Malaria in pregnancy is an obstetric, social and medical problem requiring multidisciplinary and multidimensional solution. Pregnant women constitute the main adult risk group for malaria and 80% of deaths due to malaria in Africa occur in pregnant women and children below 5 years. Malaria and pregnancy are mutually aggravating conditions. The physiological changes of pregnancy and the pathological changes due to malaria have a synergistic effect on the course of each other, thus making the life difficult for the mother, the child and the treating physician. P. falciparum malaria can run a turbulent and dramatic course in pregnant women. The non- immune, primi-gravidae are usually the most affected. In pregnant women the morbidity due to malaria includes anemia, fever illness, hypoglycemia, cerebral malaria, pulmonary edema, puerperal sepsis and mortality can occur from severe malaria and haemorrhage. The problems in the new born include low birth weight, prematurity, malaria illness and mortality. Malaria in pregnancy is a major cause of maternal morbidity worldwide and leads to poor birth outcomes. Pregnant women are more prone to complications of malaria infection than non-gravid women. Pregnant women are more susceptible than the general population to malaria: they are more likely to become infected, suffer a recurrence, develop severe complications and to die from the disease. The role of a Nurse in the prevention and care of malaria in pregnancy starts in the ante natal clinic. Ante natal care is a critical service delivery point through which control /prevention of malaria in pregnancy takes place. The four (4) key Nursing roles in malaria interventions that are delivered through the ANC are; 1. Focused Antenatal Care & Health Education. II. Early diagnosis &treatment of symptomatic women. III. Intermittent preventive treatment (IPT). IV. Regular& appropriate use of long lasting insecticide treated nets (LLINs).SSS Others are --  Evidence-based, goal-directed actions  Individualized, woman-centered care  Early detection and treatment of problems and complications  Prevention of complications and disease  Quality vs. quantity of visits  Care by skilled Nurses and health promotion  Birth preparedness & complication readiness

1. SEMINAR PRESENTATION ON
“MALARIA IN PREGNANCY; THE NURSES
ROLE IN PREVENTION AND CARE”
Presented by
NWAKWUE UGOCHUKWU NNAMDI (BSc, RN, MNIM)
School of Science and Tech.
National Open University of Nigeria
Enugu Study Center,
August, 2014.

2. Objectives of Seminar Paper
To explore the malaria transmission cycle
To appreciate the Nurses’ utilization of
antenatal care in prevention of malaria in
pregnancy
To clarify how nurses can utilize the
components of focused antenatal care
To understand nursing care of malaria in
pregnancy.

3. INTRODUCTION TO MALARIA IN
PREGNANCY
 Malaria in pregnancy is an obstetric, social and medical
problem requiring multidisciplinary and multidimensional
solution.
 Pregnant women constitute the main adult risk group for
malaria. 80% of deaths due to malaria in Africa occur in
pregnant women and children below 5 years. Malaria in
pregnancy is caused by Plasmodium falciparum.
 Malaria and pregnancy are mutually aggravating conditions.
 The physiological changes of pregnancy and the pathological
changes due to malaria have a synergistic effect on the course
of each other, thus making life difficult for the mother, the
foetus and the attending health care provider.

4. INCIDENCE
Malaria is widespread in tropical and subtropical
regions in a broad band around the equator,
including much of Sub-Saharan Africa, Asia, and
the Americas.
The World Health Organization in the year 2000
estimated that by 2010, there will be 219 million
documented cases of malaria. That year(2000),
the disease killed between 660,000 - 1.2 million
people, many of whom were children in
Africa(WHO, 2000).

