. Mrs. Nkhata has no history of ante-partum or intra-partum haemorrhage as well as Pre-eclampsia or eclampsia.

PSYCHOLO !C"L H!S#O$Y Mrs. Nkhata sai% that the pregnancy that she has now was a planne% one an% also that the %ecision to ha&e the pregnancy was ma%e 'y 'oth her an% her hus'an% such that they 'oth were &ery happy for the pregnancy. She also sai% that she %i% not ha&e any psychological pro'lems %ue to 'oth pre&ious pregnancy as well as the current one e(cept for the fear of la'our pains. !MM)N!S"#!ONS Mrs. N*hata e(plaine% that she ha% recei&e% two %oss of #etanus #o(oi% +accine with the first pregnancy an% two %oses with the current pregnancy. Howe&er, she e(presse% lack of knowle%ge on the fre-uency an% num'er of %oses of tetanus #o(oi% +accine she is e(pecte% to recei&e %espite knowing the importance of the immuni.ations. /N+!$ONM/N#"L H!S#O$Y On en&ironmental history, Mrs. N*hata sai% that she has a two 'e%room house with a seat room which is occupie% 'y three mem'ers of thee family, the hus'an%, the first 'orn chil% an% herself. #he house is iron sheet roofe%, cement floore% an% electrifie%. She sai% that she gets water from a Communal 0ater Point which is a'out 12 metres from her house 'ut she makes sure she has enough water all the time 'y keeping some in 'uckets knowing that there is a pro'lem of water scarcity in her area at times. On waste %isposal, she sai% that there is a ru''ish pit 'ehin% the house which is use% for waste %isposal an% she keeps 'urning the waste in the pit to pre&ent it from 'eing 'lown 'ack to the house 'y win% when it3s full. SOC!O-/CONOM!C H!S#O$Y

Mrs. Nkhata is a 4orm four Lea&er currently working with *)*) Matches Company as a Packer. Her hus'an% is an electrician who is self employe%. She sai% that her family is a'le to get their nee%s an% necessities from the com'ine% income that they get from their %uties an% they li&e happily. Mrs. Nkhata reporte% no e(posure to increase% workloa% for she is currently gi&en light work 'y her 'osses ha&ing un%erstoo% her con%ition. Mrs. Nkhata %oes not smoke any kin% of cigar nor %rinks any kin% of alcohol although the hus'an% takes alcohol 'ut in a reasona'le manner. P$/S/N# O5S#/#$!C H!S#O$Y Mrs. Nkhata is gra&i%a 6 Para 7 mother Last normal menstrual perio% 8 /(pecte% %ate of %eli&ery 8 estation 'y %ates H!+ Status +;$L 8 8 8 71th 9uly, 6272 66n% "pril, 6277 :2 weeks, %ays Non-reacti&e Non-reacti&e

She is currently not on any me%ications e(cept for the 4errous Sulphate she is gi&en when se &isits antenatal clinic meant to help in the formulation of haemoglo'in. /L!M!N"#!ON Mrs. Nkhata has no any pro'lem with either 'owel mo&ement or urination. Howe&er, she sai% that she ha% in the early %ays of pregnancy a pro'lem of fre-uency micturation.

O59/C#!+/ ;"#" Vital Signs

#emperature 5loo% Pressure Pulse $ate $espiration $ate

8 8 8 8

:<.=>C 762?=2mmHg =2 'eats peer minute 66 'reaths per minute

/N/$"L "PP//"$"NC/ Mrs Nkhata is a 7<6 cm tall woman, slim an% light 'rown in comple(ion. She was wearing a re% 'louse an% a 'lack skirt with a pair of 'lack slip-ons @shoesA. On this %ay she weighe% 1B kilograms, gaining 6 kilograms from the weight %uring her 'ooking &isit which was 1< kilograms. H/"; Her hea% is o&oi% in shape with long chemical ma%e hair an% there was neither %an%ruff nor presence of scars or masses on the scalp. 4"C/ #here were no signs of facial oe%ema on 'oth inspection an% palpation. #he face also %i% not ha&e scars on inspection. /Y/S #he eyes are symmetrical an% o&oi% in shape with no signs of peri-or'ital oe%ema an% ha% a pink conCuncti&a. /"$S #he ears are symmetrical with the upper ears in line with the outer 'or%ers of the eyes. #here were no sore, no ear %ischarge, no lesions an% no signs of inflammation on palpating the pre an% post auricular lymph no%es. NOS/

