unpleasant cutaneous sensation that provokes a desire to scratch the skin. Itmay be due to poor personal hygiene, heat rash, minor skin disease.Prevention Advice to take daily bath. Advice to wear non- irritating clothes, cotton panty. Leg CrampsLeg Cramps are painful muscle spasm in the muscles. They occur most frequently atnight but may occur at other times.Leg cramps are more common in the third trimester.Prevention Advice to take enough calcium ( milk, greenleafy vegetables) Advice to take warm bath to improve the circulation. Advice to do exercise regularly. Strengthen the legs, point or pull toes upward towards the knees.
  27. 27. B. INTRANATAL NURSINGChildbirth is a normal physiological process, but complications may arise. Septicemiamay result from unskilled and septic manipulations, and tetanus neonatorum from theuse of unsterilized instruments. The need for effective intranatal care is thereforeindispensable, even if the delivery is going to be a normal one. The emphasis is on thecleanliness. It entails – clean hands and fingernails, a clean surface for delivery, cleancutting and care of the cord, and keeping birth canal clean by avoiding harmfulpractices. Hospitals and health centers should be equipped for delivery with midwiferykits, a regular supply of sterile gloves and drapes, towels, cleaning materials, soap andantiseptic solution, as well as equipment for sterilizing instruments and supplies.Objectives of Intranatal Care To delivery with minimum injury to the newborn and mother. To be readiness to deal with complications such as prolonged labour, haemorrhage, convulsions, malpresentations, prolapse of the cord etc. To do care of the baby at delivery like resuscitation, care of the cord, care of the eyes etc. To prevent infection. To detect and deal with any complications.e.g. Antepartum and postpartum haemorrhage, prolonged labour, malpresentation, prolapse cord etc. To resuscitate the baby and to provide immediate care to baby.1. Domiciliary CareMothers with normal obstetric history may be advised to have their confinement in theirown homes, provided the home conditions are satisfactory. In such cases, the deliverymay be conducted by Health Worker Female or trained Dai. This is known as“domiciliary midwifery service.”Advantages of the domiciliary midwifery service The mother delivers in the familiar surroundings of her home and this may tend to remove the fear associated with delivery in a hospital, The chances for cross infection are generally fewer at home than in the nursery/ hospital, and The mother is able to keep an eye upon her children and domestic affairs; this may tend to ease her mental tensionMost deliveries will have to take place in the home with the aid of Female HealthWorkers or trained dais. Domiciliary out reach is a major component of intranatalhealth care: The Female Health Worker, who is a pivot of domiciliary care, should beadequately trained to recognize the ‘danger signals’ during labour and seek immediatehelp in transferring the mother to the nearest Primary Health Centre or Hospital. Thedanger signals are: Sluggish pains or no pains after rupture of members.
  28. 28. Good pains for an hour after rupture of members, but no progress Prolapse of the cord or hand Meconium – stained liquor or a slow irregular or excessively fast fetal heart Excessive ‘show’ or bleeding during labour Collapse during labour A placenta not separated within half an hour after delivery Postpartum haemorrhage or collapse2. Complications and obstetrical emergency during intranal period Prolonged LabourThe prolonged labour may occur due to fault in power, fault in passage and fault inpassager etc. so the preventive measures should be done before the delivery.Preventive Measures• Antenatal and early intranatal detection of the factors likely to produce prolonged labour and then to institute its appropriate management.• Use partograph to record fetal, maternal and labour condition and maintain it meticulously which help in early detection• Selective and judicious augmentation of labour can be employed by low rupture of the membranes followed by the oxytocin drip.• Keep vigilant during labour and appropriate management should promptly be instituted if the first is delayed as evidence from the cervicograph and there is tendency of slow descent in the second stage. Abnormal Uterine ContractionAbnormal uterine contraction may be due to obstructed labour due to contracted pelvic,congenital malformation of fetus like hydrocephalus, brow presentation, neglectedtransverse lie etc.Preventive Measures• Periodic and careful antenatal visits.• Early detection of factors affecting labour, such as passage or passenger during antenatal or early intranatal period to place an appropriate method of delivery.• Careful and constant observation of the mature of uterine contraction and keep record meticulously in partograph Obstructed LabourThe obstructed labour may be due to contracted pelvis, cephalopelvic disproportion,congenital malformation of the fetus etc.
