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

for the fear of labour pains. IMMUNISATI NS Mrs. N!hata e"plaine# that she ha# recei$e# two #oss of Tetanus To"oi# %accine with the first pregnancy an# two #oses with the current pregnancy. &owe$er' she e"presse# lack of knowle#ge on the fre(uency an# number of #oses of tetanus To"oi# %accine she is e"pecte# to recei$e #espite knowing the importance of the immuni)ations. *N%I+ NM*NTA, &IST +n en$ironmental history' Mrs. N!hata sai# that she has a two be#room house with a seat room which is occupie# by three members of thee family' the husban#' the first born chil# an# herself. The house is iron sheet roofe#' cement floore# an# electrifie#. She sai# that she gets water from a .ommunal /ater Point which is about 01 metres from her house but she makes sure she has enough water all the time by keeping some in buckets knowing that there is a problem of water scarcity in her area at times. n waste #isposal' she sai# that there is a rubbish pit behin# the house which is use# for waste #isposal an# she keeps burning the waste in the pit to pre$ent it from being blown back to the house by win# when it2s full. S .I -*. N MI. &IST +Mrs. Nkhata is a 3orm four ,ea$er currently working with !U!U Matches .ompany as a Packer. &er husban# is an electrician who is self employe#. She sai# that her family is able to get their nee#s an# necessities from the combine# 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 by her bosses ha$ing un#erstoo# her con#ition.

Mrs. Nkhata #oes not smoke any kin# of cigar nor #rinks any kin# of alcohol although the husban# takes alcohol but in a reasonable manner. P+*S*NT 4ST*T+I. &IST +-

Mrs. Nkhata is gra$i#a 5 Para 6 mother ,ast normal menstrual perio# 7 *"pecte# #ate of #eli$ery 7 9estation by #ates &I% Status %;+, 7 7 7 60th 8uly' 5161 55n# April' 5166 :1 weeks' #ays Non-reacti$e Non-reacti$e

She is currently not on any me#ications e"cept for the 3errous Sulphate she is gi$en when se $isits antenatal clinic meant to help in the formulation of haemoglobin. *,IMINATI N Mrs. Nkhata has no any problem with either bowel mo$ement or urination. &owe$er' she sai# that she ha# in the early #ays of pregnancy a problem of fre(uency micturation.

48*.TI%* ;ATA Vital Signs Temperature 4loo# Pressure Pulse +ate +espiration +ate 7 7 7 7 :<.=>. 651?=1mm&g =1 beats peer minute 55 breaths per minute

9*N*+A, APP**A+AN.* Mrs Nkhata is a 6<5 cm tall woman' slim an# light brown in comple"ion. She was wearing a re# blouse an# a black skirt with a pair of black slip-ons @shoesA. which was 0< kilograms. &*A; &er hea# is o$oi# in shape with long chemical ma#e hair an# there was neither #an#ruff nor presence of scars or masses on the scalp. 3A.* There were no signs of facial oe#ema on both inspection an# palpation. The face also #i# not ha$e scars on inspection. *-*S The eyes are symmetrical an# o$oi# in shape with no signs of peri-orbital oe#ema an# ha# a pink conCuncti$a. *A+S The ears are symmetrical with the upper ears in line with the outer bor#ers of the eyes. There were no sore' no ear #ischarge' no lesions an# no signs of inflammation on palpating the pre an# post auricular lymph no#es. N S* &er nostrils are symmetrical with no any #ischarge. She has no history of epista"is an# #i# not ha$e any polyps in the nostrils. M UT& &er lips were smooth with no sores or cracks. &er tongue an# oral mucosa were pink with no sore' no korpliks spots or signs of can#i#iasis. There were neither #ecaye# n this #ay she weighe# 0B kilograms' gaining 5 kilograms from the weight #uring her booking $isit