Her nostrils are symmetrical with no any %ischarge. She has no history of epista(is an% %i% not ha&e any polyps in the nostrils. MO)#H Her lips were smooth with no sores or cracks. Her tongue an% oral mucosa were pink with no sore, no korpliks spots or signs of can%i%iasis. #here were neither %ecaye% teeth nor gingi&itis. She has neither cleft lip nor cleft palate. #he tonsilor, su'man%i'ular an% su' mental lymph no%es were not enlarge%. N/C* She has no pro'lems with neck fle(ion as well as forwar% an% 'ackwar% neck 'en%ing. On inspection, there were no o'&ious signs of %isten%e% Cugular &eins, no sores, no o'&ious lesions. On palpation, there were neither signs of enlarge% thyroi% glan% nor enlarge% %eep cer&ical, su'-cla&icle an% infra -cla&icle lymph no%es. CH/S# On inspection, the chest %i% not ha&e scars, lesions or signs of a pigeon chest with normal respiratory mo&ements. On auscultation, there were normal lung an% heart soun%s. 5$/"S#S #he 'reasts are symmetrical in 'oth si.e an% shape an% they 'oth are light 'rown in colour with %ark alleorae. #he 'reasts ha&e no scars, scales, lesions, no sores, rashes, re%ness an% no %impling. On 'reast palpation, no masses were felt e(cept for the normal mammary glan%. #he nipples are %ark in colour, clean an% not in&erte%. )PP/$ /D#$/M!#!/S #he arms are symmetrical with no signs of oe%ema on 'oth inspection an% palpation. She has a capillary refill of less than : secon%s an% has pink palms. Howe&er, Mrs. Nkhata reporte% ha&ing tingling sensation of the upper e(tremities. "5;OM/N

On inspection of the a'%omen, there was a %ark linea nigra, some striae gra&i%alum with no sores or scars. #he a'%omen was o&oi% in shape with a me%ium si.e. 4oetal mo&ements were also o'ser&e% me%ially on inspection. Li&er an% spleen were not palpa'le in%icating a'sence of organomegally. #he calculate% gestation 'y %ates was :2 weeks an% Fundal height Pelvic, Lateral and Fundal Palpation 4un%al height 4oetal Presentation 8 4oetal Lie 4oetal Position 4oetal Heart $ate 8 8 8 8 6E weeks

Cephalic Longitu%inal $ight Occipital "nterior 7F6 'eats per minute

LO0/$ /D#$/M!#!/S #he lower e(tremities are symmetrical with no scars, &aricose &eins as well as signs of oe%ema on inspection. On palpation, no ti'ial, ankle or pe%al oe%ema was %etecte%. No signs of +aricose +eins or ;eep +ein #hrom'osis were %etecte% on palpation of the cuff muscles. Howmans sign was not o'ser&e% on fle(ion on the feet. /N!#"L!" )pon inspection of the genitalia, no oe%ema, sores, warts, genital ulcers, a'normal &aginal %ischarge or signs of hematoma were o'ser&e%. #here were no signs of &aricose &eins or genital mutilation or circumcision seen. #he &aginal %ischarge was mil%, whitish an% o%ourless.

P$O5L/MS ?N//;S !;/N#!4!/;.

