PREVENTIVE OBSTETRICS

MASTER PLAN

SUBJECT : OBSTETRIC AND GYNAECOLOGICAL

NURSING

GENERAL OBJECTIVE: On completion of the seminar the students will be

able to get adequate knowledge regarding preventive obstetrics and able to
prevent 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
SL.NO.
CONTENT

1 INTRODUCTION

2 TERMMINOLOGIES

3
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 Family
4
CONCLUSION
5
BIBLIOGRAPHY
 PREVENTIVE OBSTETRICS

INTRODUCTION

Preventive obstetrics is the concept of prevention or early detection of particular

health deviations through routine periodic examinations and screenings. The concept of
preventive obstetrics concerns with the concepts of the health and well-being of the
mother and her baby during the antenatal, intranatal and postnatal period. It aims to
promote the well- being of mothers and babies and to support sound parenting and stable
families. Nursing care centered on health promotion and health maintenance during
pregnancy presents an excellent opportunity for nurses to teach expectant mothers 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 a

healthy mother at the end of a healthy pregnancy. Pregnancy and child birth normal
physiologic process that change from conception to delivery. The nurse has a unique
opportunity to reinforce the normal cycle of these processes and at the same time,
assess client for problems that require intervention. Additionally, the nurse can teach
clients about the changes that are taking place and provide valuable guidance for
clients about when to seek guidance from health care providers.

Early contact between the health care team and the pregnant client provides the
opportunity to address the concepts of health promotion and health maintenance. Health
promotion consists of education and counseling activities that help enhance and maintain
health which prevents from obstetrics. For the prevention of obstetrics systematic
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 and
puerperium, the mother will have good health and that every pregnancy may
culminate in a healthy mother and a healthy baby.

Although different parts of the world have different leading causes of maternal
death attributable to pregnancy, in general, three major disorders have persisted for the
last 35 years like hypertensive disorders infection, and haemorrhage. The number of
maternal deaths overall is small; however maternal mortality remains a significant
problem because a high proportion of deaths are preventable mainly through
improving the access to a utilization of prenatal care services. Nurses can be
instrumental in educating the public about the importance of obtaining early and
regular care during pregnancy.

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PREVENTIVE OBSTETRIC

DEFINITION

Preventive

Preventive is the term used to prevention or slowing the course of an illness or

disease. 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
arise during antenatal, intranatal and postnatal period.
Preventive Obstetric measure can be categorized into three main stages. They
are as follows:-

A. Antenatal Nursing
B. Intranatal Nursing
C. Postnatal Nursing

A. ANTENATAL NURSING

Antenatal care is the care during pregnancy. Antenatal care is essential even for
a normal and healthy, pregnant women for her own well- being and that of the baby to
be born 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 as possible during the first trimester and should continue throught the second
and third trimesters.

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.
1. Preconceptional Counseling and Care

When couple is seen and counseled about pregnancy. Its course and outcome well before
the time of actual conception is called preconception counseling. It is a very new concept.
Objective is to ensure that a woman enters pregnancy with an optimal state of health
st
which would be safe both to herself and the fetus. Organogenesis is completed by the 1
trimester. By the time the woman is seen first in the antenatal clinic it is often too late 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 where
health education (general advice about nutrition, lifestyle, avoidance of teratogens,
folic acid supplementation, etc) and risk assessment can be focused toward a planned
pregnancy. Preconception counseling is of much greater importance in two main
groups of 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.
 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 Services

The 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 Women

Care during pregnancy should be started as early as possible. The mother must be
registered within 20 weeks of pregnancy either at health centre/ antenatal clinic or at
home by a nurse/health visitor/ female health worker (ANM) or trained person.
Through physical and obstetrical check up should be done to screen for risk factors,
make assessment and give appropriate care for prevention and control of various
health problems and complications.

Antenatal Visits and Antenatal Care

Ideally a woman should be seen and given care during pregnancy once a month during
the first trimester or till seven months, once in fortnight during the second trimester or
till the eighth month and thereafter every week till confinement. But often these many
visits are not feasible, neither for the mother nor for the health infrastructure available.

The care should begin soon after conception and continue throughout pregnancy. A
schedule to follow for the mother is to attend the antenatal clinic once a month during
the first seven months, twice a month during the next two months and thereafter once
a week if everything is normal. Therefore a minimum three visits one in each trimester
have 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
visit should be paid in the home of the mother to make observation of actual
conditions and accordingly prepare the mother. The main purpose of contact during
antenatal period is to make observations and assess general health, obstetrical health
status, identify risk factors and provide appropriate care.
The preventive services for mothers in the prenatal period are
as follows:-

The first visit irrespective of when it occurs should include:-

Taking Health History

It includes recording history of menstruation, medical history, obstetrical history,
socioeconomic history.

Physical Examination
It includes recording of height, weight, blood pressure, temperature, pulse etc. general
observations from head to toe.

Obstetrical Examination
It 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 needed

On 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 necessary

Risk Approach

While continuing to provide appropriate care for all mothers, ‘high risk’ cases must be
identified as early as possible and arrangements to be made for skilled care. These
cases comprise 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
 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 women
with attention to those who need them most. Maximum utilization of all resources,
including human resources is involved in such care. Services of traditional birth
attendants, community health workers and women’s groups are utilized. The risk
strategy is expected to lead to improvements in both the quality and coverage of
health care 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 Records

The antenatal card is prepared at the first examination. It is generally made of thick
paper to facilitate filing. It contains a registration number, identifying data, previous
health history, and main health events. The record is kept at the MCH/FP center. A
link is maintained between the Antenatal card, Postnatal card and under- fives card.
Maintenance of records is essential for evaluation and further improvement of
MCH/FP services.

