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COLEGIO DE DAGUPAN Arellano Street, Dagupan City COLLEGE OF NURSING TORCH T- oxoplasmosis O- thers (syphilis) R- ubella C- ytomegalovirus H- erpes ESTIMATION OF PREGNANCY BARTHOLOMEWS RULE OF 4

UPDATED PRENATAL VISITS 2011 (DOH) Recommended Practice

At least 4 pre-natal visits as follows: 1st visit = before 4 months 2nd visit = 6 months 3rd visit = 8 month 4th visit = 9 months

DANGER SIGNS OF PREGNANCY (UPDATED) Vaginal bleeding Swelling of the legs, face and/or hands Severe headache, dizziness, blurred vision Pallor or anemia Fever and chills Vomiting Fast or difficult breathing Severe abdominal pain Vaginal discharge Painful urination Watery vaginal discharge Convulsions Absence or reduced fetal movements (<10 kicks in 12 hours during 2nd half of pregnancy)

NAEGELES RULE -3 +7 +1 (Apr to Dec) +9 +7 (Jan to Mar)

Recommended Practice The pregnant woman is advised to seek immediate consultation with a specialist or hospital when danger signs occur

MCDONALDS RULE Used in 2nd and 3rd trimester Formula for estimating AOG in lunar months o FH x 2 __________ 7 Formula for estimating AOG in lunar weeks o FH x 8 __________ 7

IRON/ FOLATE SUPPLEMENTATION

JOHNSONS RULE For estimated fetal weight Needs Fundic ht in cm If unengaged: o EFW (estimated fetal wt) in g = [FH-11] x 155 If engaged: o EFW in g= [FH-12] x 155

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HAASE RULE Estimated fetal length First five months of pregnancy o Square the month For the 2nd half of pregnancy o Multiply month by 5 o Ex: 7 months x 5= 35 cm Daily Food Needs and Servings Food Milk and milk products Meat and meat products Cereals/ grain products Fruit/ fruit juices Vegetables/ vegetable juices fluids Number of Servings 1 quart a day (4 glasses per day) 3-4 servings 4-5 servings 3-4 servings 3-4 servings 4-6 glasses of water or more plus other fluids to equal 8 cups/day

LEOPOLDS MANEUVER Done to determine the attitude, fetal presentation, lie, presenting part, degree of descent, an estimate of the size, and number of fetuses 1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part 2nd maneuver: with both hands moving down, identify the back of the fetus where the ball of the stethoscope is placed to determine FHT 3rd maneuver: using the right hand, grasp the symphisis pubis part using thumb and fingers 4th maneuver: the examiner changes position by facing the patients feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow Preparation: o Empty bladder! o Warm hands before touching the abdomen

Hygienic Measures BATH Avoid soaps on nipples Towel-dry breasts Daily bath Tub bath may cause accidental slipping Douching not needed to manage vaginal discharge o Leucorrhea is estrogen-induced

CLOTHING Loose, comfortable clothers Flat shoes No round garters

NUTRITIONAL REQTS DURING PREGNANCY Nutrients Calories Requirements 300 cal/day above the pre-pregnancy reqt Increase in 2nd trimester 60 mg/day Food Sources Whole grains, vegetables, fruits

SLEEP AND REST Average sleep 8h 1-2 hrs afternoon nap At work, get to stand and walk about for few minutes at least once in every 2 hours

TRAVELING Lean meat, poultry, fish, beans, lentils, nuts, eggs, cheese, milk Dairy products, tofu, salmon, etc Long distance travels by lands need stop-overs so client can get out of the car and walk Traveling by air requires pressurized planes o Usually not allowed Best time to travel o 2nd trimester o Pregnant is most comfortable o Danger of abortion is not great o Threat of preterm is of minimum

Protein -fetal tissue growth CalciumPhosphorus

Ca- 1200 mg/day 10 mcg/day of vitamin D for absorption 30 mg/day 2nd trim. 60 to 120 mg/day plus copper and zinc for low hgb 70mg/day Vit C 15 mg/day 400 mcg/day

Iron Iron def- most common prob. In pregnancy Zinc Folic Acid Prevents neural tube defects Iodine Magnesium Vitamin E

