The first pregnancy way term with 40 weeks gestation by fundal height.

The baby was delivered at Ndirande Health Centre and she delivered by Spontaneous erte! "elivery but sustained a tear which was sutured and healed without any complications. The baby was #400g at birth and was born without any congenital nor during birth complication. $abour had taken about %4 hours thus from & pm to 'am. (rs. Nkhata has no history of ante)partum or intra)partum haemorrhage as well as *re)eclampsia or eclampsia.

*S+CH,$,-.C/$ H.ST,0+ (rs. Nkhata said that the pregnancy that she has now was a planned one and also that the decision to have the pregnancy was made by both her and her husband such that they both were very happy for the pregnancy. She also said that she did not have any psychological problems due to both previous pregnancy as well as the current one e!cept for the fear of labour pains. .((1N.S/T.,NS (rs. N2hata e!plained that she had received two doss of Tetanus To!oid accine with the first pregnancy and two doses with the current pregnancy. However3 she e!pressed lack of knowledge on the fre4uency and number of doses of tetanus To!oid accine she is e!pected to receive despite knowing the importance of the immuni5ations. 6N .0,N(6NT/$ H.ST,0+ ,n environmental history3 (rs. N2hata said that she has a two bedroom house with a seat room which is occupied by three members of thee family3 the husband3 the first born child and herself. The house is iron sheet roofed3 cement floored and electrified. She said that she gets water from a Communal 7ater *oint which is about 80 metres from her house but she makes sure she has enough water all the time by keeping some in buckets knowing that there is a problem of water scarcity in her area at times.

,n waste disposal3 she said that there is a rubbish pit behind the house which is used for waste disposal and she keeps burning the waste in the pit to prevent it from being blown back to the house by wind when it9s full. S,C.,)6C,N,(.C H.ST,0+ (rs. Nkhata is a :orm four $eaver currently working with 2121 (atches Company as a *acker. Her husband is an electrician who is self employed. She said that her family is able to get their needs and necessities from the combined income that they get from their duties and they live happily. (rs. Nkhata reported no e!posure to increased workload for she is currently given light work by her bosses having understood her condition. (rs. Nkhata does not smoke any kind of cigar nor drinks any kind of alcohol although the husband takes alcohol but in a reasonable manner. *06S6NT ,;ST6T0.C H.ST,0+ (rs. Nkhata is gravida < *ara % mother $ast normal menstrual period = 6!pected date of delivery = -estation by dates H. Status "0$ = = = %8th >uly3 <0%0 <<nd /pril3 <0%% #0 weeks3 days Non)reactive Non)reactive

She is currently not on any medications e!cept for the :errous Sulphate she is given when se visits antenatal clinic meant to help in the formulation of haemoglobin. 6$.(.N/T.,N

(rs. Nkhata has no any problem with either bowel movement or urination. However3 she said that she had in the early days of pregnancy a problem of fre4uency micturation.

,;>6CT. 6 "/T/ Vital Signs Temperature ;lood *ressure *ulse 0ate 0espiration 0ate = = = = #?.&@C %<0A&0mmHg &0 beats peer minute << breaths per minute

-6N60/$ /**66/0/NC6 (rs Nkhata is a %?< cm tall woman3 slim and light brown in comple!ion. She was wearing a red blouse and a black skirt with a pair of black slip)ons BshoesC. ,n this day she weighed 8D kilograms3 gaining < kilograms from the weight during her booking visit which was 8? kilograms. H6/" Her head is ovoid in shape with long chemical made hair and there was neither dandruff nor presence of scars or masses on the scalp. :/C6 There were no signs of facial oedema on both inspection and palpation. The face also did not have scars on inspection. 6+6S The eyes are symmetrical and ovoid in shape with no signs of peri)orbital oedema and had a pink conEunctiva.

