BSC SEM 6 UNIT 3 MIDWIFERY / OBSTETRIC AND GYNECOLOGY NURSING- I

🩺 Assessment and Management of Normal Pregnancy (Antenatal Care)

Antenatal care (ANC) is systematic, regular monitoring of a pregnant woman and her fetus from the time of conception until the onset of labor to ensure the wellbeing of both.

🌸 Objectives of Antenatal Care

Ensure the birth of a healthy baby.
Maintain the health of the mother during pregnancy.
Recognize high-risk pregnancies and provide early interventions.
Provide health education (nutrition, hygiene, childbirth preparation).
Prepare the mother and family for labor, delivery, and parenthood.

I. 👩‍⚕️ Initial Assessment (First Visit)

Usually occurs around 6–12 weeks of gestation.

🔍 A. History Collection

Personal details: Name, age, address, occupation.
Obstetric history:
- Gravida (G), Para (P), Abortions (A), Living children (L) – e.g., G3P2A0L2.
Menstrual history:
- Last Menstrual Period (LMP)
- Expected Date of Delivery (EDD) = LMP + 9 months + 7 days.
Medical/surgical history: Diabetes, hypertension, asthma, surgeries.
Family history: Genetic disorders, twin pregnancy.
Socioeconomic status: Income, education, housing.
Dietary habits, addictions (smoking, alcohol, etc.).

🩻 B. Physical Examination

General Examination:
- Height and weight (baseline).
- BMI calculation.
- Blood pressure (rule out preeclampsia).
- Pallor, edema, jaundice, thyroid, lymph nodes.
Breast Examination:
- To detect lumps or nipple retraction.
- Educate about breast care.
Abdominal Examination:
- Palpation of uterus (fundal height).
- Lie, presentation, and fetal heart sounds after 20 weeks.
Pelvic Examination:
- Done only if needed (bleeding, discharge, etc.)

🧪 C. Investigations

Hemoglobin (Hb): To detect anemia.
Blood group and Rh typing.
Blood sugar (Fasting/Random): For gestational diabetes.
Urine test: For albumin, sugar, and infection.
HIV, HBsAg, VDRL (mandatory tests).
Ultrasound:
- First trimester: Dating scan.
- Second trimester: Anomaly scan (~18–22 weeks).
- Third trimester: Growth and position.

II. 📅 Subsequent Antenatal Visits

WHO/INC Guidelines (Minimum Visits):

1st visit: By 12 weeks (1st trimester)
2nd visit: Between 14–26 weeks (2nd trimester)
3rd visit: Between 28–34 weeks
4th visit: After 36 weeks

(More visits if high-risk pregnancy)

✍️ Check-ups at Each Visit

Weight and BP monitoring
Urine test (sugar & albumin)
Fundal height measurement (assess fetal growth)
Fetal heart rate (120–160 bpm)
Fetal movements after 20 weeks
Look for danger signs:
- Bleeding
- Severe headache
- Swelling of hands/face
- Blurred vision
- Reduced fetal movement

III. 💊 Management of Normal Pregnancy

✅ Routine Care and Advice

Iron & Folic Acid (IFA):
- 100 mg elemental iron + 500 mcg folic acid once daily after 14 weeks, for 180 days.
Calcium Supplement:
- 500 mg twice daily from 14 weeks till 6 months postpartum.
Tetanus + Adult Diphtheria (Td) Injection:
- 2 doses: 1st at 16 weeks, 2nd after 4 weeks (or booster if previously immunized).
Deworming:
- Single dose of Albendazole 400 mg after 2nd trimester.
Nutrition:
- High protein, iron, calcium, and fiber diet.
- 300 kcal extra per day.
Hygiene:
- Personal cleanliness, avoid infections.
Rest and Sleep:
- Minimum 8 hours at night + rest during day.
Exercise:
- Light physical activity (walking, yoga).
Sexual activity:
- Safe unless contraindicated by doctor.

🧘‍♀️ Health Education

Danger signs in pregnancy
Birth preparedness
Institutional delivery
Postnatal care and breastfeeding
Family planning options after delivery

IV. 🚨 When to Refer to Higher Centre (Danger Signs)

Bleeding per vagina
Severe headache/visual disturbances
Swelling of face and limbs
Severe abdominal pain
High fever
No fetal movement >6 hours
Convulsions, unconsciousness
Blood pressure >140/90 mmHg

V. 🤱 Preparation for Labor and Delivery

Encourage hospital delivery (Janani Suraksha Yojana / PMMVY schemes in India).
Identify transportation.
Arrange for blood donor if needed.
Keep emergency contact numbers ready.
Keep delivery kit ready after 36 weeks.

Summary Table 📋

Assessment Area	Management/Action
History taking	Identify risks, plan care
Physical examination	Monitor health, detect abnormalities
Lab investigations	Identify anemia, infections, gestational diabetes
Nutritional advice	Balanced diet + supplements
Routine meds	IFA, Calcium, Albendazole, Td injection
Health education	Danger signs, birth preparedness, breastfeeding
Referral criteria	Danger signs or complications
Preparation for birth	Institutional delivery, emergency planning

🌸 Pre-Pregnancy Care – Review of Sexual Development

Pre-pregnancy (preconception) care involves a comprehensive health assessment and guidance given to a woman or couple before conception to optimize maternal and fetal outcomes.

One key part of this is the Review of Sexual Development, which helps healthcare providers understand the biological, physical, hormonal, and psychological readiness of a woman for pregnancy.

🌼 I. Purpose of Reviewing Sexual Development in Pre-Pregnancy Care

To assess normal pubertal and reproductive development.
To identify any abnormalities in sexual or reproductive anatomy.
To ensure hormonal balance for conception.
To provide timely treatment for any sexual development disorders.
To address psychosocial readiness for sexual activity and pregnancy.

🌺 II. Normal Sexual Development – A Brief Overview

Sexual development occurs in five major stages, mainly during adolescence and early adulthood:

1. Infancy and Childhood (0–8 years)

Gender identity develops.
No reproductive capability.
Minimal sexual hormone activity.

2. Pre-Puberty (8–11 years)

Subtle physical changes begin (breast budding in girls).
Hormonal axis starts to mature.

3. Puberty (Average: Girls – 10–14 years)

Triggered by the Hypothalamic–Pituitary–Gonadal (HPG) Axis:

Gonadotropin-Releasing Hormone (GnRH) from hypothalamus stimulates:
- FSH and LH from anterior pituitary.
- These act on ovaries to produce estrogen and develop ova.

In Girls:

Thelarche – Breast development.
Pubarche – Appearance of pubic hair.
Menarche – First menstrual period (usually by 12–13 years).
Growth spurt – Peak height velocity.

4. Reproductive Maturity (15–45 years)

Ovulatory cycles become regular (about 2 years after menarche).
Fertility potential is optimal.
Menstrual cycles are usually 28±7 days with ovulation around day 14.

5. Perimenopause and Menopause

(Not directly relevant for pre-pregnancy, but important for long-term reproductive planning.)

🌹 III. Key Areas of Review in Pre-Pregnancy Sexual Development Assessment

Area	Key Points to Assess
Menstrual history	Age at menarche, regularity, cycle length, flow amount.
Secondary sexual characteristics	Breast development, pubic/axillary hair – Tanner Staging.
Hormonal status	FSH, LH, estrogen, prolactin, thyroid hormones, if needed.
Anatomy of reproductive system	Uterus, ovaries, vagina – via pelvic exam or ultrasound.
Sexual activity history	Onset, frequency, use of contraception, sexual dysfunction.
Psychosocial maturity	Emotional readiness for sexual life and pregnancy.
Infections/STIs	History of UTIs, STDs, or genital tract infections.
Partner history	Sexual history, fertility, infections.

🌿 IV. Abnormalities to Be Ruled Out

Delayed puberty – No thelarche by age 13 or no menarche by 16.
Primary amenorrhea – No menstruation by 16 years of age.
Secondary amenorrhea – Cessation of periods for 3–6 months.
Polycystic Ovarian Syndrome (PCOS) – Irregular menses, hirsutism, obesity.
Thyroid dysfunction – Can delay menarche or cause irregular cycles.
Congenital anomalies – E.g., Müllerian agenesis, imperforate hymen.
Sexual dysfunction or abuse history – Requires psychological support.

💡 V. Nursing Responsibilities in Reviewing Sexual Development

Maintain privacy and ensure non-judgmental attitude.
Take detailed history with empathy and confidentiality.
Educate the woman/couple about normal sexual development.
Counsel on fertility, safe sex practices, and menstrual health.
Refer to specialist if abnormalities are found.
Involve the partner when appropriate for joint decision-making.

🌈 VI. Importance of Review for Fertility & Safe Pregnancy

Ensures optimal physical and hormonal health for conception.
Helps identify and treat conditions like PCOS, hypothyroidism, or anatomical barriers to conception.
Promotes timely interventions to support reproductive health.
Reduces the risk of complications during pregnancy like infertility, miscarriage, or preterm labor.

🌏 Socio-Cultural Aspects of Human Sexuality

Human sexuality is not just a biological or physical concept. It is also deeply influenced by social, cultural, religious, moral, and psychological factors. These aspects shape how individuals understand, express, and behave in relation to their sexuality.

🌸 I. Definition of Human Sexuality

Human sexuality refers to a person’s capacity for sexual feelings, orientation, identity, behavior, roles, and relationships. It includes biological sex, gender identity, sexual orientation, intimacy, reproduction, and eroticism.

🌍 II. Socio-Cultural Aspects of Human Sexuality

These aspects define how sexuality is perceived, accepted, and practiced in different societies.

🔹 1. Cultural Beliefs and Norms

Each culture has specific values, rules, and expectations regarding sexuality.
What is acceptable in one culture may be taboo in another.
Example: Premarital sex may be accepted in Western cultures but discouraged in traditional societies.

🔹 2. Gender Roles and Expectations

Societies assign gender-based behaviors (e.g., men expected to be dominant, women passive).
These roles influence how men and women express sexuality.
In some cultures, women are discouraged from speaking openly about sexual needs.

🔹 3. Religion and Morality

Religions often guide sexual behavior with rules regarding:
- Marriage
- Contraception
- Masturbation
- Homosexuality
- Abortion
Example: Islam and Christianity promote chastity before marriage.

🔹 4. Family and Social Influence

Family upbringing impacts sexual understanding.
Societies where open discussion is encouraged lead to better sexual health awareness.
In conservative families, sexual matters may be considered shameful or private.

🔹 5. Media and Technology

Exposure to TV, films, internet, and social media has changed sexual attitudes, especially in youth.
Promotes both awareness and sometimes unrealistic expectations or risky behavior.

🔹 6. Education and Literacy

Educated individuals are more likely to:
- Understand safe sex
- Use contraception
- Prevent STIs
In areas with low literacy, myths and misconceptions about sexuality may persist.

🔹 7. Sexual Orientation and Identity

Social and cultural settings affect the acceptance or rejection of LGBTQ+ individuals.
Discrimination, stigma, or even violence may occur in societies with rigid gender norms.

🔹 8. Myths and Misconceptions

Beliefs such as:
- “Masturbation causes weakness”
- “Only men have strong sexual desire”
- “First intercourse must involve pain/bleeding”
These myths affect attitudes, self-esteem, and relationships.

🔹 9. Marriage and Sexuality

Some cultures associate sexuality strictly with marriage and reproduction.
Others see it as part of individual expression and pleasure.

📊 III. Examples of Socio-Cultural Impact on Sexual Health

Factor	Impact
Taboos around discussing sex	Lack of knowledge, unsafe practices
Religious restrictions	Delayed or suppressed sexual expression
Gender inequality	Sexual violence, reproductive health issues
Media influence	Body image issues, early sexual exposure
Stigma on LGBTQ+	Mental health problems, isolation

🧠 IV. Nursing/Healthcare Implications

👩‍⚕️ Nurses should:

Respect cultural and personal values.
Offer non-judgmental, confidential sexual health counseling.
Promote scientific education to counter myths.
Advocate for sexual rights and gender equality.
Encourage parent-child and teacher-student communication on sexuality.

🌸 Preconception Care (PCC)

Preconception care refers to a set of preventive, promotive, and curative health services provided before conception to improve maternal and fetal outcomes. It prepares a woman (and couple) for healthy pregnancy and childbirth by addressing health issues and promoting positive health practices.

🎯 Objectives of Preconception Care

Optimize the health of the woman before conception.
Identify and manage risk factors (medical, genetic, behavioral).
Promote healthy lifestyle and nutrition.
Educate the couple about fertility, pregnancy planning, and birth spacing.
Reduce the risk of adverse maternal and neonatal outcomes.

🩺 Key Components of Preconception Care

1️⃣ Health and Medical Assessment

Detailed personal, obstetric, menstrual, and family history.
Past complications: miscarriages, stillbirths, cesarean, hypertension, diabetes.
Current health status: Chronic diseases (e.g., thyroid, asthma, epilepsy, etc.).

2️⃣ Physical Examination

General examination: Height, weight, BMI, blood pressure.
Check for anemia, goiter, infections, or physical abnormalities.
Pelvic exam (if needed): Assess reproductive organs.

3️⃣ Laboratory Investigations

Hemoglobin level
Blood group and Rh typing
Blood sugar (to detect diabetes)
Thyroid function test
Urine test (for albumin, sugar, and infection)
Screening for STIs, HIV, Hepatitis B & C, Rubella immunity, etc.

4️⃣ Nutritional Assessment & Intervention

Check for undernutrition or obesity.
Folic acid supplement (400 mcg/day at least 1 month before conception to prevent neural tube defects).
Iron and calcium if anemic or malnourished.
Advise balanced diet, plenty of fluids, fruits, vegetables, and proteins.

5️⃣ Immunization Status

Ensure vaccines are updated:
- Rubella (if non-immune; avoid pregnancy for 1 month after vaccine).
- Hepatitis B, Tdap, COVID-19, etc., as per guidelines.

6️⃣ Genetic Counseling

For couples with:
- Family history of genetic disorders
- Repeated pregnancy losses
- Known inherited diseases (e.g., Thalassemia, Sickle cell anemia)
Screening and testing may be advised.

7️⃣ Lifestyle Modification

Stop smoking, alcohol, and drug use.
Encourage exercise and weight management.
Manage stress and promote mental well-being.

8️⃣ Psychosocial Assessment

Check for mental health issues (depression, anxiety).
Evaluate family support, intimate partner violence, stressors.
Promote healthy relationships and emotional readiness.

9️⃣ Sexual and Reproductive Health Counseling

Educate about:
- Menstrual cycle and fertile period.
- Safe sex practices and STI prevention.
- Spacing between pregnancies.
- Fertility and ovulation tracking.

🔟 Environmental and Occupational Exposure

Assess exposure to:
- Chemicals, radiation, pesticides.
- Harmful workplace substances.
Guide for protective measures.

📌 Role of Nurse/Health Worker in Preconception Care

Responsibility	Action
Education	Educate couples on health, pregnancy planning, and family life.
Screening	Conduct tests and identify risk factors.
Counseling	On nutrition, contraception, substance abuse, STDs.
Referral	Refer to higher center if needed (e.g., geneticist, obstetrician).
Follow-up	Regular check-ins to ensure readiness for pregnancy.

🚫 Risk Factors Addressed in PCC

Diabetes, hypertension, thyroid disease
Anemia, obesity, underweight
Poor nutrition, infections, uncontrolled chronic diseases
Genetic diseases
Psychological stress, domestic violence
Environmental exposures

✅ Benefits of Preconception Care

Reduces maternal and perinatal mortality and morbidity.
Prevents neural tube defects and congenital anomalies.
Helps achieve planned, wanted pregnancies.
Promotes health-seeking behavior and early antenatal care.
Enhances knowledge of reproductive health and rights.

🌸 Pre-conception Counseling.

🔹 Definition:

Pre-conception counseling is the process of providing information, education, and support to couples (especially women) before conception occurs, to ensure a healthy pregnancy and optimal outcomes for the mother and baby.

It is an essential aspect of reproductive and maternal health care, especially in the field of midwifery and gynecology nursing.

🔹 Objectives of Pre-conception Counseling in Midwifery:

Assess and optimize the woman’s health before pregnancy.
Identify and manage any risk factors that may affect conception, pregnancy, or childbirth.
Promote awareness of normal birth, its process, benefits, and how to prepare for it.
Encourage healthy lifestyle modifications.
Educate about fertility and conception timing.
Empower women to make informed choices about their reproductive health.

🔹 Components of Pre-conception Counseling (Midwifery Focus):

1️⃣ Comprehensive Health Assessment:

Medical history (chronic diseases, infections, etc.)
Menstrual history (cycle regularity, dysmenorrhea, etc.)
Obstetric and gynecological history
Family history (genetic or hereditary disorders)
Lifestyle and nutrition
Psychosocial evaluation

2️⃣ Nutritional Counseling:

Balanced diet, rich in iron, calcium, folic acid.
Start Folic acid (400 mcg/day) supplementation to prevent neural tube defects.
Address anemia or malnutrition if present.

3️⃣ Fertility Awareness & Timing:

Educate about ovulation period (usually days 12–16 of cycle).
Teach fertility tracking methods (BBT, cervical mucus method).
Inform about healthy sexual practices to enhance conception.

4️⃣ Immunization Status:

Check for immunity to Rubella, Hepatitis B, Varicella, Tetanus, COVID-19, etc.
Administer vaccines if needed before conception.

5️⃣ Infection Screening and Treatment:

Screen for STIs, HIV, Hepatitis B & C, TORCH infections.
Treat infections prior to conception.

6️⃣ Chronic Disease Management:

Control of diabetes, hypertension, epilepsy, thyroid disorders, etc.
Adjust medications to pregnancy-safe alternatives.

7️⃣ Lifestyle Modifications:

Quit smoking, alcohol, and drugs.
Encourage regular exercise and stress management.
Avoid environmental toxins and hazards.

8️⃣ Genetic Counseling (if needed):

For couples with family history of genetic conditions.
In cases of consanguineous marriage, advanced maternal age, or previous child with genetic defect.

9️⃣ Psychological Preparation:

Address mental health issues (anxiety, depression).
Support through counseling or therapy if needed.
Discuss emotional readiness for parenthood.

🔹 Counseling Regarding Normal Birth:

Awareness and Preparation for Normal Vaginal Delivery (NVD):

🌼 What to Cover:

Benefits of normal birth: Less complications, quicker recovery, early bonding.
Stages of labor and delivery: Latent, active, transition, pushing, delivery of placenta.
Coping techniques: Breathing exercises, movement, massage, hydrotherapy.
Support system: Role of birth partner/doula/midwife.
Hospital vs home birth: Pros and cons, based on risk assessment.

🌼 Promotion of Normal Birth:

Avoid unnecessary medical interventions (like elective C-sections).
Educate on birth plans and women’s rights during childbirth.
Encourage skin-to-skin contact and early breastfeeding.
Use midwifery-led care model to reduce interventions.

🌼 Danger Signs to Watch:

Preterm labor signs
Bleeding
High BP symptoms
Abnormal fetal movements
Prolonged or painful labor

🔹 Role of Midwifery and Gynecology Nurse in Pre-conception Counseling:

Roles	Responsibilities
Educator	Teach women/couples about health, fertility, and normal birth.
Counselor	Provide emotional and mental health support.
Care Provider	Perform assessments, refer to specialists if needed.
Advocate	Promote women’s rights to informed, respectful maternity care.
Communicator	Coordinate between obstetrician, pediatrician, and woman.

🔹 Importance in Reducing Maternal and Neonatal Morbidity/Mortality:

Early interventions reduce complications during pregnancy and labor.
Encourages planned and safe pregnancies.
Improves maternal and neonatal outcomes.

🧬 Genetic Counseling.

🔷 Definition:

Genetic counseling is a communication process that deals with the occurrence or risk of a genetic disorder in a family. It includes risk assessment, education, support, and guidance to individuals or families who are at risk for or affected by genetic conditions.

WHO Definition: Genetic counseling is the process through which individuals or families receive advice and information about genetic disorders, their consequences, and the chances of recurrence.

🔷 Objectives of Genetic Counseling:

To assess the risk of recurrence of genetic disorders.
To provide accurate and updated information on genetic conditions.
To offer emotional support and coping strategies.
To guide on available tests and management options.
To support informed decision-making about reproduction.

🔷 Types of Genetic Counseling:

Type	Purpose
Prospective Counseling	For couples planning to marry or conceive.
Retrospective Counseling	Given after birth of an affected child.
Carrier Counseling	For individuals who carry a gene for a disorder.
Prenatal Counseling	For a woman already pregnant, with high-risk results.
Postnatal Counseling	After delivery if a baby is born with a genetic condition.
Cancer Genetic Counseling	For those with family history of cancers.

🔷 Indications for Genetic Counseling (When it is needed):

Family history of inherited disorders (e.g., thalassemia, sickle cell).
Consanguineous marriage (marriage between close relatives).
Advanced maternal age (>35 years).
Previous child with congenital anomalies.
History of multiple miscarriages or stillbirths.
Carrier screening (e.g., cystic fibrosis, Tay-Sachs).
Abnormal prenatal test results (ultrasound, amniocentesis).
Newborn screening abnormalities.
Suspected X-linked or autosomal disorders.
Infertility or subfertility due to genetic causes.

🔷 Steps in Genetic Counseling Process:

Referral – from obstetrician, pediatrician, or nurse.
Collection of information:
- Family history (pedigree chart)
- Medical and reproductive history
Risk assessment:
- Determine inheritance pattern (dominant, recessive, X-linked)
Education:
- Explain the condition, cause, prognosis, and management
- Explain screening and diagnostic options
Support and Decision-making:
- Help in understanding reproductive options
- Provide emotional support
Follow-up and referrals:
- Refer to specialists (geneticist, psychologist)
- Plan next steps (testing, pregnancy planning, etc.)

🔷 Common Genetic Disorders Encountered in Counseling:

Disorder	Inheritance Type
Thalassemia	Autosomal Recessive
Sickle Cell Anemia	Autosomal Recessive
Down Syndrome (Trisomy 21)	Chromosomal Nondisjunction
Hemophilia	X-linked Recessive
Turner Syndrome (XO)	Chromosomal Disorder
Cystic Fibrosis	Autosomal Recessive
Duchenne Muscular Dystrophy	X-linked Recessive
Tay-Sachs Disease	Autosomal Recessive

🔷 Role of Nurse in Genetic Counseling (Midwifery and Gynecology Context):

Role	Description
Educator	Teach couples about inheritance, risk factors, testing.
Counselor	Provide emotional support and non-directive guidance.
Advocate	Respect clients’ rights and decisions, promote informed choice.
Communicator	Bridge communication between client and geneticist.
Care Coordinator	Schedule and arrange necessary referrals and follow-ups.
Prenatal support	Assist in prenatal screening (NT scan, triple marker, amniocentesis).
Health Promoter	Educate community on consanguinity, carrier screening, and healthy conception.

🔷 Ethical Considerations in Genetic Counseling:

Confidentiality
Informed consent
Non-directiveness (the counselor should not impose personal views)
Respect for autonomy
Right to know and right not to know
Cultural and religious sensitivity

🔷 Genetic Testing Options Explained in Counseling:

Test	Description
Carrier Testing	Checks if a person carries a gene for a condition.
Prenatal Testing	Detects genetic conditions during pregnancy (e.g., amniocentesis).
Newborn Screening	After birth to detect treatable conditions early.
Preimplantation Genetic Diagnosis (PGD)	Testing embryos before IVF implantation.
Predictive Testing	For adult-onset conditions (e.g., Huntington’s).

🔷 Impact of Genetic Counseling:

Reduces birth of babies with severe genetic defects.
Helps in early diagnosis and management.
Reduces emotional and financial burden on families.
Empowers couples with reproductive choices (e.g., IVF with PGD, adoption, etc.)

🌸 Planned Parenthood.

🔷 Definition:

Planned Parenthood is the practice of deciding when and how many children to have, through the use of education, counseling, and family planning services, including contraception. It aims to promote reproductive health, maternal well-being, child health, and empowered family life.

It enables couples to achieve their desired number of children and determine the spacing and timing of their births.

🔷 Objectives of Planned Parenthood:

To prevent unplanned or unwanted pregnancies.
To improve maternal and child health outcomes.
To help in spacing pregnancies, allowing the woman’s body to recover.
To empower couples with choices regarding reproduction.
To reduce the incidence of unsafe abortions.
To support women’s physical, emotional, and financial health.

🔷 Scope of Planned Parenthood Services:

Area	Services Provided
Family Planning	Contraceptive education and provision
Maternal Health	Antenatal, intranatal, and postnatal care
Infertility Services	Counseling, basic investigations, referral
STD/HIV Prevention	Screening, prevention, education
Cancer Screening	Cervical and breast cancer screening
Youth Counseling	Adolescent sex education and menstrual health
Safe Abortion Services	MTP as per law and guidelines

🔷 Role of Nurse in Planned Parenthood (Midwifery & Gynae):

Nursing Role	Responsibilities
Health Educator	Teach about reproductive health, contraception, menstrual hygiene
Counselor	Offer pre- and post-family planning counseling
Service Provider	Distribute contraceptives, assist in IUCD insertion, monitor side effects
Care Provider	Offer antenatal/postnatal care and referrals for infertility
Advocate	Promote women’s rights in reproductive decisions
Record Keeper	Maintain records of contraceptive use, follow-ups, outcomes

🔷 Family Planning Methods Under Planned Parenthood:

🔹 Temporary Methods:

Method	Description
Barrier	Condoms, diaphragms
Hormonal Pills	Mala-N, Mala-D
Injectables	Antara (DMPA)
IUCDs	Copper-T 380A, Multiload
Emergency Contraceptive	Taken within 72 hours of unprotected sex
Natural Methods	Rhythm method, lactational amenorrhea method (LAM)

🔹 Permanent Methods:

Method	Description
Female Sterilization	Tubectomy
Male Sterilization	Vasectomy

🔷 Importance of Planned Parenthood in Public Health:

Reduces maternal and infant mortality.
Promotes safe motherhood and child survival.
Controls population growth.
Supports economic and social development.
Prevents unsafe abortions and complications.
Empowers women through control over fertility.

🔷 Challenges in Planned Parenthood Implementation:

Myths and misconceptions
Cultural and religious barriers
Lack of male participation
Limited access in rural areas
Poor health infrastructure
Fear of side effects

🔷 Nursing Strategies to Promote Planned Parenthood:

Health education in community & clinics
Postpartum family planning counseling
Involving male partners in counseling
Organizing Adolescent Reproductive Health (ARSH) sessions
Door-to-door outreach by ANMs/ASHA workers
Collaborating with government schemes like:
- Mission Parivar Vikas
- National Family Welfare Programme

🔷 Planned Parenthood and Midwifery Practice:

Midwives and gynecology nurses are frontline workers in:

Educating women during antenatal visits about spacing.
Providing postnatal contraception counseling.
Supporting safe abortion and reproductive rights.
Integrating family planning into MCH (Mother and Child Health) services.

Pregnancy assessment and antenatal care (I, II & III Trimesters)

🌸 Assessment of Pregnancy.

🔷 Definition:

Assessment of pregnancy is the systematic evaluation of a woman to confirm the presence of pregnancy, determine its viability, establish gestational age, and identify any potential risks or complications.

It is the first and essential step in antenatal care, where the midwife or nurse plays a key role in early detection and support.

🔷 Objectives of Pregnancy Assessment:

To confirm pregnancy accurately.
To establish gestational age.
To detect any early complications or high-risk conditions.
To initiate early antenatal care (ANC).
To provide appropriate health education and counseling.

🔷 Components of Pregnancy Assessment:

🔶 1️⃣ History Taking:

a. Personal & Demographic Information:

Name, age, address, marital status, education, occupation

b. Menstrual History:

Last Menstrual Period (LMP)
Cycle regularity
Estimated Due Date (EDD) using Naegele’s Rule:
➤ EDD = LMP + 9 months + 7 days

c. Obstetric History (GTPAL):

G = Gravida (number of pregnancies)
T = Term births
P = Preterm births
A = Abortions (spontaneous or induced)
L = Living children

d. Medical & Surgical History:

Diabetes, hypertension, epilepsy, thyroid, surgeries

e. Family History:

Hereditary diseases (e.g., thalassemia, hemophilia)

f. Psychosocial History:

Stress, domestic violence, support system, mental health

🔶 2️⃣ Physical Examination:

a. General Examination:

Parameter	Significance
Weight	Baseline, nutrition status
Height	Short stature may relate to CPD
Blood pressure	Early detection of PIH/pre-eclampsia
Pulse	Circulatory status
Pallor	Anemia
Edema	Nutritional status, PIH
Jaundice	Liver disorders

b. Breast Examination:

Look for enlargement, tenderness, darkened areola, Montgomery tubercles

c. Abdominal Examination (from 12 weeks onward):

Fundal height (to assess gestational age)
Abdominal girth
Fetal parts (palpation in 2nd & 3rd trimester)
Fetal heart sounds (FHS) – heard by Doppler after 10–12 weeks

d. Pelvic Examination (if needed):

Softening of cervix (Goodell’s sign)
Softening of lower uterine segment (Hegar’s sign)
Bluish discoloration of vagina (Chadwick’s sign)
Size and position of uterus

🔶 3️⃣ Laboratory Investigations:

Test	Purpose
Urine Pregnancy Test (UPT)	Detects hCG to confirm pregnancy
Blood group and Rh typing	To prevent Rh incompatibility
Hemoglobin (Hb%)	Detects anemia
VDRL	Syphilis screening
HIV, HBsAg	Infectious disease screening
Random Blood Sugar (RBS)	Diabetes screening
Urine Routine	Protein, sugar, infection
Thyroid profile	TSH abnormalities

🔶 4️⃣ Ultrasound (USG):

Timing	Purpose
6–9 weeks (early scan)	Confirm intrauterine pregnancy, viability, gestational age
11–13 weeks (NT scan)	Detect chromosomal abnormalities
18–22 weeks (Anomaly scan)	Detect fetal anomalies
Third trimester	Assess growth, amniotic fluid, placenta

🔷 Signs of Pregnancy Noted in Assessment:

🔹 Presumptive Signs (experienced by woman)

Missed period (amenorrhea)
Morning sickness
Breast changes
Frequent urination
Quickening

🔹 Probable Signs (noted by examiner)

Enlarged abdomen
Positive urine pregnancy test
Changes in cervix and uterus (Goodell’s, Hegar’s, Chadwick’s signs)

🔹 Positive Signs (confirmative)

Fetal heart sounds
Visualization of fetus on ultrasound
Palpation of fetal parts

🔷 Tools Used in Pregnancy Assessment:

Stethoscope / Doppler for FHS
Measuring tape for fundal height
Weighing scale
Sphygmomanometer
Speculum and sterile gloves (for pelvic exam)
Urine pregnancy kit
Ultrasound machine

🔷 Role of Midwife/Nurse in Pregnancy Assessment:

Role	Duties
Care Provider	Conduct examinations, administer tests
Educator	Counsel on diet, rest, danger signs
Counselor	Support emotionally and psychologically
Health Promoter	Promote early ANC registration
Referrer	Refer high-risk pregnancies to specialists
Record Keeper	Maintain MCP card, ANC register, lab reports

🔷 Importance of Early and Accurate Assessment:

Ensures early detection of complications
Helps in timely interventions
Improves maternal and fetal outcomes
Builds trust and rapport with the health system
Promotes safe motherhood

🌸 Normal Pregnancy – Assess and Confirm Pregnancy.

🔷 Definition of Normal Pregnancy:

A normal pregnancy is a physiological condition where a fertilized ovum (zygote) implants in the uterine endometrium, grows and develops into a fetus over approximately 40 weeks (280 days), resulting in the birth of a healthy baby without complications.

🔷 Duration of Pregnancy:

Measured from the first day of the Last Menstrual Period (LMP).
Divided into three trimesters:
- First Trimester: 0–12 weeks
- Second Trimester: 13–28 weeks
- Third Trimester: 29–40 weeks

🔷 Assessing and Confirming Pregnancy:

Confirming pregnancy is the first step in antenatal care. It involves a combination of subjective symptoms, objective signs, and diagnostic tests.

🔶 1. Presumptive Signs of Pregnancy (Subjective – reported by the woman)

Symptom	Explanation
Amenorrhea	Absence of menstruation is usually the first sign.
Nausea and Vomiting (Morning Sickness)	Due to increased hCG levels.
Breast changes	Tenderness, enlargement, darkened areola.
Urinary frequency	Due to hormonal changes and uterine pressure on bladder.
Fatigue	Early pregnancy leads to tiredness.
Quickening (by 16–20 weeks)	First fetal movements felt by mother.

🔹 Note: These signs are not conclusive. They may be due to other conditions (e.g., stress, illness).

🔶 2. Probable Signs of Pregnancy (Objective – observed by examiner)

Sign	Explanation
Chadwick’s sign	Bluish discoloration of vaginal mucosa.
Goodell’s sign	Softening of cervix.
Hegar’s sign	Softening of lower uterine segment.
Abdominal enlargement	Progressive uterine growth.
Positive pregnancy test (urine or serum hCG)	Detects hCG in body fluids.
Braxton Hicks contractions	Irregular, painless uterine contractions.
Uterine souffle	Soft blowing sound over uterus (maternal blood flow).

🔹 These signs are stronger indicators but not 100% diagnostic.

🔶 3. Positive (Definitive) Signs of Pregnancy

These signs confirm the presence of a fetus and can be detected only by a skilled examiner or specific instruments.

Sign	Detected By
Fetal heartbeat (110–160 bpm)	Doppler (by 10–12 weeks), Fetoscope (by 18–20 weeks)
Fetal movements felt by examiner	By 20 weeks
Ultrasound visualization of gestational sac, fetus, and heartbeat	Transvaginal USG (5–6 weeks), Transabdominal (6–8 weeks)
Palpation of fetal parts	During abdominal examination in 2nd or 3rd trimester

🔷 Pregnancy Confirmation Methods in Clinical Practice:

✅ a. Urine Pregnancy Test (UPT):

Home test kits or done in clinics.
Detects hCG hormone.
Best done with first morning urine (more concentrated).
Can be positive as early as 6–10 days after conception.

✅ b. Serum β-hCG Test:

More sensitive than urine test.
Can confirm pregnancy earlier (as soon as 7–9 days after ovulation).
Used to assess ectopic pregnancy or molar pregnancy.

✅ c. Ultrasound (USG):

Transvaginal USG:
- Detects gestational sac as early as 4.5–5 weeks.
- Fetal heartbeat seen by 6–7 weeks.
Transabdominal USG:
- Useful from 6–8 weeks onward.

🔷 Steps of Pregnancy Assessment by Nurse/Midwife:

History Taking:
- Menstrual history (LMP)
- Symptoms of early pregnancy
- Sexual and obstetric history
Physical Examination:
- General exam (weight, BP, edema)
- Abdominal palpation
- Pelvic examination (if needed)
Laboratory Tests:
- UPT
- Blood hCG test (if needed)
- Baseline investigations (CBC, blood group, VDRL, HIV, HBsAg)
Ultrasound Scan:
- First scan (6–9 weeks) to confirm viability, location (intrauterine), and gestational age.
Documentation:
- Enter pregnancy details in Mother and Child Protection (MCP) Card
- Register in ANC register and schedule antenatal visits.

🔷 Nurse’s Role in Pregnancy Confirmation:

Role	Description
Educator	Teach about signs of pregnancy and when to seek care.
Counselor	Support emotional aspects of pregnancy discovery.
Care provider	Perform UPT, assess vitals, arrange for USG and labs.
Advocate	Promote early ANC registration and safe motherhood.

🔷 Importance of Early Pregnancy Confirmation:

Initiate early antenatal care (ANC).
Identify high-risk pregnancies.
Prevent complications (e.g., anemia, PIH, GDM).
Provide nutritional support (Iron, Folic acid).
Educate on birth preparedness and danger signs.

🌸 Diagnosis of Pregnancy

🔷 Definition:

Diagnosis of pregnancy is the process of determining whether a woman is pregnant through the identification of specific signs, symptoms, physical changes, laboratory tests, and imaging studies.

It helps to confirm pregnancy, determine gestational age, and initiate antenatal care at the earliest.

🔷 Importance of Diagnosing Pregnancy Early:

To confirm viable intrauterine pregnancy
To establish the Estimated Date of Delivery (EDD)
To begin early antenatal care (ANC)
To identify high-risk pregnancies
To educate the woman about pregnancy, nutrition, and danger signs

🔷 Categories of Signs Used for Diagnosis of Pregnancy:

The diagnosis of pregnancy is based on three categories of signs:

Category	Type of Sign
1️⃣ Presumptive Signs	Subjective symptoms reported by the woman
2️⃣ Probable Signs	Objective signs observed by the clinician
3️⃣ Positive Signs	Conclusive evidence of pregnancy

🔶 1️⃣ Presumptive Signs of Pregnancy

(These are not diagnostic because they may occur due to other conditions)

Sign/Symptom	Description
Amenorrhea	Absence of menstruation
Nausea/Vomiting	Common in early pregnancy (Morning sickness)
Breast changes	Tenderness, enlargement, darkened areola
Urinary frequency	Due to hormonal changes and pressure on bladder
Fatigue	General tiredness
Quickening	First fetal movement felt by the mother (16–20 weeks)
Food cravings or aversions	Altered taste preferences

🔸 These signs are suggestive but not confirmative.

🔶 2️⃣ Probable Signs of Pregnancy

(These are stronger indicators but not 100% reliable)

Sign	Description
Chadwick’s sign	Bluish discoloration of vaginal mucosa
Goodell’s sign	Softening of the cervix
Hegar’s sign	Softening of lower uterine segment
Enlarged abdomen	Due to growing uterus
Braxton Hicks contractions	Irregular painless uterine contractions
Positive urine pregnancy test (hCG detection)	Commonly used screening test
Ballottement	Rebounding of fetus when tapped per vagina

🔸 These signs may still occur in non-pregnant conditions (e.g., tumors, hormonal disorders).

🔶 3️⃣ Positive (Confirmative) Signs of Pregnancy

(These signs confirm pregnancy without doubt)

Sign	Method
Fetal heart sounds (110–160 bpm)	Heard via Doppler (10–12 weeks) or fetoscope (18–20 weeks)
Fetal movements felt by examiner	Palpated after 20 weeks
Ultrasound detection of gestational sac, fetal pole, or heartbeat	Transvaginal USG (5–6 weeks), Transabdominal (6–8 weeks)
X-ray (not preferred in pregnancy)	Used only in rare late cases where ultrasound not available

🔹 These signs are conclusive evidence of pregnancy.

🔷 Laboratory and Diagnostic Methods to Confirm Pregnancy:

✅ 1. Urine Pregnancy Test (UPT):

Detects hCG (Human Chorionic Gonadotropin) hormone.
Best done using first morning urine.
Positive as early as 6–10 days after conception.

✅ 2. Serum β-hCG Test (Blood Test):

More sensitive and quantitative.
Used in early pregnancy or in suspected ectopic pregnancy or molar pregnancy.
hCG levels double every 48–72 hours in normal early pregnancy.

✅ 3. Ultrasonography (USG):

Transvaginal USG: Detects gestational sac at 4.5–5 weeks, fetal heartbeat at 6–7 weeks.
Transabdominal USG: Visible sac and fetus from 6–8 weeks.
Most accurate method for early and definitive diagnosis.

🔷 Role of Nurse/Midwife in Diagnosis of Pregnancy:

Role	Responsibilities
Care provider	Perform UPT, assist with pelvic exam
Health educator	Educate on early signs, testing methods, and healthy habits
Counselor	Provide emotional support after confirmation
Communicator	Explain test results and coordinate follow-up
ANC Registrar	Register the mother for antenatal care services
Referrer	Refer high-risk or complicated cases to physician/specialist

🔷 Key Points to Remember:

Diagnosis ≠ Just testing – It includes full clinical judgment, history, and observation.
Urine test is usually the first step, but ultrasound gives final confirmation.
Misdiagnosis may occur in cases of pseudocyesis (false pregnancy), tumors, or hormonal imbalances.
Early diagnosis is crucial for safe motherhood, early interventions, and antenatal care.

🌸 Signs of Pregnancy.

🔷 Definition:

Signs of pregnancy are the observable changes in a woman’s body that suggest or confirm that she is pregnant. These are grouped based on their diagnostic reliability into presumptive, probable, and positive signs.

