TERM PAPER

TOPIC: PREVENTIVE OBSTETRICS

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 INTRODUCTION

Preventive obstetrics is the concept of prevention or early detection of particular

health deviations through routine periodic examinations and screenings. The
concept of preventive obstetrics concerns with the concepts of the health and well-
being of the mother and her baby during the antenatal, intranatal and postnatal
period. It aims to promote the well- being of mothers and babies and to support
sound parenting and stable families. Nursing care centered on health promotion and
health maintenance during pregnancy presents an excellent opportunity for nurses to
teach expectant mothers about normal changes expected and alert them to a variety
of risk factors.
The goal of the preventive obstetrics is the delivery of a healthy infant by a
healthy mother at the end of a healthy pregnancy. Pregnancy and child birth normal
physiologic process that change from conception to delivery. The nurse has a unique
opportunity to reinforce the normal cycle of these processes and at the same time,
assess client for problems that require intervention. Additionally, the nurse can teach
clients about the changes that are taking place and provide valuable guidance for
clients about when to seek guidance from health care providers.

Early contact between the health care team and the pregnant client provides
the opportunity to address the concepts of health promotion and health maintenance.
Health promotion consists of education and counseling activities that help enhance
and maintain health which prevents from obstetrics. For the prevention of obstetrics
systematic supervision (examination and advice) of a woman during pregnancy,
antenatal care, preconceptional counseling and care are the major preventive
measures.

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 The aim of preventive obstetrics is to ensure that through the pregnancy and
puerperium, the mother will have good health and that every pregnancy may
culminate in a healthy mother and a healthy baby.

Although different parts of the world have different leading causes of

maternal death attributable to pregnancy, in general, three major disorders have
persisted for the last 35 years like hypertensive disorders infection, and hemorrhage.
The number of maternal deaths overall is small; however maternal mortality remains
a significant problem because a high proportion of deaths are preventable mainly
through improving the access to a utilization of prenatal care services. Nurses can be
instrumental in educating the public about the importance of obtaining early and
regular care during pregnancy.

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 PREVENTIVE OBSTETRICS
Preventive
Preventive is the term used to prevention or slowing the course of an illness or
disease. It is intended or used to prevent or hinder acting as an obstacle.
Obstetric
The branch of medicine that deals with the care of women during pregnancy,
Childbirth and recuperative period following delivery is known as obstetric.
Preventive Obstetric
Preventive obstetric is the term for prevention of the complication that may arise
during antenatal, intranatal and postnatal period.
GOAL AND AIM
The goal of the preventive obstetrics is the delivery of a healthy infant by a healthy
mother at the end of a healthy pregnancy. Pregnancy and child birth normal
physiologic process that change from conception to delivery. The nurse has a unique
opportunity to reinforce the normal cycle of these processes and at the same time,
assess client for problems that require intervention. Additionally, the nurse can teach
clients about the changes that are taking place and provide valuable guidance for
clients about when to seek guidance from health care providers.
The aim of preventive obstetrics is to ensure that through the pregnancy and
puerperium, the mother will have good health and that every pregnancy may
culminate in a healthy mother and a healthy baby.
Preventive Obstetric measure can be categorized into three main stages. They are as
follows:-
A. Antenatal Nursing
B. Intranatal Nursing
C. Postnatal Nursing

A.ANTENATAL NURSING
Antenatal care is the care during pregnancy. Antenatal care is essential even for a
normal and healthy, pregnant women for her own well- being and that of the baby to
be born because no pregnancy and child birth is free from risk for both mother and
baby.
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Ideally the care should start immediately after conception but practically as early as
possible during the first trimester and should continue throughout the second and
third trimesters.
OBJECTIVES OF ANTENATAL CARE
 To promote, protect and maintain the health of the mother during
pregnancy.
 To detect “high risk” cases and give them special attention.
 To foresee complications and prevent them.
 To remove anxiety and dread associated with delivery.
 To reduce maternal and infant mortality and morbidity.
 To teach the mother elements of child care, nutrition, personal hygiene,
and environmental sanitation.
 To sensitize the mother to the need for family planning, including advice
to cases seeking medical termination of pregnancy.
 To detect and treat any abnormality found in pregnancy as early as
possible.
1. Preconception Counseling and Care
When couple is seen and counseled about pregnancy. Its course and outcome well
before the time of actual conception is called preconception counseling. It is a very
new concept. Objective is to ensure that a woman enters pregnancy with an optimal
state of health which would be safe both to herself and the fetus. Organogenesis is
completed by the 1st trimester. By the time the woman is seen first in the antenatal
clinic it is often too late to advice because all the adverse factors have already begun
to exert their effect.
In an ideal world antenatal care world commence at the preconception stage where
health education (general advice about nutrition, lifestyle, avoidance of teratogens,
folic acid supplementation, etc.) and risk assessment can be focused toward a
planned pregnancy. Preconception counseling is of much greater importance in two
main groups of women:
 Ones with underlying medical conditions that may be affected by or may
influence the outcome of pregnancy. Examples of such conditions include
diabetes, various endocrinopathies, hemostatic or thrombotic problem and cardiac
disease. Patients following organ transplantation (kidney, liver, heart and lungs)
are also now contributing to the ranks of these patients along with survivors of
childhood malignancies. A multidisciplinary approach to optimize/ stabilize the

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 underlying condition and planning care during the antenatal period is a key
component to optimizing pregnancy outcome.

 Ones where there are identifiable factors that would suggest the couple are at a
risk of fetal anomaly. Such identifiable factors may include a previous child
affected by a single gene disorder or syndromic disorder, a family history of
genetic disorder or history of parental chromosomal abnormality.

Counseling is a major part of prenatal diagnosis. The majority of parents to be do

not perceive themselves at risk and 95 percent of abnormalities do occur
unexpectedly, in pregnancies not considered at risk.

Preconceptional Counseling permits

 Identification of high risk factors is done by detailed evaluation of medical,
obstetric, family and personal history. Risk factors are assessed by laboratory
tests, if required.
 Treatable factors like pre- existing chronic diseases (hypertension, diabetes,
epilepsy) are stabilized in an optimal state by early intervention before
pregnancy.
 Proper counseling to those with history of recurrent fetal loss or with family
history of congenital abnormalities (genetic, chromosomal or structural), as
there may be some untreatable factors.
 Overweight or underweight is to be corrected with proper dietary advice.
 Rubella and hepatitis immunization in a non – immune woman is to be
offered.
 To record a base level health status including BP reading.
 Folic acid supplementation (4mg a day) starting 4 weeks prior to conception
up to12 weeks of pregnancy is advised.
 Good understanding with the physician so that much of the problems and fear
of the incoming pregnancy could be removed. The counseling should be done
by primary health care providers. The help of obstetricians, physicians and
geneticists may be required and should be extended.
2. Essential Antenatal Care Services
The essential components of services during pregnancy include are:-

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  Registration of Pregnant Women
 Antenatal Visits and Antenatal Care
 Immunization Against Tetanus
 Iron and Folic Acid and Vitamin A and D Supplementation
 Health education / prenatal advice during Pregnancy

 Registration of Pregnant Women

Care during pregnancy should be started as early as possible. The mother must be
registered within 20 weeks of pregnancy either at health center/ antenatal clinic or at
home by a nurse/health visitor/ female health worker (ANM) or trained person.
Through physical and obstetrical checkup should be done to screen for risk factors,
make assessment and give appropriate care for prevention and control of various
health problems and complications.
 Antenatal Visits and Antenatal Care
Ideally a woman should be seen and given care during pregnancy once a month
during the first trimester or till seven months, once in fortnight during the second
trimester or till the eighth month and thereafter every week till confinement. But
often these many visits are not feasible, neither for the mother nor for the health
infrastructure available.
The care should begin soon after conception and continue throughout pregnancy. A
schedule to follow for the mother is to attend the antenatal clinic once a month
during the first seven months, twice a month during the next two months and
thereafter once a week if everything is normal. Therefore a minimum three visits one
in each trimester have been recommended.
 The first visit should be done within 20 weeks or as early as the mother is
registered.
 The second visit at 32 weeks of pregnancy.
 The third visit at 36 weeks of pregnancy.
Further visits may be made if justified by the condition of the mother. At least one
visit should be paid in the home of the mother to make observation of actual
conditions and accordingly prepare the mother. The main purpose of contact during
antenatal period isto makes observations and assesses general health, obstetrical
health status, identify risk factors and provide appropriate care.
The preventive services for mothers in the prenatal period are as follows:-
The first visit irrespective of when it occurs should include:-
a) Taking Health History

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 It includes recording history of menstruation, medical history, obstetrical history,
socioeconomic history.
b) Physical Examination
It includes recording of height, weight, blood pressure, temperature, and pulse etc.
general observations from head to toe.
c) Obstetrical Examination
It includes general observations, examination of breasts, abdominal measurement,
palpation and inspection, vaginal examination if necessary.
d) Laboratory Investigations
• Complete urine analysis
• Stool examination
• Complete blood count including hemoglobin estimation.
• Serological examination.
• Blood grouping and Rh determination.
• Chest X- ray, if needed
• Gonorrhea test, if needed
On subsequent visits
• Physical examination including weight and blood pressure
• Laboratory tests including urine examination and hemoglobin estimation
• Iron and folic acid supplementation and medications as needed.
• Immunization against tetanus
• Group or individual teaching on nutrition, self-care, family planning, delivery
and parenthood
• Home visiting by a female health worker or trained person (trained traditional
Birth attendant)
• Referral services, when necessary
Risk Approach
While continuing to provide appropriate care for all mothers, ‘high risk’ cases must
be identified as early as possible and arrangements to be made for skilled care.
These cases comprise the following:-
 Women below 18 years of age or over 35 years in primigravida.
 Women who have had four or more pregnancies and deliveries.
 Short structured primigravida
 Those who have practiced less than 2 years or more than 10 years of birth
spacing.
 Those with cephalopelvic disproportion (CPD), genital prolapse.
 Mal presentations, e.g. breech, transverse lie etc.
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  Antepartum hemorrhage, threatened abortion
 Preeclampsia and eclampsia
 Anemia
 Twins, hydramnios
 Previous stillbirth, intrauterine death, manual removal of placenta
 Elderly grand multipara
 Those mother with blood Rh negative.
 Those with obesity and malnutrition.
 Prolonged pregnancy ( 14 days beyond expected date of delivery)
 Previous cesarean or instrumental delivery
 Pregnancy associated with medical conditions, e.g. cardiovascular disease,
kidney disease, diabetes, tuberculosis, liver disease etc.
The purpose of risk approach is to provide maximum services to all pregnant women
with attention to those who need them most. Maximum utilization of all resources,
including human resources is involved in such care. Services of traditional birth
attendants, community health workers and women’s groups are utilized. The risk
strategy is expected to lead to improvements in both the quality and coverage of
healthcare at all levels, particularly at primary health care level.
Prevention
• Administration of folic acid 5mg daily months before conception.
• By improving pre- pregnancy health of woman.
• Providing quality antenatal care.
• Screening all pregnancies for high risk.
• Provide appropriate clinical and technological care by specialist on time.
• Prevent all kinds of infection.
• Early diagnosis of malformation and termination.
• Avoidance of medication (without physician’s prescription).
• Health education on MCH and FP care.
Maintenance of Records
The antenatal card is prepared at the first examination. It is generally made of thick
Paper to facilitate filing. It contains a registration number, identifying data, previous
health history, and main health events. The record is kept at the MCH/FP center. A
link is maintained between the Antenatal card, Postnatal card and under- fives card.
Maintenance of records is essential for evaluation and further improvement of
MCH/FP services.
Home Visit