6/0S The ears are symmetrical with the upper ears in line with the outer borders of the eyes. There were no sore3 no ear discharge3 no lesions and no signs of inflammation on palpating the pre and post auricular lymph nodes. N,S6 Her nostrils are symmetrical with no any discharge. She has no history of epista!is and did not have any polyps in the nostrils. (,1TH Her lips were smooth with no sores or cracks. Her tongue and oral mucosa were pink with no sore3 no korpliks spots or signs of candidiasis. There were neither decayed teeth nor gingivitis. She has neither cleft lip nor cleft palate. The tonsilor3 sub) mandibular and sub mental lymph nodes were not enlarged. N6C2 She has no problems with neck fle!ion as well as forward and backward neck bending. ,n inspection3 there were no obvious signs of distended Eugular veins3 no sores3 no obvious lesions. ,n palpation3 there were neither signs of enlarged thyroid gland nor enlarged deep cervical3 sub)clavicle and infra )clavicle lymph nodes. CH6ST ,n inspection3 the chest did not have scars3 lesions or signs of a pigeon chest with normal respiratory movements. ,n auscultation3 there were normal lung and heart sounds. ;06/STS The breasts are symmetrical in both si5e and shape and they both are light brown in colour with dark alleorae. The breasts have no scars3 scales3 lesions3 no sores3 rashes3 redness and no dimpling. ,n breast palpation3 no masses were felt e!cept for the normal mammary gland. The nipples are dark in colour3 clean and not inverted.

1**60 6FT06(.T.6S The arms are symmetrical with no signs of oedema on both inspection and palpation. She has a capillary refill of less than # seconds and has pink palms. However3 (rs. Nkhata reported having tingling sensation of the upper e!tremities. /;",(6N ,n inspection of the abdomen3 there was a dark linea nigra3 some striae gravidalum with no sores or scars. The abdomen was ovoid in shape with a medium si5e. :oetal movements were also observed medially on inspection. $iver and spleen were not palpable indicating absence of organomegally. The calculated gestation by dates was #0 weeks and Fundal height Pelvic, Lateral and Fundal Palpation :undal height :oetal *resentation = :oetal $ie :oetal *osition :oetal Heart 0ate = = = = <' weeks

Cephalic $ongitudinal 0ight ,ccipital /nterior %4< beats per minute

$,760 6FT06(.T.6S The lower e!tremities are symmetrical with no scars3 varicose veins as well as signs of oedema on inspection. ,n palpation3 no tibial3 ankle or pedal oedema was detected. No signs of aricose eins or "eep ein Thrombosis were detected on palpation of the cuff muscles. Howmans sign was not observed on fle!ion on the feet. -6N.T/$./ 1pon inspection of the genitalia3 no oedema3 sores3 warts3 genital ulcers3 abnormal vaginal discharge or signs of hematoma were observed. There were no signs of

varicose veins or genital mutilation or circumcision seen. The vaginal discharge was mild3 whitish and odourless.

*0,;$6(S AN66"S ."6NT.:.6". 2nowledge deficit on se!uality during intra and post partum periods related to inability set times on when to stop and resume se!. $ack of ade4uate information on immunisations related to limited information given on immunisations as evidenced by inability to outline the normal schedule for Tetanus To!oid accine. 2nowledge deficit on :ocussed /ntenatal Care and its importance related to limited information given about focussed antenatal care as evidenced by late coming for initial visit. *ossibily of not using family planning methods related to untrue speculations that "epo) *rovera is phasing out.

C/06 *0, ."6" :ocus /ntenatal Care looks at comprehensive care given to a pregnant woman with specified type of care per each visit of the four e!pected visits that the woman attends antenatal clinic. .t looks at 4uality of care and not 4uantity of the number of visits. :ocused /ntenatal Care emphasises on treating every mother as an individual or uni4ue person with individual problems and needs. The care that was given to (rs. Nkhata was based on the problems and needs that she had as well as specific care according to hergestation age. ,n this day3 (rs. Nkhata was treated comprehensively starting with history taking to fill in gaps followed by H. and Syphilis tests then full physical assessment which involved using all the four modalities of inspection3 palpation3 auscultation and percussion.