🔷 Classification of Signs of Pregnancy:

Category	Description	Diagnostic Value
1️⃣ Presumptive Signs	Felt by the woman herself	Least reliable
2️⃣ Probable Signs	Observed by a healthcare provider	More reliable
3️⃣ Positive Signs	Definitive signs confirming pregnancy	Absolutely reliable

🔶 1️⃣ Presumptive Signs of Pregnancy

(Subjective signs – experienced by the woman; not confirmative)

Sign	Description
Amenorrhea	Absence of menstruation (first and most common sign)
Morning sickness	Nausea and vomiting, usually during first trimester
Breast changes	Tenderness, enlargement, darkening of areola
Urinary frequency	Increased urination due to hormonal and uterine changes
Fatigue	Tiredness and low energy levels
Quickening	First perception of fetal movement (felt around 16–20 weeks)
Food cravings/aversions	Unusual desires or dislikes toward certain foods
Mood swings	Emotional instability due to hormonal changes

🔸 These signs can be caused by other conditions (stress, illness, hormonal imbalance), so they are not confirmative.

🔶 2️⃣ Probable Signs of Pregnancy

(Objective signs – observed by nurse/midwife; more suggestive but still not confirmative)

Sign	Description
Chadwick’s sign	Bluish coloration of the vaginal mucosa due to increased vascularity
Goodell’s sign	Softening of the cervix
Hegar’s sign	Softening of the lower uterine segment
Abdominal enlargement	Progressive increase in abdominal size due to growing uterus
Ballottement	Fetus rebounds when cervix is tapped during a vaginal exam
Braxton Hicks contractions	Irregular, painless uterine contractions felt after 16 weeks
Positive pregnancy test (UPT/serum hCG)	Detects presence of hCG hormone in urine or blood

🔸 These signs may still be present in conditions like uterine tumors, hormonal changes, or pseudocyesis (false pregnancy).

🔶 3️⃣ Positive (Confirmative) Signs of Pregnancy

(Absolutely confirm the presence of a fetus)

Sign	Detected by
Fetal heart sounds (FHS)	Heard using Doppler by 10–12 weeks or fetoscope by 18–20 weeks
Fetal movements felt by examiner	Palpated after 20 weeks
Ultrasound visualization of fetus	Gestational sac visible by 5–6 weeks; heartbeat by 6–7 weeks

✅ These signs are conclusive and can only occur in pregnancy.

🔷 Summary Table: Signs of Pregnancy

Category	Examples
Presumptive	Amenorrhea, nausea, breast tenderness, fatigue, quickening
Probable	Uterine enlargement, positive hCG test, cervical softening
Positive	Fetal heartbeat, fetal movements (felt by examiner), ultrasound findings

🔷 Role of Nurse/Midwife in Identifying Signs of Pregnancy:

Take complete history and assess signs and symptoms.
Perform physical examination and interpret findings.
Conduct and interpret UPT and lab investigations.
Refer for ultrasound for confirmation.
Provide health education and counseling based on gestational age.

🌸 Differential Diagnosis and Confirmatory Tests of Pregnancy.

🔷 Definition:

Differential diagnosis refers to the process of distinguishing pregnancy from other medical conditions that may mimic the signs and symptoms of pregnancy (especially in early stages).
Confirmatory tests are diagnostic tools used to definitively confirm pregnancy, especially when presumptive or probable signs are misleading or inconclusive.

🔶 Why is Differential Diagnosis Important?

Because presumptive and probable signs of pregnancy (e.g., missed periods, nausea, breast tenderness, abdominal enlargement) may also occur in other conditions.
It helps avoid misdiagnosis and ensures appropriate care.

🔷 Conditions Mimicking Pregnancy (Differential Diagnosis)

Condition	Reason it Mimics Pregnancy
Pseudocyesis (False pregnancy)	Emotional or psychological cause leads to signs of pregnancy without actual conception.
Uterine fibroids (leiomyoma)	Can cause abdominal enlargement, amenorrhea, and uterine mass.
Ovarian cysts/tumors	May mimic a growing abdomen and pelvic mass.
Ectopic pregnancy	Early pregnancy symptoms present, but implantation occurs outside the uterus (e.g., in fallopian tube).
Hormonal imbalance	Causes amenorrhea, breast tenderness.
Menopause	Irregular periods, hot flashes, mood swings can be mistaken for pregnancy signs.
Obesity	May lead to misinterpretation of abdominal enlargement.
Molar pregnancy (Hydatidiform mole)	Rapid uterine growth, positive hCG but no viable fetus.
Ascites or abdominal tumors	Cause visible and palpable abdominal enlargement.
Stress or psychological disorders	May alter menstruation and mimic other pregnancy signs.

🔷 Confirmatory Tests for Pregnancy

These are used to confirm or rule out pregnancy with certainty.

✅ 1. Pregnancy Test – Detection of hCG

Test Type	Description
Urine Pregnancy Test (UPT)	Detects hCG hormone in urine. Simple, quick, and used in clinics or at home. Becomes positive around 6–10 days after conception.
Serum β-hCG Test	More sensitive and quantitative than UPT. Detects very early pregnancy. Useful in suspected ectopic or molar pregnancy. Normal pregnancy shows doubling of hCG every 48–72 hrs in early weeks.

✅ 2. Ultrasonography (USG)

Type	Use
Transvaginal USG	Confirms pregnancy as early as 4.5–5 weeks (gestational sac), fetal heartbeat by 6–7 weeks.
Transabdominal USG	Visible gestational sac from 6–8 weeks. Used for dating pregnancy, fetal well-being, and ruling out ectopic/molar pregnancy.

🔹 Ultrasound is the gold standard for confirmatory diagnosis.

✅ 3. Clinical Examination Findings (Positive Signs)

Sign	Description
Fetal Heart Sounds (FHS)	Heard via Doppler (10–12 weeks), fetoscope (18–20 weeks)
Fetal movements felt by examiner	Palpable from around 20 weeks
Palpation of fetal parts	Done in 2nd and 3rd trimester during abdominal examination

✅ 4. Additional Investigations (in special cases)

Investigation	Purpose
TVS (Transvaginal Sonography)	To rule out ectopic pregnancy or confirm early intrauterine pregnancy
Complete Blood Count (CBC)	To assess anemia, infections
Thyroid Profile	To rule out hypothyroidism-related amenorrhea
Pelvic MRI/CT scan	In case of pelvic masses, suspected tumors (not routine)
Histopathological examination	For molar pregnancy diagnosis (grape-like vesicles on USG and high hCG levels)

🔷 Comparison Chart: Differential Diagnosis vs Confirmatory Tests

Aspect	Differential Diagnosis	Confirmatory Tests
Purpose	Rule out other conditions mimicking pregnancy	Prove the presence of an intrauterine fetus
Based on	Clinical signs, history, and other diseases	Hormone levels, imaging, fetal activity
Examples	Pseudocyesis, fibroid uterus, PCOD, molar pregnancy	UPT, serum hCG, ultrasound, fetal heart sounds
Outcome	Avoid misdiagnosis, treat other causes	Confirms viable pregnancy

🔷 Nurse/Midwife’s Role:

Role	Responsibility
Assessment	Identify presumptive, probable, and positive signs
Testing	Perform or assist in urine pregnancy test
Referral	Refer for ultrasound or specialist opinion if suspicious findings
Education	Inform client about interpretation of test results
Support	Emotional counseling in false pregnancy, abnormal pregnancy, or unexpected outcomes
Documentation	Record all findings accurately in ANC records

🌸 Review of Maternal Nutrition & Malnutrition.

🔷 Definition of Maternal Nutrition:

Maternal nutrition refers to the nutritional status of a woman before conception, during pregnancy, and after childbirth. It includes the intake of essential macronutrients (carbohydrates, proteins, fats) and micronutrients (vitamins and minerals) required to support the health of both the mother and the developing fetus.

🔷 Importance of Maternal Nutrition:

For Mother	For Fetus/Infant
Prevents anemia, infections, fatigue	Supports brain development
Reduces risk of pre-eclampsia and GDM	Prevents intrauterine growth retardation (IUGR)
Promotes healthy weight gain	Reduces risk of preterm birth, LBW
Aids postpartum recovery	Ensures adequate birth weight and organ formation

🔷 Daily Nutritional Requirements During Pregnancy:

Nutrient	Recommended Intake & Role
Energy	+300 kcal/day (extra in 2nd & 3rd trimester)
Protein	+23g/day; for tissue building, fetal growth
Iron	35–60 mg/day; prevent anemia, support blood volume
Folic Acid	400–600 mcg/day; prevent neural tube defects
Calcium	1000–1200 mg/day; fetal bones and teeth
Iodine	150 mcg/day; prevent cretinism, brain development
Vitamin A	Essential for vision and immunity (but excess is teratogenic)
Water	2.5–3 liters/day; to support increased blood volume and prevent dehydration

💊 Iron + Folic Acid (IFA) tablets are given as per national guidelines during pregnancy.

🔷 Balanced Diet for Pregnant Women:

Should include:

Cereals (rice, wheat, millets)
Pulses and legumes
Green leafy vegetables (iron, folate, calcium)
Fruits (vitamins, fiber)
Milk and dairy products (calcium, protein)
Meat, fish, eggs (if non-vegetarian)
Oils and fats (in moderation)
Water (adequate hydration)

🔷 Malnutrition in Pregnancy:

🔶 Definition:

Maternal malnutrition refers to deficiency or imbalance of essential nutrients in pregnant women. It includes undernutrition, micronutrient deficiencies, or overnutrition (obesity).

🔶 Types of Maternal Malnutrition:

Type	Features
Undernutrition	Low BMI (<18.5), low weight gain, fatigue
Micronutrient deficiencies	Iron, folic acid, iodine, vitamin A/D deficiency
Overnutrition/Obesity	Excessive weight gain, risk of GDM, hypertension

🔷 Effects of Malnutrition During Pregnancy:

➤ On the Mother:

Anemia
Weakness, fatigue
Increased susceptibility to infections
Pre-eclampsia, eclampsia
Postpartum hemorrhage
Delayed wound healing
Maternal mortality

➤ On the Fetus/Baby:

Intrauterine growth retardation (IUGR)
Low birth weight (LBW)
Preterm birth
Congenital anomalies (due to folate deficiency)
Stillbirth or neonatal death
Developmental delays
Poor immune function

🔷 Common Nutritional Deficiencies in Pregnant Women:

Nutrient Deficiency	Clinical Effects
Iron	Anemia, fatigue, poor oxygen supply
Folic acid	Neural tube defects, anemia
Calcium	Leg cramps, osteoporosis, preeclampsia
Iodine	Goiter, cretinism in newborn
Vitamin A	Night blindness, weak immunity
Vitamin D	Bone weakness, poor fetal bone growth
Protein	Edema, poor fetal tissue growth

🔷 Assessment of Maternal Nutrition:

Method	Parameters
Anthropometric	Weight, height, BMI, MUAC
Clinical examination	Pallor, edema, mouth/skin/nail changes
Dietary history	24-hour recall, food frequency
Lab investigations	Hb%, serum proteins, calcium, iron, etc.

🔷 Nutritional Interventions for Pregnant Women:

Iron-folic acid supplementation (IFA)
Deworming in 2nd trimester
Calcium tablets in 2nd & 3rd trimester
Nutrition education and counseling
Extra meal support (in ICDS/Anganwadi centers)
Monitoring weight gain during ANC visits
High-protein, high-calorie diet for undernourished women
Salt iodization for iodine intake

🔷 Government Programs Supporting Maternal Nutrition in India:

Program	Features
POSHAN Abhiyaan	National nutrition mission for pregnant and lactating mothers
ICDS (Integrated Child Development Scheme)	Provides supplementary nutrition, health check-up, education
Janani Suraksha Yojana (JSY)	Encourages institutional deliveries and maternal care
IFA Supplementation Guidelines	Under National Iron+ Initiative (NIPI)

🔷 Role of Nurse and Midwife:

Role	Activities
Educator	Teach about balanced diet, meal planning
Screening agent	Identify undernourished women during ANC
Counselor	Provide individualized diet advice
Supplement provider	Distribute IFA, calcium, deworming tablets
Referral	Send severe cases to dietician or specialist
Monitoring	Track weight gain, Hb%, dietary compliance
Advocate	Promote use of government nutrition schemes

🤝🌸 Building Partnership with Women Following RMC Protocol.

🔷 What is RMC?

RMC – Respectful Maternity Care is an approach that ensures women are treated with dignity, respect, and compassion during pregnancy, childbirth, and postpartum care. It is a fundamental human right and a key principle of quality maternal health care.

🔷 Definition of Building Partnership with Women:

Building partnership with women means establishing a mutual, trusting, respectful relationship between the health provider (nurse, midwife, doctor) and the woman. It involves collaborative decision-making, open communication, and the recognition of the woman’s rights, preferences, and values.

🔷 Principles of RMC (Respectful Maternity Care):

Based on White Ribbon Alliance’s Charter of Rights for Women and Newborns.

Freedom from harm and ill-treatment
Right to information, informed consent and refusal, and respect for choices
Confidentiality and privacy
Dignity and respect
Equitable care (non-discrimination)
Timely and quality care
Freedom from abuse and neglect
Right to companionship
Continuity of care

🔷 Steps in Building Partnership with Women under RMC Protocol:

🔶 1️⃣ Establishing Trust and Rapport

Greet the woman respectfully using her name.
Introduce yourself and your role.
Make her feel safe, valued, and comfortable.

🔶 2️⃣ Providing Complete Information

Explain all procedures in simple, understandable language.
Encourage questions and clarify doubts.
Use visuals or local language aids when needed.

🔶 3️⃣ Informed Consent and Shared Decision-Making

Always seek informed consent before examinations or interventions.
Respect her right to refuse or accept care.
Support her decisions regarding birth plan, pain relief, feeding, etc.

🔶 4️⃣ Maintaining Privacy and Confidentiality

Ensure privacy using curtains, screens, or private areas.
Do not discuss her personal health information publicly.
Handle her documents and reports confidentially.

🔶 5️⃣ Allowing Birth Companions

Encourage a supportive person (husband, mother, friend) to stay during labor and delivery, as per the woman’s preference.

🔶 6️⃣ Culturally Sensitive Care

Respect her cultural practices and values, as long as they do not harm her or the baby.
Adjust care plans to align with her beliefs when possible.

🔶 7️⃣ Empowering the Woman

Encourage her to express pain, ask for comfort, change positions during labor.
Support her participation in baby care and breastfeeding decisions.
Appreciate her role and effort during childbirth.

🔷 Nurse/Midwife’s Role in Building Partnership:

Role	Activities
Communicator	Use empathetic, non-judgmental communication
Advocate	Stand up for her rights and preferences
Educator	Teach her about her body, baby care, and options
Supporter	Offer emotional support during labor and postpartum
Protector	Prevent disrespect, discrimination, or abuse
Care Provider	Deliver safe, evidence-based care with kindness

🔷 Examples of RMC in Practice:

Situation	Respectful Care Approach
Woman asks about labor pain relief	Explain all options and allow her to choose
Woman from rural area feels shy	Speak gently, ensure female staff, maintain privacy
Woman wants to sit or walk in labor	Allow mobility unless medically contraindicated
Woman refuses a vaginal exam	Respect refusal, explain purpose, and seek consent again later
Woman cries or shows fear	Console, encourage, and offer continuous support

🔷 Benefits of Building Partnership with Women in Maternity Care:

For the Woman	For the Health System
Feels safe, respected, and confident	Higher satisfaction and institutional delivery rates
More likely to return for future care	Better maternal and newborn outcomes
Reduces birth trauma and depression	Builds community trust in health services
Improves cooperation and communication	Reduces staff burnout and conflict
Promotes positive childbirth experience	Encourages adherence to care recommendations

🔷 Barriers to Building Partnership:

Staff shortage or high workload
Lack of training in RMC
Poor infrastructure (privacy issues)
Cultural bias or judgmental attitudes
Language barriers

🔷 Overcoming Barriers – What Nurses Can Do:

Practice empathy and active listening
Participate in RMC training programs
Use IEC materials to explain procedures
Advocate for infrastructure improvements (e.g., screens for privacy)
Collaborate with community health workers (ASHA/ANM)

👨‍👩‍👧 Father’s Engagement in Maternity Care.

🔷 Definition:

Father’s engagement in maternity care refers to the active involvement of the male partner (father) in all phases of maternity — pre-conception, pregnancy, childbirth, and postnatal care — to promote the health and well-being of the mother, baby, and family.

🔷 Why is Father’s Engagement Important?

Benefits to Mother	Benefits to Baby	Benefits to Father
Emotional support, reduced stress	Better bonding, improved health	Builds attachment and confidence
Shared responsibility	Better breastfeeding outcomes	Promotes shared parenting
Encourages ANC visits	Lower neonatal morbidity	Improves relationship with partner
Decreased maternal depression	Safer delivery environment	Informed decision-making

🔷 Stages Where Father’s Engagement is Needed:

✅ 1. Pre-Conception Phase:

Family planning decisions
Health screening (e.g., STDs)
Discussing spacing between children
Supporting lifestyle changes (e.g., quitting tobacco)

✅ 2. Antenatal Period (ANC):

Attending ANC check-ups with the mother
Participating in health education sessions
Emotional support during pregnancy
Assisting in dietary and medication compliance
Helping with household chores to reduce maternal workload

✅ 3. Intra-Natal (Labour & Delivery):

Acting as a birth companion if permitted
Providing moral support during labor
Being present during normal delivery or C-section (where allowed)
Assisting in transport and logistics for institutional delivery

✅ 4. Postnatal Period (PNC):

Supporting mother in breastfeeding and rest
Helping with newborn care (bathing, changing, comforting)
Monitoring postpartum danger signs
Ensuring timely immunizations and PNC visits
Preventing postpartum depression through shared responsibility

🔷 Barriers to Father’s Engagement:

Cultural/Traditional	Practical	Systemic
Belief that maternity is “women’s domain”	Work responsibilities, time constraints	Lack of male-friendly hospital policies
Gender norms & stigma	Lack of awareness	No private space for fathers in labor rooms
Shyness or discomfort	Illiteracy	Poor communication from health workers

🔷 Strategies to Promote Father’s Engagement:

Strategy	Example/Activity
Health education	Conduct joint counseling sessions for couples during ANC
Birth preparedness sessions	Involve fathers in planning transport, hospital bag, birth plan
Male involvement campaigns	Community awareness using media, posters, videos
Policy support	Encourage health facilities to allow birth companions
Father-friendly spaces	Seating area and involvement in child immunization clinics
Role modeling	Encourage male CHWs or satisfied fathers to share experiences

🔷 Role of Nurses and Midwives in Promoting Father’s Engagement:

Role	Responsibilities
Educator	Explain the importance of male involvement in ANC, PNC
Facilitator	Welcome fathers during check-ups, encourage questions
Advocate	Promote respectful inclusion of men in birth preparedness
Supporter	Guide them in emotional and practical support to the mother
Bridge Builder	Reduce hesitation or cultural barriers between fathers and health staff
Record Keeper	Involve father’s contact in documentation for follow-up

🔷 Examples of Father Involvement Activities:

Husband attending health talks with wife at PHC
Partner providing daily iron/folic acid tablets at home
Father encouraging exclusive breastfeeding
Father accompanying mother during labor for emotional support
Sharing postnatal duties like baby’s immunization visits

🔷 National & Global Guidelines Promoting Father’s Engagement:

Guideline/Program	Provisions
RMNCH+A Approach (India)	Encourages male involvement in maternal and child health
WHO Recommendations	Promote birth companionship and family-centered care
National Population Policy	Advocates male participation in reproductive health
LaQshya Program (India)	Encourages birth companion of choice (including father)

🌸 Physiological Changes During Pregnancy.

🔷 Introduction:

Pregnancy is a physiological state, not a disease. To support the growth and development of the fetus, a woman’s body undergoes numerous changes across different systems. These changes are mainly influenced by pregnancy hormones such as estrogen, progesterone, hCG, hPL, and relaxin.

These changes begin as early as conception and continue until delivery and postpartum.

🔷 System-Wise Physiological Changes During Pregnancy:

✅ 1️⃣ Reproductive System Changes

a. Uterus

Increases in size from 50g (non-pregnant) to ~1000g at term
Capacity increases from 10 mL to ~5 liters
Shape changes from pear-shaped to ovoid
Increased blood flow (up to 500–800 mL/min at term)

b. Cervix

Softening (Goodell’s sign)
Bluish discoloration (Chadwick’s sign)
Increased mucus production → forms mucus plug (operculum)

c. Vagina and Vulva

Increased vascularity → bluish color
Increased vaginal secretions → leukorrhea

d. Ovaries

Ovulation stops
Corpus luteum secretes progesterone until placenta takes over (~12 weeks)

✅ 2️⃣ Endocrine System Changes

Gland	Change
Pituitary	Enlarges, increases prolactin secretion for milk production
Thyroid	Enlarges slightly; increased thyroid hormones (T3, T4)
Parathyroid	Increases → maintains calcium balance
Pancreas	Increased insulin production (to overcome insulin resistance from hPL)
Placenta	Acts as a temporary endocrine gland – secretes hCG, hPL, estrogen, progesterone

✅ 3️⃣ Cardiovascular System Changes

Change	Description
Blood volume	Increases by 40–50% → helps with uteroplacental perfusion
Cardiac output	Increases by 30–50%
Heart rate	Increases by 10–15 bpm
BP	Slight drop in 2nd trimester, returns to normal by term
Physiological anemia	Plasma volume increases more than RBC → hemodilution
Systolic murmur	May occur due to increased blood flow
Supine hypotension syndrome	Compression of inferior vena cava when lying flat

✅ 4️⃣ Respiratory System Changes

Change	Description
Oxygen demand	Increases by 20–30% to support fetal growth
Tidal volume	Increases by ~40%
Respiratory rate	Slightly increases or remains same
Shortness of breath	Common in late pregnancy due to upward displacement of diaphragm

✅ 5️⃣ Gastrointestinal (GI) System Changes

Change	Effect
Progesterone	Slows GI motility → constipation, bloating
Nausea and vomiting	Due to hCG (especially in 1st trimester)
Heartburn (pyrosis)	Due to relaxed lower esophageal sphincter
Ptyalism	Increased salivation
Gums	May become soft and bleed easily (gingivitis)

✅ 6️⃣ Urinary System Changes

Change	Description
Kidney size	Slightly increases to meet increased filtration needs
GFR (Glomerular Filtration Rate)	Increases by 50%
Urinary frequency	Due to increased blood flow and pressure on bladder
Risk of UTI	Increased due to urinary stasis and dilated ureters

✅ 7️⃣ Musculoskeletal System Changes

Change	Description
Relaxin hormone	Softens ligaments and joints for childbirth
Lordosis	Increased curvature of spine → back pain
Waddling gait	Due to relaxed pelvic joints
Leg cramps	Due to pressure on nerves, calcium/phosphate imbalance

✅ 8️⃣ Integumentary System Changes

Change	Description
Linea nigra	Dark line from pubic area to umbilicus
Striae gravidarum	Stretch marks (abdomen, breasts, thighs)
Melasma (Chloasma)	“Mask of pregnancy” – dark patches on face
Increased hair and nail growth	Due to hormonal changes
Sweat and oil glands	Become more active → acne, oily skin

✅ 9️⃣ Breast Changes

Change	Description
Breast enlargement	Due to estrogen and progesterone
Tenderness and tingling	Common early sign
Areola darkening and enlargement	Due to increased pigmentation
Montgomery’s tubercles	Small glands on areola become prominent
Colostrum	Yellowish pre-milk secretion from 16 weeks onward

✅ 🔟 Hematological Changes

Parameter	Change
Hemoglobin	May slightly decrease (due to hemodilution)
WBC count	Increases mildly (normal pregnancy leukocytosis)
Platelets	May decrease slightly
Coagulation factors	Increase → pregnancy is a hypercoagulable state (risk of thrombosis)

🔷 Psychological Changes

Trimester	Emotional State
First	Ambivalence, mood swings, anxiety
Second	Acceptance, increased body image awareness
Third	Impatience, anxiety about labor and baby’s health

🔷 Role of Nurse/Midwife in Managing Physiological Changes:

Role	Activities
Educator	Teach about normal changes and self-care
Counselor	Provide reassurance and emotional support
Health Promoter	Suggest diet, rest, and exercise for relief of discomforts
Care Provider	Monitor vitals, labs, and screen for complications
Referrer	Alert physician if changes indicate pathology (e.g., hypertension, bleeding)

🌸 Physiological Changes in the Reproductive System During Pregnancy.

🔷 Introduction:

During pregnancy, the reproductive system undergoes significant anatomical, hormonal, and functional changes to support implantation, fetal development, labor, and postpartum recovery. These changes are primarily driven by pregnancy hormones like estrogen, progesterone, hCG, relaxin, and hPL.

🔶 1️⃣ Uterus

Change	Description
Size and Weight	Uterus enlarges from 7.5 cm to ~30 cm; weight increases from 50 g to 1000 g by term.
Shape	Pear-shaped → spherical (early) → ovoid (late pregnancy).
Position	Rises out of the pelvis into abdominal cavity by 12–14 weeks.
Capacity	Increases from 10 mL to 5–10 liters.
Muscle hypertrophy	Myometrial cells enlarge and stretch, not multiply.
Blood supply	Increases up to 500–800 mL/min at term (90% goes to placenta).
Contractility	Braxton Hicks contractions (painless, irregular) begin ~2nd trimester – help tone the uterus.

🔶 2️⃣ Cervix

Change	Description
Softening	Known as Goodell’s sign – due to increased vascularity and hormonal effect.
Color change	Becomes bluish-purple due to increased blood flow – called Chadwick’s sign.
Glandular activity	Increases and forms a mucus plug (operculum) to seal cervical canal and protect fetus from infections.
Increased vascularity	Leads to edema, softening, and increased friability.

🔶 3️⃣ Vagina and Vulva

Change	Description
Increased vascularity	Bluish discoloration (part of Chadwick’s sign), congestion, and edema.
Softening of tissues	Due to estrogen and relaxin → allows stretching during delivery.
Increased vaginal discharge	Thick, white, non-foul smelling leukorrhea – protective but may increase infection risk if hygiene is poor.
Acidic pH	pH decreases (~3.5–6.0) due to increased lactic acid production – inhibits bacterial growth but favors Candida albicans (fungal infections).

🔶 4️⃣ Ovaries

Change	Description
Ovulation ceases	Suppressed due to high estrogen and progesterone levels.
Corpus luteum	Maintains early pregnancy by secreting progesterone until placenta takes over (~12 weeks).
No follicular development	Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels are suppressed.

🔶 5️⃣ Fallopian Tubes

Change	Description
Congestion and edema	Occur due to increased estrogen levels.
No active role after conception	Transported ovum reaches uterus in early pregnancy; after that, tubes are relatively inactive.

🔶 6️⃣ Breasts (Though not reproductive organs, they’re part of reproductive system functionally)

Change	Description
Enlargement and tenderness	Caused by estrogen and progesterone.
Increased blood flow	Veins become more prominent.
Darkening of areola and nipple	Due to increased melanocyte activity.
Montgomery’s tubercles	Sebaceous glands become prominent on the areola.
Colostrum production	Begins as early as 16 weeks (thick, yellow pre-milk).
Preparation for lactation	Prolactin from the anterior pituitary increases gradually.

🔷 Summary Table: Reproductive System Changes During Pregnancy

Organ	Key Changes
Uterus	Enlargement, increased blood flow, Braxton Hicks contractions
Cervix	Goodell’s sign, Chadwick’s sign, mucus plug
Vagina	Leukorrhea, acidic pH, increased elasticity
Ovaries	Corpus luteum sustains early pregnancy, no ovulation
Breasts	Enlargement, colostrum secretion, areolar changes

🔷 Clinical Significance of These Changes:

Helps in early diagnosis of pregnancy (Goodell’s and Chadwick’s signs).
Supports fetal growth and placental perfusion.
Prepares the body for labor, delivery, and postpartum lactation.
Nurses should differentiate normal physiological changes from pathological signs (e.g., infection vs leukorrhea).

🔷 Nurse/Midwife’s Role in Monitoring Reproductive Changes:

Role	Responsibilities
Educator	Explain normal changes and how to manage discomforts.
Examiner	Assess for cervical changes, vaginal discharge, uterine growth.
Care provider	Ensure maternal hygiene, prevent infections, provide supplements.
Counselor	Reassure women about body changes and address concerns.
Referrer	Identify abnormal findings (e.g., bleeding, abnormal discharge) and refer.

❤️ Cardiovascular System – Physiological Changes During Pregnancy.

🔷 Introduction:

During pregnancy, the cardiovascular system adapts significantly to meet the increased metabolic demands of the mother and the growing fetus. These changes begin early in pregnancy and peak in the second trimester, remaining until delivery.

They are mainly influenced by hormonal changes, especially estrogen, progesterone, relaxin, and increased blood volume.

🔷 Major Cardiovascular Changes in Pregnancy:

✅ 1️⃣ Blood Volume Increases

Parameter	Change
Total blood volume	Increases by 40–50% (approx. 1500 mL extra)
Plasma volume	Increases more than red cell mass → causes hemodilution
Red cell mass	Increases by ~20–30% with iron supplementation
Clinical effect	Leads to physiological anemia of pregnancy (Hb may drop to 10.5–11 g/dL)

✅ 2️⃣ Cardiac Output Increases

Parameter	Change
Cardiac output	Increases by 30–50% due to increased stroke volume and heart rate
Peak	Reaches peak around 20–24 weeks
Heart rate	Increases by 10–15 beats/min
Stroke volume	Increases due to increased preload (blood return)

✅ 3️⃣ Blood Pressure Changes

Parameter	Change
Systolic BP	May remain same or slightly decrease
Diastolic BP	Drops in second trimester (~10–15 mmHg), returns to normal by term
Reason	Due to vasodilation from progesterone and relaxin
Clinical Tip	Persistent rise in BP after 20 weeks may indicate pre-eclampsia

✅ 4️⃣ Vascular Resistance and Vasodilation

Feature	Description
Peripheral vascular resistance	Decreases due to progesterone and increased blood volume
Vasodilation	Leads to warm skin, nasal congestion, and sometimes dizziness

✅ 5️⃣ Heart Position and Sounds

Feature	Description
Heart displacement	Slightly upward and to the left due to enlarging uterus
Auscultation changes	May hear systolic murmurs or louder heart sounds – physiological and benign
ECG changes	May show left axis deviation or slight changes, usually normal

✅ 6️⃣ Supine Hypotension Syndrome (Aortocaval Compression)

Condition	Description
Cause	When lying flat in late pregnancy, the gravid uterus compresses inferior vena cava
Symptoms	Dizziness, pallor, hypotension, nausea, sweating, fainting
Management	Advise woman to lie in left lateral position to relieve pressure

✅ 7️⃣ Venous Circulation and Varicosities

Feature	Change
Venous pressure in lower limbs	Increases due to pressure from the uterus
Varicose veins	May appear in legs, vulva, or rectum (hemorrhoids)
Risk of thrombosis	Pregnancy is a hypercoagulable state due to increased clotting factors – risk of DVT and embolism

🔷 Summary Table: Cardiovascular Changes in Pregnancy

Parameter	Change During Pregnancy
Blood volume	↑ by 40–50%
Cardiac output	↑ by 30–50%
Heart rate	↑ by 10–15 bpm
Blood pressure	↓ in 2nd trimester, normal at term
Vascular resistance	↓ due to vasodilation
Murmurs	Systolic murmur may be heard
Clotting tendency	↑ (hypercoagulability)
Supine hypotension	Risk increases after 20 weeks

🔷 Clinical Significance:

Significance	Explanation
Early detection of preeclampsia	Monitor BP trends in each trimester
Iron supplementation	To prevent or correct physiological anemia
Avoid supine position	Especially in 3rd trimester – left lateral recommended
Monitor for varicose veins or thrombosis	Elevate legs, advise light exercise

🔷 Role of Nurse and Midwife:

Role	Responsibilities
Monitor vital signs	BP, HR, signs of anemia
Educate woman	About position changes, warning signs (e.g., dizziness, palpitations)
Assess for edema and varicose veins	Suggest support stockings and leg elevation
Check for signs of thrombosis	Leg pain, swelling, redness
Provide iron and folic acid	Prevent anemia
Emergency referral	If symptoms of pre-eclampsia or cardiac distress are seen

🌬️ Physiological Changes in the Respiratory System During Pregnancy.

🔷 Introduction:

During pregnancy, the respiratory system undergoes several physiological adaptations to meet the increased oxygen demands of both the mother and the growing fetus. These changes begin early in pregnancy and are influenced by hormones (especially progesterone and estrogen) and mechanical pressure from the growing uterus.

🔷 Goals of Respiratory Changes in Pregnancy:

To increase oxygen availability for the fetus
To remove excess carbon dioxide from the fetus through maternal lungs
To maintain acid-base balance
To adapt to mechanical changes in the thorax due to uterine enlargement

🔶 Major Respiratory Changes in Pregnancy:

✅ 1️⃣ Increased Oxygen Demand

Feature	Description
Oxygen consumption	Increases by 20–30%
Basal metabolic rate (BMR)	Rises due to fetal growth and maternal tissue metabolism
Reason	To supply oxygen to placenta, uterus, fetus, and maternal organs

✅ 2️⃣ Tidal Volume Increases

Parameter	Change
Tidal volume	Increases by ~40%
Minute ventilation	Increases by 30–50%
Respiratory rate	May slightly increase or remain unchanged
Alveolar ventilation	Increases due to deeper breathing

✅ 3️⃣ Chest and Diaphragm Adaptations

Feature	Change
Diaphragm elevation	Rises by ~4 cm due to enlarging uterus
Chest circumference	Increases by 5–7 cm
Rib cage expansion	Ribs flare outward due to relaxin and estrogen
Effect	Though the lungs are compressed, total respiratory function is maintained through increased efficiency of breathing

✅ 4️⃣ Respiratory Alkalosis

Change	Description
Progesterone effect	Acts as a respiratory stimulant on the respiratory center
Result	Leads to mild respiratory alkalosis (↓ PaCO₂) and increased pH
Clinical importance	Facilitates CO₂ removal from fetal to maternal blood via placenta (feto-maternal gas exchange)

✅ 5️⃣ Nasal and Upper Respiratory Tract Changes

Change	Description
Capillary engorgement	Nasal mucosa becomes more vascular and congested
Nasal stuffiness & epistaxis	Common complaints due to estrogen effects
Voice changes or snoring	May occur due to swelling in vocal cords or nasal passages

🔷 Summary Table: Respiratory Changes in Pregnancy

Parameter	Change
Oxygen consumption	↑ by 20–30%
Tidal volume	↑ by ~40%
Minute ventilation	↑ by ~50%
Respiratory rate	Slight ↑ or unchanged
Diaphragm position	Elevated by ~4 cm
Rib cage mobility	↑ due to hormone-mediated relaxation
Nasal mucosa	Congested → nasal stuffiness/bleeding
ABG (Arterial Blood Gas)	Mild respiratory alkalosis (↓ PaCO₂, ↑ pH)

🔷 Common Respiratory Discomforts During Pregnancy:

Discomfort	Cause
Shortness of breath (dyspnea)	Increased tidal volume and upward diaphragm displacement
Nasal congestion	Estrogen-induced mucosal swelling
Mild hyperventilation	Due to progesterone’s effect on respiratory center
Snoring	Weight gain and mucosal edema

📝 These symptoms are usually physiological and non-pathological, but they should be differentiated from respiratory diseases (e.g., asthma, pulmonary embolism).

🔷 Role of Nurse and Midwife:

Role	Responsibilities
Educator	Explain that shortness of breath is common and usually not dangerous
Reassurer	Reduce anxiety about breathing changes in pregnancy
Health Promoter	Encourage sleeping in propped-up or semi-Fowler’s position
Monitor	Observe for signs of respiratory distress, cyanosis, or abnormal breath sounds
Referrer	Refer to physician if breathlessness is sudden, severe, or associated with chest pain or cough

🔷 Clinical Alert Signs (Not Normal):

While most changes are physiological, watch for:

Persistent or worsening breathlessness
Tachypnea (>20 breaths/min)
Chest pain
Cough with sputum or blood
Cyanosis or wheezing
Signs of pulmonary embolism or asthma

🌊 Physiological Changes in the Urinary System During Pregnancy.

🔷 Introduction:

During pregnancy, the urinary system undergoes various structural and functional changes to accommodate the increased metabolic and circulatory demands of the mother and fetus. These changes are influenced by hormones (mainly progesterone and relaxin) and the mechanical pressure from the enlarging uterus.

🔷 Why Urinary Changes Are Important:

To eliminate increased waste products from the mother and fetus
To maintain fluid and electrolyte balance
To support plasma volume expansion
To adapt to mechanical compression from the gravid uterus

🔶 Key Structures Affected:

Kidneys
Ureters
Urinary bladder
Urethra

🔶 1️⃣ Kidney Changes

Feature	Change
Size	Slight increase in kidney length (by 1–1.5 cm)
Renal plasma flow (RPF)	Increases by ~50–70% in early pregnancy
Glomerular filtration rate (GFR)	Increases by ~40–50% → leads to more urine formation
Functional adaptation	Enhances clearance of urea, creatinine, and waste from fetus and mother
Serum urea/creatinine	Slightly lower than normal due to increased excretion
Mild glycosuria/proteinuria	May occur due to increased GFR → should be monitored to rule out gestational diabetes or pre-eclampsia

🔶 2️⃣ Ureteral Changes

Feature	Change
Dilation (Hydroureter)	Progesterone causes relaxation of smooth muscles → ureters become dilated, especially on the right side
Urinary stasis	Increased risk of urinary tract infections (UTIs) and pyelonephritis
Length and tone	Peristalsis decreases, ureters elongate and become tortuous

🔶 3️⃣ Bladder Changes

Feature	Change
Bladder capacity	May reduce due to pressure from the growing uterus
Increased frequency of urination	Especially in 1st and 3rd trimesters
Nocturia	Common in later pregnancy
Urinary incontinence	Can occur due to relaxed pelvic floor muscles and pressure on the bladder
Risk of infection	Stagnation of urine increases risk of cystitis and ascending infections

🔶 4️⃣ Urethral Changes

Feature	Change
Softening	Due to estrogen and progesterone
Lengthening	Urethra becomes slightly elongated due to bladder displacement
Increased sensitivity	May lead to burning sensation or frequency even without infection

🔷 Common Urinary Complaints in Pregnancy:

Complaint	Cause
Frequency	Enlarged uterus pressing on bladder
Urgency	Hormonal effects and pressure
Nocturia	Increased renal perfusion in lying position
Mild stress incontinence	Relaxed pelvic muscles and pressure
Burning micturition	May be due to infection or mucosal sensitivity
UTIs	Due to urinary stasis and dilated ureters

🔷 Clinical Significance:

Increased risk of asymptomatic bacteriuria, which can progress to pyelonephritis if untreated
Changes must be monitored to distinguish between normal physiology and pathology
UTIs during pregnancy can lead to preterm labor, low birth weight, and other complications

🔷 Urine Tests in Pregnancy Monitoring:

Test	Purpose
Routine urine examination	Check for albumin (protein), sugar, pus cells
Urine culture	For detecting asymptomatic or symptomatic infections
Proteinuria	Indicates risk of pre-eclampsia if persistent
Glycosuria	May suggest gestational diabetes – needs further evaluation

🔷 Nurse/Midwife’s Role in Urinary Care During Pregnancy:

Role	Responsibilities
Educator	Teach hygiene, hydration, and signs of UTI
Monitor	Observe urinary symptoms and perform regular urine testing
Care Provider	Encourage pelvic floor exercises to prevent incontinence
Referrer	Refer if there is persistent proteinuria, hematuria, or UTI symptoms
Health Promoter	Encourage at least 2.5–3 liters of fluid intake daily (unless contraindicated)

🔷 Self-Care Advice for Pregnant Women:

Drink plenty of water
Empty bladder regularly
Wipe front to back after urination
Avoid holding urine for long periods
Wear breathable, cotton underwear
Practice Kegel exercises to strengthen pelvic muscles

🍽️ Gastrointestinal System – Physiological Changes During Pregnancy.