*nowle%ge %eficit on se(uality %uring intra an% post partum perio%s relate% to ina'ility set times on when to stop an% resume se(. Lack of a%e-uate information on immunisations relate% to limite% information gi&en on immunisations as e&i%ence% 'y ina'ility to outline the normal sche%ule for #etanus #o(oi% +accine. *nowle%ge %eficit on 4ocusse% "ntenatal Care an% its importance relate% to limite% information gi&en a'out focusse% antenatal care as e&i%ence% 'y late coming for initial &isit. Possi'ily of not using family planning metho%s relate% to untrue speculations that ;epoPro&era is phasing out.

C"$/ P$O+!;/; 4ocus "ntenatal Care looks at comprehensi&e care gi&en to a pregnant woman with specifie% type of care per each &isit of the four e(pecte% &isits that the woman atten%s antenatal clinic. !t looks at -uality of care an% not -uantity of the num'er of &isits. 4ocuse% "ntenatal Care emphasises on treating e&ery mother as an in%i&i%ual or uni-ue person with in%i&i%ual pro'lems an% nee%s. #he care that was gi&en to Mrs. Nkhata was 'ase% on the pro'lems an% nee%s that she ha% as well as specific care accor%ing to hergestation age. On this %ay, Mrs. Nkhata was treate% comprehensi&ely starting with history taking to fill in gaps followe% 'y H!+ an% Syphilis tests then full physical assessment which in&ol&e% using all the four mo%alities of inspection, palpation, auscultation an% percussion. ! ma%e sure that the client3s care was pro&i%e% in a &ery con%uci&e en&ironment, thus ensuring pri&acy as well as cleanliness. ! ma%e sure that she felt well taken care of an% welcome to the clinic 'y 'eing respectful, accommo%ati&e an% letting her ask -uestions an% e(press fears than looking at the care as a 'ur%en throughout the proce%ures.

/N+!$ONM/N# ;uring the filling in of gaps, collection of important information that was misse% out on the 'ooking %ay, an en&ironment that ensure% pri&acy an% comfort was ensure%. #he %ata was collecte% at an enclose% place where no one else coul% listen to what was 'eing %iscusse% an% this ma%e the client to 'e more open an% to gi&e the information that was re-uire%. Likewise, %uring the physical e(amination, a cu'ical was use% to promote pri&acy consi%ering that proce%ures in&ol&e% this time inclu%e e(posure of sensiti&e areas like the chest, a'%omen an% genitalia. 4!LL!N !N O4 "PS

)pon re&iew of the "ntenatal car%?page for Mrs. Nkhata se&eral areas that re-uire% to 'e fille% in were realise%. !n a%%ition to that, some more areas in the health passport were i%entifie% which also nee%e% filling in. #he health %i% not ha&e information on her family me%ical history an% her me%ical an% surgical history which is suppose% to 'e fille% o the first an% secon% pages of the health passport an% this is also where some important personal %ata is %ocumente%. See "ppen%i(...... showing the pages after filling in. Not only that 'ut also 'loo% group an% rhesus factor were not teste% 'ut still more 'eing an important information especially when it comes to emergencies like anaemia, ! still referre% her go also go for the tests when she goes for the other tests. On the antenatal page as well, gra&i%ity an% parity of the mother were not in%icate% %uring the first &isit 'ut got %ocumente% on this &isit. TESTS 4ocuse% "ntenatal recommen%s mothers un%ergoing se&eral %ifferent tests at %ifferent &isits an% %ifferent gestation ages. Such tests are like H!+, Syphilis, haemoglo'in le&el, urine protein an% C;F count in case of those who are H!+ positi&e 'ut not on antiretro&iral therapy.

