Kuliah Sem4 2008-6

Fakulti Kejururawatan

ANTENATAL CARE : Routine examination & Abdominal palpation

by Nor Marini Ibrahim

After the lecture, students should be able to:     

Explain the aims of prenatal care Perform physical examination Perform abdominal palpation Give health education to pregnant woman Tell the type of immunization to pregnant woman

AIMS OF ANTENATAL CARE: support & encourage a family’s healthy psychological adjustment to childbearing 3. Monitor the progress of pregnancy in order to ensure maternal health & normal fetal development 4. Recognise deviation from the normal & provide management or treatment as required 5. Ensure that women reaches the end of their pregnancy physicaly & emotionally prepared for her delivery

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Help & support the mother in her choice of infant feeding to promote b/feeding & give advice about preparation for lactation when appropriate. Build up a trusting relationship between the family & their caregivers which will encourage them to participate in and make informed choices about the care they receive.

ow chart of Pregnant woman at maternity clin REGISTRATION

URINE TEST, WEIGHT, HEIGHT MEASUREMENT & BLOOD PRESURE

Preliminery process by nurse

PHYSICAL & ABDOMENT EXAMINATION, ATT Inj.

HEALTH EDUCATION

BLOOD TEST (GRP, Rh., HB & VDRL)

REFER DOCTOR

ADDMISION/APPOINTMENTI/TREATMEN

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REGISTRATION/BOOKING A VISIT

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Should be done as soon as the mother knows that she is pregnant - Approprite advice should be given early regarding care for both mother & fetus because the fetal organs are almost completely formed by 12 weeks of pregnancy. Maternal nutrition, infection, smoking or drug taking

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INTERVIEWING THE ANTENATAL MOTHER Social history - name, race, ic no., educational status, occupation, name of husband, husband’s ic no., address & contacting telephone number, date of marriage Family history - any family members suffering from diabetes, asthma, tuberculosis, hypertension, heart case Medical & surgical history - risk factors for human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS), or other sexually transmitted infection - Any previous operation esp. involved the reproductive organ (LSCS)

Obstetric history - Number of pregnancy (Gravida) - Number of living children (para) - Weeks of pregnancy - Type & place of delivery - Other complications (postpartum hemorrhage), cervical tear, instrumental delivery etc. - Menstrual history (regular or not, LMP) Detail of past & present pregnancy, including - Miscarriages or abortion - Outcome of each pregnancy (team,preterm,stillbirth or baby alive & well) - Problems in previous pregnancy (PPH, placenta previa, twin etc) - Other complication-pre-eclampsia, gdm

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Physical examination Height if 145 cm & below is associated with small pelvis & may cause cephalo pelvis dispropotion (CPD) Weight as a baseline weight Weight the mother at every visit Any weight lost-indicate intra uterine growth retardation (IUGR) or intra uterine death Weight gain usually slow during the first 20 weeks

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Obesity can lead to gestational diabetes & pregnancy induced hypertension. Guideline for maternal weight: - 2.0 kg in first 20 weeks - 0.5 kg per weeks until term - 12.0 kg approximate total weight gain during the whole pregnancy

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Blood pressure Check the blood pressure every visitto know the baseline Whether within normal limit (of pregnancy) - 2nd trimester usually fall below prepregnancy levels - 3rd trimester usually goes back up to the pre-pregnancy level Raise in systolic > 130 mmHg or / diastolic > 90 mmHg – may indicate pre-eclampsia or pregnancy induced hypertension (PIH)

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Urine test Is performed to exclude abnormality like presence of sugar & albumin - urine albumin: dipstick test, done every visit. - presence of albumin 1+ (30mg/dl or more) – may associated with preeclampsia, urinary tract infection or pyelonephritis

- urine sugar: dipstick test done every visit. - normally negative or trace - if persistently presence of sugar - green on two visit – refer to doc for further investigation - yellow/orange/red – refer immediately. MOGTT (modified glucose tolerance test will be done to detect GDM)

