NORMAL PREGNANCY.pptx

Normal pregnancy slides

1. NORMAL PREGNANCY   DEFINITION: pregnancy , process and series of changes that take place in a woman’s organs and tissues as a result of a developing fetus. Pregnancy occurs when the male and female reproductive cells unit to form a zygote or a fertilized ovum. The fertilized ovum embeds in the maternal tissues to develop into a fetus and finally expelled as a baby at the end of pregnancy.

2. DURATION Pregnancy last averagely for a period of 280 days 40weeks or nine months and seven days During this period the fertilized ovum embeds and develop in the lining of the uterus called decidua. while the fetus lies in a fluid called liquor amini. The fetus is surrounded by two membranes called the chorion and amnion. it is attached to the placenta by umbilical cord through which the fetus derives its nutrients and oxygen from maternal blood via the placenta and waste products also excreted

3. SIGNS OF PREGNANCY POSSIBLE (PRESUMPTIVE) SIGNS Early breast changes 3-4 weeks Amenorrhoea Morning sickness 4-14 week Bladder irritation Quickening 16 -20week

4. SIGN CONT. PROBABLE SIGNS Presence of HCG in urine and blood Softened isthmus ( Hegars sign) Blueing of the vagina ( Chadwicks sign) Pulsating of the fornices ( Osianders sign) Skin pigmentation Braxton Hicks contractions Ballottement of fetus

5. SIGNS CONT. POSITIVE SIGNS Visualisation of gestational sac Fetal heart sounds Fetal movement Palpable fetal parts

6. PHYSIOLOGICAL CHANGES DURING PREGNANCY THE BODY OF THE UTERUS The decidua occurs after embedment of the blastocyst under the influence of estrogen and progesterone. There is thickening and increased vascularity of the lining of the uterus especially the fundus and the upper boarder of the uterus.

7. PHYSIOLOGICAL CHANGES DURING OF PREGNANCY The decidua is thought to play a role in the establishment of spontaneous labour i.e. release of prostaglandin which aids cervical ripening. The decidua and trophoblast release relaxin that causes relaxation of the myometrium.

8. PHYSIOLOGICAL CHANGES DURING PREGNANCY Myometrium: under the influence of oestrogen, there is uterine muscle growth i.e. hyperplasia (increase in number) due to division and hypertrophy (increase in size) of the myometrial cells. The muscle cells expand due to distension by the growing fetus, liquor and placenta. The uterus increase in weight from 57-60g to 900g (1000g). It increases in size from 7.5x5x2.5cm to 30x23 x 20cm.

9. PHYSIOLOGICAL CHANGES DURING PREGNANCY The hypertrophy and hyperplasia of the muscle cells causes the 3 layers to become clearly defined. The muscle fibres become prepared for their respective functions during and after delivery. The myometrium is both contractile and elastic

10. PHYSIOLOGICAL CHANGES DURING PREGNANCY Perimetrium: This is a layer of peritoneum. It does not totally cover the uterus, but deflect over the bladder anteriorly and over the rectum posteriorly. The anterior and posterior folds open out allowing the enlarging uterus to rise unrestricted.

11. PHYSIOLOGICAL CHANGES DURING PREGNANCY The blood supply to the uterus increases to meet the growing needs of the functioning placenta and uterus. Oestrogen causes development of new blood vessels. The arteries, veins and lymphatic's are enlarged. The richly supplied uterine arteries straightens out as the uterus grow s.

12. CHANGES IN UTERINE SHAPE AND SIZE For the first few weeks, the uterus maintains its original pear shape but later the upper part enlarges and it becomes globular in shape. The lower part softens and elongates. This is the beginning of the differentiation between upper and lower part of the uterus.

13. CHANGES IN UTERINE SHAPE AND SIZE 12 th WEEK OF pregnancy The uterus is about the size of a grape fruit. It is no more anteverted and anteflexed as it has risen out of the pelvis and become upright though often it inclines and rotates to the right ( right obliquity of the uterus ).

14. CHANGES IN UTERINE SHAPE AND SIZE The uterus becomes more globular and the isthmus opens out. The fundus may be palpated abdominally above the symphysis pubis. 16 th WEEK The uterus becomes spherical in shape, and can be palpated midway between the symphysis and umbilical. The cervix and isthmus develop into the lower uterine segment which is thinner and contains less muscle and blood vessels ( site of incision for caesarean section).

15. CHANGES IN UTERINE SHAPE AND SIZE 20 th WEEK At 20 weeks the fundus of the uterus can be palpated at the level of the umbilicus. From this period until term the uterus becomes ovoid in shape. 30 th WEEK The lower uterine segment can be identified but still not complete. The fundus may be palpated midway between the umbilicus and xiphisternum.