teeth nor gingi$itis. She has neither cleft lip nor cleft palate. The tonsilor' subman#ibular an# sub mental lymph no#es were not enlarge#. N*.! She has no problems with neck fle"ion as well as forwar# an# backwar# neck ben#ing. n inspection' there were no ob$ious signs of #isten#e# Cugular $eins' no sores' no ob$ious lesions. n palpation' there were neither signs of enlarge# thyroi# glan# nor enlarge# #eep cer$ical' sub-cla$icle an# infra -cla$icle lymph no#es. .&*ST n inspection' the chest #i# not ha$e scars' lesions or signs of a pigeon chest with normal respiratory mo$ements. soun#s. 4+*ASTS The breasts are symmetrical in both si)e an# shape an# they both are light brown in colour with #ark alleorae. The breasts ha$e no scars' scales' lesions' no sores' rashes' re#ness an# no #impling. n breast palpation' no masses were felt e"cept for the normal mammary glan#. The nipples are #ark in colour' clean an# not in$erte#. UPP*+ *DT+*MITI*S The arms are symmetrical with no signs of oe#ema on both inspection an# palpation. She has a capillary refill of less than : secon#s an# has pink palms. &owe$er' Mrs. Nkhata reporte# ha$ing tingling sensation of the upper e"tremities. A4; M*N n inspection of the ab#omen' there was a #ark linea nigra' some striae gra$i#alum with no sores or scars. The ab#omen was o$oi# in shape with a me#ium si)e. 3oetal mo$ements were also obser$e# me#ially on inspection. ,i$er an# spleen were not palpable in#icating absence of organomegally. The calculate# gestation by #ates was :1 weeks an# n auscultation' there were normal lung an# heart

Fundal height Pelvic, Lateral and Fundal Palpation 3un#al height 3oetal Presentation 7 3oetal ,ie 3oetal Position 3oetal &eart +ate 7 7 7 7 5E weeks

.ephalic ,ongitu#inal +ight ccipital Anterior

6F5 beats per minute

, /*+ *DT+*MITI*S The lower e"tremities are symmetrical with no scars' $aricose $eins as well as signs of oe#ema on inspection. n palpation' no tibial' ankle or pe#al oe#ema was #etecte#. No signs of %aricose %eins or ;eep %ein Thrombosis were #etecte# on palpation of the cuff muscles. Howmans sign was not obser$e# on fle"ion on the feet. 9*NITA,IA Upon inspection of the genitalia' no oe#ema' sores' warts' genital ulcers' abnormal $aginal #ischarge or signs of hematoma were obser$e#. There were no signs of $aricose $eins or genital mutilation or circumcision seen. The $aginal #ischarge was mil#' whitish an# o#ourless.

P+ 4,*MS ?N**;S I;*NTI3I*;. !nowle#ge #eficit on se"uality #uring intra an# post partum perio#s relate# to inability set times on when to stop an# resume se". ,ack of a#e(uate information on immunisations relate# to limite# information gi$en on immunisations as e$i#ence# by inability to outline the normal sche#ule for Tetanus To"oi# %accine.

!nowle#ge #eficit on 3ocusse# Antenatal .are an# its importance relate# to limite# information gi$en about focusse# antenatal care as e$i#ence# by late coming for initial $isit. Possibily of not using family planning metho#s relate# to untrue speculations that ;epoPro$era is phasing out.

.A+* P+ %I;*; 3ocus Antenatal .are 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. It looks at (uality of care an# not (uantity of the number of $isits. 3ocuse# Antenatal .are emphasises on treating e$ery mother as an in#i$i#ual or uni(ue person with in#i$i#ual problems an# nee#s. The care that was gi$en to Mrs. Nkhata was base# on the problems an# nee#s that she ha# as well as specific care accor#ing to hergestation age. n this #ay' Mrs. Nkhata was treate# comprehensi$ely starting with history taking to fill in gaps followe# by &I% an# Syphilis tests then full physical assessment which in$ol$e# using all the four mo#alities of inspection' palpation' auscultation an# percussion. I ma#e sure that the client2s care was pro$i#e# in a $ery con#uci$e en$ironment' thus ensuring pri$acy as well as cleanliness. I ma#e sure that she felt well taken care of an# welcome to the clinic by being respectful' accommo#ati$e an# letting her ask (uestions an# e"press fears than looking at the care as a bur#en throughout the proce#ures. *N%I+ NM*NT ;uring the filling in of gaps' collection of important information that was misse# out on the booking #ay' an en$ironment that ensure# pri$acy an# comfort was ensure#. The #ata was collecte# at an enclose# place where no one else coul# listen to what was being #iscusse# an# this ma#e the client to be more open an# to gi$e the information that was re(uire#.