H!+, +;$L an% Haemoglo'in le&el are the tests that are e(pecte% to 'e %one on 'ooking so as to ha&e a 'aseline %ata for some of them like H!+ an% haemoglo'in are teste% again after sometime i.e. H!+ is teste% again after : months while haemoglo'in le&el is reteste% at :< weeks. )rine protein is e(pecte% to 'e teste% e&ery &isit from first to fourth &isit 'ut unfortunately none of these were %one on the first &isit On this &isit ! playe% a role of helping Mrs. Nkhata get teste% for H!+ an% Syphilis whose results came out negati&e as in%icate% on the antenatal car% @"ppen%i(.....A after filling in the gaps. Howe&er, ! referre% the client to Gueen /li.a'eth Central Hospital for the tests which coul% not 'e %one at N%iran%e "ntenatal Clinic %ue to lack of materials like the haemacue kits an% protein %ipsticks. #he referral was %one after N%iran%e Health Centre also reporte% not ha&ing the materials PHYS!C"L /D"M!N"#!ON "s in%icate% in thee o'Cecti&e %ata, %uring physical assessment, no specific pro'lems were presente% or %etecte% from Mrs. Nkhata an% all the fin%ings were %ocumente% on the antenatal car% an% were also communicate% to the client. See "ppen%i(...... showing the antenatal car% with fin%ings of the a'%ominal assessment. M/;!C"#!ONS Most of me%ications at the "ntenatal Clinic are gi&en accor%ing to gestation ages of the mothers an% most of them are gi&en for prophylactic purposes i.e. SP is gi&en to pre&ent a mother from malaria, 4errous Sulphate is gi&en to pre&ent anaemia whilst "'en%a.ole is gi&en to com'at worms infestation. SP is gi&en e&ery four weeks 'etween the gestations of 7< to :< weeksH 4errous Sulphate is gi&en at e&ery &isit throughout pregnancy whilst "'en%a.ole is gi&en Cust once an% at first &isit. SP is gi&en in such a way to pre&ent the tetratonegic effects that the sulphur may ha&e on the foetus. On this &isit, Mrs. Nkhata, ha&ing the gestation age of :2 weeks, she was gi&en 'oth SP ta'lets @:A as well as 4errous Sulphate @:2 ta'letsA. SP was gi&en after confirming that F weeks ha% passe% since the last %ose was taken.

M!;0!4/$Y C"$/

"N"LYS!S O4 C"$/ " lot of things an% care were %one %uring Mrs. Nkhata3s 'ooking antenatal &isit. ! shoul% sincerely gi&e cre%it to the care pro&i%er who han%le% Mrs. Nkhata on the first &isit for the goo% Co' for most things e(pecte% to 'e %one on 'ooking especially %ata nee%e% to 'e fille% on the antenatal car% was fille%. Howe&er, not e&ery 'it of information was collecte% an% %ocumente%H for e(ample, no information was %ocumente% in%icating gra&i%ity an% parity on the antenatal car%. #his information is &ery important to e&ery mi%wife who woul% come into contact with the client for it gi&es a picture of the kin% of client one is %ealing with i.e. prim-gra&i%a, multigra&i%a or gran% multipara. #hese also %etermine the kin% of care that a client will get. Secon%ly, the %ata %ocumente% on the antenatal car% for a'%ominal assessment seem to ha&e 'een taken for grante% 'y the care pro&i%er %uring the pre&ious &isit. Ha&ing 'een gi&en the %ate for the last normal menstrual perio%, there was no reason he?she coul% not calculate the gestation 'y %ates for this %ay knowing its importance. #he calculate% gestation 'y %ates is &ery important to a mi%wife for it gi&es a 'ase comparison with the fun%al height %one 'y tape measure or finger 'rea%ths. !t also seems that the mi%wife who care% for Mrs. Nkhata %uring the first &isit %oes not know what it means when we say presentation 'y a'%ominal assessment for she?he in%icate% that it was a &erte( presentation of which &erte( can not 'e %etermine% 'y pel&ic palpation 'ut &aginally. She?he woul% rather in%icate cephalic for presentation an% a position i.e. $ight Occipital "nterior, Left Occipital "nterior or other positions. 5loo% Pressure is on of the important &ital signs in pregnant women an% unfortunately, it was not %one on the 'ooking %ay. Yes its true there coul% 'e no a sphygmomanometer 'ut still more a referral to N%iran%e only for a 'loo% pressure check woul% 'e helpful. Pregnant women are at a risk of %e&eloping pre-eclampsia which is high 'loo% pressure in pregnancy an% can only 'e %iagnose% if 'loo% pressure if checke% at e&ery &isit.