Home Visit

Home visits are paid by the Female Health Worker or Public Health Nurse. If the
delivery is planned at home, several visits are required. The home visit will provide
opportunities to study the environmental and social conditions at home and to provide
prenatal advice. In the home environment, the woman will have more confidence to
make an informed decision about home birth.

Immunization Against Tetanus

A pregnant woman must get two injections of Tetanus Toxoid during the period
between 16 – 36 weeks, at one month interval. These protect the mother and baby
nd
both from the risk of tetanus. The 2 injection should preferably be given at least at
one month before delivery. If a woman is registered late then in that case even one
injection will do. If the woman is immunized earlier within three years of the
pregnancy, then one booster dose will be enough.

Iron and Folic Acid and Vitamin A and D Supplementation

It is being found that 50-60 percent of pregnant women are anaemic due to iron
deficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to take
one tablet containing 60 mg.of elemental iron and 500 mg of folic acid three times
daily after third month of pregnancy till 3 months after child birth if the mother is
found having anaemia.

During pregnancy, the mother requires extra iron and folic acid due to changes taking
place in the body and growth of fetus in the womb. Therefore each mother is given
one tablet of iron and folic acid twice a day for at least 100 days to prevent anaemia in
mother and to promote proper growth of fetus.
Anemia is common in pregnancy and low – income group. It is a major cause of
maternal 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

th th
should be estimated at the first antenatal visit at the 28 and finally at 36 weeks.
nd
Avoid excessive blood loss during the 2 stage of labour.
Health education / prenatal advice during Pregnancy

A major component of antenatal care is health education and prenatal advice. The
mother is more receptive to advice concerning herself and her baby at this time than
any other time. A woman during pregnancy needs to know about her nutrition,
personal hygiene, 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 community
midwife and general practitioner) caring for the mother is the provision of information
about everyday activities that may or may not be affected by or have an effect on the
pregnancy.

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 pregnancy

Nutritional intake is an important factor in the maintenance of maternal health during

pregnancy and in the provision of adequate nutrients for embryonic/fetal development.
Assessing nutritional status and providing nutritional information or referral to a
dietitian are part of the nurse’s responsibilities in prenatal care.

Dietary extremes are associated with risks in pregnancy. Obesity is associated with
gestational diabetes, hypertension and monitoring difficulties. Malnutrition is
associated with maternal anemia and fetal growth restriction, while deficiency of
certain vitamins predispose to congenital abnormalities, folic acid deficiency is linked
to the risk of neural tube defects (NTDs). A balanced diet rich in fresh fruit and
vegetable is recommended. It is prudent to avoid unpasturized milk and cheeses and
pâtés. Pregnant woman should avoid eating liver due to its high vitamin A content.
Vegans should have Iron and vitamin supplementation and ethnic groups lacking
sunlight are advised to have extra vitamin D.
A balanced and adequate diet is of utmost importance during pregnancy and lactation
to meet the increased needs of the mother, and to prevent nutritional stress. If maternal
stores of iron are poor as may happen after repeated pregnancies and if adequate iron
is not available to the mother during pregnancy, it is possible that the fetus will lay
down insufficient iron stores.

Relationship between Maternal and Foetal

Nutrition Energy

Inadequate food intake and poor nutrient utilization

Maternal Malnutrition

Reduced blood volume expansion

Inadequate increase in cardiac output

Decreased blood and nutrient supply to the foetus

Reduced placental size

Reduced nutrient transfer

Foetal growth retardation

The increase in energy is to support the growth of the foetus, placenta, and maternal
tissue and for the increase in basal metabolic rate due to additional work of growing
foetus and increase in maternal body size.

Personal Hygiene

Advice regarding personal hygiene is equally important. The need to bathe every day
and to wear clean clothes should be explained. About eight midday meals should be
advised. Constipation should be avoided by regular intake of green leafy vegetables,
fruits and extra fluid. Purgatives such as caster oil to relieve constipation should be
avoided. Light household work should be encouraged but manual physical labour
during pregnancy may adversely affect the fetus.
• Fresh air and sunshine

This is here in abundance and most women are in the open air for a large part of the
day and it is good for them but advice regarding their sleeping arrangements should be
given.

• The bowels

The bowel action should occur daily and without the use of laxatives. Drinking glass
of warm water on getting up each morning and drinking plenty of fluids during the
day can encourage this. Plenty of roughage in the diet is also helpful.Constipation
should be avoided by regular intake of green leafy vegetables, fruits and extra
fluids.Purgatives like caster oil should be avoided to relieve constipation.

• Care of Teeth

The usual care after eating should continue. A dental check is advisable and any dental
carries should be treated. Use soft brush in this period.

• Personal Cleanliness and Bathing

During pregnancy sweet glands become more active so advice for bathing at least
once a day, preferably twice but clean clothes should be used daily.The need to bath
every day and to wear clean clothes should be explained. The hair should also be kept
clean and tidy.

Rest and Sleep

A pregnant woman needs sufficient rest. She should do less and lighter work. She
must have 8-10 hours of sleep every night. She needs to take short nap during the day.
As the pregnancy advances, the mother requires more frequent short rests during the
day. She should avoid strenuous work, carrying heavy loads or weights e.g. bringing
water from long distance, drawing of water from a well etc.

Rest is important for the maintenance of good health. She should need adequate rest
and relaxation. Relaxation of the mind produces relaxation of the muscle and a
relaxed lower uterine segment and pelvic floor makes it easier for the baby to be born.

