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Course: Maternity Nursing�Topic: Nursing Care in Antenatal Period�

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Module Goals

The learner will be able to:

Define antenatal care
Recognize the physiological changes in pregnancy
Describe common discomforts of pregnancy and safe management practices
State key warning signs & symptoms during pregnancy

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Antenatal Care:

Medical and nursing care and supervision from the time of conception to the onset of labor.
Consists of

Screening for pregnancy risk factors
Periodic assessments to prevent and treat pregnancy complications
Patient education regarding pregnancy and delivery and care of the newborn

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Why Antenatal Care?

Early identification of pregnancy risk factors
Reduces child and maternal mortality
Provides emotional support
Provides patient centered education
Ensures a labor and delivery plan
Counselling and care for HIV, malaria, TB and other conditions
Supports patient adjustment to motherhood

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It helps to provide the necessary medical and nursing care needed up to the birth of the baby. It may include screenings of pregnancy (Mother: anemia, sexually transmitted diseases, systemic diseases, cervical cancers, etc. Fetus: Gross anomaly, fetal growth patten, developmental stages, well-being).
It helps to identify the risk associated with the pregnancy and prepare the family and care providers to address these risks (sometimes referrals have to be made based on the severity of risks associated with the pregnancy and childbirth).
It reduces the chances of stillbirths (with continuous monitoring). Child and maternal mortality is decreased with effective medical and nursing management.
The pregnant woman during the antenatal care is provided with the relevant information about the pregnancy, nutrition and birth along with the phases of pregnancy. This builds self-confidence and develops trust and understanding with the health system.
Assures counseling on HIV, Malaria, TB: Pregnant women who have such diseases remain vulnerable.
Plan the delivery: It helps the woman and family to choose the place of the birth (community, hospital, birth centers) and mode of delivery (normal, C-section).
It provides support and encouragement to the woman and her family about the psychological adjustments of pregnancy, childbirth, breastfeeding, and parenthood.

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Antenatal Care Components:

A complete health history
Physical examination
Calculation of duration of pregnancy
Screening tests
Identification of high-risk patients
Patient education

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Please refer Maternal History Slide Deck https://docs.google.com/presentation/d/1GdL1aILiZo75RyN7A_vRRGfWcRMrci2d/edit#slide=id.p1 for maternal history
Please refer Maternal Physical Examination Slide Deck https://drive.google.com/file/d/1oT5M0JlshSVtmbsh_UAPF8md489AsFd5/view?usp=sharing for Physical Examination
(Physical Examination: Comprises of General, Obstetric and midwife examination)

The duration of pregnancy is established by assessing the last normal menstrual period, size of the uterus on bimanual or abdominal examination (up to 18 weeks), the height of the fundus at or after 18 weeks, and with the help of an ultrasound examination.
Important Screening test (laboratory and diagnostics): Special screening test for Syphilis, HIV, Rhesus type, pap smear (cervical cancer for 30 or above), routine urine test, glucose, complete blood count, ultrasound). Recommended tests per maternal age: a pregnant woman above 35 years would be prescribed a blood test called Double Marker/triple marker/quad marker to identify the chromosomal abnormalities.
High-Risk Patients are identified: High-risk patients are identified during the antenatal visit by assessing the woman and fetus for the complications of risk factors. The risk factors may be co-morbidity or underlying diseases, maternal age (teenage or more than 40), vaginal bleeding, high blood pressure, diabetes, history of stillbirth, etc.
During antenatal visits, advice is given to the pregnant woman regarding the transitions, psychological and physiological changes, DOs, DONTs, coping strategies, nutritional needs.

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The Bundle of Joy Comes with a Price

Common Discomforts include:

Nausea and Vomiting
Swollen Breasts, Feet, and Veins
Constipation
Hemorrhoids
Frequent Urination and vaginal discharge
Shortness of Breath

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Common Discomforts (Contd..):

Difficulty getting up and down from a sitting or lying position
Hot flushes
Aches and pains
Mask of Pregnancy
Cramps
Leg pain
Headaches
Back Pain