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Home visits are paid by the Female Health Worker or Public Health Nurse. If the
delivery is planned at home, several visits are required. The home visit will provide
Opportunities to study the environmental and social conditions at home and to
provide prenatal advice. In the home environment, the woman will have more
confidence to make an informed decision about home birth.

 Immunization Against Tetanus

A pregnant woman must get two injections of Tetanus Toxoid during the period
Between 16 – 36 weeks, at one month interval. These protect the mother and baby
both from the risk of tetanus. The 2nd injection should preferably be given at least at
one month before delivery. If a woman is registered late then in that case even one
injection will do. If the woman is immunized earlier within three years of the
pregnancy, then one booster dose will be enough.
 Iron and Folic Acid and Vitamin A and D Supplementation
It is being found that 50-60 percent of pregnant women are anemic due to iron
Deficiencies. Anemia is also aggravated in pregnancy. It is therefore important to
take one tablet containing 60 mg of elemental iron and 500 mg of folic acid three
times daily after third month of pregnancy till 3 months after child birth if the
mother is found having anemia.
During pregnancy, the mother requires extra iron and folic acid due to changes
taking place in the body and growth of fetus in the womb. Therefore each mother is
given one tablet of iron and folic acid twice a day for at least 100 days to prevent
anemia in mother and to promote proper growth of fetus.
Anemia is common in pregnancy and low – income group. It is a major cause of
maternal and fetal mortality.
Prevention of Anemia
 Avoidance of frequent of child birth: At least two years an interval between
pregnancies is most necessary to replace the lost iron during childbirth process and
lactation. This can be achieved by proper family planning guidance.
 Supplementary iron Therapy: Iron supplementary should be a routine after the
patient becomes free from nausea and vomiting. Daily 60mg iron with 1mg
folic acid is a quite effective prophylactic procedure.
Dietary Prescription: Well-balanced diet rich in iron and protein should be
advised. The food rich in iron are liver, meat, egg, green vegetables, green pea
bean, whole wheat etc.

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 Adequate treatment: Should be instituted to eradicate the illness likely to cause
anemia. These are hookworm infestation, dysentery, and malaria, bleeding piles,
urinary tract infection etc.
 Early detection of falling hemoglobin level is to be made. Hemoglobin level
should be estimated at the first antenatal visit at the 28th and finally at 36th
weeks.
 Avoid excessive blood loss during the 2nd stage of labor.
 Health education / prenatal advice during Pregnancy
A major component of antenatal care is health education and prenatal advice. The
mother is more receptive to advice concerning herself and her baby at this time
than any other time. A woman during pregnancy needs to know about her nutrition,
personal hygiene, rest and sleep, exercise, use of drugs, warning signs etc.
Pregnancy can be both an exciting and worrying time for the mother and her
partner. Part of the role of the health care professionals (usually fulfilled by the
community midwife and general practitioner) caring for the mother is the provision
of information about everyday activities that may or may not be affected by or
have an effect on the pregnancy.
 Diet during pregnancy
 Personal Hygiene
 Rest and Sleep
 Physical work
 Exercise
 Comfortable clothing and shoes
 Smoking
 Alcohol
 Breast Care
 Drugs
 Radiation
 Protections from infections and illnesses
 Sexual activities
 Travel
 Reporting of untoward signs and symptoms
 Child care
 Follow up visits
 Warning Signs

1. DIET DURING PREGNANCY

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 Nutritional intake is an important factor in the maintenance of maternal health
during pregnancy and in the provision of adequate nutrients for embryonic/fetal
development. Assessing nutritional status and providing nutritional information or
referral to a dietitian are part of the nurse’s responsibilities in prenatal care.
Dietary extremes are associated with risks in pregnancy. Obesity is associated with
gestational diabetes, hypertension and monitoring difficulties. Malnutrition is
associated with maternal anemia and fetal growth restriction, while deficiency of
certain vitamins predispose to congenital abnormalities, folic acid deficiency is
linked to the risk of neural tube defects (NTDs). A balanced diet rich in fresh fruit
and vegetable is recommended. It is prudent to avoid unpasteurized milk and
cheeses and pâtés. Pregnant woman should avoid eating liver due to its high
vitamin A content. Vegans should have Iron and vitamin supplementation and
ethnic groups lacking sunlight are advised to have extra vitamin D.
A balanced and adequate diet is of utmost importance during pregnancy and
lactation to meet the increased needs of the mother, and to prevent nutritional stress.
If maternal stores of iron are poor as may happen after repeated pregnancies and if
adequate iron is not available to the mother during pregnancy, it is possible that the
fetus will lay down insufficient iron stores.
Relationship between Maternal and Fetal Nutrition

Energy

Inadequate food intake and poor nutrient utilization

Maternal Malnutrition

Reduced blood volume expansion

Inadequate increase in cardiac output

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 Decreased blood and nutrient supply to the fetus

Reduced placental size

Reduced nutrient transfer

Fetal growth retardation

The increase in energy is to support the growth of the fetus, placenta, and
maternal tissue and for the increase in basal metabolic rate due to additional work
of growing fetus and increase in maternal body size.
2. PERSONAL HYGIENE
Advice regarding personal hygiene is equally important. The need to bathe
every day and to wear clean clothes should be explained. About eight midday meals
should be advised. Constipation should be avoided by regular intake of green leafy
vegetables, fruits and extra fluid. Purgatives such as castor oil to relieve
constipation should be avoided. Light household work should be encouraged but
manual physical labor during pregnancy may adversely affect the fetus.
oFresh air and sunshine
This is here in abundance and most women are in the open air for a large part of
the day and it is good for them but advice regarding their sleeping arrangements
should be given.
oThe bowels
The bowel action should occur daily and without the use of laxatives. Drinki ng
glass of warm water on getting up each morning and drinking plenty of fluids
during the day can encourage this. Plenty of roughage in the diet is also helpful.
Constipation should be avoided by regular intake of green leafy vegetables, fruits
and extra fluids. Purgatives like castor oil should be avoided to relieve
constipation.
oCare of Teeth

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 The usual care after eating should continue. A dental check is advisable and any
dental carries should be treated. Use soft brush in this period.
oPersonal Cleanliness and Bathing
During pregnancy sweet glands become more active so advice for bathing at least
once a day, preferably twice but clean clothes should be used daily. The need to
bath everyday and to wear clean clothes should be explained. The hair should
also be kept clean and tidy.
3. REST AND SLEEP
A pregnant woman needs sufficient rest. She should do less and lighter work. She
must have 8-10 hours of sleep every night. She needs to take short nap during the
day. As the pregnancy advances, the mother requires more frequent short rests
during the day. She should avoid strenuous work, carrying heavy loads or
weights e.g. bringing water from long distance, drawing of water from a well etc.
Rest is important for the maintenance of good health. She should need adequate
rest and relaxation. Relaxation of the mind produces relaxation of the muscle and
a relaxed lower uterine segment and pelvic floor makes it easier for the baby to
be born.
4. PHYSICAL WORK
A job provides satisfaction, self-esteem and confidence, along with financial
peace of mind. Women can continue working in pregnancy as long as they wish
and as long as they and their baby remain well. Avoidance of exposure to
hazardous chemicals, Smoky environments, excessive lifting and exercise and at
least an 8- hour rest at night is recommended.
5. EXERCISE
Exercise in pregnancy should be encouraged; through with advancing gestation
physical constraints may limit sporting activities. Exercise can improve
cardiovascular function, lower blood pressure and improve self- esteem and
confidence. Swimming is often helpful throughout pregnancy especially with
advancing gestation as it is essentially anon-weight bearing exercise. It is
advisable however to avoid hyperthermia, dehydration and exhaustion.
Consider decreasing weight – bearing exercises like jogging, running and
concentrate on non-weight bearing activities such as swimming, cycling or
stretching. Advise her to avoid risky activities such as surfing, mountain climbing
and skydiving. Limit activity to shorter intervals. Exercise for 10 to 15 minutes;
rest for 2 to 3 minutes, then exercise for another 10 to 15 minutes. The exercise
should be decrease as the pregnancy progresses.
6. COMFORTABLE CLOTHING AND SHOES

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 It is advisable to wear loose and comfortable cotton clothes, not too tight such as
blouse or cholo. Binder which supports the breasts should be advised, but must
not be too tight so as to flatten the nipples but lift the breast well. A support for
the abdomen is sometimes required, especially in a multigravida who has
pendulous abdomen so the pregnant mother should advise to support her whole
abdomen with a light belt. Pregnant should avoid high heeled shoes. She should
wear flat shoes to maintain center of balance and to prevent backache to some
extent.
7. SMOKING
It should be strongly discouraged in pregnancy. The target should be cessation of
smoking, but if not possible, then cutting down to as few as possible is advisable.
Smokers (especially those smoking > 20/day) have a slightly higher incidence of
miscarriage, a slightly higher perinatal death rate (20% increase in 20/day smokers,
and35% increase if > 20/day) and babies of smokers are 150 to 300 gram lighter
than babies of nonsmokers. Furthermore, smoking is associated with a three-fold
increase in risk of cleft palate. Smoking during pregnancy, however, doesn’t affect
long term mental or motor development. The mechanisms involved include
interference of carbon monoxide with oxygen transfer, shifting the oxygen
dissociation curve to the left in both maternal and fetal hemoglobin and reduced
intervillous blood flow. Appropriate advice and support should be provided for
women who wish to try stopping smoking, with optimum benefits achieved if
smoking is stopped prior to conception.
Smoking should be cut down to a minimum, as heavy smoking by the mother can
result in babies much smaller than average size due to placental insufficiency. The
perinatal mortality amongst babies whose mothers smoked during pregnancy is
between 10 to 40percent higher than in nonsmokers. Mothers who are moderate to
heavy drinkers (alcohol) become pregnant, have greater risk of pregnancy loss and
if they do not abort, their babies may have various physical and mental problems.
Heavy drinking has been associated with fetal alcohol syndrome (FAS), which
includes intrauterine growth retardation and developmental delay. Advice should
also be given about dental care and sexual behavior during pregnancy. Sexual
intercourse should be restricted during the last trimester of pregnancy.
8. ALCOHOL
An expectant mother should be advised to avoid drinking alcohol as drinking
alcohol is injurious to the fetus and also to her own health. It leads to low birth
weight and retardation.