,ikewise' #uring the physical e"amination' a cubical 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' ab#omen an# genitalia. 3I,,IN9 IN 3 9APS

Upon re$iew of the Antenatal car#?page for Mrs. Nkhata se$eral areas that re(uire# to be fille# in were realise#. In a##ition to that' some more areas in the health passport were i#entifie# which also nee#e# filling in. The health #i# not ha$e information on her family me#ical history an# her me#ical an# surgical history which is suppose# to be fille# o the first an# secon# pages of the health passport an# this is also where some important personal #ata is #ocumente#. See Appen#i"...... showing the pages after filling in. Not only that but also bloo# group an# rhesus factor were not teste# but still more being an important information especially when it comes to emergencies like anaemia' I still referre# her go also go for the tests when she goes for the other tests. n the antenatal page as well' gra$i#ity an# parity of the mother were not in#icate# #uring the first $isit but got #ocumente# on this $isit. TESTS 3ocuse# Antenatal recommen#s mothers un#ergoing se$eral #ifferent tests at #ifferent $isits an# #ifferent gestation ages. Such tests are like &I%' Syphilis' haemoglobin le$el' urine protein an# .;F count in case of those who are &I% positi$e but not on antiretro$iral therapy. &I%' %;+, an# &aemoglobin le$el are the tests that are e"pecte# to be #one on booking so as to ha$e a baseline #ata for some of them like &I% an# haemoglobin are teste# again after sometime i.e. &I% is teste# again after : months while haemoglobin le$el is reteste# at :< weeks. Urine protein is e"pecte# to be teste# e$ery $isit from first to fourth $isit but unfortunately none of these were #one on the first $isit

n this $isit I playe# a role of helping Mrs. Nkhata get teste# for &I% an# Syphilis whose results came out negati$e as in#icate# on the antenatal car# @Appen#i".....A after filling in the gaps. &owe$er' I referre# the client to Gueen *li)abeth .entral &ospital for the tests which coul# not be #one at N#iran#e Antenatal .linic #ue to lack of materials like the haemacue kits an# protein #ipsticks. The referral was #one after N#iran#e &ealth .entre also reporte# not ha$ing the materials P&-SI.A, *DAMINATI N As in#icate# in thee obCecti$e #ata' #uring physical assessment' no specific problems were presente# or #etecte# from Mrs. Nkhata an# all the fin#ings were #ocumente# on the antenatal car# an# were also communicate# to the client. See Appen#i"...... showing the antenatal car# with fin#ings of the ab#ominal assessment. M*;I.ATI NS Most of me#ications at the Antenatal .linic are gi$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$ent a mother from malaria' 3errous Sulphate is gi$en to pre$ent anaemia whilst Aben#a)ole is gi$en to combat worms infestation. SP is gi$en e$ery four weeks between the gestations of 6< to :< weeksH 3errous Sulphate is gi$en at e$ery $isit throughout pregnancy whilst Aben#a)ole is gi$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. n this $isit' Mrs. Nkhata' ha$ing the gestation age of :1 weeks' she was gi$en both SP tablets @:A as well as 3errous Sulphate @:1 tabletsA. SP was gi$en after confirming that F weeks ha# passe# since the last #ose was taken. MI;/I3*+- .A+*

ANA,-SIS

3 .A+*

A lot of things an# care were #one #uring Mrs. Nkhata2s booking antenatal $isit. I shoul# sincerely gi$e cre#it to the care pro$i#er who han#le# Mrs. Nkhata on the first $isit for the goo# Cob for most things e"pecte# to be #one on booking especially #ata nee#e# to be fille# on the antenatal car# was fille#. &owe$er' not e$ery bit of information was collecte# an# #ocumente#H for e"ample' no information was #ocumente# in#icating gra$i#ity an# parity on the antenatal car#. This 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$i#a or gran# multipara. These also #etermine the kin# of care that a client will get. Secon#ly' the #ata #ocumente# on the antenatal car# for ab#ominal assessment seem to ha$e been taken for grante# by the care pro$i#er #uring the pre$ious $isit. &a$ing been gi$en the #ate for the last normal menstrual perio#' there was no reason he?she coul# not calculate the gestation by #ates for this #ay knowing its importance. The calculate# gestation by #ates is $ery important to a mi#wife for it gi$es a base comparison with the fun#al height #one by tape measure or finger brea#ths. It 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 by ab#ominal assessment for she?he in#icate# that it was a $erte" presentation of which $erte" can not be #etermine# by pel$ic palpation but $aginally. She?he woul# rather in#icate cephalic for presentation an# a position i.e. +ight ccipital Anterior' ,eft ccipital Anterior or other positions.

