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Course: Maternity Nursing

Topic: Prenatal Assessment and Assessment of Risk Factors

The Nurses International Community

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Module Goals

The learner will be able to:

Describe the sequence of prenatal visits
List the critical lab tests performed during each stage of pregnancy
Identify maternal risk factors
Describe the elements of patient teaching session

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What is Prenatal Visit?

Significance of Prenatal Visits

The prenatal visit is a meeting between the health care provider and pregnant woman that occurs periodically throughout her pregnancy, and where the pregnant woman is assessed for pregnancy health factors, and fetus is evaluated for expected health and growth patterns

Assessment is the first step for decision-making to promote a healthy outcome
Prenatal visits ensures comprehensive maternal and fetal assessment
Prenatal visits helps in early identification of potential risk factors/complications

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Sequence of Prenatal Visits

WHO (2016) Current recommendations for eight prenatal visits:

Initial visit up to week 12, then at week 20 , 26, 30, 34, 36, 38 and 40

Pregnant mothers return for delivery at 41 weeks if not given birth by then

First prenatal visit should be made as soon as pregnancy is diagnosed
Subsequent visits made according to the advice of the health care provider based on individual needs of the pregnant woman

Partial source: WHO (2016). Recommendations on antenatal care for a positive pregnancy experience.

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2016 WHO ANC Guidelines

Source: WHO (2016). Recommendations on antenatal care for a positive pregnancy experience.

WHO FANC model	2016 WHO ANC model
First trimester
Visit 1: 8-12 weeks	Contact 1: up to 12 weeks
Second trimester
Visit 2: 24-26 weeks	Contact 2: 20 weeks Contact 3: 26 weeks
Third trimester
Visit 3: 32 weeks Visit 4: 36-38 weeks	Contact 4: 30 weeks Contact 5: 34 weeks Contact 6: 36 weeks Contact 7: 38 weeks Contact 8: 40 weeks
Return to delivery at 41 weeks if not given birth.

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Subsequent Visits

Low risk patient receives care during the first trimester, the subsequent visits can be arranged as follows:
Every 8 weeks until 28 weeks
Then at 34 weeks
Then primigravida are seen every 2 weeks from 36 weeks
Multigravida are seen at 38 weeks and every two weeks after that unless breech presentation was found during 34 week visit
Primigravida are seen at 40 and 41 weeks , while multigravida are only seen at 41 weeks, if they have not delivered by then

(Bettercare/Primary Maternal care)

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Activities of Prenatal Visit

Comprehensive health history (first antenatal visit)
Comprehensive physical examination (Both mother and fetus)
Lab tests/screening tests
Identification of potential risk factors
Prenatal patient teaching
Information about the next prenatal visit

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Prenatal Visit: Comprehensive Health History

Pregnant woman receive a comprehensive health history in the first prenatal visit that is documented for continuity of care

Comprehensive health history includes:

Previous obstetric history
Present obstetric history
Medical history
History of medication and allergies
Surgical history
Family medical history
Social circumstances of the patient

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Prenatal Visit: Comprehensive Physical Examination

Comprehensive physical examination must be carried out at each visit.
Components of comprehensive physical exam are:

General examination

Height, weight, general appearance
Routine urinalysis and test for urine glucose and protein
Vital signs

Systems examination

Thyroid gland, breasts, lymph nodes in neck/axillae/inguinal areas
Respiratory System and Cardiovascular system
Both external and internal genitalia
Abdomen: general appearance and palpation, fetal- lie and position, fetal heart rate

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Case study:

A healthy 18-year-old primigravida attends her first antenatal visit at 22 weeks pregnancy. Her rapid syphilis and HIV tests are negative. Her Rh blood group is positive. She is classified as at low risk for problems during her pregnancy.

What is the best time for a pregnant woman to attend an antenatal care clinic for the first time?

When should this patient return for her next antenatal visit?

Contact info: info@nursesinternational.org

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Prenatal Visit: Laboratory/Screening Tests

Significance of lab tests/screening tests:

Diagnose or rule out health risks
Corroborate the findings from health history and physical assessment.

