Age Marital Status Address Educational Level Tribe Religion Ne!

t o" #in

25 Years : Married

: : : : :

Gamulani in Ndirande Form Four Leaver Ngoni slam Mr$ N%&ata '(usband)

*AST AN+ *RESENT ME+ ,AL ( ST-RY Mrs$ N%&ata &as no &istor. o" &./ertension0 diabetes0 ast&ma and e/ile/s.$ S&e also &as no &istor. o" cardiac diseases0 renal diseases and no an. ot&er medical condition$ S&e said t&at t&e onl. disease t&at s&e &as ever su""ered "rom is malaria 1&ic& 1as also treated b. ta%ing 2uinine$ Mrs$ N%&ata also said t&at t&ere is no an. illness t&at s&e is su""ering "rom no1$ S3RG ,AL ( ST-RY Mrs$ N%&ata said t&at s&e &as never undergone an. %ind o" surger.0 not even "emale circumcision$ S&e also re/orted to &ave never received an. blood trans"usion$ FAM LY ( ST-RY Mrs$ N%&ata re/orted no &istor. o" an. c&ronic medical diseases in &er "amil. or t&at o" &er &usband$ (o1ever0 s&e said t&at t&ere is &istor. o" t1ins "rom t&e &usband4s "amil.$ T&e t1ins are t1o sisters to t&e &usband$

GYNAE,-L-G ,AL (( ST-RY Mrs$ N%&ata said t&at s&e reac&ed menarc&e in 2552 and b. t&en s&e 1as 67 .ears old$ S&e also said t&at &er menstrual "lo1 lasts "or 5 da.s$ S&e said t&at t&e "lo1 is

moderate0 regular and 1it&out d.smenorr&oea$ S&e also said t&at s&e &as no &istor. o" Se!uall. Transmitted n"ections0 abortions0 or an. ot&er g.naecological conditions$ FAM LY *LANN NG ( ST-RY Mrs$ N%&ata s&o1ed %no1ledge o" "amil. /lanning met&ods and s&e managed to mention some o" t&e common met&ods li%e 8adelle0 ntra uterine contrace/tive device0 ,ombined and *rogestin onl. -ral contrace/tives0 +e/o9*rovera and ,ondoms$ Mrs$ N%&ata said t&at s&e &ad never used an. o" t&e "emale contrace/tives: &o1ever0 &er &usband could use condoms at times as a contrace/tive met&od$ S&e continued to sa. t&at s&e a"ter deliver. 1ants to use +e/o9*rovera but s&e also e!/ressed &aving &eard t&at +e/o9*rovera is /&asing out$ S&e told me t&at &er re/roductive goal is to &ave t&ree c&ildren 1it& a s/acing o" 5 .ears bet1een t&e coming second born and t&e t&ird born$

;REASTFEE+ NG ( ST-TY Mrs$ N%&ata re/orted t&at s&e &ad breast"ed t&e "irst c&ild e!clusivel. "or si! mont&s 1it&out an. "ood su//lements and also continued breast"eeding t&e bab. u/ to 6 .ear and < mont&s a"ter s&e &ad started giving t&e bab. ot&er "ood items$ S&e also /lans to e!clusivel. breast"eed t&e coming babies "or si! mot&s be"ore s&e starts giving t&em ot&er "oods$ SE=3AL ( ST-RY Mrs$ N%&ata e!/lained t&at &er &usband and &er0 do no &ave a s/eci"ic time agreed on 1&en to sto/ &aving se!$ S&e also said t&at t&e. do not &ave %no1ledge on t&e rig&t time to sto/ or resume se! t&us a"ter deliver.$ S&e told me t&at 1it& t&e /revious /regnanc.0 t&e. sto//ed &aving se! at 7 mont&s and resumed > mont&s a"ter deliver. but s&e said t&at t&is 1as on neit&er cultural nor religious belie"s$ S&e said t&at t&ere are no an. /roblems 1it& t&is current /regnanc. as /er issues to do 1it& se!$ S&e

re/orted t&e. still 1ere &aving se! 1it& t&e &usband at t&is gestation age and 1ere /lanning to sto/ 1&en t&e /regnanc. reac&es ? mont&s$ N3TR T -NAL ( ST-RY According to Mrs$ N%&ata4s dietar. call o" t&e da. be"ore coming to t&e clinic '> t& Februar.0 2566)0 it seems t&at t&e N%&ata4s "amil. manages a diet 1&ic& is 1ell mi!ed 1it& all t&e re@uired si! "ood grou/s on dail. basis$ S&e also /roved to be %no1ledgeable o" t&e si! "ood grou/s b. mentioning all o" t&em 1it& e!am/les$ Mrs$ N%&ata also re/orted no &istor. o" /ica to1ards non "ood items 1it& bot& &er /regnancies$ (o1ever0 s&e said t&at t&e /regnanc. &as made &er li%e some o" t&e "oods s&e never li%ed li%e "res& "is&$ Mrs$ N%&ata said t&at s&e does not eat /or% based on religious ground as s&e is a Muslim but said t&at &er culture does not restrict &er "rom eating ant "ood$ S&e e!/lained t&at s&e &as enoug& "ood in &er &ouse t&at is enoug& "or &er "amil. all t&e times$ S&e &as good /re/aration and storage met&ods o" "ood 1it& some good storage /rinci/les li%e no relis& remains to be used t&e ne!t da.0 t&e. onl. /re/are enoug& "ood "or t&e da.$