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 Pregnant women are advised to limit alcohol consumption and a consumption 20
gm. /week (2 units) appears to be generally safe. Heavy alcohol consumption
(greater than12 units or 120 gm. / day) is associated with the development of fetal
alcohol syndrome. The syndrome is characterized by growth retardation,
neurological and structural defects (facial, cardiac, joints). A lesser degree of
alcohol consumption but still greater than 8 units/day may also be associated with
fetal alcohol syndrome as well as other associated features such as increased risk of
miscarriage and reduced head circumference.
9. BREAST CARE
The mother should advice to clean her breast during bath. If the nipples are
Anatomically normal, nothing is to be done beyond ordinary cleanliness. But if
nipples are retracted, correction should be done. For this mother is taught about
nipple care. She should wash her breast, with soap and water. To toughen the
nipples, it should be massaged by using soap and water and then roll them between
the forefinger and thumb and draw them out every day during the last two months.
This should be done three times a day. After massage, the nipples should be dried
and an oily substance applied to make them supple. Advise mother to wear a well-
fitting and supportive brassiere.
10.DRUGS
The mother should be advised not to take any medicine unless it is prescribed by the
doctor. As far as possible, medicine should be avoided for the three months unless
very essential. The mother must inform to the doctor about pregnancy when seeking
any treatment from the doctor or health personnel.
The use of drugs that are not absolutely essential should be discouraged. Certain
drugs taken by the mother during pregnancy may affect the fetus adversely and
cause fetal malformations. The classical example is thalidomide, a hypotonic drug,
which caused deformed hands and feet of the babies born. The drug proved most
serious when taken between 4 to 8 weeks of pregnancy. Other examples are LSD
which is known to cause chromosomal damage, streptomycin which may cause 8th
nerve damage and deafness in the fetus, iodine- containing preparations which may
cause congenital goiter in the fetus. Corticosteroids may impair fetal growth, sex
hormones may produce virilism, and tetracycline may affect the growth of bones
and enamel formation of teeth. Anesthetic agents including pethidine administered
during labor can have depressant effort on the baby and delay the onset of effective
respiration. Later still in the puerperium, if the mother is breast- feeding, there are
certain drugs which are excreted in breast milk. A great deal of caution is required
in the drug – intake by pregnant women.

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11.RADIATION
Exposure to radiation is a positive danger to the developing fetus. The most
common source of radiation is abdominal X-ray during pregnancy. Studies have
shown that mortality rates from leukemia and other neoplasm were significantly
greater among children exposed to intrauterine X-ray. Congenital malformations
such as microcephaly are known to occur due to radiation. Hence, X-ray
examination in pregnancy should be carried out only for definite indications.
12.PROTECTIONS FROM INFECTIONS AND ILLNESSES
Infections in pregnancy are responsible for significant morbidity and mortality. The
direct financial costs of disease can be as starting and are much more difficult to
measure. Some consequences of maternal infection last a life time.
Education and counseling are important aspects of care for the prevention of
maternal infections. Adolescent’s mothers are at high risks because of earlier
partners. The recent trend of exchanging sex for drugs is contributing to a rise in
infection rates, especially among poor, and minority women. The prevention of
disease and the reduction of maternal and neonatal effects continue to be
monumental challenges.
An expectant mother must be instructed to protect herself from the risk of any
infection especially measles, German measles and syphilis because these infections
can causes spontaneous abortion, malformation, mental retardations, still-birth,
perinatal death etc. The child may develop congenital syphilis. If the mother is
found having syphilis she must get herself treated by the trained health personnel
especially from health center/hospital.
13.SEXUAL ACTIVITIES
Patient inhibition to ask and failure to address the issue by health professionals has
resulted in considerable misconceptions. In general with an uncomplicated
pregnancy, there are no contraindications to coitus or other form of sexual
enjoyment in pregnancy including cunnilingus and masturbation. There is no
evidence that these have a damaging influence on the fetus or risk inducing
premature labor. With advance inggestation certain coital positions may be
physically awkward. There may be decline in some women in sexual desire and
activity in early pregnancy toward the end of pregnancy. Coitus may be avoided
with premature rupture of membranes and where there have been recurrent episodes
of APH and in the presence of a placenta previa major.
The mother should be advised to avoid coitus during the first three months and the
last two months. In the first three months it increases the risk of abortion. The risk

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 of abortion is more in mothers who have previous history of abortion. In late
pregnancy it predisposes to infection.
14.TRAVEL
The mother should be instructed to avoid travel during the first three and last two
months of pregnancy especially long and tedious journey. If traveling for long
distances, periods of activity and rest should be scheduled. While sitting, the
woman can practice deep breathing, foot circling, and alternating contracting and
relaxating different muscle groups. Fatigue should be avoided.
15.REPORTING OF UNTOWARDS SIGNS AND SYMPTOMS
The expectant woman must be instructed to report to health personnel the follow
ingsigns and symptoms.
• Unusual pain, bleeding from vagina.
• Swelling in the feet, hands or face
• Headache, dizziness, blurred vision at times. These symptoms indicate the
onset of high blood pressure which is very dangerous and can prove fatal if
timely care is not given.
• High fever
• Baby’s movements not being felt.
• Any other sigh or symptom which is considered unusual.
16.CHILD CARE
The mother should be educated on various aspects of child care. Mother craft
classes can be arranged if possible to train the mother regarding care during
pregnancy, childbearing, breast feeding, weaning and child nutrition, growth and
development of child, clothing, immunization, care during minor ailments, family
planning etc. Mothers attending antenatal clinics must be given mother craft
education that consists of nutrition education, hygiene and childrearing, childbirth
preparation and family planning information.
17.FOLLOW UP VISITS
It is important that mother must be educated about the need for regular visits and
proper care during pregnancy. They must be convinced to pay follow up visit and
follow the instructions regarding diet, personal hygiene, rest, physical work,
exercise, smoking, drinking, and protection from infections, sexual activities, and
travel etc. so as to promote health of both mother and the growing fetus.
18.WARNING SIGNS
The mother should be given instructions that she should report immediately, any of
the following warning signals like swelling of the feet, convulsions, headache,

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 blurring of the vision, bleeding or discharge per vagina and any other unusual
symptoms.
3.Specific Health Protection
Specific protection for pregnant women’s health is an essential aspect of prenatal
care. This is because 50 to 60% of women, belonging to low socio-economic groups
are anemic in the last trimester of pregnancy. The major causative factors are iron
and folic acid deficiencies. Anemia is known to be associated with high incidence
of premature births, postpartum hemorrhage, and puerperal sepsis and thrombo
embolic phenomena in the mother.
 Anemia
Surveys in different parts of India indicate that about 50 to 60 percent of women
belonging to low socio- economic groups are anemic in the last trimester of
pregnancy. The major etiological factors being iron and folic acid deficiencies. It is
well known that anemia per se is associated with high incidence of premature
births, postpartum hemorrhage, and puerperal sepsis and thromboembolic
phenomena in the mother.
 Other Nutritional Deficiencies
Protection is required against other nutritional deficiencies that may occur during
pregnancy such as protein, vitamin and mineral deficiencies. So Vitamin A and D
capsules should be supplied for the pregnant mother.
 Toxemias of Pregnancy
The presence of albumin in urine and increase in blood pressure indicates
toxemias of pregnancy. Their early detection and management are indicated.
Efficient antenatal care minimizes the risk of toxemias of pregnancy.
 Diabetes
This plays an important role for presentational diabetes. To prevent early
pregnancy loss and congenital anomalies, medical care should begin before
conception. A complete assessment of the diabetic status and associated
complications is done to find out if she is fit to go through pregnancy.
Evaluation of thyroid function is also recommended in type 1 diabetes as
hypothyroidism is frequently encountered in these women. Those on oral
hypoglycemic agents should be switched to insulin therapy preferably before
conception.
 Tetanus Protection
If the mother was not immunized earlier, two doses of tetanus toxoid should be
given, the first dose at 16th to 20th week and the second dose at 20th to 24th week
of pregnancy. For a woman who has been immunized earlier, one booster dose will
18
 be sufficient. When such a booster dose is given, it will provide necessary cover for
subsequent pregnancies for the next five years.
 Rubella
Rubella infection suffered by the mother, especially in early pregnancy can have
devastating consequences for the fetus. In an attempt to reduce the incidence of
congenital rubella defects, vaccination has been undertaken.