Lab tests/screening tests for pregnancy:

Blood tests: Blood group, Rh factor, Haemoglobin, blood sugar, Sexually transmitted infections (STIs), Triple screen test
Urine tests: Protein, glucose, Urinalysis
Ultrasonogram

Cervical smear cytology
Group B Strep test
Vaginal smears: Syphilis, Gonorrhea, Chlamydia, Bacterial vaginosis, Listeriosis

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Prenatal Laboratory Tests: Blood Test

Haemoglobin (Hgb) :

Tested at first visit, then at 28 and 36 weeks
Hgb >12 g/dl is normal lab finding

Serum glucose :

Test at 24 weeks
Random blood glucose must be tested if glycosuria is present at any prenatal visit

Partial source: WHO (2015). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (3rd ed.). Luxembourg: World Health Organization.

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Prenatal Laboratory Tests: Blood Tests

Blood group and Rh factor:

Blood grouping and Rh factor test should be done at first antenatal visit
Women with Rh negative factor must be tested for Rh anti-D antibodies at first visit, 26, 32 and 38 weeks
If Rh anti-D antibodies are identified in the blood, the husband or partner blood should be tested for antigen
For anti-D antibody titre below 1:16 in woman, the titre test should be repeated within 2 weeks
Rh negative women are given immune-globulin at:

first injection at 28 weeks gestation
second injection within 72 hours of giving birth

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Prenatal Lab Tests: STIs Screening

Syphilis :

if syphilis rapid test positive, confirm with VDRL or RPR titre test
VDRL or RPR titre 1: 16 is positive for syphilis
If VDRL or RPR titre is 1:8 or lower, then confirm with TPHA or FTA test

HIV:

NAT, Antibody/Antigen test, Rapid HIV test
If one rapid HIV screening test result is positive, confirm positive result with another rapid test using a kit from a different manufacturer

If the first syphilis and HIV screens are negative, test repeated at 30 weeks

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Acronym:

VDRL: Venereal Disease Research Laboratory test

RPR: Rapid Plasmin Reagin

TPHA: Treponema Pallidum Haemagglutin Assay

FTA: Fluorescent Treponemal Antibody

According to Center for Disease Control website:

There are three types of HIV tests available: nucleic acid tests (NAT), antigen/antibody tests, and antibody tests. HIV tests are typically performed on blood or oral fluid. They may also be performed on urine.

A NAT looks for the actual virus in the blood and involves drawing blood from a vein. The test can either tell if a person has HIV or tell how much virus is present in the blood (known as an HIV viral load test). While a NAT can detect HIV sooner than other types of tests, this test is very expensive and not routinely used for screening individuals unless they recently had a high-risk exposure or a possible exposure and have early symptoms of HIV infection.
An antigen/antibody test looks for both HIV antibodies and antigens. Antibodies are produced by immune system when exposed to viruses like HIV. Antigens are foreign substances that cause your immune system to activate. If you have HIV, an antigen called p24 is produced even before antibodies develop. Antigen/antibody tests are recommended for testing done in labs and are now common in the United States. This lab test involves drawing blood from a vein. There is also a rapid antigen/antibody test available that is done with a finger prick.
HIV antibody tests only look for antibodies to HIV in blood or oral fluid. In general, antibody tests that use blood from a vein can detect HIV sooner after infection than tests done with blood from a finger prick or with oral fluid. Most rapid tests and the only currently approved HIV self-test are antibody tests.

(https://www.cdc.gov/hiv/basics/hiv-testing/test-types.html )

