Domiciliary Care in Midwifery TK Indrani
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Organising Prenatal Care ActivitiesOne

 
ORGANISING PRENATAL CARE ACTIVITIES
It is necessary to develop and use a set of guidelines for the selection of cases to be visited. You will also have to be clear about the criteria to be used for scheduling the frequency of home visits and what you should do during each visit.
  1. Priority for home visits should be given to the following:
    1. High-risk pregnant women and those who are at term.
    2. Follow-up visits which have been requested by the medical officer or health assistant (female).
    3. New cases and follow-up visits based on data obtained during previous visits.
    4. Those who are defaulters either from the MCH clinic or who have been reported by the depot holders (Dai).
    5. Requests from relatives and referrals from the health worker (male) Dais/CHWs, etc.
    6. Women who have not received tetanus toxoid.
  2. Case finding and registering pregnant women:
    1. Identify and register pregnant women when you visit the homes since the numbers who attend MCH clinics is still rather limited.
    2. Ask about the presence of a daughter-in-law or a married daughter who may have returned to the parents’ home for confinement.
    3. Make every effort to locate as early as possible those women who do not wish to remain pregnant so that they can be referred for MTP before 10 weeks of pregnancy are completed.2
    4. Register pregnant women by completing the information required in:
      1. the maternity record
      2. the maternity register.
  1. Frequency of visits: You should confirm with the policy regarding the frequency of visits required in your state.
However, suggested frequency of contacts for delivering prenatal care is as follows:
  1. Between the 20th and 22nd week
  2. Between the 28th and 30th week
  3. During the 34th week
  4. During the 36th week
  5. During the 38th week.
Register the case by 12 weeks of pregnancy or as soon as pregnancy is confirmed.
The above schedule should be followed only when the course of the woman's pregnancy is within normal limits. More frequent visits will be necessary if she is a high-risk case or she has signs or symptoms of an abnormal pregnancy (Table 1.1).
  1. Identifying and classifying high-risk pregnant women: Whenever you register a pregnant woman, you should use the following criteria to identify and classify high-risk cases:
    1. She is a primipara and especially if she is under 15 years or over 35 years.
    2. She is below 152 cm in height.3
    3. She has had 4 or more pregnancies.
    4. She has an abnormal obstetric history, i.e. abortion, still bests, premature delivery antiportem or postportem haemorrhage eclampsia, caesarean section or instrumental delivery.
    5. She has a medical condition e.g., Tuberculosis, severe anaemia, heart disease, kidney trouble or diabetes.
    6. She has abnormal findings in the present pregnancy.
    7. She has conceived after treatment for infertility.
  1. Content of prenatal care: Whenever you see a pregnant woman, you should do the following:
    1. Take a complete history at the initial visit and obtain additional information at subsequent visits.
    2. Do a physical examination each time and abdominal palpation depending on the stage of pregnancy.
    3. Do urine and blood tests as indicated.
    4. Treat minor ailments including those related to pregnancy.
    5. Give appropriate advice regarding any health problems which are found and if necessary refer the woman to a hospital or PHC.
    6. Record accurately all information collected in the maternity record.
Accurate recording of the health data that you collect is necessary for planning and delivering prenatal care to the pregnant women in your area (Table 1.2).4
Table 1.1   Normal pregnancy and possible complications according to trimester
Stage of pregnancy
Main signs and symptoms
Possible prenatal complications
1st Trimester (under 13 weeks)
i. Absence of menstruation
ii. Frequent urination
iii. Nausea and vomiting
iv. Weight gain of about 1.12 kg.
i. Vaginal bleeding
ii. Abortion
iii. Tubal pregnancy
iv. Hyperemesis (excessive vomiting)
v. Dehydration
2nd Trimester (between 14 and 26 weeks)
i. Slight fluid from nipples
ii. Quickening
iii. Gradual increase in height of fundus
iv. Noticeable enlargement of abdomen
v. Foetal parts and movement can be felt
vi. Foetal heart sounds can be heard
vii. Weight gain 250 gm per week and total weight gain of about 2 to 3.5 kg.
i. Abortion
ii. Kidney infection
iii. Toxaemia (towards end of the 61 month)
3rd Trimester (between 27 and 40 weeks)
i. Frequent urination
ii. Fundus reaches diaphragm and then descends lightening
iii. Abdominal girth between 82 and 87 cm at term.
iv. Slight oedema of ankles and legs.
v. 0.5 kg weight gain per week and total weight gain between 9 to 11 kg.
i. Haemorrhage
ii. Mai presentation
iii. Non-engagement of the head
iv. Excessive fluid
Note: Every normal case of pregnancy should be examined by the medical officer of the PHC at least once during pregnancy. You should be present during the examination so that you can note the sending treatment. If any, and advice given so that you can do the necessary follow-up and supervision usually the selection of cases for delivery at home is finalised during the examination by the medical officer.
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Table 1.2   Content of prenatal care
Scheduled clinic or home visit
Health assessment procedures
Health care advice and action to be taken
(1)
(2)
(3)
Initial contact before 11th week
i. Take a history.
ii. Do a general physical examination including an abdominal examination.
