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antenatal care.ppt

  1. 1. Health Care and Fetal Assessment During Pregnancy (Antenatal care) By Captain Ala’a Ababneh
  2. 2. Preconception care • Preconception care is health care and screening conducted before pregnancy occurs so that medical risk factors or life style behaviors can be identified, managed, or changed before pregnancy. • Most woman who seek medical care as soon as they realize that they are pregnant. • Most birth defects occur between 2 to 8 weeks of gestation. • Ideally prenatal care occur before pregnancy occur. • Preconception care is best achieved when pregnancy is planned.
  3. 3. Prenatal care • Early and regular prenatal dramatically reduces infant and maternal morbidity and mortality. • Goals of prenatal care: 1. To support and encourage family’s healthy psychological adjustment to child bearing. 2. To monitor the progress of pregnancy in order to ensure maternal health and normal fetal development. 3. To recognize deviation from the normal and provide management or treatment as required. 4. To ensure that the woman reaches the end of her pregnancy physically and emotionally prepared for delivery.
  4. 4. 5. Provide health education and advices to the pregnant woman and her family. 6. To build up a trusting relationship. 7. To reduce infant and maternal mortality. 8. Provide physical assessment and care. 9. Educating about self care during pregnancy. 10. Teaching health habits that may be continued after pregnancy. 11. Preparing parents for adaptation to parenthood.
  5. 5. • Major emphasis is placed on preventive aspects of care. • The normal pregnancy depends on: • Health status. • Emotional status. • Past health.
  6. 6. • Prenatal care is ideally a multidisciplinary activity in which nurses work with physicians or midwifes, nutritionists, social workers, and others. Collaboration among those individuals is necessary to provide holistic care.
  7. 7. Cultural competence • Cultural consideration are important in caring for woman during pregnancy. • The nurse must integrate the safe cultural practices and accept this practice in providing care. • Should not be harmful to the mother or to the fetus.
  8. 8. Prenatal visits • Initial assessment interview can be establish the trusting relationship between the nurse and the pregnant woman. • It is planned visits. • Focuses on the subjective and objective data.
  9. 9. Booking visits • Visit should take place as soon as possible after pregnancy has been confirmed. • Aim of booking visits: 1. Assess levels of health by taking a detailed history and screening tests. 2. To ascertain baseline recording the wt, ht, BP, ( used for comparison as pregnancy progressed). 3. Identify risk factors. 4. Give advice according to needs. 5. To provide an opportunity for the woman to express any feeling or concerns about this pregnancy or previous obstetric experience.
  10. 10. Initial health history • Personal information, age, education, occupation, marital status, nutritional hx. • Woman and her family medical hx, to identify possible health problems such as heart disease, genetic disorders, DM, …. • Obstetric and gynecologic history: data are gathered on the woman’s age of menarche, menstrual history, and contraceptive history, the nature of any infertility or gynecologic conditions, and a detailed history of all her pregnancy, including the present pregnancy, and their outcomes. The data of the last pap test and the result are noted. The date of here LMP is obtained to established the EDB.
  11. 11. • Physical examination: the initial physical examination provides the baseline for assessing subsequent changes. • The physical examinations begins with assessment of vital signs and height and weight (BMI). • The bladder should be empty before pelvic examination. • You can choose the head to toe progression. • Heart and lung sounds are evaluated. • The thyroid gland is assessed. • Pelvic examination. • One vaginal examination during pregnancy is recommended
  12. 12. • Laboratory tests: specimens are collected at the initial visits so that the cause of any abnormal findings can be treated. • Urine sample is obtained
  13. 13. Subsequent visits • The initial visit usually occurs in the first trimester, with monthly visits through week 28 of pregnancy. Thereafter, visits are scheduled every 2 weeks until week 36, and then every week till birth.
  14. 14. • Woman’s wt, BP, and urine checked for protein acetone, and glucose monitored to detect early hypertension and DM. • Abdominal assessment estimation of the gestational age through measurement the height of the fundus.
  15. 15. • Fundal height: the fundal height, measurement of the height of the uterus above symphysis pubis, is used as one indicator of fetal growth. • From gestational weeks 18-32, the height of the fundus in cm is approximately the same as the numbers of gestational weeks, with an empty bladder. • In addition fundal height measurement may aid in the identification of high risk factors.
  16. 16. o At 36 week fundal height reach xiphoid process. o Between 38-40 weeks fundal height drop 4cm from xiphoid process (as a result of lightening).