🔷 Introduction:

During pregnancy, the gastrointestinal (GI) system undergoes multiple anatomical and functional changes to support fetal growth and adapt to hormonal and mechanical influences. These changes are primarily caused by:

Progesterone: Smooth muscle relaxant
Estrogen: Increases vascularity and affects liver function
Mechanical pressure from the enlarging uterus

🔷 Major Gastrointestinal Changes in Pregnancy:

✅ 1️⃣ Oral Cavity and Esophagus

Change	Description
Gingivitis & gum bleeding	Due to increased vascularity and estrogen effect (common in 1st trimester)
Ptyalism (excessive salivation)	Often seen in early pregnancy
Dental caries	May increase due to acid reflux and poor oral hygiene
Esophageal reflux (Heartburn/Pyrosis)	Caused by relaxation of lower esophageal sphincter and increased intra-abdominal pressure → allows gastric acid to reflux into esophagus

✅ 2️⃣ Stomach

Change	Description
Nausea and vomiting	Common in 1st trimester due to hCG and estrogen – called morning sickness
Delayed gastric emptying	Due to progesterone-induced smooth muscle relaxation
Increased risk of gastritis or reflux	Especially in later pregnancy due to pressure from the uterus

✅ 3️⃣ Intestines

Change	Description
Constipation	Due to decreased peristalsis and water absorption; worsened by iron supplements
Flatulence and bloating	Caused by slowed digestion and increased gas formation
Hemorrhoids (Piles)	Caused by constipation and increased pelvic pressure; common in 3rd trimester

✅ 4️⃣ Liver and Gallbladder

Organ	Change
Liver	No size change, but slight changes in liver enzyme levels (alkaline phosphatase ↑ due to placental production)
Gallbladder	Becomes hypotonic → bile stasis → risk of gallstones and cholestasis
Cholestasis of pregnancy	Causes itching (pruritus), especially on palms and soles; may affect fetal outcome

✅ 5️⃣ Appetite and Food Preferences

Change	Description
Increased appetite	Often from 2nd trimester onward
Food cravings and aversions	Common, possibly due to hormonal changes
Pica	Craving for non-food substances (e.g., clay, ice, chalk) – indicates iron/zinc deficiency

🔷 Common GI Symptoms in Pregnancy:

Symptom	Likely Cause
Morning sickness	hCG, estrogen
Constipation	Progesterone, iron
Heartburn	Relaxed LES and uterine pressure
Hemorrhoids	Constipation, pelvic pressure
Bloating	Slowed digestion
Nausea/Vomiting	1st trimester hormones
Excess salivation (ptyalism)	Increased estrogen
Itching (in cholestasis)	Bile stasis in liver

🔷 Clinical Significance:

Must differentiate between normal and abnormal (e.g., hyperemesis gravidarum = excessive vomiting with dehydration and weight loss)
Monitor for signs of liver dysfunction in cholestasis
Ensure nutritional adequacy despite nausea, vomiting, or food aversions

🔷 Nurse/Midwife’s Role in GI Care During Pregnancy:

Role	Activities
Educator	Teach dietary habits, hydration, iron-rich foods
Counselor	Reassure about symptoms like nausea, heartburn
Monitor	Assess bowel habits, weight gain, appetite
Referrer	In case of persistent vomiting, jaundice, or bleeding piles
Care provider	Suggest remedies for constipation, prescribe iron with stool softeners if needed

🔷 Self-Care Advice for GI Health in Pregnancy:

Eat small, frequent meals
Avoid spicy, oily, acidic foods
Drink plenty of water
Eat fiber-rich foods (fruits, vegetables, whole grains)
Avoid lying down immediately after meals
Practice gentle exercise or walking
Sit in a comfortable position while eating

🔷 When to Seek Medical Help:

Persistent vomiting with dehydration (hyperemesis gravidarum)
Constipation lasting >5 days
Severe or bleeding hemorrhoids
Intense itching (possible intrahepatic cholestasis)
Upper abdominal pain or jaundice

🔥 Metabolic Changes During Pregnancy.

🔷 Introduction:

Pregnancy is a hypermetabolic state. The body undergoes significant metabolic adaptations to:

Support fetal growth and development
Prepare the mother for labor, delivery, and lactation
Ensure survival during fasting or stress

These changes are driven by hormones such as hPL (human placental lactogen), progesterone, estrogen, cortisol, insulin, and thyroid hormones.

🔷 Key Metabolic Changes in Pregnancy:

✅ 1️⃣ Increased Basal Metabolic Rate (BMR)

Change	Description
BMR increases by 20–30%	Due to the increased energy needs of mother and fetus
Increased oxygen consumption	To meet fetal metabolic demands
Heat production rises	Pregnant women feel warm or may sweat more

✅ 2️⃣ Carbohydrate Metabolism

Trimester	Change
First trimester	↑ Insulin sensitivity → mild hypoglycemia in fasting state
Second & Third trimesters	Placental hormones (especially hPL) cause insulin resistance → ensures glucose is available to the fetus

🔹 The mother becomes slightly insulin-resistant in later pregnancy — this is physiological but may lead to gestational diabetes in some women.

✅ 3️⃣ Protein Metabolism

Feature	Description
Positive nitrogen balance	Promotes fetal tissue growth, uterus, breasts, placenta
Protein demand increases	Especially in 2nd and 3rd trimester for fetal development
Sources	Dietary protein and maternal stores are mobilized

✅ 4️⃣ Fat Metabolism

Stage	Change
Early pregnancy	Fat storage increases in maternal adipose tissues (estrogen & insulin effect)
Late pregnancy	Fat is mobilized to meet increased maternal energy demands and fetal needs
Increased lipolysis	Leads to higher levels of free fatty acids and triglycerides in maternal blood

🔹 This adaptation ensures glucose is reserved for the fetus while the mother uses fat as energy.

✅ 5️⃣ Mineral and Electrolyte Metabolism

Mineral	Change
Calcium	Increased absorption from the gut; needed for fetal bones & teeth
Iron	↑ requirement for fetal hemoglobin & maternal blood volume → risk of anemia if diet is inadequate
Sodium & Water	Retained → contributes to plasma volume expansion and physiological edema
Iodine	Needed for fetal brain development → deficiency may cause cretinism

✅ 6️⃣ Water Metabolism

Feature	Change
Fluid retention	↑ total body water by ~6–8 liters (plasma, amniotic fluid, tissues)
Edema	Common in feet and legs due to sodium retention and pressure on veins
Risk of dehydration	Despite fluid retention, increased demand means mother must stay hydrated

🔷 Summary Table: Metabolic Changes in Pregnancy

Type of Metabolism	Change
BMR	↑ by 20–30%
Glucose	↑ insulin resistance (2nd & 3rd trimester)
Protein	Positive nitrogen balance, increased demand
Fat	Early storage → late mobilization
Iron & calcium	Increased absorption and demand
Water	Retained → ↑ plasma volume, slight edema

🔷 Clinical Significance:

Gestational diabetes can develop due to insulin resistance
Nutritional counseling is essential to meet protein, iron, calcium, and calorie requirements
Anemia and hypoglycemia must be monitored, especially in undernourished women
Weight gain monitoring is important:
➤ Normal BMI women should gain 11–16 kg during pregnancy
Fluid intake and edema management are part of antenatal care

🔷 Role of Nurse/Midwife:

Role	Responsibilities
Educator	Teach about balanced diet and nutrient needs
Monitor	Weight gain, blood sugar, edema, anemia
Supporter	Provide emotional and dietary support
Care provider	Distribute iron, calcium, IFA tablets
Referrer	Refer for gestational diabetes screening if risk factors are present

🦴 Skeletal Changes During Pregnancy.

🔷 Introduction:

During pregnancy, the skeletal system undergoes various structural and postural changes to accommodate the growing fetus, support increased maternal weight, and prepare the body for labor and delivery. These changes are mostly due to the action of hormones such as relaxin, estrogen, and progesterone, and mechanical stress caused by the enlarging uterus.

🔷 Why Skeletal Changes Occur:

To allow enlargement of the uterus and abdominal cavity
To adjust posture and balance due to weight gain
To loosen joints and ligaments for childbirth
To support fetal nutrient requirements, especially calcium

🔶 Key Skeletal and Postural Changes During Pregnancy:

✅ 1️⃣ Postural Alterations

Change	Description
Lumbar lordosis	Increased inward curve of the lower back to balance the shifting center of gravity → leads to backache
Waddling gait	Due to relaxation of pelvic joints and ligaments
Forward tilting of pelvis	Uterus pulls the pelvis forward, changing alignment
Rounded shoulders	Caused by breast enlargement and posture compensation

✅ 2️⃣ Pelvic Joint and Ligament Softening

Change	Description
Relaxation of ligaments	Due to hormone relaxin → increases flexibility of pelvic joints
Sacroiliac joint loosening	Pelvic bones move slightly apart to prepare for delivery
Symphysis pubis widening	Slight separation of pubic symphysis (can cause pain and instability)
Benefit	Allows pelvis to expand during childbirth (facilitates vaginal delivery)

✅ 3️⃣ Calcium and Bone Metabolism

Change	Description
Increased calcium demand	For fetal bone and teeth formation
Maternal calcium absorption	↑ intestinal absorption of calcium under influence of vitamin D and parathyroid hormone
Bone density	May reduce temporarily if calcium intake is insufficient
Risk	In severe deficiency, maternal bones may demineralize → osteomalacia or bone pain

✅ 4️⃣ Rib Cage Expansion

Change	Description
Rib flare	Ribs widen outward and upward to allow lung expansion
Subcostal angle increases	From ~68° to 103°
Reason	Compensates for diaphragm elevation due to enlarged uterus

🔷 Common Skeletal Discomforts in Pregnancy:

Discomfort	Cause
Back pain	Due to increased lumbar lordosis and weight gain
Pelvic pain	Loosening of pelvic joints and pubic symphysis
Leg cramps	Possibly due to calcium/magnesium deficiency or nerve compression
Foot pain or flat feet	Due to relaxed ligaments and weight gain

🔷 Preventive & Supportive Measures:

Measure	Description
Posture correction	Sit and stand with back support, avoid high heels
Pelvic exercises	E.g., pelvic tilts, squats to strengthen back and pelvis
Calcium supplementation	As per ANC guidelines (usually 1000–1200 mg/day)
Light exercise	Walking, prenatal yoga to reduce stiffness and pain
Back support belts	For late pregnancy to relieve back pain
Avoid prolonged standing or sitting	To reduce musculoskeletal strain

🔷 Nurse/Midwife’s Role in Managing Skeletal Changes:

Role	Responsibilities
Educator	Teach posture, movement, and exercise techniques
Counselor	Reassure that mild discomfort is common and temporary
Care Provider	Recommend calcium and vitamin D supplements
Referrer	Refer for physiotherapy if severe back or pelvic pain
Supporter	Provide ergonomic tips during daily activities and work

🔷 Summary Table: Skeletal Changes in Pregnancy

Change	Effect
↑ Lumbar lordosis	Backache
↑ Joint laxity	Pelvic flexibility, waddling gait
↑ Symphysis pubis width	Pelvic pain, instability
Rib cage expansion	Aids respiratory adaptation
↑ Calcium requirement	Risk of deficiency if diet is poor

🌺 Skin Changes During Pregnancy.

🔷 Introduction:

Pregnancy brings about many cutaneous (skin) changes, most of which are physiological and caused by hormonal fluctuations, increased vascularity, and stretching of the skin due to the enlarging uterus and breasts.

These changes vary in intensity and visibility from woman to woman and are influenced by genetics, ethnicity, and skin type.

🔷 Causes of Skin Changes in Pregnancy:

Cause	Description
Hormones	Estrogen, progesterone, and melanocyte-stimulating hormone (MSH)
Increased blood volume	Causes vascular skin changes
Mechanical stretching	Leads to marks and thinning of skin
Immune changes	Can affect pre-existing skin conditions

🔶 Common Physiological Skin Changes During Pregnancy:

✅ 1️⃣ Pigmentation Changes

Skin Change	Description
Linea nigra	Dark vertical line from pubic area to umbilicus (or above); more prominent in darker-skinned women
Melasma (Chloasma/Mask of pregnancy)	Brown patches on cheeks, forehead, upper lip; triggered by sun exposure
Darkening of nipples, areola, genitalia	Due to increased melanin production
Nevi and freckles	May become darker or increase in size (should still be monitored for abnormal changes)

✅ 2️⃣ Striae Gravidarum (Stretch Marks)

Feature	Description
Appearance	Pink, red, or purple lines over abdomen, breasts, thighs, or buttocks
Cause	Skin stretching + breakdown of elastic tissue
When	Typically appear after 2nd trimester
After delivery	Fade to silvery or white lines over time (not completely disappear)

✅ 3️⃣ Vascular Changes

Change	Description
Spider angiomas	Small, red, spider-like blood vessels on face, neck, chest
Palmar erythema	Redness of palms due to estrogen effect
Varicose veins	In legs, vulva, or rectum (hemorrhoids) due to pressure and vascular congestion
Increased warmth of skin	Due to increased blood flow

✅ 4️⃣ Hair and Nail Changes

Change	Description
Hair growth	May increase due to estrogen (scalp, body hair); some may experience less hair fall during pregnancy
Hair loss after delivery	Common (called postpartum telogen effluvium) – usually temporary
Nails	May grow faster, become more brittle or soft

✅ 5️⃣ Sweat and Oil Gland Changes

Glands	Change
Sweat glands	More active → increased sweating (hyperhidrosis)
Sebaceous glands	↑ oil secretion → acne may worsen or improve
Montgomery’s tubercles	Enlarged sebaceous glands on areola – normal and protective for breastfeeding

✅ 6️⃣ Itching (Pruritus)

Cause	Description
Skin stretching	Common over abdomen, breasts
Hormonal changes	Can make skin drier or more sensitive
Intrahepatic cholestasis of pregnancy	A pathological cause; causes intense itching, especially on palms and soles → needs urgent medical attention

🔷 Summary Table: Skin Changes in Pregnancy

Type of Change	Examples
Pigmentation	Linea nigra, melasma, darkened nipples
Structural	Stretch marks, spider veins, varicose veins
Glandular	Increased sweating, oiliness, acne
Hair/Nail	Increased hair growth, faster nail growth
Other	Palmar erythema, Montgomery’s tubercles

🔷 Clinical Significance:

Most changes are harmless and temporary
Some may cause cosmetic concerns or discomfort
Important to differentiate normal changes from skin disorders (e.g., rashes, infections, or pregnancy-specific dermatoses)

🔷 Nurse/Midwife’s Role:

Role	Responsibilities
Educator	Reassure that skin changes are normal and usually fade postpartum
Supporter	Provide emotional support if woman feels self-conscious
Care Provider	Suggest safe skin care tips – moisturizers, mild cleansers, sun protection
Monitor	Watch for abnormal skin conditions like pruritic urticarial papules and plaques of pregnancy (PUPPP) or cholestasis-related itching
Referrer	Send to dermatologist if suspicious skin lesions, severe itching, or signs of allergy appear

🔷 Skin Care Advice During Pregnancy:

Use mild, non-irritating cleansers and moisturizers
Avoid harsh cosmetics or bleaching agents
Wear sunscreen to reduce melasma worsening
Apply cocoa butter or vitamin E lotions to improve skin elasticity (limited evidence, but may help)
Drink plenty of water
Use loose, breathable clothing to avoid sweat rash
Seek help if itching is severe or affecting sleep

🧬 Endocrine System Changes During Pregnancy.

🔷 Introduction:

The endocrine system plays a central role in pregnancy. It undergoes dramatic changes to support:

Fetal growth and development
Maternal adaptation
Labor, delivery, and lactation

Multiple hormonal glands either increase their activity or produce new hormones via the placenta.

🔷 Major Endocrine Glands Involved in Pregnancy:

Pituitary gland
Thyroid gland
Parathyroid gland
Pancreas
Adrenal glands
Placenta (temporary endocrine organ)

🔶 1️⃣ Pituitary Gland Changes

Hormone	Change & Function
Prolactin (from anterior pituitary)	↑ dramatically to prepare for lactation
Oxytocin (from posterior pituitary)	Stored for labor (uterine contractions) and milk ejection reflex
FSH & LH	↓ suppressed during pregnancy due to high estrogen & progesterone
ACTH & MSH	↑ mildly, contributing to skin pigmentation changes

🔶 2️⃣ Thyroid Gland Changes

Change	Description
Size	Slight enlargement (↑ vascularity and activity)
T3 and T4	↑ levels due to stimulation by hCG (especially in early pregnancy)
TSH	↓ mildly in 1st trimester; normalizes later
Function	Supports fetal brain development and maternal metabolism

🔸 Iodine requirement increases to meet fetal thyroid needs.

🔶 3️⃣ Parathyroid Gland Changes

Change	Function
Mild hypertrophy	↑ Parathyroid hormone (PTH) to regulate calcium levels
Ensures	Adequate calcium transfer to fetus (for bones and teeth)

🔶 4️⃣ Pancreatic Changes

Change	Description
Early pregnancy	↑ insulin sensitivity → may cause mild hypoglycemia
Later pregnancy (2nd–3rd trimester)	Insulin resistance increases due to hPL, estrogen, progesterone
Outcome	Maternal blood glucose ↑ → glucose available to fetus
Risk	Gestational diabetes in some women due to poor insulin compensation

🔶 5️⃣ Adrenal Gland Changes

Hormone	Change
Cortisol	↑ due to estrogen; helps in metabolism and stress response
Aldosterone	↑ to help in sodium and water retention → contributes to plasma volume expansion
Androgens (DHEA-S)	Secreted by fetal adrenal gland → converted to estrogen by placenta

🔶 6️⃣ Placenta as an Endocrine Organ

The placenta acts as a temporary endocrine gland and produces key pregnancy hormones:

Hormone	Function
hCG (human chorionic gonadotropin)	Maintains corpus luteum in early pregnancy; used in pregnancy tests
hPL (human placental lactogen)	Causes insulin resistance, mobilizes maternal fat for energy, promotes breast development
Estrogen	Stimulates uterine growth, breast changes, blood flow
Progesterone	Maintains uterine lining, prevents contractions, supports implantation
Relaxin	Softens ligaments and cervix for labor preparation

🔷 Summary Table: Endocrine Changes in Pregnancy

Gland	Hormonal Change	Function
Pituitary	↑ Prolactin, Oxytocin	Lactation, labor
Thyroid	↑ T3, T4	Metabolism, fetal brain development
Parathyroid	↑ PTH	Calcium regulation
Pancreas	↑ Insulin resistance	Glucose supply to fetus
Adrenal	↑ Cortisol, Aldosterone	Metabolism, fluid retention
Placenta	↑ hCG, hPL, Estrogen, Progesterone	Pregnancy maintenance

🔷 Clinical Significance:

Condition	Related Hormone
Gestational diabetes	hPL, insulin resistance
Pregnancy goiter / Hyperthyroidism symptoms	↑ thyroid hormones
Hypocalcemia in mother	High fetal calcium demand
Preterm labor	Imbalance in progesterone, oxytocin
Postpartum depression	Sudden drop in estrogen and progesterone after birth

🔷 Nurse/Midwife’s Role in Managing Endocrine Changes:

Role	Activities
Monitor	Weight, glucose levels, thyroid function, signs of hormonal imbalance
Educator	Teach about gestational diabetes, dietary management
Care provider	Ensure supplementation (e.g., iron, calcium, iodine)
Referrer	Suspected thyroid or endocrine disorders to endocrinologist
Supporter	Counsel about emotional and behavioral changes due to hormones

🧠🌸 Psychological Changes During Pregnancy.

🔷 Introduction:

Pregnancy is not only a physical journey but also a psychological and emotional transformation. A woman undergoes a wide range of mental, emotional, and behavioral changes as she adjusts to the demands of pregnancy, impending motherhood, and changes in identity, relationships, and life roles.

These changes are influenced by:

Hormones (estrogen, progesterone)
Social factors (family support, financial situation)
Previous pregnancy experiences
Cultural expectations

🔷 Phases of Psychological Adaptation During Pregnancy (Trimester-Wise)

✅ 1️⃣ First Trimester: “Ambivalence and Adjustment”

Emotional States	Description
Ambivalence	Mixed feelings – excitement, fear, disbelief, anxiety
Mood swings	Due to hormonal shifts (estrogen & progesterone)
Fatigue and irritability	Common, may feel overwhelmed
Concern about miscarriage	Common fear in early pregnancy
Body image awareness begins	Especially with nausea or bloating

✅ 2️⃣ Second Trimester: “Acceptance and Attachment”

Emotional States	Description
Better mood	Hormonal balance improves; physical discomforts lessen
Acceptance of pregnancy	Begins to feel more “real” as body changes and fetal movements begin
Fetal bonding starts	Talking to baby, imagining baby’s future
Feeling attractive or unattractive	Based on body changes and cultural norms
Focus shifts to baby and motherhood	Begins forming maternal identity

✅ 3️⃣ Third Trimester: “Preparation and Anticipation”

Emotional States	Description
Anxiety about labor	Worry about pain, complications, hospital stay
Fear of parenthood	Will I be a good mother? Can I manage everything?
Impatience and irritability	Due to physical discomfort, fatigue, restlessness
Increased dependence on partner/family	May need emotional and physical support
Nesting behavior	Urge to prepare home and surroundings for baby (common in late pregnancy)

🔷 Factors Influencing Psychological Response to Pregnancy:

Factor	Influence
Planned vs unplanned pregnancy	Planned = more acceptance; Unplanned = denial, stress
Support system	Partner and family support improve psychological well-being
Socioeconomic status	Financial insecurity → stress and anxiety
Age and maturity	Teen pregnancy may bring more confusion; older women may have more pressure
Past pregnancy experience	Previous miscarriage or complications → increased worry
Cultural beliefs and expectations	May affect emotional response and behaviors

🔷 Common Psychological Issues in Pregnancy:

Condition	Features
Anxiety	Worry about baby, labor, parenting, finances
Depression	Low mood, sleep disturbance, poor appetite, fatigue, hopelessness
Pregnancy denial	Rare; woman doesn’t acknowledge pregnancy
Obsessive thoughts	About baby’s health, cleanliness, safety
Fear of labor (Tokophobia)	Can affect decision on delivery method (e.g., request for elective C-section)

🔷 Role of Nurse and Midwife in Supporting Mental Health:

Role	Responsibilities
Observer	Watch for signs of depression, anxiety, fear, or emotional withdrawal
Counselor	Provide nonjudgmental emotional support and listening
Educator	Teach normal psychological changes and coping strategies
Supporter	Encourage involvement of family or birth partner
Referrer	Refer to mental health professional if needed
Advocate	Ensure privacy, respect, and dignity for the pregnant woman

🔷 Mental Health Screening Tools:

Used in ANC clinics to detect perinatal depression/anxiety:

Edinburgh Postnatal Depression Scale (EPDS)
PHQ-9 (Patient Health Questionnaire)
GAD-7 (for anxiety disorders)

🔷 Psychological Preparation for Childbirth:

Antenatal classes – to reduce fear and increase confidence
Breathing exercises & relaxation techniques
Involving birth partner in support
Clarifying doubts about labor and hospital stay
Empowering woman to make informed choices

🔷 Summary Table: Emotional Changes by Trimester

Trimester	Key Emotions
1st	Ambivalence, anxiety, mood swings
2nd	Acceptance, bonding, emotional stability
3rd	Fear, anticipation, restlessness

Ante-natal care: I Trimester.

🤰 Antenatal Assessment.

🔷 Introduction:

Antenatal assessment is the systematic evaluation of a pregnant woman during her pregnancy (antenatal period) to ensure the well-being of both the mother and fetus, identify risk factors or complications, and provide timely interventions. It is an essential component of antenatal care (ANC).

It includes physical, psychological, and laboratory assessments at regular intervals throughout pregnancy.

🔷 Aims of Antenatal Assessment:

Confirm and monitor progress of pregnancy
Identify high-risk pregnancies (e.g., diabetes, hypertension)
Monitor fetal growth and well-being
Educate and prepare the mother for childbirth
Prevent, detect, and manage complications early

🔷 Timing of Antenatal Visits (As per Indian Guidelines):

Visit	Time
1st visit	Within 12 weeks (preferably as soon as pregnancy is suspected)
2nd visit	Between 14–26 weeks
3rd visit	Between 28–34 weeks
4th visit	After 36 weeks (or more frequent if high-risk)

Minimum 4 visits are essential (WHO recommends 8 for better outcomes).

🔷 Components of Antenatal Assessment:

✅ 1️⃣ History Collection

a. Personal History

Name, age, address, education, occupation
Diet, lifestyle, substance use (smoking, alcohol)

b. Obstetric History (G-P-A-L)

Gravida, para, abortions, live births
Previous pregnancies, complications, mode of delivery

c. Menstrual History

Last menstrual period (LMP)
Expected date of delivery (EDD) using Naegele’s Rule: EDD = LMP + 9 months + 7 days

d. Medical & Surgical History

Hypertension, diabetes, tuberculosis, asthma
Previous surgeries (e.g., C-section, appendectomy)

e. Family History

Genetic disorders, twin pregnancies, diabetes

f. Psychosocial History

Support system, mental health, domestic violence

✅ 2️⃣ Physical Examination

Examination	Purpose
General Appearance	Nutritional status, hygiene, anemia signs
Height & Weight	Assess BMI, monitor weight gain
Pallor	Indicates anemia
Jaundice/Cyanosis	Suggest liver or heart disease
Edema	Common in feet (normal), face (warning sign)
Pulse & BP	Detect hypertension/pre-eclampsia
Respiratory rate	Monitor for breathlessness or infection
Breast Examination	For symmetry, lumps, and nipple readiness for breastfeeding

✅ 3️⃣ Abdominal Examination (from 16–20 weeks onward)

Step	Description
Inspection	Shape, size, striae, fetal movements
Palpation
– Fundal height: To assess fetal growth
– Leopold’s maneuvers: To determine lie, presentation, and position
Auscultation	Fetal Heart Sound (FHS) with fetoscope/Doppler (~120–160 bpm is normal)
Measurement	Fundal height in cm = roughly gestational age in weeks after 24 weeks

✅ 4️⃣ Pelvic Examination (if indicated)

Done in late pregnancy or when needed (e.g., bleeding, labor signs)
Assess pelvic adequacy, cervix condition

✅ 5️⃣ Laboratory Investigations

Test	Purpose
Hemoglobin (Hb%)	Detect anemia
Blood group & Rh	Prepare for complications like Rh incompatibility
Urine (Albumin/Sugar)	Screen for UTI, pre-eclampsia, diabetes
Blood sugar (FBS/PPBS or GCT)	Screen for gestational diabetes
HIV, HBsAg, VDRL	Screen for infections
Thyroid profile (TSH)	Screen for thyroid disorders
Ultrasound (USG)	Confirm gestational age, fetal anatomy, placental location

✅ 6️⃣ Fetal Assessment

Tool	Purpose
Ultrasound	Growth, amniotic fluid, anomalies
Fetal Heart Sound (FHS)	Reassure fetal well-being
Kick Count	Maternal monitoring of fetal movement (after 28 weeks)

10 kicks in 12 hours = normal

✅ 7️⃣ Health Education & Counseling

Topic	Importance
Nutrition	Balanced diet, iron/calcium-rich food
Rest and exercise	Importance of sleep, light physical activity
Danger signs	Bleeding, blurred vision, convulsions, severe headache
Personal hygiene	Vulval, breast care, clothing
Breastfeeding	Early initiation and exclusive breastfeeding
Birth preparedness	Transportation, delivery kit, place of delivery
Family support	Emotional and physical support from husband/family

🔷 Documentation in Antenatal Card / MCP Card (Mother-Child Protection Card)

All findings should be recorded systematically
Helps in continuity of care and decision-making during delivery

🔷 Nurse/Midwife’s Role in Antenatal Assessment:

Role	Responsibilities
Examiner	Conduct physical and abdominal exams
Monitor	Track vital signs, fetal growth, and well-being
Educator	Teach about nutrition, rest, hygiene, and danger signs
Counselor	Address anxiety, emotional needs, birth planning
Care provider	Provide supplements (IFA, calcium), TT immunization
Referrer	High-risk cases referred to medical officer or specialist

🔷 Danger Signs to Watch During ANC:

🚨 Immediate referral required if woman reports:

Vaginal bleeding
Severe abdominal pain
Swelling of face or hands
Severe headache or blurred vision
No fetal movement
Convulsions or fever

📝 History Taking During Antenatal Assessment.

🔷 Introduction:

History taking is the first and most crucial step in antenatal assessment. It involves systematically collecting relevant information about the pregnant woman’s past and present health, lifestyle, obstetric history, and risk factors. A thorough history helps in:

Identifying high-risk pregnancies
Planning individualized antenatal care
Establishing a trusting relationship with the mother

🔷 Objectives of History Taking:

To confirm pregnancy and calculate gestational age
To detect risk factors and complications
To assess maternal and fetal well-being
To plan further investigations and care
To educate and prepare the woman for safe motherhood

🔷 Components of Antenatal History Taking:

✅ 1️⃣ Identifying Data:

Information	Examples
Name	Full name of the woman
Age	In completed years
Address	For follow-up and home visits
Registration number	For hospital/clinic record
Religion & caste	May influence diet and beliefs
Marital status	Married/single/divorced
Date of registration	First antenatal visit date

✅ 2️⃣ Chief Complaints:

Ask the woman about any current symptoms (e.g.):

Missed periods
Nausea/vomiting
Breast tenderness
Fatigue
Vaginal discharge
Abdominal pain

Also ask if she has no complaints, to record well-being.

✅ 3️⃣ Menstrual History:

Element	Description
Age at menarche	Age at first period
Cycle regularity and duration	28-day cycle, 4–5 days bleeding?
Last menstrual period (LMP)	To calculate EDD (Expected Date of Delivery) using Naegele’s Rule
Any menstrual problems	Heavy flow, dysmenorrhea, irregular periods

✅ 4️⃣ Obstetric History (G-P-A-L)

Symbol	Meaning
G (Gravida)	Total number of pregnancies (including current)
P (Para)	Number of deliveries after 20 weeks
A (Abortions)	Number of spontaneous or induced abortions (<20 weeks)
L (Living children)	Number of currently living children

For each past pregnancy, ask about:

Year of delivery
Gestational age at delivery
Mode of delivery (normal/C-section)
Sex of baby and birth weight
Any complications (e.g., PPH, preeclampsia, stillbirth)

✅ 5️⃣ Medical and Surgical History:

Ask about:

Chronic illnesses: Hypertension, diabetes, asthma, epilepsy, tuberculosis, thyroid disorders
Previous surgeries: C-section, myomectomy, appendectomy, etc.
Allergies to drugs, food
Medications currently being taken

✅ 6️⃣ Family History:

Genetic diseases: Thalassemia, sickle cell, hemophilia
Multiple births (twins/triplets)
Diabetes, hypertension, epilepsy
History of maternal deaths, congenital anomalies in the family

✅ 7️⃣ Personal History:

Subsection	Includes
Dietary habits	Vegetarian/non-vegetarian, likes/dislikes, nutrition awareness
Appetite & sleep	Changes during pregnancy
Bowel and bladder	Constipation, urinary frequency
Addictions	Smoking, tobacco, alcohol (ask sensitively)
Occupation	Physical labor, workplace stress, exposure to chemicals
Exercise & rest	Routine activities and fatigue level
Travel history	Recent long journeys, malaria-endemic areas

✅ 8️⃣ Psychosocial and Emotional History:

Support from husband/family
Fear, anxiety, mood swings
History of domestic violence or stress
Willingness to continue the pregnancy
Cultural or spiritual beliefs about pregnancy

✅ 9️⃣ Immunization and Supplement History:

Item	Record
TT vaccination	Number of doses, date
Iron/Folic Acid intake	Duration, compliance
Calcium supplements	Ongoing or planned
Deworming (Albendazole)	Taken in 2nd trimester?

🔷 Documentation Tool: Antenatal/ANC Card or MCP Card

All findings should be documented in:

Antenatal card at health facility
Mother and Child Protection (MCP) card (India) for community tracking

🔷 Nurse/Midwife’s Role in History Taking:

Role	Responsibilities
Listener	Encourage open communication and trust
Observer	Note verbal and non-verbal cues
Recorder	Accurately document findings
Educator	Start health education based on findings
Referrer	Identify high-risk pregnancies for early referral

🔷 Red Flag Findings in History (High-Risk Indicators):

Previous C-section or complicated delivery
Chronic diseases (diabetes, hypertension)
History of stillbirth, miscarriage
Teenage (<18) or elderly (>35) pregnancy
History of multiple pregnancies
Bleeding or severe vomiting in current pregnancy
No antenatal checkups till 2nd trimester

👩‍⚕️ Physical Examination During Antenatal Assessment.

🔷 Introduction:

Physical examination during pregnancy is a systematic head-to-toe assessment of the expectant mother to evaluate her general health, detect physical changes, and monitor pregnancy progress. It helps in identifying high-risk conditions and ensures early interventions to promote safe motherhood and fetal well-being.

🔷 Objectives of Physical Examination:

To establish baseline health status
To detect signs of pregnancy and monitor progression
To screen for complications (e.g., anemia, hypertension, edema)
To assess maternal and fetal well-being
To provide a basis for further care and investigations

🔷 Preparation Before Examination:

Ensure privacy and good lighting
Use clean, disinfected equipment (e.g., stethoscope, BP apparatus, weighing machine)
Ask woman to empty bladder before abdominal exam
Position her comfortably on a flat surface (supine or semi-Fowler’s)
Ensure verbal consent and gentle approach

🔷 Components of Physical Examination:

✅ 1️⃣ General Appearance

Observation	What to Look For
General health	Alertness, posture, fatigue
Hygiene	Personal cleanliness
Body build	Thin, average, obese
Facial expression	Anxious, pale, puffy (could indicate anemia or pre-eclampsia)
Gait	Normal or waddling gait (in late pregnancy)

✅ 2️⃣ Vital Signs

Parameter	Normal Range & Importance
Temperature	Normal or low-grade rise in early pregnancy
Pulse	↑ 10–15 bpm is normal
Respiratory rate	Mild increase due to oxygen demand
Blood pressure	Should be <140/90 mmHg; elevated BP suggests pre-eclampsia

✅ 3️⃣ Height and Weight

Parameter	Use
Height	Short stature (<145 cm) may suggest cephalopelvic disproportion (CPD) risk
Weight	Monitor weight gain throughout pregnancy (normal gain: 11–16 kg for average BMI)

✅ 4️⃣ Skin and Mucosa

Observation	Significance
Pallor	Indicates anemia
Jaundice	May indicate liver disorder
Cyanosis	Suggests hypoxia
Edema	Normal in feet; facial or hand edema = warning sign
Skin pigmentation	Linea nigra, chloasma (normal)

✅ 5️⃣ Head-to-Toe Examination

🔸 Head and Scalp

Hair texture, dandruff, lice
Headaches → may indicate pre-eclampsia

🔸 Eyes

Pale conjunctiva → anemia
Blurred vision → possible pre-eclampsia
Pupil response, sclera (for jaundice)

🔸 Ears, Nose, Throat

Check for nasal congestion (common), throat infections

🔸 Mouth and Gums

Bleeding gums → due to estrogen
Oral hygiene status
Dental caries → risk of infection

✅ 6️⃣ Neck and Thyroid

What to Assess	Importance
Thyroid enlargement	Mild is normal; significant swelling suggests hyper/hypothyroidism
Neck nodes	Enlarged lymph nodes may indicate infection

✅ 7️⃣ Breast Examination

What to Check	Significance
Size, symmetry	Enlarges during pregnancy
Areola and nipple	Darkening, Montgomery’s tubercles (normal), inverted nipples (may affect breastfeeding)
Colostrum secretion	Begins ~16 weeks onward
Lumps or masses	Should be ruled out for breast conditions

✅ 8️⃣ Abdominal Examination (after ~16–20 weeks gestation)

Step	Purpose
Inspection	Look for size, shape, fetal movement, scars, stretch marks
Palpation	Fundal height (in cm ≈ gestational age in weeks after 24 weeks)
Leopold’s maneuvers to assess:
– Fundal presentation
– Fetal lie
– Position
– Engagement
Auscultation	Fetal heart sound (FHS): Normal = 120–160 bpm

✅ 9️⃣ Pelvic Examination (only when indicated)

Component	Use
Perineum	Check for hygiene, infections, varicosities
Vaginal exam	Performed in 3rd trimester or if complications arise (e.g., bleeding)
Assesses cervical effacement, dilation, and pelvic adequacy

✅ 🔟 Extremities and Spine

Observation	Significance
Edema	Pitting/non-pitting, localized or generalized
Varicose veins	In legs or vulva
Spinal curvature	Lordosis due to growing uterus
Clonus/reflexes	Hyperreflexia may suggest pre-eclampsia

🔷 Common Abnormal Findings to Monitor:

Finding	Possible Cause
Severe pallor	Moderate/severe anemia
Facial puffiness & hand swelling	Pre-eclampsia
High BP	Gestational hypertension
Absent FHS	Intrauterine fetal death
Excessive weight gain (>2 kg/month)	Risk of PIH or pre-eclampsia

🔷 Nurse/Midwife’s Role in Physical Examination:

Role	Responsibility
Assessor	Conduct the full head-to-toe and obstetric exam
Educator	Explain normal vs. warning signs to the woman
Supporter	Ensure privacy, comfort, and dignity during the exam
Referrer	Refer to medical officer if abnormal signs are detected
Recorder	Document all findings in ANC/MCP card accurately

🩺 Breast Examination During Pregnancy.

🔷 Introduction:

Breast examination is a vital part of the physical examination during pregnancy, as it helps to assess the mother’s readiness for breastfeeding, identify abnormal findings, and educate her on breast care and lactation.

Performed during antenatal visits (preferably early in pregnancy and again later), this examination also builds the foundation for successful early initiation of breastfeeding.

🔷 Objectives of Breast Examination:

Assess breast development and changes in pregnancy
Identify conditions that may affect breastfeeding (e.g., inverted nipples)
Detect any abnormalities, lumps, infections
Educate mother on breast hygiene and care
Promote confidence in breastfeeding and early lactation practices

🔷 Timing of Breast Examination:

Initial examination: During the first antenatal visit
Follow-up: During third trimester or if any complaints arise (pain, discharge, lumps)

🔷 Preparation for Breast Examination:

Explain the procedure to the woman and take verbal consent
Provide privacy and ensure a comfortable, warm room
Ask the woman to lie down or sit with her upper clothing removed
Ensure warm hands, clean gloves if needed

🔷 Steps of Breast Examination:

✅ 1️⃣ Inspection (Look)

Observe both breasts in the following positions:

Arms by the side
Hands on hips
Arms raised above the head

What to Look For	Significance
Size and symmetry	Mild asymmetry is normal; marked difference may need attention
Shape	Normal round/pendulous or flat
Skin changes	Redness, dimpling, shiny skin, peau d’orange (orange peel appearance = cancer suspicion)
Veins	May be more prominent in pregnancy (normal)
Areola and nipples	Darkening, enlargement (normal)
Montgomery’s tubercles	Raised sebaceous glands on areola – normal during pregnancy

✅ 2️⃣ Palpation (Feel)

Ask the woman to lie on her back with one arm behind her head.

Step	Description
Palpate each breast	Using flat fingers in a circular or up-down motion from outer to inner breast
Check all quadrants	Especially upper outer quadrant (common site of breast lumps)
Feel for lumps, masses	Note size, mobility, tenderness, borders
Check axillary (underarm) area	For lymph nodes (swollen nodes may indicate infection or malignancy)
Check nipple discharge	Squeeze gently – colostrum (thick yellow) may be seen after 16 weeks (normal)

Bloody or purulent discharge is abnormal

✅ 3️⃣ Assess Nipple Type:

Type	Effect on Breastfeeding
Normal/Protruding	Good for feeding
Flat	May need exercises/stimulation
Inverted	May make latching difficult → needs early correction

Test for Inverted Nipple (Pinch Test):
Gently pinch the areola – if nipple retracts inward → inverted nipple.