16. CHANGES IN UTERINE SHAPE AND SIZE 36 th WEEK The uterus now reaches the level of the xiphisternum 38 th -40 th WEEK The softening of the tissues of the pelvic floor, the good uterine tone and the formation of lower uterine segment encourages the fetus to sink into the lower pole of the uterus. This is known as engagement and causes reduction in the fundal height described as lightening.

17. CHANGES IN UTERINE SHAPE AND SIZE THE CERVIX The cervix acts as a barrier against infection, it also helps to retain the pregnancy. Under the influence of progesterone, endocervical cells secrete mucus which becomes thicker and more viscous during pregnancy.

18. THE CERVIX This thickened mucus forms a cervical plug called the operculum that seals the cervix and provides protection from ascending infection. The cervix remains 2.5cm long but oestrogen causes it to increase in width which exposes endocervical cells giving an appearance of erosion. The vascularity increases and if viewed through a speculum the cervix looks purple. In late pregnancy, softening of the cervix and effacement occurs which allow dilatation.

19. THE VAGINA Oestrogen causes the muscle layer to hypertrophy and there is changes in the connective tissue which allow the vagina to be more elastic and thus stretch during delivery. The vagina is more vascular, appearing reddish purple in colour. The mucosa have a marked desquamation of the superficial cells which increases the amount of normal white vaginal discharge this is called leucorrhoea .

20. THE VAGINA The mucosa cells also have an increased glycogen content which is acted upon by the Doederlein’s bacilli to produce more lactic acid which gives a more acidic medium. This provide extra protection but an increasing susceptility to other microorganisms commonly Candida albicans.

21. CHANGES IN THE CARDIOVASCULAR SYSTEM THE HEART : Due to increasing workload, the heart may slightly increase in size and displaced upwards to the left. Cardiac output increases from 5 to 7 liters per minute. The resting heart rate is increased by 15 bpm by the end of pregnancy. The increased cardiac output is balanced by reduced peripheral resistance due to relaxation and dilatation of arterial walls by the action of progesterone .

22. CHANGES IN THE CORDIOVASCULAR SYSTEM Blood pressure may remain the same or drop in the first trimester. But reaches its lowest level in the mid-trimester. Return to the level of the first trimester towards term.(end of pregnancy) The fall in blood pressure during the mid-trimester can cause fainting attacks

23. CHANGES IN THE CARDIOVASCULAR SYSTEM The supine position can decrease cardiac output by as much as 25% due to compression of the inferior vena cava The pregnant woman may suffer supine hypotensive syndrome characterized by fainting, dizziness light headedness, nausea etc.

24. THE BLOOD The red cell mass increases to meet the extra oxygen requirement. The total amount of haemoglobin increase during pregnancy. Plasma volume increases from the 10 th week and reaches a level 50% above the non pregnant values by 32 nd – 34 th week. The increased plasma volume is much greater than that of the red cell mass causing haemodilution. This is characterized by lowered haemoglobin level and is known as physiological anaemia.

25. CHANGES IN THE CARDIOVASCULAR SYSTEM Neutrophils increase, thereby enhancing the blood’s phagocytic and bactericidal properties. The other white blood cells do not change. The increased blood flow is directed to the uterus and 80% goes to the placenta. There is Poor venous return and increased venous pressure in the legs contributing to dependent oedema, varicose veins of the legs, vulva and haemorrhoids.

26. CHANGES IN THE CARDIOVASCULAR SYSTEM Blood flow to the kidney is increased by 30-50% which helps to enhance excretion. Blood flow is increased to the capillaries of the mucus membranes and skin especially in the hands and feet. However, blood flow in the lower limbs is slowed especially in late pregnancy. This helps to eliminate the excess heat produced by the increased metabolism.

27. CHANGES IN THE CARDIOVASCULAR SYSTEM The associated vasodilatation explains why pregnant women” feel the heat”, sweat profusely and have clammy hands and feet. Blood flow to the breasts increases throughout pregnancy. Evidence of this is seen in the dilated veins, enlargement of the breasts, heat and tingling sensation felt especially during early pregnancy.

28. CHANGES IN THE CARDIOVASCULAR SYSTEM IRON METABOLISM : The increased red cell mass and the needs of the developing fetus and placenta lead to increased iron requirement in pregnancy with an increase in iron metabolism and absorption. PLASMA PROTEIN : The level of plasma proteins increase during pregnancy but the haemodilution effect causes a fall in its concentration especially albumin. This leads to a decrease in osmotic pressure which results in Physiological oedema as a common feature of uncomplicated pregnancy.

29. CHANGES IN THE CARDIOVASCULAR SYSTEM CLOTTING FACTORS: Fibrinogen, clotting factor 7, clotting factor 10 and platelets are increased leading to a change in clotting time-from 12 to 8. This predisposes to a higher risk of thrombosis, embolism and disseminated intravascular coagulation. IMMUNITY: Human chorionic gonadotrophin and prolactin suppress the immune system of the pregnant woman. Levels of IgG, and IgM decrease.