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Discomforts of Pregnancy

First Trimester(0-14 weeks)	Second Trimester (15-28 weeks)	Third Trimester (29-42 weeks)
Breast tenderness Skin changes Morning sickness Increased urinary frequency Fatigue Backache, Headache Ligament pain Stuffy nose Bleeding gums Mood swings Ambivalence Irritability Depression Changing body image Fearfulness Increased sensitivity Indecisiveness Increased or decreased sexual desires	Skin changes Backache Headache Constipation Fainting/dizziness Heartburn Dyspnea Ligament pain, Varicose veins Ankle Edema Weight gain Leg cramps Increased fetal movements Stuffy nose Bleeding gums Increased vaginal discharge Mood swings Irritability Depression Changing body image Fearfulness Increased sensitivity Indecisiveness Increased or decreased sexual desires	Skin changes Slight nausea Increased urinary frequency Fatigue Backache/hip pain Headache Constipation Heartburn Dyspnea Ligament pain Varicose veins Ankle Edema Weight gain Leg cramps Fetal movements Hemorrhoids StufFy nose, Bleeding gums Increased vaginal discharge Mood swings, Irritability, Anxiety, Depression Insomnia Changing body image Fearfulness Increased sensitivity Indecisiveness Increased or decreased sexual desires

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Common Discomforts and Management

Nausea and Vomiting:

Resolves after first trimester

Management:

Dry Foods (toast)
Avoid oily and greasy foods
Small frequent meals
Hydration
Ginger ale, ginger tea, peppermint tea

Constipation and hemorrhoids:

Management:

Eat high fiber rich foods
Daily exercise
Drink water and fluids
Ice packs and sitz bath may help

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Nausea and vomiting:

Nausea and vomiting are common symptoms of most women during pregnancy. It usually occurs after the second week of the missed period and lasts till the first trimester. However, some women may not experience it while some women may have it throughout the pregnancy. Dry foods like toast, biscuits (taken before getting up from the bed) tend to help with nausea. Greasy and oily food have to be avoided as it is difficult for the gastrointestinal tract to digest and causes more acid. Small frequent meals will help to soothe nausea and vomiting and ensures nutrition. Water plays a vital role in nausea and vomiting (dehydration can cause nausea and vomiting), it helps to replace the fluid loss during vomiting, provides freshness. Research shows that ginger ale, ginger tea, and peppermint tea also helps to relieve nausea.

Constipation:

It is defined as the difficulty of passing stool and can occur at any stage of pregnancy. To prevent it, a pregnant woman should include more vegetables and fruits on her diet. Eat whole grains like brown rice, wheat, and flour. Water and fluids help to soften the stool. A minimum of Eight glasses of water is recommended every day during pregnancy. Light exercises like walking helps to prevent constipation. Home or plant remedies that soften the stool like Chia seeds, psyllium seeds may also help.

Hemorrhoids result from the inflammation of veins due to friction and pressure caused by hard stool. The lump-like structure appears inside or out of the rectum, and tends to be painful and may bleed. If bleeding occurs, the care provider should be notified.

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Common Discomforts and Management (Contd.)

Swollen Breasts: Soothing clothes, hydration, cooling down helps
Swollen Legs: elevate legs, cool down, less packaged foods
Swollen Veins: Elevate legs, use of stocking or bandages, Cool cabbage leaf (genital)

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Swollen Breast: A pregnant woman experiences tender and larger breasts as they prepare for breast milk. It may also feel itchy during the last months of pregnancy, a watery, yellowish fluid that may leak (which is normal). Advise the mother to eat a proper diet, stay hydrated, wear loose clothes that are made with natural fibers, and cool down (Note: heat and perspiration worsen the itchiness and tenderness). Application of raw cabbage leaves are known to alleviate tenderness and swelling.

Swollen Legs and Feet: This occurs as the growing uterus presses down the major blood vessels. It is more common in late pregnancy and seen more during the afternoon or in hot weather. Swelling improves if feet are kept up supported with pillows at least 2-3 times a day (or sleep with slightly elevated legs with the help of pillow). A pregnant woman should consume less packaged food, salty, and sugary drinks to prevent edema.

Swollen Veins: They are called varicose veins, they may appear on legs and genitals, and sometimes it may hurt. If it occurs in the feet, it can be relieved by elevating legs, wearing stockings, and elastic bandages. If it appears in the genital area, a cool cabbage leaf is found to help relieve pain and discomfort.

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Common Discomforts and Management (Contd.)

Difficulty getting up and down

Roll on side
Push up with hands
Stand up

Hot flushes:

Wear natural fabrics, cool clothes
Frequent showers
Hydration

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Common Discomforts and Management (Contd.)

Frequent urination

Due to pressure of growing fetus on the bladder

Vaginal discharge

Due to hormone changes

Heartburn & shortness of breath

Due to relaxed abdominal sphincter and pressure of upward growing fetus

(Choose small frequent meals, up-right position post meal )

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Frequent Urination and Vaginal Discharge: Occurs most often in the first and last months of pregnancy. As the growing uterus presses down the bladder, there remains a small space for urine storage. It is highly recommended not to hold the bladder and urinate as per the needs. Holding urine may cause discomfort, bladder infections, or vaginal infections (signs of infections that has to be watched and reported during the entire pregnancy).