iii. Take height and weight.
iv. Take temperature, pulse and respiration.
v. Test urine for sugar and albumin,
vi. Test blood: haemoglobin estimation using the Tallqvist's scale.
i. Register pregnant women, compile and record data collected.
ii. Refer for MTP if abortion is desired.
iii. Refer women with high-ris907k characteristics to the Medical officer.
iv. On the basis of the health assessment give appropriate advice regarding.
  1. the minor discomforts of pregnancy
  2. personal hygiene, diet, and activity
  3. what to do if complications arise
  4. clinic attendance
  5. schedule monthly contacts with women having a history of bleeding or abortion
v. Treatminor ailments which are found.
vi. Dispense iron and folic acid tablets if indicated and or refer to PHC for further treatment.
vii. Administer 1st dose of tetanus toxoid on eligible women.
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Second contact between 20th and 22nd week
i. Take a history especially for eclampsia to supplement previous data or collect initial data.
ii. Do physical examination and a complete abdominal examination. Note the height of the fundus.
iii. Listen for foetal heart sounds
iv. Look for the presence of oedema
v. Take the blood pressure, if possible
vi. Take height and weight
vii. Take temperature, pulse, and respiration
viii. Test urine for sugar and albumin
ix. Test blood: haemoglobin estimation using the Tallqvist's scale.
i. Register pregnant women, compile and record data if not done previously.
ii. Refer new high-risk cases to the medical officer.
iii. On the basis of the health assessement.
  1. Dispense iron and folic acid tablets.
  2. Administer 1st dose of tetanus toxoid if not already given.
  3. Treat minor ailments which are found.
  4. If complications of pregnancy are found, give initial treatment and refer.
  5. Teach women about signs and symptoms of eclampsia.
  6. Ask women to report to you if they develop signs and symptoms of toxaemia.
iv. Schedule follow-up contacts with high-risk cases and women with complications of pregnancy.
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Third contact between 28th and 30th week
i. Take a history to determine any changes since previous visit,
ii. Do a physical examination and an abdominal examination as follows:
  1. Note the height of the fundus.
  2. Palpate to determine foetal presentation.
  3. Listen for foetal heart sounds.
  4. Check hands and ankles for oedema.
  5. Take the blood pressure - if possible.
  6. Take the weight.
  7. Take the temperature pulse and respiration.
  8. Test urine for sugar and albumen.
  9. Do haemoglobin estimation.
i. Register if new, otherwise compile and record data collected.
ii. Refer new high-risk cases to the MCH clinic or to the medical officer.
iii. Treat minor ailments which are found.
iv. On the basis of the health assessment:
  1. Dispense iron and folic acid tablets.
  2. Administer 2nd dose of tetanus toxoid.
  3. If complications of pregnancy are found, e.g. eclampsia, ante-partum haemorrhage, etc. give initial treatment, advise and refer.
  4. Discuss the relationship of maternal health to infant health and the effect of family size on health.
  5. Discuss diet and personal hygiene including care of the breasts in preparations for lactation.
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Fourth contact during 34th week.
i.&ii. Same as at third contact
iii. Look for any sudden increase in weight.
iv. Ascertain any abnormal presentation of the foetus.
i-iv. Same as at third contact.
v. Discuss methods of family spacing and sanitation.
vi. Select cases to be delivered at home.
vii. Involve the members of the family and the dai (as and when appropriate) impreposing for home delivery.
viii. Refer all cases of mal presentation at or about the 34th week to the medical officer.
Fifth contact during 36th week
i-iv. Same as at fourth contact.
v. Determine whether the head is engaged.
i-iv. Same as third contact.
v. Refer any primipara in whom engagement of the head has not taken place.
vi. Ascertain what preparations have been made in the home for delivery.
vii. Make sure that the family knows when to call you or the dai for the delivery.
viii. If delivery is to be done at the PHC or a hospital, ascertain that the family has made plans for transport and for care of the household during absence of the mother.
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ix. Assist the woman to decide on the contraceptive method to be used after delivery. Arrange for hospital admission if trectomy is selected.
Sixth contact during 38th week.
i-v. Same as at fifth contact,
vi. Note whether lightening has occurred when doing palpation.
i-ix. Same as at fifth contact.
x. Review with the woman care of the newborn.
xi. Review with the woman what to expect during delivery, especially if she is a primipara.
Every primipara should be examined by the medical officer some time after the 34th week of pregnancy.
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THE PRENATAL HISTORY
The history should be taken on the first visit, but sometimes it is not possible to complete it. In such cases, you will have to make a second visit soon to obtain the rest of the information. In taking a history keep the following points in mind.
  1. Before beginning your enquiries explain to her why the information is required.
    1. This will ensure her cooperation.
    2. Be tactful in phrasing your questions and be careful not to belittle, irritate or alarm the woman.
    3. Be patient when answers are given by her slowly or vaguely.
    4. Organise your questions so that you can get the information in a systematic manner.
  2. The prenatal history should include the following aspects.
 