 HIV Screening
Pregnant women are ethically obligated to seek reasonable care during pregnancy
and to avoid causing harm to the fetus. Maternity nurses should be advocates for the
fetus, but not at the expense of the pregnant woman. Incidence of perinatal
transmission from man HIV – positive mother to her fetus ranges from 25% to 35%.
Methods of preventing maternal – fetal transmission ad fetal treatment currently are
not available. Until there is change in technology that alters the diagnosis or
treatment of the fetus, testing of the pregnant woman should be voluntary. Health
care providers have an obligation to make sure the pregnant woman is well
informed about HIV symptoms and testing.
HIV may pass from an infected mother to her fetus through the placenta or to her
infant during delivery or breast feeding. About one third of the children of HIV
positive mothers infected through this routine. The risk of transmission is higher if
the mother is newly infected or if she has already developed AIDS. Prenatal testing
for HIV infection should be done as early in pregnancy as possible for pregnant
women who are at risk (if they or their partners have multiple sexual partners, have
sexually transmitted disease or use illicit injectable drugs). Universal confidential
voluntary screening of pregnant women in high prevalence areas may allow
infected woman to choose therapeutic abortion, make an informed decision on
breast feeding or receive appropriate care.
 Hepatitis B
Screening for hepatitis B aims to determine whether the patient has ever been
exposed to the virus, and whether is immune to the virus or whether she is a
potential risk of transmitting the infection to the neonate, her partner and to health
care professionals. A combined course of active and passive immunization can then
be undertaken in the neonate at risk after birth. The importance of preventing
hepatitis B infection in the neonate is that while in the adult patient the virus is
cleared within 6 months in 90percent of infected individuals, in neonates 90 percent
become chronic carriers with the risk of post infective hepatitis cirrhosis and hepato
cellular carcinoma.

19
 Syphilis
Screening for syphilis should be performed for the prevention of congenital
syphilis in the neonate. Treatment confers benefits to mother too, by preventing
development of cardiovascular and neurological complications of the advanced
stages of the disease.
Syphilitic infection in the woman is transmissible to the fetus, especially when
she is suffering from primary or secondary stages after the 6th month of pregnancy.
Neurological damage with mental retardation is one of the most serious
complications. Blood should be tested for syphilis (VDRL) at the first visit and late
in pregnancy.
It is routine procedure in antenatal clinics to test blood for syphilis at the first visit.
Since the mother can subsequently get infected with syphilis, the ideal procedure
would be to test blood for syphilis both early and late in pregnancy. Congenital
syphilis is easily preventable. Ten daily injections of procaine penicillin (600,000
units) are almost always adequate.
 German Measles
Rubella infection contracted during the first 16 weeks of pregnancy can cause
major defects such as cataract, deafness and congenital heart diseases. Vaccination
of all women of child bearing age, who are seronegative, is desirable. Before
vaccinating, it is desirable that pregnancy is ruled out and effective contraception be
maintained for eight weeks after vaccination because of possible risk to the fetus
from the virus, should them other become pregnant.
 Rh Status
It is a routine procedure in antenatal clinics to test the blood for Rhesus type in
early pregnancy. If the woman is Rh- negative and the husband is Rh-positive, she
is kept under surveillance for determination of Rh- antibody levels during antenatal
period. The blood is further examined at 28th week and 34th to 36th week of
gestation for antibodies. Rh anti – D immunoglobulin should be given at 28th week
of gestation so that sensitization during the first pregnancy can be prevented. If the
baby is Rh positive, the Rh anti-D immunoglobulin is given again within 72 hours
of delivery. It should also be given after abortion. Post maturity should be avoided.
Whenever there is evidence of hemolytic process in fetus in utero, the mother
should be shifted to an equipped center specialized to deal with Rh problems. The
incidence of hemolytic disease due to Rh factor in India is estimated to be
approximately one for every 400-500 live births.
 Prenatal Genetic Screening

20
 Screening for genetic abnormalities and for direct evidence of structural anomalies
is performed in pregnancy in order to make the option of therapeutic abortion
available when severe defects are detected. Typical examples are screening for
trisomy-21 and severe neural tube defects. Women aged 35 years and above, and
those who already have an afflicted child are at high risk.
4. Preparing for Confinement
The preparation for safe delivery is very important. It should be done well in
advance to avoid any type of difficulty or emergency which might occur at the time
of delivery. The health personnel discuss with the couple and may be other
members of the family about the alternative suitable place for confinement which
includes home, health centre or hospital. The decision will depend upon the health
status of both mother and the fetus, risk factors and environmental conditions at
home. High risk mother must be delivered at primary health center, first referral
unit or hospital at the discretion of doctor. However a normal healthy mother may
be delivered at home. But she must be delivered by a trained birth attendant, female
health worker (ANM),health supervisor ( LHV) to protect the life of both mother
and the baby and prevent them from any infection especially tetanus. It is important
to arrange transport in advance for transportation of mother to hospital or first
referral unit during emergency, if any. The following preparation should be done
for delivery at home.
Preparation of the room or some place for confinement:-
 The room or some place in the room should be clean, ventilated and well
lighted. It should be kept ready beforehand.
Preparation of the articles include:
 Washed and sun-dried sufficient old clothes.
 Washed and sun-dried bed sheet, blanket and mat.
 Stove/gas burner, match box.
 Large vessel with lid, bucket and a mug, a parat and a tasla.
 A lantern and a torch
 A new razor blade, clean cotton
 A plastic sheet to be placed over the mattress to protect it from fluid and
blood.
 Washed and sun dried linens or towel to wrap the baby.
 Arrangements to burn or deep bury the placenta.
The trained Dai should be ready with her own kit for delivery. It should have the
following articles:

21
 a) Enema cans two bowels and one kidney tray, torch, a pair of scissors.
b) Clean gauze pieces, cord ligatures, mucus sucker and baby weighing spring
balance.
c) Drugs and antiseptic like injection methergin, methylated spirit.
d) Hand washing articles.
These equipments and articles must be kept ready by the mother and family so
that there is no problem at the time of delivery. The instructions must be given to
another regarding these. Similarly the trained dais and health workers should be
ready with their delivery kit for conduct of delivery at home.
5. Psychological preparation of the mother
Psychological preparation of the mother is important during pregnancy and
delivery. The expectant mother, especially the primary Para mother has fear and
anxiety about child birth, its outcome, and complications etc. It is very important to
discuss various aspects of pregnancy and delivery. This helps in overcoming their
fears and anxieties. Sufficient time and opportunity must be given to expectant
mothers to have free and frank talk on all aspects of pregnancy and delivery. The
“mother craft” classes at the MCH centers help a great deal in removing their fears
and in gaining confidence.
6. Family Planning
Family planning is related to every phase of the maternity cycle. Educational and
motivational efforts must be initiated during the antenatal period. If the mother has
had two or more children, she should be motivated for puerperal sterilization. The
mother should be educated and motivated for small family norm and spacing of
children.
7.Education for Self – Care
Health maintenance is an important aspect of prenatal care. Patient participation in
the care ensures prompt reporting of untoward responses to pregnancy. Patient as
symptom of responsibility of health maintenance is prompted by understanding of
maternal adaptations to the growth of the unborn child and a readiness to learn.
Nurses in their role of teacher provide patients with the information necessary for
compliance with health care measures.
The expectant mother needs information about many subjects. During the initial
health assessment, the woman may have indicated a need to learn self-care activities
such as prevention of urinary tract infection.
Supportive maternity brassiere with pads to absorb discharge may be worn at
night, wash with warm water and keep dry, see maternal physiology and sexual

22
 counseling. Both partners need reassurance and support, support significant other
who can reassure woman about her attractiveness, etc. improved communication
with her partner, family and others, refer to social worker, if needed or supportive
services ( financial assistance, food stamps)
First Trimester
Antenatal care in the first trimester starts with a visit to the GP after a missed
period and confirmation of pregnancy. It also provides an ideal opportunity for the
woman to discuss any anxieties she may have.
8. Hematological Investigations
These include hemoglobin estimation and a complete blood picture if indicated.
Blood group determination and antibody screen is also performed to identify rhesus
negative women who will need prophylaxis against rhesus is immunization.
 Full blood count
This is the most commonly performed hematological investigation in pregnancy.
Pregnancy is associated with a physiological dilutional anemia due to greater
increase in plasma volume than red cell mass and therefore the lower limit for a
normal Hemoglobin is10.5 g/dl in pregnancy as opposed to 11.5g/dl in the non-
pregnant female. Many women enter pregnancy with a low iron reserve and
therefore if anemia is detected in pregnancy it should be appropriately investigated
by assessment of ferritin, total iron binding capacity (TIBC), serum and red cell
folate and B12 levels based on the blood picture. The most common cause of
anemia in pregnancy is iron deficiency anemia. FBC estimation is performed 4 – 8
weekly in the second half of pregnancy and low hemoglobin on admission in labor
is an indication for sending a specimen to the lab for group and save in case of
intrapartum or postpartum bleeding.
 Blood grouping and screening for antibodies
Blood grouping at booking, enables the determination women who are rhesus
negative and therefore may be at risk of rhesus isoimmunization. The incidence of
rhesus disease has dramatically fallen over the last thirty years the introduction of
anti – D administration. Despite screening at 28 and 34 weeks or after any potential
sensitizing event and administration of prophylactic anti – D at these times, a small
number of Rh D negative women still develop anti-D antibodies because of small
silent hemorrhages predominantly in the third trimester or because of failure of
timely administration of anti D immunoglobulin. Screening for red cell antibodies
should be repeated in all women in early pregnancy in subsequent pregnancies,
even if rhesus positive, as there may be other clinically significant antibodies as a
consequence of previous pregnancy or blood transfusion. An antibody screen is
23
performed to detect the presence of antibodies that may put the baby at risk of
hemolytic disease or result in difficulties with cross- matching blood for the
mother if required at any age of pregnancy, labor or postnatally. If antibodies are
detected, the titer is determined and subsequent samples taken for further
estimation at appropriate time interval.