  17. 17. • Abdominal palpation by using Leopold maneuvers used to assess the presentation, position of the fetus. • Fundus palpation; to determine what is the occupied part head, breech. • Lateral palpation: to determine the position of the fetus back to hear the fetal heart sound. • Pelvis palpation: palpate the lower pole of the uterus just above pelvis, to determine the fetus part above the symphysis pubis ( head, breach). • Pawlik’s maneuver: the lower pole of the uterus is grasped it the right hand  noting the position of cephalic prominence.
  18. 18. • After obtaining information through the assessment process, the data are analyzed to identify deviations from the norm and unique needs of the pregnant woman and her family. Although comprehensive health care requires collaboration among professionals from several disciplines, nurses are in an excellent position to formulate diagnosis that can be used to guide independent interventions.
  19. 19. Risk factors arising during pregnancy 1. Fetal movement pattern changed. 2. Decrease Hb level than 10g/dl. 3. Wt gain or loss. 4. Proteinuria, glycosurea. 5. BP above 140/90 mm/hg. 6. Uterus small or large for dates. 7. Excess or decreased liquor. 8. Mal presentation. 9. Head not engaged in prim woman by 38 weeks. 10. Vaginal bleeding. 11. Premature labor. 12. Vaginal infection. 13. Sever headache.
  20. 20. Factors that indicate the need for intensified antenatal care. 1. Age less than 18 or above 35 years. 2. Primigravida above 35 years. 3. Grand multiparty. 4. Vaginal bleeding at any time during pregnancy. 5. Uncertain EDD.
  21. 21. • Past obstetric history: 1. Still birth or neonatal death. 2. Small or large for dates. 3. Congenital abnormalities. 4. RH isoimmunization. 5. PIH, premature labor. 6. APH,PPH, precipitate labor. 7. abortions
  22. 22. • Maternal health: 1. Previous hx of DVT or pulmonary embolism. 2. Chronic illness, increased BP, family hx of DM. 3. Hx of infertility, uterine anomaly, including fibroids. 4. Smoking more than 10 cigarettes/day.
  23. 23. • Booking examination: 1. BP 140/90 and above. 2. Wt above 85kg or less 45kg. Ht less than 150cm. 3. Cardiac murmurs, RH –ve, blood disorders. 4. Pelvic mass, and shoe size less than35.
  24. 24. Education for self-care
  25. 25. Personal hygiene • Excessive sweating and perspiration, vaginal secretion. • Baths and warm showers can be therapeutic because they relax tense, tired muscles, help counter insomnia, and make the pregnant woman feel fresh. • Tub bathing is contraindicated after rupture of membranes.
  26. 26. Prevention of UTI • The nurse can assess the woman’s understanding and use of good hand washing techniques before and after urination and the importance of wiping the perineum from front to back . Soft, absorbent toilet tissue, preferably white and unscented, should be used. • Woman should wear cotton underpants and avoid wearing tight fitting jeans for long periods, anything that allows a buildup of heat and moisture in the genital area may foster the growth of bacteria.
  27. 27. • The nurse should advise the pregnant to drink at least 2 L of liquid a day, preferably water, to maintain adequate fluid intake that ensures frequent urination. • The consumption of yogurt and acidophilus milk also may help prevent urinary tract and vaginal infections. • Women are told not to ignore the urge to urinate. • They always should urinate before going to bed at night. • Drinking cranberry juice.
  28. 28. Kegel exercise • Kegel exercise , deliberates contraction and relaxation of the pubococcygeus muscle, strengthen the muscles around the reproductive organs and improve muscle tone. • The muscles of the pelvic floor encircle the vaginal outlets, and they need to be exercised, because exercised muscle can then contract and stretch readily at the time of birth. • Practices of pelvic muscle exercises during pregnancy also result in fewer complaints of urinary incontinence in late pregnancy and postpartum.
  29. 29. Preparation for breastfeeding Nipple preparation - the women are taught to cleanse the nipples with warm water to keep ducts from being blocked. - soap, ointment, & alcohol should not be applied. Colostrum if any dropping place pads inside the bra and keep them dry. • Exercise to erect inverted nipple in the last 2 months of pregnancy.
  30. 30. Physical activity • Physical activity promotes a feeling of well being in the pregnant woman. Its improves circulation and oxygnation, promote relaxation and rest, and counteracts boredom, as it dose in the nonpregnant woman. • 30 minutes of moderate physical exercise is recommended ( ACOG).