General Health History
  1. Whether she has had any illness which required prolonged bed-rest.
  2. Whether she has had persistent cough.
  3. Whether she has ever had an operation or accident.
  4. Whether she is taking any medicines regularly and for what reason.
  5. Whether she has any current complaints, e.g. fever, pallor, breathlessness, or abdominal colic with frequent diarrhoea.
 
Family Health History
  1. The health of the husband and whether he is able to work.
  2. The ages of children and their health status.
  3. Whether parents of husband or wife are alive and well.
  4. Causes of death of members in either husband's family or the wife's family.
  5. Serious illnesses in family or among close relatives.
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Social History
  1. Type of house.
  2. Source of water for household.
  3. Disposal of excreta, sullage water and refuse.
  4. Whether livestock or poultry are kept.
  5. Number of meals prepared and served each day.
  6. Source of health care when there are illnesses in the family.
  7. Whether a family planning method is being used and whether it is successful.
  8. Regularity of attendance at a family planning clinic.
 
Postobstetric History
May be available if the woman was previously registered
  1. Abortions, stillbirths or ectopic pregnancies.
  2. Foetal or neonatal deaths.
  3. Premature births.
  4. Abnormal pregnancies or difficult labour.
  5. Haemorrhage during pregnancy or labour.
  6. Treatment for anaemia.
  7. Any health problems in the woman following delivery.
  8. Any health problems in the infant following birth.
  9. Source of health care during previous pregnancies and deliveries.
  10. Whether she had a medical examination within two months after the last delivery.
 
History of Present Pregnancy
  1. Identifying data, e.g. house number, name, age, parity, number of live children, age of last child.
  2. The first day of the last menstrual period and the expected date of confinement.
  3. How she feels in general.
  4. Whether she wants this pregnancy.
  5. Whether she has had or at present has persistent vomiting, headache, swelling of ankles or face, vaginal bleeding or discharge.12
  6. Whether she feels the foetal movements and if so, when did she start feeling them.
  7. Whether she is presently breastfeeding a child.
  8. The adequacy of her diet.
  9. Her usual daily activities.
 
THE PRENATAL EXAMINATION
The prenatal examination should include several routine procedures and a physical examination.
 
Routine Procedures
  1. Testing the urine for the presence of albumin and sugar.
  2. Taking the temperature, pulse and respiration.
  3. Estimating haemoglobin level using the Tallqvist's method.
  4. Taking the blood pressure, if possible.
  5. Taking the weight and measuring the height (height only once usually during the first examination).
 
Physical Examination
Make it a point to observe the pregnant woman initially in a well-lighted place.
Note her general appearance, i.e. note whether she is well built or small in stature, whether she looks generally healthy and active or whether she looks weak and listless. It is also useful to note her gait and whether she walks with a limp since this may indicate a pelvic deformity which may interfere with normal delivery.
The inspection of the woman's body should be done in a systematic way so that none of the points are omitted. Pay special attention to the examination of the face, breasts, hands, legs, abdomen and vulva.13
It is a good rule to begin the examination with the head and to proceed downwards.
Try to ensure as much privacy as possible and avoid any unnecessary exposure of the woman's body while conducting the examination.
 
Inspection of the Head and Face
  1. Look for any puffiness of the face since this can be a sign of toxaemia after the sixth month of pregnancy.
  2. Check the colour of the conjunctiva and lower lip for pallor since she may be anaemic and in need of treatment and advice.
  3. Examine the eyes for any discharge, or dryness of the conjunctiva and give the necessary treatment.
  4. Check the germs for any evidence of infection, or bleeding and the teeth for caries so that treatment or referral can be initiated.
  5. Note the presence of any cracks or sores at the corners of the mouth since she may be in need of dietary advice or drugs.
  6. Look for any swelling of the neck, especially in areas where goitre is endemic.
  7. If she has a cough, find out when it started and whether it is accompanied by fever to determine the necessary action to be taken.
  8. Note any signs of breathlessness or bluish colour of the lips for which she will need examination by the medical officer.
 
Examination of the Breasts
  1. Check the breasts to ascertain that enlargement and pigmentation are proceeding according to the stage of the pregnancy.
  2. Observe the size and shape of the nipples to see if they are inverted and give advice accordingly.
  3. Note whether there is any costing or soreness of the nipples and advice her how to take care for these conditions.14
  4. Palpate the breasts for any lump or tenderness. If these are present, refer her to the medical officer.
 
Hands and Legs
  1. Observe and test hands, ankles and feet for any swelling since advice or referral will be necessary depending upon the severity and the stage of the pregnancy.
  2. Look for the presence of varicose veins on the legs since advice, treatment or referral may be necessary depending on the severity of the condition.
 