5. LIFE CYCLE OF MALARIA PARASITE

7. CLINICAL MANIFESTATIONS
 Headache
 Fever & shivering
 Joint pain
 Nausea and
vomiting
 Hemolytic
anaemia
 Jaundice
COMMON
SIGNS AND SYMPTOMS
 Hemoglobin in
urine
 Convulsions
 Bitter taste in the
mouth
 Anorexia
 Malaise

8. What Makes Malaria in Pregnancy a Threat
 P. falciparum has the unique ability of cyto-adhesion. Chondroitin sulfate A and
hyaluronic acid have been identified as the adhesion molecules for parasite
attachment to placental cells.
 The parasites sequester along the surface of the placental membrane,
specifically the trophoblastic villi, extravillous trophoblasts, and syncytial
bridges.
 Intervillous spaces are filled with parasites and macrophages, interfering with
oxygen and nutrient transport to the foetus.
 All the placental tissues exhibit malarial pigments (with or even without
parasites).
 These changes impede oxygen-nutrient transfer and can cause general
hemorrhaging.
 These changes contribute to the complications experienced by both mother and
child.

9. Effects of Malaria on Pregnancy
• High risk of abortion
• Higher incidence of preterm delivery
• Intrauterine growth retardation
• Low birth weight
• Intrauterine fetal demise
• Congenital malaria
• Failure to thrive
• High perinatal morbidity and mortality

10. INVESTIGATIONS
Full Blood
count
Thick and Thin Film
Rapid
Diagnostic test
Polymerase
chain Rxn
Chest X-ray
Clinical
Investigations
The Nurse
demonstrates critical
thinking

11. Nurses Role in Prevention and Care of
Malaria in Pregnancy
Focused ANC & Health
Education
Early Diagnosis & Treatment
Intermittent Preventive
Treatment
Support Areas
 Evidenced
based & goal
directed actions
 Individualized
woman
centered care
 Early detection
& Treatment of
complications
Support Areas
 Prevention of
complications and
disease
 Quality Vs.
Quantity of visits
 Care by skilled
personnel
 Birth
Preparedness &
complication
readiness
4 key Areas
Use of Long Lasting Insecticide
treated net

12. Nurses Role in Focused Antenatal Care
and Health Education
Skilled
Nursing
Roles
4th Visit; 32 to 40wks.
During Visits, the Nurse evaluates health of the pregnant woman and also provides
regular malaria prevention and treatment intervention skills
Evidence Focused
Family Centered
Quality of Visits
1st Visit; before 16wks
2nd Visit;16 to >28wks
3rd Visit; 28 to >32wks

13. Nurses Role in IPT-- Intermittent Preventive
Treatment (IPT) is the use of antimalarial medication given in
treatment doses at predetermined intervals after quickening and
in order to clear a presumed burden of parasites.
The Nurse Educates
Benefits of
Sulphadoxine-
Pyrmethamine(sp)
such as
 Good safety
profile
 Effectiveness
 Single dose
regimen
 The Nurse
ensures
compliance
and
completion of
single dosing
during
antenatal visit
as IPT.
 Watch out for
allergy
 The Nurse also
ensures that
pregnant women
with symptomatic
malaria are tested
and treated
promptly.
 SP should be part of
a comprehensive
antenatal package
provided by the
Nurse

14. Dosing of SP
The Nurse educates to
3rd Dose
2nd Dose
1st Dose
Continue with prevention
At least one month after 2nd
At least one month after 1st dose
After 16wks (after quickening)

15. LLINs is
effective in
 Creating a
physical
barrier
 Killing of
vectors
 Repelling of
vectors
During ANC visits, the
following are taught
that LLINs provide:-
 Protection against
malaria
 Kills and repels
Mosquitoes
 Kills other insects
 Safe for pregnant
women and infants.
The Nurse also
educates the pregnant
woman on the care of
the environment:-
 No stagnant water
 Bushes are cleared
 Nets on Doors and
windows
 No indiscriminate
refuse dumping
Nurses Role in the Use of LLINs
LLINs is a type of net with insecticide embedded into the fiber of the
net in such a way the insecticide is able to maintain its effect on
average for about three years or following 20 washes.
Long
lasting
Insecticide
treated
NETs