Physical work

A job provides satisfaction, self esteem and confidence, along with financial peace of
mind. Women can continue working in pregnancy as long as they wish and as long as
they 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
night is recommended.
Exercise

Exercise in pregnancy should be encouraged; through with advancing gestation

physical contraints may limit sporting activities. Exercise can improve cardiovascular
function, lower blood pressure and improve self- esteem and confidence. Swimming is
often helpful throughout pregnancy especially with advancing gestation as it is
essentially a non weight bearing exercise. It is advisable however to avoid
hyperthermia, dehydration and exhaustion.

Consider decreasing weight – bearing exercises like jogging, running and concentrate
on non weight bearing activities such as swimming, cycling or stretching. Advise her
to avoid risky activities such as surfing, mountain climbing and skydiving. Limit
activity to shorter intervals. Exercise for 10 to 15 minutes; rest for 2 to 3 minutes, then
exercise for another 10 to 15 minutes. The exercise should be decrease as the
pregnancy progresses.

Comfortable clothing and shoes

It is advisable to wear loose and comfortable cotton clothes, not too tight such as
blouse or cholo.Brassier which supports the breasts should be advised, but must not be
too tight so as to flatten the nipples but lift the breast well. A support for the abdomen
is sometimes required, especially in a multigravida who has pendulous abdomen so
the pregnant 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
center of balance and to prevent backache to some extent.

Smoking

It should be strongly discouraged in pregnancy. The target should be cessation of

smoking, 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 of
miscarriage, a slightly higher perinatal death rate (20% increase in 20/day smokers, and
35% increase if > 20/day) and babies of smokers are 150 to 300 gm lighter than babies of
non smokers. Furthermore, smoking is associated with a three-fold increase in risk of cleft
palate. Smoking during pregnancy, however, doesn’t affect long term mental or motor
development. The mechanisms involved include interference of carbon monoxide with
oxygen transfer, shifting the oxygen dissociation curve to the left in both maternal and
fetal hemoglobin and reduced intervillous blood flow. Appropriate advice and support
should be provided for women who wish to try stopping smoking, with optimum benefits
achieved if smoking is stopped prior to conception.

Smoking should be cut down to a minimum, as heavy smoking by the mother can result in
babies much smaller than average size due to placental insufficiency. The perinatal
mortality amongst babies whose mothers smoked during pregnancy is between 10 to 40
percent 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 been
associated with fetal alcohol syndrome (FAS), which includes intrauterine growth
retardation and developmental delay. Advice should also be given about dental care
and sexual behavior during pregnancy. Sexual intercourse should be restricted during
the last trimester of pregnancy.

Alcohol

An expectant mother should be advised to avoid drinking alcohol as drinking alcohol

is injurious to the fetus and also to her own health. It leads to low birth weight and
retardation.

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 than
12 unts or 120 gm/ day) is associated with the development of fetal alcohol syndrome.
The syndrome is characterized by growth retardation, neurological and structural
defects (facial, cardiac, joints). A lesser degree of alcohol consumption but still greater
than 8 units/day may also be associated with fetal alcohol syndrome as well as other
associated features such as increased risk of miscarriage and reduced head
circumference.

Breast Care

The mother should advice to clean her breast during bath. If the nipples are anatomically
normal, nothing is to be done beyond ordinary cleanliness. But if nipples are retracted,
correction should be done. For this mother is taught about nipple care. She should wash
her breast, with soap and water. To toughen the nipples, it should be massaged by using
soap and water and then roll them between the forefinger and thumb and draw them out
everyday during the last two months. This should be done three times a day. After
massage, the nipples should be dried and an oily substance applied to make them supple.
Advise mother to wear a well fitting and supportive brassiere.

Drugs

The mother should be advised not to take any medicine unless it is prescribed by the
doctor. As far as possible, medicine should be avoided for the three months unless
very essential. The mother must inform to the doctor about pregnancy when seeking
any treatment from the doctor or health personnel.

The use of drugs that are not absolutely essential should be discouraged. Certain drugs
taken by the mother during pregnancy may affect the fetus adversely and cause fetal
malformations. The classical example is thalidomide, a hypotonic drug, which caused
deformed hands and feet of the babies born. The drug proved most serious when taken
between 4 to 8 weeks of pregnancy. Other examples are LSD which is known to cause
th
chromosomal damage, streptomycin which may cause 8 nerve damage and deafness in
the fetus, iodine- containing preparations which may cause congenital goiter in the fetus.
Corticosteroids may impair fetal growth, sex hormones may produce virilism, and
tetracycline may affect the growth of bones and enamel formation of teeth. Anaesthetic
agents including pethidine administered during labour can have depressant effort on the
baby and delay the onset of effective respiration. Later still in the puerperium, if the
mother is breast- feeding, there are certain drugs which are excreted in breast milk. A
great deal of caution is required in the drug – intake by pregnant women.

Radiation

Exposure to radiation is a positive danger to the developing fetus. The most common
source of radiation is abdominal X-ray during pregnancy. Studies have shown that
mortality rates from leukemia and other neoplasm were significantly greater among
children exposed to intrauterine X-ray. Congenital malformations such as
microcephaly are known to occur due to radiation. Hence, X-ray examination in
pregnancy should be carried out only for definite indications.

Protections from infections and illnesses

Infections in pregnancy are responsible for significant morbidity and mortality. The
direct financial costs of disease can be as starting and are much more difficult to
measure. Some consequences of maternal infection last a life time.

Education and counseling are important aspects of care for the prevention of maternal
infections. Adolescents mothers are at high risks because of earlier partners. The
recent trend of exchanging sex for drugs is contributing to a rise in infection rates,
especially among poor, and minority women. The prevention of disease and the
reduction of maternal and neonatal effects continue to be monumental challenges.