Examination of the Abdomen
After the thirtieth week of pregnancy, examination of the abdomen can help you to estimate the stage of the pregnancy, the presence of excessive fluid accumulation, the position of the foetus, the possibility of twins and the presence of other abnormalities.
The examination should be carried out using a combination of:
  1. Visual inspection
  2. Palpation or feeling with the hands.
  3. Listening for the foetal heart sounds using a foetoscope.
Visual inspection
  1. Look for any bulge above the symphysis pubis so that you can estimate the stage of pregnancy. The height of the fundus can be measured when you palpate the uterus.
  2. Note the size and shape of the uterus for comparison with the normal egg-shaped longitudinal enlargement of the organ.
    When the uterus is egg-shaped, the lie of the foetus is longitudinal. If the shape of the uterus looks broader than it is—long, the lie of the foetus is transverse.15
  3. Ask the woman to stand up and note whether her abdominal muscles sag or the contents hang down loosely.
    A multiparous woman will usually have a drooping abdomen due to previous pregnancies.
    However, if a primipara is found to have a drooping abdomen, she needs to be referred for a medical examination since it may indicate that she has a pelvic abnormality or a deformity of the spine.
    After the 37th week, you will also be able to note whether lightening (descent of the foetal head) has occurred by observing her in the side view while she is standing up.
    After the head descends, the abdomen looks more prominent.
  4. Look for any foetal movements. Remember that the back of the foetus will be on the side opposite to that where you have noted the movements. This information is helpful to you in determining the position of the foetus.
  5. Look for the presence of any abdominal scar, and if this is present, find out the reasons for the operation.
Observe the colour of the abdominal stretch markings. Silvery gray marks indicate stretching of the skin during a previous pregnancy, while pink marks are connected with more recent pressure on the skin and are, therefore, more often seen in a primigravia.
Palpation: Points to remember about palpation of the abdomen:
  1. The procedure is usually done after 16 weeks, to check the height of the fundus and to estimate the period or stage of the pregnancy.
  2. After the 30th week of pregnancy, palpation is done to determine the lie, presentation and whether the head is engaged or can enter the pelvic brim.
  3. After the 30th week of pregnancy, palpation can also help you to determine whether there is more than one foetus, excessive fluid or other abnormality.16
  4. Before you begin the procedure, explain what you are going to do and how it will feel. This is especially important in examining a primipara in order to reduce any fears she may have about discomfort or pain.
  5. Ask the woman to empty her bladder so that it does not interfere with the examination. The urine should be collected for testing.
  6. Have her lie down on a flat surface with her arms lying loosely at her side. Cover her body with a light cover and expose only the portion which is being examined.
  7. Try to get the woman to relax by discussing some topic which is of interest to her, e.g. her other children, the festival which is coming soon, etc.
  8. Make sure that your hands are warm.
  9. If you are right handed, stand on the woman's right side to do the procedure so that you can do a thorough palpation. If you are left handed, stand on her left side.
Whenever you palpate the abdomen, use the palms of your hands and pads of your fingers instead of tips, because these sleshy portions are less likely to stimulate contractions of the uterus and cause less discomfort for the woman.
Palpation procedures: There are four types of abdominal palpation procedures that you are expected to carry out. These are the following:
  1. Measuring the height of the fundus.
  2. Palpation of the fundus.
  3. Lateral palpation.
  4. Pelvic palpation (external).17
Measuring the height of the fundus: Measure the height of the (fundus) uterus from the pelvic bone to the upper border of the fundus using a tape measure
or
Divide the height of the uterus into six parts—
From symphysis to umbilicus into three parts. Each part corresponds with weeks of pregnancy.
  • First one third from symphysis pelvis to umbilicus is 12 weeks pregnancy.
  • Second 1/3rd is 12 to 16 weeks
  • Third 1/3rd upto umbilicus is 16 to 24 weeks
From umbilicus to xiphisternum is divided into three parts:
  • First 1/3rd from umbilicus to xiphisternum is 24 to 28 weeks.
  • Second 1/3rd corresponds with 28 weeks to 32 weeks.
  • Third 1/3rd is 32 weeks to 36 weeks.
If the height of the uterus is at 32 weeks and the flanks are full, it is considered as 40 weeks' pregnancy.
Palpating the fundus
  1. Lay both hands on either side of the fundus, cupping your fingers close together and around the upper edge of the uterus.
  2. Apply gentle, deliberate pressure to determine which part of the foetus is at the upper part of the fundus.
  3. If the head is uppermost, it can be felt as being hard and round and freely moveable between the thumb and fingers.
  4. The buttocks can feel firm but they are not as hard as the head or as well defined in shape.
Lateral palpation
  1. Place the palms of both hands on either side of the abdomen at the level of the fundal height about 4 to 5 inches away from the midline, using the palm of your hand, palpate up to the illiac fossa, either side.18
  2. If a longitudinal hard ridge is felt, it is the lack of the foetus. On the opposite side should be the soft ports (nodules) i.e. feet and legs.
  3. When you palpate laterally, keep one hand to press on the uterus and keep it from moving while pressure is applied with the other hand. This should be done alternately on either side.
 