30. CHANGES IN THE RESPIRATORY SYSTEM In late pregnancy, the ribs flare out maintaining the capacity of the thoracic cavity by counteracting the effects of the enlarging uterus which presses on the diaphragm. The respiratory rate does not alter but the amount of exhaled air per minute increases as well as gaseous exchange and breathing is deeper. These changes make the pregnant woman often conscious of the need to breath. Increase vascularity to the nose can cause nasal congestion and nose bleeding can occur.

31. CHANGES IN THE GASTROINTESTINAL SYSTEM The hygroscopic effect of oestrogen causes the gums to become spongy and bleed easily. Dental problems may occur because of gingivitis. Increased salivation ( Ptyalism ) is common. There is a change in the sense of taste leading to dietary changes and food craving. Some women crave for substances of no nutritional value such as coal, chalk and clay, this is known as pica. The relaxing effect of progesterone has a major influence on the gastrointestinal tract.

32. CHANGES IN THE GASTROINTESTINAL SYSTEM Heartburn is common due to gastric reflux as a result of relaxation of the cardiac sphincter. There is delayed gastric emptying which causes the woman not to feel hungry often. The enlarging uterus displaces the stomach and intestines and this gives the pregnant woman a feeling of fullness with the intake of meals and hours after. Peristalsis is slowed which results in constipation occurring frequently during pregnancy

33. CHANGES IN THE GASTROINTESTINAL SYSTEM Relaxation of smooth muscles affects those in the veins of the anus and haemorrhoids can occur. Nausea and vomiting, often termed morning sickness occur especially during early pregnancy due to raised oestrogen and HCG levels. Vomiting can be excessive known as hyperemesis gravidarum .  

34. CHANGES IN THE URINARY SYSTEM The kidneys increase in weight, progesterone causes the calyces and renal pelvis to dilate. The ureters also dilate and lengthen and relaxation causes them to kink. Peristalsis movement slows down in the ureters and stasis of urine with reflux occur which predisposes to pyelonephritis. The renal threshold is reduced and sugar may be present in the urine. The uterus presses on the bladder in early and late pregnancy causing frequency of micturition.

35. SKIN CHANGES Increased activity of the melanin stimulating hormone causes deeper pigmentation during pregnancy. Some develop deeper patchy colouring on the face which resemble a mask and is known as choloasma. A pigmented line running from the pubis to the umbilicus and sometimes higher is called linea nigra.

36. SKIN CHANGES The nipple becomes darker and tough in preparation for breast feeding. The perineum darkens in order to enable it to stretch during delivery. As maternal size increase, stretching in the collagen layer occur particularly over the breasts, abdomen and areas of fat deposition e.g. thigh .

37. SKIN CHANGES The maximum stretched areas become thin and stretch marks called s triae gravidarum appear. Increased blood supply to the skin leads to sweating. Women feel hotter due to progesterone induced rise in temperature of 0.5◦C together with vasodilatation.

38. SKELETAL CHANGES Progesterone and relaxin courses relation of ligaments and muscles especially during the latter week of pregnancy. The pelvic joints and ligaments relax which allows the pelvis to increase in capacity. The symphisis pubis softens as well as the sacroiliac joints. The sacrococcygeal joint loosens allowing the coccyx to be displaced backwards.

39. SKELETAL CHANGES Backache and ligamental pain is common as a result of this relaxation especially in the multi gravid. Posture may alter to compensate for a change in the center of gravity especially if the abdominal muscle tone is poor. The gravid uterus pulls the body forward and the woman leans backwards in order to balance and she exaggerate the normal lumbar curve (pregnancy pride).

40. MATERNAL WEIGHT Weight gain during pregnancy comprises the products of conception (fetus, placenta and liquor) and hypertrophy of several maternal tissues (uterus, breast, blood etc.) Many factors influence weight gain which include; The expected increase is 2 kg in the 1 st 20 weeks then 0.5 kg per week till term making an approximate weight gain of 12 kg in the 40 weeks gestation.  

41. CHANGES IN THE ENDOCRINE SYSTEM Placental hormones: Since the fetus depends on glucose for body and brain growth, human placental lactogen alters maternal glucose metabolism, free fatty acids are mobilized and progesterone reduces muscle tone thus conserving energy and also allows deposition of fat.

42. CHANGES IN THE ENDOCRINE SYSTEM Pituitary hormones: The anterior pituitary gland increases the production of ACTH, melanin stimulating hormone and thyrotrophic hormone. The secretion of FSH and LH are inhibited and production of prolactin increases but its action is withheld by oestrogen, however it stimulates production of colostrum. The posterior pituitary produces oxytocin though it is not active until the level of oestrogen and progesterone change.