  29. 29. Preventive Measures Antenatal• Risk assessment in the antenatal clinic: Past medical and obstetrical history of obstructed labour. Assessment of pelvis for bony and soft passage anomalies. Abdominal examination for engagement. Ultrasonography is employed to assess fetal anomalies.• Refer the mother in an appropriate place or hospital where the choice of safe delivery is contemplated Intranatal• Keep continuous vigilance by using partograph.• Careful assessment of the progress of labour.• Timely intervention of a prolonged labour and prompt action need to be taken with mothers who likely to develop obstructed labour.C. POSTNATAL NURSING Care of the mother and newborn after delivery is known as postnatal or post-partal care. Following delivery, the mother and baby are visited daily for ten days.During each of these visits the midwife/ FHW checks temperature, pulse andrespirations of the mother, examines her breasts, checks the progress of normalinvolution of uterus, examines lochia for any abnormality, checks urine and bowels andadvices on perineal toileting. The immediate postnatal complications such as puerperalsepsis, throbophlebitis and secondary haemorrhage must be kept in mind. At the end ofthe 6th week, the woman needs an examination by the physician in the health center tocheck up involution of the uterus, which should be complete by then. Further visitsshould be done once a month during the first six months and thereafter once in 2 to 3months until the end of one year. In rural areas, where only limited care is possible,efforts should be made by the FHW to give at least 3 to 6 postnatal visits. The commonconditions found during the late postnatal period are sub involution of uterus, prolapseof uterus and cervicitis. Postnatal examination offers an opportunity to detect andcorrect these defects. Anemia if presents need to be treated. Health education regardingaffordable nutritious diet and postnatal exercises to restore the stretched abdominal andpelvic muscles must be provided to enable the mother have a normal post- partumperiod. The psychological aspect of postnatal care needs to be addressed based on aneeds assessment. New mothers may have timidity and fears due to ignorance andinsecurity regarding the care of the baby. In order to endure the emotional stress ofchildbirth, she requires the support and companionship of her husband as well asencouragement and assistance of family. Fear and insecurity may be eliminated byproper prenatal instructions, postnatal enforcing and supportive care.
  30. 30. Objectives of postnatal care To prevent complications of the post-partal period. To restore, promote and maintain health of the mother and baby. To promote breast feeding. To establish good nutritious of the baby. To check the adequacy of breast feeding. To prevent infection and identify any health problem/disorder in the baby. To support and strengthen the parents confidence and their role within their family and cultural environment. To provide family planning instructions and services. To provide basic health education to mother and family on various aspects of mother and child care..1. Complications of the postnatal periodCertain complications may arise during the postnatal period which is be recognizedearly and dealt with promptly. These are as follows: Puerperal sepsisThis is infection of the genital tract within 3 weeks after delivery. This is accompaniedby rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in lowerabdomen, etc. Puerperal sepsis can be prevented by attention to asepsis, before and afterdelivery. This is particularly important in domiciliary midwifery service.PreventionPuerperal sepsis is to a great extent preventable. Certain measure should be taken underbefore, during and following labour.Antenatal Detect and eradicate the septic focus especially located in the teeth, gums, tonsils, middle ears etc. Maintain and improve the health of status of the patient especially to raise Hb level, prevent eclampsia, early treatment of any abnormalities. Vaginal examination during pregnancy especially in the last months should be kept in a minimum and should be carried out with strict surgical asepsis. Intercourse should be avoided during the last two months to prevent introduction of organisms like streptococcus. The patient should avoid contact with persons suffering from infectious disease. The patient should take care of personal hygiene.Intranatal The nurse, doctor and other personnel entering into labour room should wear mask, gown and cap to prevent the infection of personnel spread to labour room. The delivery should be conducted taking full surgical asepsis.