Vaginal discharge happens more during pregnancy and happens more during the end of the pregnancy. It is not a sign of worry for a woman to have vaginal discharge. However, if the color and smell of discharge changes like green, gray, bad odor, itches, and burns, it could be signs of infections. In such a case, a doctor has to be consulted immediately.

Vaginal discharge ebbs and flows throughout a woman’s menstrual cycle due to a fluctuation in hormone levels. Once pregnant, hormones continue to play a role in the changes to vaginal discharge. Changes to the cervix during pregnancy also affect vaginal discharge. As the cervix and vaginal wall soften, the body produces excess discharge to help prevent infections. The baby’s head may also press against the cervix near the end of the pregnancy, which often leads to increased vaginal discharge.

Heartburn: The hormones of pregnancy causes the sphincter of the esophagus to relax resulting in the acid of the stomach coming out into the esophagus. In addition to that, the increased volume of the uterus also pushes the GI organs up adding more refluxes (happens more during the end of gestation). It can be avoided by sitting upright for 30-40 minutes post meals. It wise to take small frequent meals, less spicy foods to decrease acidity. Nevertheless, in the case of severe acidity, a doctor may prescribe antacid to relieve discomfort.

Many women get shortness of breathing as the lungs do not have enough room to expand. It is a normal phenomenon. If severe, it is advised to seek medical help.

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Common Discomforts and Management (Contd.)

Mask of Pregnancy:

Harmless dark colored areas may appear on face, breast and abdomen.

Wearing hat and quality sunscreens helps.

Cramps and sudden pain in the side of lower abdomen:

The growing uterus causes cramps. Watch for contractions that are regular and frequent

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Mask of Pregnancy: During pregnancy, dark-colored areas and pigments may appear on the face, breast, and belly. It may trouble woman but these are generally harmless and goes away with the birth. To avoid it, a woman can wear a hat. Some women may develop purple pigments or on their arms due to enlarged underlying vessels. They are also not harmful and goes away with the birth.

Cramps: A Pregnant woman might be worried when she experiences mild cramps (like period pain) in the first three months. It happens as the uterus grows in size. It is normal to have mild cramps (like mild monthly bleeding cramps) at times during the first three months of pregnancy. These cramps happen because the womb is growing. Sometimes cramps come and go or even become consistent (sometimes a woman even might have a strong and painful contraction with spotting or bleeding. Such cramps are considered warning signs. It could indicate tubal pregnancy or miscarriage. If these symptoms appear, one should seek medical help immediately.

On the other hand, the sudden sharp pain in the side of the lower abdomen is felt (during sudden movements) due to the stretching of the ligaments (round ligaments) which hold the uterus from either side. This is not dangerous, and the pain will go away in a few minutes. In case it is painful, putting on warm clothes and stroking the belly will help in easing pain.

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Common Discomforts and Management (Contd.)

Foot or Leg pain:

Flexing foot upward, fluids

Headaches:

Massage, hydration

Report headaches with visual changes

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Foot or leg pain: Many women get a sharp pain and tingling at night or when they stretch and point their toes. To manage it, flex feet (pointing upward).

However, leg pain can be dangerous if there is swelling or warmth in one leg or foot, pain in the leg while walking or squeezing, painful red area, or a hard lump like structure in the legs. It could be dangerous (Deep Vein Thrombosis) and need medical attention.

Management of simple leg pain:

Calcium and potassium-rich food help prevent leg pain. Simple acts like not pointing toes can help relieve the cramps.

Headaches:

Are common in pregnancy but are usually harmless. Headaches may stop with rest and relaxation and hydration. INstruct mother to drink more juice or water, or gently massages temples. No medication should be taken unless prescribed by the care practitioner.

Some women have migraine headaches. These often on the side of the head. The woman may see spots and feel nauseated. Bright light or sunshine can worsen migraine headaches. Migraines may worsen in pregnancy.

Migraine medication is contraindicated in pregnancy. It may cause preterm labor and harm to the fetus. Resting in a quiet dark room may help. The mother should talk with her health care provider if headaches become troublesome.

* Headaches late in pregnancy are a warning sign of preeclampsia, especially if there is also high blood pressure or swelling of the face or hands.

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Common Discomforts and Management (Contd.)