)rine protein test is also &ital in the way that presence of protein in urine is in%icati&e of pre-eclampsia Mrs. Nkhata ha% come for 'ooking at a gestation age of 6< weeks 'y fun%al height an% this clearly shows lack of knowle%ge on focuse% antenatal care as well as its importance. Mrs. Nkhata 'eing a Para one with 'irth of first 'orn in 622= when focuse% antenatal was alrea%y un%er implementation, it was e(pecte% she must ha&e alrea%y 'een e(pose% to such type of care. )nfortunately, the mother came at 6< weeks gestation following the ol% routine antenatal system. 0hen i aske% her, she sai% coming at 62 weeks an% a'o&e was what she knew. #his mother lacke% information on focuse% antenatal an% its importance which reflects that she was not gi&en enough information a'out it %uring her first pregnancy. /DP/C#/; 4!N;!N S 4O$ #H/ N/D# +!S!# Mrs. Nkhata ha% come for her secon% antenatal &isit at a gestation age of 6E weeks, howe&er, accor%ing to focuse% antenatal, 'y this time she was suppose% to 'ecoming for her thir% &isit which is suppose% to 'ee 'etween 6B weeks an% :6 weeks. !n this case Mrs. Nkhata will ha&e her thir% an% final normal &isit at :< weeks though at this time a mother is normally e(pecte% to 'e coming for a fourth &isit. 0hen Mrs. Nkhata comes at :< weeks which woul% 'e on ............., she will un%ergo se&eral assessments some that are routine like &itals signs whilst some will 'ase on her con%ition as 'eing in thir% trimester or ha&ing a :< weeks gestation. Some of thee care will also 'ase of the gaps that the mi%wife will i%entify as 'eing left out %uring the pre&ious &isit. On the ne(t &isit the mi%wife will ha&e to check on the care gi&en on the pre&ious &isit, e&aluate an% then ha&e a 'asing for planning his?her care an% this will also %epen% on the current pro'lems an% the unmet nee%s of the client. #he mi%wife will collect some information from the client to fill in the gaps that are not fille% %uring this &isit. She will also check on the progress of pregnancy 'y asking Mrs. Nkhata on how she fairing with her pregnancy. Some of the -uestions she may ask are the presence of foetal mo&ements an% minor %isor%ers of pregnancy for this will help the mi%wife to isolate the pro'lems that the client has at present.

Mrs. Nkhata will also ha&e to un%ergo se&eral tests which will 'e %ue 'y this time i.e. haemoglo'in le&el an% urine protein. Haemoglo'in le&el is checke% on 'ooking an% in thir% trimester, at :< weeks to 'e specific whilst for urine protein is checke% at e&ery &isit to the antenatal clinic. +ital signs are another aspect that will ha&e to 'e checke% 'y the mi%wife as part of monitoring progress of pregnancy. "ny a'normality in the &ital signs is in%icati&e of a pro'lem in the pregnant woman. 4or e(ampleH high 'loo% pressure coul% 'e in%icati&e of pre-eclampsia, fe&er coul% in%icate a systemic infection an% increase% respiratory rate coul% mean %ifficulty 'reathing, though, it is thought to 'e normal at :< weeks. Physical assessment will also 'e %one inclu%ing general assessment as well as a'%ominal assessment. eneral assessment will in&ol&e a hea% to assessment an% no a'normality is e(pecte% from it. #he a'%ominal assessment will in&ol&e inspection, palpation an% auscultation of the a'%omen to check si.e an% shape of a'%omen, fun%al height, lie, presentation an% position of foetus as well as foetal heart rate. #he a'%omen is inspecte% for scars, linea nigra, striae gra&i%alum, si.e an% shape, foetal mo&ements, 'la%%er fullness an% &isi'le organomegally. #hee fun%al height will 'e measure% using a tape measure of finger 'rea%ths so as to %etermine the age of pregnancy. #hen the pel&is will 'e palpate% for presentation which is normally, lateral palpation will 'e %one to note the lie an% position of the foetus. 4un%al palpation will also 'e %one to rule out multiple gestation or presentation in a situation where the hea% is not locate% in the pel&ic. 4oetal heart rate will also ha&e to 'ee auscultate% using a fetalscope to confirm well'eing of the foetus.