Red meat, liver, spinach, fish, poultry etc Liver, meat, shell fish

EXERCISES SEX Cleansing breathing (sigh) Pelvic rock Squatting/ tailor-sitting Abdominal breathing Kegel Panting

175 mcg/day 320 mg/day 10 mg/day

1st trimester o Less interest in sex due to nausea, fatigue 2nd trimester o Interest in sex may increase

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3rd trimester o Less interest due to discomforts

CARE OF THE TEETH Because of estrogen effect on vascularity, the gums of pregnant woman are painful and swollen o Use soft bristled toothbrush

S-A-D HABITS Smoking Alcohol Drugs

HIGH RISK PREGNANCY First Trimester Bleeding Abortion Ectopic pregnancy 2nd Trimester Bleeding H.mole Incompetent cervix 3rd Trimester Bleeding Placenta previa Abruptio placenta General Management for Hemorrhagic D/o: CBR Avoid sex! No IE! UTZ prep Assess AOG Assess for signs of labor Assess hypovolemia! Send discharges for histopathology ABORTION The termination of a pregnancy death before 20 to 24 weeks of gestation from LMP Fetus weigh 500 grams. Prevalence: 15 to 20% Medical abortion Oxytocin Combined regimens include methotrexate or mifepristone, followed by a prostaglandin (either misoprostol or gemeprost) Surgical abortion o D&C o Manual Vacuum Aspiration

Common site: AMPULLA/ TUBAL Dangerous site: INTERSTITIAL PAINFUL! Cullens sign o Indicated hematoperitoneum Adnexal fullness and tenderness, missed menstrual period o Unruptured tubal pregnancy Dull pain to colicky pain as the tube stretches DIAGNOSIS o Ultrasonography Showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. Done after 6th week of pregnancy Low serum progesterone level Vaginal Ultrasound Scan o showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present UNRUPTURED o Missed period o Abdominal pain within 3 to 5 weeks of missed period (maybe generalized or one sided) o Scant, dark brown vaginal bleeding o Vague discomfort TUBAL RUPTURE o Sudden, sharp, severe pain! o unilateral pain radiating to the shoulder o Intraperitoneal bleeding that extends to diaphragm and phrenic nerve o Cullens sign Nursing Care o Vital signs q15min o IVF o Monitor vaginal bleeding o I and O o Methotrexate! o No alcohol during the therapy o No vitamins containing folic acid Management o Removal by Salpingostomy It is usually done before the tube ruptures After the sx, Methotrexate is being given to dissolve residual tissue

ECTOPIC PREGNANCY the fertilized ovum is implanted outside the uterine cavity failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding

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o Laparatomy for advanced ectopic pregnancy If the placenta of the second or third trimester abdominal pregnancy is attached to a vital organ, separation and removal are not usually attempted because of the risk of hemorrhage. The cord is usually cut flush with the placenta and the abdomen is closed, leaving the placenta in place. Degeneration and absorption of the placenta will occur without complication Methotrexate can be given after (IM) HYDATIDIFORM MOLE gestational trophoblastic disease there is fertilization! Bunch of GRAPES! Gestational anomaly of the placenta consisting of a bunch of clear vesicles This neoplasm is formed from the swelling of the chorionic villi and lost nucleus of the fertilized egg The nucleus of the sperm duplicates, producing a diploid number 46 XX GROWS RAPIDLY! Hydropic (fluid-filled) vesicles grow rapidly Assessment: Early signs o Vesicles passed thru the vagina o Hyperemesis gravidarum High levels of HCG Late signs o Vesicles look like snowstorm on UTZ o Anemia o Abdominal cramping o Gestational HPN before 24 weeks Serious late complications o Pulmonary embolus o Hyperthyroidism Management o D and C o No oxytocin! May cause embolism due to UC leading to rupture o Methotrexate after sx o Avoid pregnancy for 1 yr! o IUD and OCP can be used a congenital shortened cervix