  31. 31. Members should be kept preserved as long as possible. Well management on every step of labour which prevents possibility of infection. Avoid prolonged labour and mother from exhaustion. Traumatic vaginal delivery should preferable be avoided and intrauterine manipulation if required should be done by maintaining strict surgical asepsis. After placenta delivery, explore the vagina to determine if there are any pieces of membranes or blood clots retained in uterus. Enema should be given in first stage of labour to prevent the contamination of stool in 2nd stage of labour. Dust should be avoided in the labour room. Laceration of the genital tract should be repaired promptly. Excessive blood loss during delivery should be replaced promptly by blood transfusion to improve the general body resistance.Postnatal Period Aseptic precaution should be taken for at least one week following delivery until the open wound the uterus and the genital tract injury, if any, are healed up. Nurse should take aseptic precaution and wear mask while giving perineal care. Restrict too much visitors in ward. Sterilized sanitary pad should be used and changed frequently to prevent lochia to decompose and become offensive on the pad. Clean the vulval area with antiseptic solution after each urination and defecation. Isolation as well as barrier nursing measure for infected patient and infants is imperative. Advise to avoid sexual intercourse for 4-6 weeks after delivery. Thrombo – phlebitisThis is an infection of the veins of the legs, frequently associated with varicose veins.The leg may become tender, pale and swollen. So the mother should be encouraged todo the leg exercise to increase the muscle tone. Deep vein ThrombosisIt is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence ofinfection.PreventionThe three important factors i. e. trauma, sepsis and anemia should be prevented and tobe treated effectively after detection. Dehydration during delivery should be promptlycorrected.Leg exercise and early ambulation are encouraged especially following operativedelivery. Postpartum Hemorrhage
  32. 32. Postpartum hemorrhage is the condition of excessive bleeding from the genital tract atany time following the baby’s birth up to 6 weeks after delivery. It may occur at anytime that is during third stage of labour, with in 24 hours or after 24 hours of labour.Preventive measures of PPHSL.N Antenatal Period Intranatal Period Postnatal Period1. • Ensure regular • Judiciously administer • Continue to monitor antenatal care sedative, analgesic and vital signs oxytocin2. • Maintain Hb level as • Avoid hasty delivery of the • Observe the lochia, near as normal baby. type, amount and • One should take at least 2- consistency. 3 minutes to deliver the trunk after the head is born. • Baby should be pushed out by the retracted uterus and not be pulled out.3. • Check blood • Prevent the labour being • Check Hb level if grouping and typing prolonged needed4. • Identify high risk • Avoid fiddling and • Prevent infection mothers ( twins, kneading of the uterus or hydramnios, APH, pulling the cord before the grand multipara etc) placental separation and deliver in a well equipped hospital5. • Strict application of active • Observe the mother management of third stage for two hours after e.g. Immediate oxytocin delivery and ensure Control Cord Traction that the uterus is hard Uterine Massage and contracted enough.6. • In all cases of the induced • Encourage the mother or augmented labour by for breast feeding. oxytocin should be kept on continuous oxytocin infusion for at least one hour after delivery.7. • Examine the placenta and • Encourage and assist membranes and cord to empty the bladder carefully periodically and for ambulation.