Performing the Syphilis rapid test: (Bettercare/Maternal Care)
Prepare the Abbott Determine TB Whole Blood Assay kit that contains 10 cards with 10 tests.
EDTA capillary tubes marked to indicate 50 μl, lancets, alcohol swabs, and sterile gauze swabs.
Clean patient’s fingertip with an alcohol swab and allow the finger to dry.
Remove a test strip from the foil cover.
Prick the skin of the fingertip with a lancet. Wipe the first drop of blood away with a sterile gauze swab.
Collect the next drop of blood into the EDTA tube. Either side of the tube can be used to collect blood. Fill the tube from the tip to the first black circle (i.e 50μl blood). Avoid the collection of air bubbles.
Apply the 50μl of blood from the EDTA tube onto the sample pad marked with an arrow on the test strip.
Wait until all the blood has been absorbed into the sample pad and then apply 1 drop of Chase Buffer. The bottle must be held vertically (upside down) above the test strip when a drop of the buffer is dropped onto the sample pad.
Wait a minimum of 15 minutes and then read the result. The maximum waiting time for reading the test is 24 hours. After 24 hours the test becomes invalid.
Reading the results of rapid test:
Positive: A red bar will appear within both the Control window and the Patient window on the test strip. Any visible red bar in the patient window must be regarded as positive.
Negative: A red bar will appear within the Control window but no red bar is seen in the Patient window.
Invalid: If no red bar appears in the Control window, even if a red bar is visible in the Patient window, the result is invalid and the test must be repeated.

Interpretation of the syphilis rapid test:

A positive test indicates that a person has antibodies against syphilis which means person either has active (untreated) syphilis or was infected in the past and no longer has the disease.
A negative test indicates that the person does not have syphilis in present or in past, unless was very recently infected and has not formed antibodies yet.

Performing HIV Rapid Test:

Clean the patient’s fingertip with an alcohol swab and allow the finger to dry.
Remove a test strip from the foil cover.
Prick the skin of the fingertip with a lancet. Wipe the first drop of blood away with a sterile gauze swab.
Collect the next drop of blood with the EDTA tube. Either side of the tube can be used to collect blood. Fill the tube from the tip to the first black circle (i.e. 50 μl of blood). Avoid the collection of air bubbles.
Apply the 50 μl of blood from the EDTA tube onto the sample pad marked with an arrow on the test strip.
Wait 1 minute until all the blood has been absorbed into the sample pad and then apply 1 drop of Chase Buffer. The bottle must be held vertically (upside down) above the test strip when a drop of the buffer is dropped on the sample pad.
Wait a minimum of 15 minutes and then read the results. The maximum waiting time for reading the test is 24 hours. After 24 hours the test becomes invalid.
Reading the results of HIV rapid test:
Positive: A red bar will appear within both the Control window and the Patient window on the test strip. Any visible red bar in the Patient window must be regarded as positive. The result is positive even if the patient bar appears lighter or darker than the control bar.
Negative: A red bar will appear within the Control window and but no red bar is seen in the Patient window.
Invalid: If no red bar appears in the Control window, even if a red bar is visible in the Patient window, the result is invalid and the test must be repeated.

Interpretation of HIV rapid test result:

A positive test indicated that the person has antibodies against HIV and therefore is infected with HIV.
A negative test indicates that a person does not have antibodies against HIV therefore not infected with HIV, unless was recently infected and antibodies have not appeared yet.

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Prenatal Laboratory Tests: Triple or Quad Screen Test

The triple or quad screen test, is useful in screening for neural tube defects and other chromosomal abnormalities such as Down’s syndrome
Blood test between 15-20 weeks gestation
Maternal serum tested for levels of three or four proteins :

Alpha-fetoprotein (AFP)
Human Chorionic Gonadotropin (hCG)
Estriol
Inhibin-A

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Prenatal Lab Tests: Urine Test

Prenatal Lab Tests: Cervical Smear

Urine is tested for protein and glucose at every prenatal visit
If possible, all patient should have a midstream urine specimen sent for urinalysis, and then sent for culture to diagnose asymptomatic bacteriuria, if blood or pus is detected in the urine

A pap smear is performed for cytology when ;

Age 30 years or more without previous normal cervical smear report
With cervical smear reported abnormal or with cervix that looks abnormal
HIV positive patients without cervical smear reported as normal within the last year

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Glossary:

Asymptomatic Bacteriuria: Presence of bacteria in urine without any symptoms of bladder or kidney infections.