INCOMPETENT CERVIX RECURRENT PREMATURE DILATION OF THE CERVICAL OS Passive painless dilation of the cervical os without labor or contractions of the uterus Usually occur in the second to 3rd trimester pregnancy ETIOLOGY: o Cervical competence is usually based on the part of the cervical length o Short labors o Recurring loss of pregnancy o Maternal stress and lifestyle o Congenitally short cervix o Cervical Trauma o Forced D & C o Uterine anomalies DIAGNOSIS: o UTZ Short cervix Management: o Cerclage @ 11 to 15 weeks gestation After which the woman is refrain from intercourse and prolonged standing of more than 90 minutes, and heavy lifting o not eligible for the cerclage if you have: Hyperirritability of the cervix baby has already died more than 4 cm dilated water is broken o types of cerclage McDonald procedure removed at 37 weeks Shirodkar cerclage remain intact for life. CS! Hefner cerclage later diagnosis of the incompetent cervix. Uterosacral cardinal ligament cerclage

PLACENTA PREVIA

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DIABETES MELLITUS Effects of DM to Mother and Baby Mother Baby Infertility LGA, macrosomia Spontaneous Congenital anomalies abortions Polyhydramnios PIH Fetal hypoxia r/t IUFD Infections Neonatal hypoglycemia Preterm labor (1hr after birth) Dystocia Respiratory distress syndrome (6h after birth) Insulin reqts during pregnancy o First trimester Stable insulin May not increase need o Second trimester Rapid increase in insulin due to increased secretion of HPL o Third trimester Rapid increase o Labor IV regular insulin o Postpartum Rapid decrease to prepregnant level May not need insulin in the first 24 hours after delivery Diagnostics o 50-g oral glucose challenge test 26 to 28 weeks gestation 24 and 28 wks for early risk of GDM Plasma glucose of 140 mg/dl needs a ff-up test with 3h glucose tolerance test Management o Regular prenatal visits o UTZ o Balanced diet o Exercise Contraceptions after delivery o Condom, diaphragm o OCPs are C/I- decrease CHO tolerance o IUD C/I poor response to infection Class III- marked limitations of activities; less than regular/ ordinary activities cause symptoms Class IV- marked limitation of activities; asymptomatic at rest Complications o LSHF o Maternal dysrrhythmias o Spontaneous abortions o IUGR o Preterm labor Criteria for establishing a dx of cardiac dse in pregnancy o Persistent diastolic or presystolic murmurs o Permanent/ equivocal cardiomegaly o Severe dysrrhythmias o Severe dyspnea to stage of pressure on the diaphragm The presence of severe DYSPNEA, SYNCOPE WITH EXERTION, HEMOPTYSIS, PAROXYSMAL NOCTURNAL TACHYCARDIA, CHEST PAIN- requires further evaluation! Management: o Pain relief o Forceps/ Vacuum delivery o O2 o Avoidance of hemorrhage o Pulse/ HR is the most sensitive and reliable indicator of CHF

PROM Rupture of BOW before labor Diagnostics: o Nitrazine Test: yellow to blue (AF positive) o Ferning Test: AF, high in Na content will assume a ferning pattern when dried on a slide o Sterile speculum exam: most reliable; direct visualization of fluid fr cervical os Complications: o Chorioamnionitis o Cord prolapsed o Pretem labor Management: o Bed rest o No ambulation o Monitor FHT and early sx of infection

CARDIAC DISEASE Risk Factors: RHD, Congenital heart defects, MI (pregnancy is extremely C/I for clients with MI) Classification of Heart Diseases Class I- no limitation of physical activity; regular activities do not produce symptoms Class II- slight limitation; asymptomatic at rest but regular activities produce palpitations, fatigue, dyspnea and angina pains

PRETERM LABOR 20 weeks and 37 weeks of pregnancy Uterine activity present Progressive cervical change Uterine contractions more frequent than every 10 minutes persisting for 1 hour or more Dull, intermittent low back pain (below the waist) Give TOCOLYTICS! o Ritodrine (Yutopar) o Terbutaline (Brethine)