*AST -;STETR ,AL ( ST-RY Mrs$ N#&ata is *ara 6 1it& "irst deliver. in 2552 and s&e 1as 22 .ears b. t&en$ ;REA#+-AN T&e "irst /regnanc. 1a. term 1it& B5 1ee%s gestation b. "undal &eig&t$ T&e bab. 1as delivered at Ndirande (ealt& ,entre and s&e delivered b. S/ontaneous Certe! +eliver. but sustained a tear 1&ic& 1as sutured and &ealed 1it&out an. com/lications$ T&e bab. 1as DB55g at birt& and 1as born 1it&out an. congenital nor during birt& com/lication$ Labour &ad ta%en about 6B &ours t&us "rom 7 /m to <am$ Mrs$ N%&ata &as no &istor. o" ante9/artum or intra9/artum &aemorr&age as 1ell as *re9eclam/sia or eclam/sia$

*SY,(-L-G ,AL ( ST-RY Mrs$ N%&ata said t&at t&e /regnanc. t&at s&e &as no1 1as a /lanned one and also t&at t&e decision to &ave t&e /regnanc. 1as made b. bot& &er and &er &usband suc& t&at t&e. bot& 1ere ver. &a//. "or t&e /regnanc.$ S&e also said t&at s&e did not &ave an. /s.c&ological /roblems due to bot& /revious /regnanc. as 1ell as t&e current one e!ce/t "or t&e "ear o" labour /ains$ MM3N SAT -NS Mrs$ N#&ata e!/lained t&at s&e &ad received t1o doss o" Tetanus To!oid Caccine 1it& t&e "irst /regnanc. and t1o doses 1it& t&e current /regnanc.$ (o1ever0 s&e e!/ressed lac% o" %no1ledge on t&e "re@uenc. and number o" doses o" tetanus To!oid Caccine s&e is e!/ected to receive des/ite %no1ing t&e im/ortance o" t&e immuniEations$ ENC R-NMENTAL ( ST-RY -n environmental &istor.0 Mrs$ N#&ata said t&at s&e &as a t1o bedroom &ouse 1it& a seat room 1&ic& is occu/ied b. t&ree members o" t&ee "amil.0 t&e &usband0 t&e "irst born c&ild and &ersel"$ T&e &ouse is iron s&eet roo"ed0 cement "loored and electri"ied$ S&e said t&at s&e gets 1ater "rom a ,ommunal Aater *oint 1&ic& is about 55 metres "rom &er &ouse but s&e ma%es sure s&e &as enoug& 1ater all t&e time b. %ee/ing some in buc%ets %no1ing t&at t&ere is a /roblem o" 1ater scarcit. in &er area at times$ -n 1aste dis/osal0 s&e said t&at t&ere is a rubbis& /it be&ind t&e &ouse 1&ic& is used "or 1aste dis/osal and s&e %ee/s burning t&e 1aste in t&e /it to /revent it "rom being blo1n bac% to t&e &ouse b. 1ind 1&en it4s "ull$ S-, -9E,-N-M , ( ST-RY Mrs$ N%&ata is a Form "our Leaver currentl. 1or%ing 1it& #3#3 Matc&es ,om/an. as a *ac%er$ (er &usband is an electrician 1&o is sel" em/lo.ed$ S&e said t&at &er "amil. is able to get t&eir needs and necessities "rom t&e combined income t&at t&e. get "rom t&eir duties and t&e. live &a//il.$

Mrs$ N%&ata re/orted no e!/osure to increased 1or%load "or s&e is currentl. given lig&t 1or% b. &er bosses &aving understood &er condition$ Mrs$ N%&ata does not smo%e an. %ind o" cigar nor drin%s an. %ind o" alco&ol alt&oug& t&e &usband ta%es alco&ol but in a reasonable manner$ *RESENT -;STETR , ( ST-RY Mrs$ N%&ata is gravida 2 *ara 6 mot&er Last normal menstrual /eriod : E!/ected date o" deliver. : Gestation b. dates ( C Status C+RL : : : 65t& 8ul.0 2565 22nd A/ril0 2566 D5 1ee%s0 da.s Non9reactive Non9reactive

S&e is currentl. not on an. medications e!ce/t "or t&e Ferrous Sul/&ate s&e is given 1&en se visits antenatal clinic meant to &el/ in t&e "ormulation o" &aemoglobin$ EL M NAT -N Mrs$ N%&ata &as no an. /roblem 1it& eit&er bo1el movement or urination$ (o1ever0 s&e said t&at s&e &ad in t&e earl. da.s o" /regnanc. a /roblem o" "re@uenc. micturation$

-;8E,T CE +ATA Vital Signs Tem/erature ;lood *ressure *ulse Rate : : : D>$7F, 625G75mm(g 75 beats /eer minute