43. CHANGES IN THE ENDOCRINE SYSTEM Thyroid hormones: The thyroid gland enlarges in response to a reduced level of plasma iodine though its activity is not increased. High level of oestrogen cause the liver to produce more thyroid binding globulin thus T4 is bound rather than free. Adrenal hormones: Corticosteroid production is increased and may be one of the reasons for glycosuria in pregnancy.

44. CHANGES IN THE ENDOCRINE SYSTEM Striae and hypertension which occur in pregnancy is related to its increased secretion. Aldosterone production increased which enhances the re-absorption of sodium maintaining a balance in the Increased Excretion of Sodium and Chloride by Progesterone .

45. Changes in the Nervous System Emotional instability is common in pregnancy. Anxiety, fear, irritability and depression may be manifested during pregnancy. THE BREAST The breast increases in size to 450-500g during pregnancy, hormone activity causes changes in the breast. Oestrogen develops the duct system while progesterone the glandular tissue .

46. THE BREAST The nipple and areola is prepared for breastfeeding. The breast enlarges and Montgomery tubercles are seen on the areola which is darkened. Prolactin stimulates the production of colostrum.

47. SIGNS OF PREGANCY POSSIBLE (PRESUMPTIVE) SIGNS Early breast changes i.e. prickling, tingling sensation, enlargement and fullness, prominent and darkened areola can be used as an early sign. Women who take contraceptive pills may have such symptoms.   Amenorrhoea: Absence of menses may be used as a suspicion of pregnancy but use of contraceptive, hormonal imbalance, emotional stress, certain diseases e.g. HIV can also cause amenorrhoea.  

48. SIGNS OF PREGANCY Morning sickness: A feeling of nausea, vomiting, malaise, weakness and tiredness may occur from 4-14 weeks. However, gastrointestinal tract disorders, pyrexia illness and cerebral irritation can result in these symptoms.  

49. SIGNS OF PREGANCY Frequency of micturition: Pressure from the growing uterus during 6 th -12 th week result in this but urinary tract infections and pelvic tumors can cause this to occur in women who are not pregnant.   Quickening: The first movement of the fetus felt by pregnant women may be an indicator of pregnancy. A primigravida feels it at 18-20 weeks and a multigravida 16­-18 weeks. However intestinal movement and gas in the intestines can give similar feeling.  

50. PROBABLE SIGNS Presence of HCG in the blood and urine i.e. positive pregnancy test (hydatidiform mole and choriocarcinoma may give similar results) Uterine growth and enlarged abdomen (tumours, ovarian cyst, and fibroid can cause this).   Hegar’s sign : This is a sign elicited when a bimanual examination is done. The softening and elongation of the isthmus causes two fingers inserted into the anterior fornix to meet with a hand placed on the abdomen.

51. PROBABLE SIGNS   Jacquemier’s (Chadwick’s) sign is a dark purplish discoloration of the vaginal membrane caused by increase vascularity.   Osiander’s sign is an increased pulsation of the uterine arteries felt in the lateral vaginal fornices.  The above signs may be present in pelvic congestion.

52. POSITIVE SIGNS These are signs that do not have differential diagnosis with other conditions and once they are present in a woman it can be concluded that pregnancy has taken place. These include; Ballottement of the fetus on abdominal examination Palpation of fetal parts during abdominal exam. Fetal movement palpable or visible

53. POSITIVE SIGNS Fetal heart sounds heard on auscultation with a fetal stethoscope or Doppler (Sonic aid which can detect FH at 11-12 weeks) Ultrasound scanning can be used to detect the presence of a fetal sac as early as 4 weeks gestation Visualization of fetus by x-ray (not used nowadays)

54. DIAGNOSIS OF PREGNANCY The presumptive sings are used to suspect pregnancy. All the positive sings described above may be used to confirm pregnancy A lot of biochemical pregnancy tests are available to help in the diagnosis of pregnancy. These tests depend on the presence of HCG in the blood or urine. Early morning urine for pregnancy test gives accurate results if instructions pertaining to the particular tests are followed.

55. DIAGNOSIS OF PREGNANCY examples of some test are; Gravindex test-drop of urine is placed on a slide and the reagent added, an agglutination implies positive results Pregnosticon test is similar to the above but is more accurate The current Enzyme Linked Immunosorbent Assay (ELISA) can detect very low levels of HCG in the urine. USG can be used to diagnose pregnancy as early as 4 weeks.  

56. MINOR DISORDERS OF PREGNANCY MORNING SICKNESS – NAUSEA AND VOMITING This is one of the earliest and commonest symptoms of pregnancy. The actual cause is not known but some attribute it to hormonal influence during pregnancy. The woman feels nauseated on rising in the morning and may actually vomit or have nausea with excessive salivation.