  33. 33. Inversion of the uterusThe uterus is said to be inverted if it rums inside – out partially or completely duringdelivery of the placenta.Preventive measures Don’t employ any method to expel the placenta when the uterus is relaxed. Avoid pulling cord simultaneously with fundal pressure. Attempt proper technique to deliver the placenta and of manual removal of placenta. Pay visilant observation for separation of placenta. Urinary tract infection and incontinence of urineIt is one of the common causes of puerperal pyrexia, the incidence being 15 % of alldeliveries. It is due to frequent catheterization either during labour or in earlypuerperium to relieve retention of urine, recurrence of previous pyelitis, poor personalhygiene and vaginal hygiene, trauma following instrumental delivery, poor fluid intake.It is extremely important to look for these complications in the postnatal period andprevent or treat them promptly. Postnatal BluesPregnancy and puerperium are highly stressful periods in a woman’s life. The person isthreatened by various changes such as physiological changes, and endocrine changesoccurring in ones body, as she is in reorganization of psyche in accordance with thenew mother role especially in the first pregnancy. Body image changes and unconsciousintrapsychic conflicts related to pregnancy, childbirth, and motherhood becomeactivated. It is no wounder that 25% to %0% of the pregnant womrn develop mildpsychological symptoms in the puerperal period. The commonest type is the milddepression and irritability known as the postnatal blues. - Hein Roth 2006Prevention Advice to the family and relatives to deal properly with the postnatal situation of the postnatal mother. Help her to feed the baby and assist her in domestic duties. Advice to provide sufficient rest, balance diet and to give love and care.2. Restoration of mother to optimum healthThe second objective of postnatal care is to provide care whereby, the woman canrecuperate physically and emotionally from her experience of delivery. The broad areasof this care fall into three divisions:
  34. 34. Physical Postnatal ExaminationsSoon after delivery, the health checks-ups must be frequent, i.e., twice a day during thefirst 3 days, and subsequently once a day till the umbilical cord drops off. At each ofthese examinations, the health personnel should checks temperature, pulse andrespiration, examines the breasts, checks progress of normal involution of the uterus,examines lochia for any abnormality, checks urine and bowels and advises or perinealtoilet including care of the stitches, if any. The immediate postnatal complications,puerperal sepsis, thrombophlebitis, secondary haemorrhage should be kept in mind. Atthe end of 6 weeks, an examination is necessary to check up involution of the uteruswhich should be complete by then. Further visits should be done once a month duringthe 6 months and thereafter once in 2 or 3 months tills the end of one year.In rural areas only limited postnatal care is possible. Efforts should be made by theFHWs to give at least 3 to 6 postnatal visits. The common conditions found onexamination during the late postnatal period are sub involution of uterus, retroverteduterus, prolapse of uterus and cervicitis. Postnatal examination offers an opportunity todetect and correct these defects. AnemiaRoutine hemoglobin examination should be done during postnatal visits, and whenanemia is discovered, it should be treated. In some cases it may be necessary tocontinue treatment for a year or more. NutritionThough a malnourished mother is able to secrete as much breast milk as well nourishedone, she does it at the cost of her own health. The nutritional needs of the mother mustbe adequately met. Often the family budget is limited, the mother should be shown themeans how she can eat better with less money. Postnatal ExercisesPostnatal exercises are necessary to bring the stretched abdominal and pelvic musclesback to normal as quickly as possible. Gradual resumption of normal house – holdduties may be enough to restore one’s figure. PsychologicalThe next big area of postnatal care involves a consideration of the psychological factorspeculiar to the recently delivered woman. One of the psychological problems is fearwhich is generally borne of ignorance. Other problems are timidity and insecurityregarding the baby. If a woman is to endure cheerfully the emotional stresses ofchildbirth, she requires the support and companionship of her husband. Fear and