🔷 Common Normal Breast Changes During Pregnancy:

Change	Description
Breast enlargement	Due to hormonal effects (estrogen, progesterone, prolactin)
Areola darkening	Due to increased melanin
Increased tenderness	Especially in early pregnancy
Colostrum secretion	May start by 2nd trimester
Visible veins	Due to increased blood flow

🔷 Abnormal Findings to Report or Refer:

Hard, fixed lumps
Painful swelling or redness
Cracked, bleeding nipples
Discharge that is bloody or foul-smelling
Peau d’orange appearance
Rapid nipple retraction or ulceration

🔷 Breast Care Advice for Pregnant Women:

Advice	Purpose
Wash breasts daily with plain water	Keep nipples clean and infection-free
Avoid strong soaps or scrubbing	Prevent dryness and cracking
Wear a supportive cotton bra	Prevent sagging and reduce discomfort
Practice nipple rolling/stretching	For flat or inverted nipples (if needed)
Report any pain, lump, or discharge	Early detection of infection or issues
Learn about early initiation and exclusive breastfeeding	For successful lactation

🔷 Role of Nurse and Midwife:

Role	Responsibility
Examiner	Conduct proper and gentle breast exam
Educator	Teach about breast care and feeding techniques
Supporter	Prepare mother emotionally for breastfeeding
Referrer	In case of abnormal findings or feeding issues
Advocate	Promote early breastfeeding and skin-to-skin contact after birth

🧪 Laboratory Investigations During Pregnancy.

🔷 Introduction:

Laboratory investigations during pregnancy are a crucial part of antenatal care (ANC). They help in the early detection and management of medical, nutritional, and infectious conditions that may affect the health of the mother and fetus.

These tests are done during the first visit and repeated as per clinical need or protocol, especially in high-risk pregnancies.

🔷 Aims of Laboratory Investigations:

Confirm pregnancy and monitor progress
Detect anemia, infections, gestational diabetes, and Rh incompatibility
Assess renal, hepatic, and thyroid function if needed
Screen for congenital infections and STDs
Identify high-risk conditions early

🔷 Essential Lab Investigations During Pregnancy:

Test	Purpose / Interpretation

✅ 1️⃣ Hemoglobin (Hb%)

Detects anemia
Normal value in pregnancy: ≥11 g/dL
<11 g/dL → mild anemia, <7 g/dL → severe anemia

✅ 2️⃣ Blood Grouping and Rh Typing

Detects ABO and Rh incompatibility
If mother is Rh-negative and father is Rh-positive, risk of isoimmunization
May require anti-D immunoglobulin (Rhogam)

✅ 3️⃣ Urine Examination

a. Urine Routine & Microscopy

Check for albumin (proteinuria → may suggest pre-eclampsia)
Sugar (glycosuria → may suggest gestational diabetes)
Pus cells (UTI)

b. Urine Culture

If symptomatic or bacteriuria suspected
Important to prevent pyelonephritis or preterm labor

✅ 4️⃣ Blood Sugar Testing

a. Random Blood Sugar (RBS)
b. Fasting Blood Sugar (FBS)
c. Oral Glucose Tolerance Test (OGTT / GCT)

Done between 24–28 weeks
To screen for gestational diabetes mellitus (GDM)
Normal fasting sugar: <95 mg/dL; 2-hr post-glucose <140 mg/dL

✅ 5️⃣ VDRL Test (Venereal Disease Research Laboratory)

Detects syphilis (a sexually transmitted disease)
Positive cases are treated with penicillin to prevent fetal infection

✅ 6️⃣ HIV Test (with Pre- and Post-Counseling)

Mandatory under PPTCT (Prevention of Parent-To-Child Transmission) program
Helps plan ARV therapy and safe delivery if positive

✅ 7️⃣ HBsAg (Hepatitis B Surface Antigen)

To detect hepatitis B infection
Positive mothers → newborn must receive HBV vaccine + immunoglobulin at birth

✅ 8️⃣ Thyroid Function Test (TSH, T3, T4)

Especially important in areas with iodine deficiency or if symptoms present
Hypothyroidism → risk of fetal brain development issues
Normal TSH in first trimester: ~0.1–2.5 mIU/L

✅ 9️⃣ Sickling Test / Hemoglobin Electrophoresis

For detecting sickle cell anemia or thalassemia trait
Done if there’s family history or regional risk (tribal areas)

✅ 🔟 TORCH Screening (if indicated)

Includes testing for:

Toxoplasmosis
Others (Hepatitis B, Syphilis, HIV)
Rubella
Cytomegalovirus (CMV)
Herpes simplex virus

→ Only done if history of recurrent abortions, congenital anomalies, or IUGR

✅ 1️⃣1️⃣ COVID-19 Testing (As per current local guidelines)

🔷 Optional/Additional Tests (Based on Risk or Symptoms):

Test	Reason
Liver Function Test (LFT)	If cholestasis, jaundice, or pre-eclampsia suspected
Renal Function Test (RFT)	If hypertension, proteinuria
Serum Ferritin	If severe anemia
Ultrasound (USG)	Early dating scan, anomaly scan, fetal well-being
Pap Smear	If not done in last 3 years

🔷 When Are Tests Repeated?

Test	Frequency
Hemoglobin	At booking, 24–28 weeks, and 36 weeks
Blood sugar	Between 24–28 weeks or earlier if high-risk
Urine routine	Every ANC visit or monthly
HIV/VDRL/HBsAg	Once during pregnancy, or more if indicated

🔷 Nurse/Midwife’s Role in Lab Investigations:

Role	Responsibilities
Educator	Explain importance of tests to mother
Counselor	Provide pre/post-test counseling (HIV, VDRL)
Sample collector	Collect or assist in proper sample collection
Recorder	Document results in ANC card / MCP card
Referrer	Notify doctor if abnormal results are found
Follow-up	Ensure repeat testing or treatment as required

🔷 Documentation:

All test results must be recorded clearly in:

ANC Register
Mother and Child Protection (MCP) Card
Hospital or PHC Records

🔷 Summary Table: Key Lab Investigations

Test	Purpose
Hb%	Detect anemia
Blood Group & Rh	Identify incompatibility
Urine Routine	Detect protein, sugar, UTI
Blood Sugar (GCT/OGTT)	Screen for gestational diabetes
VDRL	Detect syphilis
HIV	For PPTCT management
HBsAg	Screen for hepatitis B
TSH	Assess thyroid function
USG	Confirm gestational age, anomalies

🤰🩺 Identification and Management of Minor Discomforts of Pregnancy.

🔷 Introduction:

During pregnancy, women experience a variety of minor physiological discomforts due to hormonal changes, anatomical adaptations, and mechanical pressure from the growing fetus.
These discomforts are common and usually not dangerous, but they can affect a pregnant woman’s quality of life, sleep, and emotional well-being.

Midwives and nurses must:

Identify them early
Provide non-pharmacological remedies
Educate the woman about normal vs. warning signs

🔷 Common Minor Discomforts of Pregnancy – Trimester-wise:

✅ 1️⃣ First Trimester Discomforts (0–12 weeks):

Discomfort	Cause	Management
Nausea and vomiting (morning sickness)	hCG, estrogen, gastric sensitivity	Small frequent meals, avoid spicy/oily foods, dry toast/crackers in morning, drink fluids between meals
Breast tenderness	Hormonal changes (estrogen, progesterone)	Wear supportive bra, avoid tight clothing
Frequent urination	Pressure of uterus on bladder	Encourage fluid intake; avoid caffeine; empty bladder regularly
Fatigue	Hormonal changes, increased BMR	Rest, adequate sleep, iron-rich diet
Mood swings	Hormonal changes, stress	Emotional support, relaxation techniques

✅ 2️⃣ Second Trimester Discomforts (13–28 weeks):

Discomfort	Cause	Management
Heartburn (acid reflux)	Relaxed LES (progesterone) + uterine pressure	Eat small meals, avoid lying flat after meals, avoid spicy/fried food, elevate head while sleeping
Constipation	↓ peristalsis, iron supplements	High-fiber diet, warm water, light exercise, stool softeners if prescribed
Flatulence/bloating	Hormonal + slow digestion	Avoid gas-forming foods, eat slowly, light walking
Backache	Weight gain, postural changes, lordosis	Good posture, pelvic tilt exercises, support belt, rest
Varicose veins	Increased venous pressure, hormones	Elevate legs, avoid prolonged standing, use support stockings
Skin changes (e.g., melasma, linea nigra, itching)	Increased melanin, estrogen	Reassurance, avoid harsh soaps, moisturize skin, sunscreen for melasma

✅ 3️⃣ Third Trimester Discomforts (29–40 weeks):

Discomfort	Cause	Management
Shortness of breath	Diaphragm pushed up by uterus	Sit upright, sleep with extra pillow, avoid tight clothes
Ankle/leg edema	Fluid retention, pressure on veins	Rest with legs elevated, avoid prolonged standing, hydration
Leg cramps	Mineral deficiency, poor circulation	Calf-stretching, massage, increase calcium & magnesium
Insomnia	Anxiety, discomfort	Sleep hygiene, warm bath before bed, left-side lying
Frequent urination	Fetal head pressing on bladder	Reassurance, fluid restriction at bedtime
Braxton-Hicks contractions	Uterine muscle practice	Normal unless regular/painful; rest, hydration, observe pattern
Hemorrhoids (piles)	Constipation, pelvic pressure	High-fiber diet, sitz bath, avoid straining, prescribed ointments

🔷 General Guidelines for Managing Discomforts:

Educate the mother on expected normal changes
Encourage healthy diet and hydration
Promote regular antenatal exercises
Emphasize personal hygiene and rest
Offer emotional reassurance and support
Identify when to refer (in case discomfort turns into danger sign)

🔷 Danger Signs Needing Referral (Not Minor Discomforts):

Symptom	May Indicate
Vaginal bleeding	Threatened abortion or placenta previa
Severe headache, blurred vision	Pre-eclampsia
Painful contractions before 37 weeks	Preterm labor
Decreased fetal movements	Fetal distress
Severe abdominal pain	Ectopic pregnancy or placental abruption
Persistent vomiting	Hyperemesis gravidarum

🔷 Role of Nurse and Midwife:

Role	Responsibility
Observer	Identify and assess discomforts
Educator	Teach self-care, posture, nutrition, warning signs
Supporter	Provide emotional reassurance
Care provider	Give remedies, monitor response
Referrer	If symptoms worsen or danger signs appear

🤰🗣️ Antenatal Care and Counseling (Lifestyles in Pregnancy).

🔷 Introduction:

Antenatal care (ANC) is the care provided to a pregnant woman from the time of conception until the onset of labor. It includes routine checkups, screening, health education, counseling, and support to ensure the well-being of both mother and fetus.

A major part of ANC is counseling the mother about healthy lifestyle practices, which helps in preventing complications, promoting positive pregnancy outcomes, and empowering women to take charge of their health.

🔷 Objectives of Antenatal Care and Lifestyle Counseling:

Promote healthy behavior during pregnancy
Prevent maternal and fetal complications
Ensure proper fetal growth and development
Educate women about pregnancy changes and self-care
Prepare the woman for labor, delivery, breastfeeding, and motherhood
Detect and manage high-risk conditions early

🔷 Core Components of ANC Counseling on Lifestyle in Pregnancy:

✅ 1️⃣ Nutrition and Diet Counseling

Aspect	Counseling Tips
Balanced diet	Teach about including cereals, pulses, vegetables, fruits, dairy, meat (if non-veg), and healthy fats
Calorie intake	Increase by ~300 kcal/day in 2nd and 3rd trimesters
Protein	Minimum 60–70 gm/day; crucial for fetal growth
Iron & Folic acid	Promote iron-rich foods (green leafy veg, jaggery, dates); counsel on IFA tablets (100 mg iron + 0.5 mg folic acid)
Calcium	Advise calcium-rich foods and supplements
Hydration	At least 8–10 glasses/day
Avoid	Junk food, excess salt/sugar, unpasteurized dairy, raw meat, and caffeine

✅ 2️⃣ Rest, Sleep, and Physical Activity

Aspect	Counseling Tips
Rest	Minimum 8 hours of night sleep + 1–2 hrs of daytime rest
Position	Encourage left-side lying in later pregnancy for better uterine blood flow
Exercise	Moderate walking, antenatal yoga, pelvic tilts; avoid heavy lifting or risky activities
Avoid prolonged standing or sitting	Encourage position changes, stretching

✅ 3️⃣ Personal Hygiene

Aspect	Counseling Tips
Daily bathing	To prevent skin infections, maintain cleanliness
Genital hygiene	Use clean, dry undergarments; wipe front to back
Breast care	Gentle cleaning with water, avoid harsh soaps, wear supportive bras
Oral hygiene	Brush twice daily, dental check-up if needed
Hair and nails	Keep clean and trimmed

✅ 4️⃣ Clothing and Footwear

Aspect	Counseling Tips
Clothing	Loose, breathable cotton clothes; avoid tight wear
Footwear	Low-heeled, non-slippery shoes; avoid heels and tight shoes to reduce fall risk and swelling

✅ 5️⃣ Sexual Activity

Advice	Counseling Tips
Safe in normal pregnancy	With comfortable positions and hygiene
Avoid	If history of miscarriage, bleeding, placenta previa, or ruptured membranes

✅ 6️⃣ Avoidance of Harmful Substances

Substance	Counseling Message
Tobacco	Increases risk of low birth weight, miscarriage, stillbirth
Alcohol	Can cause fetal alcohol syndrome (mental & physical defects)
Drugs	Avoid self-medication; many are teratogenic
Caffeine	Limit tea/coffee to <2 cups/day

✅ 7️⃣ Mental and Emotional Health

Counseling Focus	Tips
Emotional changes are normal	Due to hormones, body changes
Encourage family support	Especially from husband
Teach stress management	Deep breathing, meditation, rest
Identify signs of depression/anxiety	Refer if needed

✅ 8️⃣ Immunization Advice

Vaccine	When
Tetanus & Diphtheria (TT/TD)	2 doses: First as early as possible, second after 4 weeks
COVID-19 vaccine (as per policy)	If not completed earlier
Influenza vaccine (if recommended)	To protect mother and newborn

✅ 9️⃣ Supplementation Counseling

Supplement	Advice
Iron & Folic Acid (IFA)	1 tablet daily after 1st trimester for 180 days
Calcium	2 tablets daily from 2nd trimester onwards
Deworming	Albendazole 400 mg once after 12 weeks if indicated

✅ 🔟 Travel and Work Advice

Topic	Counseling Tips
Travel	Avoid long, bumpy rides; use seat belts below the belly
Work	Safe to work unless complications; avoid standing too long or heavy lifting
Maternity leave	Explain benefits and legal rights

✅ 1️⃣1️⃣ Danger Signs Counseling

Educate about warning signs that require immediate medical attention:

🚨 Red flags:

Vaginal bleeding
Severe headache or blurred vision
Convulsions
Fever
Severe abdominal pain
Reduced fetal movement
Swelling of hands/face

🔷 Role of Nurse/Midwife in Counseling:

Role	Responsibility
Educator	Provide accurate lifestyle and health education
Supporter	Offer emotional reassurance
Advocate	Promote healthy practices in home and community
Communicator	Use culturally sensitive, easy-to-understand language
Referrer	Identify and refer for special counseling or complications

🥗🤰 Nutrition in Pregnancy.

🔷 Introduction:

Nutrition during pregnancy plays a crucial role in ensuring the health of the mother and fetus. Adequate and balanced nutrition promotes:

Normal fetal growth and development
Reduced complications in pregnancy and childbirth
Enhanced maternal strength and postpartum recovery
Better outcomes in lactation and newborn health

Pregnant women have increased needs for energy, proteins, vitamins, and minerals, especially in the 2nd and 3rd trimesters.

🔷 Goals of Nutrition in Pregnancy:

Ensure appropriate weight gain
Prevent anemia, low birth weight, and congenital defects
Maintain maternal immunity and energy
Prepare for breastfeeding
Prevent nutritional deficiencies and malnutrition

🔷 Daily Nutritional Requirements During Pregnancy:

Nutrient	Recommended Increase	Sources
Calories	+300 kcal/day (2nd & 3rd trimester)	Cereals, pulses, dairy, fruits
Protein	60–70 g/day	Milk, eggs, meat, legumes, soy, paneer
Iron	40–60 mg/day	Green leafy vegetables, dates, jaggery, liver, IFA tablets
Folic Acid	0.5 mg/day	Leafy greens, nuts, citrus fruits, supplements
Calcium	1200–1500 mg/day	Milk, curd, cheese, ragi, sesame
Iodine	250 mcg/day	Iodized salt, seafood
Vitamin A	800 mcg/day	Carrots, mango, pumpkin, liver
Vitamin C	80 mg/day	Amla, citrus fruits, tomatoes
Zinc	12 mg/day	Whole grains, meat, nuts

🔷 Weight Gain in Pregnancy:

Pre-pregnancy BMI	Recommended Weight Gain
Underweight (<18.5)	12.5–18 kg
Normal (18.5–24.9)	11.5–16 kg
Overweight (25–29.9)	7–11.5 kg
Obese (>30)	5–9 kg

🔸 Weight gain should be gradual:

~1–2 kg in 1st trimester
~0.5 kg/week in 2nd and 3rd trimesters

🔷 Principles of Healthy Eating During Pregnancy:

Eat a balanced diet including all food groups
Include small frequent meals (5–6 times/day) to avoid nausea and heartburn
Drink at least 8–10 glasses of water per day
Avoid skipping meals, especially breakfast
Choose fresh, home-cooked food
Ensure clean and safe food handling to avoid infections

🔷 Special Considerations:

Condition	Dietary Advice
Nausea/Vomiting	Dry crackers, small meals, avoid spicy/fatty foods
Constipation	High fiber diet, fruits, vegetables, warm water
Heartburn	Small frequent meals, avoid lying down after eating
Vegetarians	Ensure protein from pulses, soy, nuts, dairy
Underweight mothers	High-energy snacks: banana, nuts, peanut butter
Overweight mothers	Avoid junk food, sweets; opt for light, low-fat meals

🔷 Foods to Encourage:

✅ Whole grains
✅ Leafy greens (spinach, fenugreek)
✅ Milk and milk products
✅ Seasonal fruits (banana, papaya, guava, orange)
✅ Eggs, fish, lean meat
✅ Nuts and seeds (almonds, sesame, flax)

🔷 Foods to Avoid:

🚫 Raw/undercooked meat, eggs
🚫 Unpasteurized milk or cheese
🚫 Excess caffeine (>2 cups/day)
🚫 Alcohol, smoking, tobacco
🚫 Junk/fast food, excess salt/sugar
🚫 Papaya and pineapple in early pregnancy (controversial; better to avoid)

🔷 Iron and Folic Acid Supplementation:

As per Indian guidelines:

IFA tablets: 1 tablet daily after 1st trimester (100 mg elemental iron + 0.5 mg folic acid) for 180 days
Continue post-delivery for 180 days more
Take after meals with water (not tea/milk)

🔷 Calcium Supplementation:

2 tablets/day of 500 mg calcium from 2nd trimester onward
Taken separately from iron tablets (e.g., iron in morning, calcium at night)

🔷 Nutrition Education by Nurse/Midwife:

Role	Responsibilities
Educator	Explain nutritional needs and healthy food choices
Counselor	Handle food taboos, cultural practices, poor appetite
Motivator	Encourage compliance with supplements
Observer	Monitor weight gain, signs of deficiency
Referrer	For nutritionist support if severely undernourished or obese

🔷 Pregnancy Nutrition Counseling Tips:

🔹 Use the “Rainbow plate” concept – variety of colors = variety of nutrients
🔹 Involve family members in counseling for better support
🔹 Address myths and misconceptions (e.g., “eat for two”)
🔹 Explain importance of exclusive breastfeeding preparation.

🤝 Shared Decision-Making (SDM) in Antenatal and Maternity Care.

🔷 Introduction:

Shared Decision-Making (SDM) is a collaborative process in which the pregnant woman and the health care provider (nurse, midwife, or doctor) work together to make decisions about her care, based on:

The best available medical evidence,
The woman’s preferences, values, needs, and
Her individual context (social, emotional, cultural).

It empowers women to actively participate in their pregnancy care and strengthens respectful maternity care (RMC).

🔷 Definition:

Shared decision-making is a patient-centered approach where clinical decisions are made jointly by the health care provider and the pregnant woman, taking into account both clinical evidence and the woman’s informed preferences.

🔷 Key Principles of SDM:

Respect for woman’s autonomy
Two-way communication
Mutual respect and trust
Informed choice with unbiased information
Partnership in care planning

🔷 Steps of Shared Decision-Making:

Step	Description
1. Introduce Choice	Let the woman know she has a say in her care (e.g., “There are different options available…”)
2. Explain Options	Present risks, benefits, alternatives in simple language
3. Explore Preferences	Ask about her values, fears, expectations (e.g., natural birth vs. C-section)
4. Support Decision	Guide without pressure; use visuals, pamphlets if needed
5. Confirm and Plan	Respect her choice, document it, and develop a care plan together

🔷 Examples of Shared Decision-Making in Maternity Care:

Situation	Choices Involved
Birth Plan	Natural birth, epidural, water birth, home vs. hospital
Mode of Delivery	VBAC (vaginal birth after cesarean) vs. elective C-section
Pain Relief	Breathing exercises, epidural, TENS, natural methods
Labor Induction	Induction vs. expectant management
Feeding Options	Breastfeeding vs. formula (if medical issues)
Vaccinations	COVID-19 or influenza vaccine in pregnancy
Antenatal Testing	Whether or not to do non-invasive prenatal testing (NIPT), amniocentesis

🔷 Benefits of Shared Decision-Making:

✅ Increases maternal satisfaction and trust
✅ Improves compliance with care
✅ Reduces anxiety and fear
✅ Respects cultural and personal values
✅ Builds partnership and respectful care
✅ Helps in risk understanding and realistic expectations

🔷 Barriers to SDM in Maternity Care:

Barrier	Solution
Low literacy or language barriers	Use pictures, interpreters, simple words
Power imbalance	Midwife must create a safe, respectful space
Lack of time in busy OPDs	Prioritize key decisions, schedule follow-up
Cultural factors	Respect beliefs while gently explaining evidence
Provider bias	Stay neutral and avoid judgment in counseling

🔷 Role of Nurse/Midwife in SDM:

Role	Responsibilities
Educator	Provide clear, unbiased information about all options
Facilitator	Create a respectful, open environment
Supporter	Encourage questions, validate concerns
Advocate	Ensure woman’s choice is respected by the team
Communicator	Document decisions in ANC card or birth plan
Empowerer	Help woman understand her rights and voice them confidently

🔷 Tools to Support SDM:

Decision aids (charts, comparison tables)
Visual guides (infographics, videos)
Printed leaflets or booklets
Birth plan templates
Checklists for preferences

⚠️ Risky Behaviors in Pregnancy.

🔷 Introduction:

Certain lifestyle behaviors or exposures during pregnancy are considered risky because they can harm the mother, fetus, or both. These behaviors increase the chances of complications such as miscarriage, birth defects, preterm labor, low birth weight, and even stillbirth.

Midwives and nurses play a vital role in identifying, counseling, and supporting women to avoid or stop such behaviors during antenatal care.

🔷 Definition:

Risky behaviors in pregnancy are actions, habits, or exposures that negatively impact maternal and fetal health and increase the risk of poor pregnancy outcomes.

🔷 Common Risky Behaviors During Pregnancy:

✅ 1️⃣ Smoking (Tobacco Use)

Impact	Effects
🚬 Smoking (cigarettes, bidi, hookah) or chewing tobacco	Causes intrauterine growth restriction (IUGR), placental abruption, low birth weight, preterm labor, stillbirth, sudden infant death syndrome (SIDS)
🔹 Passive smoking is also harmful
🔸 Reduces oxygen supply to fetus due to carbon monoxide exposure

✅ 2️⃣ Alcohol Consumption

Impact	Effects
🍷 Even small amounts of alcohol during pregnancy are unsafe
May cause Fetal Alcohol Spectrum Disorders (FASD):
– Mental retardation
– Facial deformities
– Behavioral issues
Leads to miscarriage, stillbirth, poor neurodevelopment

✅ 3️⃣ Illicit Drug Use

Drugs	Possible Effects
Cocaine, heroin, marijuana, methamphetamine	Miscarriage, premature birth, low birth weight, neonatal withdrawal syndrome (NAS), congenital anomalies, stillbirth
May also cause placental abruption, poor bonding, and neonatal addiction

✅ 4️⃣ Excessive Caffeine Intake

Risk	Recommendation
High caffeine (>200 mg/day) linked to miscarriage, low birth weight
Limit to 1–2 cups of tea/coffee per day

✅ 5️⃣ Unsafe Sexual Practices

Behavior	Risk
Unprotected sex with multiple partners	Increases risk of STIs (HIV, Syphilis, Hepatitis B) that can be transmitted to fetus
Can lead to premature rupture of membranes, miscarriage, congenital infections

✅ 6️⃣ Poor Nutrition or Eating Disorders

Risk	Effect
Skipping meals, crash dieting, eating junk food	Leads to nutrient deficiencies, anemia, poor fetal growth
Eating disorders (anorexia, bulimia) worsen pregnancy outcomes

✅ 7️⃣ Self-medication and Use of Unsafe Drugs

Issue	Effect
Taking unprescribed medicines or herbal drugs	May cause birth defects, miscarriage
Some antibiotics, acne meds, painkillers (e.g., NSAIDs) are teratogenic

✅ 8️⃣ Exposure to Environmental Hazards

Risk	Examples
Chemical exposures at work or home (e.g., pesticides, paint, cleaning agents)	May affect fetal brain development, cause miscarriage
Radiation (X-rays) in early pregnancy	Can lead to congenital anomalies if unprotected

✅ 9️⃣ Sedentary Lifestyle / Lack of Physical Activity

Impact	Risk
Leads to excessive weight gain, gestational diabetes, back pain, poor circulation
Moderate activity like walking or prenatal yoga is encouraged

✅ 🔟 Stress and Mental Health Neglect

Risk	Effects
Chronic stress, anxiety, depression	Increases risk of preterm labor, low birth weight, postpartum depression
Also affects mother-infant bonding and breastfeeding

🔷 Nurse/Midwife’s Role in Preventing Risky Behaviors:

Role	Responsibilities
Educator	Inform the woman and family about risks and healthy alternatives
Supporter	Provide emotional support and safe space to talk
Counselor	Address addiction, stress, family problems
Referrer	Refer to psychiatrist, de-addiction, or support groups if needed
Motivator	Encourage compliance with health-promoting behavior

🔷 Effective Counseling Techniques:

Use non-judgmental approach
Build trust and rapport
Use visual aids or real stories
Involve family members in behavior change
Use 5 A’s model: Ask, Advise, Assess, Assist, Arrange (follow-up)

🔷 Summary Table: Risky Behaviors and Consequences

Behavior	Consequence
Smoking	Low birth weight, IUGR, stillbirth
Alcohol	Fetal alcohol syndrome
Drugs	Neonatal withdrawal, preterm birth
Unprotected sex	STIs, congenital infections
Poor diet	Anemia, fetal malnutrition
Self-medication	Birth defects
Caffeine excess	Miscarriage
Stress	Preterm labor
Lack of exercise	GDM, obesity

💞 Counseling Regarding Sexual Life During Pregnancy.

🔷 Introduction:

Sexual activity is a normal and important part of a couple’s relationship, including during pregnancy. However, hormonal, emotional, and physical changes may affect a woman’s sexual desire and comfort. Many couples have concerns or misconceptions about sex during pregnancy, which can cause stress or avoidance.

Therefore, sexual counseling during antenatal care is essential for promoting healthy relationships, emotional bonding, and safe practices.

🔷 Objectives of Sexual Counseling During Pregnancy:

To educate couples about the safety and normalcy of sex in pregnancy
To reduce fear, guilt, or anxiety about intercourse
To promote emotional closeness and communication
To clarify when sex is safe or unsafe
To address cultural beliefs, taboos, or myths
To screen for and prevent sexually transmitted infections (STIs)

🔷 Physiological and Psychological Changes Affecting Sexual Life:

Trimester	Changes in Sexual Desire
1st trimester	↓ due to nausea, fatigue, breast tenderness, mood swings
2nd trimester	↑ due to improved energy, increased blood flow to genitals
3rd trimester	↓ due to physical discomfort, back pain, anxiety about labor

Partner’s understanding and emotional support are important throughout.

🔷 Is Sex Safe During Pregnancy?

✅ YES – In normal, low-risk pregnancies, sex is safe

The baby is well protected in the uterus by the amniotic sac and strong uterine muscles
The mucus plug in the cervix prevents infection
Orgasms and penetration do not cause miscarriage in a healthy pregnancy

🔷 When to Avoid Sexual Intercourse (High-Risk Cases):

Condition	Reason
History of miscarriage	Risk of recurrence
Placenta previa	Risk of bleeding
Preterm labor or contractions	May trigger early labor
Leaking of amniotic fluid (PROM)	Risk of infection
Vaginal bleeding or unexplained spotting	Requires investigation
Cervical insufficiency	Risk of early labor
Multiple pregnancy with complications	More cautious approach
Active sexually transmitted infection (STI)	Risk of transmission to fetus
Painful intercourse or discomfort	May require medical evaluation

🔷 Counseling Topics for Couples:

✅ 1️⃣ Normalize the Conversation

Assure them that many couples have similar concerns
Use sensitive, non-judgmental language
Create a private and supportive environment

✅ 2️⃣ Discuss Safe Practices

Aspect	Tips
Positions	Encourage comfortable, non-pressure positions (e.g., side-lying, woman on top) especially in late pregnancy
Lubrication	Can be used if vaginal dryness occurs
Gentle intimacy	Kissing, cuddling, massage to maintain connection
Use protection if needed	Especially if partner has STIs or multiple partners

✅ 3️⃣ Dispel Myths

Myth	Reality
Sex harms the baby	Baby is safe in the womb unless complications exist
Sex causes miscarriage	Not in normal pregnancy
Sex should be stopped after 5th month	Not necessary unless advised by doctor
All women lose sexual desire	Changes vary—some may feel increased or decreased desire

✅ 4️⃣ Promote Communication Between Partners

Encourage open sharing of feelings
Address changes in desire or body image
Emphasize emotional closeness and mutual respect

🔷 Nurse/Midwife’s Role in Sexual Counseling:

Role	Responsibility
Educator	Provide facts about sex and safety in pregnancy
Counselor	Address myths, fears, discomforts
Supporter	Promote communication and intimacy in couple
Referrer	Refer to doctor or psychologist if dysfunction, trauma, or STI is suspected
Advocate	Ensure privacy, dignity, and cultural sensitivity

🔷 Counseling Tips:

Use simple language
Respect cultural and personal beliefs
Avoid making assumptions about the couple’s sexual preferences
Involve the partner, if appropriate and acceptable
Provide written material or leaflets if available
Always document the counseling session if part of antenatal education

🚨 Danger Signs During Pregnancy.

🔷 Introduction:

Pregnancy is generally a physiological process, but complications can arise at any time. Some symptoms, if not identified and treated early, can lead to serious maternal or fetal morbidity or mortality.

Therefore, it is vital to educate every pregnant woman and her family about the danger signs of pregnancy so they can seek immediate medical attention when necessary.

🔷 Definition:

Danger signs during pregnancy are symptoms or signs that indicate potential complications that can threaten the life of the mother, fetus, or both, and require immediate medical evaluation and intervention.

🔷 Major Danger Signs During Pregnancy (According to WHO and RCH Guidelines):

✅ 1️⃣ Vaginal Bleeding

Possible Causes	Risks
Threatened abortion, placenta previa, placental abruption	Miscarriage, hemorrhage, fetal death

🔸 Any amount of bleeding is abnormal during pregnancy and must be reported.

✅ 2️⃣ Severe Headache

Possible Causes	Risks
Pre-eclampsia (pregnancy-induced hypertension)	Risk of seizures (eclampsia), stroke, fetal growth restriction

✅ 3️⃣ Blurred Vision / Dimming of Vision / Spots Before Eyes

Possible Cause	Risk
Pre-eclampsia	Indicates risk of seizures or cerebral edema

✅ 4️⃣ Severe Abdominal Pain

Possible Causes	Risks
Ectopic pregnancy, placental abruption, uterine rupture	Life-threatening bleeding, maternal shock

✅ 5️⃣ Convulsions or Fits

Possible Cause	Risk
Eclampsia	Maternal and fetal death if untreated

✅ 6️⃣ High Fever with Chills

Possible Causes	Risks
Malaria, urinary tract infection, sepsis	Preterm labor, maternal infection, fetal distress

✅ 7️⃣ Loss of Fetal Movement (No Fetal Kicks After 28 Weeks)

Significance	Action
May indicate fetal distress or intrauterine fetal death (IUFD)	Needs immediate fetal monitoring and ultrasound

🔹 Normal fetal movement: 10 kicks in 12 hours

✅ 8️⃣ Swelling of Face, Hands, and Feet (Sudden or Severe)

Possible Cause	Risk
Pre-eclampsia	May lead to seizures, low birth weight, preterm birth

🔸 Mild leg swelling is common, but facial or hand edema is abnormal.

✅ 9️⃣ Leaking of Amniotic Fluid Before Labor (PROM)

Significance	Risk
Indicates rupture of membranes before labor begins	Increases risk of infection, cord prolapse, preterm birth

✅ 🔟 Painful or Regular Uterine Contractions Before 37 Weeks

Significance	Risk
Suggests preterm labor	Premature delivery, neonatal complications

✅ 1️⃣1️⃣ Difficulty in Breathing / Chest Pain / Palpitations

Possible Causes	Risks
Severe anemia, cardiac disease, pulmonary embolism	Respiratory failure, fetal hypoxia

🔷 Other Warning Signs:

Sign	Possible Problem
Excessive vomiting	Hyperemesis gravidarum → dehydration, electrolyte imbalance
Itching all over body, especially palms/soles	Cholestasis of pregnancy (risk to fetus)
Burning urination	Urinary tract infection
Painful swollen legs	DVT (deep vein thrombosis)
Unconsciousness or confusion	Seizure, stroke, metabolic imbalance

🔷 Immediate Action When Danger Signs Are Observed:

Do NOT delay in seeking help
Refer to the nearest healthcare facility/hospital
Inform the ANM/ASHA worker for transportation or support
Monitor vital signs if in clinical setting
Record all symptoms and timings

🔷 Role of Nurse and Midwife:

Role	Responsibilities
Educator	Teach every pregnant woman about these signs during antenatal care
Observer	Identify early danger signs during routine checkups
Supporter	Provide emotional and physical support during emergency
Referrer	Ensure timely referral to higher centers
Documenter	Record observations and interventions in ANC card or register

🔷 Health Education Tips for Pregnant Women (in Simple Language):

👉 “If you have bleeding, swelling of face, no baby movement, or severe headache, go to hospital immediately.”
👉 Use flipcharts, posters, videos during ANC clinics
👉 Involve family members/husbands in education
👉 Use MCP Card to write and explain danger signs

👶👜 Birth Preparedness and Complication Readiness (BPCR).

🔷 Introduction:

Birth Preparedness and Complication Readiness (BPCR) is a key component of safe motherhood programs. It ensures that the pregnant woman, her family, and health care providers are well-prepared for normal delivery and are also ready to handle emergencies.

It promotes timely use of skilled maternal and neonatal care, especially during the critical time of labor, delivery, and the immediate postpartum period.

🔷 Definition:

BPCR is a strategy that helps a pregnant woman and her family to plan for a safe delivery and to be ready for any obstetric complications or emergencies that may arise before, during, or after childbirth.

🔷 Objectives of BPCR:

To reduce maternal and neonatal morbidity and mortality
To ensure skilled birth attendance
To facilitate timely care-seeking in emergencies
To empower women and families to take decisions
To improve communication between families and health providers

🔷 Key Components of Birth Preparedness:

Component	Description
✅ Identify a skilled birth attendant	Doctor, nurse-midwife, or trained ANM
✅ Choose a place of delivery	PHC, CHC, sub-center, hospital, private or government facility
✅ Arrange transport	Know the nearest transport options, keep contact numbers ready
✅ Save money	For transport, medicine, food, emergency care
✅ Pack a birth kit	Clothes, sanitary pads, baby clothes, soap, towel, ID, MCP card
✅ Arrange a birth companion	Someone to accompany the woman during labor
✅ Prepare for home care after delivery	Clean room, rest arrangements, newborn care supplies
✅ Ensure nutrition and rest	For energy during labor and recovery afterward

🔷 Key Components of Complication Readiness:

Component	Description
✅ Know danger signs	Bleeding, high fever, convulsions, no fetal movement, severe headache, labor >12 hours
✅ Identify nearest referral center	Where emergency obstetric and newborn care (EmONC) is available
✅ Arrange emergency transport	Local driver, ambulance services (like 108 in India)
✅ Have blood donor available	In case of hemorrhage, anemia, or C-section
✅ Involve key decision-makers	Ensure family members are informed and supportive
✅ Keep emergency contacts ready	Hospital, midwife, ASHA, ANM, local health worker

🔷 WHO Recommended Danger Signs for Counseling (Antenatal and Postnatal):

🔴 During Pregnancy:

Vaginal bleeding
Severe headache
Blurred vision
Abdominal pain
Swelling of face/hands
High fever
Loss of fetal movement

🔴 During Labor/Postpartum:

Prolonged labor (>12 hours)
Heavy vaginal bleeding
Convulsions
Retained placenta
Foul-smelling vaginal discharge
High fever

🔴 For Newborn:

Difficulty breathing
Poor feeding
Cold or hot to touch
Yellow skin (jaundice)
Inactivity

🔷 Role of Nurse and Midwife in BPCR:

Role	Activities
Educator	Teach BPCR during every antenatal visit, especially in the 3rd trimester
Planner	Help mother make a personalized birth plan
Facilitator	Assist in linking with health services and referral centers
Supporter	Empower family to make informed decisions
Observer	Monitor compliance with the plan
Referrer	Prompt referral in case of complications

🔷 Tools to Support BPCR:

Mother and Child Protection (MCP) Card – space to document birth plan
Flipcharts and Posters – for community education
Birth Preparedness Checklist – simple tool for field health workers
ASHA Home Visits – in 3rd trimester for counseling and preparation

🔷 Benefits of BPCR:

✅ Timely arrival at health facility
✅ Reduction in delays (Three Delays Model):

Delay in deciding to seek care
Delay in reaching care
Delay in receiving care at the facility

✅ Improved maternal and neonatal outcomes
✅ Empowered families and communities
✅ Strengthened health system linkages

🤝🌸 Respectful Care and Compassionate Communication in Maternity Services.

🔷 Introduction:

Respectful maternity care (RMC) and compassionate communication are fundamental rights of every woman during pregnancy, childbirth, and postpartum. These principles ensure that care is provided in a dignified, supportive, and empathetic manner, free from abuse, neglect, or discrimination.

Midwives and nurses are at the frontline of maternal care, and their communication style and attitude can directly impact a woman’s health, trust, and birth experience.

🔷 Definition:

Respectful care is the delivery of maternal care that is human rights-based, woman-centered, and culturally appropriate, ensuring dignity, privacy, and informed consent at every stage.

Compassionate communication involves actively listening, empathizing, and responding to the physical and emotional needs of the woman using kindness and respect.

🔷 Key Principles of Respectful Maternity Care (RMC):

Dignity and Respect
Privacy and Confidentiality
Informed Consent and Decision-making
Non-discrimination (irrespective of caste, class, religion, economic status)
Freedom from abuse, neglect, and coercion
Companionship and emotional support
Right to information and communication in understandable language

🔷 Importance of RMC and Compassionate Communication:

Builds trust between provider and woman
Improves maternal satisfaction and mental health
Promotes positive health-seeking behavior
Encourages institutional delivery and follow-up
Reduces birth trauma, depression, and violence
Supports early breastfeeding and bonding

🔷 Practical Examples of Respectful Care:

Situation	Respectful Action
During examination	Always seek verbal consent, explain the procedure
During labor	Allow birth companion, provide reassurance and encouragement
Personal privacy	Cover with clean drapes, close doors/curtains
Communication	Use her name, speak gently, make eye contact
Decision-making	Explain options (e.g., normal birth vs. C-section), ask for her choice
Pain or fear	Acknowledge feelings, offer comfort and coping techniques
Discharge	Provide complete information about postnatal care and newborn care

🔷 Common Disrespect and Abuse in Maternity Settings (To Be Avoided):

🚫 Scolding, shouting, blaming the woman
🚫 Performing procedures without consent
🚫 Not allowing a birth companion
🚫 Leaving the woman unattended during labor
🚫 Ignoring complaints of pain
🚫 Breach of confidentiality
🚫 Discrimination based on caste, age, or literacy
🚫 Threatening or forcing treatment

🔷 Skills for Compassionate Communication:

Skill	Description
Active listening	Give full attention, nod, and respond empathetically
Empathy	Try to understand what the woman is feeling (e.g., “I can see you’re scared. I’m here to help you.”)
Gentle tone and body language	Calm voice, open posture, eye contact
Clear explanation	Use simple, local language and check understanding
Respect personal space and cultural norms	Ask before touching, adjust to customs if safe
Encouragement and reassurance	Use phrases like: “You are doing well,” “You’re strong,” “I am with you.”