Procedure for testing urine:
Patient will collect fresh specimen of urine in a clean, dry container.
Reagent strip should be dipped such that all the reagent areas are covered and removed immediately.
Remove excess urine by drawing edge of the strip across the edge of the container.
Hold the strip horizontally close to the color chart on strip container label and compare the colors of the test strip with those on the charts.
Test results must be read within the time frame as instructed in the chart.

Lenstrip-5: result read after 30-60 seconds

Multistix: as instructed on the chart

Combi-9: read after 60 seconds

After 2 minutes the colours on the reagent strips no longer give a reliable result.

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WHO Guidelines for Screening and Treatment

of Cervical Pre-cancer

Early detection, by screening all women in the target age group, followed by treatment of detected precancerous lesions can prevent the majority of cervical cancers.
Cervical cancer screening should be performed at least once for every woman in the target age group where most benefit can be achieved: 30-49 years.
Cervical cancer screening, at least once, is recommended for every woman in the target age group, but this may be extended to women younger than age 30 if there is evidence of a high risk for CIN2+
HPV testing, cytology and visual inspection with acetic acid (VIA) are all recommended screening tests.
For cervical cancer prevention to be effective, women with positive screening test results must receive effective treatment.

Source: WHO (2014).Comprehensive cervical cancer control: a guide to essential practice (2nd ed.)

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WHO Guidelines for Screening and Treatment

of Cervical Pre-cancer

Continued…..

It is recommended to take either a “screen-and-treat” approach or a “screen, diagnose and treat” approach.
Decisions on which screening and treatment Approach to use in a particular country or health-care facility should be based on a variety of factors, including benefits and harms, potential for women to be lost to follow-up, cost, and availability of the necessary equipment and human resources.
In the screen-and-treat approach, the treatment decision is based on a screening test and treatment is provided soon or, ideally, immediately after a positive screening test (i.e. without the use of a diagnostic test).

Source: WHO (2014).Comprehensive cervical cancer control: a guide to essential practice (2nd ed.)

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WHO Guidelines for Screening and Treatment of Cervical Pre-cancer

The screen-and-treat approach reduces loss to follow-up, and can reduce the time lag for women to receive treatment.
Among women who test negative with VIA or cytology, the interval for re-screening should be three to five years.
Among women who test negative with HPV testing, re-screening should be done after a minimum interval of five years.
If cancer is suspected in women who attend screening, they should not be treated but should be referred to a facility for diagnosis and treatment of cancer.

Source: WHO (2014).Comprehensive cervical cancer control: a guide to essential practice (2nd ed.)

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Prenatal Screening Test: Group B Strep

Group B Streptococcus (GBS) is a type of bacteria often found in the urinary tract, digestive system, and reproductive tracts
Not a sexually transmitted infection
Usually does not cause health problems to the mother, but may sometimes cause:

Infection of urinary tract, chorioamnionitis
If passed to the infection to the fetus during vaginal delivery, may cause severe life threatening infection/sepsis in the newborn

Routine GBS testing done between 35 weeks and 37 weeks gestation

Samples from vagina and rectum taken with cotton swab
Culture samples tested in lab
result available in 1 to 3 days

Source: KidsHealth, October 2018, Group B strep and Pregnancy.

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Prenatal Screening Test: Ultrasonogram

Early ultrasonography screening benefits:

Accurately determines gestational age before 24 weeks
Diagnose multiple pregnancies early
Identify the site of placenta
Diagnose abruptio placenta ( a life threatening condition)
Diagnose severe congenital abnormalities

Nuchal fold thickness is soft marker of congenital defects

Thickness of >6 mm is abnormal at 18-22 weeks gestation

Identify short cervix which is a risk factor for premature delivery

Shortening of cervix if endocervical canal length < 3cm or <2.5 cm

Contact info: info@nursesinternational.org

According to Bettercare/Maternal Care/1.Antenatal care:
Patients who might benefit greatly from additional information which might be obtained:
Patients with gestational age of 14 to 16 weeks
patient aged 37 years or more because they have increased risk for having fetus with a chromosomal abnormality (especially Down syndrome).
patients with previous history or family history of congenital abnormalities. The nearest hospital with a genetic service should be contacted to determine the need for amniocentesis.