4loo# Pressure is on of the important $ital signs in pregnant women an# unfortunately' it was not #one on the booking #ay. -es its true there coul# be no a sphygmomanometer but still more a referral to N#iran#e only for a bloo# pressure check woul# be helpful. Pregnant women are at a risk of #e$eloping pre-eclampsia which is high bloo# pressure in pregnancy an# can only be #iagnose# if bloo# pressure if checke# at e$ery $isit. Urine 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 booking at a gestation age of 5< weeks by fun#al height an# this clearly shows lack of knowle#ge on focuse# antenatal care as well as its

importance. Mrs. Nkhata being a Para one with birth of first born in 511= when focuse# antenatal was alrea#y un#er implementation' it was e"pecte# she must ha$e alrea#y been e"pose# to such type of care. Unfortunately' the mother came at 5< weeks gestation following the ol# routine antenatal system. /hen i aske# her' she sai# coming at 51 weeks an# abo$e was what she knew. This mother lacke# information on focuse# antenatal an# its importance which reflects that she was not gi$en enough information about it #uring her first pregnancy. *DP*.T*; 3IN;IN9S 3 + T&* N*DT %ISIT Mrs. Nkhata ha# come for her secon# antenatal $isit at a gestation age of 5E weeks' howe$er' accor#ing to focuse# antenatal' by this time she was suppose# to becoming for her thir# $isit which is suppose# to bee between 5B weeks an# :5 weeks. In this case Mrs. Nkhata will ha$e her thir# an# final normal $isit at :< weeks though at this time a mother is normally e"pecte# to be coming for a fourth $isit. /hen Mrs. Nkhata comes at :< weeks which woul# be on .............' she will un#ergo se$eral assessments some that are routine like $itals signs whilst some will base on her con#ition as being in thir# trimester or ha$ing a :< weeks gestation. Some of thee care will also base of the gaps that the mi#wife will i#entify as being left out #uring the pre$ious $isit. n 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 basing for planning his?her care an# this will also #epen# on the current problems an# the unmet nee#s of the client. The mi#wife will collect some information from the client to fill in the gaps that are not fille# #uring this $isit. She will also check on the progress of pregnancy by asking Mrs. Nkhata on how she fairing with her pregnancy. Some of the (uestions she may ask are the presence of foetal mo$ements an# minor #isor#ers of pregnancy for this will help the mi#wife to isolate the problems that the client has at present. Mrs. Nkhata will also ha$e to un#ergo se$eral tests which will be #ue by this time i.e. haemoglobin le$el an# urine protein. &aemoglobin le$el is checke# on booking an# in thir# trimester' at :< weeks to be 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 be checke# by the mi#wife as part of monitoring progress of pregnancy. Any abnormality in the $ital signs is in#icati$e of a problem in the pregnant woman. 3or e"ampleH high bloo# pressure coul# be in#icati$e of pre-eclampsia' fe$er coul# in#icate a systemic infection an# increase# respiratory rate coul# mean #ifficulty breathing' though' it is thought to be normal at :< weeks. Physical assessment will also be #one inclu#ing general assessment as well as ab#ominal assessment. 9eneral assessment will in$ol$e a hea# to assessment an# no abnormality is e"pecte# from it. The ab#ominal assessment will in$ol$e inspection' palpation an# auscultation of the ab#omen to check si)e an# shape of ab#omen' fun#al height' lie' presentation an# position of foetus as well as foetal heart rate. The ab#omen is inspecte# for scars' linea nigra' striae gra$i#alum' si)e an# shape' foetal mo$ements' bla##er fullness an# $isible organomegally. Thee fun#al height will be measure# using a tape measure of finger brea#ths so as to #etermine the age of pregnancy. Then the pel$is will be palpate# for presentation which is normally' lateral palpation will be #one to note the lie an# position of the foetus. 3un#al palpation will also be #one to rule out multiple gestation or presentation in a situation where the hea# is not locate# in the pel$ic. 3oetal heart rate will also ha$e to bee auscultate# using a fetalscope to confirm wellbeing of the foetus.