🔷 Role of Midwife/Nurse in Ensuring RMC and Compassionate Care:

Role	Responsibility
Advocate	Stand for women’s rights in maternity care
Communicator	Build trust, rapport, and openness
Protector	Prevent mistreatment, abuse, or neglect
Educator	Inform the woman about her care, procedures, and options
Supporter	Offer emotional and physical support during labor and delivery
Team member	Promote respectful culture among staff and junior workers

🔷 National and Global Initiatives Supporting RMC:

WHO framework on quality maternal and newborn care
LaQshya Program (India) – focuses on respectful and quality care during labor
White Ribbon Alliance – promotes Respectful Maternity Care Charter
Suman Program (India) – Surakshit Matritva Aashwasan for dignified care

📋🖊️ Recording and Reporting of Clinical Procedures as per Government of India (GoI) Guidelines

(Midwifery and Gynecology Nursing Perspective – as per RCH, RMNCH+A, and NHM norms)

🔷 Introduction:

Accurate recording and reporting of clinical procedures is a legal, ethical, and professional requirement in nursing and midwifery practice. It ensures continuity of care, supports monitoring and evaluation, guides policy-making, and improves accountability in maternal and child health services.

The Government of India (GoI), through the Ministry of Health & Family Welfare (MoHFW), has laid down standardized formats and protocols under various programs like:

RCH Program
RMNCH+A (Reproductive, Maternal, Newborn, Child & Adolescent Health)
NHM (National Health Mission)

🔷 Objectives of Recording and Reporting in Clinical Practice:

To ensure systematic documentation of all services provided
To support referral, follow-up, and evaluation
To provide legal evidence of procedures performed
To ensure supply chain (logistics) planning
To track key health indicators for planning and policy

🔷 What Should Be Recorded in Clinical Practice:

✅ During Antenatal Care (ANC):

What to Record	Where to Record
ANC registration details	ANC register, MCP card
Obstetric history (G-P-A-L)	ANC card, register
Physical exam findings	ANC case sheet
Investigations (Hb, BP, urine, USG)	ANC lab records
IFA/Calcium tablet distribution	Supplementation record
Immunization (TT/TD doses)	MCP card, immunization register
Birth preparedness counseling	ANC checklist or BPCR plan
Danger signs taught	MCP card notes
High-risk identification	High-risk ANC register

✅ During Intrapartum (Labor and Delivery):

What to Record	Tool/Format
Date & time of admission	Labor room register
Partograph entries	Individual partograph chart
Fetal heart rate, BP, contractions	Partograph
Interventions (ARM, oxytocin, episiotomy)	Case sheet
Delivery details (time, mode, sex of baby, APGAR)	Delivery register
Maternal complications	Complication register
Referral details (if any)	Referral slip, register
Essential newborn care (ENBC)	Newborn care register

✅ During Postnatal Care (PNC):

What to Record	Where
Postnatal vitals	PNC register, home visit format
Lochia, uterine involution	Postnatal assessment sheet
Breastfeeding status	PNC visit checklist
Newborn condition	Newborn register
Family planning counseling	Eligible couple register
Discharge details	Case sheet, discharge slip

✅ During Clinical Procedures (Perineal care, catheterization, injections, IUCD insertion):

Each procedure should include:

Date and time
Indication for procedure
Procedure performed (with technique used)
Consent (if applicable)
Complications (if any)
Follow-up advice

📝 Use standard procedure logbooks, nursing notes, or GoI registers (IUCD insertion register, injection register, etc.)

🔷 GoI Specified Registers and Formats:

Tool/Format	Use
ANC Register	For ANC registration and visits
Delivery Register	Records of all institutional births
Postnatal Register	Mother & baby check-ups after delivery
High-Risk Pregnancy Register	Tracking special cases
MCP Card (Mother and Child Protection Card)	Hand-held record given to every mother
Partograph	To monitor labor progression
Referral Slip	Used when referring to higher facility
Family Planning Register	IUCDs, OCPs, injectable contraception
HMIS (Health Management Information System)	Monthly online reporting by ANM/ASHA/PHC
ANM Monthly Report (Form 6)	For sub-center-level reporting under NHM

🔷 Essential Elements of Good Recording:

Element	Description
✅ Accuracy	No false data; based on actual observation
✅ Clarity	Use clear handwriting or digital entry
✅ Legibility	Easy to read and understand
✅ Confidentiality	Keep patient data private
✅ Timeliness	Enter data as soon as procedure is done
✅ Completeness	All required fields must be filled
✅ Signature & Date	Always sign after entry

🔷 Legal and Ethical Importance:

Medical records are legal documents
Can be used in court or audits
Incomplete or false entries may cause legal or professional action
Respect for client confidentiality and informed consent is critical

🔷 Nurse/Midwife’s Role in Recording and Reporting:

Role	Activities
Recorder	Accurately write all procedures, findings, and outcomes
Reporter	Submit monthly reports to supervisor/PHC
Verifier	Double-check calculations, lab reports, medication doses
Educator	Teach patients about the information in MCP card
Communicator	Report abnormal findings immediately to MO
Coordinator	Link with ASHA/AWW for follow-up and community reporting

🔷 Digital Tools & e-Reporting (GoI Initiatives):

e-Mamta (for mother and child tracking in Gujarat and other states)
RCH Portal – web-based platform for service tracking
ANMOL App – tablet-based application for ANMs
HMIS Portal – national-level health service reporting system

🩺 Government of India (GoI) – Current Model of Antenatal Care (ANC) Provision

(As per RMNCH+A Strategy, LaQshya Guidelines, and latest MoHFW norms)

(Midwifery and Gynecology Nursing Perspective)

🔷 Introduction:

The Government of India has standardized the Antenatal Care (ANC) model to improve maternal and fetal outcomes, especially under the umbrella of the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy.

The model aims at universal, quality ANC services, focusing on early registration, risk identification, timely interventions, and continuity of care.

🔷 Current Model of ANC Provision – Key Highlights:

✅ 1. Early Registration of Pregnancy

Within 12 weeks of gestation
At any Sub-center, PHC, CHC, UPHC, or private facility
Recorded in MCP Card and RCH Portal
Allows early screening for risk factors like anemia, hypertension, diabetes

✅ 2. Recommended Minimum 4 ANC Visits

Visit	Timing
1st Visit	By 12 weeks (first trimester)
2nd Visit	Between 14–26 weeks
3rd Visit	Between 28–34 weeks
4th Visit	Between 36 weeks and term

🔹 In high-risk pregnancies, more frequent ANC visits are advised.

✅ 3. Monthly Village Health and Nutrition Day (VHND)

Held at Anganwadi Center
Services include ANC check-ups, IFA distribution, immunization, counseling
Conducted by ANM, ASHA, and AWW collaboratively

✅ 4. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)

Conducted on 9th of every month
Free and quality ANC services to all pregnant women
Includes examination by specialists and MBBS doctors
Focus on identifying high-risk pregnancies

✅ 5. Key Services Provided in ANC Model:

Category	Services Included
Assessment	Height, weight, BP, abdominal exam, fetal heart sound
Laboratory	Hb%, blood group & Rh, urine (sugar/protein), HIV, VDRL, HBsAg, blood sugar, thyroid if needed
Immunization	2 doses of TT/TD or 1 booster if vaccinated in last pregnancy
Supplementation
– IFA tablets (100 mg Iron + 0.5 mg Folic Acid) – 180 days
– Calcium 500 mg – twice daily
– Albendazole 400 mg (single dose after 2nd trimester)
Ultrasound
– Early USG (before 12 weeks) for dating
– Anomaly scan at 18–20 weeks
– Growth scan if needed
Counseling	Nutrition, danger signs, birth preparedness, family planning, breastfeeding, rest

✅ 6. Identification and Management of High-Risk Pregnancy (HRP)

Common HRP indicators include:

Age <18 or >35
Severe anemia (Hb <7 gm/dL)
Hypertension, diabetes
Previous C-section, stillbirth
Malpresentation
Twin pregnancy

🩺 HRPs are tracked and referred using High-Risk ANC Register.

✅ 7. Record Keeping & Monitoring

Tool	Use
MCP Card	Carried by the woman; records all services
ANC Register	Maintained at sub-center/PHC
RCH Portal (Mother Tracking System)	Digital entry of services provided
ANMOL App	Tablet-based tool for ANMs
LaQshya Dashboard	For quality monitoring in labor rooms and maternity OTs

🔷 New GoI Initiatives Strengthening ANC Model:

🌟 LaQshya Program

Ensures quality ANC, intrapartum, and postpartum care
Focus on dignified and respectful care
Monitors labor room and maternity OT standards

🌟 SUMAN (Surakshit Matritva Aashwasan)

Provides free, quality, respectful maternal and newborn care
Includes zero cost delivery, drugs, diagnostics, and transport

🔷 Role of ANM/Staff Nurse/Midwife in ANC Model:

Role	Responsibilities
Service Provider	Conduct ANC checkups, physical exams, distribute supplements
Counselor	Educate women and family on diet, danger signs, and birth preparedness
Record Keeper	Maintain ANC register, MCP card, and digital records
Risk Identifier	Screen for and refer high-risk pregnancies
Community Link	Coordinate with ASHA and AWW for VHND and follow-ups

🌸👩‍⚕️ Role of Doula and ASHA in Maternal and Newborn Care

(Midwifery and Gynecology Nursing Perspective – Respectful Maternity Care and Community-Based Services)

🔷 Who is a Doula?

A Doula is a trained, non-medical support person who provides continuous physical, emotional, and informational support to a woman before, during, and after childbirth.

The term “Doula” comes from the Greek word meaning “a woman who serves.”
While not a common designation under GoI programs yet, Doula-based care is being promoted in some states and private settings under respectful maternity care (RMC) initiatives.
Doulas are not clinical staff (do not perform deliveries or administer medications), but offer psychosocial and physical comfort.

✅ Role of a Doula:

Time	Activities
During Pregnancy

Provide education on labor and delivery
Help with birth planning
Offer emotional support and reduce anxiety
Accompany to antenatal visits (if permitted) | | During Labor |
Give continuous presence and encouragement
Support breathing, massage, position changes
Act as a link between woman and care provider
Ensure woman’s voice is heard | | After Birth |
Assist in early initiation of breastfeeding
Support emotional transition to motherhood
Help with newborn care and comfort measures

🌟 Research shows that having a doula can reduce C-section rates, shorten labor, and improve maternal satisfaction.

🔷 Who is an ASHA? (Accredited Social Health Activist)

Introduced under the National Rural Health Mission (NRHM), now part of NHM (National Health Mission)
ASHA is a trained female community health volunteer
Selected from the same village/community, usually married/widowed/divorced women aged 25–45 years

ASHA means “hope,” and she serves as the bridge between the community and the public health system.

✅ Role of ASHA in Maternal and Newborn Care:

Stage	Key Activities
Before Pregnancy

Promote family planning
Distribute condoms, OCPs
Counsel newlyweds about reproductive health | | During Pregnancy
Register pregnant women at sub-center/PHC
Escort women to ANC clinics and PMSMA days
Home visits to educate on diet, rest, danger signs
Promote birth preparedness and complication readiness (BPCR)
Track high-risk pregnancies and support referral
Ensure women get TT/TD injections, IFA tablets, calcium
Distribute MCP cards | | During Labor |
Accompany woman to delivery center
Ensure institutional delivery at public facility
Provide emotional support and comfort
Ensure birth companion policy is implemented | | After Delivery |
Make 6 postnatal home visits (as per HBNC guidelines)
Monitor mother’s health, uterine involution, bleeding, breastfeeding
Educate on exclusive breastfeeding and newborn care
Identify danger signs in mother or baby
Assist in birth registration and linking to nutrition services | | Child Health |
Promote immunization
Track growth and development
Counsel on complementary feeding
Mobilize for VHND (Village Health and Nutrition Day) |

🔷 ASHA Incentives (GoI Performance-Based):

Activity	Incentive (approximate)
Early registration of pregnancy	₹100
Accompanying woman for ANC	₹250
Ensuring institutional delivery (JSY)	₹600 (rural) / ₹400 (urban)
Postnatal visits (HBNC)	₹250–350
Full immunization	₹100–200

(Incentive amounts may vary by state)

🔷 Comparison: Doula vs ASHA

Feature	Doula	ASHA
Trained in childbirth support	Yes (non-medical)	Yes (community health)
Belongs to community	Sometimes	Always
Paid incentive by GoI	No (usually private/NGO)	Yes
Clinical responsibility	No	No (but links with ANM/PHC)
Emotional labor support	Strong role	Limited
Continuity of care	Antenatal to postpartum	Yes
Formal recognition by GoI	No (yet)	Yes

II Trimester.

Education and Management of Physiological Changes & Discomforts in 2nd Trimester of Pregnancy (14–28 weeks)

📌 INTRODUCTION:

The second trimester is often referred to as the “honeymoon phase” of pregnancy. Many women feel more energetic and experience fewer symptoms compared to the first trimester. However, new physiological changes and minor discomforts may emerge, which require proper nursing assessment, anticipatory guidance, and interventions.

🧠 EDUCATION & MANAGEMENT BASED ON SYSTEM-WISE CHANGES:

1. Reproductive System Changes

Change	Discomfort	Management/Nursing Interventions
Uterus enlarges (rises above the pelvis)	Abdominal stretching, round ligament pain	➤ Teach abdominal support techniques ➤ Use maternity belt ➤ Encourage side-lying position
Increased vaginal discharge (leukorrhea)	May cause discomfort or concern	➤ Reassure it’s normal unless foul-smelling or itchy ➤ Teach perineal hygiene ➤ Wear cotton underwear, avoid douching

2. Cardiovascular System Changes

Change	Discomfort	Management/Nursing Interventions
Increased blood volume and cardiac output	Palpitations, dizziness, dependent edema	➤ Reassure unless persistent ➤ Encourage rest with legs elevated ➤ Avoid prolonged standing ➤ Monitor BP regularly (for gestational hypertension)

3. Musculoskeletal System

Change	Discomfort	Management/Nursing Interventions
Softening of ligaments, weight gain	Backache, postural changes	➤ Advise good posture ➤ Use firm mattress ➤ Pelvic tilt exercises ➤ Avoid high heels

4. Gastrointestinal System

Change	Discomfort	Management/Nursing Interventions
Progesterone slows GI motility	Constipation, bloating, heartburn	➤ High fiber diet, increase fluid intake ➤ Gentle physical activity ➤ Small, frequent meals for heartburn ➤ Avoid spicy/fatty foods

5. Urinary System

Change	Discomfort	Management/Nursing Interventions
Uterus presses on bladder	Frequency of urination (less than 1st trimester)	➤ Reassure ➤ Encourage adequate hydration ➤ Teach UTI prevention (wiping front to back)

6. Skin Changes

Change	Discomfort	Management/Nursing Interventions
Melasma, linea nigra, striae gravidarum	Cosmetic concern, itching	➤ Reassure – usually fades postpartum ➤ Use mild moisturizers for itching ➤ Avoid excessive sun exposure

7. Breasts

Change	Discomfort	Management/Nursing Interventions
Enlargement, areolar darkening, colostrum secretion	Breast tenderness, tightness	➤ Wear supportive maternity bra ➤ Teach about colostrum being normal ➤ Avoid expressing milk

🤰 COMMON MINOR DISCOMFORTS IN 2ND TRIMESTER AND NURSING MANAGEMENT:

Discomfort	Cause	Nursing Education and Management
Leg cramps	Pressure on pelvic nerves, calcium deficiency	➤ Leg elevation during rest ➤ Calf-stretching exercises ➤ Ensure calcium/magnesium intake
Varicose veins	Decreased venous return due to uterine pressure	➤ Avoid standing for long ➤ Wear compression stockings ➤ Leg elevation
Nasal congestion/epistaxis	Estrogen-induced vascular engorgement	➤ Use saline drops ➤ Humidifier use ➤ Avoid nasal sprays with medication unless prescribed
Mood swings	Hormonal shifts	➤ Emotional support ➤ Encourage communication with partner/family ➤ Refer to counselor if needed

🎓 HEALTH TEACHING/EDUCATION BY MIDWIFE:

Fetal Movement Monitoring
- Starts to be felt around 18–22 weeks.
- Teach how to identify and record movements.
Warning Signs to Report Immediately
- Vaginal bleeding
- Severe abdominal pain
- Severe headache or visual disturbances
- Sudden swelling of hands/face
- Absence of fetal movements
Dietary Education
- Iron, calcium, protein-rich foods
- Iron + folic acid supplementation
- Adequate hydration
Importance of Antenatal Check-ups
- Monitor fetal growth, BP, weight, urine protein, hemoglobin
- Immunization: Tetanus Toxoid (as per schedule)
Safe Physical Activity
- Moderate walking, pelvic floor exercises
- Avoid heavy lifting or unsafe postures
Sexual Activity
- Safe unless contraindicated by doctor (e.g., placenta previa, bleeding)
Birth Preparedness
- Start discussing place of delivery, emergency plans, transportation

🧑‍⚕️ ROLE OF MIDWIFE IN NURSING CARE:

Provide empathetic communication and address individual concerns
Offer culturally sensitive health education
Maintain documentation of changes and teaching given
Encourage family involvement and support
Screen for mental health issues or intimate partner violence

🌸 MIDWIFERY NURSING: Rh-Negative Mother & Prophylactic Anti-D Immunoglobulin

🧬 WHAT IS Rh FACTOR?

Rh factor (Rhesus factor) is a protein found on red blood cells.
People who have it are Rh-positive (Rh⁺).
Those who do not have it are Rh-negative (Rh⁻).

⚠️ WHY IS Rh INCOMPATIBILITY A CONCERN IN PREGNANCY?

➤ Problem arises if:

The mother is Rh-negative, and
The baby is Rh-positive (inherited from Rh-positive father),
Then fetal Rh⁺ red blood cells may enter mother’s bloodstream (called fetomaternal hemorrhage or FMH),
Mother’s immune system sees Rh⁺ cells as “foreign” and produces antibodies against them (called anti-D antibodies).

➤ These antibodies:

Don’t usually affect the first pregnancy.
But in subsequent pregnancies, they can cross the placenta and destroy fetal Rh⁺ red blood cells, causing:
- Hemolytic Disease of the Fetus and Newborn (HDFN) or
- Erythroblastosis fetalis – a life-threatening condition for the baby.

💉 WHAT IS ANTI-D IMMUNOGLOBULIN?

Anti-D (Rho(D) immune globulin) is a passive antibody injection that destroys fetal Rh-positive cells in the mother’s bloodstream before her body can react and make antibodies.

📆 WHEN IS PROPHYLACTIC ANTI-D GIVEN?

🔹 1. Antenatal prophylaxis

Timing	Details
Around 28 weeks	To prevent sensitization due to silent FMH in late pregnancy
After any event that can cause fetal cells to enter maternal blood:	– Bleeding during pregnancy – Amniocentesis, chorionic villus sampling – External cephalic version – Trauma or abdominal injury – Miscarriage, abortion, ectopic pregnancy, MTP

🔹 2. Postnatal prophylaxis

Timing	Details
Within 72 hours after delivery	If baby is confirmed Rh-positive

🩸 DOSE OF ANTI-D

Situation	Usual Dose
Antenatal (28 weeks)	300 µg IM (protects against 30 mL fetal blood)
Postnatal (within 72 hrs)	300 µg IM
After miscarriage or invasive procedures	50–300 µg depending on gestational age & risk

🧪 TESTS BEFORE ADMINISTRATION

Mother’s blood group & Rh typing
Indirect Coombs test (ICT): to detect if the mother is already sensitized.
- ➤ If ICT is negative → give Anti-D
- ➤ If ICT is positive → she is already sensitized → no benefit of Anti-D
Kleihauer–Betke test (if available): Measures the amount of fetal blood in maternal circulation to calculate Anti-D dose (especially in large fetomaternal hemorrhage)

🧑‍⚕️ ROLE OF MIDWIFE / NURSE

🌼 Nursing Assessment:

Identify Rh-negative mothers early
Take detailed obstetric and transfusion history
Monitor for bleeding, trauma, or procedures

🌼 Nursing Education:

Educate mother on importance of Anti-D injection
Explain risk of not taking prophylaxis
Inform about potential reactions (minor like soreness, rare allergic reaction)

🌼 Administration:

Give IM in deltoid or gluteal muscle
Document batch number, dose, time, and site
Monitor for 15–30 mins post-injection for any allergic reaction

🚨 IF ANTI-D IS NOT GIVEN – RISK

Mother becomes Rh-sensitized (permanently)
Future pregnancies at high risk of HDFN
May require:
- Intrauterine transfusion
- Early delivery
- Neonatal intensive care
- Risk of stillbirth or neonatal death

📝 IMPORTANT POINTS TO REMEMBER

Anti-D is only effective if the mother has not yet formed her own anti-D antibodies
Anti-D does not harm the baby or the mother
Always check baby’s Rh type after delivery before deciding on postnatal Anti-D
Anti-D is not a vaccine; it provides temporary protection

🌸 MIDWIFERY NURSING: Second Trimester Tests (14 to 28 Weeks)

📆 Overview:

The second trimester is a critical time to:

Monitor fetal growth and development
Detect congenital anomalies
Identify maternal risks like gestational diabetes and anemia
Ensure early interventions

🧪 MAJOR SECOND TRIMESTER TESTS:

Test	Timing	Purpose	Nurse’s Role

1. Ultrasound – Level II (Anomaly Scan)

| Usually at 18–22 weeks | | To assess: Fetal anatomy, congenital malformations, amniotic fluid, placental position, fetal heart & spine | | ➤ Explain procedure ➤ Ensure full bladder if transabdominal ➤ Provide emotional support |

2. Triple Marker or Quadruple Marker Test

| Between 15–20 weeks, ideally 16–18 weeks | | Triple Marker: Measures AFP, hCG, Estriol Quad Marker: Adds Inhibin-A Screens for Down syndrome, Trisomy 18, Neural tube defects | | ➤ Explain it’s a screening, not diagnostic ➤ Refer for genetic counseling if abnormal ➤ Ensure correct gestational age for accurate results |

3. Glucose Challenge Test (GCT) / Oral Glucose Tolerance Test (OGTT)

| Usually at 24–28 weeks | | Screens for gestational diabetes mellitus (GDM) | | ➤ 50g glucose given orally, check sugar after 1 hour (GCT) ➤ If abnormal, confirm with OGTT (75g/100g) ➤ Instruct fasting, explain procedure clearly |

4. Hemoglobin/Hematocrit

| Any time, but repeated at 24–28 weeks | | Detects anemia | | ➤ Educate on iron-rich foods ➤ Reinforce compliance with iron + folic acid tablets |

5. Blood Pressure Monitoring

| At every antenatal visit | | Early identification of pregnancy-induced hypertension | | ➤ Teach warning signs (headache, swelling, vision changes) ➤ Refer if elevated BP (>140/90 mmHg) |

6. Urine Routine and Microscopy

| Every visit | | Checks for proteinuria (PIH), glucosuria (GDM), UTI | | ➤ Explain clean-catch method ➤ Collect sample properly ➤ Educate on UTI prevention |

7. Indirect Coombs Test (If Rh-negative mother)

| At 28 weeks | | Detects Rh sensitization | | ➤ If negative → Administer Anti-D immunoglobulin ➤ Monitor further exposure risks |

8. Fetal Movement Assessment

| Starts around 18–22 weeks | | Indicates fetal wellbeing | | ➤ Teach mother to feel for movements ➤ Encourage “kick count” later in pregnancy |

🧑‍⚕️ ROLE OF MIDWIFE / NURSE:

Educate the mother about the purpose and importance of each test.
Prepare her physically and emotionally for invasive or anxiety-provoking tests.
Ensure proper timing of tests according to gestational age.
Follow up on abnormal results and coordinate with physicians.
Provide non-judgmental support, especially if birth defects are suspected.
Maintain accurate documentation of all test results.

🚨 Special Cases That May Need Additional Tests:

Multiple pregnancy
Previous congenital anomalies
Advanced maternal age (≥35 years)
Family history of genetic disorders
Previous gestational diabetes or PIH

🌸 MIDWIFERY NURSING: Health Education in Second Trimester (14–28 Weeks)

🩺 WHY IS HEALTH EDUCATION IMPORTANT IN 2nd TRIMESTER?

This is the phase where the woman:

Feels more stable physically and emotionally
Begins to feel fetal movements
Is receptive to learning about pregnancy and childbirth
May start experiencing some physical discomforts

🧠 Hence, health education during this trimester focuses on:

Promoting maternal and fetal well-being
Early detection of complications
Preparing for birth and parenthood

📚 SECOND TRIMESTER HEALTH EDUCATION TOPICS:

1. ✅ Antenatal Check-ups

Regular visits every 4 weeks
Monitoring BP, weight, fundal height, fetal heart rate, and urine tests
Importance of follow-up tests (anomaly scan, GDM screening)

2. 🥗 Nutrition

Balanced diet with adequate calories, proteins, calcium, iron, and vitamins
Increase iron-rich foods (green leafy vegetables, jaggery, dates)
Folic acid and iron supplementation
Avoid junk food and excessive caffeine

3. 💊 Medications and Supplements

Compliance with Iron + Folic acid (IFA) tablets
Deworming (if advised)
Anti-D injection for Rh-negative mothers at 28 weeks

4. 🤰 Fetal Movement Awareness

Teach the mother to identify fetal movement (quickening usually starts around 18–22 weeks)
Educate on importance of fetal movement as a sign of fetal health

5. 🧘‍♀️ Exercise and Physical Activity

Encourage mild exercises like walking, stretching
Introduce antenatal yoga or breathing exercises (if no contraindication)
Avoid heavy lifting or sudden jerky movements

6. 💤 Rest and Sleep

Encourage 8 hours of night sleep and short daytime rest
Teach left lateral sleeping position for optimal uteroplacental blood flow
Use pillow support for back and legs

7. 🧴 Body Changes and Hygiene

Teach about normal physiological changes: breast enlargement, linea nigra, melasma
Promote daily bath, clean and dry undergarments, perineal hygiene
Address issues like leukorrhea, varicose veins, backache

8. 🧠 Mental and Emotional Wellbeing

Discuss mood swings, fears, and expectations
Involve family or partner for emotional support
Encourage joining antenatal support groups

9. 🍼 Preparation for Breastfeeding

Importance of exclusive breastfeeding
Care of breasts during pregnancy
Addressing myths or misconceptions

10. 🏥 Birth Preparedness and Complication Readiness

Plan place of delivery (institutional delivery)
Keep birth companion and emergency contacts ready
Save money, arrange transport
Recognize danger signs:
- Vaginal bleeding
- Severe headache or blurred vision
- Abdominal pain
- Reduced fetal movement
- Swelling of hands/face

11. ❤️ Sexual Activity

Safe unless contraindicated
Teach about safe positions, emotional understanding, and hygiene

12. 💉 Immunization

Tetanus Toxoid or Tdap as per local guidelines
Educate about timing and side effects

13. 🚭 Lifestyle Modifications

Stop smoking, alcohol, tobacco, or pan masala
Avoid self-medication
Maintain a clean, stress-free environment

14. 👨‍👩‍👧 Involve the Family

Educate spouse and family about mother’s needs
Encourage shared responsibility and emotional support

🧑‍⚕️ ROLE OF MIDWIFE / NURSE:

Conduct individual and group health education sessions
Use charts, models, flipbooks, videos for better understanding
Provide empathy and culturally sensitive care
Keep records and follow-up for high-risk mothers

🌸 MIDWIFERY NURSING: Interpreting Screening Results in Pregnancy (2nd Trimester Focus)

🧠 WHAT ARE SCREENING TESTS?

Screening tests are done to identify the risk of a condition (not to confirm it).
In pregnancy, they help detect potential fetal anomalies, maternal risks, or complications early.
If positive or abnormal, they must be followed up with diagnostic tests.

📋 COMMON SECOND TRIMESTER SCREENING TESTS & INTERPRETATION:

1. 🧪 Triple Marker Test (AFP, hCG, Estriol)

2. 🧪 Quadruple Marker Test (AFP, hCG, Estriol, Inhibin-A)

Marker	High Level Indicates	Low Level Indicates
AFP	Neural tube defects, abdominal wall defects	Down syndrome
hCG	Down syndrome	Trisomy 18
Estriol	–	Low in Down syndrome & Trisomy 18
Inhibin-A (in Quad test)	High in Down syndrome	–

➤ Interpretation:

Normal result: Risk is low → no further testing needed.
Abnormal result: Risk is high → offer diagnostic test (e.g., amniocentesis).

🧑‍⚕️ Nurse’s Role:

Explain it’s a risk estimate, not a diagnosis.
Provide emotional support if abnormal.
Refer to fetal medicine specialist/genetic counselor.

3. 💉 Oral Glucose Challenge Test (GCT)

Result	Interpretation
< 140 mg/dL	Normal
≥ 140 mg/dL	Abnormal – proceed to OGTT

4. 🧬 Indirect Coombs Test (ICT)

Result	Interpretation
Negative	No antibodies → Give Anti-D
Positive	Sensitization occurred → No benefit from Anti-D, monitor closely

5. 🔬 Hemoglobin (Hb)/Hematocrit

🧑‍⚕️ Intervention:

Iron + folic acid tablets
Dietary advice
Deworming
IV iron or blood transfusion (if needed)

6. 🧫 Urine Routine & Microscopy

Finding	Interpretation
Protein +	Possible PIH (Pre-eclampsia)
Glucose +	May indicate GDM
Pus cells	Suggests urinary tract infection (UTI)

7. 🧍‍♀️ Blood Pressure Monitoring

8. 🧼 Ultrasound – Anomaly Scan (Level II)

📌 KEY POINTS IN SCREENING INTERPRETATION:

Screening ≠ Diagnosis
Positive screening needs confirmatory diagnostic tests.
Early detection = better management and birth preparedness.

🧑‍⚕️ MIDWIFE’S RESPONSIBILITY:

Educate pregnant women about purpose and process of screening tests.
Ensure screening is done at the correct gestational age.
Interpret reports along with the doctor and explain results simply to the mother.
Provide emotional support, especially if the result is abnormal.
Coordinate referrals to specialist clinics if needed.

🌸 MIDWIFERY NURSING: Health Education on IFA (Iron and Folic Acid)

✅ INTRODUCTION:

IFA tablets are essential supplements given to pregnant women to prevent:

Anemia (due to iron deficiency)
Neural tube defects in the fetus (due to folic acid deficiency)
Low birth weight, preterm birth, and maternal complications

📚 KEY HEALTH EDUCATION POINTS:

1. ✨ Importance of IFA During Pregnancy

Component	Function
Iron	Forms hemoglobin, prevents anemia, supports oxygen supply to baby
Folic Acid	Prevents neural tube defects (spina bifida), helps in cell growth and fetal development

2. 💊 Recommended Dosage (As per Government of India/WHO guidelines)

Group	Dose
Pregnant women (second trimester onward)	1 tablet daily (60 mg elemental iron + 500 mcg folic acid) for 180 days
Postnatal mothers	1 tablet daily for 6 months after delivery
Adolescent girls/women of reproductive age	1 tablet weekly for anemia prevention

3. 🕐 When and How to Take IFA Tablet

Time: Preferably after meals, not on empty stomach
With water (not tea, coffee, or milk)
Take at same time daily for consistency
Swallow whole tablet—do not crush or chew

4. ⚠️ Possible Side Effects (and their Management)

Side Effect	Management Advice
Nausea	Take after food, at night if needed
Constipation	Drink plenty of fluids, eat fiber-rich foods
Dark stools	Normal – reassure mother
Metallic taste	Suck on lemon candy, rinse mouth
Vomiting	Report to nurse or doctor if persistent

5. 🍲 Dietary Advice Along with IFA

Encourage iron-rich foods: green leafy vegetables, jaggery, dates, lentils, red meat
Enhance absorption by taking Vitamin C-rich foods (e.g., lemon, amla)
Avoid tea or coffee 1 hour before/after taking the tablet

6. 🩸 Signs of Anemia to Watch For

Fatigue and weakness
Pale skin, lips, or palms
Breathlessness or dizziness
Headaches
Palpitations

➡️ If these symptoms occur, consult health worker for evaluation.

7. 🧑‍⚕️ NURSE/MIDWIFE’S ROLE:

Educate mother on importance of compliance
Demonstrate how and when to take the tablet
Dispel myths: IFA doesn’t make baby dark or heavy!
Follow up regularly: Ask about side effects, ensure compliance
Maintain records of IFA distribution and consumption
If hemoglobin < 7 g/dL → refer for higher care or injectable iron

8. 📦 STORAGE AND HANDLING

Keep in cool, dry place, away from children
Check expiry date before use

✅ KEY MESSAGES FOR THE MOTHER:

“Taking your red tablet daily gives you strength and helps your baby grow healthy.”
“Don’t stop IFA if you have black stools—that means it’s working!”
“IFA is like a daily health tonic for you and your baby!”

🌸 MIDWIFERY NURSING: Calcium and Vitamin D Supplementation

✅ INTRODUCTION:

Calcium and Vitamin D are essential micronutrients required during pregnancy and lactation for:

Healthy bone and teeth development of the fetus
Muscle and nerve function
Prevention of pregnancy-related complications like preeclampsia, low birth weight, and maternal bone loss

🧠 WHY IS SUPPLEMENTATION NEEDED?

Even with a good diet, most pregnant women do not meet the increased demands of calcium and Vitamin D due to:

Poor dietary intake
Low sun exposure (especially in covered dress cultures)
Increased fetal demands
Hormonal changes affecting calcium metabolism

📆 WHEN TO START?

Calcium and Vitamin D supplementation should begin from the second trimester (14–16 weeks) and continue throughout pregnancy and up to 6 months postpartum.

💊 RECOMMENDED DAILY DOSE:

Group	Calcium	Vitamin D
Pregnant & lactating women	1000–1200 mg/day	400–600 IU/day (can go up to 1000 IU if needed)
As per Govt. of India (RCH Guidelines)	500 mg elemental calcium + 250 IU Vitamin D twice daily	Total: 1000 mg calcium + 500 IU Vitamin D

🔍 SOURCES:

🍲 Dietary Sources of Calcium:

Milk, curd, paneer, cheese
Ragi (finger millet), soybeans
Green leafy vegetables (e.g., spinach, methi)
Nuts and seeds (e.g., almonds, sesame)
Fish with bones (e.g., sardines)

🌞 Sources of Vitamin D:

Sunlight exposure (best source) – at least 30 minutes/day on face, hands
Fortified foods (milk, cereals)
Fish (salmon, tuna), eggs

🧪 DEFICIENCY RISKS:

In Mother:

Leg cramps, backache, fatigue
Osteomalacia (bone softening)
Preeclampsia
Risk of fractures (in long-term)

In Baby:

Low birth weight
Rickets
Poor bone and tooth development

⚠️ SIGNS OF DEFICIENCY:

Calcium Deficiency	Vitamin D Deficiency
Muscle cramps/spasms	Bone pain, fatigue
Weak nails, tooth decay	Delayed milestones in baby
Tingling in fingers	Increased risk of preeclampsia

🧑‍⚕️ HEALTH EDUCATION POINTS FOR MOTHERS:

📍 On Supplementation:

Take 2 tablets/day (morning and evening), each with 500 mg calcium + 250 IU vitamin D
Avoid taking with Iron tablet – gap of 2 hours is important (iron and calcium compete for absorption)
Take with food to improve absorption
Continue even during breastfeeding period

📍 On Diet:

Include milk/milk products daily
Encourage sunlight exposure—preferably morning sun
Increase physical activity for better calcium utilization

📦 STORAGE AND HANDLING:

Store tablets in a cool, dry place
Check for expiry date
Keep out of reach of children

🧑‍⚕️ NURSE’S/MIDWIFE’S ROLE:

Assessment:
- Identify women at risk (poor diet, multiple pregnancies, underweight, vitamin D deficiency)
Education:
- Explain benefits of calcium and vitamin D for mother and baby
- Teach proper timing of intake with other supplements
- Emphasize diet + sunlight
Distribution & Monitoring:
- As per government programs, give calcium tablets free under RCH or PMSMA
- Ensure compliance and follow-up
- Record and report side effects (e.g., constipation, nausea)

🔄 COMMON MISCONCEPTIONS TO ADDRESS:

Myth	Fact
“Milk alone is enough”	No, supplementation is still needed to meet full requirement
“Sunlight exposure causes tanning”	Only early morning sunlight is needed for Vitamin D synthesis
“Too much calcium will make baby big”	Not true – calcium supports healthy bones, not baby weight

🌸 MIDWIFERY NURSING: Glucose Tolerance Test (GTT) in Pregnancy

✅ INTRODUCTION

The Glucose Tolerance Test (GTT) is used to:

Screen and diagnose gestational diabetes mellitus (GDM) during pregnancy
Detect how well the body metabolizes glucose

📆 WHEN IS IT DONE?

Test	Timing
Screening test (GCT)	24–28 weeks gestation for all pregnant women
Early testing (before 24 weeks)	If high risk (obese, PCOS, history of GDM, family history of diabetes)

🧪 TYPES OF TESTS

1. 💉 Glucose Challenge Test (GCT) – Screening Test

Purpose	To screen for GDM
Procedure	– No fasting needed – Give 50g glucose orally – Blood sample taken after 1 hour
Interpretation	– < 140 mg/dL → Normal – ≥ 140 mg/dL → Abnormal → proceed to OGTT

2. 💉 Oral Glucose Tolerance Test (OGTT) – Diagnostic Test

Based on WHO/IADPSG Guidelines (75g OGTT – one-step test)

| Preparation | – Fasting required (8–10 hours) – Avoid heavy exercise or sugary foods 1 day prior | | Procedure | – Take fasting blood sample – Administer 75g glucose orally (dissolved in 250–300 mL water) – Collect blood at: ➤ Fasting ➤ 1 hour ➤ 2 hours |

📊 WHO/IADPSG Criteria (2020):

Time	Normal Value	GDM if ≥
Fasting	≤ 92 mg/dL	92 mg/dL
1 hour	≤ 180 mg/dL	180 mg/dL
2 hour	≤ 153 mg/dL	153 mg/dL

➡️ If any one of the above values is equal or more, GDM is diagnosed.

🧑‍⚕️ NURSE’S ROLE IN GTT:

🌼 Before the Test:

Educate the woman on purpose and preparation
Ensure fasting for 8–10 hours
Take detailed history of risk factors (obesity, PCOS, previous GDM, macrosomic baby, family history)
Prepare glucose solution (75g glucose in 250–300 mL water)
Check for any vomiting tendencies or discomforts

🌼 During the Test:

Take fasting sample
Administer glucose solution within 5 minutes
Monitor for nausea or vomiting
Ensure the woman does not eat, drink (except water), or walk around during test period
Take blood samples at 1 and 2 hours post-glucose

🌼 After the Test:

Give light meal
Record and document all results
Communicate findings with doctor
If abnormal: refer to dietician, diabetic counselor, or endocrinologist

🍽️ MANAGEMENT IF GDM IS DIAGNOSED:

Medical Nutrition Therapy (MNT) – diet plan
Daily glucose monitoring
Exercise and lifestyle modification
Insulin therapy if uncontrolled
Close monitoring of fetal growth
Plan for safe delivery

🧠 EDUCATION FOR MOTHER:

Importance of taking the test even if no symptoms
GDM can affect both mother and baby:
- Macrosomia (big baby)
- Shoulder dystocia
- Preeclampsia
- Neonatal hypoglycemia
GDM usually resolves after delivery, but increases the risk of:
- Type 2 diabetes later in life
- GDM in future pregnancies

📝 GOVERNMENT GUIDELINES (INDIA – DIPSI Method):

Single step test (Non-fasting)
75g oral glucose → Blood sugar checked after 2 hours
If ≥ 140 mg/dL → GDM diagnosed

🔸 This method is used widely in community and rural settings.