57. MINOR DISORDERS OF PREGNANCY As the name implies morning sickness but it can occur any time during the day and impair the woman’s appetite. The smell of food substances can stimulate vomiting. MANAGEMENT Reassure the expectant mother that is a normal process of pregnancy. The woman must avoid things that tend to nauseate her. She should be reassured that it is a temporal situation that may resolve during 12-16 weeks.

58. MANAGEMENT Advice client to take easily digestible foods and snacks at bed time to avoid hypoglycaemia Advice client to slowly get out of bed Dry biscuits also help before rising Avoid fatty and fried foods Monitor client’s vital signs. Promethazine theocolate (avomine) 25mg bd may be administered  

59. HEART BURNS This occurs commonly in the last 12 weeks of pregnancy. The burning sensation in the throat and stomach is usually associated with the action of progesterone causing relaxation of the cardiac sphincter and reflux of gastric juice into the oesophagus

60. MANAGEMENT Reassure the expectant mother Advice mother to avoid fatty, spicy or indigestible food. She should have light easily digestible diet. She can have some peppermints which relieve the flatulence (air) A tea spoon full of milk of magnesia or mist magnesium Trisilicate can also be taken orally.  

61. MANAGEMENT Client should sit up after meals She should sleep with extra pillows at night. Client should eat little food at frequent intervals She should wear loose clothing in other not to put pressure on the abdomen.  

62. CONSTIPATION There is decreased muscle tone during pregnancy due to the action of progesterone causing slow peristaltic action leading to constipation MANAGEMENT Advice the client to take more fresh fruits and roughage Teach client exercises she can tolerate Take extra fluids first thing in the morning and last thing at night Serve prescribed laxities and discourage enema and purgatives    

63. BACKACHE Backache is usually caused by relaxation of the sacroiliac joint and over stretching of the ligaments. It may also be an early sign of labour. MANAGEMENT Reassure client and explain the cause of pain Ensure rest and sleep Advice client not to lift heavy objects Application of warm compresses and massaging relief pain Advise her to sleep on a hard firm surface or mattress

64. MANAGEMENT Explain the need to attend regular antenatal clinic She should maintain good posture when sitting or walking Avoid high heeled shoes Avoid standing for long periods Serve analgesics as prescribed  

65. LEUCORRHOEA Leucorrhoea is excessive discharge of white mucus from the membrane lining the genital organs of the female. It is due to increased blood supply to the genital tract during pregnancy. MANAGEMENT Educate the client on the importance of personal hygiene Bath at least twice a day She should avoid having unprotected sex She should avoid douching and insertion of foreign materials into the vagina Wash panties well and dry in the sun.

66. LEUCORRHOEA Encourage them to eat well balanced diet rich in proteins and vitamins When cleaning the perineal area it should be from front to back She should wear cotton panties and avoid nylon panties Rule out the possibility of infection Maintain good vulva hygiene Prescribed Metronidazole ( flagyl ) 400mg tid for a week.  

67. INSOMNIA Sleep disturbance in pregnancy is due to a lot of physical factors such as nocturnal micturition, excessive fetal movement, thoughts about the outcome of pregnancy and labour, unstable marriage and stress of marriage. MANAGEMENT Reassure the client Take warm beverages last thing before bed Encourage her to have warm bath before going to bed Provide or prescribe mild sedatives Help in solving any domestic or social problems. Avoid sleeping too early during the night She should sleep in a well-ventilated and cool room.

68. PTYALISM This is excessive salivation which occurs from the 8 th week of gestation. It is thought to be due to hormonal influence. This may accompany morning sickness or heartburns  MANAGEMENT Chewing of sticks or gum sometimes help Some women prefer sour taste Advice the woman to avoid spitting around but get a container which should be emptied frequently.  

69. PICA This is the term used when pregnant women crave for unnatural substances such as charcoal, clay, chalk etc. that has no nutritional value. MANAGEMENT: Advice the woman on the need to avoid the substances as they can be potentially harmful. An alternative must be found if possible.

70. HAEMORRHOIDS These are varicose veins in the anus. They may be painful and cause bleeding. They sometimes prolapse and become external.   MANAGEMENT Avoid constipation. Topical application may be prescribed e.g. xylocaine cream, anusol suppositories etc. Cold compresses can give relief. Drink lost of fluid. Eat more vegetables and fruits.  

71. LEG CRAMPS Cramps are sudden gripping contractions of the calf muscle frequently occurring during the third trimester. This usually wakes the woman up during the night and presents with painful calf the following day. It is due to ischaemia and lowered serum calcium level. MANAGEMENT Do leg stretching exercise be for retiring to bed Support legs on pillows or raise foot end of bed when sitting or sleeping Dorsiflex the foot when cramps occur. Encourage the intake of high calcium foods Calcium supplements can be prescribed.  