/DP/C#//; 4!N;!N S 4un%al height 4oetal Presentation 8 8 :< weeks

Cephalic

4oetal Lie 4oetal Position 4oetal Heart $ate

8 8 8

Longitu%inal $ight Occipital "nterior?Left Occipital "nterior 7F2 I 7<2 'eats per minute

#he a'o&e e(pecte% fin%ings are thee normal e(pecte% fin%ing in the a'sence of possi'ility of ha&ing a'normal fin%ings ;$) S On this &isit Mrs. Nkhata will only 'e pro&i%e% with 4errous Sulphate as a %rug to supplement iron for haemoglo'in formation. SP will not 'e gi&en 'ecause it is 'elie&e% to ha&e a teratonic effect on the fetus when gi&en at the gestation of :< weeks an% a'o&e. /DP/C#/; ;!SO$;/$S 5y this time the e(pecte% %isor%ers that Mrs. Nkhata may ha&e are %ifficulty 'reathing, fre-uent micturation, hea%ache, constipation, 'ackache, oe%ema &aricosities, haemorrhoi%s an% cramps for these are the common %isor%ers that usually come in thir% trimester. MANAGEMENT OF THE E PE!TE" M#N#$ "#SO$"E$S HEA$T%&$N #his is a 'urning, irritating sensation in the oesophagus also known as gastric reflu( @4raser, Cooper an% Nolte, 622<A. oesophageal sphincter tone. !f it happens that Mrs. Nkhata %e&elops heart'urn, e%ucation an% counseling on li'est(le
)odi'ication will 'e pro&i%e% an% will inclu%e awareness of posture i.e. Maintaining upright positions @especially after mealsA, sleeping in a proppe% up position an% dietar( )odi'ications @e.g. small fre-uent meals, eating slowly, re%uction of high-fat foo%s an% caffeineA.

astric reflu( commonly occurs as a result of

%elaye% gastric emptying, %ecrease% intestinal motility, an% %ecrease% lower

S*ELL#NG+E"EMA

"s the growing uterus puts pressure on the &eins that return 'loo% from feet an% legs, swollen feet an% ankles may 'ecome an issue. "t the same time, swelling in legs, arms or han%s may place pressure on ner&es, causing tingling or num'ness. 4lui% retention an% %ilate% 'loo% &essels may lea&e the face an% eyeli%s puffy, especially in the morning. #o re%uce swelling, the client will 'e a%&ise% to use col% compresses on the affecte% areas. Lying %own or using a footrest may relie&e ankle swelling. She might e&en ele&ate her feet an% legs while she sleeps which will also minimise the swelling 'y gra&ity. ",SPNEA #his is a common symptom 'etween the gestation of :F an% :< weeks. !t is as a result of the pressure 'y the growing uterus on the %iaphragm @4raser, Cooper an% Nolte, 622<A. !f Mrs. Nkhata happens to %e&elop %yspnoea, she will 'e e%ucate% of the physiology of the pro'lem for her to un%erstan% what3s happening. She will also 'e a%&ise% on sleeping in semi-fowlers position so as to 'e increasing the area for lung e(pansion hence impro&e% respiratory con%ition. She will also 'e encourage% to ha&e perio%s an% resting to re%uce the 'o%y nee% for o(ygen. !ONST#PAT#ON Constipation in pregnancy especially thir% trimester is usually cause% 'y re%uce% motility of large intestine which comes %ue to the muscle la(ati&e effect of the hormone progesterone which is pro%uce% in large amounts this perio%, !ncrease% water rea'sorption from large intestine %ue to hormone al%osterone effect, Pressure on the pel&ic colon 'y the pregnant uterus an% se%entary life %uring pregnancy . if the client will come with the pro'lem of constipation, she will a%&ise% on %rinking plenty of flui%s, high fi're foo%s an% get plenty of e(ercise. #hese help in softening the 'owels hence re%uce% risk of constipation. %A!-A!HE