An expectant mother must be instructed to protect herself from the risk of any
infection especially measles, German measles and syphilis because these infections
can cause spontaneous abortion, malformation, mental retardations, still-birth,
perinatal death etc. The child may develop congenital syphilis. If the mother is found
having syphilis she must get herself treated by the trained health personnel especially
from health center/hospital.

Sexual activities

Patient inhibition to ask and failure to address the issue by health professionals has
resulted in considerable misconceptions. In general with an uncomplicated pregnancy,
there are no contraindications to coitus or other form of sexual enjoyment in
pregnancy including cunnilingus and masturbation. There is no evidence that these
have a damaging influence on the fetus or risk inducing premature labour. With
advancing gestation certain coital positions may be physically awkward. There may
be decline in some women in sexual desire and activity in early pregnancy toward the
end of pregnancy. Coitus may be avoided with premature rupture of membranes and
where there have been recurrent episodes of APH and in the presence of a placenta
previa major.

The mother should be advised to avoid coitus during the first three months and the last
two months. In the first three months it increases the risk of abortion. The risk of
abortion is more in mothers who have previous history of abortion. In late pregnancy
it predisposes to infection.
Travel

The mother should be instructed to avoid travel during the first three and last
two months of pregnancy especially long and tedious journey.

If traveling for long distances, periods of activity and rest should be scheduled. While
sitting, the woman can practice deep breathing, foot circling, and alternating
contracting and 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 care

The mother should be educated on various aspects of child care. Mother craft classes
can be arranged if possible to train the mother regarding care during pregnancy, child
bearing, 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 consists
of nutrition education, hygiene and childrearing, childbirth preparation and family
planning information.

Follow up visits

It is important that mother must be educated about the need for regular visits and
proper care during pregnancy. They must be convinced to pay follow up visit and
follow the instructions regarding diet, personal hygiene, rest, physical work, exercise,
smoking, drinking, and protection from infections, sexual activities, and travel etc.so
as to promote health of both mother and the growing fetus.

Warning Signs

The mother should be given instructions that she should report immediately, any of the
following warning signals like swelling of the feet, convulsions, headache, blurring of the
vision, bleeding or discharge per vagina and any other unusual symptoms.
3. Specific Health Protection

Specific 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 are
anemic in the last trimester of pregnancy. The major causative factors are iron and
folic acid deficiencies. Anaemia is known to be associated with high incidence of
premature births, postpartum haemorrhage, and puerperal sepsis and thromboembolic
phenomena in the mother.

Anaemia

Surveys in different parts of India indicate that about 50 to 60 percent of women

belonging 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 known that
anaemia per se is associated with high incidence of premature births, postpartum
haemorrhage, and puerperal sepsis and thromboembolic phenomena in the mother.

Other Nutritional Deficiencies

Protection is required against other nutritional deficiencies that may occur during
pregnancy such as protein, vitamin and mineral deficiencies. So Vitamin A and D
capsules should be supplied for the pregnant mother.

Toxemias of Pregnancy

The presence of albumin in urine and increase in blood pressure indicates toxemias of
pregnancy. Their early detection and management are indicated. Efficient antenatal
care minimizes the risk of toxemias of pregnancy.

Diabetes

This plays an important role for presentational diabetes. To prevent early pregnancy
loss and congenital anomalies, medical care should begin before conception. A
complete assessment of the diabetic status and associated complications is done to
find out if she is fit to go through pregnancy.

Evaluation of thyroid function is also recommended in type 1 diabetes as hypothyroidism

is frequently encountered in these women. Those on oral hypoglycemic agents should be
switched to insulin therapy preferably before conception.

Tetanus Protection

If the mother was not immunized earlier, two doses of tetanus toxoid should be given,
th th th th
the first dose at 16 to 20 week and the second dose at 20 to 24 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
subsequent pregnancies for the next five years.
Rubella

Rubella infection suffered by the mother, especially in early pregnancy can have
devastating consequences for the fetus. In an attempt to reduce the incidence of
congenital rubella defects, vaccination has been undertaken.

HIV Screening

Pregnant women are ethically obligated to seek reasonable care during pregnancy and to
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 from an
HIV – positive mother to her fetus ranges from 25% to 35%. Methods of preventing
maternal – fetal transmission ad fetal treatment currently are not available. Until there is
change in technology that alters the diagnosis or treatment of the fetus, testing of the
pregnant woman should be voluntary. Health care providers have an obligation to make
sure 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 infant
during delivery or breast feeding. About one third of the children of HIV positive mothers
infected through this routine. The risk of transmission is higher if the mother is newly
infected or if she has already developed AIDS. Prenatal testing for HIV infection should
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 disease or use illicit
injectable drugs). Universal confidential voluntary screening of pregnant women in high
prevalence areas may allow infected woman to choose therapeutic abortion, make an
informed decision on breast feeding or receive appropriate care.

Hepatitis B

Screening for hepatitis B aims to determine whether the patient has ever been exposed
to the virus, and whether is immune to the virus or whether she is a potential risk of
transmitting the infection to the neonate, her partner and to health care professionals.
A combined course of active and passive immunization can then be undertaken in the
neonate at risk after birth. The importance of preventing hepatitis B infection in the
neonate is that while in the adult patient the virus is cleared within 6 months in 90
percent of infected individuals, in neonates 90 percent become chronic carriers with
the risk of post infective hepatitis cirrhosis and hepatocellular carcinoma.

Syphilis

Screening for syphilis should be performed for the prevention of congenital syphilis in
the neonate. Treatment confers benefits to mother too, by preventing development of
cardiovascular and neurological complications of the advanced stages of the disease.

Syphilitic infection in the woman is transmissible to the fetus, especially when she is
th
suffering from primary or secondary stages after the 6 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.
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
would be to test blood for syphilis both early and late in pregnancy. Congenital
syphilis is easily preventable. Ten daily injections of procaine penicillin ( 600,000
units) are almost always adequate.