Res/iration Rate

22 breat&s /er minute

GENERAL A**EEARAN,E Mrs N%&ata is a 6>2 cm tall 1oman0 slim and lig&t bro1n in com/le!ion$ S&e 1as 1earing a red blouse and a blac% s%irt 1it& a /air o" blac% sli/9ons 's&oes)$ -n t&is da. s&e 1eig&ed 5? %ilograms0 gaining 2 %ilograms "rom t&e 1eig&t during &er boo%ing visit 1&ic& 1as 5> %ilograms$ (EA+ (er &ead is ovoid in s&a/e 1it& long c&emical made &air and t&ere 1as neit&er dandru"" nor /resence o" scars or masses on t&e scal/$ FA,E T&ere 1ere no signs o" "acial oedema on bot& ins/ection and /al/ation$ T&e "ace also did not &ave scars on ins/ection$ EYES T&e e.es are s.mmetrical and ovoid in s&a/e 1it& no signs o" /eri9orbital oedema and &ad a /in% conHunctiva$ EARS T&e ears are s.mmetrical 1it& t&e u//er ears in line 1it& t&e outer borders o" t&e e.es$ T&ere 1ere no sore0 no ear disc&arge0 no lesions and no signs o" in"lammation on /al/ating t&e /re and /ost auricular l.m/& nodes$ N-SE (er nostrils are s.mmetrical 1it& no an. disc&arge$ S&e &as no &istor. o" e/ista!is and did not &ave an. /ol./s in t&e nostrils$ M-3T(

(er li/s 1ere smoot& 1it& no sores or crac%s$ (er tongue and oral mucosa 1ere /in% 1it& no sore0 no %or/li%s s/ots or signs o" candidiasis$ T&ere 1ere neit&er deca.ed teet& nor gingivitis$ S&e &as neit&er cle"t li/ nor cle"t /alate$ T&e tonsilor0 sub9 mandibular and sub mental l.m/& nodes 1ere not enlarged$ NE,# S&e &as no /roblems 1it& nec% "le!ion as 1ell as "or1ard and bac%1ard nec% bending$ -n ins/ection0 t&ere 1ere no obvious signs o" distended Hugular veins0 no sores0 no obvious lesions$ -n /al/ation0 t&ere 1ere neit&er signs o" enlarged t&.roid gland nor enlarged dee/ cervical0 sub9clavicle and in"ra 9clavicle l.m/& nodes$ ,(EST -n ins/ection0 t&e c&est did not &ave scars0 lesions or signs o" a /igeon c&est 1it& normal res/irator. movements$ -n auscultation0 t&ere 1ere normal lung and &eart sounds$ ;REASTS T&e breasts are s.mmetrical in bot& siEe and s&a/e and t&e. bot& are lig&t bro1n in colour 1it& dar% alleorae$ T&e breasts &ave no scars0 scales0 lesions0 no sores0 ras&es0 redness and no dim/ling$ -n breast /al/ation0 no masses 1ere "elt e!ce/t "or t&e normal mammar. gland$ T&e ni//les are dar% in colour0 clean and not inverted$ 3**ER E=TREM T ES T&e arms are s.mmetrical 1it& no signs o" oedema on bot& ins/ection and /al/ation$ S&e &as a ca/illar. re"ill o" less t&an D seconds and &as /in% /alms$ (o1ever0 Mrs$ N%&ata re/orted &aving tingling sensation o" t&e u//er e!tremities$ A;+-MEN -n ins/ection o" t&e abdomen0 t&ere 1as a dar% linea nigra0 some striae gravidalum 1it& no sores or scars$ T&e abdomen 1as ovoid in s&a/e 1it& a medium siEe$ Foetal

movements 1ere also observed mediall. on ins/ection$ Liver and s/leen 1ere not /al/able indicating absence o" organomegall.$ T&e calculated gestation b. dates 1as D5 1ee%s and Fundal height Pelvic, Lateral and Fundal Palpation Fundal &eig&t Foetal *resentation : Foetal Lie Foetal *osition Foetal (eart Rate : : : : 2< 1ee%s

,e/&alic Longitudinal Rig&t -cci/ital Anterior 6B2 beats /er minute

L-AER E=TREM T ES T&e lo1er e!tremities are s.mmetrical 1it& no scars0 varicose veins as 1ell as signs o" oedema on ins/ection$ -n /al/ation0 no tibial0 an%le or /edal oedema 1as detected$ No signs o" Caricose Ceins or +ee/ Cein T&rombosis 1ere detected on /al/ation o" t&e cu"" muscles$ Howmans sign 1as not observed on "le!ion on t&e "eet$ GEN TAL A 3/on ins/ection o" t&e genitalia0 no oedema0 sores0 1arts0 genital ulcers0 abnormal vaginal disc&arge or signs o" &ematoma 1ere observed$ T&ere 1ere no signs o" varicose veins or genital mutilation or circumcision seen$ T&e vaginal disc&arge 1as mild0 1&itis& and odourless$

*R-;LEMS GNEE+S +ENT F E+$ #no1ledge de"icit on se!ualit. during intra and /ost /artum /eriods related to inabilit. set times on 1&en to sto/ and resume se!$

Lac% o" ade@uate in"ormation on immunisations related to limited in"ormation given on immunisations as evidenced b. inabilit. to outline t&e normal sc&edule "or Tetanus To!oid Caccine$ #no1ledge de"icit on Focussed Antenatal ,are and its im/ortance related to limited in"ormation given about "ocussed antenatal care as evidenced b. late coming "or initial visit$ *ossibil. o" not using "amil. /lanning met&ods related to untrue s/eculations t&at +e/o9 *rovera is /&asing out$