. made sure that the client9s care was provided in a very conducive environment3 thus ensuring privacy as well as cleanliness. . made sure that she felt well taken care of and welcome to the clinic by being respectful3 accommodative and letting her ask 4uestions and e!press fears than looking at the care as a burden throughout the procedures. 6N .0,N(6NT "uring the filling in of gaps3 collection of important information that was missed out on the booking day3 an environment that ensured privacy and comfort was ensured. The data was collected at an enclosed place where no one else could listen to what was being discussed and this made the client to be more open and to give the information that was re4uired. $ikewise3 during the physical e!amination3 a cubical was used to promote privacy considering that procedures involved this time include e!posure of sensitive areas like the chest3 abdomen and genitalia. :.$$.N- .N ,: -/*S 1pon review of the /ntenatal cardApage for (rs. Nkhata several areas that re4uired to be filled in were realised. .n addition to that3 some more areas in the health passport were identified which also needed filling in. The health did not have information on her family medical history and her medical and surgical history which is supposed to be filled o the first and second pages of the health passport and this is also where some important personal data is documented. See /ppendi!...... showing the pages after filling in. Not only that but also blood group and rhesus factor were not tested but still more being an important information especially when it comes to emergencies like anaemia3 . still referred her go also go for the tests when she goes for the other tests. ,n the antenatal page as well3 gravidity and parity of the mother were not indicated during the first visit but got documented on this visit. TESTS

:ocused /ntenatal recommends mothers undergoing several different tests at different visits and different gestation ages. Such tests are like H. 3 Syphilis3 haemoglobin level3 urine protein and C"4 count in case of those who are H. positive but not on antiretroviral therapy. H. 3 "0$ and Haemoglobin level are the tests that are e!pected to be done on booking so as to have a baseline data for some of them like H. and haemoglobin are tested again after sometime i.e. H. is tested again after # months while haemoglobin level is retested at #? weeks. 1rine protein is e!pected to be tested every visit from first to fourth visit but unfortunately none of these were done on the first visit ,n this visit . played a role of helping (rs. Nkhata get tested for H. and Syphilis whose results came out negative as indicated on the antenatal card B/ppendi!.....C after filling in the gaps. However3 . referred the client to Gueen 6li5abeth Central Hospital for the tests which could not be done at Ndirande /ntenatal Clinic due to lack of materials like the haemacue kits and protein dipsticks. The referral was done after Ndirande Health Centre also reported not having the materials *H+S.C/$ 6F/(.N/T.,N /s indicated in thee obEective data3 during physical assessment3 no specific problems were presented or detected from (rs. Nkhata and all the findings were documented on the antenatal card and were also communicated to the client. See /ppendi!...... showing the antenatal card with findings of the abdominal assessment. (6".C/T.,NS (ost of medications at the /ntenatal Clinic are given according to gestation ages of the mothers and most of them are given for prophylactic purposes i.e. S* is given to prevent a mother from malaria3 :errous Sulphate is given to prevent anaemia whilst /benda5ole is given to combat worms infestation. S* is given every four weeks between the gestations of %? to #? weeksH :errous Sulphate is given at every visit throughout pregnancy whilst /benda5ole is given Eust once and at first visit. S* is given

in such a way to prevent the tetratonegic effects that the sulphur may have on the foetus. ,n this visit3 (rs. Nkhata3 having the gestation age of #0 weeks3 she was given both S* tablets B#C as well as :errous Sulphate B#0 tabletsC. S* was given after confirming that 4 weeks had passed since the last dose was taken. (."7.:60+ C/06

/N/$+S.S ,: C/06 / lot of things and care were done during (rs. Nkhata9s booking antenatal visit. . should sincerely give credit to the care provider who handled (rs. Nkhata on the first visit for the good Eob for most things e!pected to be done on booking especially data needed to be filled on the antenatal card was filled. However3 not every bit of information was collected and documentedH for e!ample3 no information was documented indicating gravidity and parity on the antenatal card. This information is very important to every midwife who would come into contact with the client for it gives a picture of the kind of client one is dealing with i.e. prim)gravida3 multigravida or grand multipara. These also determine the kind of care that a client will get. Secondly3 the data documented on the antenatal card for abdominal assessment seem to have been taken for granted by the care provider during the previous visit. Having been given the date for the last normal menstrual period3 there was no reason heAshe could not calculate the gestation by dates for this day knowing its importance. The calculated gestation by dates is very important to a midwife for it gives a base comparison with the fundal height done by tape measure or finger breadths. .t also seems that the midwife who cared for (rs. Nkhata during the first visit does not know what it means when we say presentation by abdominal assessment for sheAhe indicated that it was a verte! presentation of which verte! can not be determined by pelvic palpation but vaginally. SheAhe would rather indicate cephalic for presentation and a position i.e. 0ight ,ccipital /nterior3 $eft ,ccipital /nterior or other positions.