Pelvic palpation
Pelvic palpations are two. Place your right hand at the lower end of the uterus. Thumb on one side, all the other four fingers of the side. The border of the little finger side of the palm is placed at the end of the uterus, using the thumb and fingers grasp the part lying in the lower pole of the uterus.
If it is hard, round and moveable or not moveable, it is head of the foetus.
If it is soft, large and smooth, it is breech (Buttocks) of the foetus. Second pelvic palpation is done only if the head of the foetus is not mobile.
Second pelvic palpation is also done to see whether the head is entered in the pelvic brim or not.
Method of doing:
  1. Grasp the sides of the uterus firmly just below the level of the umbilicus with the fingers at the lower end of the uterus and the thumbs outstretched over the umbilicus. The little fingers of each hand in this position should be at the level of the anterior iliac cost.
  2. If the head is not yet engaged, it will be felt as a round solid object which can easily be moved about. After the head is engaged, the shoulder will be felt as a fixed, knob-shaped port about 3 finger breadths above the pubis. You should also use a combined grip with the left hand at the copper pole of the uterus to compare the shape and consistency of the contents at each end.19
  3. While doing fundal grip, lateral grip and fundal height measurements the woman's leg should flexed.
  4. For the second pelvic grip. Woman's leg should be straight and the examining person should stand spacing the woman's (toes) feet.
  5. To find out if the head is engaged, use the same grasp as in (iv) above.
    You will find the following when the head is engaged:
    1. Most of the head cannot be felt above the pelvic brim.
    2. The head cannot be moved.
    3. The higher cephalic prominence will be felt less than 5 cm above the pelvic brim.
    4. The anterior shoulder will be about 5 cm above the symphysis pelvis.
      By the 38th week, the head of the foetus of any primipara should be engaged. If this is not found on examination, refer promptly to the medical officer since, further investigation is necessary. In the multiparous woman, engagement usually occurs with the onset of labour.
  6. To determine the cephalic prominence, you should stand facing the feet of the woman and place both hands on either side of the lower pole of the uterus just above the symphysis pelvis.
The procedure can only be done after the head is engaged. Apply gentle pressure towards the pelvic inlet and you will find that one hand can go deeper than the other.
When the head is flexed on to the chest, the cephalic prominence is on the same side as the feet and hands of the foetus.
If the head is extended, the cephalic prominence is on the same side as the back of the foetus.
Listening for the foetal heart sounds: After the 20th week of pregnancy in addition to inspection and palpation of the abdomen. You must examine the abdomen by listening for the foetal heart sounds (Table 1.3).20
Table 1.3   Common positions of the foetus and location of the foetal heart
Common position of the foetus
Location of the foetal heart
LOA (Left occiput anterior) the head is at the bottom pole of the uterus with the occiput or back of the head at the left and front and the face towards the right and back. The back of the foetus is on the left.
The heart is midway between the umbilicus and the left anterior iliac spine.
LOP (Left occiput posterior). The head is at the bottom pole of the uterus with the occiput at the left and the face is towards the right and front. The back of the foetus is on the left.
The heart is just below the upper border of the left hip bone.
ROA (Right occiput anterior) The head is at the bottom pole of the uterus with the occiput at the right and front and the face towards the left and back. The back of the foetus is on the right.
The heart is between the upper border of the right lip bone and the umbilicus but closer to the midline.
ROP (Right occiput posterior) The head is at the bottom pole of the uterus and the occiput is at the right and back and the face is towards the left and front. The back of the foetus is on the right.
The heart is first below the upper border of the right hip bone.
LSA and RSA (Left sacro anterior and right sacro anterior) are breach presentations with the back and buttocks facing either left front or right front.
The heart is usually at or just above the level of the umbilicus on either the left or right side.
  1. You will be using a foetal stethoscope or foetoscope to do this. The foetal heart sounds can be heard over the area where the left scapula and the ribs of the foetus come in contact with the anterior wall of the uterus.
  2. Place the foetoscope over the area where the foetal heart has been located and remove your hand from it. You should not touch it while listening because it will produce extra sounds.
  3. Keep your ear in firm contact with the fetoscope and make sure that is kept at a right angle to the point 21where you have placed it. If this is not done, the wall of the abdomen will move and it will become displaced.
  4. Closing your eyes may help you to concentrate on listening.
Listening for the foetal heart sound is important because:
  1. It is a positive sign of pregnancy
  2. It is proof that the foetus is alive
  3. It can confirm the presentations and position of the foetus.
 
Inspection of the Vulva
To complete your physical examination of the pregnant woman, you should do a visual inspection of the vulva at least once during the pregnancy and whenever she has any complaints about vaginal discharge, itching or sores on the vulva. When doing a inspection of the vulva, you should do the following:
  1. Note whether there is any redness or sign of inflammation.
  2. Look for successive vaginal discharge and note whether it is foul smelling or looks as though it contains pus.
  3. Look for the presence of varicose veins on the labia so that treatment or advice can be initiated as necessary before delivery.
  4. Note whether there are any sores on the vulva since their presence may denote venerable disease. Such cases should be referred promptly for treatment.
 