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o Isoxsuprine o Indomethacin (Indocin) Promote fetal lung maturity o Antenatal glucocorticoids Given IM Applying pressure on uncontracted uterus o Uterine relaxation due to effects of anesthesia or analgesia Fundus is no longer palpable Sudden gush of blood from the vagina Uterus appears in the vulva Management Prevent! o Never apply pressure on an uncontracted uterus o Never pull the cord to hasten placental delivery If the placenta has already separated o The uterus is replaced in the uterine cavity then oxytocin is administered If the placenta is still attached o Under anesthesia- reinsertion of the uterus into the pelvic cavity o Lower uterine segment is inserted first and fundus last. Then oxytocin is given o Do not attempt to remove the placenta if it is still attached to the uterus as this will only enlarge the bleeding area. Remove after uterus is replaced and contracting o The placenta is delivered when uterus is already replaced and contracting o

PRECIPITATE LABOR Labor that lasts less than 3 hours from the onset of contractions to the time of birth CAUSES: o Hypertonic uterine contractions MATERNAL COMPLICATIONS o Uterine rupture o Lacerations of the birth canal o Amniotic fluid embolism o Postpartum hemorrhage PREDISPOSING FACTORS o Multiparity o Large pelvis Adequate prenatal care If accelerated labor pattern occurs during oxytocin administration, stop infusion right away and turn woman on her side Deliver the baby as usual and transport to the hospital Promote initial breastfeeding during transport to facilitate contraction

UTERINE RUPTURE Tearing of the muscles of the uterus occurs when the uterus can no longer withstand the strain placed upon it CAUSES o Rupture of scar from previous CS o Prolonged labor, obstructed labor o Over-distention of the uterus o Oxytocin (over infusion) o Precipitate labor and delivery o Manual removal of the placenta During the peak of contraction, the woman complains of a sudden sharp tearing pain after which, relief is felt as the uterus loses the capacity to contract Blood transfusion IVF Emergency laparotomy to deliver the baby Provide emotional support Post-op care after hysterectomy o Explain need to avoid driving for 3-6 weeks o Avoid jogging, sex, dancing, heavy lifting for 6 to 8 weeks

INDUCTION OF LABOR Oxytocin o s/e: water intoxication HPN

CS Indications: CPD, previous CS, Fetal distress, breech, DM, dystocia, etc Blood loss: less than 1000 ml Spinal anesthesia Exercises after CS (Brayshaw) o Foot and leg exercises o Abdominal tightening, pelvic tilting/rocking (after 24 hrs) o Pelvic floor exercise, hip hitching (after 4-5 days) o Aerobics (10-12 wks after surgery)

Types of Regional Anesthesia Paracervical block o Active phase of labor o Produces rapid relief fr uterine pain and contraction pain o No effect on perineal area! Peridural block o Active/ 2nd stage o Ex: epidural, caudal, combination of epidural and spinal Intradural block

UTERINE PROLAPSE INVERSION OF THE UTERUS A serious complication of the third stage wherein the uterus is partly or completely turned outside out CAUSES o Pulling of umbilical cord

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2nd stage of labor Flat position after 8 to 12 hours Ex: spinal, saddle block (low spinal- for rapid relief of pain as in forceps delivery) Pudendal block o 2nd stage for episiotomy and 3rd stage for episiorrhaphy o Local anesthetic agent is placed in the area of the pudendal nerve through the vagina and near right and left ischial spines o Used in NSD, forceps o No effect on the fetus o o o POSTPARTUM HEMORRHAGE Most common cause of PPH UTERINE ATONY Other causes: o Retained placenta o Placenta accrete o Cervical or vaginal lacerations o Uterine rupture or inversion o Lower genital tract lacerations o Hematomas o Infection EARLY PPH o Excessive bleeding may occur during the period between the separation of the placenta and its expulsion or removal o After the placenta has been expelled, persistent or excessive blood loss most commonly is a result of atony of the uterus orb prolapsed of the uterus into the pelvis LATE PPH o Results from subinvolution of the placental site, retained placental tissue, or endometritis CAUSES o Remember 4 Ts! o TONE o TISSUE o TRAUMA o THROMBOSIS GENERAL MANAGEMENT FOR PPH o Check if uterus is deviated to one side (empty bladder) o Gently massage the uterus! o Ice o Oxytocin o If bleeding persists, BIMANUAL COMPRESSION This procedure involves inserting a fist into the vagina and pressing knuckles against the anterior side of the uterus while placing the other hand on the abdomen and massaging the posterior uterus o If the uterus still does not become firm, Manual exploration of the uterine cavity for retained placenta is done!