;uring pregnancy, ligaments 'ecome softer an% stretch to prepare for la'our. #his can put a strain on the Coints of the lower 'ack an% pel&is, which can result in 'ackache. #o o&ercome this pro'lem Mrs. Nkhata will 'e a%&ise% to a&oi% hea&y lifting, 'en% her knees an% keep her 'ack straight when lifting or picking up things from the groun%, mo&e her feet when turning an% a&oi% su%%en twisting mo&ements, 0ork at a surface high enough to pre&ent her from stooping an% to sit with her 'ack straight an% wellsupporte%. "nother a%&ice will 'e that she shoul% make sure she gets enough rest, particularly later in pregnancy.

F$E.&ENT M#!T&$AT#ON "s the 'a'y mo&es %eeper into your pel&is towar%s term of pregnancy, a woman feel more pressure on your 'la%%er an% may fin% herself urinating more often, e&en %uring the night. #his e(tra pressure may also cause her to leak urine J especially when she laughs, coughs or snee.es. !n this case the client will Cust ha&e to 'e assure% that this is normal with a goo% e(planation of the cause. She will also ha&e to 'e a%&ise% on perineal care to pre&ent ascen%ing infections. !$AMPS Cramp is a su%%en, sharp pain, usually in calf muscles or feet. !t is most common at night, 'ut no'o%y really knows what causes it. #he woman will 'e oriente% to skills she will ha&e practice to com'at the pro'lem for e(ampleH pulling up of toes har% up towar%s the ankle, or ru' the muscle har%. entle e(ercise in pregnancy, particularly ankle an% leg mo&ements, which can impro&e 'loo% circulation an% may help to pre&ent cramp occurring an% plenty of calcium rich foo%s @leafy green &egeta'les, %airy pro%ucts, sunflower see%s, salmon an% %rie% 'eansA an% magnesium rich foo%s @nuts, %ates an% figs, yellow corn, green &egeta'les an% applesA in her %iet. FEA$ "s the pregnancy %raws near term most women 'ecome afrai% of the la'our pains, fears a'out chil%'irth may 'ecome more persistent. How much will it hurtK How long will

it lastK How will they copeK !f Mrs. Nkhata happens to come with such a pro'lem, she will 'e a%&ise% on the importance of hospital %eli&ery where pain relief mechanisms are a&aila'le. She will also 'e aske% to ha&e time with other women who ha&e ha% positi&e e(perience of la'our an% this will help in relie&ing her fears.