;lood *ressure is on of the important vital signs in pregnant women and unfortunately3 it was not done on the booking day. +es its true there could be no a sphygmomanometer but still more a referral to Ndirande only for a blood pressure check would be helpful. *regnant women are at a risk of developing pre)eclampsia which is high blood pressure in pregnancy and can only be diagnosed if blood pressure if checked at every visit. 1rine protein test is also vital in the way that presence of protein in urine is indicative of pre)eclampsia (rs. Nkhata had come for booking at a gestation age of <? weeks by fundal height and this clearly shows lack of knowledge on focused antenatal care as well as its importance. (rs. Nkhata being a *ara one with birth of first born in <00& when focused antenatal was already under implementation3 it was e!pected she must have already been e!posed to such type of care. 1nfortunately3 the mother came at <? weeks gestation following the old routine antenatal system. 7hen i asked her3 she said coming at <0 weeks and above was what she knew. This mother lacked information on focused antenatal and its importance which reflects that she was not given enough information about it during her first pregnancy. 6F*6CT6" :.N".N-S :,0 TH6 N6FT .S.T (rs. Nkhata had come for her second antenatal visit at a gestation age of <' weeks3 however3 according to focused antenatal3 by this time she was supposed to becoming for her third visit which is supposed to bee between <D weeks and #< weeks. .n this case (rs. Nkhata will have her third and final normal visit at #? weeks though at this time a mother is normally e!pected to be coming for a fourth visit. 7hen (rs. Nkhata comes at #? weeks which would be on .............3 she will undergo several assessments some that are routine like vitals signs whilst some will base on her condition as being in third trimester or having a #? weeks gestation. Some of thee care will also base of the gaps that the midwife will identify as being left out during the previous visit. ,n the ne!t visit the midwife will have to check on the care given on the previous visit3 evaluate and then have a basing for planning hisAher care and this will also depend on the current problems and the unmet needs of the client.

The midwife will collect some information from the client to fill in the gaps that are not filled during this visit. She will also check on the progress of pregnancy by asking (rs. Nkhata on how she fairing with her pregnancy. Some of the 4uestions she may ask are the presence of foetal movements and minor disorders of pregnancy for this will help the midwife to isolate the problems that the client has at present. (rs. Nkhata will also have to undergo several tests which will be due by this time i.e. haemoglobin level and urine protein. Haemoglobin level is checked on booking and in third trimester3 at #? weeks to be specific whilst for urine protein is checked at every visit to the antenatal clinic. ital signs are another aspect that will have to be checked by the midwife as part of monitoring progress of pregnancy. /ny abnormality in the vital signs is indicative of a problem in the pregnant woman. :or e!ampleH high blood pressure could be indicative of pre)eclampsia3 fever could indicate a systemic infection and increased respiratory rate could mean difficulty breathing3 though3 it is thought to be normal at #? weeks. *hysical assessment will also be done including general assessment as well as abdominal assessment. -eneral assessment will involve a head to assessment and no abnormality is e!pected from it. The abdominal assessment will involve inspection3 palpation and auscultation of the abdomen to check si5e and shape of abdomen3 fundal height3 lie3 presentation and position of foetus as well as foetal heart rate. The abdomen is inspected for scars3 linea nigra3 striae gravidalum3 si5e and shape3 foetal movements3 bladder fullness and visible organomegally. Thee fundal height will be measured using a tape measure of finger breadths so as to determine the age of pregnancy. Then the pelvis will be palpated for presentation which is normally3 lateral palpation will be done to note the lie and position of the foetus. :undal palpation will also be done to rule out multiple gestation or presentation in a situation where the head is not located in the pelvic. :oetal heart rate will also have to bee auscultated using a fetalscope to confirm wellbeing of the foetus.