SIGNS AND SYMPTOMS OF ABNORMAL PREGNANCY
The pregnant woman should be taught about the signals which require immediate action on her part so that her 22pregnancy can continue to term and result in a live infant.
If she develops any of the following signs and symptoms, she should either report to you or seek case at the hospital.
  1. Vaginal bleeding no matter how slight.
  2. Swelling of the face and fingers.
  3. Severe continuous headache.
  4. Dizziness or blurring of vision.
  5. Pain in the abdomen.
  6. Persistent vomiting.
  7. Chills and fever.
  8. Sudden gush of fluid from the vagina.
  9. Yellowish colouration of the eyes or skin (Jaundice).
Dealing with complications associated with pregnancy immediate care at the hospital is needed.
Remember that a woman having signs and symptoms of abnormal pregnancy will require more frequent and closer supervision throughout her pregnancy. She should be strongly encouraged to attend the MCH clinic regularly so that her condition can be checked.
 
Minor Ailments Related to Pregnancy
The minor ailments which are related to pregnancy can be the cause of sleeplesness, can interfere with good nutrition and can result in much discomfort (Table 1.4).
You must try to help the woman by treating minor disorders which she may have.
The most common ailments which may occur during pregnancy are as follows:
  1. Norming sickness
  2. Heart-burn and nausea
  3. Backache
  4. Constipation
  5. Varicose vein23
    Table 1.4   Dealing with minor ailments related to pregnancy
    Sl. No. Disorder
    Treatment
    Advice
    Referral
    1. Normal Sickness
    i. Emidoxyn Tablets
    ii. Milk of magnesia tablets
    iii. Rehydration powder as required
    Advise her to:
    1. Eat dry foods on arising
    2. Take small frequent meals
    3. Make foods appetizing or savoury
    4. Avoid greasy foods v. Eat raw vegetables
    5. Take more sugar
    6. Drink plenty of fluid e.g. barley water or juice
    7. Report at once if urine becomes dark or decreases in amount
    i. If unable to retain food or fluids
    ii. If urine becomes scanty or dark or other signs of dehydrations are present i.e. anxious look, shaken eyes, or creasing of the skin.
    2. Heart-burn and Nausea
    i. Milk of magnesia
    ii. Emidoxyn tablets
    i. Avoid eating greasy, spiced or rich foods
    ii. Take sips of milk or hot water with crushed mint leaves
    iii. Avoid eating just before bed time
    iv. Use an extra pillow v. Take light exercise
    24
    3. Backache
    i. APC tablets
    ii. Calcium glyconate tablets
    iii. Methyl salicylate ointment
    i. Explain exercise strengthening back and abdominal muscles
    ii. Teach her good posture
    iii. Advise her to:
    1. decrease amount of rest
    2. increase milk intake
    4. Constipation
    i. Milk of magnesia tablets
    i. Drink at least glasses of fluid daily
    ii. Eat well-washed raw fruits and vegetables, coarsely ground cereals and green leafy vegetables
    iii. Take regular light exercise
    5. Varicose veins (legs)
    i. Bandage legs from below upwards
    i. Avoid long periods of standing
    ii. Change position frequently
    25
    iii. Elevate hips and legs whenever at rest
    iv. Avoid squatting for too long at a time
    v. Reduce food intake if required
    6. Varicose veins (Vulva)
    i. Perineal support pad. Malcea soft pad from well washed clothes and attach it to a loose belt worn around the hips to give support.
    i. Avoid long periods of standing
    ii. Elevate hips and legs whenever at rest
    i. If no relief from perineal support pad
    7. Haemorrhoids (Piles)
    i. Sit in tub of warm water to which magnesium sulphate has been added.
    ii. Apply oil or vaseline on finger and gently push the piles back into the anus
    iii. Milk of magnesia tablets
    i. Same as for constipation
    ii. Advise her to avoid squatting for too long at a time
    i. If any bleeding
    ii. If piles cannot be pushed back
    26
    8. Pruritis (itching of the vulva)
    i. Apply gentian violet solution hoarse on alternate days for 1 week
    ii. If skin is raw from scratching dust with zinc boric powder
    i. Wash the perineal area with soap and water daily
    ii. Keep the finger nails cut short
    iii. Avoid scratching the area
    i. If vaginal discharge is profuse or foul smelling
    ii. If there is frequency of urination
    iii. If condition persists for over one week
    9. Vaginal through
    i. Rule out other kinds of vaginal discharge,
    ii. Apply gentian violet solution as for pruritis.
    i. Wash the perineal area with soap and water daily
    i. If no change in condition after treatment of one week
    27
  6. Haemorrhoids (plus)
  7. Pruritus (itching of the vulva)
  8. Vaginal through.
 