,ARE *R-C +E+ Focus Antenatal ,are loo%s at com/re&ensive care given to a /regnant 1oman 1it& s/eci"ied t./e o" care /er eac& visit o" t&e "our e!/ected visits t&at t&e 1oman attends antenatal clinic$ t loo%s at @ualit. o" care and not @uantit. o" t&e number o" visits$ Focused Antenatal ,are em/&asises on treating ever. mot&er as an individual or uni@ue /erson 1it& individual /roblems and needs$ T&e care t&at 1as given to Mrs$ N%&ata 1as based on t&e /roblems and needs t&at s&e &ad as 1ell as s/eci"ic care according to &ergestation age$ -n t&is da.0 Mrs$ N%&ata 1as treated com/re&ensivel. starting 1it& &istor. ta%ing to "ill in ga/s "ollo1ed b. ( C and S./&ilis tests t&en "ull /&.sical assessment 1&ic& involved using all t&e "our modalities o" ins/ection0 /al/ation0 auscultation and /ercussion$ made sure t&at t&e client4s care 1as /rovided in a ver. conducive environment0 t&us ensuring /rivac. as 1ell as cleanliness$ made sure t&at s&e "elt 1ell ta%en care o" and 1elcome to t&e clinic b. being res/ect"ul0 accommodative and letting &er as% @uestions and e!/ress "ears t&an loo%ing at t&e care as a burden t&roug&out t&e /rocedures$ ENC R-NMENT

+uring t&e "illing in o" ga/s0 collection o" im/ortant in"ormation t&at 1as missed out on t&e boo%ing da.0 an environment t&at ensured /rivac. and com"ort 1as ensured$ T&e data 1as collected at an enclosed /lace 1&ere no one else could listen to 1&at 1as being discussed and t&is made t&e client to be more o/en and to give t&e in"ormation t&at 1as re@uired$ Li%e1ise0 during t&e /&.sical e!amination0 a cubical 1as used to /romote /rivac. considering t&at /rocedures involved t&is time include e!/osure o" sensitive areas li%e t&e c&est0 abdomen and genitalia$ F LL NG N -F GA*S 3/on revie1 o" t&e Antenatal cardG/age "or Mrs$ N%&ata several areas t&at re@uired to be "illed in 1ere realised$ n addition to t&at0 some more areas in t&e &ealt& /ass/ort 1ere identi"ied 1&ic& also needed "illing in$ T&e &ealt& did not &ave in"ormation on &er "amil. medical &istor. and &er medical and surgical &istor. 1&ic& is su//osed to be "illed o t&e "irst and second /ages o" t&e &ealt& /ass/ort and t&is is also 1&ere some im/ortant /ersonal data is documented$ See A//endi!$$$$$$ s&o1ing t&e /ages a"ter "illing in$ Not onl. t&at but also blood grou/ and r&esus "actor 1ere not tested but still more being an im/ortant in"ormation es/eciall. 1&en it comes to emergencies li%e anaemia0 still re"erred &er go also go "or t&e tests 1&en s&e goes "or t&e ot&er tests$ -n t&e antenatal /age as 1ell0 gravidit. and /arit. o" t&e mot&er 1ere not indicated during t&e "irst visit but got documented on t&is visit$ TESTS Focused Antenatal recommends mot&ers undergoing several di""erent tests at di""erent visits and di""erent gestation ages$ Suc& tests are li%e ( C0 S./&ilis0 &aemoglobin level0 urine /rotein and ,+B count in case o" t&ose 1&o are ( C /ositive but not on antiretroviral t&era/.$

( C0 C+RL and (aemoglobin level are t&e tests t&at are e!/ected to be done on boo%ing so as to &ave a baseline data "or some o" t&em li%e ( C and &aemoglobin are tested again a"ter sometime i$e$ ( C is tested again a"ter D mont&s 1&ile &aemoglobin level is retested at D> 1ee%s$ 3rine /rotein is e!/ected to be tested ever. visit "rom "irst to "ourt& visit but un"ortunatel. none o" t&ese 1ere done on t&e "irst visit -n t&is visit /la.ed a role o" &el/ing Mrs$ N%&ata get tested "or ( C and S./&ilis 1&ose results came out negative as indicated on t&e antenatal card 'A//endi!$$$$$) a"ter "illing in t&e ga/s$ (o1ever0 re"erred t&e client to 2ueen EliEabet& ,entral (os/ital "or t&e tests 1&ic& could not be done at Ndirande Antenatal ,linic due to lac% o" materials li%e t&e &aemacue %its and /rotein di/stic%s$ T&e re"erral 1as done a"ter Ndirande (ealt& ,entre also re/orted not &aving t&e materials *(YS ,AL E=AM NAT -N As indicated in t&ee obHective data0 during /&.sical assessment0 no s/eci"ic /roblems 1ere /resented or detected "rom Mrs$ N%&ata and all t&e "indings 1ere documented on t&e antenatal card and 1ere also communicated to t&e client$ See A//endi!$$$$$$ s&o1ing t&e antenatal card 1it& "indings o" t&e abdominal assessment$ ME+ ,AT -NS Most o" medications at t&e Antenatal ,linic are given according to gestation ages o" t&e mot&ers and most o" t&em are given "or /ro/&.lactic /ur/oses i$e$ S* is given to /revent a mot&er "rom malaria0 Ferrous Sul/&ate is given to /revent anaemia 1&ilst AbendaEole is given to combat 1orms in"estation$ S* is given ever. "our 1ee%s bet1een t&e gestations o" 6> to D> 1ee%s: Ferrous Sul/&ate is given at ever. visit t&roug&out /regnanc. 1&ilst AbendaEole is given Hust once and at "irst visit$ S* is given in suc& a 1a. to /revent t&e tetratonegic e""ects t&at t&e sul/&ur ma. &ave on t&e "oetus$ -n t&is visit0 Mrs$ N%&ata0 &aving t&e gestation age o" D5 1ee%s0 s&e 1as given bot& S* tablets 'D) as 1ell as Ferrous Sul/&ate 'D5 tablets)$ S* 1as given a"ter con"irming t&at B 1ee%s &ad /assed since t&e last dose 1as ta%en$