9.Screening for Urinary Tract infection

Urinary tract infections may be asymptomatic. Whether symptomatic or not,
urinary tract infections present a risk to both mother and fetus. Prevention of these
infections is essential. The woman’s understanding and use of general hygiene
measures are assessed. Before developing a plan of care, the nurse needs to elicit
feelings or idea concerning cultural, ethnic, religious, or other factors affecting
health practices. Therationale being that some cases asymptomatic bacteriuria and
a lower urinary tractinfection may lead to complications of the advanced stages of
the disease.
The woman may need to learn that every woman should always wipe from front to
backafter urinating or moving her bowels and use a clean piece of toilet paper for
each wipe. Wiping from back to front may carry bacteria from the rectal area to the
urethral opening and increase risk of infection. Soft, absorbent toilet tissue,
preferably white and unscented, should be used because harsh, scented or printed
toilet paper may cause irritation. Women need to change panty shields or sanitary
napkins often. Bacteria can multiply on soiled napkins. Women need to wear
underpants and pantyhose with a cotton crotch. They should avoid wearing tight –
fitting slacks or jeans or panty shields for long periods.
Some women don’t have an adequate fluid and food intake. After eliciting her food
preferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12
glasses)of liquid a day.
10.Minor Disorder of Pregnancy
Most pregnant women do suffer from minor disorders during pregnancy. Minor
disorder is a condition caused by pregnancy, which is not present in the pre
pregnant state. It should be solved in correct time to prevent complication offering
minor treatment and proper explanation for the reduction of these problems and
anxiety. The exact cause of minor disorders are still unknown but it could be due to
increasing level of hormone especially progesterone in the blood.
The common minor disorders are
{ Morning Sickness ( Nausea and Vomiting)
24
 { Indigestion
{ Varicose veins
{ Backache
{ Fainting
{ Heartburn
{ Constipation
{ Itching
{ Leg Cramp
 Morning Sickness ( Nausea and Vomiting)
Nausea and vomiting especially in the morning, soon after getting out of bed,
are usually common in primigravida. It may due to emotional factors, fatigue, and
carbohydrate metabolism. So it is important to prevent it from getting worse as
hyperemesis gravidarum may occur.
Prevention
 Identify the particular odour of foods that are most upsetting and avoid the
odour of certain foods, because women are very sensitive to smells.
 Eat dry crackers or bread 15 minutes before getting up from the bed in the
morning.
 Advice to consume small frequent meal (every 2 hours if possible).
 Avoiding spicy and greasy food and consuming protein snack at night
 Advice to take light and dry snacks instead of heavy meal.
 Avoid brushing after eating.
 Keep room well ventilated for fresh air.
 Indigestion
Indigestion often occurs after eating too much of heavy or greasy food or
drinking too much of alcohol. It is characterized by discomfort or a burning
feeling in the mid –chest or stomach.
Prevention
 Avoid fatty, greasy and spicy foods
 Eat small frequent meals instead of the usual three meals.
 Avoid alcohol, coffee and cigarettes.
 Eat boiled foods.
 Varicose veins
Varicose veins are enlarged superficial veins on the legs; vulva and anus varicose
veinsare disorder of the second and third trimesters. It is due to increased
maternal age, excessive weight gain large fetus and multiple pregnancies etc.
Prevention

25
 Exercise regularly and avoid tight clothes.
 Avoid standing for long time and sitting with feet hanging down.
 Lift the legs up with extra pillows while sitting, resting or sleeping.
 Avoid crossing legs at the knees because it provides the pressure on her veins.
 Backache
This is common problem during pregnancy especially in the third trimesters.
Slight backache may be due to faulty posture and is more common in
multigravida. It may be due to fatigue, by lifting heavy objectives and poor
postures, fatigue.
Prevention
 Take adequate rest in proper position and posture.
 Wear supportive shoes with low heels, avoid high heels shoes.
 Do prenatal exercise and do not gain more weight.
 Avoid excessive twisting, bending, stretching and also excessive standing or
walking.
 Fainting ( Syncope)
It is the disorder common in second and third trimester. Many pregnant
women occasionally fall to faint, especially in warm and crowed areas. It is due
to anemia, sudden changes of position, standing for long periods in warm and
crowd areas.
Prevention
Avoid prolonged standing.
Rest in side lying position in left lateral to prevent supine hypotension.
Eat regularly iron containing food and plenty of liquid.
Advice to be alert for safety.
 Heartburn
Heartburn is a burning sensation in the mediastinal region due to back flow
(regurgitation) of acid contents into the esophagus often accompanied by bad test
in the mouth.
Prevention
 Avoids foods known to cause gastric upset.
 Avoid greasy, fried foods, coffee, alcohol and cigarettes.
 Advice to take small frequent meal, but eat slowly.
 Take adequate rest in sleeping with more pillows on propped position.
 Explain that this is related to pregnancy and the problem disappears after
pregnancy.
 Constipation

26
 Constipation is a condition of infrequent, irregular and difficulty in passing stool
or the passing of hard stool. It is common during pregnancy. It is due to lack of
physical activity or exercise, decrease fluids, oral iron supplement, pressure of
enlarging uteruson intestine.
Prevention
 Encourage to maintain bowel habit, going to toilet at same time every day
and toilet when having the urge.
 Encourage to drinking adequate liquid ( of least 200ml per day)
 Advice to eat in regular schedule.
 Encourage eating fruits, vegetables, gains and roughage in the diet.
 Advice to do regular daily exercise.
 Itching
Itching is an unpleasant cutaneous sensation that provokes a desire to scratch the
skin. It may be due to poor personal hygiene, heat rash, minor skin disease.
Prevention
 Advice to take daily bath.
 Advice to wear non- irritating clothes, cotton panty.
 Leg Cramps
Leg Cramps are painful muscle spasm in the muscles. They occur most
frequently at night but may occur at other times. Leg cramps are more common
in the third trimester.
Prevention
 Advice to take enough calcium ( milk, green leafy vegetables)
 Advice to take warm bath to improve the circulation.
 Advice to do exercise regularly.
 Strengthen the legs, point or pull toes upward towards the knees

B. INTRANATAL NURSING

Childbirth is a normal physiological process, but complications may arise.

Septicemia may result from unskilled and septic manipulations, and tetanus
neonatorum from the use of unsterilized instruments. The need for effective
intranatal care is therefore indispensable, even if the delivery is going to be a normal
one. The emphasis is on the cleanliness. It entails – clean hands and fingernails, a
clean surface for delivery, clean cutting and care of the cord, and keeping birth canal
clean by avoiding harmful practices. Hospitals and health centers should be
equipped for delivery with midwifery kits, a regular supply of sterile gloves and

27
drapes, towels, cleaning materials, soap and antiseptic solution, as well as equipment
for sterilizing instruments and supplies.
Objectives of Intranatal Care
1. To delivery with minimum injury to the newborn and mother.
2. To be readiness to deal with complications such as prolonged labour,
hemorrhage, convulsions, malpresentations, prolapse of the cord etc.
3. To do care of the baby at delivery like resuscitation, care of the cord, care of the
eyes etc.
4. To prevent infection.
5. To detect and deal with any complications e.g. Antepartum and postpartum
hemorrhage, prolonged labor, mal presentation, prolapse cord etc.
6. To resuscitate the baby and to provide immediate care to baby.
1. Domiciliary Care
Mothers with normal obstetric history may be advised to have their confinement in
their own homes, provided the home conditions are satisfactory. In such cases, the
delivery may be conducted by Health Worker Female or trained Dai. This is known
as “domiciliary midwifery service.”
Advantages of the domiciliary midwifery service
a) The mother delivers in the familiar surroundings of her home and this may
tend to remove the fear associated with delivery in a hospital,
b) The chances for cross infection are generally fewer at home than in the
nursery/hospital, and
c) The mother is able to keep an eye upon her children and domestic affairs; this
may tend to ease her mental tension
Most deliveries will have to take place in the home with the aid of Female Health
Workers or trained dais. Domiciliary outreach is a major component of intranatal
health care: The Female Health Worker, who is a pivot of domiciliary care, should
be adequately trained to recognize the ‘danger signals’ during labor and seek
immediate help in transferring the mother to the nearest Primary Health Centre or
Hospital. The danger signals are:
 Sluggish pains or no pains after rupture of members.
 Good pains for an hour after rupture of members, but no progress
 Prolapse of the cord or hand
 Meconium – stained liquor or a slow irregular or excessively fast fetal heart
 Excessive ‘show’ or bleeding during labor
 Collapse during labor
 A placenta not separated within half an hour after delivery

28
  Postpartum hemorrhage or collapse
2.Complications and obstetrical emergency during intranal period
 Prolonged Labor
The prolonged labor may occur due to fault in power, fault in passage and fault in
passenger etc. so the preventive measures should be done before the delivery.
Preventive Measures
 Antenatal and early intranatal detection of the factors likely to produce prolonged
labor and then to institute its appropriate management.
 Use partograph to record fetal, maternal and labor condition and maintain
itmeticulously which help in early detection
 Selective and judicious augmentation of labor can be employed by low rupture of
the membranes followed by the oxytocin drip.
 Keep vigilant during labour and appropriate management should promptly be
instituted if the first is delayed as evidence from the cervico graph and there is
tendency of slow descent in the second stage.
 Abnormal Uterine Contraction
Abnormal uterine contraction may be due to obstructed labor due to contracted
pelvic, congenital malformation of fetus like hydrocephalus, brow presentation,
neglected transverse lie etc.
Preventive Measures
 Periodic and careful antenatal visits.
 Early detection of factors affecting labor, such as passage or passenger
during antenatal or early intranatal period to place an appropriate method of
delivery.
 Careful and constant observation of the mature of uterine contraction and
keep record meticulously in partograph
 Obstructed Labor
The obstructed labor may be due to contracted pelvis, cephalopelvic
disproportion, congenital malformation of the fetus etc.
Preventive Measures
1. Antenatal
 Risk assessment in the antenatal clinic:
 Past medical and obstetrical history of obstructed labour.
 Assessment of pelvis for bony and soft passage anomalies.
 Abdominal examination for engagement.
 Ultrasonography is employed to assess fetal anomalies.

29
  Refer the mother in an appropriate place or hospital where the choice of safe
delivery is contemplated
2. Intranatal
 Keep continuous vigilance by using partograph.
 Careful assessment of the progress of labor.
 Timely intervention of a prolonged labor and prompt action need to be taken
with mothers who likely to develop obstructed labor.