  35. 35. insecurity may be eliminated by proper prenatal instruction. The so called postpartumpsychosis is perhaps precipitated by birth, and it is rather uncommon. SocialIt has been said that the most important thing a woman can do is to have a baby. This isonly part of the truth. The really important thing is to nurture and raise the child in awholesome family atmosphere. She, with her husband, must develop her own methods.3. Breast – feedingPostnatal care offers an excellent opportunity to find out how the mother is gettingalong with her baby, particularly with regard to feeding. For many children breast milkprovides the main source of nourishment in the first year of life. In some societies,lactation continues to make an important contribution to the child’s nutrition for 18thmonths or longer.Postnatal care includes helping the mother to establish successful breast-feeding. Formany babies breast milk provides the main source of nourishment in the first year oflife. When the standard of environmental sanitation is poor and education low, thecontent of feeding bottle is likely to be as nutritionally poor as it is bacteriologicallydangerous. It is therefore very important to advise mothers to provide exclusive breastfeeding in the initial months.4. Respiratory Distress Syndrome and Neonatal Problems Asphyxia NeonatorumAsphyxia neonatorm is defined as failure to initiate and maintain spontaneousrespiration within one minutes of birth. It may due to traumatic forceps or vaccumdelivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine hypoxiadue to placental insufficiency APH, and premature separation of placenta.Prevention• Antenatal screening of high risk patients.• Complete fetal monitoring, particularly in high risk pregnancy group to ensure early detection of fetal distress• Intrapartum fetal monitoring. Respiratory Distress syndromeRespiratory distress syndrome almost always occurs in preterm babies. It may be due toprematurely, maternal anemia, pre- eclampsia, diabetes, APH after 28 weeks ofgestation, intrauterine hyposia etc.
  36. 36. Prevention• Administration of dexamethasone in patients anticipating preterm delivery especially before 34 weeks for lung maturity.• Assessment of lung maturity before premature induction of labour and induction of labour and to delay the induction as much as possible without any risk to the fetus.• Prevent fetal hypoxia in diabetic mothers.• Avoid smoking, anemia, pre- eclampsia, APH and other complication during pregnancy.• Suction immediately after birth to patent the airway.5. Prevention of Birth Injuries Intracranial injury and haemorrhageThe intracranial injury and haemorrhage is due to trauma, rapid compression as inbreech delivery, face presentation, instrumental delivery.PreventionComprehensive intranatal and antenatal care is the key to success in the reduction ofintracranial injuries.• Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal monitoring.• Episiotomy and use of forceps to deliver the premature baby minimize the intracranial disturbance.• Avoid traumatic vaginal delivery in preference to caesarean section.• Difficult forceps should be avoided.• In vaccum delivery, traction is made only after proper cephalic application.• Avoid prolonged and difficult labour.Prevention of injuries in the new born babiesComprehensive antenatal and intranatal care is the key to success in reduction of birthtrauma and consequently in the reduction of perinantal mortality and neonatalmorbidity.Antenatal period Screen out the risk babies. Employ liberal use of C/S and episiotomy. Contracted pelvis, CPD, malpresentation should be included and manage accordingly.Intranatal periodDuring normal delivery Continuous fetal monitoring to detect fetal distress, extract baby before he become compromised. This can prevent traumatic cerebral anoxia.
  37. 37. Episiotomy is to be done carefully after placing two fingers in between the head and the stretched perineum- to prevent injury to the scalp. The neck shouldn’t be unduly stretched while delivering the shoulders to minimize injuries to the brachial plexus or steromastoidSpecial care in preterm delivery Prevent anoxia Avoid strong sedation. Liberal episiotomy and use of forceps to minimize intracranial compression. Administer vitamin k 1 mg intramuscularly to prevent or minimize haemorrhage from the traumatized area.Forceps Delivery Difficult forceps are to be withheld in preference to the safer caesarean section. Never apply traction unless the application is a correct oneVentouse Delivery It is relatively less traumatic, but it should be avoided in preterm babies.Vaginal Breech DeliveryTo prevent intracranial injuries: - The crucial period in breech delivery is duringdelivery of the after- coming head. Never be in haste during delivery of the head which find little time to mould. Episiotomy should be done as a routine to minimize head compression. Controlled delivery of the head by forceps is preferable.To prevent spinal injury: - Acute bending at the neck is to be prevented while forcepsare being applied to the after coming head or delivery of the head.To prevent fracture: - The limbs are delivered in a manner described in breechdelivery.6. Major Disorders of Newborn Baby Ophthalmia NeonatorumOphthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks of lifewhich is characterized by purulent discharge, swelling and redness of affected eyes.Prevention • Any suspicious vaginal discharge during the antenatal period should be treated and the strict aseptic technique should maintain at birth. • The newborn baby’s closed eyes and face with sterile water and swab at bath times to avoid infection of the eye.