2. Patients with gestational age of 18 to 22 weeks:

those patients for whom accurate determination of the gestational age and EDD is very important like patient needing elective delivery (e.g with two previous caesarean sections, previous perinatal death, a previous vertical uterine incision or hysterotomy, and diabetes), gross obesity, previous severe pre-eclampsia or preterm labour before 34 weeks, Rhesus sensitisation where accurate determination of the duration of pregnancy helps in management of the patient.

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Case study:

A healthy 18-year-old primigravida has cancelled her 28 weeks prenatal visit for personal reasons and rescheduled for a 30 week prenatal visit.

Her rapid syphilis and HIV tests at the first antenatal visit, were negative.

Her Rh blood group is positive.

She was classified as at low risk for problems during her pregnancy in her previous visits.

What lab test/screening test should be done during this 30-week prenatal visit?

Contact info: info@nursesinternational.org

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Maternal Risk Factors

Maternal risk factors are assessed through collective information obtained from health history, physical exam, and laboratory/screening tests
Once all the test results have been obtained, the client is graded according to risk:

Low risk: no maternal or fetal risk factors present
Intermediate risk: has risks which requires some, but not continuous additional care
High risk: has risks requiring continuous additional care

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Maternal Risk Factor

Teenager, especially 15 years or below

risks for premature births, low birth weight

Anemia:

Hgb of 7-11 g/dl is moderate anemia
Hgb< 7 g/dl is severe anaemia
Pallor conjunctiva, nail beds, gums

High blood sugar together with glycosuria must be investigated further for diabetes.
High Blood Pressure

Systolic ≥ 140 mm/Hg and/or diastolic ≥ 90 mmHg

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Maternal Risk Factors

Pre-eclampsia:

High blood pressure with +1 proteinuria
Severe headache, blurred or double vision or flashes
Puffy face, swollen hands and legs

Preterm labor:

Multiple pregnancy
History of previous preterm labor
Polyhydramnios (excessive accumulation of amniotic fluid)

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Maternal Risk Factors

Blood group Rh factor:

If the woman has anti-D antibodies titre of 1:16 or higher, she has been sensitized to Rhesus D antigen
If the antigen was found in husband/partner’s blood, then these antibodies may endanger the fetus
These women must be referred to the hospital for further management of the patient

Positive Syphilis and HIV test

Cause congenital abnormalities
Can be fatal to both mother and baby if untreated

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Maternal Risk Factors

Antepartum haemorrhage

Can cause perinatal death
Common causes are abruptio placenta and placenta previa

Fetal lie- transverse

Horizontal to mother’s spine at 8 months
Fatal to mother and baby if not head down at time of birth

Pregnancy extending beyond 42 weeks gestation (post dates)

Increased risk of intrapartum fetal distress
Meconium aspiration
Intrauterine death

Complications in previous pregnancies

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Maternal Risk Factors

Fetal risk factors

Uterine growth is greater or less than 2 finger widths (2 cm) every month
If the symphysis-fundus height measurement is

Less than 10th percentile - assess causes for poor fundal growth
More than 90th percentile - assess causes for uterus larger than dates

Fetal heart rate is lower than 120 beats/min or higher than 160 beats/min
Fetal movement counts reduced to more than half of the usual counts, or less than 3 kicks in an hour

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Case study:

Tina arrives for her 28 weeks prenatal visit. In her previous prenatal visit she was classified as low risk for problems during her pregnancy.

What complications should the nurse look for in this patient at this visit?

When should she attend next prenatal visit if she and her fetus remain normal?

Contact info: info@nursesinternational.org

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Patient Teaching Concepts:

Planning of patient education involves:

Determining the patient’s readiness to learn
Assessing patient’s learning needs and abilities
Selecting an appropriate setting for patient education
Determining appropriate patient teaching methods

Patient teaching based on warning signs/risk factors include:

Explaining what the warning sign mean
Information on management and prevention
Provide instructions and contact information in the event of a problem

Provide information on health promotion
Address questions and concerns and discomforts

Contact info: info@nursesinternational.org

Assessment of learning needs, abilities, and patient’s readiness to learn is the first step to effective patient centered education.