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Blood Testing At first visit, blood test is done to determine ABO blood grouping & Rhesus (RH) factor, Heamoglobin, VDRL (Veneral Disease Research Laboratory) test for syphilis, Human immunodeficiency virus (HIV) - Rhesus factor only mother with RH factor –ve will be screened again at 28th, 32th, & 40th week for the RH factor to ensure that the pregnancy is not stimulating antibody activity

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Heamoglobin level -Hb is repeated at 28th weeks & 36th weeks gestation to ensure that the pregnancy is not stimulating antibody activity. -iron supplements may be given with folic acid & vitamin to mothers -iron is needed for forming hb -folic acid is needed for forming red blood cells -vitamin C is vital for the optimum uptake of iron.

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EXAMINATION OF PREGNANCY Examination head to toes (demonstration will done in the nursing lab) General appearance, Observe: hair: is it clean & well groomed? face: - colour - anaemic - ? Anxious, unhappy, depressed, lethargic - eye, nose & ear- clean, any discharges - mouth – dental caries, any ulcer

Neck - observe for swelling at thryoid area Hands - is skin clean & free from septic spots, ulcers - any complaint of numbness of fingers Breasts examination done at every visit - observe the cleanliness of the breast & advise mother on cleaning the breasts

Nipple : - Check that the nipple is protruding enough so than baby can grasp it & feed on during breast feeding - Palpate the breasts gently with the flat of hand to feel for any lumps. - Advise mother to wear supportive bras for comfort.

Inspection of vagina - Enquires on vaginal discaj - ↑ during pregnancy - Characteristics of the discharge - amount - colour - odour - any irritation - If excessive, foul smelly & cause itchiness-refer for treatment, advise on personel hygiene

Check for edema - Swelling of feet, ankles & hands is common during pregnancy - it can be uncomfortable for the patient, but she can be reassured that it will go away after delivery - An effective treatment for edema: - Bedrest - Drinking plenty of water & avoiding excessive salt

Abdominal Examination Aims/The specific objectives are to  Observe signs of pregnancy  Assess fetal size & growth  Assess fetal health  Diagnose the location of fetal part  Detect any deviation from normal

Abdominal Examination – steps Abdominal inspection - scars – LSCS - size - shape - skin change

ABDOMINA L PALPATION

Abdominal Palpation (Leopold Maneuvers) -steps Palpate abdomen with hands that are clean & warm. Cold hands tend to induce contraction of the abdominal & uterine muscles & the mother resents the discomfort of them. c) Measure fundal height & estimating the period of gestation (POG) ► place one hand just below the xiphisternum ► press gently & move the hand down the abdomen until she feels the curved upper border of fundus ► measure the distance of fundus from the pubic bone up over the top of the uterus. Use a tape measure.

measure the distance of fundus from the pubic bone up over the top of the uterus. Use a tape measure.

that distance, measured in centimeters (cm), ► is approximately equal to the weeks of gestation (1 cm = 1 week) – this is known as MacDonald’s Rule. ► the height of the fundus correlates well with gestation age. ► measurement falling within 1-3 cm of expected value considered normal. ► fundal height 4cm different than expected are considered abnormal & suggest the need for further investigation ►

► if a tape measure is unavailable, these rough guidelines can be used : ● at 12/52, the uterus is just barely palpate above the pubic bone, using only an abdominal hand. ● at 16/52, the top of uterus is ½ way between the pubic bone & umbilicus. ● at 20-22/52, the top of the uterus is right at the umbilicus. ● at full term,the top of the uterus is at level of the ribs (xyphoid process).

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Abdominal Palpation ►Place the pregnant women in the supine position & stand beside her ►Perform the first maneuver to determine presentation/done to determine whether it contains breech or head at the fundus. ● facing the women’s head, place both hands on the abdomen to determine fetal position in the uterine fundus. ● feels for the buttocks, which will feel soft & irregular (indicates vertex presentation); feel

First maneuver

Second maneuver

► Second maneuver to determine position ● while still facing the women, move hands down the lateral sides of the abdomen to palpate on which side the back is (feels hard & smooth) ● continue to palpate to determine on which side the limbs are located.