🌸 MIDWIFERY NURSING: IMMUNIZATION DURING PREGNANCY

✅ INTRODUCTION

Immunization during pregnancy plays a critical role in:

Protecting mother from infectious diseases
Providing passive immunity to the newborn
Reducing maternal and neonatal morbidity and mortality

💉 WHY IMMUNIZATION IS IMPORTANT IN PREGNANCY?

Enhances maternal immunity
Provides transplacental transfer of antibodies to fetus
Prevents neonatal infections (e.g., neonatal tetanus, pertussis)
Reduces complications from infections in pregnancy

📆 ROUTINE IMMUNIZATION SCHEDULE FOR PREGNANT WOMEN (India)

Vaccine	When Given	Dose	Route	Purpose
Tetanus + Diphtheria (Td) (formerly TT)	– First dose: As early as possible after 12 weeks – Second dose: 4 weeks after the 1st dose	0.5 mL IM	Intramuscular (Deltoid)	Prevents maternal and neonatal tetanus & diphtheria
Booster dose	If Td taken in last pregnancy within 3 years	1 dose only	IM	Maintains immunity

🔹 New Addition (Optional in India, Mandatory in Some Countries)

Vaccine	When Given	Purpose
Tdap (Tetanus, Diphtheria, Pertussis)	Between 27–36 weeks (preferably before 32 weeks)	Protects mother and baby from whooping cough (pertussis)
Influenza Vaccine	Any trimester, preferably early in flu season	Protects against seasonal flu – reduces risk of preterm labor and complications
Hepatitis B (HBV)	If mother is at high risk or HBsAg negative	Prevents perinatal transmission of hepatitis B

⚠️ VACCINES CONTRAINDICATED IN PREGNANCY:

Live attenuated vaccines should NOT be given:
- Measles, Mumps, Rubella (MMR)
- Varicella (Chickenpox)
- Oral Polio Vaccine (OPV)
- HPV Vaccine

🔴 If accidentally given, counseling should be done. No need for termination.

🧠 EDUCATION TO PREGNANT WOMEN:

Explain why immunization is necessary
Assure that Td and other recommended vaccines are safe in pregnancy
Inform about mild side effects (fever, pain at injection site)
Encourage to bring and maintain the MCH card (Mother and Child Health card)
Stress on timing and compliance with both doses

🧑‍⚕️ ROLE OF MIDWIFE/NURSE:

Assessment:
- Check immunization history
- Determine eligibility for Td/Tdap/Influenza
Education:
- Counsel on benefits and safety of vaccines
- Clear myths and misconceptions
Administration:
- Use correct aseptic technique
- Maintain cold chain and expiry date checks
- Give IM injection in deltoid muscle
Documentation:
- Record in ANC register and MCH card
- Note date, vaccine type, batch number, and site
Follow-up:
- Remind mother for 2nd dose or booster
- Observe for any adverse reaction

📦 COLD CHAIN MAINTENANCE:

Store vaccines between +2°C to +8°C
Avoid exposure to sunlight and freezing
Use vaccine carrier for field visits

🌸 MIDWIFERY NURSING: ANTENATAL ASSESSMENT

✅ INTRODUCTION

Antenatal assessment is the systematic evaluation of the pregnant woman throughout the course of her pregnancy to monitor:

Maternal health
Fetal development
Early detection of complications
Health education and counseling

This is a core function of midwifery nursing in both hospital and community settings.

📅 ANTENATAL VISIT SCHEDULE (WHO Recommended)

Visit Number	Timing
1st visit	Before 12 weeks (as early as possible)
2nd visit	Between 14–26 weeks
3rd visit	Between 28–32 weeks
4th visit	Between 36–38 weeks

🔹 High-risk pregnancies may require more frequent visits.

🧾 COMPONENTS OF ANTENATAL ASSESSMENT

1. 👩‍⚕️ History Taking

A. Personal History

Name, age, marital status, address
Occupation, dietary habits, lifestyle

B. Obstetric History (GTPAL)

Gravida, Term, Preterm, Abortions, Living children
Previous pregnancy outcomes
Complications in past pregnancies

C. Medical/Surgical History

Hypertension, diabetes, asthma, heart disease
Surgeries (e.g., cesarean, fibroids, D&C)

D. Menstrual History

Age at menarche, cycle regularity
Last menstrual period (LMP)
Estimated date of delivery (EDD) using Naegele’s Rule:
➤ LMP + 9 months + 7 days

E. Family History

Genetic disorders, twins, hypertension, diabetes

F. Psychosocial History

Stress, domestic violence, mental health

2. 🧍‍♀️ General Physical Examination

Parameter	What to Assess
Appearance	General well-being
Weight	Initial and progression
Height	For BMI and pelvic assessment
Blood Pressure	Risk of preeclampsia
Pulse & Respirations	Vital signs
Pallor	Check for anemia
Edema	Face, hands, ankles
Breast Exam	Changes, readiness for breastfeeding
Teeth & Gums	Nutritional status, bleeding gums

3. 📋 Obstetrical Examination

A. Abdominal Examination (after 16 weeks)

Step	Purpose
Inspection	Shape, size, fetal movements, scars
Palpation (Leopold’s Maneuvers)	Determine lie, presentation, position, and engagement
Fundal Height (in cm)	Correlates with gestational age (after 20 weeks: cm ≈ weeks)
Auscultation	Fetal heart sounds with fetal Doppler or stethoscope (after 20 weeks)

B. Pelvic Examination

Performed only when necessary or at term
Assess pelvic adequacy, vaginal infections, cervical status

4. 🧪 ROUTINE INVESTIGATIONS

Test	Purpose
Hemoglobin (Hb)	Detect anemia
Blood Group & Rh Typing	For Rh incompatibility
VDRL	Syphilis screening
HIV, HBsAg	Prevent mother-to-child transmission
Urine (Albumin, Sugar, Microscopy)	Detect proteinuria (PIH), glucosuria (GDM), UTI
Blood Sugar / OGTT	Screening for GDM
Ultrasound	Dating scan, anomaly scan, fetal growth monitoring

5. 🗣️ HEALTH EDUCATION & COUNSELING

Importance of ANC visits
Danger signs in pregnancy
Nutrition and supplements (IFA, Calcium)
Birth preparedness and complication readiness (BPCR)
Hygiene, sleep, physical activity
Breastfeeding and newborn care
Immunization (Tetanus, Influenza, Tdap if applicable)

6. 📈 MONITORING FETAL GROWTH & WELL-BEING

Method	When
Fundal height	Each visit after 20 weeks
Fetal movements	Starts ~18–22 weeks; mother to monitor daily
Fetal heart rate (FHR)	After 20 weeks (Normal = 110–160 bpm)
Ultrasound	Fetal growth, placental position, anomalies

🧑‍⚕️ ROLE OF THE MIDWIFE/NURSE

Assessment:
- Perform history-taking and full physical exam
- Interpret findings and identify high-risk pregnancies
Care and Monitoring:
- Monitor vital signs, fetal development, lab reports
- Refer to doctor if any abnormal findings are observed
Health Education:
- Provide targeted counseling based on the trimester
- Discuss danger signs and emergency readiness
Documentation:
- Maintain ANC card and hospital record
- Ensure completeness of test results and follow-ups
Support:
- Provide emotional support and family involvement
- Encourage open communication about discomforts or concerns

🔴 DANGER SIGNS TO WATCH FOR DURING ASSESSMENT

Vaginal bleeding
Severe headache, blurred vision
Swelling of hands/face
Reduced or absent fetal movement
High blood pressure
High fever or signs of infection

🌸 MIDWIFERY NURSING: Abdominal Palpation in Pregnancy

✅ INTRODUCTION

Abdominal palpation is a non-invasive clinical method used to assess the size, position, and well-being of the fetus by manually examining the pregnant woman’s abdomen.

It is a key component of antenatal assessment, especially from 24 weeks onward, and helps the midwife/nurse plan appropriate care for labor and delivery.

🎯 PURPOSE OF ABDOMINAL PALPATION

Estimate gestational age and fetal growth
Determine the fetal lie, presentation, and position
Check engagement of presenting part
Assess fetal movement and well-being
Detect uterine abnormalities (multiple pregnancy, polyhydramnios, IUGR)

🧍‍♀️ PREPARATION OF MOTHER

Step	Description
Explain	Purpose and procedure to reduce anxiety
Privacy	Provide privacy and maintain dignity
Position	Mother in supine position with knees flexed, head slightly elevated
Empty bladder	Ask mother to void before exam
Expose abdomen	Only lower abdomen exposed, cover other parts for comfort
Warm hands	Use warm hands to avoid discomfort
Stand on right side	Always stand on mother’s right side

👋 TECHNIQUES – LEOPOLD’S MANEUVERS (4 Steps)

These are the standard steps used for abdominal palpation.

1️⃣ Leopold’s First Maneuver – Fundal Grip

Purpose	Identify the fetal part in the fundus (head or breech)
Method	Use both hands to palpate the upper abdomen (fundus)
Findings

Round, hard, ballotable: Head
Irregular, soft, bulky: Breech (buttocks)

2️⃣ Leopold’s Second Maneuver – Lateral Grip

Purpose	Identify the fetal back and limbs (Lie and Position)
Method	Place hands on either side of the abdomen and palpate gently
Findings

Smooth, firm, curved surface: Back
Irregular, nodular parts (limbs): Front side

3️⃣ Leopold’s Third Maneuver – Pawlik’s Grip

Purpose	Identify the presenting part above the pelvic inlet
Method	Grasp the lower abdomen above the pubic symphysis with thumb and fingers
Findings

Hard, round, mobile: Head (not engaged)
Soft, irregular: Breech

4️⃣ Leopold’s Fourth Maneuver – Pelvic Grip

Purpose	Determine engagement of presenting part
Method	Face the mother’s feet, place both hands on lower abdomen, and press downwards
Findings

Deeply engaged: Head not easily movable
Floating: Head can be moved side to side

🩺 AUSCULTATION OF FETAL HEART SOUND (FHS)

Use fetoscope or Doppler
Heard best over fetal back (after 20 weeks)
Normal FHR: 110–160 bpm
Always document and report abnormal FHR

📊 INTERPRETING FINDINGS

Term	Meaning
Lie	Relationship of fetal long axis to mother’s long axis (Longitudinal, Transverse, Oblique)
Presentation	Part of fetus that enters pelvis first (Cephalic – head, Breech – buttocks)
Position	Fetal back in relation to mother’s side (LOA, ROA, LOP, etc.)
Engagement	When widest part of fetal head enters the pelvic inlet

⚠️ ABNORMAL FINDINGS TO WATCH FOR

Transverse lie → may need cesarean
Breech presentation → refer for ECV or specialist opinion
Polyhydramnios/oligohydramnios
Multiple pregnancy
Intrauterine growth restriction (IUGR)

🧑‍⚕️ MIDWIFE/NURSE’S ROLE

Performing palpation skillfully and gently
Educating the mother about fetal position
Recording findings in ANC card
Reporting abnormalities to doctor
Reassuring the mother, especially if fetal movements are decreased
Teaching mothers to monitor kick counts at home

🌸FETAL ASSESSMENT DURING PREGNANCY

✅ INTRODUCTION

Fetal assessment is the process of monitoring the growth, development, position, and well-being of the fetus during pregnancy. It ensures that the fetus is developing normally and helps detect any risks early to plan proper care.

Midwives and nurses play a vital role in regular fetal monitoring as part of antenatal care.

🩺 PURPOSE OF FETAL ASSESSMENT

Monitor fetal growth and gestational development
Detect fetal distress, anomalies, or growth restriction
Assess fetal position and presentation for delivery planning
Evaluate placental function and amniotic fluid levels

📋 METHODS OF FETAL ASSESSMENT (ANTENATAL)

1. 🗓️ Fundal Height Measurement

When	From 20 weeks onward
How	Measure from pubic symphysis to uterine fundus using tape
Normal	Fundal height in cm ≈ gestational age in weeks (± 2 cm)
Abnormal	Discrepancy may indicate IUGR, multiple pregnancy, or poly/oligohydramnios

2. 👶 Fetal Movement Monitoring (Quickening)

3. 🧏‍♀️ Auscultation of Fetal Heart Rate (FHR)

4. 🤰 Abdominal Palpation (Leopold’s Maneuvers)

5. 📺 Ultrasound Examination

6. 🩸 Biochemical Tests (Screening Tests)

7. 💉 Non-Stress Test (NST) – For High-Risk Pregnancies

8. 💧 Amniotic Fluid Index (AFI)

9. 🧪 Doppler Study (Advanced)

🚨 SIGNS OF FETAL DISTRESS (TO WATCH FOR):

Decreased or absent fetal movements
Abnormal fetal heart rate
Abnormal Doppler flow
Oligohydramnios
Abnormal NST

➡️ Immediate medical evaluation and management required.

🧑‍⚕️ NURSE’S/MIDWIFE’S RESPONSIBILITIES

Perform and record routine fetal assessments
Educate mother about kick counts and danger signs
Support during ultrasound, NST, and other procedures
Maintain accurate antenatal documentation
Refer to doctor if any abnormal fetal findings
Provide emotional reassurance to anxious mothers

🌸Auscultation of Fetal Heart Rate (FHR)

✅ INTRODUCTION

Auscultation of the fetal heart rate is a non-invasive, essential clinical skill used to assess fetal well-being during pregnancy and labor. It provides valuable information about the fetal condition and helps identify signs of distress early.

🎯 PURPOSE OF FHR AUSCULTATION

Confirm fetal viability
Monitor fetal well-being
Detect fetal distress or abnormal heart rate
Support decision-making regarding labor and delivery

🕰️ TIMING OF AUSCULTATION

Period	When to Auscultate
Antenatal period	From 18–20 weeks (earlier with Doppler) at every ANC visit
During labor	Every 30 minutes in 1st stage, every 5–15 minutes in 2nd stage (or as per protocol)

🛠️ EQUIPMENT USED

Instrument	Description
Pinard Fetoscope	Trumpet-shaped instrument used from 18–20 weeks onward
Handheld Doppler	Uses ultrasound waves; can detect FHR as early as 10–12 weeks
CTG (Cardiotocography)	For continuous monitoring in high-risk pregnancies or labor

🧍‍♀️ PREPARATION OF MOTHER

Explain the procedure to reassure and gain cooperation
Provide privacy
Position: Semi-recumbent or supine with knees flexed
Ensure the abdomen is exposed from the pubic area to the fundus
Ask the mother to empty her bladder

📍 LOCATING FHR FOR AUSCULTATION

Best heard over the fetal back, depending on fetal position
Use Leopold’s maneuvers to determine fetal lie and position before auscultating

Presentation	FHR Best Heard
Cephalic (LOA/ROA)	Below umbilicus, left or right side
Breech	Above umbilicus
Transverse lie	Near the flank

👂 PROCEDURE

Using Pinard Fetoscope:

Warm the fetoscope before use
Place the wide end firmly on the mother’s abdomen
Ask mother to remain quiet and still
Listen for rhythmic “tick-tick” or “lub-dub” sound
Count for 1 full minute
Record the rate in beats per minute (bpm)

Using Handheld Doppler:

Apply ultrasound gel to the area
Turn on Doppler device
Place probe over fetal back area
Listen and adjust position until a clear heart sound is heard
Count bpm or note device reading
Clean the probe and remove gel after use

📊 NORMAL & ABNORMAL FHR VALUES

Parameter	Value
Normal FHR	110–160 bpm
Tachycardia	>160 bpm
Bradycardia	<110 bpm

➡️ Abnormal values may indicate:

Fetal distress
Umbilical cord compression
Maternal fever, anemia, dehydration

🧑‍⚕️ NURSE’S / MIDWIFE’S ROLE

Perform FHR auscultation at each ANC visit
Use Leopold’s maneuvers to locate fetal back
Document findings: rate, rhythm, clarity, and location
Educate mother on fetal movement and danger signs
Report abnormal FHR immediately to obstetrician
Monitor FHR closely during labor and high-risk situations

🔴 WHEN TO REFER OR ALERT DOCTOR

FHR consistently <110 or >160 bpm
Irregular rhythm
Absent FHR
Accompanied by decreased fetal movements or bleeding

🌸DOPPLER vs. PINARD’S STETHOSCOPE

(For Auscultation of Fetal Heart Rate)

✅ INTRODUCTION

Both the Doppler device and Pinard’s stethoscope are used to auscultate the fetal heart sounds during pregnancy and labor. They help assess fetal well-being and detect fetal distress.

Midwives and nurses must be skilled in using both, depending on the setting, availability, and gestational age.

🔍 1. PINARD’S STETHOSCOPE

📌 Description:

A non-electronic, trumpet-shaped instrument made of metal, wood, or plastic.
Used for manual auscultation of fetal heart sounds.

📅 When to Use:

After 18–20 weeks of gestation (when FHR is audible through the abdominal wall)

✅ Advantages:

No electricity or batteries required
Inexpensive and durable
Easy to clean and sterilize
Promotes close physical contact, improving mother–midwife bonding

❌ Limitations:

Requires training and skill to use properly
May be difficult in obese mothers, anterior placenta, or noisy environments
Cannot be used before 18 weeks
No visual display or printout

🔍 2. DOPPLER FETAL MONITOR

📌 Description:

A handheld ultrasound device that uses Doppler effect to detect and amplify fetal heart sounds.
Has a digital display and/or speaker.

📅 When to Use:

Detects FHR as early as 10–12 weeks
Useful throughout pregnancy and during labor monitoring

✅ Advantages:

Detects FHR early in pregnancy
Louder, clearer sound
Has digital display (bpm) for easy reading
More comfortable and reassuring for the mother
Effective in obese women or those with thick abdominal walls

❌ Limitations:

Requires batteries or power
More expensive than Pinard
Needs gel application
Less practical in low-resource/rural settings

🧾 COMPARISON TABLE

Feature	Pinard’s Stethoscope	Doppler Fetal Monitor
Type	Manual	Electronic
Usable from	18–20 weeks	10–12 weeks
Power Source	None	Battery/electric
Cost	Very low	Moderate to high
Training Required	Moderate	Minimal
Display of FHR	No	Yes (digital display)
Use in noisy settings	Difficult	Easier
Useful in obese women	Less effective	More effective
Community/Rural Use	Excellent	Limited by power supply
Infection Control	Easy to disinfect	Requires cleaning of probe and gel

🧑‍⚕️ NURSE’S/MIDWIFE’S ROLE:

Know when and how to use each tool
Educate mother about fetal heart sounds
Maintain equipment hygiene and functionality
Record:
- FHR (beats per minute)
- Time and date
- Position of fetus (LOA, ROA, etc.)
Report any abnormal FHR or absence of fetal heart sounds

🌸ASSESSMENT OF FETAL WELL-BEING

✅ INTRODUCTION:

Fetal well-being assessment refers to the evaluation of the health status of the fetus in the uterus to ensure that it is growing normally and not in distress. It is a vital component of antenatal care, helping to reduce maternal and neonatal morbidity and mortality.

Midwives and nurses play a crucial role in early detection of fetal compromise through clinical skills, observation, and proper use of tools and techniques.

🎯 GOALS OF FETAL WELL-BEING ASSESSMENT:

Confirm fetal viability and normal development
Detect signs of fetal compromise or hypoxia
Monitor growth and amniotic fluid volume
Prevent complications such as stillbirth, IUGR, fetal distress
Decide timing and mode of delivery in high-risk pregnancies

📆 WHEN TO ASSESS FETAL WELL-BEING?

Routine assessments during every ANC visit
More frequent in high-risk pregnancies, including:
- Hypertension
- Diabetes
- Previous stillbirth
- IUGR
- Rh incompatibility
- Decreased fetal movements

📋 METHODS OF FETAL WELL-BEING ASSESSMENT:

1. 🧍‍♀️ Fundal Height Measurement

When	From 20 weeks onward
How	Measure from symphysis pubis to uterine fundus in cm
Interpretation	Fundal height (cm) ≈ gestational age (weeks) ±2
Deviation	May indicate IUGR, macrosomia, polyhydramnios or oligohydramnios

2. 🤰 Fetal Movement Monitoring (Kick Count)

3. 🩺 Fetal Heart Rate Monitoring (Auscultation)

4. 📺 Ultrasonography (USG)

a. Early Pregnancy Scan (Dating scan)

✔ Confirms viability, gestational age, and number of fetuses

b. Anomaly Scan (18–22 weeks)

✔ Detects congenital structural abnormalities

c. Growth Scan (28–34 weeks)

✔ Measures fetal weight, growth pattern, position, amniotic fluid

d. Biophysical Profile (BPP)

Assesses 5 parameters on USG:

Parameter	Normal Score (2 points each)
Fetal movement	≥3 movements
Fetal tone	≥1 extension/flexion
Fetal breathing	≥30 seconds
Amniotic fluid	≥2 cm pocket
Non-Stress Test	Reactive

✔ Total score: 8–10 = Normal; 6 = equivocal; ≤4 = abnormal

5. 💧 Amniotic Fluid Index (AFI)

| Normal | 8–18 cm | | <5 cm | Oligohydramnios (risk of fetal distress, cord compression) | | >24 cm | Polyhydramnios (risk of macrosomia, preterm labor) |

✔ Measured via ultrasound

6. 📉 Non-Stress Test (NST)

7. 🧪 Doppler Flow Studies

🧑‍⚕️ ROLE OF NURSE / MIDWIFE IN FETAL WELL-BEING ASSESSMENT:

Assess fetal growth and development at every ANC visit
Perform and interpret fundal height, FHR, fetal movement
Educate the mother on fetal kick count and when to report abnormalities
Assist with ultrasound, NST, Doppler as per doctor’s orders
Record all findings accurately in ANC register/card
Refer to higher center if signs of fetal compromise are present
Provide emotional support to mother, especially in high-risk cases

🚨 DANGER SIGNS INDICATING FETAL DISTRESS:

Decreased or absent fetal movement
Abnormal FHR
Poor fundal height growth
Non-reactive NST
Reduced amniotic fluid
Intrauterine growth restriction (IUGR)

🌸DFMC – Daily Fetal Movement Count.

✅ INTRODUCTION:

DFMC (Daily Fetal Movement Count) is a simple, non-invasive, and effective method used to assess fetal well-being by counting fetal movements felt by the mother. It helps detect early signs of fetal distress or hypoxia, especially in the third trimester.

It is one of the most cost-effective self-monitoring tools for pregnant women.

🎯 PURPOSE OF DFMC:

Detect decreased fetal activity, an early sign of fetal compromise
Promote maternal-fetal bonding
Empower the mother to be actively involved in fetal monitoring
Prevent stillbirth or intrauterine death

📅 WHEN TO START DFMC?

Generally recommended from 28 weeks of gestation onward
Especially important in high-risk pregnancies:
- Hypertension, diabetes
- IUGR (Intrauterine Growth Restriction)
- Oligohydramnios
- Decreased fetal movements previously
- Previous stillbirth

🧾 METHODS OF COUNTING FETAL MOVEMENTS:

1️⃣ Cardiff “Count to Ten” Method (Most commonly used)

2️⃣ Modified Count Method (2-Hour Method)

🧍‍♀️ INSTRUCTIONS TO THE MOTHER:

Choose a quiet time daily (after food or in the evening)
Sit comfortably or lie on left side
Count and record every kick, roll, or flutter
Maintain a kick count chart or notebook
If movements are less than normal or suddenly decrease → report immediately

📝 SAMPLE DFMC CHART:

Date	Start Time	No. of Movements	Time to Reach 10 Kicks	Remarks
01/04/2025	9:00 AM	10	By 10:45 AM	Normal
02/04/2025	9:00 AM	6	Till 12:00 PM	Needs evaluation

🔴 ABNORMAL FINDINGS:

Less than 10 movements in 12 hours
Gradual or sudden decrease in usual pattern
No movement felt for several hours
Accompanied by other danger signs (bleeding, pain, leaking, headache)

➡️ Refer immediately for NST, ultrasound, or further evaluation

🧑‍⚕️ ROLE OF NURSE / MIDWIFE:

Educate pregnant women on how and why to do DFMC
Demonstrate the correct way to count and record movements
Provide chart or sample format to record daily movements
Reinforce during each ANC visit
Take immediate action if mother reports decreased or absent fetal movement
Offer emotional support, especially if mother is anxious or unsure

🌸BIOPHYSICAL PROFILE (BPP)

✅ INTRODUCTION

The Biophysical Profile (BPP) is a comprehensive, non-invasive test used to assess fetal well-being, especially in the third trimester or in high-risk pregnancies. It combines ultrasound findings and fetal heart rate monitoring to evaluate if the fetus is receiving adequate oxygen and nutrition.

🎯 PURPOSE OF BPP:

Detect fetal hypoxia or distress
Assess fetal central nervous system activity
Decide the timing of delivery in high-risk pregnancies
Prevent complications like stillbirth or intrauterine growth restriction (IUGR)

📅 INDICATIONS FOR BPP:

Decreased fetal movement
Prolonged pregnancy (> 40 weeks)
Gestational diabetes mellitus (GDM)
Pregnancy-induced hypertension (PIH)
Intrauterine growth restriction (IUGR)
Oligohydramnios or polyhydramnios
Previous stillbirth
Rh incompatibility
Non-reactive NST (non-stress test)

📋 COMPONENTS OF BIOPHYSICAL PROFILE (5 Parameters):

Each parameter is assessed by ultrasound (except NST) and scored as either:

2 points = Normal
0 points = Abnormal

Component	Criteria (Normal = 2 points)	Abnormal = 0 points
1. Fetal Breathing Movements	At least 1 episode of rhythmic breathing lasting 30 seconds in 30 minutes	Absent or less than 30 seconds
2. Gross Body Movements	At least 3 discrete body/limb movements in 30 minutes	Less than 3
3. Fetal Tone	At least 1 episode of extension/flexion of limbs or spine	Slow extension, no flexion
4. Amniotic Fluid Volume (AFI or single pocket)	At least 1 vertical pocket of fluid ≥ 2 cm or AFI ≥ 5 cm	No pocket or < 2 cm
5. Non-Stress Test (NST)	Reactive – 2 accelerations in 20 minutes	Non-reactive NST

📊 TOTAL BPP SCORING:

Score (Out of 10)	Interpretation	Action
8–10	Normal	Reassure, repeat weekly
6	Equivocal/Suspicious	Repeat BPP in 12–24 hours or do further testing
4 or less	Abnormal (possible fetal distress)	Immediate evaluation and consider delivery

🛠️ HOW BPP IS PERFORMED:

Ultrasound is used to assess 4 parameters (breathing, movement, tone, amniotic fluid)
Non-Stress Test (NST) is done using external fetal monitors
Entire test takes 30 minutes to 1 hour
Performed in tertiary care or diagnostic centers by trained personnel

🧑‍⚕️ ROLE OF MIDWIFE / NURSE:

Preparation:
- Explain procedure to the mother and provide emotional support
- Ensure she has eaten something light before the test (for better fetal activity)
- Position mother comfortably
During Procedure:
- Assist radiologist or doctor during ultrasound
- Help apply NST belts and monitor FHR for 20 minutes
- Encourage mother to relax and remain still
After Procedure:
- Record and report the score
- Provide guidance based on the result
- If score is low, ensure referral and follow-up for emergency evaluation or delivery
Educate the Mother:
- Teach about the importance of fetal movement and timely testing
- Reassure during normal results and counsel on warning signs

🔴 WHEN TO ALERT THE DOCTOR:

Total BPP score is 4 or less
Decreased fetal movement continues
Non-reactive NST
Abnormal amniotic fluid volume

🌸 NON-STRESS TEST (NST)

✅ INTRODUCTION:

The Non-Stress Test (NST) is a non-invasive, painless, and safe procedure used to assess fetal well-being by monitoring the fetal heart rate (FHR) in response to fetal movements.

It is called “non-stress” because no stress is applied to the fetus (like uterine contractions), unlike the contraction stress test.

🎯 PURPOSE OF NST:

Evaluate the oxygenation and neurological function of the fetus
Detect fetal hypoxia or distress early
Assess placental function
Help decide timing of delivery, especially in high-risk pregnancies

📆 WHEN IS NST DONE?

Usually performed in the third trimester (after 28 weeks), especially in:

Decreased fetal movements
Hypertension or preeclampsia
Diabetes mellitus
Post-dated pregnancy (beyond 40 weeks)
Intrauterine growth restriction (IUGR)
Multiple pregnancy
Rh isoimmunization
Previous stillbirth or miscarriage
Oligohydramnios/polyhydramnios

🛠️ EQUIPMENT NEEDED:

Cardiotocograph (CTG) machine
- With 2 external transducers:
  - Ultrasound transducer (for fetal heart rate)
  - Tocodynamometer (for uterine activity)
Gel, belts, watch/timer, bed or reclining chair

🧍‍♀️ PREPARATION OF THE MOTHER:

Explain the procedure and obtain consent
Ask the mother to eat a light meal before the test (to stimulate fetal activity)
Encourage her to empty her bladder
Position her in semi-Fowler’s or left lateral position
Apply gel and secure the transducers on the abdomen

👩‍⚕️ PROCEDURE OF NST:

Attach the FHR transducer and uterine activity transducer to the abdomen.
Ask the mother to press a button every time she feels fetal movement.
Monitor and record the fetal heart rate and uterine activity for 20 minutes (may be extended to 40 minutes if needed).
Save or print the CTG strip.

📊 INTERPRETATION OF NST:

NST Result	Criteria	Interpretation
Reactive NST (Normal)	– At least 2 accelerations in 20 minutes – Each acceleration: ≥15 bpm above baseline, lasting ≥15 seconds	✅ Reassuring Normal fetal oxygenation
Non-Reactive NST	– No accelerations or – Accelerations do not meet above criteria	⚠️ Needs further evaluation May indicate fetal distress or sleep cycle
Unsatisfactory/Incomplete	– Poor tracing quality – Unable to interpret results	❌ Repeat NST or perform Biophysical Profile (BPP)

📍 OTHER OBSERVATIONS ON NST:

Baseline FHR: 110–160 bpm
Variability: Moderate variability (6–25 bpm) is normal
No decelerations: Late or variable decelerations may suggest hypoxia

🧑‍⚕️ NURSE / MIDWIFE’S RESPONSIBILITIES:

🌼 Before the Test:

Explain the purpose, gain trust
Ensure privacy and comfort
Check that the mother has eaten
Ask about fetal movement and any recent concerns

🌼 During the Test:

Monitor fetal movements
Check the CTG machine for proper tracing
Reassure the mother throughout
If fetus is inactive, try gentle stimulation (change position, juice intake)

🌼 After the Test:

Interpret and record findings
Report non-reactive or abnormal NST immediately to the obstetrician
Document date, time, results, and mother’s condition
If reactive, reassure the mother and schedule the next follow-up
Advise kick counts and to report decreased fetal movement

📝 DOCUMENTATION FORMAT:

Parameter	Observation
FHR baseline	140 bpm
Variability	Moderate
Accelerations	2 accelerations present
Decelerations	Absent
Fetal movements felt	4
Result	Reactive
Action Taken	No further intervention needed

🌸 CARDIOTOCOGRAPHY (CTG)

(Also known as Electronic Fetal Monitoring – EFM)

✅ INTRODUCTION

Cardiotocography (CTG) is a non-invasive procedure used to monitor fetal heart rate (FHR) and uterine contractions simultaneously. It helps assess fetal well-being, especially during the third trimester and labor.

It is a vital tool in high-risk pregnancies and labor monitoring to detect early signs of fetal distress.

🧠 PURPOSE OF CTG:

Monitor baseline fetal heart rate
Evaluate fetal response to uterine contractions
Detect fetal distress/hypoxia
Monitor uterine contraction pattern
Help guide decisions about timing and mode of delivery

📅 WHEN IS CTG USED?

During Antenatal Period:

High-risk pregnancy (PIH, GDM, IUGR, Rh incompatibility)
Decreased fetal movement
Post-dated pregnancy (>40 weeks)
Non-reactive NST
Suspected placental insufficiency

During Intrapartum Period:

To monitor fetal response during labor
Induction of labor or oxytocin use
Meconium-stained liquor
Previous cesarean section
Multiple gestation

🛠️ EQUIPMENT USED:

CTG Machine with:
- Ultrasound transducer – to monitor FHR
- Tocodynamometer – to monitor uterine contractions
Gel
Belts or straps

🧍‍♀️ PREPARATION OF THE MOTHER:

Explain procedure to obtain consent
Ensure the mother has emptied her bladder
Position: Semi-recumbent or left lateral
Apply gel to abdomen and fix both probes:
- Ultrasound transducer over fetal back (detected via Leopold’s maneuvers)
- Toco probe over uterine fundus (where contractions are felt)

📋 PARAMETERS MONITORED:

1. Fetal Heart Rate (FHR)

| Normal Baseline | 110–160 bpm | | Tachycardia | >160 bpm | | Bradycardia | <110 bpm |

2. Baseline Variability

(The beat-to-beat fluctuation of FHR)

3. Accelerations

Sudden ↑ in FHR by ≥15 bpm lasting ≥15 seconds
Sign of fetal well-being

4. Decelerations

Drop in FHR; may indicate cord compression or hypoxia

Type	Meaning
Early	Normal, due to head compression
Late	Abnormal, due to uteroplacental insufficiency
Variable	Cord compression – may need intervention

5. Uterine Contractions

Frequency, duration, intensity (measured in mmHg on monitor)

📊 INTERPRETATION OF CTG (3-Tier System – FIGO/WHO)

CTG Category	Features	Clinical Action
Normal	Baseline 110–160 bpm, moderate variability, no late decels	Continue routine monitoring
Suspicious	One abnormal feature (e.g., mild bradycardia, reduced variability)	Closer observation, repeat test
Pathological	Persistent bradycardia, absent variability, late decels	Urgent intervention or delivery

🧑‍⚕️ ROLE OF NURSE / MIDWIFE:

Preparation:
- Explain and reassure the mother
- Ensure comfortable positioning
- Apply transducers correctly
Monitoring:
- Monitor FHR and contractions for at least 20–30 minutes
- Observe and record any abnormal patterns
- Note fetal movements during the trace
Documentation:
- Record date, time, FHR, variability, accelerations, decelerations, uterine activity
- Keep printed CTG strip in patient’s file
Action:
- Inform obstetrician immediately if abnormal CTG
- Assist with further evaluation (BPP, emergency delivery)
- Provide emotional support to anxious mothers

🛑 WHEN TO REPORT IMMEDIATELY:

FHR <110 or >160 bpm
No variability
Late decelerations
Prolonged contractions or hyperstimulation

🌸 USG – Ultrasonography in Pregnancy

✅ INTRODUCTION

Ultrasonography (USG) is a safe, non-invasive, and widely used imaging technique in obstetrics. It uses high-frequency sound waves to create images of the developing fetus, placenta, uterus, and surrounding structures.

USG is an essential tool in antenatal care for assessing fetal development, detecting abnormalities, and guiding decisions throughout pregnancy.

🎯 PURPOSE OF USG IN PREGNANCY:

Confirm pregnancy and viability
Determine gestational age and EDD
Monitor fetal growth and position
Detect congenital anomalies
Assess placental location and amniotic fluid
Diagnose multiple pregnancy
Identify complications (IUGR, ectopic, molar pregnancy, etc.)

📅 TYPES & TIMING OF ROUTINE USGs:

Scan	Timing	Purpose
Dating Scan (Early Pregnancy Scan)	6–9 weeks	Confirm viability, rule out ectopic pregnancy, assess crown-rump length (CRL) for dating
NT Scan (Nuchal Translucency)	11–14 weeks	Screen for chromosomal abnormalities (Down syndrome, Trisomy 18)
Anomaly Scan (Level II)	18–22 weeks	Detect structural abnormalities (brain, heart, spine, kidneys, limbs)
Growth Scan	28–32 weeks	Assess fetal size, weight, growth pattern, and well-being
Term Scan	36–38 weeks	Confirm fetal position, placental site, and amniotic fluid volume
Other USGs	As needed	For complications like bleeding, pain, IUGR, PIH, or previous history of loss

🧪 SPECIALIZED TYPES OF USG:

Type	Use
Transvaginal USG (TVS)	Early pregnancy, cervical length
Doppler USG	Assesses blood flow in umbilical artery and fetal vessels
3D/4D USG	Better visualization of fetal anomalies and movement

📊 KEY ASSESSMENTS IN USG:

Parameter	What It Shows
Fetal Heartbeat	Viability (usually visible by 6–7 weeks)
Gestational Age	Based on CRL, BPD, FL, HC, AC
Fetal Number	Singleton or twins/triplets
Fetal Position	Cephalic, breech, transverse
Fetal Weight and Growth	Assessed in later trimesters
Amniotic Fluid Index (AFI)	Normal: 8–18 cm Oligohydramnios: <5 cm Polyhydramnios: >24 cm
Placental Location	Anterior, posterior, fundal, low-lying (placenta previa)
Structural Anomalies	Cleft lip, neural tube defects, cardiac anomalies, limb deformities

🧑‍⚕️ ROLE OF NURSE / MIDWIFE IN USG:

🌼 Before the USG:

Educate the mother about the purpose of the scan
Instruct about bladder filling if needed (for early transabdominal USG)
Provide emotional support, especially in anxious mothers
Review any prior test reports

🌼 During the USG:

Assist in positioning the mother
Help apply gel and ensure privacy
Support the radiologist or sonographer if needed
Calm and reassure the mother throughout the procedure

🌼 After the USG:

Ensure mother understands results (as appropriate)
Document USG findings in ANC card and records
Guide next steps if abnormalities are suspected (referral, follow-up scans)
Reinforce kick count monitoring and follow-up appointments

⚠️ WHEN TO ALERT DOCTOR:

No fetal heartbeat after 7 weeks
Low-lying placenta or placenta previa
Major congenital anomalies
Abnormal growth or IUGR
Reduced amniotic fluid
Non-cephalic presentation near term

✅ SAFETY OF USG:

No ionizing radiation
Safe in all trimesters
Can be repeated as clinically indicated
Transvaginal USG is safe and more accurate in early pregnancy

🌸 VIBROACOUSTIC STIMULATION (VAS)

✅ INTRODUCTION

Vibroacoustic Stimulation (VAS) is a non-invasive procedure used to stimulate the fetus using sound and vibration to provoke a fetal heart rate (FHR) acceleration. It is mainly used to assess fetal well-being and confirm fetal reactivity during a non-stress test (NST).

🎯 PURPOSE OF VAS:

To stimulate fetal movement during a non-reactive NST
Confirm the presence of fetal reactivity
Reduce the need for extended monitoring or more invasive tests
Differentiate between fetal sleep and hypoxia
Assist in intrapartum fetal assessment

📅 WHEN IS VAS INDICATED?

During a non-reactive NST (no accelerations within 20 minutes)
In high-risk pregnancies where quick reassurance of fetal well-being is needed
To stimulate fetal activity for better FHR evaluation
Sometimes during labor to assess fetal response

🛠️ EQUIPMENT REQUIRED:

VAS device (artificial larynx or acoustic stimulator)
CTG/NST machine (cardiotocograph)
Conductive gel (if needed)
Watch/timer

🧍‍♀️ PREPARATION OF THE MOTHER:

Explain the purpose of the procedure
Ensure the mother is in a semi-recumbent or left lateral position
Ask the mother to report fetal movements
Place the FHR transducer using Leopold’s maneuver to locate fetal back

👩‍⚕️ PROCEDURE OF VAS:

Apply the CTG transducer and ensure baseline FHR tracing is obtained.
Place the VAS device over the fetal head area (usually over the fetal back) on the maternal abdomen.
Deliver sound stimulus for 1–3 seconds.
Repeat stimulus up to 3 times, at 1-minute intervals, if no response is noted.
Monitor the fetal heart rate for 5–10 minutes after stimulation.