Back Pain:

Common during pregnancy due to lordosis of the spine

Management:

Massage, warm compression
Avoiding lifting
Light exercise, Yoga

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Urinary Infection (UTI) During Pregnancy

Management or Prevention of UTI

Hydration
Hygiene
Healthy food habits
Seek Immediate Medical Attention

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Urinary tract infection (UTI) is the most common but easily treatable problem that many women experience. It occurs with urethral dilation due compression from the growing uterus on the ureters. Hormones such as progesterone may cause smooth muscle dilation and urinary stasis and vesicoureteral reflux which may result in stasis and resulting infection.

Opportunistic bacteria in the urinary tract may cause infection.

Management:

If a pregnant woman is at the risk of having a UTI or already has a UTI, the Following may help manage or treat UTI:

Drinking enough water and fluids i.e. at least 6-8 glasses of water per day. This helps to flush harmful bacteria. Some fruits and juices like Cranberry juice and lemon juice helps to create an acidic environment and kills bacteria.
Taking Vitamin C rich food (citrus), beta-carotene (carrots), and zinc helps to fight infection.
Refined food and drinks, caffeine, alcohol, and sugar help to exaggerate the infection, so it is best to avoid such foods.
Holding urine for a long time may also lead to a UTI. The bladder should be emptied as soon as there is an urge. Urinate after sexual intercourse to flush the bacteria.
The vagina should be blotted dry (a damp environment promotes bacterial growth). When cleaning, wipe front to back. Soaps, antiseptic creams, powders, alcohol-based hygiene spray may be irritating and should not be used.
Underwear should be changed everyday, tight fitting underwear and outfits leads to sweating and promotes microbial growth. The use of undergarments made up of natural fabrics like cotton is advisable.
UTIs must be treated during pregnancy because they are associated with preterm labor. If the infection of the urinary tract is serious, some antibiotics will be prescribed by the doctor to treat the infection.

Signs of Urinary Tract Infection:

Burning sensation during urination
Frequent urination/ incontinence
Cramps in lower abdomen
Pain during sexual intercourse
Fever, chills
Cloudy or smelly urine
Blood or mucus in urine
If the infection becomes serious and starts to spread, it may cause increased back pain, fever, chills, nausea, and vomiting requiring immediate medical attention.

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Fever During Pregnancy

Fever during pregnancy is never normal
May be bacterial or Viral
Fever in early pregnancy may cause: Miscarriage, birth defects
Fever in late Pregnancy: Preterm labour & preterm baby

Management:

Seek medical help

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What Would the Nurse Do?

A 19 years old female who is 12 weeks pregnant comes to the emergency room complaining of a sharp pain on her right lower abdomen while she moves and walks. She is worried that it might be something with the baby.

What is the nurse’s concern?

What is the nurse’s action?

what education should be provided to the patient?

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Warning Signs of Pregnancy:

Persistent headache
Dizziness or fainting
Changes in vision
Extreme swelling of limbs & Face
Fever
Trouble breathing

Interventions: Seek Immediate Medical attention !!!

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Headache: Headache that becomes worse and lasts after medications and fluid intake. There may be throbbing on the side of the head above the ear, vision becomes blurred, and the patient may feel dizzy. This may indicate preeclampsia, migraine, or even stroke. It needs immediate medical attention.

Dizziness or fainting: Dizziness and fainting are considered a warning sign of pregnancy at or after 16 weeks of gestation. A pregnant woman may faint, might have dizziness and lightheadedness (comes and goes away over many days), and may even experience memory loss for a particular time. These symptoms are common, but should be evaluated as they could indicate preeclampsia, a heart or lung problem, stroke, or a problem with blood sugar.

Changes in Vision: If a pregnant woman sees flashes of light, bright spots, blind spots, blurry vision, double vision, or difficulty focusing at or after 16 weeks of pregnancy or even a few weeks after the birth of a baby. Such vision changes may be worrisome as it could indicate a stroke or preeclampsia.

Extreme Swelling of Limbs and face: Swelling of limbs is common during pregnancy and happens more often during the last trimester. However, severe swelling that causes difficulty bending fingers, wearing rings, swollen lips, and mouth, and difficulty opening eyes is an emergency and needs immediate medical attention. It could indicate preeclampsia.

Fever: A temperature of more than 38°C (100.4 F) is a danger for both mother and baby. Higher temperatures can lead to severe malformation of the fetus, miscarriage, and preterm birth. Fever associated with diarrhea, abdominal pain, back pain, foul-smelling vaginal discharge, or difficulty urinating may indicate infections like Kidney infections, gall bladder infection, pneumonia, flu, appendicitis, bowel infections, and should be evaluated.