RUBINS POSTPARTUM PHASES Taking-in o 1-3 days postpartum o Dependent Taking-hold o 3-14 days after o Striving for independence Letting-go o 10-14 days o Independence Post-partal blues o 4-5 days to 6 weeks

POSTPARTUM 1st 24 hours after delivery- fundus is at the level of the umbilicus Fundus is on the side o EMPTY THE BLADDER! Boggy, soft uterus o Check for bleeding o Massage the uterus initially th 9 to 10th day- fundus is no longer palpable Reversal pattern of lochia o Check for bleeding o Abnormal: bright red bleeding

Postpartum visits

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Management: o Warm compress before nursing o Express milk after feeding o Handwashing o Prevent blocked duct! Rotate infants positions each feeding Manually express excess milk after feeding Massage caked area toward nipple while breastfeeding o Wear supportive bra o Warm compress to prevent engorgement o D/C feeding on the affected breast o Dicloxacillin and erythromycin- can continue BF

UTERINE ATONY Marked hypotonia of the uterus #1 cause of PPH

APGAR SCORING Performed at 1 min and 5 mins apart Interpretation o 0-3- poor and needs resuscitation o 4-6 fair; may need suctioning and oxygenation; condition guarder o 8-10 good; no signs of immediate distress Most impt Apgar- HR Least impt- color

SUBINVOLUTION OF THE UTERUS delay in the return of the uterus to its prepregnant size, shape and function Enlarged and boggy uterus Prolonged or reversal pattern in lochial discharge Foul odor in lochia if caused by infection Backache Assess uterus and fundus Elevate legs to promote venous return Frequent voiding Methergine 0.2 mg for 2 weeks D and C Treat the cause: o Removal of uterine tumors and antibiotics for infection o Evacuation of the retained placental fragments by D and C

MASTITIS Appears during the 2nd and 3rd week postpartum Staphylococcus aureus from the oral-nasal cavity of the infant Unilateral breast involvement Engorgement or swelling Breast feels hard and appears reddened Fever, tachycardia, malaise Reduced milk supply o Edema and engorgement obstruct the milk flow Breast abscess (collection of pus in the breast)

BALLARD SCORING Ballard Maturational Assessment this scoring allows for the estimation of age in the range of 26 weeks-44 weeks

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CAPUT SUCCADANEUM VS. CEPHALHEMATOMA Caput Scalp edema Present at birth Fr pressure of soft cervix against presenting head Bilateral Crosses the suture line Disappears 3-5 days No mngt needed BREASTFEEDING EO No. 51 Milk Code Pre-requisites o Physiologic readiness o Absence of emotional stress o Sucking- stimulates let-down reflex o Rest, exercise and diet (prenatal and postnatal) o Absence of C/I Drugs C/I during BF o Phenylbutazone and indomethacin o Chloramphenicol, INH, tetracycline o Estrogen o Phenindione, reserpine o Antineoplastic o Atropine o Lithium An INVERTED NIPPLE is not a C/I . Nipple shiled may be used Contraception: LAM Position: upright, with mother semi-reclining or in rocking chair or chair with arm for support Twins: football hold Bubble or burp frequently Breastmilk o Colostrum thin, yellow fluid o Transitional milk milk produced after colostrums and stat before mature milk o Foremilk thin, watery, breast milk secreted at the beginning of a feeding o Hindmilk Thick, high fat breast milk secreted at the end of a feeding o Mature milk Breast milk that contains 10% solids for energy and Cephalhematoma Bld collection bet a skull and periosteum Appears 12-24 hrs after delivery Fr pressure of hard pelvis/ forceps against presenting head Unilateral Does not cross the suture line Regresses in 2-3 weeks No mngt needed growth

NEWBORN SCREENING FACTS RA 9288 Newborn Screening Act of 2004 o Protects the rights of children to survival and full and healthy development as normal individuals o Provide for a comprehensive, integrative and sustainable national NBS system to ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening and be spared from heritable conditions National Obj of NBS o Newborn has access to NBS o Sustainable NBS system o All health practitioners are aware of the advantages o Parents recognize their responsiblity