► Third maneuver to confirm presentation ● move hands down the sides of the abdomen to grasp the lower uterine segment & palpate the area just above the symphysis pubis. ● place thumb & fingers of one hand apart & grasp the presenting part by bringing fingers together ● feels for the presenting part. If the presenting part is head, it will be around, firm & ballottable. If it is buttocks, it will feel sort & irregular

Third maneuver

►Fourth maneuver to determine attitude of the fetal head. ● the hand is moved downward toward the symphysis pubis. ● if you palpate a hard area on the side opposite the fetal back, the fetus is in flexion coz you have palpated the chin ● if the hard area is on the same side as the back, the fetus is in extension coz the area palpated is the occiput

Fourth maneuver

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AUSCULTATION Is done to assess the fetal wellbeing Listen for the heartbeat Check fetal heart for rate, rhythm & tone FHR assessment can be done by using fetoscope or droppler (ultrasound) or continuously with an electronic fetal monitor applied externally or internally

Fetoscope

Using fetoscope

Using daptone

Using continuous external EFM device

Using continuous internal EFM

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Measuring FHR Purpose: To Assess Fetal Well-Being Assist the woman & have her lie down. Cover her with a sheet to ensure privacy & then expose her abdomen. Palpate the abdomen to determine the fetal lie, position & presentation. Locate the back of the fetus (the ideal position to hear the heart rate) Place the fetoscope over the fetal back Listen for the sound of heart rate. Assess the woman’s pulse rate & compare

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Once the fetal heart rate has been identified, count the number of beats in one minute & record the result Record the heart rate on the woman’s medical record.

FETAL ACTIVITY ● Fetal movement ● Not usually felt by the mother until the 16 weeks (for multigravida) & 20 weeks (for primigravida) ● By ultrasound as early as 7-8 weeks ● movements increase in strength & frequency through pregnancy esp. at night (at rest) ● at 36/52 – normally a slow change in movement with fewer violent kicks & more rolling & stretching fetal movement ● sudden decrease in fetal movement is a

● Kick Count/Fetal Kick ● ask the mother to count each distinct fetal movement, starting from the time she awakens in the morning. ● when reaches 10 movements or kick, she is done counting for the day & record in the fetal kick chart/fetal movement chart ● if at 12 noon, hasn’t reached a count of 10 movement-must report for further investigation.

HEALTH EDUCATION ● Objective (for the mother) - ↑ confidence - to have a healthy, happy pregnancy & speedy rehabilitation afterwards - prepares for labor - prepares for a role of motherhood

● DIET - Well balanced diet - ↑ dietary protein, vitamins & mineral salt, iron ● REST & SLEEP ● CLEANLINESS - encourage general hygiene - clothing – comfortable & loose ● BOWEL - constipation is common - high fibre diet & fruit - mild laxative if require

● SMOKING & ALCOHOL -Impair of fetal growth, increase risk of pre-term delivery & adverse effect on intellectual development ● DRUG - Should advice to avoid any form of medication unless authorized by the doctor ● BREAST CARE & BREAST FEEDING ● PREPARATION FOR DELIVERY ● HOW TO BATH BABY ● MINOR DISORDERS OF PREGNANCY

● IMMUNIZATION - Inj. ATT (Anti-tetanus toxoid) - to prevent neonatal tetanus if baby having cord sepsis - 1st dose – is given when the mother feels the first fetal movement, normally at 24/52 of pregnancy - 2nd dose – at 4-6/52 later after the first dose - if mother’s subsequent pregnancy is within the 3-5 year – booster dose of ATT

FOLLOW – UP VISIT PERIOD OF FREQUENCY OF VISIT AMENORRHEA/PREGNAN CY28/52 From UPT +ve till Every 4 weeks/monthly 28/52 - 36/52

Every 2 weeks

36/52 till delivery

Every week

If any abnormality associated

More frequent (e.g every week)

THANK YOU