C. POSTNATAL NURSING
Care of the mother and newborn after delivery is known as postnatal or
postpartum care. Following delivery, the mother and baby are visited daily for ten
days. During each of these visits the midwife/ FHW checks temperature, pulse
and respirations of the mother, examines her breasts, checks the progress of
normal involution of uterus, examines lochia for any abnormality, checks urine
and bowels and advices on perineal toileting. The immediate postnatal
complications such as puerperal sepsis, thrombophlebitis and secondary
hemorrhage must be kept in mind. At the end of the 6th week, the woman needs
an examination by the physician in the health center to check up involution of the
uterus, which should be complete by then. Further visits should be done once a
month during the first six months and thereafter once in 2 to 3months until the
end of one year. In rural areas, where only limited care is possible, efforts should
be made by the FHW to give at least 3 to 6 postnatal visits. The common
conditions found during the late postnatal period are sub involution of uterus,
prolapsed of uterus and cervicitis. Postnatal examination offers an opportunity to
detect and correct these defects. Anemia if presents need to be treated. Health
education regarding affordable nutritious diet and postnatal exercises to restore
the stretched abdominal and pelvic muscles must be provided to enable the
mother have a normal post- partumperiod.
The psychological aspect of postnatal care needs to be addressed based on a
needs assessment. New mothers may have timidity and fears due to ignorance
and insecurity regarding the care of the baby. In order to endure the emotional
stress of childbirth, she requires the support and companionship of her husband
as well as encouragement and assistance of family. Fear and insecurity may be
eliminated by proper prenatal instructions, postnatal enforcing and supportive
care.
Objectives of postnatal care
1. To prevent complications of the post-partal period.
30
 2. To restore, promote and maintain health of the mother and baby.
3. To promote breast feeding.
4. To establish good nutritious of the baby.
5. To check the adequacy of breast feeding.
6. To prevent infection and identify any health problem/disorder in the baby.
7. To support and strengthen the parents confidence and their role within their
family and cultural environment.
8. To provide family planning instructions and services.
9. To provide basic health education to mother and family on various aspects of
mother and child care.
1. Complications of the postnatal period
Certain complications may arise during the postnatal period which is be recognized
early and dealt with promptly. These are as follows:
 Puerperal sepsis
This is infection of the genital tract within 3 weeks after delivery. This is
accompanied by rise in temperature and pulse rate, foul smelling lochia, pain and
tenderness in lower abdomen, etc. Puerperal sepsis can be prevented by attention to
asepsis, before and after delivery. This is particularly important in domiciliary
midwifery service.
Prevention
Puerperal sepsis is to a great extent preventable. Certain measure should be taken
under before, during and following labor.
Antenatal
 Detect and eradicate the septic focus especially located in the teeth, gums,
tonsils, middle ears etc.
 Maintain and improve the health of status of the patient especially to raise Hb
level, prevent eclampsia, early treatment of any abnormalities.
 Vaginal examination during pregnancy especially in the last months should
be kept in a minimum and should be carried out with strict surgical asepsis.
 Intercourse should be avoided during the last two months to prevent
introduction of organisms like streptococcus.
 The patient should avoid contact with persons suffering from infectious
disease.
 The patient should take care of personal hygiene.
 Intranatal

31
  The nurse, doctor and other personnel entering into labor room should wear
mask, gown and cap to prevent the infection of personnel spread to labour
room.
 The delivery should be conducted taking full surgical asepsis.
 Members should be kept preserved as long as possible.
 Well management on every step of labor which prevents possibility of
infection.
 Avoid prolonged labour and mother from exhaustion.
 Traumatic vaginal delivery should preferable be avoided and intra uterine
manipulation if required should be done by maintaining strict surgical
asepsis.
 After placenta delivery, explore the vagina to determine if there are any
pieces of membranes or blood clots retained in uterus.
 Enema should be given in first stage of labour to prevent the contamination
of stool in 2nd stage of labour.
 Dust should be avoided in the labour room.
 Laceration of the genital tract should be repaired promptly.
 Excessive blood loss during delivery should be replaced promptly by blood
transfusion to improve the general body resistance.
Postnatal Period
 Aseptic precaution should be taken for at least one week following delivery
until the open wound the uterus and the genital tract injury, if any, are healed
up.
 Nurse should take aseptic precaution and wear mask while giving perineal
care.
 Restrict too much visitors in ward.
 Sterilized sanitary pad should be used and changed frequently to prevent
lochia to decompose and become offensive on the pad.
 Clean the vulval area with antiseptic solution after each urination and
defecation.
 Isolation as well as barrier nursing measure for infected patient and infants is
imperative.
 Advise to avoid sexual intercourse for 4-6 weeks after delivery.
 Thrombophlebitis
This is an infection of the veins of the legs, frequently associated with varicose
veins. The leg may become tender, pale and swollen. So the mother should be
encouraged to do the leg exercise to increase the muscle tone.

32
 Deep vein Thrombosis
It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the
absence of infection.
Prevention
The three important factors i. e. trauma, sepsis and anemia should be prevented and
to be treated effectively after detection. Dehydration during delivery should be
promptly corrected. Leg exercise and early ambulation re encouraged especially
following operative delivery.
 Postpartum Hemorrhage
Postpartum hemorrhage is the condition of excessive bleeding from the genital tract
at any time following the baby’s birth up to 6 weeks after delivery. It may occur at
anytime that is during third stage of labour, within 24 hours or after 24 hours of
labour.

PREVENTIVE MEASURES OF PPH

SL.N Antenatal Period Intranatal Period Postnatal Period

1.  Ensure regular  Judiciously administer  Continue to monitor

antenatal care sedative, analgesic and vital signs
oxytocin
2.  Maintain  Avoid hasty delivery  Observe the lochia,
hemoglobin level as of the baby. type, amount and
near as normal  One should take at consistency.
least 2-3 minutes to
deliver the trunk
after the head is
born.
 Baby should be
pushed out by the
retracted uterus and
not be pulled out.
3.  Check blood  Prevent the labour  Check hemoglobin
grouping and typing being prolonged level if needed
4.  Identify high risk  Avoid fiddling and  Prevent infection
mothers ( twins, kneading of the uterus
hydramnios, APH) or pulling the cord
and deliver in a well before the placental
33
 equipped hospital separation
5.  Strict application of  Observe the mother
active management of for two hours after
third stage e.g. delivery and ensure
Immediate oxytocin that the uterus is hard
Control Cord Traction and contracted
Uterine Massage enough.
6.  In all cases of the  Encourage the
induced or augmented mother for breast
labour by oxytocin feeding.
should be kept on
continuous oxytocin
infusion for at least
one hour after
delivery.
7.  Examine the placenta  Encourage and
and assist to empty the
membranes and cord bladder
carefully periodically and for
ambulation.

 Inversion of the uterus

The uterus is said to be inverted if it rums inside – out partially or completely during
delivery of the placenta.
Preventive measures
 Don’t employ any method to expel the placenta when the uterus is relaxed.
 Avoid pulling cord simultaneously with fundal pressure.
 Attempt proper technique to deliver the placenta and of manual removal of
placenta.
 Pay vigilant observation for separation of placenta.
 Urinary tract infection and incontinence of urine
It is one of the common causes of puerperal pyrexia, the incidence being 15 % of all
deliveries. It is due to frequent catheterization either during labour or in early
puerperium to relieve retention of urine, recurrence of previous pyelitis, poor
personal hygiene and vaginal hygiene, trauma following instrumental delivery, poor
fluid intake. It is extremely important to look for these complications in the postnatal
period and prevent or treat them promptly.
 Postnatal Blues

34
Pregnancy and puerperium are highly stressful periods in a woman’s life. The person
is threatened by various changes such as physiological changes, and endocrine
changes occurring in one’s body, as she is in reorganization of psyche in accordance
with the new mother role especially in the first pregnancy. Body image changes and
unconscious intrapsychic conflicts related to pregnancy, childbirth, and motherhood
become activated. It is no wonder that 25% to %0% of the pregnant women develop
mild psychological symptoms in the puerperal period. The commonest type is the
mild depression and irritability known as the postnatal blues.
Prevention
 Advice to the family and relatives to deal properly with the postnatal situation
of the postnatal mother.
 Help her to feed the baby and assist her in domestic duties.
 Advice to provide sufficient rest, balance diet and to give love and care.

2.Restoration of mother to optimum health

The second objective of postnatal care is to provide care whereby, the woman can
recuperate physically and emotionally from her experience of delivery. The broad
areas of this care fall into three divisions:
a) Physical
 Postnatal Examinations
Soon after delivery, the health checks-ups must be frequent, i.e., twice a day during
the first 3 days, and subsequently once a day till the umbilical cord drops off. At
each of these examinations, the health personnel should checks temperature, pulse
and respiration, examines the breasts, checks progress of normal involution of the
uterus, examines lochia for any abnormality, checks urine and bowels and advises or
perineal toilet including care of the stitches, if any. The immediate postnatal
complications, puerperal sepsis, thrombophlebitis, secondary hemorrhage should be
kept in mind. At the end of 6 weeks, an examination is necessary to check up
involution of the uterus which should be complete by then. Further visits should be
done once a month during the 6 months and thereafter once in 2 or 3 months tills the
end of one year.
In rural areas only limited postnatal care is possible. Efforts should be made by the
FHWs to give at least 3 to 6 postnatal visits. The common conditions found on
examination during the late postnatal period are sub involution of uterus,
retroverteduterus, prolapse of uterus and cervicitis. Postnatal examination offers an
opportunity todetect and correct these defects.
 Anemia

35
 Routine hemoglobin examination should be done during postnatal visits, and when
anemia is discovered, it should be treated. In some cases it may be necessary to
continue treatment for a year or more.
 Nutrition
Though a malnourished mother is able to secrete as much breast milk as well-
nourished one, she does it at the cost of her own health. The nutritional needs of the
mother must be adequately met. Often the family budget is limited, the mother
should be shown the means how she can eat better with less money.
 Postnatal Exercises
Postnatal exercises are necessary to bring the stretched abdominal and pelvic
muscles back to normal as quickly as possible. Gradual resumption of normal house
– hold duties may be enough to restore one’s figure.
b) Psychological
The next big area of postnatal care involves a consideration of the psychological
factors peculiar to the recently delivered woman. One of the psychological problems
is fear which is generally borne of ignorance. Other problems are timidity and
insecurity regarding the baby. If a woman is to endure cheerfully the emotional
stresses of childbirth, she requires the support and companionship of her husband.
Fear and insecurity may be eliminated by proper prenatal instruction. The so called
postpartum psychosis is perhaps precipitated by birth, and it is rather uncommon.
c) Social
It has been said that the most important thing a woman can do is to have a baby.
This is only part of the truth. The really important thing is to nurture and raise the
child in a wholesome family atmosphere. She, with her husband, must develop her
own methods.
3.Breast feeding
Postnatal care offers an excellent opportunity to find out how the mother is getting
galong with her baby, particularly with regard to feeding. For many children breast
milk provides the main source of nourishment in the first year of life. In some
societies, lactation continues to make an important contribution to the child’s
nutrition for 18thmonths or longer.
Postnatal care includes helping the mother to establish successful breast-feeding. For
many babies breast milk provides the main source of nourishment in the first year of
life. When the standard of environmental sanitation is poor and education low, the
content of feeding bottle is likely to be as nutritionally poor as it is bacteriologically
dangerous. It is therefore very important to advise mothers to provide exclusive
breastfeeding in the initial months.