German Measles

Rubella infection contracted during the first 16 weeks of pregnancy can cause major
defects such as cataract, deafness and congenital heart diseases. Vaccination of all
women of child bearing age, who are seronegative, is desirable. Before vaccinating, it
is desirable that pregnancy is ruled out and effective contraception be maintained for
eight weeks after vaccination because of possible risk to the fetus from the virus,
should the mother become pregnant.

Rh Status

It is a routine procedure in antenatal clinics to test the blood for Rhesus type in early
pregnancy. If the woman is Rh- negative and the husband is Rh-positive, she is kept under
surveillance for determination of Rh- antibody levels during antenatal period. The blood is
th th th
further examined at 28 week and 34 to 36 week of gestation for antibodies. Rh anti –
th
D immunoglobulin should be given at 28 week of gestation so that sensitization during
the first pregnancy can be prevented. If the baby is Rh positive, the Rh anti-D
immunoglobulin is given again within 72 hours of delivery. It should also be given after
abortion. Post maturity should be avoided. Whenever there is evidence of hemolytic
process in fetus in utero, the mother should be shifted to an equipped center specialized to
deal with Rh problems. The incidence of hemolytic disease due to Rh factor in India is
estimated to be approximately one for every 400-500 live births.

Prenatal Genetic Screening

Screening for genetic abnormalities and for direct evidence of structural anomalies is
performed in pregnancy in order to make the option of therapeutic abortion available
when severe defects are detected. Typical examples are screening for trisomy-21 and
severe neural tube defects. Women aged 35 years and above, and those who already
have an afflicted child are at high risk.

4. Preparing for Confinement

The preparation for safe delivery is very important. It should be done well in advance
to avoid 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 family
about the alternative suitable place for confinement which includes home, health
centre or hospital. The decision will depend upon the health status of both mother and
the fetus, risk factors and environmental conditions at home.

High risk mother must be delivered at primary health center, first referral unit or hospital
at the discretion of doctor. However a normal healthy mother may be delivered at home.
But she must be delivered by a trained birth attendant, female health worker (
ANM),health supervisor ( LHV) to protect the life of both mother and the baby and
prevent them from any infection especially tetanus. It is important to arrange transport
in advance for transportation of mother to hospital or first referral unit during
emergency, 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 the
following 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 that
there is no problem at the time of delivery. The instructions must be given to another
regarding these. Similarly the trained dais and health workers should be ready with
their delivery kit for conduct of delivery at home.

5. Psychological preparation of the mother

Psychological preparation of the mother is important during pregnancy and delivery. The
expectant mother, especially the primary Para mother has fear and anxiety about child
birth, its outcome, and complications etc.It is very important to discuss various aspects of
pregnancy and delivery .This helps in overcoming their fears and anxietes.Sufficient time
and opportunity must be given to expectant mothers to have free and frank talk on all
aspects of pregnancy and delivery. The “mother craft” classes at the MCH centers help a
great deal in removing their fears and in gaining confidence.
6. Family Planning

Family planning is related to every phase of the maternity cycle. Educational and
motivational efforts must be initiated during the antenatal period. If the mother has had
two or more children, she should be motivated for puerperal sterilization. The mother
should be educated and motivated for small family norm and spacing of children.

7. Education for Self – Care

Health maintenance is an important aspect of prenatal care. Patient participation in the

care ensures prompt reporting of untoward responses to pregnancy. Patient as
symptom of responsibility of health maintenance is prompted by understanding of
maternal adaptations to the growth of the unborn child and a readiness to learn. Nurses
in their role of teacher provide patients with the information necessary for compliance
with health care measures.

The expectant mother needs information about many subjects. During the initial
health assessment, the woman may have indicated a need to learn self care activities
such as prevention 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
reassure woman about her attractiveness, etc improved communication with her
partner, family and others, refer to social worker, if needed or supportive services
( financial assistance, food stamps)

First Trimester

Antenatal care in the first trimester starts with a visit to the GP after a missed period
and confirmation of pregnancy. It also provides an ideal opportunity for the woman to
discuss any anxieties she may have.

8. Hematological Investigations

These include hemoglobin estimation and a complete blood picture if indicated. Blood
group determination and antibody screen is also performed to identify rhesus negative
women who will need prophylaxis against rhesus isoimmunization.

Full blood count

This is the most commonly performed hematological investigation in pregnancy.

Pregnancy is associated with a physiological dilutional anemia due to greater increase
in plasma volume than red cell mass and therefore the lower limit for a normal Hb is
10.5 g/dl in pregnancy as opposed to 11.5g/dl in the non pregnant female. Many
women enter pregnancy with a low iron reserve and therefore if anemia is detected in
pregnancy it should be appropriately investigated by assessment of ferritin, total iron
binding capacity (TIBC), serum and red cell folate and B12 levels based on the blood
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 low
hemoglobin on admission in labour is an indication for sending a specimen to the lab
for group and save in case of intrapartum or postpartum bleeding.

Blood grouping and screening for antibodies

Blood grouping at booking, enables the determination women who are rhesus negative
and therefore may be at risk of rhesus isoimmunization. The incidence of rhesus
disease has dramatically fallen over the last thirty years the introduction of anti – D
administration. Despite screening at 28 and 34 weeks or after any potential sensitizing
event and administration of prophylactic anti – D at these times, a small number of
RhD negative women still develop anti-D antibodies because of small silent
hemorrhages predominantly in the third trimester or because of failure of timely
administration of anti D immunoglobulin. Screening for red cell antibodies should be
repeated in all women in early pregnancy in subsequent pregnancies, even if rhesus
positive, as there may be other clinically significant antibodies as a consequence of
previous pregnancy or blood transfusion. An antibody screen is performed to detect
the presence of antibodies that may put the baby at risk of hemolytic disease or result
in difficulties with cross- matching blood for the mother if required at any age of
pregnancy, labour or postnatally. If antibodies are detected, the titer is determined and
subsequent samples taken for further estimation at appropriate time interval.