According to the Aston & Oermann (2014):

informal and targeted conversations and observations during delivery of care are some of the strategies clinicians can use to collect data on these assessments.
‘One of the best strategies for assessment of learning needs and readiness to learn is by questioning patients about their understanding of their conditions, treatments, and what they want to learn. These questions should be open ended and probing.’
‘Asking the right questions and observing the patient's responses provide information about readiness to learn, and enables the clinician to identify misconceptions about the health problem and treatments.’
‘Being ready to learn means the patient is ready physically, psychologically and cognitively to engage in learning.’
Physical readiness to learn is influenced by health status and limitations because of patients condition, pain medications and other conditions
Psychological readiness is influenced by anxiety, stress, ability to concentrate, and developmental stage.
Cultural values and current health practices, learning styles, literacy, etc. also affect the readiness to learn

According to MedlinePlus, Jan 2019, Choosing effective patient education materials:

Agree with the patient on realistic learning objectives and select resources that fit the patient and help achieve these objectives
Find out how your patient likes to learn
Focus on what patient needs to know and not on what is nice to know.
Be aware of the patients limits and how much information they can handle at a time
Avoid fear tactics. Focus instead on the benefits of the education and inform patient on what to pay special attention to.
Using a mixed media approach often works best.
Consider factors such as literacy, numeracy and culture when developing a plan
Organize the information for easier comprehension
Partner with the patients by actively involving patients/support person in their learning process instead of just continuously providing information onesidedly.
Have teach-back and return demonstrations before moving to next learning topic.
Be aware that education plan may need to be adjusted based on patient health status and environmental factors.
Keep in mind that no resource is a substitute for one-on-one patient teaching.

According to MedlinePlus, Jan 2019, Maximizing your teaching moment:

After assessment of patients learning needs, readiness to learn, and selection of appropriate education materials and methods, you will need to-

Set up a good learning environment such as adjusting the lighting, privacy where necessary, adjust comfortable room temperature where possible, quiet environment, etc.
Pay attention to your own demeanor such as adopting right tone of voice, making appropriate amount of eye contact (based on cultural needs), having patience, sitting near (as culturally appropriate) and at eye level to the patient , etc.
Continuously assess patient’s concerns and readiness to learn by listening well and reading patients verbal and non verbal signals.
Involve patients support person where necessary

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Patient Teaching (Continued... )

All pregnant women should be provided education and counseling concerning :

Nutrition for mother and fetus (Prenatal and postnatal)
Exercise
Breastfeeding
Family Planning
Danger signs of pregnancy
Care of the newborn infant
Onset of labour and
Information about labor process included for primigravida
Avoiding HIV infections or management if HIV positive

Contact info: info@nursesinternational.org

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Patient Teaching - Danger Signs of Pregnancy

Symptoms and signs that suggest abruptio placentae:

Vaginal bleeding

Persistent, severe abdominal pain; decreased fetal movements

Symptoms and signs that suggest pre-eclampsia:

Persistent headache

Flashes before the eyes

Sudden swelling of the hands, feet, or face

Shortness of breath

Symptoms and signs that suggests preterm labor:

Rupture of the membranes;regular uterine contractions before due date for birth

Contact info: info@nursesinternational.org

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Case Study:

Rina, an 18 week primigravida complains of frequently needing to urinate, a burning sensation during urination, and lower back pain on the left side.

What would be the appropriate action for the nurse to take?

Contact info: info@nursesinternational.org

What would be the appropriate action for the nurse to take?

After listening to Rina’s complaints and concerns, the nurse would :

Inform the woman that she might have urinary tract infection (UTI) because her sign/symptoms.
Explain that UTIs are caused by infection of bacteria in urinary tract
Inform Rina that a midstream urine sample needs to be obtained.

Provide instructions to prevent UTI in the future.