M +A FERY ,ARE

ANALYS S -F ,ARE A lot o" t&ings and care 1ere done during Mrs$ N%&ata4s boo%ing antenatal visit$ s&ould sincerel. give credit to t&e care /rovider 1&o &andled Mrs$ N%&ata on t&e "irst visit "or t&e good Hob "or most t&ings e!/ected to be done on boo%ing es/eciall. data needed to be "illed on t&e antenatal card 1as "illed$ (o1ever0 not ever. bit o" in"ormation 1as collected and documented: "or e!am/le0 no in"ormation 1as documented indicating gravidit. and /arit. on t&e antenatal card$ T&is in"ormation is ver. im/ortant to ever. mid1i"e 1&o 1ould come into contact 1it& t&e client "or it gives a /icture o" t&e %ind o" client one is dealing 1it& i$e$ /rim9gravida0 multigravida or grand multi/ara$ T&ese also determine t&e %ind o" care t&at a client 1ill get$ Secondl.0 t&e data documented on t&e antenatal card "or abdominal assessment seem to &ave been ta%en "or granted b. t&e care /rovider during t&e /revious visit$ (aving been given t&e date "or t&e last normal menstrual /eriod0 t&ere 1as no reason &eGs&e could not calculate t&e gestation b. dates "or t&is da. %no1ing its im/ortance$ T&e calculated gestation b. dates is ver. im/ortant to a mid1i"e "or it gives a base com/arison 1it& t&e "undal &eig&t done b. ta/e measure or "inger breadt&s$ t also seems t&at t&e mid1i"e 1&o cared "or Mrs$ N%&ata during t&e "irst visit does not %no1 1&at it means 1&en 1e sa. /resentation b. abdominal assessment "or s&eG&e indicated t&at it 1as a verte! /resentation o" 1&ic& verte! can not be determined b. /elvic /al/ation but vaginall.$ S&eG&e 1ould rat&er indicate ce/&alic "or /resentation and a /osition i$e$ Rig&t -cci/ital Anterior0 Le"t -cci/ital Anterior or ot&er /ositions$ ;lood *ressure is on o" t&e im/ortant vital signs in /regnant 1omen and un"ortunatel.0 it 1as not done on t&e boo%ing da.$ Yes its true t&ere could be no a s/&.gmomanometer but still more a re"erral to Ndirande onl. "or a blood /ressure c&ec% 1ould be &el/"ul$ *regnant 1omen are at a ris% o" develo/ing /re9eclam/sia 1&ic& is &ig& blood /ressure in /regnanc. and can onl. be diagnosed i" blood /ressure i" c&ec%ed at ever. visit$

3rine /rotein test is also vital in t&e 1a. t&at /resence o" /rotein in urine is indicative o" /re9eclam/sia Mrs$ N%&ata &ad come "or boo%ing at a gestation age o" 2> 1ee%s b. "undal &eig&t and t&is clearl. s&o1s lac% o" %no1ledge on "ocused antenatal care as 1ell as its im/ortance$ Mrs$ N%&ata being a *ara one 1it& birt& o" "irst born in 2557 1&en "ocused antenatal 1as alread. under im/lementation0 it 1as e!/ected s&e must &ave alread. been e!/osed to suc& t./e o" care$ 3n"ortunatel.0 t&e mot&er came at 2> 1ee%s gestation "ollo1ing t&e old routine antenatal s.stem$ A&en i as%ed &er0 s&e said coming at 25 1ee%s and above 1as 1&at s&e %ne1$ T&is mot&er lac%ed in"ormation on "ocused antenatal and its im/ortance 1&ic& re"lects t&at s&e 1as not given enoug& in"ormation about it during &er "irst /regnanc.$ E=*E,TE+ F N+ NGS F-R T(E NE=T C S T Mrs$ N%&ata &ad come "or &er second antenatal visit at a gestation age o" 2< 1ee%s0 &o1ever0 according to "ocused antenatal0 b. t&is time s&e 1as su//osed to becoming "or &er t&ird visit 1&ic& is su//osed to bee bet1een 2? 1ee%s and D2 1ee%s$ n t&is case Mrs$ N%&ata 1ill &ave &er t&ird and "inal normal visit at D> 1ee%s t&oug& at t&is time a mot&er is normall. e!/ected to be coming "or a "ourt& visit$ A&en Mrs$ N%&ata comes at D> 1ee%s 1&ic& 1ould be on $$$$$$$$$$$$$0 s&e 1ill undergo several assessments some t&at are routine li%e vitals signs 1&ilst some 1ill base on &er condition as being in t&ird trimester or &aving a D> 1ee%s gestation$ Some o" t&ee care 1ill also base o" t&e ga/s t&at t&e mid1i"e 1ill identi". as being le"t out during t&e /revious visit$ -n t&e ne!t visit t&e mid1i"e 1ill &ave to c&ec% on t&e care given on t&e /revious visit0 evaluate and t&en &ave a basing "or /lanning &isG&er care and t&is 1ill also de/end on t&e current /roblems and t&e unmet needs o" t&e client$ T&e mid1i"e 1ill collect some in"ormation "rom t&e client to "ill in t&e ga/s t&at are not "illed during t&is visit$ S&e 1ill also c&ec% on t&e /rogress o" /regnanc. b. as%ing Mrs$ N%&ata on &o1 s&e "airing 1it& &er /regnanc.$ Some o" t&e @uestions s&e ma. as% are t&e /resence o" "oetal movements and minor disorders o" /regnanc. "or t&is 1ill &el/ t&e mid1i"e to isolate t&e /roblems t&at t&e client &as at /resent$