9. Screening for Urinary Tract infection

Urinary tract infections may be asymptomatic. Whether symptomatic or not, urinary

tract infections present a risk to both mother and fetus. Prevention of these infections
is essential. The woman’s understanding and use of general hygiene measures are
assessed. Before developing a plan of care, the nurse needs to elicit feelings or ideas
concerning cultural, ethnic, religious, or other factors affecting health practices. The
rationale being that some cases asymptomatic bacteriuria and a lower urinary tract
infection 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
back after 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
urethral opening and increase risk of infection. Soft, absorbent toilet tissue, preferably
white and unscented, should be used because harsh, scented or printed toilet paper
may cause irritation. Women need to change panty shields or sanitary napkins often.
Bacteria can multiply on soiled napkins. Women need to wear underpants and
pantyhose with a cotton crotch. They should avoid wearing tight – fitting slacks or
jeans or panty shields for long periods.

Some women don’t have an adequate fluid and food intake. After eliciting her food
preferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12 glasses)
of liquid a day.
10. Minor Disorder of Pregnancy

Most pregnant women do suffer from minor disorders during pregnancy. Minor
disorder is a condition caused by pregnancy, which is not present in the prepregnant
state. It should be solved in correct time to prevent complication offering minor
treatment and proper explanation for the reduction of these problems and anxiety. The
exact cause of minor disorders are still unknown but it could be due to increasing level
of 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, are It
usually common in primigravida. may due to emotional factors, fatigue, and
carbohydrate metabolism. So it is important to prevent it from getting worse as
hyperemesis gravidarum may occur.

Prevention

o 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 night
o Advice to take light and dry snacks instead of heavy meal.
o Avoid brushing after eating.
o Keep room well ventilated for fresh air.

Indigestion

Indigestion often occurs after eating too much of heavy or greasy food or drinking too
much of alcohol. It is characterized by discomfort or a burning feeling in the mid –
chest or stomach.

Prevention

Avoid fatty, greasy and spicy foods

 Eat small frequent meals instead of the usual three
meals. Avoid alcohol, coffee and cigarettes.
Eat boiled foods.

Varicose veins

Varicose veins are enlarged superficial veins on the legs; vulva and anus varicose
veins are 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.

Backache

This is common problem during pregnancy especially in the third trimesters. Slight
backache may be due to faulty posture and is more common in multigravida.It may be
due 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 women
occasionally 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
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 in
the 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.

Constipation

Constipation is a condition of infrequent, irregular and difficulty in passing stool or

the passing of hard stool. It is common during pregnancy. It is due to lack of physical
activity or exercise, decrease fluids, oral iron supplement, pressure of enlarging uterus
on 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.

Itching

Itching is an unpleasant cutaneous sensation that provokes a desire to scratch the skin.
It may 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 Cramps

Leg Cramps are painful muscle spasm in the muscles. They occur most frequently at night
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.
B. INTRANATAL NURSING

Childbirth is a normal physiological process, but complications may arise. Septicemia

may result from unskilled and septic manipulations, and tetanus neonatorum from the use
of unsterilized instruments. The need for effective intranatal care is therefore
indispensable, even if the delivery is going to be a normal one. The emphasis is on the
cleanliness. It entails – clean hands and fingernails, a clean surface for delivery, clean
cutting and care of the cord, and keeping birth canal clean by avoiding harmful practices.
Hospitals and health centers should be equipped for delivery with midwifery kits, a
regular supply of sterile gloves and drapes, towels, cleaning materials, soap and antiseptic
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 Care

Mothers with normal obstetric history may be advised to have their confinement in
their own homes, provided the home conditions are satisfactory. In such cases, the
delivery may 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 tension

Most deliveries will have to take place in the home with the aid of Female Health
Workers or trained dais. Domiciliary out reach is a major component of intranatal
health care: The Female Health Worker, who is a pivot of domiciliary care, should be
adequately trained to recognize the ‘danger signals’ during labour and seek immediate
help in transferring the mother to the nearest Primary Health Centre or Hospital. The
danger signals are:

Sluggish pains or no pains after rupture of members.

 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 collapse

2. Complications and obstetrical emergency during intranal period

Prolonged Labour

The prolonged labour may occur due to fault in power, fault in passage and fault in
passager 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 Contraction

Abnormal uterine contraction may be due to obstructed labour due to contracted

pelvic, congenital malformation of fetus like hydrocephalus, brow presentation,
neglected transverse 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 Labour

The obstructed labour may be due to contracted pelvis, cephalopelvic disproportion,

congenital malformation of the fetus etc.
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 and
respirations of the mother, examines her breasts, checks the progress of normal
involution of uterus, examines lochia for any abnormality, checks urine and bowels
and advices on perineal toileting. The immediate postnatal complications such as
puerperal sepsis, throbophlebitis and secondary haemorrhage must be kept in mind. At
th
the end of the 6 week, the woman needs an examination by the physician in the
health center to check up involution of the uterus, which should be complete by then.
Further visits should be done once a month during the first six months and thereafter
once in 2 to 3 months 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 common conditions found during the late postnatal period are sub involution of
uterus, prolapse of uterus and cervicitis. Postnatal examination offers an opportunity
to detect and correct these defects. Anemia if presents need to be treated. Health
education regarding affordable nutritious diet and postnatal exercises to restore the
stretched abdominal and pelvic muscles must be provided to enable the mother have a
normal post- partum period.