The nurse would then tailor education on UTI and its prevention based on the level of knowledge Rina has about it. Nurse would provide following information:

Wiping from front to back after urinating or passing stool to prevent bacteria from entering the urinary tract.
Drinking plenty of water on a daily basis to help prevent UTI, and manage UTI infections along with antibiotic treatment.
Partner should clean their hands and genitals before sex.
Urinate right after having sex to help prevent spread of bacteria.

The nurse would then ask Rina to repeat “teach-back” the information nurse provided her on prevention of UTI to ensure she understood it.
Ask Rina if she has any more concerns or questions, and address then before ending the education session.

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Arranging Next Prenatal Visit

Arrangement for the next prenatal visit should be done at the end of every prenatal visit
Next prenatal visit should be based on the need of the pregnant woman
Inform the woman:

Date of the next visit
Location
Who will be seeing her
What to do in case of emergency
What to do if not able to make the visit

Contact info: info@nursesinternational.org

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Cultural Considerations

Sex-selective abortions practice vary among countries and cultures

Health care providers should be aware of the cultural practices in their areas
Health care providers should be aware of national regulations and policies for revealing sex of the fetus

Health care providers should be aware of any harmful or high risk cultural practices regarding pregnancy in their areas

Contact info: info@nursesinternational.org

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Reference:

Aston, K., & Oermann, M.H. (2014). Patient education in home care: Strategies for success. Home Healthcare Now, 32 (5); 288-294. Retrieved from: https://www.nursingcenter.com/journalarticle?Article_ID=2460148&Journal_ID=2695880&Issue_ID=2460020

BetterCare- Primary Maternal Care/Maternal Care

https://bettercare.co.za/learn/maternal-care/text/01.html#side-room-and-special-screening-investigations

Center for Disease Control (2020). Diagnosis of birth defects. Accessed from: https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html

Contact info: info@nursesinternational.org

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Reference:

Khoshnaw, K.t., et al. (n.d.). Shortening of cervical canal. Radiopaedia.Accessed from: https://radiopaedia.org/articles/shortening-of-the-cervical-canal?lang=us

KidsHealth.Org, October 2018, Group B strep and Pregnancy. Retrieved from: https://kidshealth.org/en/parents/groupb.html?ref=search

KidsHealth.org, October 2018, Rh Incompatibility During Pregnancy.Retrieved from: https://kidshealth.org/en/parents/rh.html?ref=search

Contact info: info@nursesinternational.org

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Reference:

Klein, S. Miller, S., & Thomson, F. (2020) A Book for Midwives: Care for pregnancy, birth, and women’s health. Berkeley, California: Hesperian Health Guides.

https://en.hesperian.org/hhg/A_Book_for_Midwives:Questions_in_a_pregnancy_health_history

Lab Test Online UK (2019). Cervical Cytology. The Association for Clinical Biochemistry and Laboratory Medicine. Accessed from: https://labtestsonline.org.uk/tests/cervical-cytology

Contact info: info@nursesinternational.org

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Reference:

Lally, M. & Valentine-French, S. (2019). Lifespan development: A psychological perspective (2nd ed.) Retrieved from: http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf . Under Creative Commons Attribution-Noncommercial-Share Alike 3.0 unported license http://creativecommons.org/licenses/by-nc-sa/3.0/

MedlinePlus, Jan 2014, Choosing effective patient education materials. Retrieved from: https://medlineplus.gov/ency/patientinstructions/000455.htm

MedlinePlus, Jan 2019, Maximizing your teaching moment. Retrieved from: https://medlineplus.gov/ency/patientinstructions/000460.htm

Contact info: info@nursesinternational.org

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Reference:

Qaqish, N., Gaillard, F., et al. (n.d.) Nuchal Fold. Radiopaedia Accessed from: https://radiopaedia.org/articles/nuchal-fold?lang=us

WHO (2016). Recommendations on antenatal care for positive pregnancy experience. Luxembourg: World health Organization. Retrieved from : https://apps.who.int/iris/handle/10665/250796

WHO (2014). Comprehensive cervical cancer control: A guide to essential practice (2nd ed.). Retrieved from: https://www.who.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/

Contact info: info@nursesinternational.org

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