COMPLICATIONS OF PREGNANCY
Prenatal complications which are commonly found include the following:
 
Abortion
Abortion is interruption of pregnancy before the 28th week. It is characterised by varying amounts of vaginal bleeding and pain and may or may not include the expulsion of the products of conception.
The more common causes of abortion are maldevelopment of the foetus, abnormalities of the uterus or the placenta, acute infection associated with high fever, injury of the woman or very strenuous activity during pregnancy.
Abortion can either occur spontaneously or it can be induced, e.g. medical termination of pregnancy (MTP) by a trained doctor or illegal termination of pregnancy by an untrained person.
Abortions can be classified into four general types which are as follows:
  1. Threatened abortion
  2. Incomplete abortion
  3. Complete abortion
  4. Septic abortion.
If a pregnant woman has any of the following conditions, proceed as follows.28
 
Threatened Abortion
Signs and symptoms
  • Slight fresh vaginal bleeding
  • Low abdominal pain
  • Pulse rate may be more than 90 and strength of pulse strong
 
Treatment
  1. Complete rest in bed
  2. Take T.P.R.
  3. Belladona and Phenobarti tone tablets administer.
  4. Perineal care.
  5. Instruct patient to:
    1. Avoid intercourse
    2. Straining or lighting heavy objects
  6. Eat raw vegetables and fruit and drink at least 7 to 8 glasses of fluid daily.
Continue all the treatment for five days. Register and keep under close observations throughout pregnancy.
Follow-up of threatened abortion
  1. Revisit within 5 days to check if bleeding has stopped.
  2. Make a home visit or see the patient at the MCH clinic every two weeks for 2 visits.
  3. Confirm that the signs of pregnancy continue and that foetus is alive—send the using for Gravindex test.
  4. Instruct her to do the following if bleeding starts again:
    1. Rest in bed
    2. Avoid intercourse for 2 to 3 weeks
    3. Avoid straining or lifting heavy objects
    4. Continue to eat raw fruit and vegetables and drink plenty of fluids during the day
  5. If no further bleeding, see at monthly intervals. If bleeding occurs again, report at the hospital.
29
 
Incomplete Abortion
Signs and symptoms
  • Heavy fresh vaginal bleeding
  • Partial product of conception passed
  • Low abdominal pain may be there
  • Fever about 38°C may be there
  • Pulse rate above 90 and strength of pulse variable
Treatment
  1. Rest in bed with legs elevated
  2. Administer Engot tablets
  3. Take T.P.R.
  4. Refer to hospital
  5. Inform Health Assistant (F).
Follow-up of incomplete abortion
  1. Make a home visit within 3 days after she has been discharged from the hospital and do the following:
    1. Take T.P.R—if no fever
    2. Check lochia—amount, colour and odour
    3. Advice perineal care
    4. If no further pregnancy desired, urge FP method
      If fever:
    1. Administer triple sulpha tablets
    2. Refer to hospital
    3. Inform Health Assistant (F)
  2. Schedule return visits or clinic visits depending on whether further pregnancy is desired.
 
Complete Abortion
Signs and symptoms
  • Slight fresh vaginal bleeding
  • Complete product of conception passed
  • Pulse below 90 and strength of pulse strong.
Treatment
  1. Take T.P.R.
  2. Perineal care
  3. Patient to report if feverish or vaginal discharge increases.
30
Follow-up of complete abortion
  1. Revisit within 2 weeks to ascertain that the uterus has become smaller in size and that lochia has ceased.
    If the uterus remains large or lochia persists, refer her to the hospital.
  2. If no further pregnancy is desired, urge the use of a family planning method.
 
Septic Abortion
Signs and symptoms
  • Very slight fresh vaginal bleeding, foul smelling vaginal discharge.
  • May have passed products of conception
  • Low abdominal pain or tenderness
  • Fever about 38°C
  • Pulse rate more than 90 and strength of pulse variable.
Treatment
  1. Rest in bed
  2. Take T.P.R.
  3. Administer triple sulpha tablets
  4. Hot fomentation to abdomen
  5. Refer to PHC or hospital
  6. Inform Health Assistant (F).
Follow-up of septic abortion cases
  1. Revisit within one week to check TPR and vaginal discharge. If the patient has been hospitalized, ask her family to inform you when she returns home.
  2. Antenatal haemorrhage (bleeding after 28 weeks of pregnancy).
Vaginal bleeding which occurs after the 28th week of pregnancy may be due to a placenta praevia or to toxaemia.
Placenta praevia develops when the placenta lies over the cervical opening of the uterus and becomes detached before the baby is born.
This occurs more commonly among women who are multiparous.31
Antinatal haemorrhage can also occur in women who have signs and symptoms of toxaemia of pregnancy.
Any bleeding in the third trimester will require emergency treatment because of the danger of massive haemorrhage which can be fatal for the woman and result in a stillbirth or the birth of a premature baby.
The emergency treatment for this condition is as follows:
  1. Place the patient flat in bed with her seat elevated. Keep her warm with extra covers.
  2. Check and record pulse rate (if possible blood pressure).
  3. Refer her to the nearest hospital.
You should accompany the patient along with her husband.
Whenever you come across a woman who has vaginal bleeding after severity month of pregnancy, arrange for her immediate transfer to the primary health centre. Her husband should accompany her in case his permission is required for surgery inform the Health Assistant (Female) and the Dai concerned).
 