Trouble Breathing: In later pregnancy, upward pressure on the diaphragm and lungs may cause mild respiratory symptoms. A pregnant woman should seek medical attention immediately if she experiences shortness of breathing or trouble breathing and needs to be in a propped up position all the time or has tightness of the chest and throat or feeling of suffocation. This could indicate preeclampsia, pulmonary embolism, pneumonia, or any cardiac problems.

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Warning Signs of Pregnancy:

Severe abdominal pain
Decreased or no baby movement
Vaginal bleeding, spotting or fluid leakage
Severe swelling redness, pain, redness or warmness of extremity
Overwhelming fatigue
Excessive nausea and vomiting
Thoughts of harming self and baby

Interventions: Seek Immediate Medical attention !!!

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Severe abdominal pain: It is worrisome if a pregnant woman starts having sharp, stabbing pain or cramps that do not go away. Such pain starts suddenly and gets worse over time. It may also be accompanied by severe chest, shoulder, or back pain. It could be signs of preeclampsia, placental abruption, HELLP syndrome (Hemolysis, Elevated Liver Enzymes, Lowered Platelets). Early in the pregnancy, it may indicate ectopic pregnancy.

Slow or no baby Movement: The slow or no baby movement may be due to uterine infection, less amniotic fluid, or fetal distress.

Vaginal Bleeding or Fluid Leakage: Any vaginal bleeding (more than spotting), leakage of fluid out of a vagina, vaginal discharge that has a bad smell, a fluid that is stained with blood or green color, abdominal pain, or back pain is a concern. It may indicate infection or placental abruption. or a pacenta previa (placenta positioned near or covering the cervix) . or a miscarriage.

Severe swelling redness, pain, or warmness of foot: It is alarming if a woman experiences leg pain (calf), that is painful during flexion, walking, or standing, and if the painful area becomes red, swollen, or warm to touch. This is a sign of deep vein thrombosis.

Overwhelming fatigue: Excessive tiredness, weakness, lack of energy that does not go away with rest and sleep, and feelings of sadness are alarming as they may indicate heart disease, anemia, diabetes mellitus, and depression.

Hyperemesis Gravidarum: Severe nausea and vomiting that is more severe than morning sickness may cause severe dehydration and severe nutritional deficiencies for the woman and fetus. It is a concern if the woman has dry mouth, headaches, confusion, fever, and dizziness.

Thoughts of harming self and baby: Sometimes women may experience sadness, hopelessness, losing control over life, and extreme worries. She may consider self-harm or harming the baby. This is an emergency and should be referred to the care provider immediately.

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What Would the Nurse Do?

A a 38-year-old female comes to the maternity clinic with a complaint of edema of the face and limbs for 3 days. Her vital signs are: BP 150/90 mm of Hg, Pulse rate 88 bpm, Respiratory rate is 18, and Temp. 36.9 C. She also complains of double vision and dizziness.

What is the nurse’s concern?

What are the nurse’s action at this time?

What education should the nurse provide to the patient?

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Red Flags

Be alert to patients with a history of hypertension

Assess transportation and financial needs of clients who are high risk.

Be alert to patients with a history of mental health problems or depression as they are more at risk for depression in pregnancy.

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Cultural Considerations

Some cultures are secretive about pregnancy

Fear and stigma about a pregnancy outside of marriage may prevent a woman from seeking care

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References:

American Pregnancy association (2012). Urinary Tract Infection During Pregnancy. Retrieved on 18^th of September 2020 from https://americanpregnancy.org/pregnancy-complications/urinary-tract-infections-during-pregnancy-938#:~:text=Pregnant%20women%20are%20at%20increased,urinary%20tract%20infection%20during%20pregnancy.

Better Care (n.d). Antenatal Care: Chapter 1. Retrieved on 19th of September 2020 from https://bettercare.co.za/learn/maternal-care/text/01.html#goals-of-good-antenatal-care

Centres for Disease Control and prevention (2020). HEAR HER Campaign: Urgent Maternal Signs. Retrieved on 18^th of September 2020 from https://www.cdc.gov/hearher/maternal-warning-signs/index.html

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References:

Davis. D. C. (1996). The Discomforts of Pregnancy. JOCNN Clinical Issues. Retreived on 27th of October 2020 from https://www.jognn.org/article/S0884-2175(15)33319-0/pdf. PP. 74

Habak^. P. J., Griggs. R. p. (2020).Urinary Tract Infection In Pregnancy. StatePerals. Retrieved on 18^th of September 2020 from https://www.ncbi.nlm.nih.gov/books/NBK537047/

Health Wiki (2020). A Book for Midwives: Body changes and discomforts. Retrieved on 14^th of September 2020 from https://en.hesperian.org/hhg/A_Book_for_Midwives:Body_changes_and_discomforts

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