Mrs$ N%&ata 1ill also &ave to undergo several tests 1&ic& 1ill be due b. t&is time i$e$ &aemoglobin level and urine /rotein$ (aemoglobin level is c&ec%ed on boo%ing and in t&ird trimester0 at D> 1ee%s to be s/eci"ic 1&ilst "or urine /rotein is c&ec%ed at ever. visit to t&e antenatal clinic$ Cital signs are anot&er as/ect t&at 1ill &ave to be c&ec%ed b. t&e mid1i"e as /art o" monitoring /rogress o" /regnanc.$ An. abnormalit. in t&e vital signs is indicative o" a /roblem in t&e /regnant 1oman$ For e!am/le: &ig& blood /ressure could be indicative o" /re9eclam/sia0 "ever could indicate a s.stemic in"ection and increased res/irator. rate could mean di""icult. breat&ing0 t&oug&0 it is t&oug&t to be normal at D> 1ee%s$ *&.sical assessment 1ill also be done including general assessment as 1ell as abdominal assessment$ General assessment 1ill involve a &ead to assessment and no abnormalit. is e!/ected "rom it$ T&e abdominal assessment 1ill involve ins/ection0 /al/ation and auscultation o" t&e abdomen to c&ec% siEe and s&a/e o" abdomen0 "undal &eig&t0 lie0 /resentation and /osition o" "oetus as 1ell as "oetal &eart rate$ T&e abdomen is ins/ected "or scars0 linea nigra0 striae gravidalum0 siEe and s&a/e0 "oetal movements0 bladder "ullness and visible organomegall.$ T&ee "undal &eig&t 1ill be measured using a ta/e measure o" "inger breadt&s so as to determine t&e age o" /regnanc.$ T&en t&e /elvis 1ill be /al/ated "or /resentation 1&ic& is normall.0 lateral /al/ation 1ill be done to note t&e lie and /osition o" t&e "oetus$ Fundal /al/ation 1ill also be done to rule out multi/le gestation or /resentation in a situation 1&ere t&e &ead is not located in t&e /elvic$ Foetal &eart rate 1ill also &ave to bee auscultated using a "etalsco/e to con"irm 1ellbeing o" t&e "oetus$

E=*E,TEE+ F N+ NGS Fundal &eig&t Foetal *resentation : : D> 1ee%s

,e/&alic

Foetal Lie Foetal *osition Foetal (eart Rate

: : :

Longitudinal Rig&t -cci/ital AnteriorGLe"t -cci/ital Anterior 6B5 I 6>5 beats /er minute

T&e above e!/ected "indings are t&ee normal e!/ected "inding in t&e absence o" /ossibilit. o" &aving abnormal "indings +R3GS -n t&is visit Mrs$ N%&ata 1ill onl. be /rovided 1it& Ferrous Sul/&ate as a drug to su//lement iron "or &aemoglobin "ormation$ S* 1ill not be given because it is believed to &ave a teratonic e""ect on t&e "etus 1&en given at t&e gestation o" D> 1ee%s and above$ E=*E,TE+ + S-R+ERS ;. t&is time t&e e!/ected disorders t&at Mrs$ N%&ata ma. &ave are di""icult. breat&ing0 "re@uent micturation0 &eadac&e0 consti/ation0 bac%ac&e0 oedema varicosities0 &aemorr&oids and cram/s "or t&ese are t&e common disorders t&at usuall. come in t&ird trimester$ MANAGEMENT OF THE E PE!TE" M#N#$ "#SO$"E$S HEA$T%&$N T&is is a burning0 irritating sensation in t&e oeso/&agus also %no1n as gastric re"lu! 'Fraser0 ,oo/er and Nolte0 255>)$ Gastric re"lu! commonl. occurs as a result o" dela.ed gastric em/t.ing0 decreased intestinal motilit.0 and decreased lo1er oeso/&ageal s/&incter tone$ " it &a//ens t&at Mrs$ N%&ata develo/s &eartburn0 education and counseling on li'est(le
)odi'ication 1ill be /rovided and 1ill include a1areness o" /osture i$e$ Maintaining u/rig&t /ositions 'es/eciall. a"ter meals)0 slee/ing in a /ro//ed u/ /osition and dietar( )odi'ications 'e$g$ small "re@uent meals0 eating slo1l.0 reduction o" &ig&9"at "oods and ca""eine)$