72. FREQUENCY OF MICTURITION This occurs in early weeks of pregnancy when the growing uterus is still situated in the pelvis and competes for space with the bladder. In the latter weeks it occurs when there is engagement and the presenting part enters the pelvis and reduces the available space.   MANAGEMENT Reassure the woman and explain the cause to allay her anxiety Encourage her to sleep in the afternoon since her sleep will be disturbed at night Avoid fluid intake during the night Exclude other signs and symptoms of urinary tract infection  

73.   FAINTING This is as a result of vasodilatation occurring under the influence of progesterone because there has been an increase in blood volume. Fainting may occur in late pregnancy when the mother lies on her back due to supine hypotensive syndrome. MANAGEMENT Avoid long periods of standing The woman should sit or lie down if she feels faint Avoid lying on her back Avoid getting up suddenly on rising but should lie for some time before rising She should turn on the side before rising slowly.

74. ITCHING Itching begins on the abdomen and areas of striae which is linked with the liver’s respond to pregnancy hormones and with increased level of bilirubin. MANAGEMENT Advise client to have warm bath Use local applications such as calamine lotion Antihistamines may be prescribed Other causes of itching such as heat rash, scabies etc. must be excluded    

75. CARPEL TUNNEL SYNDROME The expectant mother may complain of numbness or pins and needles in her hands and fingers which is usually worse in the mornings. It is caused by fluid retention which creates oedema and pressure on the median nerve. MANAGEMENT woman should be reassured and advised to avoid sleeping on her hands Raising the hands up or on pillows can provide some relief.

76. FATIGUE Fatigue in the 1 st trimester is due to hormonal changes. The woman has an overwhelming tiredness and looks sleepy even when she wakes up in the morning after a night sleep. During the 3 rd trimester it is due to increase in weight making movement tiring. MANAGEMENT Reassure and explain cause to the woman She should be encourage to rest when necessary.

77. CONDITIONS THAT REQUIRE IMMEDIATE ACTION Vaginal bleeding however slight it is Severe frontal headache Oedema(massive) Premature rupture of membranes Severe abdominal or lower abdominal pains Excessive vomiting Pallor Fever

78. ANAEMIA Anaemia is a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal INCIDENCE; 37% of pregnant women

79. Types of Anemia During Pregnancy Several types of anemia can develop during pregnancy. These include: Iron-deficiency anemia Folate-deficiency anemia Vitamin B12 deficiency

80. Iron-deficiency anemia This occurs when the body doesn't have enough iron to produce adequate amounts of  hemoglobin . That's a protein in red blood cells (FORMATION) the blood cannot carry enough oxygen to tissues throughout the body. Iron deficiency is the most common cause of  anemia in pregnancy

81. Folate-deficiency anemia Folate is found naturally in certain foods like green leafy vegetables. folate is use to produce new cells, including healthy red blood cells. Folate deficiency can directly contribute to birth defects e.g. neural tube abnormalities (spina bifida) and low birth weight.

82. Vitamin B12 deficiency vitamin B12 is use   to form healthy red blood cells. SOURCES; meat, poultry, dairy products, and eggs EFFECTS; contribute to birth defects, such as neural tube abnormalities, preterm labour

83. Risk Factors for Anemia in Pregnancy Multiple pregnancy Close pregnancies Hyperemesis gravidarum Teenage pregnancy Inadequate intake of iron rich diet anemia before pregnancy

84. CAUSES OF ANAEMIA IN PREGNANCY Inadequate intake of foods which contain the essential nutrients ( folic acid and iron) example: Poor method of cooking The demand for essential nutrients repeatedly outstrip the supplies without adequate replenishment Chronic infections – e.g. UTIs and TB Sickle cell disease

85. CAUSES OF ANAEMIA IN PREGNANCY Infection. parasitic infections, tuberculosis Haemolysis ( as in malaria and sickle cell diseases) Recurrent bleeding, e.g. Threatened abortion. Hookworm infestation- as a result of pica. Acute blood loss, such as antepartum haemorrhage  

86. Symptoms of Anemia During Pregnancy Pale  skin , lips, and nails Feeling tired or weak Dizziness Shortness of breath Rapid heartbeat Trouble concentrating

87. PREVENTION OF ANAEMIA IN PREGNANCY Encourage patient to take a balance diet which is rich in folic acid and iron The availability and cost of foodstuff must be considered Methods of cooking vegetable should be explained to patient so that folic acid content is preserved Prescribed folic acid supplements (5mg) should be given daily throughout pregnancy.

88. PREVENTION OF ANAEMIA IN PREGNANCY Prescribed ferrous sulphate (200mg) or ferrous gluconate (325mg) should be given thrice daily throughout pregnancy ( for iron deficiency) Prevention of malaria, where it is endemic. Discourage breeding of mosquitoes near her house. By having a good drainage system. Encourage the use of insecticide treated net (ITN) at night Clear bushes around her house

89. PREVENTION OF ANAEMIA IN PREGNANCY Routine haemoglobin estimation at each antenatal clinic visit makes it possible for early recognition of patients who are at risk. Efficient replacement therapy following haemorrhages is necessary in the prevention of subsequent anaemia Patients with sickle cell disease should have specialist care throughout the pregnancy.