The psychological aspect of postnatal care needs to be addressed based on a

needs assessment. New mothers may have timidity and fears due to ignorance and
insecurity regarding the care of the baby. In order to endure the emotional stress of
childbirth, she requires the support and companionship of her husband as well as
encouragement and assistance of family. Fear and insecurity may be eliminated by
proper prenatal instructions, postnatal enforcing and supportive care .
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 period

Certain complications may arise during the postnatal period which is be recognized
early and dealt with promptly. These are as follows:

Puerperal sepsis

This is infection of the genital tract within 3 weeks after delivery. This is accompanied
by rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in
lower abdomen, etc. Puerperal sepsis can be prevented by attention to asepsis, before
and after delivery. This is particularly important in domiciliary midwifery service.

Prevention

Puerperal sepsis is to a great extent preventable. Certain measure should be taken

under before, 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.
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
nd
stool in 2 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 – phlebitis

This 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 to
do the leg exercise to increase the muscle tone.

Deep vein Thrombosis

It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence
of infection.

Prevention

The three important factors i. e. trauma, sepsis and anemia should be prevented and to
be treated effectively after detection. Dehydration during delivery should be promptly
corrected.
Leg exercise and early ambulation are encouraged especially following operative
delivery.

Postpartum Hemorrhage
Postpartum hemorrhage is the condition of excessive bleeding from the genital tract at
any time following the baby’s birth up to 6 weeks after delivery. It may occur at any
time that is during third stage of labour, with in 24 hours or after 24 hours of labour.

Preventive measures of PPH

SL.N Antenatal Period Intranatal Period Postnatal Period

1.  Ensure regular  Judiciously administer  Continue to monitor

antenatal care sedative, analgesic and vital signs
oxytocin
2.  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 needed
4.  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 hospital
5.  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.
Inversion of the uterus

The uterus is said to be inverted if it rums inside – out partially or completely during
delivery 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 urine

It is one of the common causes of puerperal pyrexia, the incidence being 15 % of all
deliveries. It is due to frequent catheterization either during labour or in early
puerperium to relieve retention of urine, recurrence of previous pyelitis, poor personal
hygiene and vaginal hygiene, trauma following instrumental delivery, poor fluid
intake. It is extremely important to look for these complications in the postnatal period
and prevent or treat them promptly.

Postnatal Blues

Pregnancy and puerperium are highly stressful periods in a woman’s life. The person
is threatened by various changes such as physiological changes, and endocrine
changes occurring in ones body, as she is in reorganization of psyche in accordance
with the new mother role especially in the first pregnancy. Body image changes and
unconscious intrapsychic conflicts related to pregnancy, childbirth, and motherhood
become activated. It is no wounder that 25% to %0% of the pregnant womrn develop
mild psychological symptoms in the puerperal period. The commonest type is the mild
depression and irritability known as the postnatal blues.

- Hein Roth 2006

Prevention

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 health

The second objective of postnatal care is to provide care whereby, the woman can
recuperate physically and emotionally from her experience of delivery. The broad
areas of this care fall into three divisions:
Physical

Postnatal Examinations

Soon after delivery, the health checks-ups must be frequent, i.e., twice a day during
the first 3 days, and subsequently once a day till the umbilical cord drops off. At each
of these examinations, the health personnel should checks temperature, pulse and
respiration, examines the breasts, checks progress of normal involution of the uterus,
examines lochia for any abnormality, checks urine and bowels and advises or perineal
toilet including care of the stitches, if any. The immediate postnatal complications,
puerperal sepsis, thrombophlebitis, secondary haemorrhage should be kept in mind. At
the end of 6 weeks, an examination is necessary to check up involution of the uterus
which should be complete by then. Further visits should be done once a month during
the 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 the
FHWs to give at least 3 to 6 postnatal visits. The common conditions found on
examination during the late postnatal period are sub involution of uterus, retroverted
uterus, prolapse of uterus and cervicitis. Postnatal examination offers an opportunity
to detect and correct these defects.

Anemia

Routine hemoglobin examination should be done during postnatal visits, and when
anemia is discovered, it should be treated. In some cases it may be necessary to
continue treatment for a year or more.

Nutrition

Though a malnourished mother is able to secrete as much breast milk as well

nourished one, she does it at the cost of her own health. The nutritional needs of the
mother must be adequately met. Often the family budget is limited, the mother should
be shown the means how she can eat better with less money.

Postnatal Exercises

Postnatal exercises are necessary to bring the stretched abdominal and pelvic muscles
back to normal as quickly as possible. Gradual resumption of normal house – hold
duties may be enough to restore one’s figure .

Psychological

The next big area of postnatal care involves a consideration of the psychological factors
peculiar to the recently delivered woman. One of the psychological problems is fear which
is generally borne of ignorance. Other problems are timidity and insecurity regarding the
baby. If a woman is to endure cheerfully the emotional stresses of childbirth, she requires
the support and companionship of her husband. Fear and
insecurity may be eliminated by proper prenatal instruction. The so called postpartum
psychosis is perhaps precipitated by birth, and it is rather uncommon.

Social

It has been said that the most important thing a woman can do is to have a baby. This is
only part of the truth. The really important thing is to nurture and raise the child in a
wholesome family atmosphere. She, with her husband, must develop her own methods.

3. Breast – feeding

Postnatal care offers an excellent opportunity to find out how the mother is getting
along with her baby, particularly with regard to feeding. For many children breast
milk provides 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
th
for 18 months or longer.