  38. 38. • The midwife and mother should always wash her hand before touching the baby’s face. Neonatal TetanusNeonatal Tetanus is a dreadful infection with a high mortality rate.Prevention • Mother should be given tetanus toxoid during pregnancy. • While cutting the cord, instrument for cord cutting should be boiled and cord should be cut under aseptic precaution. • The room should be kept clean. • Cord care should be done daily. OmphalitisAcute omphalitis is an infection of umbilical stump. It is usually mild as present as ascanty purulent discharge.Prevention • Maintain strict sterile technique during good cutting and cord dressing. Keep the environment clean as far as possible. • Identification of pathogen by umbilical culture and isolate the baby. Skin Infection ( pemphigus neonatorum)The unhygienic environments, cross infection or carrier are the source of infection. • The baby bath should be given 24 hours offer delivery. • The carriers or sources of infection are to be sought for and appropriate measure to be taken.7. Family PlanningEvery attempt should be made to motivate mothers when they attend postnatal clinics orduring postnatal contacts to adopt a suitable method for spacing the next birth or forlimiting the family size as appropriate. Contraceptives that will not affect lactation maybe prescribed immediately following delivery after a physical examination.8. Health Education to Mother and FamilyHealth education during the postnatal period should cover the following areas:
  39. 39. • Hygiene- personal and environmental• Breast Care• Breast Feeding of infant.• Care of the Newborn baby• Care of the umbilical cord• Bathing the baby• Nutritious diet for the mother• Postnatal Exercise• Rest, sleep and activity• Pregnancy spacing• Health check up for mother and baby• Prevention of infection in the baby• Birth registration• Hygiene- personal and environmentalMaternal and neonate’s personal hygiene should be maintained to prevent infection.Vulval care and daily bathing should be done as lochia drainage occurs. Cleanlinesshelps her to fresh and activates energy to care.Perineal care should be done to observethe amount, colour, odour and consistency of the lochia, to keep the stitch clean, dryand help in fast healing, to prevent local and ascending infection.• Breast CareBreast care is very important for both mother and baby because it prevents frominfection, so the mother should advised to clean her breast before and after each feedwith clean water and hand washing too. Advice to wear clean brassiere.• Breast Feeding of infantBreast milk has anti infective properties that protect the infant from infection in theearly months. It is a complete food and provides all nutrients needed to infant in the firstfew months. So encourage mother to feed the breast feeding for her baby.• Care of the Newborn babyThe care of the newborn baby is very important to make sure baby is thriving and todetect early sign of illness and abnormalities and treat it accordingly.• Care of the umbilical cordCleanliness of the umbilical cord is essential. The cord is to be inspected once more forevidence of slipping of ligature. Dressing with bland power and cord binder are notfavoured in places where the baby is placed in a clean environment. However the cordshould be cleaned at least twice a day and should be observed if there is bleeding fromthe site of the cord. And also advice the mother and family members not to enclosedwithin the baby’s napkin where contamination by urine or faces may occur.