Toxaemia of Pregnancy
This condition rarely occurs before the 24th week and is usually seen after the 30th week (3rd trimester). It is more common in primipara.
The condition is usually characterised by swelling of the legs and fingers which may be accompanied by headache (Table 1.5).
Eclampsia is the more severe form of the condition in which the woman develops a generalised swelling of the body, severe headache and convulsions.
Abortion or premature delivery or antipartum haemorrhage often occurs when a pregnant woman develops toxaemia.
If a pregnant woman has any of the following conditions, proceed as follows:32
Table 1.5   Conditions in toxaemia of pregnancy
Condition
Mild Toxaemia
Severe Toxaemia
Swelling feet and legs
Yes
Yes
Hand and fingers
No
Yes
Face
No
Yes
Puffiness of eye lids
No
Yes
Vulva
No
Yes
Convulsions
No
No
Blurring of vision and dizziness
No
Yes
Albumen in urine
Yes C trace
Yes
Blood pressure
Below 140/90
Above 140/90
Drowsiness
No
Yes
Decrease in urine output
No
Yes
33
 
Treatment for Mild Toxaemia
  1. Rest in bed
  2. Stop use of salt in diet
  3. Refer to hospital
  4. Inform Health Assistant (F).
 
Treatment for Severe Toxaemia
  1. Administer mist chloral hydrate
  2. Arrange transport
  3. Refer to hospital
  4. Inform Health Assistant (F).
    If a pregnant women has convulsions (eclampsia).
  1. Bed rest in quiet darkened room
  2. Attendant constantly with the patient
  3. During convulsions:
    1. Turn the head to one side
    2. Place padded piece of wood between the teeth to prevent bitting the tongue.
  4. Inform hospital and arrange to transfer the patient
  5. Inform Health Assistant (F).
After her return from the PHC, the patient should be kept under close observation. Instruct the family, the dai and the health worker (male) to inform you immediately if there are any signs and symptoms of ill health.
 
Kidney Infection
This may develop between the 16th and 24th week (2nd Trimester) due to compression of the ureter by the growing uterus which causes blockage of urine.
If you suspect kidney infection, refer her to a hospital.
 
Premature Rupture of the Membranes
This is a serious condition in which rupture of the membranes is not followed by the onset of labour within 24 hours. If it is not recognized and referred promptly, any of the following may occur:
  1. Premature delivery34
  2. Infection of the uterus and its contents
  3. Prolapse of the cord
  4. Breech presentation.
 
Malpresentation (Abnormal Position) of the Foetus
Malpresentation of the foetus after the 34th week of pregnancy is a serious complication. This condition is usually found only after the 30th week (early in 3rd Trimester) when abdominal palpation can be done to determine the presentation (the portion of the foetus at the mouth of the uterus) and lie (longitudinal or transverse) of the foetus.
 
Abnormal Pregnancy
There are a number of abnormal conditions which can occur during pregnancy, but only two conditions which you may encounter more frequently than others are described here.
 
Ectopic Pregnancy
It occurs when there is implantation of the fertilised ovum outside the uterus. The most common site of ectopic pregnancy is either the right or left fallopian tube. This condition is usually characterised by:
  1. Slight vaginal bleeding in a woman who is between the 6th and 10th week of pregnancy.
  2. Recurring, spasmodic, or severe: Low abdominal pain and tenderness on one side which is increased with straining, e.g. during defaecation.
  3. Nausea or a feeling of faintness may be present.
  4. History of having missed one or two menstrual periods.35
  5. Pressure of early signs of pregnancy, i.e. breast changes or morning sickness.
  6. Slight amount of dark brown vaginal discharge.
  7. Frequent stools.
  8. Rapid pulse.
Whenever you find a woman with the above signs and symptoms, proceed as follows:
  1. Check her pulse rate and the strength of the beats.
  2. Put her to bed and elevate her legs.
  3. Refer her to hospital.
  4. Ask her husband to accompany her to the hospital as an operation or blood transfusion may be required.
 
Polyhydramnios
Or an excessive amount of fluid in the uterus can occur about the 30th week (3rd Trimester) and this can continue to increase in amount until the time of delivery. This abnormality of the uterus is characterised by the following:
  1. Abdominal girth of one metre at term.
  2. The skin of the abdomen is thin, tense and has a large number of new, bluish-pink stretch marks.
  3. The shape of the uterus is globular instead of being ovoid.
  4. It is difficult to palpate the foetus.
  5. The foetal heart is heard with much difficulty or may not be audible.
  6. There may be oedema of the vulva and of the lower limbs.
36
Prompt referral is necessary whenever a woman close to term has the above characteristics because the major complications due to this condition are:
  1. Prolapse of the cord
  2. Premature delivery.
FURTHER READING
  1. Manual for Health Worker (Female) Vol. I. Published by Ministry of Health and Family Welfare, New Delhi with the assistance of WHO Project HMD-006.