Postnatal care includes helping the mother to establish successful breast-feeding. For
many babies breast milk provides the main source of nourishment in the first year of
life. When the standard of environmental sanitation is poor and education low, the
content of feeding bottle is likely to be as nutritionally poor as it is bacteriologically
dangerous. It is therefore very important to advise mothers to provide exclusive breast
feeding in the initial months.

4. Respiratory Distress Syndrome and Neonatal Problems

Asphyxia Neonatorum

Asphyxia neonatorm is defined as failure to initiate and maintain spontaneous

respiration within one minutes of birth. It may due to traumatic forceps or vaccum
delivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine hypoxia
due 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 syndrome

Respiratory distress syndrome almost always occurs in preterm babies. It may be due
to prematurely, maternal anemia, pre- eclampsia, diabetes, APH after 28 weeks of
gestation, intrauterine hyposia etc.
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 haemorrhage

The intracranial injury and haemorrhage is due to trauma, rapid compression as in

breech delivery, face presentation, instrumental delivery.

Prevention
Comprehensive intranatal and antenatal care is the key to success in the reduction of
intracranial 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 babies

Comprehensive antenatal and intranatal care is the key to success in reduction of birth
trauma and consequently in the reduction of perinantal mortality and neonatal
morbidity.

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 period

During normal delivery

Continuous fetal monitoring to detect fetal distress, extract baby before he become
compromised. This can prevent traumatic cerebral anoxia.
 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 steromastoid

Special 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 one

Ventouse Delivery

It is relatively less traumatic, but it should be avoided in preterm babies.

Vaginal Breech Delivery

To prevent intracranial injuries: - The crucial period in breech delivery is during

delivery 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

forceps are being applied to the after coming head or delivery of the head.

To prevent fracture: - The limbs are delivered in a manner described in breech

delivery.

6. Major Disorders of Newborn Baby

Ophthalmia Neonatorum

Ophthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks of life

which 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.
 • The midwife and mother should always wash her hand before touching the
baby’s face.

Neonatal Tetanus

Neonatal 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.

Omphalitis

Acute omphalitis is an infection of umbilical stump. It is usually mild as present as a

scanty 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 Planning

Every attempt should be made to motivate mothers when they attend postnatal clinics
or during postnatal contacts to adopt a suitable method for spacing the next birth or for
limiting the family size as appropriate. Contraceptives that will not affect lactation
may be prescribed immediately following delivery after a physical examination.

8. Health Education to Mother and Family

Health education during the postnatal period should cover the following areas:
• 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 environmental

Maternal and neonate’s personal hygiene should be maintained to prevent infection.

Vulval care and daily bathing should be done as lochia drainage occurs. Cleanliness
helps her to fresh and activates energy to care.Perineal care should be done to observe
the amount, colour, odour and consistency of the lochia, to keep the stitch clean, dry
and help in fast healing, to prevent local and ascending infection.

• Breast Care

Breast care is very important for both mother and baby because it prevents from
infection, so the mother should advised to clean her breast before and after each feed
with clean water and hand washing too. Advice to wear clean brassiere.

• Breast Feeding of infant

Breast milk has anti infective properties that protect the infant from infection in the
early months. It is a complete food and provides all nutrients needed to infant in the
first few months. So encourage mother to feed the breast feeding for her baby.

• Care of the Newborn baby

The care of the newborn baby is very important to make sure baby is thriving and to
detect early sign of illness and abnormalities and treat it accordingly.

• Care of the umbilical cord

Cleanliness of the umbilical cord is essential. The cord is to be inspected once more
for evidence of slipping of ligature. Dressing with bland power and cord binder are
not favoured in places where the baby is placed in a clean environment. However the
cord should be cleaned at least twice a day and should be observed if there is bleeding
from the site of the cord. And also advice the mother and family members not to
enclosed within the baby’s napkin where contamination by urine or faces may occur.
• Bathing the baby

Bathing the baby is also very important to keep clean and comfortable for the baby, to
maintain blood circulation, to prevent from infection, to detect any abnormalities or
infection and treat it accordingly.

• Nutritious diet for the mother

It 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, so
mother should eat highly nutritious foods and soups high in protein and carbohydrate
e.g. Jawno KO soup, meat soup, Dal soup, chaku etc.

• Postnatal Exercise

Postnatal exercise is the exercise done after delivery in postnatal period which is very
important to improve blood circulation, to help in involution of reproductive organs,
to prevent thrombosis and thrombophlebitis, to promote well being of the postnatal
mother, to restore the tone of the abdominal the pelvic muscles, for proper drainage of
lochia. So advice mother to do postnatal exercise.

• Rest, sleep and activity

Mother should have 1o hours rest at night and 1-2 hours at afternoon till 40-60 days of
delivery. Heavy working, heavy lifting should be avoided in puerperium because it
predispose to uterine prolapse.

• Pregnancy spacing

Mother and family members should be advised about the importance of pregnancy
spacing. There should be at least the gap of 2 years of pregnancy spacing.

• Health check up for mother and baby

Regular health check up and follow up for mother and baby is very important with in
puerperium period.

• Prevention of infection in the baby

Midwives have an important role to play in creating a safe environment that decreases
the 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.
 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 registration

CONCLUSION

Preventive obstetrics is the concept of prevention or early detection of

particular health deviations through routine periodic examinations and screenings. The
concept of preventive obstetrics concerns with the concepts of the health and well-
being of the mother and her baby during the antenatal, intranatal and postnatal period.
It aims to promote the well- being of mothers and babies and to support sound
parenting and stable families. Nursing care centered on health promotion and health
maintenance during pregnancy presents an excellent opportunity for nurses to teach
expectant mothers 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 as follows:-
• Antenatal Nursing
• Intranatal Nursing
• Postnatal Nursing

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