📊 INTERPRETATION OF VAS:

Fetal Response	Interpretation
Acceleration of FHR ≥15 bpm lasting ≥15 seconds within 15–20 minutes	✅ Reactive – reassuring
No acceleration or poor variability even after 3 attempts	⚠️ Non-reactive – possible hypoxia or fetal compromise Requires further evaluation (BPP, Doppler, delivery if needed)

📌 CONTRAINDICATIONS:

Known fetal hearing loss
Preterm pregnancy (<32 weeks) due to immature auditory system
Known congenital malformations
Placenta previa, unexplained vaginal bleeding
Intrauterine infection or chorioamnionitis

🧑‍⚕️ ROLE OF NURSE / MIDWIFE:

🌼 Before the Procedure:

Explain the procedure and gain cooperation
Ensure CTG setup is functioning
Perform Leopold’s maneuver to locate fetal back

🌼 During the Procedure:

Correctly apply VAS device and limit stimulation to <3 seconds
Observe and record FHR response
Do not overuse stimulation to avoid fetal stress

🌼 After the Procedure:

Continue CTG tracing for 10–20 minutes
Interpret findings: Was the NST reactive after VAS?
Record in ANC/labor record
Report non-reactive VAS results to the obstetrician

✅ ADVANTAGES OF VAS:

Quick and safe test
Reduces false-positive non-reactive NSTs
Improves accuracy of fetal surveillance
Non-invasive and easy to perform

❌ LIMITATIONS:

May not be effective if the fetus is compromised
Can cause temporary fetal tachycardia if overused
Should not be used indiscriminately

🌸 BIOCHEMICAL TESTS IN PREGNANCY

✅ INTRODUCTION:

Biochemical tests during pregnancy are essential for:

Monitoring the health of the mother
Screening for fetal abnormalities
Detecting maternal infections and metabolic disorders
Guiding timely medical or obstetric interventions

These tests typically involve analysis of blood, urine, and other body fluids to evaluate physiological changes and screen for diseases.

📅 TRIMESTER-WISE BIOCHEMICAL TESTS:

🩸 FIRST TRIMESTER (Up to 12 weeks)

Test	Purpose
Hemoglobin (Hb%)	Detect anemia
Blood Group & Rh Typing	Identify Rh incompatibility
Blood Sugar (FBS/RBS)	Screen for undiagnosed diabetes
HIV, HBsAg, VDRL	Screen for infections (as per PPTCT guidelines)
Urine Routine & Microscopy	Detect proteinuria, UTI, glucose
Thyroid Function Test (TSH, T3, T4)	Assess thyroid health (especially in high-risk pregnancies)
Serum Creatinine & Urea	Assess kidney function
Serum Bilirubin, LFTs	If liver disease is suspected
Rubella IgG, Toxoplasma IgM, CMV, HSV (TORCH Panel) (if indicated)	Screen for infections causing fetal malformations

🧪 SECOND TRIMESTER (13–28 weeks)

Test	Purpose
Triple Marker Test (AFP, hCG, Estriol)	Screening for Down syndrome, Trisomy 18, Neural Tube Defects
Quadruple Marker Test (Adds Inhibin-A)	More accurate screening than triple marker
Glucose Challenge Test (GCT) or Oral Glucose Tolerance Test (OGTT)	Detect Gestational Diabetes Mellitus (GDM)
Repeat Hb and Urine Tests	Monitor anemia and UTIs
Indirect Coombs Test (ICT) (for Rh-negative mothers)	Detect Rh sensitization before Anti-D administration

💉 THIRD TRIMESTER (29 weeks onward)

Test	Purpose
Repeat Hb, Blood Sugar, and Urine Tests	Monitor maternal condition
HIV, HBsAg, VDRL (Re-test in some protocols)	Ensure infection control during delivery
Serum Uric Acid	Monitor preeclampsia
Liver and Renal Function Tests	In suspected PIH or HELLP syndrome
NST, Biophysical Profile, or Doppler	Assess fetal well-being (though not biochemical, often done alongside)

🧬 SPECIAL BIOCHEMICAL TESTS (As Indicated)

Test	Use
Serum Ferritin	Assess iron stores
Vitamin D & Calcium Levels	Evaluate in cases of bone pain or muscle cramps
HbA1c	Glycemic control over 3 months (for known diabetics)
Serum Progesterone / Beta-hCG	Evaluate early pregnancy viability
Cervical Fetal Fibronectin (fFN)	Predict risk of preterm labor

🧑‍⚕️ ROLE OF MIDWIFE/NURSE:

🌼 Before Testing:

Educate the mother on purpose and preparation (e.g., fasting for GTT)
Verify identity and test requirements
Ensure consent and comfort

🌼 During Testing:

Assist with sample collection (blood/urine)
Maintain asepsis and proper labeling
Ensure cold chain/storage for sample transport (if needed)

🌼 After Testing:

Interpret and report abnormal values to the doctor
Document results in ANC card and records
Counsel the mother on results and necessary precautions/treatments
Ensure compliance with treatment (e.g., iron, insulin, antibiotics)

🌸 ANTENATAL CARE (ANC)

✅ INTRODUCTION:

Antenatal Care (ANC) refers to the supervised care of a pregnant woman from conception to the onset of labor. It is a crucial part of maternal and child health services and aims to ensure a healthy pregnancy outcome for both mother and baby.

🎯 OBJECTIVES OF ANTENATAL CARE:

Promote and maintain the health of the mother and fetus
Detect and manage high-risk pregnancies and complications
Prepare the woman for labor, birth, and postpartum care
Educate about nutrition, hygiene, newborn care, and breastfeeding
Reduce maternal and perinatal morbidity and mortality

📆 ANTENATAL VISIT SCHEDULE (WHO & Indian Guidelines)

Visit Number	When
1st visit	Before 12 weeks
2nd visit	14–26 weeks
3rd visit	28–34 weeks
4th visit	36–38 weeks
➡️ High-risk pregnancies may require more frequent visits.

📋 COMPONENTS OF ANTENATAL CARE

1. 📝 History Taking

Personal history: name, age, marital status, address
Obstetric history: Gravida, Para, Abortions, Living children (G-P-A-L)
Menstrual history: LMP, EDD (Naegele’s Rule)
Medical/surgical history: diabetes, hypertension, asthma
Family history: genetic disorders, twin pregnancy
Dietary and lifestyle habits
Socioeconomic status and support system

2. 🧍‍♀️ General Physical Examination

Height and weight (BMI)
Blood pressure
Pulse and respiration
Temperature
Signs of anemia (pallor)
Edema (face, hands, feet)
Breast examination
Oral hygiene and dental status

3. 🤰 Obstetric Examination

a. Abdominal Examination (from 16 weeks)

Inspection: shape, size, movements, scars
Palpation (Leopold’s Maneuvers):
- Fundal height (correlates with gestational age)
- Fetal lie, presentation, and position
- Engagement of the presenting part
Auscultation of Fetal Heart Rate (FHR):
- Normal: 110–160 bpm

b. Pelvic Examination

Done only if indicated (late pregnancy or in complications)
Assess pelvic adequacy, cervical changes, vaginal infections

4. 🧪 Routine Laboratory Investigations

Test	Purpose
Hemoglobin (Hb%)	Detect anemia
Blood Group & Rh Typing	Rh incompatibility
Urine Routine & Microscopy	Detect UTI, proteinuria, glycosuria
HIV, HBsAg, VDRL	Infections screening
Random Blood Sugar / OGTT	Detect gestational diabetes
Ultrasound	Confirm dating, fetal anomalies, growth monitoring
Indirect Coombs Test (ICT)	In Rh-negative mothers

5. 💊 Supplementation & Immunization

Intervention	Details
Iron + Folic Acid (IFA)	1 tablet/day from 14–16 weeks for 180 days
Calcium + Vitamin D	2 tablets/day from 14 weeks
Deworming (Albendazole 400 mg)	After first trimester
Tetanus + Diphtheria (Td) Vaccine	2 doses 4 weeks apart, starting after 16 weeks Or 1 booster dose if previously vaccinated

6. 📚 Health Education and Counseling

Balanced diet and hydration
Personal hygiene and adequate rest
Antenatal exercises and posture
Danger signs in pregnancy
Importance of regular check-ups
Birth preparedness and complication readiness (BPCR)
Breastfeeding and newborn care
Importance of institutional delivery
Avoid alcohol, smoking, and self-medication

7. 🩺 Assessment of Fetal Well-being

Fetal movement (kick count from 28 weeks)
Fetal heart rate monitoring
Ultrasound for growth and position
Non-Stress Test (NST), Biophysical Profile (BPP) if high-risk

🚨 DANGER SIGNS TO REPORT IMMEDIATELY:

Vaginal bleeding
Severe headache, blurred vision
Abdominal pain
Swelling of face and hands
Decreased or no fetal movements
Fever or foul-smelling discharge
Convulsions

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN ANC:

Provide holistic antenatal assessment
Perform routine examinations and assist in investigations
Counsel the mother and her family
Ensure immunization and supplement compliance
Identify high-risk pregnancies early
Maintain proper documentation (ANC card/record)
Refer complicated cases to higher centers
Provide emotional support and continuity of care

🌸 WOMEN-CENTERED CARE (WCC)

✅ INTRODUCTION

Women-Centered Care (WCC) is a philosophy of care that respects and prioritizes the individual needs, preferences, rights, and autonomy of the woman throughout her reproductive, maternal, and postnatal journey. It is based on holistic, respectful, and collaborative care.

WCC shifts the focus from the medical system’s needs to the woman’s experience, empowering her to make informed choices about her health.

🎯 OBJECTIVES OF WOMEN-CENTERED CARE:

Empower women to participate actively in their own health decisions
Promote dignity, respect, and compassion in maternity care
Ensure safe, satisfying, and culturally sensitive experiences during pregnancy, birth, and postpartum
Prevent disrespect, discrimination, and abuse in healthcare
Strengthen the woman’s physical, emotional, social, and spiritual well-being

❤️ CORE PRINCIPLES OF WOMEN-CENTERED CARE:

Principle	Explanation
Respect and dignity	Women are treated with courtesy, privacy, and respect regardless of background or choices
Autonomy and informed choice	Women have the right to make decisions about their care based on accurate and full information
Holistic care	Addresses physical, emotional, mental, social, spiritual, and cultural needs
Continuity of care	The same team/provider follows the woman throughout pregnancy, labor, and postnatal care
Communication and support	Open, non-judgmental, and compassionate communication
Collaboration	Woman is considered a partner in care along with the midwife, doctor, and other healthcare providers

📍 APPLICATION OF WOMEN-CENTERED CARE IN MATERNITY SERVICES:

1. During Antenatal Care (ANC):

Respect the woman’s choices about tests, supplements, birth plans
Educate and support decision-making without forcing interventions
Offer culturally acceptable information
Recognize the importance of emotional well-being during pregnancy

2. During Labor and Delivery:

Allow choice of birth position, pain relief methods, and birth companions
Encourage physiological childbirth (natural unless medically indicated)
Respect her dignity, modesty, and need for privacy
Support delayed cord clamping and immediate skin-to-skin contact

3. During Postnatal Care:

Support her choices around breastfeeding, newborn care, and postpartum rest
Involve her in decisions about contraception and family planning
Screen for postnatal depression or anxiety, and provide mental health support

👩‍⚕️ ROLE OF NURSE / MIDWIFE IN WOMEN-CENTERED CARE:

Listen actively to the woman’s preferences, concerns, and values
Provide evidence-based information in a clear, non-medical language
Advocate for the woman’s rights in clinical settings
Avoid judgment about personal, cultural, or reproductive choices
Support informed consent before any procedure or intervention
Promote shared decision-making with doctors and the woman
Respect cultural practices as long as they are safe
Ensure continuity of care and emotional support
Protect against disrespect and abuse in maternity care
Document clearly and truthfully about decisions made by the woman

🌍 GLOBAL IMPORTANCE (WHO Guidelines):

Respectful Maternity Care (RMC) is a key component of women-centered care.
WCC is essential to achieving Sustainable Development Goal 3 – reducing maternal and neonatal mortality.
Promotes trust in the healthcare system, reducing home births without skilled attendants.

📝 EXAMPLES OF WOMEN-CENTERED CARE:

Scenario	Women-Centered Approach
Woman requests not to be examined by male staff	Assign female provider where possible
Woman wants to try vaginal birth after cesarean (VBAC)	Provide information, risks, and support choice
Refuses certain tests due to religious beliefs	Respect decision and document accordingly
Experiencing fear of childbirth	Offer emotional support, education, and reassurance

✅ BENEFITS OF WOMEN-CENTERED CARE:

Improved maternal satisfaction and confidence
Better adherence to antenatal/postnatal care
Fewer unnecessary interventions (like cesarean)
Safer, more respectful birthing experiences
Strengthened mother-infant bonding and breastfeeding success

Respectful Maternity Care & Compassionate Communication

✅ INTRODUCTION:

Respectful Care and Compassionate Communication are essential components of humanized maternal healthcare. They ensure that every woman receives care that is dignified, empathetic, culturally appropriate, and free from abuse, neglect, or discrimination.

They form the foundation of Women-Centered Care and are central to the World Health Organization (WHO) standards for quality maternal and newborn care.

🎯 OBJECTIVES:

Preserve the dignity, privacy, and autonomy of women in healthcare settings
Build trust and therapeutic relationships between women and caregivers
Prevent disrespect and abuse in maternity care
Improve health outcomes and maternal satisfaction
Encourage women to seek timely and regular health services

💗 RESPECTFUL MATERNITY CARE (RMC):

(As per WHO framework)

🌼 Key Rights of Women in Maternal Care:

Right to be treated with respect and dignity
Right to information, informed consent, and choice
Right to privacy and confidentiality
Right to equitable care without discrimination
Right to freedom from harm and abuse
Right to companionship during labor (if desired)
Right to timely and appropriate care

🗣️ COMPASSIONATE COMMUNICATION:

A skill that involves speaking and listening with empathy, kindness, and sensitivity.

🌸 Principles of Compassionate Communication in Maternity Care:

Principle	Description
Active Listening	Give full attention, avoid interruptions, nod, and show interest
Use of Simple Language	Avoid medical jargon; use words the woman can understand
Empathy	Acknowledge feelings; say “I understand this is difficult for you”
Non-verbal Cues	Maintain eye contact, smile, soft tone, gentle touch
Validation of Feelings	Respect fears, concerns, and cultural beliefs
Respect for Choice	Support the woman’s decisions even if they differ from routine practice
Calmness and Patience	Especially during labor, anxiety, or complications

🧑‍⚕️ NURSE / MIDWIFE’S ROLE IN RESPECTFUL CARE & COMMUNICATION:

🔹 In Antenatal Care:

Maintain privacy during examination
Listen actively to the woman’s concerns
Explain all procedures and seek consent
Provide education without judgment
Respect cultural practices as long as they are safe

🔹 In Labor and Delivery:

Introduce yourself and explain your role
Always ask before touching or performing any procedure
Allow birth companions if the woman desires
Use calming words and provide encouragement
Avoid shouting, scolding, or blaming the woman
Allow preferred birthing position if safe and possible

🔹 In Postnatal Care:

Offer emotional support to new mothers
Respect her choices about breastfeeding or infant care
Address her mental and emotional health
Encourage questions and offer guidance kindly

🚨 EXAMPLES OF DISRESPECT & ABUSE (To be Avoided):

Yelling, scolding, or mocking the woman during labor
Performing procedures without consent
Leaving a woman unattended during labor
Refusing care due to caste, religion, age, or marital status
Denying pain relief without explanation
Not allowing a birth companion (when policy allows)

✅ BENEFITS OF RESPECTFUL & COMPASSIONATE CARE:

Increases maternal trust and satisfaction
Promotes positive birth experiences
Encourages women to return for future care
Reduces maternal stress and improves health outcomes
Builds respectful midwife-client relationships

📌 KEY PHRASES TO USE:

“You are doing well. I’m here to help you.”
“Do you have any questions or concerns?”
“Would you like someone to be with you?”
“I’ll explain what I’m going to do before we begin.”
“Your feelings are valid. We will support you.”

REFERRAL SYSTEM IN MATERNAL AND CHILD HEALTHCARE

✅ INTRODUCTION:

A referral is the process of transferring a pregnant woman or neonate from one level of care to a higher-level facility for further assessment, treatment, or management when their condition goes beyond the available resources or skills at the primary care level.

Effective referrals are critical in preventing maternal and neonatal mortality, especially in high-risk or emergency situations.

🎯 OBJECTIVES OF REFERRAL:

Provide timely and appropriate care at the correct level
Ensure continuity of care
Minimize delays in diagnosis and treatment
Prevent complications and adverse outcomes
Promote a functioning health system linkage between facilities

📦 TYPES OF REFERRAL:

Type	Description
Routine Referral	Planned referral for conditions like anemia, previous cesarean, high BP
Emergency Referral	Urgent referral for complications like bleeding, eclampsia, obstructed labor
Self-Referral	When the woman directly goes to a higher center without recommendation
Back-Referral	Referred patient sent back to original facility for follow-up care after stabilization

🧍‍♀️ CONDITIONS THAT REQUIRE REFERRAL (MATERNAL):

Severe anemia (Hb < 7 g/dL)
High-risk pregnancy (PIH, GDM, multiple pregnancy, IUGR)
Antepartum hemorrhage (APH)
Premature rupture of membranes (PROM)
Eclampsia or convulsions
Obstructed labor or prolonged labor
Malpresentation (breech, transverse lie)
Previous 2 or more cesarean deliveries
Postpartum hemorrhage (PPH)
Retained placenta or incomplete abortion
Severe infections or fever with chills

👶 CONDITIONS THAT REQUIRE REFERRAL (NEWBORN):

Low birth weight (<2 kg)
Birth asphyxia or poor Apgar score
Jaundice before 24 hours or very yellow skin
Breathing difficulty, seizures, or convulsions
Congenital anomalies
Refusal to feed or lethargy
Neonatal sepsis signs (fever, poor tone)

📝 ESSENTIAL COMPONENTS OF A GOOD REFERRAL:

Assessment: Confirm the need for referral
Stabilization: Do initial treatment to prevent deterioration (e.g., IV fluids, oxygen, injections)
Communication: Inform the referral center in advance
Documentation: Complete a referral slip/form with clear clinical notes
Transport: Arrange for safe, quick, and comfortable transport
Accompaniment: Send an attendant or staff if necessary
Back-Referral: Encourage feedback and follow-up from higher center

📋 REFERRAL SLIP FORMAT (Key Elements):

Patient name, age, gravida/para status
Reason for referral
Vital signs and examination findings
Investigations done
Treatment given before referral
Facility details and referring person’s name
Emergency contact or relative accompanying

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN REFERRAL:

Responsibility	Details
Identification	Recognize danger signs or high-risk cases early
Decision-making	Consult doctor/medical officer if unsure
Communication	Clearly explain reason for referral to the patient and family
Stabilization	Start IV, give medication, monitor vitals before transfer
Documentation	Write complete and accurate referral form
Counseling	Reassure the woman and reduce fear during the transfer
Coordination	Arrange transport, call the referral center, inform higher facility

📌 BARRIERS TO EFFECTIVE REFERRAL:

Lack of transport or delay in ambulance
Poor communication between facilities
Incomplete referral documentation
Family reluctance due to cost or distance
Lack of awareness among patients

✅ IMPORTANCE OF A STRONG REFERRAL SYSTEM:

Reduces maternal and newborn deaths
Promotes continuity and efficiency of care
Builds trust in the health system
Supports team-based care between nurses, doctors, and specialists

COLLABORATION IN MATERNAL AND NEWBORN CARE

✅ INTRODUCTION:

Collaboration in healthcare means working together across different professions and levels of care to provide the best possible outcomes for the mother, baby, and family. It involves mutual respect, shared responsibilities, and effective communication between midwives, nurses, doctors, specialists, families, and other care providers.

🎯 OBJECTIVES OF COLLABORATION:

Provide safe, comprehensive, and coordinated care
Ensure early detection and timely management of complications
Promote interdisciplinary decision-making
Avoid duplication of services and delays in treatment
Enhance patient satisfaction and healthcare provider efficiency

👩‍👩‍👦 WHO IS INVOLVED IN COLLABORATION?

Stakeholder	Role
Midwife/Nurse	First point of contact, ongoing care, monitoring, education
Obstetrician/Gynecologist	High-risk pregnancy management, deliveries, surgical care
Pediatrician/Neonatologist	Newborn resuscitation, neonatal care
Anesthetist	Labor analgesia, C-section
Dietician	Nutritional counseling in pregnancy, anemia, GDM
Lab Technician	Timely and accurate investigations
Social Worker/Counselor	Psychosocial support, domestic violence cases
Family Members	Support, decision-making, postnatal care

🔗 TYPES OF COLLABORATION IN MATERNAL CARE:

Type	Example
Intraprofessional	Midwives working together in a labor ward
Interprofessional	Nurse-midwife collaborating with doctors and dieticians
Multidisciplinary	Entire team (OB-GYN, neonatologist, social worker) planning care for a high-risk mother
Client collaboration	Mother actively involved in decision-making about her birth plan

🏥 EXAMPLES OF COLLABORATION IN PRACTICE:

Midwife identifies PIH → Refers to doctor → Doctor prescribes medication → Nurse monitors BP and educates mother
High-risk pregnancy (GDM) → Nurse monitors sugar → Dietician plans meals → Physician adjusts insulin
Obstructed labor → Midwife informs doctor → Doctor assesses and prepares for C-section → Anesthetist and OT team are involved
Neonatal resuscitation needed → Midwife delivers → Pediatrician resuscitates → NICU nurse takes over care

🌼 PRINCIPLES OF EFFECTIVE COLLABORATION:

Principle	Explanation
Mutual Respect	Value each team member’s skills and contributions
Open Communication	Share relevant information clearly and promptly
Shared Decision-Making	All team members contribute to care planning
Trust & Accountability	Each person is responsible and dependable
Client-Centered Approach	Keep the woman and baby’s needs at the center

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN COLLABORATION:

Communicator: Share clinical findings and updates with the team
Coordinator: Schedule appointments, ensure follow-ups
Educator: Provide information to the mother and team members
Advocate: Speak up for the woman’s rights and preferences
Facilitator: Help bring the team together and resolve conflict if needed
Observer: Monitor changes in condition and report promptly
Documenter: Record all referrals, decisions, and outcomes clearly

🌟 BENEFITS OF COLLABORATIVE CARE:

Better maternal and neonatal outcomes
Increased efficiency and reduced medical errors
Enhanced staff satisfaction and professional growth
Faster and more coordinated responses to emergencies
Empowered mothers through shared decision-making

🚫 CONSEQUENCES OF POOR COLLABORATION:

Delayed or inappropriate care
Miscommunication and medical errors
Increased maternal or neonatal morbidity
Staff frustration and burnout
Loss of trust by the patient/family

EMPOWERMENT IN MATERNAL AND WOMEN’S HEALTHCARE

✅ INTRODUCTION:

Empowerment in nursing and midwifery refers to the process of enabling women to take control over their own health, decisions, and lives. It involves educating, supporting, encouraging, and respecting women so they can make informed choices about their bodies, pregnancies, childbirth, and families.

Empowered women are more likely to have healthy pregnancies, seek timely care, and make decisions that benefit their own health and that of their babies.

🎯 OBJECTIVES OF EMPOWERMENT IN MATERNAL CARE:

Increase a woman’s confidence and self-efficacy
Promote informed decision-making in pregnancy and childbirth
Encourage women to actively participate in their own care
Improve maternal and neonatal health outcomes
Reduce gender inequalities and health disparities
Protect women’s rights, dignity, and autonomy

💡 TYPES OF EMPOWERMENT (IN HEALTHCARE CONTEXT):

Type	Description
Health Empowerment	Women understand their health conditions and know how to manage them
Emotional Empowerment	Women feel supported, heard, and emotionally secure
Educational Empowerment	Women are informed about their bodies, birth options, and baby care
Social Empowerment	Women can access resources, support systems, and make decisions freely
Economic Empowerment	Women have financial control and decision-making power regarding healthcare

🌼 KEY PRINCIPLES OF EMPOWERMENT IN MIDWIFERY:

Principle	Application in Practice
Respect for autonomy	Support women in making their own health decisions
Access to information	Educate in simple language using visual aids or local languages
Active participation	Encourage involvement in birth planning and self-care
Supportive care	Provide emotional encouragement and non-judgmental communication
Skill-building	Teach women about nutrition, hygiene, baby care, and breastfeeding

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN EMPOWERING WOMEN:

Educator:
- Provide antenatal and postnatal education
- Use group teaching, demonstrations, flipcharts, and individual counseling
Counselor:
- Support women in emotional distress
- Discuss fears and encourage confidence
Advocate:
- Stand up for the woman’s rights (e.g., informed consent, privacy)
- Intervene if care is disrespectful or discriminatory
Facilitator:
- Encourage birth companions, birth plans, and choice of birthing positions
Mentor:
- Teach adolescent girls and women about reproductive health, menstrual hygiene, and family planning
Supporter of Decision-Making:
- Involve women in decisions regarding labor, delivery methods, pain relief, and newborn care

📌 EXAMPLES OF EMPOWERMENT IN MATERNAL CARE:

Scenario	Empowered Action
Pregnant woman asks for birth plan	Midwife helps her create one
Woman requests to delay procedures	Her choice is respected unless urgent
First-time mother feels anxious	Nurse reassures, explains stages of labor, breathing techniques
Mother asks for breastfeeding help	Nurse shows proper latch and encourages her efforts

🌟 BENEFITS OF EMPOWERMENT:

Improves maternal confidence and self-worth
Enhances compliance with health practices
Reduces maternal stress and anxiety
Leads to better birth outcomes and postpartum recovery
Fosters positive mother-infant bonding
Builds long-term trust in the healthcare system

🚫 BARRIERS TO EMPOWERMENT:

Lack of education or health literacy
Gender-based discrimination
Cultural taboos or family restrictions
Healthcare workers who are disrespectful or unapproachable
Lack of privacy or choice in care settings

III Trimester

ONGOING RISK ASSESSMENT – MATERNAL MENTAL HEALTH

✅ INTRODUCTION:

Maternal mental health is a critical component of overall maternal well-being. Pregnancy and the postpartum period bring significant physical, emotional, and social changes, making women vulnerable to mental health challenges.

Ongoing risk assessment is the continuous process of identifying, monitoring, and responding to mental health concerns in pregnant and postpartum women to ensure timely support and care.

🎯 OBJECTIVES OF MENTAL HEALTH RISK ASSESSMENT:

Detect early signs of emotional or psychological distress
Identify risk factors for depression, anxiety, or other mental illnesses
Promote timely referral and intervention
Support the woman’s mental and emotional well-being
Ensure a safe and nurturing environment for the baby

📅 WHEN TO ASSESS?

At every ANC and PNC visit
During home visits or community health check-ups
On hospital admission for labor and post-delivery
At the 6-week postpartum check-up
Whenever the woman or family reports behavioral changes

🚩 COMMON MATERNAL MENTAL HEALTH CONDITIONS:

Condition	Timeframe
Antenatal Depression/Anxiety	During pregnancy
Postpartum Depression (PPD)	Within 6 weeks to 12 months after delivery
Baby Blues	Mild mood swings within 3–5 days of birth
Postpartum Psychosis	Severe, rare condition, usually within 2 weeks of delivery

🔍 RISK FACTORS FOR MATERNAL MENTAL ILLNESS:

Psychological	Social	Biological
History of mental illness	Domestic violence	Hormonal changes
Lack of emotional support	Poverty, unemployment	Sleep deprivation
Low self-esteem	Unplanned pregnancy	Nutritional deficiencies
Fear of childbirth	Teenage pregnancy	Chronic medical illness
Previous perinatal loss	Marital conflict	Multiple pregnancy

📋 SCREENING TOOLS USED:

Tool	Description
Edinburgh Postnatal Depression Scale (EPDS)	10-question tool to detect depression; score >10 indicates concern
PHQ-9 (Patient Health Questionnaire)	Screens for depression symptoms
GAD-7	Screens for generalized anxiety disorder
Clinical interview	Based on behavior, appearance, mood, and speech

👁️ SIGNS & SYMPTOMS TO WATCH FOR:

Emotional	Behavioral	Physical
Sadness or tearfulness	Withdrawal from others	Sleep disturbance
Anxiety or excessive worry	Neglecting self-care or baby	Appetite changes
Irritability or anger	Crying spells	Fatigue
Loss of interest or pleasure	Suicidal thoughts	Headaches/body pain

➡️ Red Flags: Suicidal ideation, hallucinations, severe withdrawal, or neglect of the baby → urgent referral needed

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN ONGOING RISK ASSESSMENT:

🌼 During Antenatal Care:

Ask open-ended questions about emotional health
Include mental health screening as part of ANC visits
Provide privacy and non-judgmental listening
Educate woman and family on common emotional changes in pregnancy
Identify high-risk cases and refer to mental health professionals

🌼 During Postnatal Care:

Assess mood and bonding with baby
Check for sleep, appetite, and coping behavior
Support breastfeeding and mother-infant attachment
Monitor for baby blues vs. postpartum depression
Arrange home visits or community follow-up when needed

🧾 SAMPLE ASSESSMENT QUESTIONS:

“How have you been feeling emotionally lately?”
“Do you feel overwhelmed or anxious often?”
“Are you sleeping and eating well?”
“Do you have thoughts of harming yourself or your baby?”
“Would you like to talk to someone about your feelings?”

👩‍👩‍👧‍👦 FAMILY & COMMUNITY INVOLVEMENT:

Educate family about warning signs and support methods
Encourage involvement of husband/partner or caregivers
Link with ASHA/ANM workers for home-based follow-up
Use peer support groups or community health programs

✅ INTERVENTIONS & REFERRALS:

Mild symptoms: Counseling, emotional support, relaxation, yoga, self-care tips
Moderate to severe symptoms: Referral to psychiatrist, psychologist, or mental health counselor
Emergency (suicidal thoughts, psychosis): Immediate hospital admission and psychiatric care

Education and Management of Physiological Changes & Discomforts in the Third Trimester (28–40 weeks)

✅ INTRODUCTION:

The third trimester marks the final phase of pregnancy (weeks 28 to delivery). The fetus undergoes rapid growth, and the mother’s body adapts to prepare for labor and birth. These changes can lead to physical discomforts, emotional stress, and the need for increased education and support.

🧠 PURPOSE OF NURSING EDUCATION IN 3rd TRIMESTER:

Prepare the woman for labor and delivery
Help her cope with discomforts
Promote fetal and maternal well-being
Encourage birth preparedness and complication readiness (BPCR)
Reinforce healthy habits and emotional support

🌼 COMMON PHYSIOLOGICAL CHANGES & THEIR MANAGEMENT:

1. Increased Abdominal Size & Uterine Pressure

Change	Discomfort	Nursing Advice
Growing uterus displaces internal organs	Shortness of breath, heaviness, pressure on bladder	– Encourage upright posture – Sleep with head elevated – Wear loose, supportive clothing

2. Backache & Pelvic Pain

Teach good posture and back support
Use maternity pillows for sleep
Suggest mild exercises/yoga (e.g., cat-cow pose)
Apply warm compresses
Wear low-heeled shoes

3. Frequent Urination

Reassure that it’s common
Encourage regular voiding
Avoid caffeine and fluids close to bedtime
Monitor for UTI symptoms (burning, pain)

4. Constipation

High-fiber diet (fruits, vegetables, whole grains)
Adequate fluid intake (8–10 glasses daily)
Encourage walking or light activity
Avoid overuse of laxatives

5. Heartburn & Indigestion

Eat small, frequent meals
Avoid spicy, fried, or acidic foods
Don’t lie down immediately after meals
Elevate head during sleep

6. Leg Cramps

Gentle leg stretching before bed
Massage and apply warm compresses
Ensure calcium + magnesium supplements
Stay hydrated

7. Edema (Swelling of Feet & Ankles)

Elevate legs while resting
Avoid standing or sitting for long periods
Wear comfortable shoes
Rule out preeclampsia if swelling is sudden/severe with high BP

8. Fatigue and Sleep Disturbances

Encourage short naps during the day
Use pillows to support the abdomen and back
Practice breathing/relaxation techniques before bed
Light walking or prenatal yoga

9. Breast Changes & Colostrum Leakage

Reassure the woman it is normal
Use soft breast pads if leaking
Wear supportive maternity bras
Educate about early signs of milk production

10. Braxton Hicks Contractions (False Labor)

Reassure that it prepares the uterus for labor
Encourage hydration and rest
Educate on the difference between true labor and false labor

👩‍🏫 HEALTH EDUCATION & PREPARATION TOPICS FOR 3RD TRIMESTER:

Topic	Content
Birth preparedness	Pack hospital bag, choose birth companion, transport plan
Danger signs	Vaginal bleeding, leaking fluid, severe headache, vision problems, no fetal movement
Fetal movement monitoring (DFMC)	Count 10 kicks in 12 hours or 4 in 1 hour
Pre-labor signs	Lightening, mucus plug, regular contractions
Labor stages & pain management	Breathing exercises, massage, support techniques
Breastfeeding	Early initiation, exclusive breastfeeding, colostrum benefits
Postnatal care & newborn care	Personal hygiene, baby bathing, cord care, immunization

🧑‍⚕️ NURSE / MIDWIFE’S ROLE:

Assess: Monitor for high-risk signs at each ANC visit
Educate: Explain all changes in a reassuring and simple manner
Support: Address physical, emotional, and social concerns
Refer: High-risk cases (e.g., PIH, IUGR, decreased fetal movement)
Document: All assessments, education given, and interventions
Empower: Help women feel confident about their bodies and upcoming labor

Third Trimester Tests and Screening (28–40 Weeks)

✅ INTRODUCTION:

The third trimester is a critical period for monitoring maternal health, fetal growth, and well-being, and to prepare for safe delivery. Various laboratory tests, imaging studies, and screenings are carried out to detect late pregnancy complications and guide decision-making for birth.

🎯 OBJECTIVES OF THIRD TRIMESTER TESTING:

Detect maternal and fetal complications (e.g., anemia, GDM, preeclampsia, IUGR)
Monitor fetal growth and position
Assess placental function and amniotic fluid
Prepare for timely referral or intervention
Ensure the mother is ready for safe labor and delivery

📋 ROUTINE THIRD TRIMESTER INVESTIGATIONS:

Test	Purpose	Timing
Hemoglobin (Hb%)	Monitor for anemia	~28–32 weeks
Urine Albumin and Sugar	Detect proteinuria (PIH), glucosuria (GDM)	Every visit
Blood Sugar (RBS/FBS/OGTT)	Detect or monitor gestational diabetes	28–32 weeks
Ultrasound (Growth Scan)	Check fetal growth, AFI, placenta	28–34 weeks
Blood Grouping (if not done earlier)	Confirm Rh status	Before 32 weeks
Indirect Coombs Test (ICT)	For Rh-negative mothers to detect alloimmunization	At 28 weeks
HIV, HBsAg, VDRL (repeat in some protocols)	Detect infections before delivery	32–36 weeks
Complete Blood Count (CBC)	Reassess anemia, infections	28–32 weeks
Tetanus Toxoid Booster (Td)	Immunization (1 or 2 doses depending on status)	After 28 weeks

🧪 SPECIAL/CONDITION-SPECIFIC TESTS:

Test	Indication
NST (Non-Stress Test)	Decreased fetal movement, PIH, IUGR
Doppler Study	Suspected IUGR, abnormal AFI, hypertensive disorders
Liver Function Test (LFT), Renal Function Test (RFT)	If preeclampsia/HELLP is suspected
Serum Uric Acid	High BP, preeclampsia
Cervical Swab Culture (if leaking or discharge)	Suspected infection or PROM
GBS (Group B Streptococcus) Screening (optional or as per local policy)	Vaginal swab at 35–37 weeks to prevent neonatal sepsis

📺 ULTRASOUND IN THIRD TRIMESTER:

Purpose	Details
Fetal Biometry	Estimate fetal weight, growth parameters
Amniotic Fluid Index (AFI)	Normal: 8–18 cm Oligohydramnios: <5 cm Polyhydramnios: >24 cm
Placental Location & Maturity	Rule out placenta previa or calcification
Fetal Position & Presentation	Breech, cephalic, transverse
Biophysical Profile (BPP)	Fetal well-being scoring (movement, tone, breathing, AFI, NST)

🧑‍⚕️ NURSE / MIDWIFE’S ROLE:

Educate the mother about the importance of third-trimester tests
Prepare the woman for each test (e.g., fasting for OGTT, hydration for USG)
Assist in sample collection and ensure correct labeling
Monitor and document test results
Identify danger signs or abnormal reports
Refer promptly if complications like anemia, GDM, preeclampsia, IUGR are detected
Provide emotional support, especially if abnormal findings are discovered

🚨 DANGER SIGNS TO SCREEN FOR IN THIRD TRIMESTER:

High BP (PIH/Preeclampsia)
Reduced fetal movements
Excessive weight gain or swelling (edema)
Vaginal bleeding or watery discharge
Signs of infection (fever, foul discharge)

Fetal Engagement in Late Pregnancy

✅ INTRODUCTION

Fetal engagement is a term used to describe when the presenting part of the fetus (usually the head) descends into the maternal pelvic brim and becomes fixed in the pelvis in preparation for labor and delivery.

This typically occurs in late third trimester, especially in primigravida women (first-time mothers), often 2–4 weeks before labor begins. In multigravidas, engagement may occur closer to or during labor.

📚 DEFINITION

Fetal engagement is said to have occurred when the biparietal diameter (BPD) of the fetal head passes through the pelvic inlet and enters the true pelvis.

🎯 PURPOSE OF ENGAGEMENT:

Prepares the fetus for descent through the birth canal
Indicates that the pelvis is adequate for vaginal delivery (especially in primigravida)
Suggests that labor may start soon

🧠 FACTORS AFFECTING ENGAGEMENT:

Factor	Effect
Parity	Earlier in primigravida, later in multigravida
Fetal Lie and Presentation	Only occurs in longitudinal lie, cephalic presentation
Pelvic adequacy	Adequate pelvis allows engagement
Uterine tone and fetal size	Overdistension or large baby may delay engagement
Position of fetus	Favorable (LOA, ROA) promotes easier engagement

📍 SIGNS OF FETAL ENGAGEMENT:

Sign	Description
Lightening	Woman feels lighter as the fundus descends
Relief from breathlessness	Less pressure on diaphragm
Increased pelvic pressure	Heaviness or pressure in lower pelvis and bladder
Frequent urination	Due to pressure on bladder
Changes in abdominal shape	Uterus appears lower
Backache	Due to shifting of fetal weight
Improved appetite	Due to reduced pressure on stomach

✋ METHODS TO ASSESS ENGAGEMENT

1️⃣ Abdominal Palpation (Leopold’s Fourth Maneuver)

| Method | Midwife faces the woman’s feet and palpates just above the symphysis pubis to feel the presenting part | | Interpretation |

Engaged: Head is fixed and cannot be moved side to side
Not engaged: Head is still mobile or ballotable

2️⃣ Pelvic Examination (Per Vaginal – PV)

(Done by doctor or trained midwife in hospital setting)

Fully engaged: 0/5 head palpable (none above pelvis)
Partially engaged: 1/5 to 4/5 palpable
Not engaged: 5/5 palpable (whole head above brim)

3️⃣ Imaging (Ultrasound)

Confirms fetal position, engagement, and station of head
Useful when abdominal findings are inconclusive

⚖️ STATION OF THE PRESENTING PART (In relation to ischial spines)

Station	Meaning
0	Head at the level of ischial spines (engaged)
+1 to +5	Below spines – descending through birth canal
–1 to –5	Above spines – not yet engaged

🧑‍⚕️ ROLE OF MIDWIFE / NURSE:

Observe and assess for signs of engagement at each ANC visit after 36 weeks
Reassure the woman about normal changes (lightening, increased urination)
Differentiate engagement vs descent during labor
Record findings in ANC card/partograph
Encourage pelvic floor exercises and upright positions to aid engagement
Refer for evaluation if engagement does not occur in primigravida by 38–39 weeks

🚨 WHEN TO SUSPECT NON-ENGAGEMENT / DELAYED ENGAGEMENT:

Persistent high head in a primigravida at term
Large fetus or abnormal lie (breech, transverse)
Cephalopelvic disproportion (CPD)
Pelvic tumor or placenta previa

➡️ Requires referral to an obstetrician for further evaluation and delivery planning.

3rd Trimester Antenatal Education Classes (Weeks 28–40)

✅ INTRODUCTION:

Antenatal education classes during the third trimester aim to prepare the pregnant woman (and her family) physically, emotionally, and mentally for labor, childbirth, and newborn care. These classes also promote maternal confidence, reduce anxiety, and encourage positive health-seeking behavior.

Midwives and nurses are key educators in delivering this life-enhancing knowledge in both hospital and community settings.