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Congenital hypothyroidism Congenital adrenal hyperplasia PKU Galactosemia G6PD Peformance of NBS o 24 hrs after life but not later than 3 days o Ideally- 48h after birth o Heel-prick method to obtain bld specimen o Done by physicians, nurses, trained midwife o Results are available 7-14 working days after Results o Negative screen- extremely low risk o Positive screen- increased risk All days from the start of the menstrual cycle up to the third high temperature reading are considered fertile days. o Effectiveness: 99% (perfect use) and 80% (typical use) Standard Days Method o Calculation of fertile and infertile days for menstrual cycles of 26 to 32 days o Works for women with menstrual cycles of 26-32 days o Identifies cycle days 8-19 as the womans fertile period o Colored beads are used to help the woman keep track of her fertile & infertile days. o

How To Use Assess the length of the menstrual cycle if it falls within the range of 2632 days. If the cycle length is less than 26 days or more than 32 days, the client cannot use the method. If the cycle meets the criteria, provide an SDM card and cycle beads. Show the woman the CycleBeads and instruct her on how to use it: On the first day of the menstrual cycle (i.e., first day of menstrual bleeding), she puts the ring on the red bead and marks this day on the calendar. She moves the ring to a bead each day preferably upon waking up. The brown beads signify infertile days while the white beads signify fertile days. When the ring is on a white bead, she abstains from sexual intercourse. Draw the clients attention to the dark brown and black beads. if menstrual bleeding occurs before the dark brown bead, her cycle is less than 26 days. if the ring has reached the black bead and still no menstrual bleeding, her cycle is more than 32 days. If either condition happens twice in a year, she cannot reliably use the SDM as her FP method.

UPDATES ON FAMILY PLANNING (2011 DOH)

New term: Fertility Awarerness- Based Methods (FABM) instead of Natural Family Planning Artifical FP: Long-Term Family Planning Methods FAB methods o Billings Ovulation Method (BOM) o Basal Body Temperature Method (BBT) o Sympto-thermal Method (STM) o Standard Days Method (SDM) o Two-Day Method (TDM) Basal Body Temperature Method (BBT) o Infertile days begin from the fourth day of the high temperature reading to the last day of the cycle.

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Women with Special Conditions Shifting from pills menstrual cycles prior to the use of pills were 26-32 days and the current cycle is expected to be 26-32 days Shifting from injectables last injection at least 3 months ago menses have returned menstrual cycle prior to use of injectable was within 26-32 days last menstrual cycle was within 26-32 days Recently used the IUD IUD has been removed Menstrual cycles while using the IUD were within 26-32 days Last menstrual cycle is within 26-32 days Postpartum and/or breastfeeding Menstruation has returned Has had at least 4 normal menstrual periods Expects current cycle to be within 26-32 days Return Visit Instruct client to return Within 7 days of her next menstrual period (bring CycleBeads, client card and partner, if possible) For warning signs: If a day has passed since the rubber ring has reached the black bead and menstruation has not come (cycle length is >32 days) If menstruation starts before the rubber ring reaches the chocolate brown bead (cycle length is <26 days) CRITERIA FOR LAM Fully or nearly fully breastfeeding o Breastfeeds on demand o No more than 4 hours interval between breastfeedings during the day and 6 hours at nighttime o Uses both breasts for feeding Amenorrhea o Menses have not yet returned o Bleeding within the 8 weeks postpartum period is not considered as menstrual bleeding for breastfeeding women Infant is less than 6 months old o Effectiveness of breastfeeding in inhibiting ovulation diminishes over time. o Ovulation resumes in 20-50% of women near the end of the 6-month postpartum period even when fully breastfeeding and amenorrheic. Choice of FP Methods for Postpartum Breastfeeding Women

BIRTH SPACING Importance Ideal gap between pregnancies is at least 3 years. If the woman has had too many pregnancies (more than 4) at close intervals (<3 years): she is more likely to have complications during pregnancy and labor. the baby is more likely to be small and sickly Family planning: Saves mothers and childrens lives Is a way for a woman to delay pregnancy until she is ready Helps her to space births so that her body can recover from her previous pregnancy and delivery Allows the family to stop having babies when they have had the number of children that is right for them Recommended Practice A pregnant woman should start considering family planning as early as during pregnancy because: She can get pregnant as early as 4 weeks after delivery if she is not exclusively breastfeeding There are methods she can use immediately after delivery (i.e., LAM, IUD, BTL) and she should be advised If she chooses female sterilization, she can have it done immediately after delivery (if she delivers in a hospital providing BTL) or within 7 days Her husband can undergo vasectomy at any time while she is pregnant