36
4.Respiratory Distress Syndrome and Neonatal Problems
 Asphyxia Neonatorum
Asphyxia neonatorum is defined as failure to initiate and maintain spontaneous
espiration within one minutes of birth. It may due to traumatic forceps or vaccum
delivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine
hypoxia due to placental insufficiency APH, and premature separation of placenta.
Prevention
o Antenatal screening of high risk patients.
o Complete fetal monitoring, particularly in high risk pregnancy group to ensure
early detection of fetal distress
o Intra partum fetal monitoring.

 Respiratory Distress syndrome

Respiratory distress syndrome almost always occurs in preterm babies. It may be
due to prematurely, maternal anemia, pre- eclampsia, diabetes, APH after 28 weeks
of gestation, intrauterine hypoxia etc.
Prevention
o Administration of dexamethasone in patients anticipating preterm delivery
especially before 34 weeks for lung maturity.
o Assessment of lung maturity before premature induction of labour and induction
of labour and to delay the induction as much as possible without any risk to the
fetus.
o Prevent fetal hypoxia in diabetic mothers.
o Avoid smoking, anemia, pre- eclampsia, APH and other complication during
pregnancy.
o Suction immediately after birth to patent the airway.
5.Prevention of Birth Injuries
 Intracranial injury and haemorrhage
The intracranial injury and haemorrhage is due to trauma, rapid compression as in
breech delivery, face presentation, instrumental delivery.
Prevention
Comprehensive intranatal and antenatal care is the key to success in the reduction of
intracranial injuries.
o Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal
monitoring.

37
 o Episiotomy and use of forceps to deliver the premature baby minimize the
intracranial disturbance.
o Avoid traumatic vaginal delivery in preference to caesarean section.
o Difficult forceps should be avoided.
o In vaccum delivery, traction is made only after proper cephalic application.
o Avoid prolonged and difficult labour.
Prevention of injuries in the new born babies
Comprehensive antenatal and intranatal care is the key to success in reduction of
birth trauma and consequently in the reduction of perinatal mortality and neonatal
morbidity.
Antenatal period
 Screen out the risk babies.
 Employ liberal use of Cesarean Section and episiotomy.
 Contracted pelvis, CPD, malpresentation should be included and manage
accordingly.
Intranatal period
During normal delivery
 Continuous fetal monitoring to detect fetal distress, extract baby before he
become compromised. This can prevent traumatic cerebral anoxia.
 Episiotomy is to be done carefully after placing two fingers in between the head
and the stretched perineum- to prevent injury to the scalp.
 The neck shouldn’t be unduly stretched while delivering the shoulders to
minimize injuries to the brachial plexus or sternomastoid
Special care in preterm delivery
 Prevent anoxia
 Avoid strong sedation.
 Liberal episiotomy and use of forceps to minimize intracranial compression.
 Administer vitamin k 1 mg intramuscularly to prevent or minimize
haemorrhage from the traumatized area.
Forceps Delivery
 Difficult forceps are to be withheld in preference to the safer caesarean
section.
 Never apply traction unless the application is a correct one
Ventouse Delivery
 It is relatively less traumatic, but it should be avoided in preterm babies.
Vaginal Breech Delivery

38
 To prevent intracranial injuries: - The crucial period in breech delivery is during
delivery of the after- coming head.
 Never be in haste during delivery of the head which find little time to mould.
 Episiotomy should be done as a routine to minimize head compression.
 Controlled delivery of the head by forceps is preferable.
To prevent spinal injury: - Acute bending at the neck is to be prevented while
forceps are being applied to the after coming head or delivery of the head.
To prevent fracture: - The limbs are delivered in a manner described in breech
delivery.
6.Major Disorders of Newborn Baby
 Ophthalmia Neonatorum
Ophthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks
of life which is characterized by purulent discharge, swelling and redness of
affected eyes.
Prevention
 Any suspicious vaginal discharge during the antenatal period should be treated
and the strict aseptic technique should maintain at birth.
 The newborn baby’s closed eyes and face with sterile water and swab at bath
times to avoid infection of the eye
 The midwife and mother should always wash her hand before touching the
baby’s face.
 Neonatal Tetanus
Neonatal Tetanus is a dreadful infection with a high mortality rate.
Prevention
• Mother should be given tetanus toxoid during pregnancy.
• While cutting the cord, instrument for cord cutting should be boiled and cord
should be cut under aseptic precaution.
• The room should be kept clean.
• Cord care should be done daily.
 Omphalitis
Acute omphalitis is an infection of umbilical stump. It is usually mild as present
as a scanty purulent discharge.
Prevention
• Maintain strict sterile technique during good cutting and cord dressing. Keep
the
environment clean as far as possible.
• Identification of pathogen by umbilical culture and isolate the baby.
39
  Skin Infection ( pemphigus neonatorum)
The unhygienic environments, cross infection or carrier are the source of
infection.
• The baby bath should be given 24 hours offer delivery.
• The carriers or sources of infection are to be sought for and appropriate
measure
to be taken.
7. Family Planning
Every attempt should be made to motivate mothers when they attend postnatal
clinics or during postnatal contacts to adopt a suitable method for spacing the next
birth or for limiting the family size as appropriate. Contraceptives that will not
affect lactation maybe prescribed immediately following delivery after a physical
examination.
8.Health Education to Mother and Family
Health education during the postnatal period should cover the following areas:
 Hygiene- personal and environmental
 Breast Care
 Breast Feeding of infant.
 Care of the Newborn baby
 Care of the umbilical cord
 Bathing the baby
 Nutritious diet for the mother
 Postnatal Exercise
 Rest, sleep and activity
 Pregnancy spacing
 Health checkup for mother and baby
 Prevention of infection in the baby
 Birth registration
Hygiene- personal and environmental
Maternal and neonate’s personal hygiene should be maintained to prevent
infection. Vulval care and daily bathing should be done as lochia drainage
occurs. Cleanliness helps her to fresh and activates energy to care.Perineal care
should be done to observe the amount, colour, odour and consistency of the
lochia, to keep the stitch clean, dry and help in fast healing, to prevent local and
ascending infection.
 Breast Care
40
 Breast care is very important for both mother and baby because it prevents from
infection, so the mother should advised to clean her breast before and after each
feed with clean water and hand washing too. Advice to wear clean brassiere.
 Breast Feeding of infant
Breast milk has anti-infective properties that protect the infant from infection in
the early months. It is a complete food and provides all nutrients needed to infant
in the first few months. So encourage mother to feed the breast feeding for her
baby.
Care of the Newborn baby
The care of the newborn baby is very important to make sure baby is thriving and
to detect early sign of illness and abnormalities and treat it accordingly.
 Care of the umbilical cord
Cleanliness of the umbilical cord is essential. The cord is to be inspected once
more for evidence of slipping of ligature. Dressing with bland power and cord
binder are not favored in places where the baby is placed in a clean environment.
However the cord should be cleaned at least twice a day and should be observed
if there is bleeding from the site of the cord. And also advice the mother and
family members not to enclosed within the baby’s napkin where contamination
by urine or faces may occur.
 Bathing the baby
Bathing the baby is also very important to keep clean and comfortable for the
baby, to maintain blood circulation, to prevent from infection, to detect any
abnormalities or infection and treat it accordingly.
 Nutritious diet for the mother
It is the most essential basic needs of everybody but especially for lactating
mother. Without nutrition, the mother cannot get energy and decrease the
secretion of milk, so mother should eat highly nutritious foods and soups high in
protein and carbohydrate e.g. meat soup, Dal soup etc.
 Postnatal Exercise
Postnatal exercise is the exercise done after delivery in postnatal period
which is very important to improve blood circulation, to help in involution of
reproductive organs, to prevent thrombosis and thrombophlebitis, to promote
wellbeing of the postnatal mother, to restore the tone of the abdominal the pelvic
muscles, for proper drainage of lochia. So advice mother to do postnatal
exercise.
Rest, sleep and activity

41
 Mother should have 1o hours rest at night and 1-2 hours at afternoon till 40-60
days of delivery. Heavy working, heavy lifting should be avoided in puerperium
because it predispose to uterine prolapse.
 Pregnancy spacing
Mother and family members should be advised about the importance of
pregnancy spacing. There should be at least the gap of 2 years of pregnancy
spacing.
 Health checkup for mother and baby
Regular health checkup and follow up for mother and baby is very important
with in puerperium period.
 Prevention of infection in the baby
Midwives have an important role to play in creating a safe environment that
decreases the chance of infant acquiring infection after birth.
 Encouraging and assisting the mother for breast feeding thus increasing
infant’s immune protection.
 Ensuring careful and frequent hand washing by all careers; the simple
procedure remains the single most important method of preventing the
spread of infection in infants.
 Rooming in the infants with his/ her mothers.
 Adequately spacing costs when infants are in the nursery with other infants.
 Always use individual equipment for each infant.
 Avoiding any irritation or trauma to the infant’s skin and mucous
membrane, asintact skin provides a barrier against infection.
 Controlling extra visitor.
 Birth registration

CONCLUSION
Preventive obstetrics is the concept of prevention or early detection of particular
health deviations through routine periodic examinations and screenings. The
concept of preventive obstetrics concerns with the concepts of the health and
well-being of the mother and her baby during the antenatal, intranatal and
postnatal period. It aims to promote the well- being of mothers and babies and to
support sound parenting and stable families. Nursing care centered on health
promotion and health maintenance during pregnancy presents an excellent
opportunity for nurses to teach expectant mothers about normal changes
expected and alert them to a variety of risk factors. Preventive Obstetric measure
can be categorized into three main stages. They are as follows:-
42
 • Antenatal Nursing
• Intranatal Nursing
• Postnatal Nursing