16. Critical Thinking in Nursing a pregnant
woman with Malaria
Nursing care
Careful
Anticipatory
Energetic

17. Application of Critical Thinking skill
Energetic
Don’t waste any
time
Monitor and provide
Appropriate nursing care
Admit all cases
Assess severity
Initiate
prescribed
treatment
Interpret Lab.
Investigations

18. Application of Critical Thinking skill
Anticipatory
1
The Nurse should be
looking for any
complications by
regular monitoring.
2
 Monitor
Maternal
and fetal
vital
parameters
2hrly
 RBS 4-6hrly
3
 Haemoglobin and
parasite count 12hrly
 Creatinine & Bilirubin
plus intake and out
put daily

19. Application of Critical Thinking skill
CAREFUL
Careful Careful Careful Careful

20. Nursing Management
• Make a rapid clinical assessment with special
attention to level of consciousness, Temperature,
blood pressure, rate and depth of respiration and
pallor.
• Admit patient to an intensive care unit if this is
available. Ensure the pregnant mother is admitted in
a well-made bed and put in a comfortable position
(lateral).
• Take patient history especially that of pregnancy and
document.
• Explain all procedures to the patient and plan care
with her and reassure her family members.

21.  Inquire and listen to complaints from the family
members and patient. Alleys fears and involve
them in care.
 Patient blood sample should be collected and sent
to the laboratory for parasitological confirmation
of malaria at the recommendation of the
physician or make a blood film and start
treatment as required.
 Ensure meticulous nursing care. This can be life-
saving, especially for the unconscious patient.

22.  Maintain a clear airway. Nurse the patient in the lateral or semi-
prone position to avoid aspiration of fluid and possible
occlusion of blood vessels. Insert a nasogastric tube and suck
out the stomach contents to minimize the risk of aspiration
pneumonia. Aspiration pneumonia is a potentially fatal
complication that must be dealt with immediately.
 Turn the patient every 2 hours. Do not allow the patient to lie in
a wet bed. Pay particular attention to pressure points.
 Keep a careful record of fluid intake and output. If this is not
possible, weigh the patient daily in order to calculate the
approximate fluid balance.
 Note any appearance of black urine (haemoglobinuria).

23.  Check the speed of infusion of fluids frequently. Too fast or too
slow an infusion can be dangerous.
 Monitor the temperature, pulse, respiration, blood pressure and
fetal heart rate. These observations should be made at least
every 4 hours.
 Report changes in the level of consciousness, occurrence of
convulsions or changes in behavior of the patient immediately.
All such changes suggest developments that require additional
management.

24.  If the temperature rises above 38 ºC, remove the patient’s
clothes, fan patient and tepid sponge intermittently. Give
prescribed antipyretic drug e.g. tablet -Paracetamol.
 Give antimalarial chemotherapy intravenously if
prescribed. If intravenous infusion is not possible, an
appropriate medication may be given intramuscularly.
Suppository formulations or oral treatment should be
substituted as soon as reliably possible (once patient can
swallow and retain tablets).
 Calculate doses as mg/kg of body weight. Therefore,
weigh the patient.

25. Provide good nursing care including daily grooming,
oral care, and bed bathing, and serving of patient bed-
pan when needed and maintain privacy throughout
care. This is vital, especially if the patient is
unconscious
More sophisticated monitoring (e.g. measurement
of arterial pH, blood gases, and central venous
pressure) may be useful if complications develop,
and will depend on the local availability of
equipment, experience and skills

26. NURSING DIAGNOSIS
1 2 3 4
Ineffective
thermoregulation
related to
malfunction of the
thermoregulatory
center evidenced
by rigor
Hyperthermia
related to
infective
process(Falci
parium or
Vivax)
evidenced by
body
temperature
of 38.5oc
Acute
Pain(Headache)
4/5 related to
toxic condition
evidenced by
patient
verbalization &
holding of head
Imbalanced nutrition
less than body
requirements related
to disease process
evidenced by loss of
appetite.