90. PREVENTION OF ANAEMIA IN PREGNANCY Avoid eating substances that have no nutritional value(pica) Report to clinic immediately you see bleeding ( for antepartum haemorrhages)

91. ADVICE FOR CLIENT WITH VAGINAL DISCHARGE Report early for diagnosis and treatment. She should avoid douching and using antiseptic in the vagina. Under wear should be changed frequently, dry in sun and/or iron it before wearing. Advise her to clean her anus from anterior to posterior.

92. ADVICE FOR CLIENT WITH VAGINAL DISCHARGE She should put on cotton underwears . Advise her to wash hands before and after touching her genitals. She should report with her husband for screening and treatment. She should also adhere to the treatment regimen to treat it completely.  

93. ANTENATAL CARE Antenatal care is the care, supervision, and attention given to a pregnant woman till she delivers. Ideally antenatal care should commence from the time the woman thinks she is pregnant or she is diagnosed as being pregnant and should continue at regular interval till she delivers safely.

94. FOCUSED ANTENATAL CARE Focused antenatal care is the WHO new approach to antenatal care which is based on scientific evidence . It seeks to improve upon the quality of the antenatal care provided to women particularly in low resource settings.

95. PRINCIPLES OF FOCUSED ANC It looks at the quality of care rather than quantity of care. (4 visits for women with normal pregnancy). Individualized care. Disease detection and not risk categorization(all pregnant women are at risk). Evidenced based practices during ANC provision. Birth preparedness and complication readiness.

96. RECOMMENDED SCHEDULE OF ANC VISITS BOOKING VISIT This is the first or initial visit the pregnant woman makes to the health care provider and should take place as soon as pregnancy has been confirmed. This visit is important because it helps to assess levels of health by history taking, screening test as well as obtaining the individual’s baseline recordings. Booking visit; during first trimester(preferably before 14 weeks)

97. RECOMMENDED SCHEDULE OF ANC VISITS 1 st scheduled visit at 16 -20 weeks 2 nd scheduled visit in the sixth month(24 – 28 weeks) 3 rd scheduled visit in the eighth month(28 – 32 weeks) 4 th scheduled visit in the ninth month(about 36 weeks How ever more frequent visits or different schedules may be required based on the woman’s needs and\or national policies ( eg.malaria or HIV)

98. ANTENATAL CARE CONT. Antenatal care should address both medical and psychosocial needs of the pregnant woman. Within the health delivery context as well as the client’s culture. Periodic visits to a health care provider are necessary for the following reasons Early detection and treatment of complications

99. ANTENATAL CARE CONT. Establishment of a supportive relationship between the pregnant woman and the health care provider. Development of a birth preparedness and emergency plan with the woman. Provision of preventive measures. Provision of advice and counselling.

100. AIMS/BENEFITS To know baseline recordings of the woman’s physical health To monitor the condition of the mother and fetus to ensure good maternal and fetal health throughout pregnancy. To monitor the progress of the pregnancy to ensure normal fetal development and delivery of a normal term health baby.

101. AIMS/BENEFITS To recognize deviation from normal or early detection of abnormalities and provide appropriate treatment or management. Certain complications can be prevented and the woman can also understand the physiological changes and thus cope with minor disorders

102. AIMS/BENEFITS Preparation towards successful breast feeding can be done during antenatal visits. To give health education on important topics To give prophylaxis treatment to conditions such as tetanus, anaemia, malaria and worm infestation

103. AIMS/BENEFITS To build a trusting relationship between the family and their caregiver. Antenatal clinic helps the prospective family to prepare psychologically for childbearing and make adjustments to it.

104. RECEPTION First impressions are lasting, therefore the reception the woman receives during booking can colour the rest of her experience. The midwife must be approachable, friendly and possess good communicative skills since this visits involves a lot of interactions and exchange of information. The midwife should greet and welcome the woman with a smile and offer her a seat. She should establish rapport to ensure a smooth communication .

105. RECEPTION The midwife can gather much information by observing the woman as she enters the room; whether she responds to a smile, looks angry, nervous or shy. A long wait or prospects of a previous interview, unresolved anger at home, unwanted pregnancy etc. may have made her irritable. Observation of physical characteristics such as posture, gait, nutritional status, feeling of unwell etc. can be done at a glance during the first contract with her.

106. HISTORY TAKING Social history This involves taking history about the social aspect of the woman and assessing the individuality of the woman. It involves personal information such as full name, address, husband’s name and address and the next of kin, this helps in identification and tracing of patient or relatives when the need arise. Her occupation as well as that of her husband will give an idea about her socioeconomic status, if her work is strenuous, it can be identified and appropriate advice given.