RELATED RESEARCHES
1. Care during labor and birth for the prevention of intrapartum-related
neonatal deaths: a systematic review and Delphi estimation of mortality
effect.
Lee AC1, Cousens S, Darmstadt GL, Blencowe H, Pattinson R, Moran NF, Hofmeyr
GJ, Haws RA, Bhutta SZ, Lawn JE.
Abstract
BACKGROUND:
Their objective was to estimate the effect of various childbirth care packages on
neonatal mortality due to intrapartum-related events ("birth asphyxia") in term
babies for use in the Lives Saved Tool (LiST).
METHODS:
They conducted a systematic literature review to identify studies or reviews of
childbirth care packages as defined by United Nations norms (basic and
comprehensive emergency obstetric care, skilled care at birth). They also reviewed
Traditional Birth Attendant (TBA) training. Data were abstracted into standard
tables and quality assessed by adapted GRADE criteria. For interventions with low
quality evidence, but strong GRADE recommendation for implementation, an
expert Delphi consensus process was conducted to estimate cause-specific
mortality effects.
RESULTS:
They identified evidence for the effect on perinatal/neonatal mortality of
emergency obstetric care packages: 9 studies (8 observational, 1 quasi-
experimental), and for skilled childbirth care: 10 studies (8 observational, 2 quasi-
experimental). Studies were of low quality, but the GRADE recommendation for
implementation is strong. Our Delphi process included 21 experts representing all
WHO regions and achieved consensus on the reduction of intrapartum-related
neonatal deaths by comprehensive emergency obstetric care (85%), basic
emergency obstetric care (40%), and skilled birth care (25%). For TBA training
they identified 2 meta-analyses and 9 studies reporting mortality effects (3 cRCT, 1
quasi-experimental, 5 observational). There was substantial between-study
heterogeneity and the overall quality of evidence was low. Because the GRADE

43
 recommendation for TBA training is conditional on the context and region, the
effect was not estimated through a Delphi or included in the LiST tool.
CONCLUSION:
Evidence quality is rated low, partly because of challenges in undertaking RCTs
for obstetric interventions, which are considered standard of care. Additional
challenges for evidence interpretation include varying definitions of obstetric
packages and inconsistent measurement of mortality outcomes. Thus, the LiST
effect estimates for skilled birth and emergency obstetric care were based on expert
opinion. Using LiST modelling, universal coverage of comprehensive obstetric
care could avert 591,000 intrapartum-related neonatal deaths each year. Investment
in childbirth care packages should be a priority and accompanied by
implementation research and further evaluation of intervention impact and cost.
2. Pelvic floor exercises during and after pregnancy: a systematic review of
their role in preventing pelvic floor dysfunction.
Harvey MA1.
Abstract
OBJECTIVE:
To review the literature on the origin, anatomical rationale, techniques, and
evidence-based effectiveness of peripartum pelvic floor exercises (PFEs) in the
prevention of pelvic floor problems including urinary and anal incontinence, and
prolapse.
DATA SOURCES:
Literature was reviewed for background information. MEDLINE, EMBASE,
CINAHL, and proceedings of scientific meetings were searched for evidence-
based data. A comprehensive literature search was performed to find all studies
that involved the use of antepartum and/or postpartum PFEs. For the MEDLINE
(1966 to 2002) and CINAHL (1980 to 2002) searches, the following key words
were used: urinary incontinence (prevention and control, rehabilitation, therapy),
fecal incontinence, exercise or exercise therapy, Kegel, muscle contraction,
muscle tonus, muscle development, pelvic floor, pregnancy, puerperium,
puerperal disorders. For the EMBASE (1980 to 2002) search, the following key
words were used: micturition disorder (prevention, rehab, disease management,
therapy), fecal incontinence, labour complication, pregnancy disorder, puerperal
disorder, antepartum care, pregnancy, kinesiotherapy, exercise, pelvic floor,
bladder. A manual search was performed of available abstracts presented at the
annual scientific meetings of the International Continence Society (1997, 1999 to
2002), American Urogynecologic Association (1997 to 1998, 2000 to 2002), and

44
 International Urogynecological Association (1997, 1999 to 2002). Twelve studies
evaluating the role of antepartum PFE were found, of which 3 randomized
controlled trials (RCTs) comparing PFEs for the prevention of urinary
incontinence to controls were included. Twelve studies evaluating postpartum
PFEs for prevention of urinary incontinence were reviewed, of which 4 RCTs
were included. Five studies evaluating postpartum PFEs for the prevention of anal
incontinence were reviewed, of which 4 RCTs were included. Participants in the
studies were primiparous women. DATA
RESULTS:
Antepartum PFEs, when used with biofeedback and taught by trained health
care personnel, using a conservative model, does not result in significant short-
term (3 months) decrease in postpartum urinary incontinence, or pelvic floor
strength. Postpartum PFEs, when performed with a vaginal device providing
resistance or feedback, appear to decrease postpartum urinary incontinence and to
increase strength. Reminder and motivational systems to perform "Kegel"
exercises are ineffective in preventing postpartum urinary incontinence.
Postpartum PFEs do not consistently reduce the incidence of anal incontinence.
CONCLUSION:
Postpartum PFEs appear to be effective in decreasing postpartum urinary
incontinence. Data regarding the effect of PFEs on prevention of anal
incontinence are lacking, and also on its prevention of prolapse.
3. The Risks of Not Breastfeeding for Mothers and Infants
Alison Stuebe, MD, MSc
Abstract
Health outcomes in developed countries differ substantially for mothers and
infants who formula feed compared with those who breastfeed. For infants, not
being breastfed is associated with an increased incidence of infectious morbidity,
as well as elevated risks of childhood obesity, type 1 and type 2 diabetes,
leukemia, and sudden infant death syndrome. For mothers, failure to breastfeed is
associated with an increased incidence of premenopausal breast cancer, ovarian
cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction,
and the metabolic syndrome. Obstetricians are uniquely positioned to counsel
mothers about the health impact of breastfeeding and to ensure that mothers and
infants receive appropriate, evidence-based care, starting at birth.
CONCLUSIONS
Formula feeding is associated with adverse health outcomes for both
mothers and infants, ranging from infectious morbidity to chronic disease. Given

45
 the compelling evidence for differences in health outcomes, breastfeeding should
be acknowledged as the biologic norm for infant feeding. Physician counseling,
office, and hospital practices should be aligned to ensure that the breastfeeding
mother-infant dyad has the best chance for a long, successful breastfeeding
experience.
4. Effects of interventions in pregnancy on maternal weight and obstetric
outcomes: meta-analysis of randomized evidence
S Thangaratinam, senior lecturer/consultant in obstetrics and maternal medicine1,
E Rogozińska, etal
Abstract
OBJECTIVE
To evaluate the effects of dietary and lifestyle interventions in pregnancy on
maternal and fetal weight and to quantify the effects of these interventions on
obstetric outcomes.
STUDY SELECTION
Randomized controlled trials that evaluated any dietary or lifestyle
interventions with potential to influence maternal weight during pregnancy and
outcomes of pregnancy.
RESULTS
They identified 44 relevant randomized controlled trials (7278 women)
evaluating three categories of interventions: diet, physical activity, and a mixed
approach. Overall, there was 1.42 kg reduction (95% confidence interval 0.95 to
1.89 kg) in gestational weight gain with any intervention compared with control.
With all interventions combined, there were no significant differences in birth
weight (mean difference −50 g, −100 to 0 g) and the incidence of large for
gestational age (relative risk 0.85, 0.66 to 1.09) or small for gestational age (1.00,
0.78 to 1.28) babies between the groups, though by itself physical activity was
associated with reduced birth weight (mean difference −60 g, −120 to −10 g).
Interventions were associated with a reduced the risk of pre-eclampsia (0.74, 0.60
to 0.92) and shoulder dystocia (0.39, 0.22 to 0.70), with no significant effect on
other critically important outcomes. Dietary intervention resulted in the largest
reduction in maternal gestational weight gain (3.84 kg, 2.45 to 5.22 kg), with
improved pregnancy outcomes compared with other interventions. The overall
evidence rating was low to very low for important outcomes such as pre-
eclampsia, gestational diabetes, gestational hypertension, and preterm delivery.
CONCLUSIONS

46
 Dietary and lifestyle interventions in pregnancy can reduce maternal
gestational weight gain and improve outcomes for both mother and baby. Among
the interventions, those based on diet are the most effective and are associated
with reductions in maternal gestational weight gain and improved obstetric
outcomes.
5. Does prenatal care improve birth outcomes? A critical review
MD Kevin Fiscella
Abstract
OBJECTIVE:
To evaluate evidence that prenatal care improves birth outcomes.
METHODS OF STUDY SELECTION:
Published observational and experimental studies of prenatal care that met
specified criteria were selected.
DATA EXTRACTION AND SYNTHESIS:
Studies were graded based on the system used by the United States Preventive
Services Task Force. Data were assessed using established criteria for the
evaluation of prenatal interventions: temporal relationship, biologic plausibility,
consistency, alternative explanations, dose-response, strength of association, and
cessation effects. Current evidence did not satisfy the criteria.
CONCLUSION:
Prenatal care has not been demonstrated to improve birth outcomes
conclusively. However, policymakers deciding on funding for prenatal care must
consider these findings in the context of prenatal care's overall benefits and
potential cost-effectiveness. Cost-effective reductions in low birth weight
deliveries may be beyond the statistical powers of detection of current studies.
BIBILIOGRAPHY.
 Lowdermilk & PerryCashion (2006); “MATERNITY NURSING”,
8thedition, Elsevier publication; PP: 123-167.
 Hiralal Konar (2011); “D.C. DUTTAS TEXTBOOK OF OBSTETRICS”;
7th edition; NCBA publication;PP :95-113
 Basavanthappa B.T;“ESSENTIALS OF MIDWIFERY &
OBSTETRICAL”, Jaypee Publications (New Delhi);PP: 130-228.
 Krishna Kumari Gulani (2005); “COMMUNITY HEALTH NURSING
(PRINCIPLES AND PRACTICES)”, 1st Edition, Maternal and Child
Health, Kumar Publishing House, page no.: 354 – 366.
 K.Park (2007) “PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL
MEDICINE”; 21stedition; Bhanot publication;PP: 415 – 422.
47
 Susan Scott Ricci (2013); “ESSENTIALS OF MATERNITY,
NEWBORN AND WOMENS HEALTH NURSING”; 3rdedition;
Lippincott publication; PP: 38-52.
 http// Industrial relations.naukrihub.com
 www.pubmed.com
 www.cinhal.com
www.medline.com

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