27. S/N NURSING
DIAGNOSIS
NURSING
OBJECTIVES
NURSING
INTERVENTION
EVALUATION
1. Ineffective
thermoregulation
related to
malfunction of the
thermoregulatory
center evidenced by
rigor.
Patient will become
comfortable and will
not experience bouts
of coldness and
hotness of body
within 1hour
30minutes of nursing
intervention.
--Cover patient with
extra clothing or
blanket.
--Educate the patient
on the present
condition.
--Check the vital
signs and fetal heart
beat and record
--During the hot
stage, expose
patient, Open nearby
windows put on fan
and tepid sponge
patient.
--Encourage patient
to drink water or
juice.
--Give prescribed
antipyretic drug,eg
Patient became
comfortable as
shivery stopped
within 50minutes
of nursing
intervention.
NURSING CARE PLAN OF A PREGNANT WOMAN WITH MALARIA.

28. 2. Hyperthermia
related to
infective
process(falciparu
m or vivax)
evidenced by
body temperature
of 38.5oc
Patient body
temperature will
come down to
37.3oc within 1hour
of nursing
intervention.
-Expose patient.
-Open nearby
windows.
-Put on fan.
-Tepid sponge
patient
intermittently.
-Give copious
fluid
/cold drink.
-Administer
prescribed
injection
paracetamol
600mg
intramuscular.
- Recheck vital
signs and feotal
heart rate and
record.
Patient body
temperature
came down
to37.4oc within
1hour of
nursing
intervention.

29. 3. Acute pain
(headache) 4/5
related to toxic
condition
evidenced by
patient
verbalization and
holding her head.
Patient will
verbalize
reduction in
severity of pain
(1/5) and will not
hold her head
within 45minutes-
1hour of nursing
intervention.
--Minimize noise in
the environment.
--Put off light on the
patient bed side.
--Encourage patient
to adopt any
comfortable
position.
--Apply cold
compress on the
head.
--Give prescribed
analgesic e.g. tablet
paracetamol 1g.
--Check vital signs
and feotal heart beat
and record.
Patient
verbalized less
pain 1/5 after
1hour of
nursing
intervention.

30. 4. Imbalanced
Nutrition less
than body
requirements
related to
disease process
evidenced by
loss of appetite.
Patient will show
interest in eating
food within 2-3
days of
hospitalization/nur
sing intervention.
--Obtain history of
nutrition,
including foods
that are preferred.
--Institute good
oral care
--Serve attractive
meals in small
quantity
--serve meals at
frequent intervals.
--Assist in feeding
patient.
--Encourage
patient to feeding
herself.
Give prescribed
hematinic.
Patient’s eating
habit improved
within 3days of
hospitalization
as patient was
able to finish
each meal
served.

31. Reference
Gitau G.M., Eldred J.M., (2005). Malaria in pregnancy: clinical,
therapeutic and prophylactic considerations. The Obstetrician
&Gynaecologist; 7:5–11. Full text at
http://onlinetog.org/cgi/reprint/7/1/5.pdf
Meghna D., Feiko O., François N., McGready R., Kwame A., Bernard
B., Robert D., (2007). Epidemiology and burden of malaria in
pregnancy. Lancet Infect. Dis.; 7:93–104
Ribera J.M., Hausmann-Muela S., D'Alessandro U., Grietens K.P.,
(2007). Malaria in Pregnancy: What Can the Social Sciences
Contribute? PLoS Med; 4(4): Full Text Available at
http://www.plosmedicine.org/article/info:doi/10.1371/journal.p
med.0040092
WHO (2000).Severe falciparum malaria. Transaction of Roy. Soc.
Trop. Med . Hyg; 94(suppl. 1):1-90. Available at
http://apps.who.int/malaria/malariainpregnancy.html

32. Nurses Play pivotal role in the Prevention
and care of Malaria in Pregnancy

33. GROUP 6, NURSING SCIENCE STUDENTS,
NOUN, ENUGU
August, 2014.