S*ELL#NG+E"EMA

As t&e gro1ing uterus /uts /ressure on t&e veins t&at return blood "rom "eet and legs0 s1ollen "eet and an%les ma. become an issue$ At t&e same time0 s1elling in legs0 arms or &ands ma. /lace /ressure on nerves0 causing tingling or numbness$ Fluid retention and dilated blood vessels ma. leave t&e "ace and e.elids /u"".0 es/eciall. in t&e morning$ To reduce s1elling0 t&e client 1ill be advised to use cold com/resses on t&e a""ected areas$ L.ing do1n or using a "ootrest ma. relieve an%le s1elling$ S&e mig&t even elevate &er "eet and legs 1&ile s&e slee/s 1&ic& 1ill also minimise t&e s1elling b. gravit.$ ",SPNEA T&is is a common s.m/tom bet1een t&e gestation o" DB and D> 1ee%s$ t is as a result o" t&e /ressure b. t&e gro1ing uterus on t&e dia/&ragm 'Fraser0 ,oo/er and Nolte0 255>)$ " Mrs$ N%&ata &a//ens to develo/ d.s/noea0 s&e 1ill be educated o" t&e /&.siolog. o" t&e /roblem "or &er to understand 1&at4s &a//ening$ S&e 1ill also be advised on slee/ing in semi9"o1lers /osition so as to be increasing t&e area "or lung e!/ansion &ence im/roved res/irator. condition$ S&e 1ill also be encouraged to &ave /eriods and resting to reduce t&e bod. need "or o!.gen$ !ONST#PAT#ON ,onsti/ation in /regnanc. es/eciall. t&ird trimester is usuall. caused b. reduced motilit. o" large intestine 1&ic& comes due to t&e muscle la!ative e""ect o" t&e &ormone /rogesterone 1&ic& is /roduced in large amounts t&is /eriod0 ncreased 1ater re9 absor/tion "rom large intestine due to &ormone aldosterone e""ect0 *ressure on t&e /elvic colon b. t&e /regnant uterus and sedentar. li"e during /regnanc. $ i" t&e client 1ill come 1it& t&e /roblem o" consti/ation0 s&e 1ill advised on drin%ing /lent. o" "luids0 &ig& "ibre "oods and get /lent. o" e!ercise$ T&ese &el/ in so"tening t&e bo1els &ence reduced ris% o" consti/ation$ %A!-A!HE

+uring /regnanc.0 ligaments become so"ter and stretc& to /re/are "or labour$ T&is can /ut a strain on t&e Hoints o" t&e lo1er bac% and /elvis0 1&ic& can result in bac%ac&e$ To overcome t&is /roblem Mrs$ N%&ata 1ill be advised to avoid &eav. li"ting0 bend &er %nees and %ee/ &er bac% straig&t 1&en li"ting or /ic%ing u/ t&ings "rom t&e ground0 move &er "eet 1&en turning and avoid sudden t1isting movements0 Aor% at a sur"ace &ig& enoug& to /revent &er "rom stoo/ing and to sit 1it& &er bac% straig&t and 1ell9 su//orted$ Anot&er advice 1ill be t&at s&e s&ould ma%e sure s&e gets enoug& rest0 /articularl. later in /regnanc.$

F$E.&ENT M#!T&$AT#ON As t&e bab. moves dee/er into .our /elvis to1ards term o" /regnanc.0 a 1oman "eel more /ressure on .our bladder and ma. "ind &ersel" urinating more o"ten0 even during t&e nig&t$ T&is e!tra /ressure ma. also cause &er to lea% urine J es/eciall. 1&en s&e laug&s0 coug&s or sneeEes$ n t&is case t&e client 1ill Hust &ave to be assured t&at t&is is normal 1it& a good e!/lanation o" t&e cause$ S&e 1ill also &ave to be advised on /erineal care to /revent ascending in"ections$ !$AMPS ,ram/ is a sudden0 s&ar/ /ain0 usuall. in cal" muscles or "eet$ t is most common at nig&t0 but nobod. reall. %no1s 1&at causes it$ T&e 1oman 1ill be oriented to s%ills s&e 1ill &ave /ractice to combat t&e /roblem "or e!am/le: /ulling u/ o" toes &ard u/ to1ards t&e an%le0 or rub t&e muscle &ard$ Gentle e!ercise in /regnanc.0 /articularl. an%le and leg movements0 1&ic& can im/rove blood circulation and ma. &el/ to /revent cram/ occurring and /lent. o" calcium ric& "oods 'lea". green vegetables0 dair. /roducts0 sun"lo1er seeds0 salmon and dried beans) and magnesium ric& "oods 'nuts0 dates and "igs0 .ello1 corn0 green vegetables and a//les) in &er diet$ FEA$ As t&e /regnanc. dra1s near term most 1omen become a"raid o" t&e labour /ains0 "ears about c&ildbirt& ma. become more /ersistent$ (o1 muc& 1ill it &urtK (o1 long 1ill

it lastK (o1 1ill t&e. co/eK " Mrs$ N%&ata &a//ens to come 1it& suc& a /roblem0 s&e 1ill be advised on t&e im/ortance o" &os/ital deliver. 1&ere /ain relie" mec&anisms are available$ S&e 1ill also be as%ed to &ave time 1it& ot&er 1omen 1&o &ave &ad /ositive e!/erience o" labour and t&is 1ill &el/ in relieving &er "ears$