107. HISTORY TAKING Social history Knowing the age of the woman is also important since pregnancy occurring in the very young and elderly women carry a risk. Marital status, educational background, tribe and religion should also be ascertained. General health and lifestyle should be assessed which include; smoking, alcohol intake, exercise, nutritional pattern, sleep pattern and bowel and bladder habits.

108. HISTORY TAKING Medical history Medical history provides an idea about the woman’s general health prior to pregnancy i.e. whether there was any existing medical condition. This history is important because there are some medical conditions which affect pregnancy adversely and there are some that are aggravated by pregnancy. Moreover women with these conditions may include diabetes mellitus, hypertension, asthma, epilepsy, kidney disease, heart disease, tuberculosis, sickle cell disease and mental illness.

109. HISTORY TAKING Medical history It must be enquired whether patient is receiving treatment for the existing condition and what drugs she is taking. Any history of accidents especially those involving the pelvis should be known. Enquiries should be made about any previous blood transfusion and their indications if known. Any history of STI should be noted and the midwife should find out the type of treatment used in the treatment of the STI Enquire about allergies to food, drugs and other substances

110. Surgical history A history of operations on the pelvis, spine and reproductive tract, RTA, e.g. myomectomy, salpingectomy etc. as well as operation pertaining to pregnancy such as caesarean section. How long the operation lasted and if C\S what was the indication for the surgery and whether there were any complications.

111. Family history This history is important because some conditions are genetic in origin and can be passed on to the unborn fetus if there is the tendency. Other conditions are familial and so relations from such families are predisposed to them, since pregnancy can increase this predisposition it is essential to enquire about these conditions. Some of these conditions include epilepsy, HPT, DM, essential hypertension, and mental illness.

112. Family history Multiple pregnancies have a higher incidence in certain families and it’s existence should be enquired. Enquire about recent infectious diseases especially TB in any family member. Any death of a family member or close relative and the cause of death.

113. MENSTRUAL HISTORY This talks about the age the mother attained menarche. Duration of the menstrual cycle e.g. 21, 24, 28 or 32 days. The first day of the last menstrual period to aid in the calculation of EDD. Whether client experiences some disorders like dysmenorrhea,

114. GYNAECOLOGICAL HISTORY\RISKY SEXUAL BEHAVIOURS Any history of STI should be noted and the midwife should find out the type of treatment used in its treatment. Risky sexual behavior e.g. multiple sexual partners, homosexuality, prostitution etc

115. Past obstetrical history Details are taken of the following The history of previous pregnancies, labours, delivery and puerperium have an important part to play in predicting the likely outcomes of the present pregnancy. It also determines how the present pregnancy should be managed and where the woman should deliver. The woman who is pregnant for the first time does not have any past history and so the outcome cannot be predicted.

116. Past obstetrical history cont. Adequate pelvic capacity can be assumed after a successful vaginal delivery and uterine efficiency is better after the first labour. An account of the previous pregnancies should be given including outcome i.e. duration of pregnancies, minor or major disorders experienced during the pregnancy.

117. Past obstetrical history cont. Any abortion should be known-duration of pregnancy before abortion, whether it was induced outcome or spontaneous, if spontaneous whether it was complete and whether evacuation was done or not. A sympathetic, non-judgment approach is required to gain this information accurately. An account of previous labours should be given, whether the labour was spontaneous, induced, preterm or post-term or c/s.

118. Past obstetrical history cont. If labour was induced possible indication should be known. The duration of the 1 st , 2 nd and 3 rd stages of labour should be enquired. The mode of delivery whether vaginal delivery, vacuum extraction or caesarean section should be known as well as the amount of blood loss during delivery. History of retained placenta should also be noted. The midwife should enquire about the size of babies and their conditions at birth

119. Present obstetrical history The woman is asked of her last menstrual period (LMP) and the number of days of flow and the nature of the flow, this helps to know if the last period of bleeding was true menses. The estimated day of delivery (EDD) is then calculated by adding 9 calendar months and 7 days to the first day of the woman’s LMP. This is for the average 28 days cycle,

120. Present obstetrical history if the cycle is short e.g. 24 days then subtract 4 days from the calculated EDD, if the cycle is long e.g. 32 days then add 4 days. In case where the woman does not know her LMP the husband can be interviewed or the woman asked to report on next visit with the right information. If this is not successful abdominal examination can help to estimate the gestational age with the level of the fundal height and rough estimation or EDD done

121. Present obstetrical history Ultrasound scan (USG) may be done to know gestation. The midwife should enquire about the general health of the woman from the onset of this pregnancy. Assess for any danger signs or risk factors. Ask of any bleeding since pregnant and any vaginal discharges.

122. Thank you