*DP*.T**; 3IN;IN9S 3un#al height 3oetal Presentation 7 3oetal ,ie 3oetal Position 3oetal &eart +ate 7 7 7 7 :< weeks

.ephalic ,ongitu#inal +ight ccipital Anterior?,eft ccipital Anterior

6F1 I 6<1 beats per minute

The abo$e e"pecte# fin#ings are thee normal e"pecte# fin#ing in the absence of possibility of ha$ing abnormal fin#ings ;+U9S n this $isit Mrs. Nkhata will only be pro$i#e# with 3errous Sulphate as a #rug to supplement iron for haemoglobin formation. SP will not be gi$en because it is belie$e# to ha$e a teratonic effect on the fetus when gi$en at the gestation of :< weeks an# abo$e. *DP*.T*; ;IS +;*+S 4y this time the e"pecte# #isor#ers that Mrs. Nkhata may ha$e are #ifficulty breathing' fre(uent micturation' hea#ache' constipation' backache' 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 This is a burning' irritating sensation in the oesophagus also known as gastric reflu" @3raser' .ooper an# Nolte' 511<A. 9astric reflu" commonly occurs as a result of #elaye# gastric emptying' #ecrease# intestinal motility' an# #ecrease# lower oesophageal sphincter tone. If it happens that Mrs. Nkhata #e$elops heartburn' e#ucation an# counseling on li'est(le
)odi'ication will be pro$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.

S*ELL#NG+E"EMA As the growing uterus puts pressure on the $eins that return bloo# from feet an# legs' swollen feet an# ankles may become an issue. At the same time' swelling in legs' arms or han#s may place pressure on ner$es' causing tingling or numbness. 3lui# retention

an# #ilate# bloo# $essels may lea$e the face an# eyeli#s puffy' especially in the morning. To re#uce swelling' the client will be a#$ise# to use col# compresses on the affecte# areas. ,ying #own or using a footrest may relie$e ankle swelling. She might e$en ele$ate her feet an# legs while she sleeps which will also minimise the swelling by gra$ity. ",SPNEA This is a common symptom between the gestation of :F an# :< weeks. It is as a result of the pressure by the growing uterus on the #iaphragm @3raser' .ooper an# Nolte' 511<A. If Mrs. Nkhata happens to #e$elop #yspnoea' she will be e#ucate# of the physiology of the problem for her to un#erstan# what2s happening. She will also be a#$ise# on sleeping in semi-fowlers position so as to be increasing the area for lung e"pansion hence impro$e# respiratory con#ition. She will also be encourage# to ha$e perio#s an# resting to re#uce the bo#y nee# for o"ygen. !ONST#PAT#ON .onstipation in pregnancy especially thir# trimester is usually cause# by re#uce# motility of large intestine which comes #ue to the muscle la"ati$e effect of the hormone progesterone which is pro#uce# in large amounts this perio#' Increase# water reabsorption from large intestine #ue to hormone al#osterone effect' Pressure on the pel$ic colon by the pregnant uterus an# se#entary life #uring pregnancy . if the client will come with the problem of constipation' she will a#$ise# on #rinking plenty of flui#s' high fibre foo#s an# get plenty of e"ercise. These help in softening the bowels hence re#uce# risk of constipation. %A!-A!HE ;uring pregnancy' ligaments become softer an# stretch to prepare for labour. This can put a strain on the Coints of the lower back an# pel$is' which can result in backache.

To o$ercome this problem Mrs. Nkhata will be a#$ise# to a$oi# hea$y lifting' ben# her knees an# keep her back straight when lifting or picking up things from the groun#' mo$e her feet when turning an# a$oi# su##en twisting mo$ements' /ork at a surface high enough to pre$ent her from stooping an# to sit with her back straight an# wellsupporte#. Another a#$ice will be that she shoul# make sure she gets enough rest' particularly later in pregnancy.