/;)C"#!ON "N; CO)NS/LL!N ;uring the assessment, se&eral areas were i%entifie% that nee%e% e%ucation an% counselling to Mrs. Nkhata. 4"M!LY PL"NN!N Mrs. Nkhata in%ee% knows what family planning is as well as the a&aila'le family planning metho%s in Malawi 'ut has pro'lems with choice of family planning metho% accor%ing to her repro%ucti&e goals. Mrs. Nkhata e(presse% that she wants to use inCecta'le contracepti&es @;epo-Pro&eraA as her family planning metho%s of choice. Howe&er, she also e(presse% fears that she ha% hear% that the metho% is phasing out soon. Looking at her repro%ucti&e goals, ! felt that Mrs. Nkhata coul% also 'enefit from other family metho%s that are long term like !ntrauterine Contracepti&e ;e&ice an% 9a%elle than the metho%s she ha% chosen ! %iscusse% with her of all the metho%s on the positi&es, negati&es an% a&aila'ility of the metho%s with much emphasis on 9a%elle which is the 'est metho% for her 'asing on her goals as she wants to ha&e a space of fi&e years 'efore gets pregnant again so the same with the metho% as it is ma%e to last for 1 years. ! also commente% on the speculation that inCecta'le contracepti&es are phasing out 'y telling her that it is not true. ! also e(plaine% to her that the 'est time to start family planning is si( weeks after %eli&ery for it is 'elie&e% that 'y this time a woman3s fertility has returne% an% also her 'o%y has returne% to her pre-pregnant state an% can resume se( @4amily Planning Han%'ook, 622EA !MM)N!S"#!ONS

5ase% on the information that she ha% recei&e% only two %oses of #etanus #o(oi% +accine with the first pregnancy an% two with the current one, ! felt she nee%e% more information on the right e(pecte% sche%ule the mothers are nee% to follow to complete all the fi&e %oses for ##+. On this %ay, an e(planation on the normal &accination sche%ule was gi&en to Mrs. Nkhata so that as she has alrea%y starte% with the two %oses, shoul% finish the remaining three %oses. 4inishing the %oses will help in re%ucing the risk of the 'a'y from getting tetanus. 0e together planne% on how she was going to get the other %oses. #he thir% %ose will 'e gi&en on =?B?77, the fourth %ose will 'e gi&en on =?B?76 an% the last %ose will %e gi&en on =?B?7:. S/D)"L!#Y Mrs. Nkhata %i% not ha&e knowle%ge on when to stop se( 'efore %eli&ery an% when resume after %eli&ery. On this %ay, oriente% her to the right time as to when she can stop se( as well as when to resume. ! tol% her that there is no limitation as to when they can stop se( thus they can ha&e se( until term of pregnancy as far as they are comforta'le. ! also e(plaine% to her that they can resume se( as early as < weeks as far as she feels that her 'o%y is rea%y for se(. 5!$#HH PL"N "N; COMPL!C"#!ON P$/P"$/;N/SS $ealising that Mrs. Nkhata was afrai% of la'our pains, ! took sometime counselling her on normal processes of pregnancy until la'our an% %eli&ery so as to alley her an(iety. !i put emphasis on the nee% an% importance of %eli&ering at the hospital where measures of managing la'our pains are use%. ! also a%&ise% her on the nee% to associate an% learn from mothers who ha% un%ergone the same e(perience se&eral times who can help her prepare for her la'our an% %eli&ery. 4OC)S/; "N#/N"#"L C"$/ 5asing on the time that she ha% starte% antenatal &isits, it showe% that she %i% not ha&e enough or no knowle%ge on focuse% antenatal care an% its importance. ! therefore planne% to e%ucate her on what focuse% antenatal is, an% its importance. Mrs. Nkhata was tol% what is %one at the clinic where focuse% antenatal system is followe% an% also

what if e(pecte% of women un%ergoing focuse% antenatal care especially when to start atten%ing antenatal an% how fre-uent. 0e also %iscusse% on the importance of atten%ing all the e(pecte% normal four &isits of antenatal care. M!NO$ ;!SO;/$S O4 P$/ N"NCY !n a%%ition to these e%ucation an% counselling sessions, Mrs. Nkhata was also prepare% for the e(pecte% minor %isor%ers that may %e&elop as the pregnancy progresses especially in the thir% trimester. Minor %isor%ers like %yspnoea, heart'urn, constipation an% 'ackache are some of the common %isor%ers that occur to mother in their thir% trimesters. So she was tol% of the %isor%ers so as when they happen she shoul% not 'e an(ious 'ut accept them as things that happen normally.

;ate for the ne(t &isit.