  31. 31. Exercise In an RCT that compared babies born to women who continued regular exercise during pregnancy with women who did not exercise regularly during pregnancy, no differences in neuro developmental outcomes at one year of age were reported. Aerobic physical activity in pregnancy may be an important determinant of birth weight within the normal range, especially in taller mothers . (Kramer et al 2004)
  32. 32. Lifestyle practices of Jordanian pregnant women (M. Gharaibeh,2005) Purpose: To describe the health-promoting lifestyle behaviors of Jordanian pregnant women. METHODS sample of 400 Jordanian pregnant women in their 20th week of gestation or beyond were recruited from five public Maternal and Child Health Centers in the city of Irbid, in the northern part of Jordan. Results: The women reported high scores on health responsibility and self-actualization, moderate scores on interpersonal support and nutrition, and low scores on physical activity and stress management behaviors.
  33. 33. Rest and relaxation • The side lying position is recommended because it promotes uterine perfusion and fetoplacental oxygenation by eliminating pressure on the ascending vena cava and descending aorta, which can lead to supine hypotension.
  34. 34. Employment • Employment of pregnant women usually has no adverse effects on pregnancy outcomes. • However, some job environment pose potential risk to the fetus. • Women with sedentary jobs need to walk around at intervals. They should not stand in one position for long periods, and they should avoid crossing their legs at the knees, because all activities can foster the development of varices and thrombophlebitis. Standing for long periods also increases the risk of preterm labor. The pregnant woman’s chair should provide adequate back support.
  35. 35. clothing • Comfortable, loose clothing is recommended. • Tight bra and belts, stretch pants, and another constrictive clothing should be avoided because tight clothing over the perineum encourages vaginitis, and impaired circulation in the legs can cause varicosities. • Maternity bra are constructed to accommodate the increased breast weight, chest circumference, and the size of breast tail tissue. These bra also have drop flaps over the nipples to facilitates breastfeeding. A good bra can help prevent neck ache and backache.
  36. 36. • Comfortable shoes that provides firm support and promote good posture and balance also advisable. • Very high heels are not recommended.
  37. 37. Immunization • Immunization with live or attenuated live viruses is contraindicated during pregnancy because of its potential teratogenicity but should be part of postpartum care. • Vaccines consisting of killed viruses may be used.
  38. 38. Dental care • Use soft tooth brush, continue routine daily dental care, avoid any radiological procedure unless there is an indication.
  39. 39. Cigarette smoke, caffeine, and drugs. • Pregnant woman should be encouraged to limit caffeine intake to no more 3 cups of coffee or cola per day.
  40. 40. Tips on giving up smoking 1. Delay each cigarette for as long as possible. 2. Find something to keep the hands occupied. 3. Use chewing gum. 4. Only smoke when sitting down. 5. Reward oneself for success.
  41. 41. Normal discomforts • Women pregnant for the first time have an increased need for explanation of the cause of the discomforts and for advice on ways to relieve them. • Nurses can do much to allay a first time mothers anxiety about such symptoms by telling her about them in advance and using terminology that the woman can understand. • Understanding the rational for treatment promotes their participation in their care.
  42. 42. Preparation for labor prenatal birth classes should be initiate at the 3rd trimester to provide the gravidas with following information:  Process of labor.  Plans to get hospital.  Methods of control pain.  Supplies to have in a suitcase ready for the trip to the hospital.  Emergency arrangement.
  43. 43. Specific challenges facing maternal health development in Jordan were identified in a joint MOH/WHO consultation on health strategies in Nov 2002. 1-Decline in general economic and social conditions limit the ability of families to cover the cost of health care. 2-Inadequate awareness on importance of the pre and post natal care. 3-Discrepancies in the quality and effectiveness of health care services among the governorates.
  44. 44. 4-The negative impact of poverty on accessibility to quality health care, particularly in view of the high proportion of un insured people. 5-Inadequate coordination and partnership between health service providers and educational institutions for health professionals. 6-Rapid advances in technology and rising health care costs and lack of instruments for rational technology selection and assessment. 7-Increasing demands and expectations of the public for effective and accessible health care. 8-Lack of health system research as an integral part of national health development. 9-Nurses, midwifes are not necessarily educated at the graduate level. 10-Lack of system for receiving feedback on referral for pregnant developed complications or for clients seeking family planning methods not available at certain antenatal center. By quality assurance best practice MOH(2004)