6F*6CT66" :.N".N-S :undal height :oetal *resentation = :oetal $ie :oetal *osition :oetal Heart 0ate = = = = #? weeks

Cephalic $ongitudinal 0ight ,ccipital /nteriorA$eft ,ccipital /nterior %40 I %?0 beats per minute

The above e!pected findings are thee normal e!pected finding in the absence of possibility of having abnormal findings "01-S ,n this visit (rs. Nkhata will only be provided with :errous Sulphate as a drug to supplement iron for haemoglobin formation. S* will not be given because it is believed to have a teratonic effect on the fetus when given at the gestation of #? weeks and above. 6F*6CT6" ".S,0"60S ;y this time the e!pected disorders that (rs. Nkhata may have are difficulty breathing3 fre4uent micturation3 headache3 constipation3 backache3 oedema varicosities3 haemorrhoids and cramps for these are the common disorders that usually come in third trimester. MANAGEMENT OF THE E PE!TE" M#N#$ "#SO$"E$S HEA$T%&$N This is a burning3 irritating sensation in the oesophagus also known as gastric reflu! B:raser3 Cooper and Nolte3 <00?C. -astric reflu! commonly occurs as a result of

delayed gastric emptying3 decreased intestinal motility3 and decreased lower oesophageal sphincter tone. .f it happens that (rs. Nkhata develops heartburn3 education and counseling on li'est(le
)odi'ication will be provided and will include awareness of posture i.e. (aintaining upright positions Bespecially after mealsC3 sleeping in a propped up position and dietar( )odi'ications Be.g. small fre4uent meals3 eating slowly3 reduction of high)fat foods and caffeineC.

S*ELL#NG+E"EMA /s the growing uterus puts pressure on the veins that return blood from feet and legs3 swollen feet and ankles may become an issue. /t the same time3 swelling in legs3 arms or hands may place pressure on nerves3 causing tingling or numbness. :luid retention and dilated blood vessels may leave the face and eyelids puffy3 especially in the morning. To reduce swelling3 the client will be advised to use cold compresses on the affected areas. $ying down or using a footrest may relieve ankle swelling. She might even elevate her feet and legs while she sleeps which will also minimise the swelling by gravity. ",SPNEA This is a common symptom between the gestation of #4 and #? weeks. .t is as a result of the pressure by the growing uterus on the diaphragm B:raser3 Cooper and Nolte3 <00?C. .f (rs. Nkhata happens to develop dyspnoea3 she will be educated of the physiology of the problem for her to understand what9s happening. She will also be advised on sleeping in semi)fowlers position so as to be increasing the area for lung e!pansion hence improved respiratory condition. She will also be encouraged to have periods and resting to reduce the body need for o!ygen. !ONST#PAT#ON Constipation in pregnancy especially third trimester is usually caused by reduced motility of large intestine which comes due to the muscle la!ative effect of the hormone

progesterone which is produced in large amounts this period3 .ncreased water re) absorption from large intestine due to hormone aldosterone effect3 *ressure on the pelvic colon by the pregnant uterus and sedentary life during pregnancy . if the client will come with the problem of constipation3 she will advised on drinking plenty of fluids3 high fibre foods and get plenty of e!ercise. These help in softening the bowels hence reduced risk of constipation. %A!-A!HE "uring pregnancy3 ligaments become softer and stretch to prepare for labour. This can put a strain on the Eoints of the lower back and pelvis3 which can result in backache. To overcome this problem (rs. Nkhata will be advised to avoid heavy lifting3 bend her knees and keep her back straight when lifting or picking up things from the ground3 move her feet when turning and avoid sudden twisting movements3 7ork at a surface high enough to prevent her from stooping and to sit with her back straight and well) supported. /nother advice will be that she should make sure she gets enough rest3 particularly later in pregnancy.

F$E.&ENT M#!T&$AT#ON /s the baby moves deeper into your pelvis towards term of pregnancy3 a woman feel more pressure on your bladder and may find herself urinating more often3 even during the night. This e!tra pressure may also cause her to leak urine J especially when she laughs3 coughs or snee5es. .n this case the client will Eust have to be assured that this is normal with a good e!planation of the cause. She will also have to be advised on perineal care to prevent ascending infections. !$AMPS Cramp is a sudden3 sharp pain3 usually in calf muscles or feet. .t is most common at night3 but nobody really knows what causes it. The woman will be oriented to skills she will have practice to combat the problem for e!ampleH pulling up of toes hard up towards the ankle3 or rub the muscle hard. -entle e!ercise in pregnancy3 particularly ankle and

leg movements3 which can improve blood circulation and may help to prevent cramp occurring and plenty of calcium rich foods Bleafy green vegetables3 dairy products3 sunflower seeds3 salmon and dried beansC and magnesium rich foods Bnuts3 dates and figs3 yellow corn3 green vegetables and applesC in her diet. FEA$ /s the pregnancy draws near term most women become afraid of the labour pains3 fears about childbirth may become more persistent. How much will it hurtK How long will it lastK How will they copeK .f (rs. Nkhata happens to come with such a problem3 she will be advised on the importance of hospital delivery where pain relief mechanisms are available. She will also be asked to have time with other women who have had positive e!perience of labour and this will help in relieving her fears.