F$E.&ENT M#!T&$AT#ON As the baby mo$es #eeper into your pel$is towar#s term of pregnancy' a woman feel more pressure on your bla##er an# may fin# herself urinating more often' e$en #uring the night. This e"tra pressure may also cause her to leak urine J especially when she laughs' coughs or snee)es. In this case the client will Cust ha$e to be assure# that this is normal with a goo# e"planation of the cause. She will also ha$e to be a#$ise# on perineal care to pre$ent ascen#ing infections. !$AMPS .ramp is a su##en' sharp pain' usually in calf muscles or feet. It is most common at night' but nobo#y really knows what causes it. The woman will be oriente# to skills she will ha$e practice to combat the problem for e"ampleH pulling up of toes har# up towar#s the ankle' or rub the muscle har#. 9entle e"ercise in pregnancy' particularly ankle an# leg mo$ements' which can impro$e bloo# circulation an# may help to pre$ent cramp occurring an# plenty of calcium rich foo#s @leafy green $egetables' #airy pro#ucts' sunflower see#s' salmon an# #rie# beansA an# magnesium rich foo#s @nuts' #ates an# figs' yellow corn' green $egetables an# applesA in her #iet. FEA$ As the pregnancy #raws near term most women become afrai# of the labour pains' fears about chil#birth may become more persistent. &ow much will it hurtK &ow long will it lastK &ow will they copeK If Mrs. Nkhata happens to come with such a problem' she will be a#$ise# on the importance of hospital #eli$ery where pain relief mechanisms are

a$ailable. She will also be aske# to ha$e time with other women who ha$e ha# positi$e e"perience of labour an# this will help in relie$ing her fears.

*;U.ATI N AN; . UNS*,,IN9 ;uring the assessment' se$eral areas were i#entifie# that nee#e# e#ucation an# counselling to Mrs. Nkhata. 3AMI,- P,ANNIN9 Mrs. Nkhata in#ee# knows what family planning is as well as the a$ailable family planning metho#s in Malawi but has problems with choice of family planning metho# accor#ing to her repro#ucti$e goals. Mrs. Nkhata e"presse# that she wants to use inCectable contracepti$es @;epo-Pro$eraA as her family planning metho#s of choice. &owe$er' she also e"presse# fears that she ha# hear# that the metho# is phasing out soon. ,ooking at her repro#ucti$e goals' I felt that Mrs. Nkhata coul# also benefit from other family metho#s that are long term like Intrauterine .ontracepti$e ;e$ice an# 8a#elle than the metho#s she ha# chosen I #iscusse# with her of all the metho#s on the positi$es' negati$es an# a$ailability of the metho#s with much emphasis on 8a#elle which is the best metho# for her basing on her goals as she wants to ha$e a space of fi$e years before gets pregnant again so the same with the metho# as it is ma#e to last for 0 years. I also commente# on the speculation that inCectable contracepti$es are phasing out by telling her that it is not true. I also e"plaine# to her that the best time to start family planning is si" weeks after #eli$ery for it is belie$e# that by this time a woman2s fertility has returne# an# also her bo#y has returne# to her pre-pregnant state an# can resume se" @3amily Planning &an#book' 511EA IMMUNISATI NS

4ase# on the information that she ha# recei$e# only two #oses of Tetanus To"oi# %accine with the first pregnancy an# two with the current one' I felt she nee#e# more information on the right e"pecte# sche#ule the mothers are nee# to follow to complete all the fi$e #oses for TT%. n 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. 3inishing the #oses will help in re#ucing the risk of the baby from getting tetanus. /e together planne# on how she was going to get the other #oses. The thir# #ose will be gi$en on =?B?66' the fourth #ose will be gi$en on =?B?65 an# the last #ose will #e gi$en on =?B?6:. S*DUA,ITMrs. Nkhata #i# not ha$e knowle#ge on when to stop se" before #eli$ery an# when resume after #eli$ery. n this #ay' oriente# her to the right time as to when she can stop se" as well as when to resume. I tol# her that there is no limitation as to when they can stop se" thus they can ha$e se" until term of pregnancy as far as they are comfortable. I also e"plaine# to her that they can resume se" as early as < weeks as far as she feels that her bo#y is rea#y for se". 4I+T&& P,AN AN; . MP,I.ATI N P+*PA+*;N*SS +ealising that Mrs. Nkhata was afrai# of labour pains' I took sometime counselling her on normal processes of pregnancy until labour an# #eli$ery so as to alley her an"iety. Ii put emphasis on the nee# an# importance of #eli$ering at the hospital where measures of managing labour pains are use#. I also a#$ise# her on the nee# to associate an# learn from mothers who ha# un#ergone the same e"perience se$eral times who can help her prepare for her labour an# #eli$ery. 3 .US*; ANT*NATA, .A+* 4asing 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. I 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. /e also #iscusse# on the importance of atten#ing all the e"pecte# normal four $isits of antenatal care. MIN + ;IS ;*+S 3 P+*9NAN.-

In 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' heartburn' constipation an# backache 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 be an"ious but accept them as things that happen normally.

;ate for the ne"t $isit.