  40. 40. • Bathing the babyBathing the baby is also very important to keep clean and comfortable for the baby, tomaintain blood circulation, to prevent from infection, to detect any abnormalities orinfection and treat it accordingly.• Nutritious diet for the motherIt is the most essential basic needs of everybody but especially for lactating mother.Without nutrition, the mother cannot get energy and decrease the secretion of milk, somother should eat highly nutritious foods and soups high in protein and carbohydratee.g. Jawno KO soup, meat soup, Dal soup, chaku etc.• Postnatal ExercisePostnatal exercise is the exercise done after delivery in postnatal period which is veryimportant to improve blood circulation, to help in involution of reproductive organs, toprevent thrombosis and thrombophlebitis, to promote well being of the postnatalmother, to restore the tone of the abdominal the pelvic muscles, for proper drainage oflochia. So advice mother to do postnatal exercise.• Rest, sleep and activityMother should have 1o hours rest at night and 1-2 hours at afternoon till 40-60 days ofdelivery. Heavy working, heavy lifting should be avoided in puerperium because itpredispose to uterine prolapse.• Pregnancy spacingMother and family members should be advised about the importance of pregnancyspacing. There should be at least the gap of 2 years of pregnancy spacing.• Health check up for mother and babyRegular health check up and follow up for mother and baby is very important with inpuerperium period.• Prevention of infection in the babyMidwives have an important role to play in creating a safe environment that decreasesthe chance of infant acquiring infection after birth. Encouraging and assisting the mother for breast feeding thus increasing infant’s immune protection. Ensuring careful and frequent hand washing by all careers; the simple procedure remains the single most important method of preventing the spread of infection in infants. Rooming in the infants with his/ her mothers. Adequately spacing costs when infants are in the nursery with other infants. Always use individual equipment for each infant.
  41. 41. Avoiding any irritation or trauma to the infant’s skin and mucous membrane, as intact skin provides a barrier against infection. Controlling extra visitor.• Birth registrationCONCLUSION Preventive obstetrics is the concept of prevention or early detection of particularhealth deviations through routine periodic examinations and screenings. The concept ofpreventive obstetrics concerns with the concepts of the health and well-being of themother and her baby during the antenatal, intranatal and postnatal period. It aims topromote the well- being of mothers and babies and to support sound parenting andstable families. Nursing care centered on health promotion and health maintenanceduring pregnancy presents an excellent opportunity for nurses to teach expectantmothers about normal changes expected and alert them to a variety of risk factors.Preventive Obstetric measure can be categorized into three main stages. They are asfollows:- • Antenatal Nursing • Intranatal Nursing • Postnatal NursingBIBILIOGRAPHY. Lowdermilk & Perry “Maternity Nursing”, 6th edition Published by Mosby (Philadelphia), , page no: 123-167. Dutta D.C Text book of Obstetrics –Including perinatology and Contraception,6th Edition (2004), New central book Agency ( Culkatta) Pg. No.95-113 Maya Devi Subedi, “Manual of Midwifery A”, 1st Edition, Chapter – 11, Antenatal Advice, Books and Stationers, 2005, page no.: 157 - 165. Basavanthappa B.T Essentials of Midwifery & Obstetrical, Japee Publications (New Delhi) Pg.No.130-228 .. Krishna Kumari Gulani, “Community Health Nursing (Principles and Practices)”, 1st Edition, Chapter-11, Maternal and Child Health, published by Kumar Publishing House, 2005, page no.: 354 – 366. K Park, “Park’s Textbook of Preventive and Social Medicine”, 19th Edition, Chapter – 9, Preventive Medicine in Obstetrics, Pediatrics and Geriatrics, published by M/s Banarsidas Bhanot, 2007, page no.: 415 – 422. LYNETTE A. AMENT, “Professional Issues In Midwifery”, Chapter – 13, Historical Perspectives on Research and the ACNM, published by Jones and Bartlett Publishers, 2007, page no.: 263 – 266. Gloria Hoffmann Wold, “Contemporary Maternity Nursing”, 1st Edition, Chapter – 1, Overview of Maternity Nursing, published by Mosby, 1996, page no.: 4 – 24. Http// Industrial relations.naukrihub.com