6"1C/T.,N /N" C,1NS6$$.N"uring the assessment3 several areas were identified that needed education and counselling to (rs. Nkhata. :/(.$+ *$/NN.N(rs. Nkhata indeed knows what family planning is as well as the available family planning methods in (alawi but has problems with choice of family planning method according to her reproductive goals. (rs. Nkhata e!pressed that she wants to use inEectable contraceptives B"epo)*roveraC as her family planning methods of choice. However3 she also e!pressed fears that she had heard that the method is phasing out soon. $ooking at her reproductive goals3 . felt that (rs. Nkhata could also benefit from other family methods that are long term like .ntrauterine Contraceptive "evice and >adelle than the methods she had chosen . discussed with her of all the methods on the positives3 negatives and availability of the methods with much emphasis on >adelle which is the best method for her basing on her

goals as she wants to have a space of five years before gets pregnant again so the same with the method as it is made to last for 8 years. . also commented on the speculation that inEectable contraceptives are phasing out by telling her that it is not true. . also e!plained to her that the best time to start family planning is si! weeks after delivery for it is believed that by this time a woman9s fertility has returned and also her body has returned to her pre)pregnant state and can resume se! B:amily *lanning Handbook3 <00'C .((1N.S/T.,NS ;ased on the information that she had received only two doses of Tetanus To!oid accine with the first pregnancy and two with the current one3 . felt she needed more information on the right e!pected schedule the mothers are need to follow to complete all the five doses for TT . ,n this day3 an e!planation on the normal vaccination schedule was given to (rs. Nkhata so that as she has already started with the two doses3 should finish the remaining three doses. :inishing the doses will help in reducing the risk of the baby from getting tetanus. 7e together planned on how she was going to get the other doses. The third dose will be given on &ADA%%3 the fourth dose will be given on &ADA%< and the last dose will de given on &ADA%#. S6F1/$.T+ (rs. Nkhata did not have knowledge on when to stop se! before delivery and when resume after delivery. ,n this day3 oriented her to the right time as to when she can stop se! as well as when to resume. . told her that there is no limitation as to when they can stop se! thus they can have se! until term of pregnancy as far as they are comfortable. . also e!plained to her that they can resume se! as early as ? weeks as far as she feels that her body is ready for se!. ;.0THH *$/N /N" C,(*$.C/T.,N *06*/06"N6SS 0ealising that (rs. Nkhata was afraid of labour pains3 . took sometime counselling her on normal processes of pregnancy until labour and delivery so as to alley her an!iety. .i put emphasis on the need and importance of delivering at the hospital where measures

of managing labour pains are used. . also advised her on the need to associate and learn from mothers who had undergone the same e!perience several times who can help her prepare for her labour and delivery. :,C1S6" /NT6N/T/$ C/06 ;asing on the time that she had started antenatal visits3 it showed that she did not have enough or no knowledge on focused antenatal care and its importance. . therefore planned to educate her on what focused antenatal is3 and its importance. (rs. Nkhata was told what is done at the clinic where focused antenatal system is followed and also what if e!pected of women undergoing focused antenatal care especially when to start attending antenatal and how fre4uent. 7e also discussed on the importance of attending all the e!pected normal four visits of antenatal care. (.N,0 ".S,"60S ,: *06-N/NC+ .n addition to these education and counselling sessions3 (rs. Nkhata was also prepared for the e!pected minor disorders that may develop as the pregnancy progresses especially in the third trimester. (inor disorders like dyspnoea3 heartburn3 constipation and backache are some of the common disorders that occur to mother in their third trimesters. So she was told of the disorders so as when they happen she should not be an!ious but accept them as things that happen normally.

"ate for the ne!t visit.