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THE GATHER APPROACH IN FAMILY PLANNING COUNSELING (updated 2011) Tasks Assess clients knowledge on FP o What client knows about FP? o Has used any method? How long? Is she satisfied with method used? Assess for violence committed against partner (VAW) o How is clients relationship with her husband/partner? o Does partner know about her coming to clinic? o Will partner support clients use of FP method? Assess for STI Risk o Why assess for STI risk? FP clients are sexually active, need to know about STIs If client gets STI, needs counseling about risks, symptoms, & treatment and need supply of condoms IUD should not be provided to clients with STI risks

Greet Importance Tasks Greet client and give her your full attention Introduce yourself Offer her a seat Ask reason for her visit and how you can help her Ensure confidentiality Beginning of establishing rapport with the client Making the client comfortable Assuring confidentiality

Ask/assess Importance Tasks Assess reproductive needs o Ask client if she plans to have another pregnancy, if yes, when she/he plans to have this Ask client about self (use FP Form 1) o General/demographic data o Medical/Obstetrical History Check for medical conditions that will not warrant the use of a specific FP method based on the WHO MEC or the MEC wheel Identify clients reproductive needs Identify client's knowledge on FP and the FP methods Identify conditions that may make client unsuitable for particular FP method Tailors succeeding discussions while helping client choose a method

Assess for STI Risk Questions that are asked in assessing STI risk: How is your relationship with your partner? Have you or your partner ever been treated for STIs in the past? Do you think your partner might have STI? Unusual discharge from the vagina? Itching or sores in or around the vagina? Pain or burning sensation? Pus from the penis? Swollen penis or testicles? Tasks Determine that the woman is not pregnant: o Menstrual period started within the last 7 days o Gave birth within the last 4 weeks o Had an abortion within the last 7 days o Gave birth within the last 6 months, is fully breastfeeding, & has not yet had menstrual period Determine that the woman is not pregnant: o Has not had sexual intercourse since last menstrual period o Uses a modern/reliable family planning method correctly

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REVISIT CLIENTS o Ask if clients situation has changed since last visit o Ask if reproductive needs have changed o Ask if client has new concerns o Ask if client has problems with her method o Reassess for STI/HIV risk o Reassess relation with partner Explain Importance Tasks Tell Importance Provide information of FP methods based on her reproductive need and knowledge Tells the client about FP methods based on her needs: short-term, longterm, permanent Tells how the method works Explains effectiveness, advantages, disadvantages, possible side effects Corrects misconceptions Helps the client make a decision Asks client what method she/he heard during the Tell step interests him/her. Checks clients suitability for his/her chosen method using the MEC Checklist for the chosen FP method. Reminds client of the possible side effects of the method chosen. Asks client how he/she can tolerate possible side effects. Asks client if there is anything not understood; repeats information, as needed. For revisit clients Explains how to start and use the chosen method Describes warning signs, what to do should it occur Confirms clients understanding of what has been said by asking her to repeat what has been said in her/his own words. Corrects misunderstanding. Asks client: How she/he uses the present method and warning signs To repeat instructions on how to use & warning sign Corrects mistakes or misunderstandings How to use the chosen method is explained Method is provided if appropriate and available Knowledge of warning signs of complications

Tasks

Importance Tasks

Help Tasks If client decides not to use a method Tells him/her about: Risk of pregnancy Availability of pre-natal services Being able to return should he/she want to use an FP method

Return/ refer Important opportunity to: Reinforce the decision clients have made to plan their family Discuss any problems they have with their chosen method Take seriously the clients concern with a supportive attitude and should never be dismissed Tasks Tells client when and where to return for Routine follow-up Schedule next visit Encourage client to come back for any problems, including warning signs If chosen method/service is not available, refers client to other service provider or facility

Sources: DOH Maternal and Child Health Nursing Textbooks American Journal of Nursing

Prepared By: Ms. Lizette Leah B. Ching