E+3,AT -N AN+ ,-3NSELL NG +uring t&e assessment0 several areas 1ere identi"ied t&at needed education and counselling to Mrs$ N%&ata$ FAM LY *LANN NG Mrs$ N%&ata indeed %no1s 1&at "amil. /lanning is as 1ell as t&e available "amil. /lanning met&ods in Mala1i but &as /roblems 1it& c&oice o" "amil. /lanning met&od according to &er re/roductive goals$ Mrs$ N%&ata e!/ressed t&at s&e 1ants to use inHectable contrace/tives '+e/o9*rovera) as &er "amil. /lanning met&ods o" c&oice$ (o1ever0 s&e also e!/ressed "ears t&at s&e &ad &eard t&at t&e met&od is /&asing out soon$ Loo%ing at &er re/roductive goals0 "elt t&at Mrs$ N%&ata could also bene"it "rom ot&er "amil. met&ods t&at are long term li%e ntrauterine ,ontrace/tive +evice and 8adelle t&an t&e met&ods s&e &ad c&osen discussed 1it& &er o" all t&e met&ods on t&e /ositives0 negatives and availabilit. o" t&e met&ods 1it& muc& em/&asis on 8adelle 1&ic& is t&e best met&od "or &er basing on &er goals as s&e 1ants to &ave a s/ace o" "ive .ears be"ore gets /regnant again so t&e same 1it& t&e met&od as it is made to last "or 5 .ears$ also commented on t&e s/eculation t&at inHectable contrace/tives are /&asing out b. telling &er t&at it is not true$ also e!/lained to &er t&at t&e best time to start "amil. /lanning is si! 1ee%s a"ter deliver. "or it is believed t&at b. t&is time a 1oman4s "ertilit. &as returned and also &er bod. &as returned to &er /re9/regnant state and can resume se! 'Famil. *lanning (andboo%0 255<) MM3N SAT -NS

;ased on t&e in"ormation t&at s&e &ad received onl. t1o doses o" Tetanus To!oid Caccine 1it& t&e "irst /regnanc. and t1o 1it& t&e current one0 "elt s&e needed more in"ormation on t&e rig&t e!/ected sc&edule t&e mot&ers are need to "ollo1 to com/lete all t&e "ive doses "or TTC$ -n t&is da.0 an e!/lanation on t&e normal vaccination sc&edule 1as given to Mrs$ N%&ata so t&at as s&e &as alread. started 1it& t&e t1o doses0 s&ould "inis& t&e remaining t&ree doses$ Finis&ing t&e doses 1ill &el/ in reducing t&e ris% o" t&e bab. "rom getting tetanus$ Ae toget&er /lanned on &o1 s&e 1as going to get t&e ot&er doses$ T&e t&ird dose 1ill be given on 7G?G660 t&e "ourt& dose 1ill be given on 7G?G62 and t&e last dose 1ill de given on 7G?G6D$ SE=3AL TY Mrs$ N%&ata did not &ave %no1ledge on 1&en to sto/ se! be"ore deliver. and 1&en resume a"ter deliver.$ -n t&is da.0 oriented &er to t&e rig&t time as to 1&en s&e can sto/ se! as 1ell as 1&en to resume$ told &er t&at t&ere is no limitation as to 1&en t&e. can sto/ se! t&us t&e. can &ave se! until term o" /regnanc. as "ar as t&e. are com"ortable$ also e!/lained to &er t&at t&e. can resume se! as earl. as > 1ee%s as "ar as s&e "eels t&at &er bod. is read. "or se!$ ; RT(( *LAN AN+ ,-M*L ,AT -N *RE*ARE+NESS Realising t&at Mrs$ N%&ata 1as a"raid o" labour /ains0 too% sometime counselling &er on normal /rocesses o" /regnanc. until labour and deliver. so as to alle. &er an!iet.$ i /ut em/&asis on t&e need and im/ortance o" delivering at t&e &os/ital 1&ere measures o" managing labour /ains are used$ also advised &er on t&e need to associate and learn "rom mot&ers 1&o &ad undergone t&e same e!/erience several times 1&o can &el/ &er /re/are "or &er labour and deliver.$ F-,3SE+ ANTENATAL ,ARE ;asing on t&e time t&at s&e &ad started antenatal visits0 it s&o1ed t&at s&e did not &ave enoug& or no %no1ledge on "ocused antenatal care and its im/ortance$ t&ere"ore /lanned to educate &er on 1&at "ocused antenatal is0 and its im/ortance$ Mrs$ N%&ata 1as told 1&at is done at t&e clinic 1&ere "ocused antenatal s.stem is "ollo1ed and also

1&at i" e!/ected o" 1omen undergoing "ocused antenatal care es/eciall. 1&en to start attending antenatal and &o1 "re@uent$ Ae also discussed on t&e im/ortance o" attending all t&e e!/ected normal "our visits o" antenatal care$ M N-R + S-+ERS -F *REGNAN,Y n addition to t&ese education and counselling sessions0 Mrs$ N%&ata 1as also /re/ared "or t&e e!/ected minor disorders t&at ma. develo/ as t&e /regnanc. /rogresses es/eciall. in t&e t&ird trimester$ Minor disorders li%e d.s/noea0 &eartburn0 consti/ation and bac%ac&e are some o" t&e common disorders t&at occur to mot&er in t&eir t&ird trimesters$ So s&e 1as told o" t&e disorders so as 1&en t&e. &a//en s&e s&ould not be an!ious but acce/t t&em as t&ings t&at &a//en normall.$

+ate "or t&e ne!t visit$