🎯 GOALS OF 3RD TRIMESTER ANTENATAL EDUCATION:

Prepare the woman for labor, delivery, and breastfeeding
Promote self-care, fetal well-being, and complication awareness
Educate on birth preparedness and complication readiness (BPCR)
Encourage informed decision-making and mother-friendly birth practices
Involve family and support persons in care and planning

📚 TOPICS TO BE COVERED IN 3RD TRIMESTER ANTENATAL CLASSES:

1️⃣ Signs of Labor and When to Go to the Hospital

True vs. false labor pains
Show, rupture of membranes, regular contractions
Danger signs in late pregnancy (bleeding, severe pain, reduced fetal movement)
Hospital bag preparation

2️⃣ Stages of Labor & Delivery Process

First, second, and third stages of labor
Role of hormones
What to expect physically and emotionally
Labor room environment
How birth companions can support

3️⃣ Pain Relief During Labor

Natural methods (breathing techniques, massage, warm showers, position changes)
Medical options (epidural, analgesics)
Pros and cons of each

4️⃣ Birthing Positions & Delivery Choices

Benefits of upright or alternative birthing positions
Role of squatting, kneeling, water birth (if offered)
Decision-making about vaginal vs cesarean delivery

5️⃣ Breathing & Relaxation Techniques

Deep breathing, guided imagery
Exercises to reduce stress and anxiety
Support during contractions

6️⃣ Postpartum Self-Care & Recovery

Physical recovery from birth (vaginal or cesarean)
Perineal hygiene
Rest and nutrition after birth
Mental health awareness (baby blues, postpartum depression)

7️⃣ Breastfeeding Education

Importance of early initiation and colostrum
Proper latch and positioning
Exclusive breastfeeding for 6 months
Overcoming challenges like sore nipples or engorgement

8️⃣ Newborn Care Essentials

First bath, diapering, clothing
Umbilical cord care
Danger signs in newborn
Immunization schedule
Mother-infant bonding and skin-to-skin contact

9️⃣ Nutrition in Late Pregnancy

Iron-rich foods, calcium, protein
Managing common discomforts (heartburn, constipation)
Hydration and portion control
Cultural and locally available nutritious food tips

🔟 Birth Preparedness and Complication Readiness (BPCR)

Identify health facility for delivery
Arrange transport and funds
Choose a birth companion
Plan for emergency care
Know your blood group and Rh status

👨‍👩‍👧 WHO SHOULD ATTEND?

Pregnant women (especially 28+ weeks)
Husbands or partners
Mothers/mothers-in-law
Other caregivers or companions

🧑‍⚕️ NURSE / MIDWIFE’S ROLE IN ANTENATAL EDUCATION:

Responsibility	Activities
Educator	Use simple language, visuals, and demonstrations
Counselor	Address fears, anxieties, myths, or misconceptions
Supporter	Encourage woman’s autonomy and confidence
Facilitator	Involve family in sessions to build a support system
Advocate	Promote respectful maternity care and informed choices

📌 METHODS USED IN ANTENATAL CLASSES:

Group discussions and Q&A sessions
Role-play or drama (for danger signs, labor)
Video demonstrations
Flipcharts, posters, and models
Breathing and relaxation exercises
Peer sharing and storytelling
Distributing handouts or checklists

✅ BENEFITS OF 3RD TRIMESTER ANTENATAL CLASSES:

Reduced maternal anxiety and fear of childbirth
Increased knowledge and preparedness
Higher rates of exclusive breastfeeding
Better pain management during labor
Higher satisfaction with birth experience
Stronger family involvement and support

Birth Preparedness and Complication Readiness (BPCR)

✅ INTRODUCTION:

BPCR is a strategy recommended by the World Health Organization (WHO) and the Ministry of Health and Family Welfare (India) to promote maternal and newborn survival by ensuring that women and their families are prepared for normal birth and can respond effectively to obstetric and newborn complications.

It is a key component of antenatal care (ANC), especially in the third trimester, and empowers women and their families to take informed, timely actions during labor and emergencies.

🎯 OBJECTIVES OF BPCR:

Reduce delays in seeking, reaching, and receiving care
Ensure safe delivery with a skilled birth attendant
Encourage emergency readiness for maternal and newborn complications
Promote community and family involvement in maternal health
Improve institutional delivery rates and reduce maternal mortality

🧾 KEY ELEMENTS OF BPCR PLAN:

1️⃣ Identify a Skilled Birth Attendant & Health Facility

Choose the nearest healthcare facility with delivery and emergency services
Know the name of the doctor, midwife, or nurse who will attend the birth
Make prior visits to the facility if possible

2️⃣ Arrange Transport

Identify two or more reliable transportation options in advance
Arrange for fuel, contact numbers, and driver availability
Include backup options for night or bad weather emergencies

3️⃣ Save Money for Delivery and Emergencies

Allocate funds for delivery charges, medicines, tests, transport
Enroll in government schemes like:
- Janani Suraksha Yojana (JSY)
- Pradhan Mantri Matru Vandana Yojana (PMMVY)
- Janani Shishu Suraksha Karyakram (JSSK) – free transport, delivery, and treatment

4️⃣ Identify a Birth Companion

Select a supportive person (husband, mother, sister) to accompany the woman
Ensure the companion knows basic signs of labor and complications
They can provide emotional, physical, and logistical support

5️⃣ Know the Danger Signs (During Pregnancy, Labor, Postpartum, Newborn)

Maternal:

Severe abdominal pain or headache
Vaginal bleeding or leaking
High fever
Convulsions or unconsciousness
Decreased fetal movement

Newborn:

Difficulty breathing
Poor feeding
Cold to touch or fever
Yellow skin before 24 hours
Convulsions or limpness

➡️ Immediate referral is critical

6️⃣ Arrange for Blood Donor

Know your blood group in advance
Identify willing donors (family/friends) with matching blood group
Know the nearest blood bank or hospital providing transfusion services

7️⃣ Pack a Birth Preparedness Bag

Include:

ANC card
Two sets of clean clothes
Baby clothes and blanket
Sanitary pads
Toiletries and soap
Clean towel
ID proof and health documents
Mobile phone and charger

8️⃣ Family and Community Support

Involve family members in planning
Link with ASHAs, ANMs, or self-help groups (SHGs)
Join antenatal classes or mothers’ support groups

🧑‍⚕️ ROLE OF NURSE / MIDWIFE IN BPCR:

Responsibility	Actions
Educator	Teach women and families about BPCR during ANC visits and community sessions
Facilitator	Help enroll in government benefit schemes
Planner	Assist in making a written BPCR plan
Observer	Monitor signs of risk or delay in preparation
Communicator	Coordinate with ASHA, referral centers, and transport services
Supporter	Reassure and motivate the woman and family to prepare early

📋 BPCR PLAN FORMAT (Simple Table):

Component	Action Planned
Health facility	PHC, CHC, or district hospital
Transport	Auto, ambulance (108), neighbor’s car
Funds saved	₹3000
Companion	Husband / sister
Blood donor	Cousin (B+)
Danger signs awareness	Yes / No
Birth kit packed	Yes / No

✅ BENEFITS OF BPCR:

Timely care in emergencies
Safe delivery with skilled attendance
Reduced maternal and neonatal complications
Increased family awareness and involvement
Fewer home deliveries and unsafe practices

Health Education on Exclusive Breastfeeding (EBF)

✅ INTRODUCTION

Exclusive breastfeeding (EBF) means that the infant receives only breast milk — no other food or drink, not even water — for the first 6 months of life, except oral rehydration solution (ORS), drops, or syrups of vitamins, minerals, or medicines when medically needed.

EBF is recommended by the World Health Organization (WHO), UNICEF, and the Ministry of Health and Family Welfare (India) for optimal infant health and development.

🎯 OBJECTIVES OF BREASTFEEDING EDUCATION:

Promote exclusive breastfeeding for 6 months
Educate mothers on correct technique and timing
Prevent common breastfeeding problems
Encourage mother-baby bonding
Improve infant survival and development

🧠 KEY MESSAGES TO EDUCATE MOTHERS:

1️⃣ Start Breastfeeding Early

Begin within 1 hour of birth
First milk (colostrum) is rich in antibodies and nutrients – essential for immunity

2️⃣ Feed Only Breast Milk for 6 Months

No water, honey, animal milk, or food should be given
Breast milk contains everything the baby needs — even in hot weather

3️⃣ Feed Frequently and on Demand

Day and night, at least 8–12 times in 24 hours
Let the baby finish one breast before switching

4️⃣ Recognize Signs of Effective Breastfeeding

Baby latches well (mouth wide open, chin touching breast)
Rhythmic sucking and swallowing
Baby passes urine at least 6 times a day
Steady weight gain

5️⃣ Do Not Use Bottles or Pacifiers

They cause nipple confusion and can reduce milk supply

6️⃣ Continue Breastfeeding During Illness

Both mother and baby should continue
Breast milk provides protection from infection

🌟 BENEFITS OF EXCLUSIVE BREASTFEEDING:

To Baby	To Mother
Enhances immunity, prevents infections	Promotes uterine involution (reduces bleeding)
Reduces risk of diarrhea, pneumonia	Delays return of menstruation (natural spacing)
Supports brain development	Lowers risk of breast and ovarian cancer
Prevents allergies and obesity	Creates emotional bonding
Easy to digest, always clean and ready	Cost-effective and convenient

🤱 BREASTFEEDING TECHNIQUE – LATCHING & POSITION

Proper Position:

Baby’s head and body aligned
Baby facing the breast, tummy to tummy
Mother supports breast with her hand
Bring baby to breast (not breast to baby)

Proper Latch:

Baby’s mouth covers areola, not just nipple
Lower lip turned outward
No clicking sounds or pain during feeding

🚼 SIGNS THAT THE BABY IS GETTING ENOUGH MILK:

Baby sleeps well between feeds
Gains weight after the first week
Passes soft, yellow stool
Satisfied and calm after feeds

💢 COMMON BREASTFEEDING PROBLEms AND SOLUTIONS:

Problem	Cause	Management
Sore Nipples	Poor latch	Correct the latch, apply breast milk to nipple
Engorgement	Infrequent feeding	Feed frequently, warm compress
Blocked Duct/Mastitis	Incomplete emptying	Massage, feed on affected side, pain relief
Low Milk Supply	Stress, infrequent feeding	Increase frequency, skin-to-skin contact, hydration

🧑‍⚕️ NURSE / MIDWIFE’S ROLE IN BREASTFEEDING EDUCATION:

Educate: Antenatal and postnatal counseling on EBF
Demonstrate: Correct positioning and latching
Support: Encourage mothers who are tired or unsure
Monitor: Baby’s feeding patterns and weight gain
Empower: Help mothers overcome social or family pressures
Involve family: Educate partners and caregivers about the importance of EBF
Refer: Complicated cases to lactation consultants or pediatricians

📢 COMMUNITY-BASED MESSAGES (IEC/BCC):

“Maa ka doodh, shishu ke liye amrit hai” (Mother’s milk is nectar for the baby)
“Chhe mahine tak sirf maa ka doodh – na paani, na kuch aur”
Posters, flipcharts, mothers’ support groups
Counselling via ASHA, ANM, or health camps

Danger Signs of Pregnancy

✅ INTRODUCTION:

Danger signs of pregnancy are warning symptoms that indicate potential complications which can threaten the health or life of the mother, fetus, or both. Prompt recognition and immediate medical care are critical to prevent maternal and fetal morbidity and mortality.

Midwives and nurses play a vital role in educating pregnant women and families about these signs and encouraging timely health-seeking behavior.

🚨 GENERAL DANGER SIGNS TO WATCH FOR (Any Trimester):

Danger Sign	Possible Complication
Severe vaginal bleeding	Miscarriage, placenta previa, abruption
Severe abdominal pain	Ectopic pregnancy, abruption, labor
Severe headache or blurred vision	Preeclampsia, high blood pressure
Swelling of face and hands	Preeclampsia
Fever and chills	Infection
Painful urination or burning	Urinary tract infection
Foul-smelling vaginal discharge	Infection
Convulsions or fits	Eclampsia
Loss of consciousness	Severe anemia, shock, eclampsia
Difficulty breathing	Anemia, cardiac issues, embolism

📆 TRIMESTER-WISE DANGER SIGNS:

🔹 First Trimester (0–12 weeks):

Danger Sign	Possible Indication
Vaginal bleeding or spotting	Threatened or missed abortion
Severe lower abdominal pain	Ectopic pregnancy, miscarriage
Fainting or dizziness	Anemia, ectopic pregnancy
High fever	Infection (UTI, TORCH)
Persistent vomiting (Hyperemesis gravidarum)	Dehydration, electrolyte imbalance

🔹 Second Trimester (13–27 weeks):

Danger Sign	Possible Indication
Bleeding or watery discharge	Threatened abortion, PROM
Abdominal pain or backache	Preterm labor, UTI
Decreased fetal movement (after 20 weeks)	Fetal distress or death
Sudden swelling of hands/face	Preeclampsia
High blood pressure symptoms	PIH, gestational hypertension

🔹 Third Trimester (28–40 weeks):

Danger Sign	Possible Indication
Vaginal bleeding	Placenta previa, placental abruption
Leaking fluid before 37 weeks	Preterm PROM
Severe abdominal pain with bleeding	Abruption placentae
Decreased or no fetal movement	Fetal hypoxia or death
Severe headache, visual disturbances	Severe preeclampsia
Convulsions	Eclampsia
Difficulty breathing	Pulmonary embolism, severe anemia
Signs of labor before 37 weeks	Preterm labor

🧑‍⚕️ ROLE OF MIDWIFE / NURSE:

Educate all pregnant women and families about danger signs at each ANC visit
Use simple language and visual aids (charts, posters)
Encourage women to report symptoms immediately
Monitor for these signs during home visits and health camps
Refer urgently to higher-level health facilities if any danger sign is observed
Document and follow up on all referred cases
Involve ASHA/ANM for community support and emergency transport

📢 KEY EDUCATION MESSAGES FOR PREGNANT WOMEN:

“Bleeding anytime in pregnancy is not normal — go to the hospital immediately.”
“If the baby is not moving like usual — don’t wait, seek help.”
“Swelling of face, headache, and blurred vision can be signs of high BP — act fast.”
“Labor pains before 9 months could mean preterm labor — go to the hospital.”

Recognition of Ruptured Membranes (Spontaneous Rupture of Membranes – SROM)

✅ INTRODUCTION:

Rupture of membranes refers to the breaking of the amniotic sac (bag of waters), resulting in the leakage of amniotic fluid through the cervix and vagina. This can occur:

Spontaneously (on its own) before or during labor
Or be artificially induced (Amniotomy) by a healthcare provider

Recognizing spontaneous rupture of membranes (SROM) is essential for safe and timely labor management, and to prevent infection or complications.

🧠 TYPES OF RUPTURE:

Type	Description
Term PROM	Rupture after 37 weeks of gestation but before labor starts
Preterm PROM (PPROM)	Rupture before 37 weeks of gestation
Prolonged ROM	Rupture of membranes lasting >18 hours before delivery
Premature Rupture of Membranes (PROM)	Rupture before the onset of labor

🔍 RECOGNITION – HOW TO IDENTIFY RUPTURED MEMBRANES:

1️⃣ Maternal Reported Symptoms:

Sudden gush or continuous trickle of clear or pale fluid from the vagina
Wetness in underwear that does not stop
May or may not be associated with labor pains
Fluid is odorless or slightly sweet in smell
No control over leakage (unlike urine)

2️⃣ Assessment Techniques by Nurse/Midwife:

Method	What to Observe
Visual inspection	Use a sterile speculum to check for fluid pooling in the vagina
Nitrazine Test	Litmus paper turns blue if fluid is alkaline (amniotic fluid)
Fern Test	A sample of fluid shows a fern-like pattern under microscope
AmniSure or ROM Plus test (if available)	Detects specific amniotic proteins (used in hospital settings)

3️⃣ Characteristics of Amniotic Fluid:

Color: Clear to slightly milky
Odor: Mildly sweet (not foul)
Volume: May be a small leak or large gush
Consistency: Watery (not thick or sticky like vaginal discharge)

⚠️ Meconium-stained fluid (green or brown) suggests fetal distress and needs urgent attention.

🚨 DANGER SIGNS WITH RUPTURED MEMBRANES:

Fever or foul-smelling discharge → Risk of infection
No uterine contractions within 24 hours → Risk of prolonged ROM
Cord prolapse (cord felt in vagina or visible outside) → Emergency
Preterm rupture (<37 weeks) → High risk to fetus (lungs immature)
Decreased fetal movement → Possible distress

🧑‍⚕️ ROLE OF NURSE / MIDWIFE:

🌼 On Recognition of Ruptured Membranes:

Stay calm and reassure the woman
Instruct her to lie on her side and limit movement (if not in labor)
Avoid vaginal examinations unless sterile or indicated (to prevent infection)
Use sterile pads or towels to observe color and amount of fluid
Check fetal heart rate immediately
Record:
- Time of rupture
- Color, amount, and odor of fluid
- Associated symptoms (pain, bleeding, fever)

🌼 Actions Based on Situation:

Scenario	Action
Term with contractions	Admit for labor monitoring
Term without contractions	Observe for 12–24 hours; induce if needed
Preterm (<37 weeks)	Hospitalize, administer antibiotics, corticosteroids (per doctor)
Cord prolapse	Trendelenburg position + emergency C-section
Foul-smelling discharge or fever	Suspect infection; report immediately

✅ EDUCATION FOR MOTHERS:

“If you feel sudden wetness or trickling of water, report to the hospital immediately.”
“Do not insert anything into the vagina (no douching or intercourse).”
“Monitor for fever, pain, bleeding, or baby’s movements.”
“Always carry your ANC card to the hospital.”

Ongoing Risk Assessment in Pregnancy

✅ INTRODUCTION:

Ongoing risk assessment refers to the continuous and systematic evaluation of the mother and fetus during pregnancy to identify actual or potential risks that may complicate the course of pregnancy, labor, or delivery.

This process ensures early detection, timely referral, and appropriate intervention to reduce maternal and neonatal morbidity and mortality.

🎯 OBJECTIVES OF ONGOING RISK ASSESSMENT:

Detect high-risk pregnancies early
Prevent complications by timely management or referral
Plan for safe delivery and postpartum care
Ensure individualized care based on risk status
Educate the woman and her family on signs that require attention

🧾 COMPONENTS OF RISK ASSESSMENT (Throughout ANC):

1️⃣ Maternal History Assessment:

Factor	Risk Indicators
Obstetric history	Previous cesarean, stillbirth, miscarriage, multiple pregnancies
Medical history	Hypertension, diabetes, epilepsy, cardiac disease
Surgical history	Uterine surgeries, pelvic surgery
Family history	Genetic disorders, twins, diabetes, hypertension
Lifestyle factors	Smoking, alcohol, poor nutrition, domestic violence

2️⃣ Physical Examination & Monitoring:

Check-up	Risk Indicators
BP monitoring	High BP (>140/90) indicates PIH or preeclampsia
Fundal height	Discrepancy with gestational age → IUGR or poly/oligohydramnios
Fetal heart rate	Bradycardia or tachycardia → fetal distress
Edema	Face/hand swelling → sign of preeclampsia
Weight gain	Sudden excessive weight gain → fluid retention, PIH
Urine test	Proteinuria (PIH), glycosuria (GDM), infection

3️⃣ Laboratory Investigations:

Hemoglobin <10 g/dL → Anemia
Positive VDRL/HBsAg/HIV → Infections
Raised blood sugar → Gestational Diabetes
Abnormal USG findings → IUGR, anomalies
ICT positive (in Rh-negative mothers) → Risk of hemolytic disease

4️⃣ Psychosocial Assessment:

Area	Concerns
Mental health	Depression, anxiety, low self-esteem
Support system	Isolation, lack of family support
Domestic violence	Safety concerns for mother and fetus
Economic status	Inability to access proper nutrition, transport, care

⚠️ HIGH-RISK CONDITIONS TO MONITOR:

Teenage pregnancy (<18 years) or advanced maternal age (>35 years)
Multiple pregnancy (twins, triplets)
Malpresentation (breech, transverse)
Rh incompatibility
Antepartum hemorrhage
Preterm labor or PROM
Gestational hypertension, eclampsia
Polyhydramnios or oligohydramnios
IUGR (Intrauterine Growth Restriction)
Previous cesarean section or uterine surgery

🧑‍⚕️ ROLE OF NURSE / MIDWIFE IN ONGOING RISK ASSESSMENT:

Function	Actions
Assessment	Regularly evaluate vitals, fetal growth, symptoms
Documentation	Update ANC records, risk factors, referrals
Communication	Discuss findings with medical team
Counseling	Educate mother about her condition and care needs
Referral	Refer promptly to higher center for complications
Support	Provide emotional support and reassurance

📝 EXAMPLE: RISK SCORING SYSTEM

(Used in some settings for easy tracking)

Factor	Points
Hb < 10 g/dL	1
Age <18 or >35 years	1
High BP or PIH	2
Previous cesarean	2
Twins	3

➡️ Total score guides the level of care:
0–2 = Low risk, 3–4 = Moderate risk, 5+ = High risk

Cultural Needs in Maternal and Newborn Care

✅ INTRODUCTION:

Cultural needs refer to the beliefs, values, customs, traditions, and practices that influence how individuals and families experience pregnancy, childbirth, and healthcare. Meeting cultural needs in midwifery involves providing respectful, sensitive, and individualized care that honors the woman’s background, ethnicity, language, and spirituality.

🎯 OBJECTIVES OF CULTURALLY SENSITIVE MATERNAL CARE:

Provide respectful and dignified care to women from all backgrounds
Enhance trust and communication between caregiver and client
Prevent misunderstanding, discrimination, or discomfort
Improve maternal satisfaction, health-seeking behavior, and outcomes
Encourage family and community support by respecting cultural norms

🧾 COMPONENTS OF CULTURAL NEEDS IN MATERNAL CARE:

1️⃣ Language and Communication

Use local language or an interpreter if needed
Use non-verbal cues, pictures, or models
Respect how the woman prefers to be addressed
Avoid medical jargon; explain terms clearly

2️⃣ Religious and Spiritual Beliefs

Respect practices like prayers, fasting, blessings
Allow religious articles or symbols during labor
Understand restrictions related to blood transfusions, medicines, or certain foods

3️⃣ Modesty and Privacy

Many cultures value modesty during examination
Provide female healthcare workers when possible
Use screens, drapes, and explain each step before touching

4️⃣ Family Involvement and Decision-Making

In some cultures, decisions are made by husband, elder women, or extended family
Include family members in discussions where appropriate
Respect family hierarchy while also protecting the woman’s autonomy

5️⃣ Food and Dietary Practices

Understand food taboos or preferences during pregnancy and postpartum
Support culturally accepted nutritious alternatives
Avoid forcing supplements or meals that go against beliefs

6️⃣ Traditional Beliefs and Practices

Postnatal rituals, confinement periods, massage, use of herbs, etc.
Allow safe practices as long as they do not harm the mother or baby
Gently educate or discourage harmful practices (e.g., delaying breastfeeding, giving honey to newborns)

7️⃣ Birthing Preferences

Preference for home birth vs hospital
Birth positions, use of chants, rituals, or oils
Role of birth companions (mother, husband, midwife, doula)

🌍 EXAMPLES OF CULTURAL NEEDS:

Culture/Region	Practice
Indian subcontinent	Warm food post-delivery, confinement for 40 days
Middle Eastern	Preference for female providers, modest clothing
African	Strong family involvement, preference for traditional birth attendants
East Asian	“Sitting month” postpartum rest, avoiding cold foods
Christian/Muslim/Jain	Dietary restrictions (e.g., no pork/beef), prayer needs

🧑‍⚕️ ROLE OF NURSE / MIDWIFE:

Role	Responsibilities
Cultural assessor	Ask open-ended questions about beliefs and preferences
Educator	Provide respectful education on safe motherhood while valuing traditions
Advocate	Ensure woman’s cultural needs are met in hospital policies
Supporter	Listen actively and provide emotional comfort
Collaborator	Involve family and community support systems in care planning

🛑 CHALLENGES IN MEETING CULTURAL NEEDS:

Language barriers
Lack of knowledge about diverse practices
Institutional policies not accommodating traditions
Time constraints in busy settings
Conflict between safety and beliefs (e.g., refusal of interventions)

➡️ Requires sensitivity, flexibility, and communication skills

Women-Centered Care (WCC)

✅ INTRODUCTION

Women-Centered Care (WCC) is a philosophy of care that places the needs, preferences, rights, and dignity of the woman at the center of all decision-making and care practices. It focuses on individualized care, empowerment, respect, and collaborative partnerships between the woman and healthcare providers.

This model is essential in maternity and reproductive health services, where the woman’s experience is as important as clinical outcomes.

🎯 OBJECTIVES OF WOMEN-CENTERED CARE:

Promote autonomy and informed decision-making for women
Ensure respect, dignity, and compassion in all care interactions
Create a safe, supportive, and inclusive environment
Improve maternal satisfaction and health outcomes
Address the physical, emotional, psychological, social, and cultural needs of women

🌼 CORE PRINCIPLES OF WOMEN-CENTERED CARE:

Principle	Description
Respect for dignity	Treat every woman with kindness, privacy, and without judgment
Informed choice	Provide clear, unbiased information to allow women to make decisions
Holistic care	Consider emotional, mental, social, spiritual, and physical health
Collaboration	Women are partners in care, not passive recipients
Continuity of care	Promote ongoing relationships with midwives or care teams
Individualized care	Recognize that each woman has unique needs and preferences
Cultural sensitivity	Respect cultural, religious, and personal beliefs and practices

👩‍🍼 APPLICATION OF WOMEN-CENTERED CARE IN MATERNAL HEALTH:

1️⃣ Antenatal Care

Educate the woman about her pregnancy and choices
Provide respectful and private examinations
Discuss birth plans and preferences
Screen for mental health, domestic violence, and cultural needs

2️⃣ Intrapartum (Labor and Delivery) Care

Allow choice of birth position, pain relief, and birth companion
Offer emotional support and continuous presence
Obtain informed consent before procedures (e.g., episiotomy, vaginal exam)
Respect labor pacing unless there is a medical reason to intervene

3️⃣ Postnatal Care

Encourage rooming-in and skin-to-skin contact
Support breastfeeding choices without pressure
Screen for postpartum depression and mental well-being
Involve the woman in decisions regarding family planning and baby care

🤝 BENEFITS OF WOMEN-CENTERED CARE:

For Women	For Health System
Increased satisfaction and trust	Improved quality of care
Improved maternal and neonatal outcomes	Better communication and teamwork
Reduced anxiety and trauma	Fewer unnecessary interventions
Empowerment and confidence	Enhanced patient-provider relationships

🧑‍⚕️ ROLE OF MIDWIFE / NURSE IN WOMEN-CENTERED CARE:

Listen actively to the woman’s values, beliefs, and wishes
Build trust through empathy, honesty, and respectful communication
Educate with clear, culturally sensitive information
Support decision-making and do not impose personal or institutional bias
Protect privacy and promote dignity in all care settings
Advocate for the woman in the healthcare team
Document preferences and concerns in the care plan
Encourage family involvement (with the woman’s consent)

🚫 BARRIERS TO WOMEN-CENTERED CARE:

Over-medicalization of pregnancy and birth
Lack of time and staffing
Cultural or language barriers
Provider bias or judgment
Lack of training in communication and empathy

➡️ These can be overcome with education, awareness, and respectful practice.

Respectful and Compassionate Communication in Maternity Care

✅ INTRODUCTION:

Respectful and compassionate communication is the foundation of quality, woman-centered maternity care. It involves interacting with pregnant and postpartum women in a way that is kind, empathetic, non-judgmental, and respectful of their dignity, beliefs, and choices.

In maternity care, communication must be both informative and emotionally supportive, especially as pregnancy and childbirth are sensitive and life-changing experiences.

🎯 OBJECTIVES:

Build trust and comfort between the woman and caregiver
Promote informed decision-making and autonomy
Reduce fear, anxiety, and emotional distress
Prevent disrespect and abuse in childbirth settings
Improve maternal satisfaction, cooperation, and health outcomes

🧭 PRINCIPLES OF RESPECTFUL & COMPASSIONATE COMMUNICATION:

Principle	Explanation
Empathy	Understand and acknowledge the woman’s feelings and fears
Active Listening	Listen with full attention, without interrupting
Clarity	Use simple, jargon-free language the woman can understand
Privacy & Confidentiality	Maintain personal boundaries and do not share private information
Non-Judgmental Approach	Accept all backgrounds, cultures, and choices without criticism
Emotional Support	Offer encouragement, reassurance, and kindness
Timely Information	Provide clear explanations before any procedure or action
Body Language	Maintain eye contact, use a calm tone, and respectful gestures

👩‍🍼 EXAMPLES IN MATERNAL CARE:

Situation	Respectful Response
Woman is in pain during labor	“You are doing great. I am right here with you.”
Woman refuses a procedure	“I understand your concern. Let me explain your options.”
Woman is anxious about delivery	“Many mothers feel the same. Let’s talk about what will happen.”
Woman speaks a different language	Use an interpreter, visual aids, or local language support
Cultural or religious belief affects care	Respect her practice unless it poses harm, and explain alternatives gently

🤰 COMMON COMMUNICATION SCENARIOS & APPROACHES:

🔹 Before a Procedure:

“I would like to check your blood pressure now. May I go ahead?”

🔹 During Examination:

“Let me know if you feel any discomfort. You can stop me anytime.”

🔹 When Discussing Diagnosis:

“Your blood pressure is a little high. I will explain what that means and how we can manage it together.”

🔹 When the Woman is Upset or Afraid:

“It’s okay to feel this way. You are not alone—we will support you every step.”

🧑‍⚕️ ROLE OF NURSE / MIDWIFE IN COMMUNICATION:

Create a safe and respectful environment
Introduce yourself clearly and explain your role
Listen actively to the woman’s story, concerns, and feelings
Provide health information in a calm, positive, and understandable way
Ask for consent before exams or procedures
Reassure and encourage throughout labor and postpartum
Ensure privacy in the labor room, ANC clinic, and postnatal ward
Include the family (with consent) in communication and decisions
Document all care discussions and decisions made

📌 COMMON BARRIERS TO RESPECTFUL COMMUNICATION:

Time constraints in busy hospitals
Language or cultural differences
Provider stress or burnout
Lack of training in communication skills
Provider bias or judgmental attitude

➡️ These can be overcome through training, awareness, and practice.

✅ BENEFITS OF RESPECTFUL AND COMPASSIONATE COMMUNICATION:

Increases maternal trust and satisfaction
Improves cooperation and adherence to care
Enhances safe childbirth experiences
Reduces complaints and conflicts
Builds positive professional relationships

Alternative Birthing Positions

✅ INTRODUCTION:

Traditionally, many hospitals follow the supine (lying on the back) position for childbirth. However, alternative birthing positions are those non-supine positions that women may adopt during labor and delivery to enhance comfort, labor progress, and natural birthing mechanisms.

Allowing a woman to choose her preferred birthing position is part of respectful, women-centered care, and can improve both the physical and emotional experience of childbirth.

🧘‍♀️ COMMON ALTERNATIVE BIRTHING POSITIONS:

1️⃣ Squatting Position

Woman squats down with knees bent and hips open
May use squatting bar, support from companion, or a stool

Benefits:

Widens pelvic outlet
Uses gravity to aid fetal descent
Effective pushing and shorter second stage

2️⃣ Sitting Position

Woman sits on a birth stool, chair, or edge of bed

Benefits:

Promotes gravity
Comfortable and easy to monitor
Good for women with back pain

3️⃣ Kneeling or Hands-and-Knees (All-Fours) Position

Woman kneels on the floor/bed, leaning forward on hands or pillows

Benefits:

Relieves back pressure
Helps rotate posterior-positioned baby
Reduces risk of perineal tears

4️⃣ Side-Lying (Lateral) Position

Woman lies on her side with one leg supported

Benefits:

Good for rest and relaxation
Reduces pressure on perineum
Recommended for high BP or FHR abnormalities

5️⃣ Upright Standing or Walking

Woman stands or walks during early labor, may lean on support

Benefits:

Uses gravity for descent
Improves contractions
Helps in early labor stages

6️⃣ Water Birth Position

Woman labors or delivers in warm water tub

Benefits:

Soothes pain and relaxes muscles
Improves mobility and sense of control
Less need for pain medication

➡️ Requires trained staff and hygienic setup

🤝 ROLE OF MIDWIFE / NURSE IN SUPPORTING ALTERNATIVE BIRTHING POSITIONS:

Role	Actions
Educator	Teach women about various positions during ANC and in labor
Supporter	Encourage mobility and position changes during labor
Facilitator	Provide equipment (birth stools, mats, squatting bars)
Safety Monitor	Ensure positions are safe and do not compromise fetal monitoring or maternal condition
Empowerer	Respect the woman’s choice unless a medical reason prevents it
Documenter	Note the position used during delivery in the birth record

⚠️ WHEN TO AVOID CERTAIN POSITIONS:

Squatting or upright positions: Avoid in high-risk cases with bleeding, cord prolapse, or preeclampsia
Water births: Avoid if infection, preterm labor, or meconium-stained liquor is present
Hands-and-knees: Caution in women with joint pain or limited mobility

🌼 ADVANTAGES OF ALTERNATIVE BIRTHING POSITIONS:

Enhances comfort and sense of control
Uses gravity to support descent
Improves uterine contractions
Reduces duration of second stage
Lowers rates of episiotomy and assisted delivery
May reduce perineal trauma

Women’s Preferred Choices in Birthing Position

✅ INTRODUCTION:

During childbirth, many women develop preferences for certain birthing positions based on comfort, cultural beliefs, body mechanics, and their sense of control. Respecting a woman’s choice in birthing position is a key component of women-centered, respectful maternity care and leads to better satisfaction and outcomes.

🎯 OBJECTIVES OF SUPPORTING BIRTHING POSITION CHOICES:

Empower women to feel in control during childbirth
Enhance comfort and effectiveness of labor and pushing
Improve maternal satisfaction and birth outcomes
Reduce unnecessary interventions (e.g., episiotomy, assisted delivery)
Respect cultural, personal, or religious preferences

🧘‍♀️ COMMONLY PREFERRED BIRTHING POSITIONS:

Women may prefer a birthing position based on pain relief, ease of movement, familiarity, or recommendations by caregivers.

1️⃣ Upright Positions (Squatting, Standing, Sitting)

Features	Benefits
Uses gravity to aid fetal descent
May be supported or with use of equipment (e.g., squatting bar, birth stool)
Often preferred by women seeking active, natural birth

✔️ Promotes faster descent and shorter second stage
✔️ Increases pelvic dimensions
✔️ Reduces need for assisted delivery

2️⃣ Hands-and-Knees (All-Fours) Position

Features	Benefits
Woman kneels with hands or arms resting on a support
Often chosen in cases of back pain or posterior baby position

✔️ Relieves backache
✔️ Helps rotate the fetus from posterior to anterior
✔️ Reduces perineal trauma

3️⃣ Side-Lying (Lateral) Position

Features	Benefits
Woman lies on her side with upper leg supported
Often preferred for comfort or when rest is needed

✔️ Good for women with high BP or fatigue
✔️ Prevents compression of vena cava
✔️ Helps conserve energy

4️⃣ Sitting or Semi-Sitting Position

Features	Benefits
Woman sits on a birthing chair, stool, or bed with back support
Allows both mobility and comfort

✔️ Uses gravity without too much strain
✔️ Allows good fetal monitoring
✔️ Preferred for controlled pushing

5️⃣ Supine or Lithotomy (on back with legs raised)

Most commonly used in hospitals but not usually the woman’s preferred choice.

Limitation	Why many women avoid
Less use of gravity
Can compress blood vessels
Often chosen by providers for ease, not by women

❌ Higher risk of assisted delivery and perineal tears
❌ Less comfortable for women during active labor

📌 FACTORS INFLUENCING WOMEN’S CHOICE OF POSITION:

Factor	Impact
Cultural beliefs	Certain positions may be considered more acceptable or effective
Previous birth experience	Women may choose based on what worked for them before
Level of pain	Pain relief or discomfort guides position changes
Support from midwife or doula	Encouragement can help women try upright or active positions
Environment	Availability of tools (birthing balls, stools, clean floor space) affects choices
Freedom to move	Women with IVs, monitoring, or epidural may have limited options

👩‍⚕️ ROLE OF MIDWIFE / NURSE IN SUPPORTING WOMEN’S CHOICES:

Educate about different birthing positions during antenatal classes
Encourage freedom of movement during labor
Ask for the woman’s preferred position and explain all safe options
Support her choice unless medically contraindicated
Assist with equipment (birth stool, squatting bar, pillows)
Provide continuous labor support and reassurance
Monitor mother and fetus in all positions safely
Respect cultural or personal values influencing her decision

✅ BENEFITS OF RESPECTING WOMEN’S CHOICE OF BIRTHING POSITION:

Improves maternal satisfaction and confidence
Enhances labor progress and efficiency
Reduces perineal trauma and interventions
Strengthens trust and communication between the woman and provider
Promotes positive birth experience

Role of Doula / ASHA Worker in Maternal and Newborn Care

✅ INTRODUCTION

Both Doulas and ASHA workers are non-medical professionals who play a vital role in supporting pregnant women and new mothers, especially in low-resource or rural settings.

A Doula is a trained birth companion who provides emotional, physical, and informational support during pregnancy, labor, and the postpartum period.
An ASHA worker is a community-based health activist under the National Rural Health Mission (NRHM) in India, trained to motivate, assist, and link women to maternal and child health services.

Both work closely with nurses, midwives, and ANMs to ensure safe, respectful, and accessible care for every mother and baby.

🧘‍♀️ ROLE OF A DOULA:

A Doula is not a medical provider, but a trained support person for labor and birth.

🌼 During Antenatal Period:

Educates the mother about pregnancy changes, diet, and exercises
Helps in birth planning (positions, pain relief options, birth preferences)
Reduces anxiety and emotional stress
Promotes self-care and breastfeeding preparation

🌼 During Labor & Delivery:

Provides continuous emotional support
Suggests breathing techniques, massage, and relaxation
Encourages the mother in her preferred birthing position
Acts as an advocate for the mother’s choices and dignity
Keeps the birth environment calm and respectful

🌼 Postnatal Support:

Supports early breastfeeding and latching
Encourages rest, nutrition, and newborn care
Assists with emotional well-being and postpartum adjustment
Refers to professionals in case of complications or depression

👣 BENEFITS OF HAVING A DOULA:

Shorter labor duration
Reduced need for cesarean and interventions
Less pain medication required
Better mother-infant bonding
Higher rates of exclusive breastfeeding
Positive birth experience and emotional support

🌾 ROLE OF ASHA (Accredited Social Health Activist):

ASHA is a female volunteer from the community, trained under NHM, and acts as a link between the community and health system.

🌼 During Antenatal Period:

Identifies and registers all pregnant women
Ensures 4 ANC check-ups and TT immunization
Counsels on diet, IFA, calcium, rest, and danger signs
Promotes birth preparedness and institutional delivery
Arranges transport and health facility referrals
Assists in Janani Suraksha Yojana (JSY) benefits

🌼 During Labor & Delivery:

Accompanies woman to the hospital
Provides emotional and basic physical support
Ensures woman has her ANC card, ID, and necessary items
Coordinates with ANM, nurse, or midwife during labor

🌼 Postnatal and Newborn Care:

Conducts home visits on Day 1, 3, 7, 14, 21, 28
Monitors lochia, uterine involution, breastfeeding, baby’s weight
Encourages immunization, exclusive breastfeeding, and family planning
Educates on newborn danger signs
Refers sick mother or baby to PHC or CHC
Mobilizes community for Village Health and Nutrition Day (VHND)

🧑‍⚕️ COLLABORATION WITH MIDWIVES & NURSES:

Activity	How Doula / ASHA Helps
Antenatal check-ups	Brings women to health center, educates about care
Birth preparedness	Helps make plans for transport, money, hospital
Labor & delivery	Provides support, encourages respectful birth practices
Home care	Follows up on mother’s and baby’s recovery
Health records	Maintains or updates records for tracking and referral
Community health	Conducts awareness programs on maternal and newborn care

📋 QUALITIES OF A GOOD DOULA / ASHA:

Trustworthy and compassionate
Good listener and communicator
Patient and calm
Understands local language and culture
Committed to women’s dignity and safety
Willing to work closely with the health team

Published March 26, 2025By mynursingapp

Categorized as BSC SEM 6 MIDWIFERY / OBSTETRIC AND GYNECOLOGY NURSING- I, Uncategorised

Recent Posts

Recent Comments