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FOLLOW THROUGH CASE STUDY

One of the Sustainable Development Goals of the United Nations is to ensure healthy lives

and promotion of wellbeing for all at all ages which is” Good Health and well-being.” One

of the targets and indicators is to reduce the global maternal mortality rate less than 70per

100,000 live births by 2030. (Ritchie, R.M.O, 2018)

Fiji’s current Maternal Mortality ratio has decreased from 48.0 per 100,000 live births in

2013 to 38.0 per 100,000live births in 2017. (World Data Atlas>Fiji Health…

In ensuring that this goal is achieved, implementation of Antenatal Clinic is empowered

through the World Health visions of the world “where every pregnant women and

newborns receives quality care throughout pregnancy, at birth and to post-partum. (WHO

2016)

The World Health Organization has recognized women centered care in maternal health

and has set guidelines to assist in the care of pregnant mothers. However these guidelines

are implemented in midwifery care. Midwifery model of care is women centered that

begins from antenatal clinic. Antenatal clinic is the recipient of various woman from

various ethnicity, social status, values, religion, educational level and ages. An interview

conducted in Oslo, Norway the data collected were scrutinize and incite in an explanatory

phenomenological approach. The objective of this interview was to survey event with diet

related instruction during routine antenatal care from various ethnical backgrounds. Result

shows according to participants that there were not enough information provided in the

antenatal care thus the information shared, is food safety focus only. However findings

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proposed that midwives are viewed as reliable pedigree of diet related information. In this

study it identifies the need for midwifery care to be able to relate information tailored

according to women’s culture and habits. [ CITATION Lis13 \l 1033 ] Indeed this is a challenge

for midwifes at the frontline in the antenatal care clinic. Midwives are the focal point of

entry to maternity health services.

In this essay it will discuss the implementation of antenatal care in a follow through case

study. How as a midwife will conduct follow through of a pregnant women in?

1. Obtaining maternal history and analyze its risk status.

2. .Able to identify psychosocial and economic factors that can affect

health status.

3. Able to analyze antenatal care, investigation and counselling.

4. Design a birth plan with the woman.

5. Outline women centered care in the utilization of the care approached.

6. Ensure physiological birth is promoted in the labor.

7. Ensure to analyze early peurperuim care in:

a) Physical and psychological adaptation

b) Maternal role attainment

c) Resumption of sexual intercourse and family planning.

8. Lastly ensure to follow up through home visit.

Midwives play an important role as the front liner of maternal health care in receiving

pregnant mothers in the clinic. Obtaining detailed maternal history is essential in antenatal

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care as it is where the priority of care will be planned and implemented accordingly. A

cross sectional study was conducted in India to analyze the association of maternal history

of neonatal death associated with subsequent neonatal mortality.

Results suggest that maternal history of neonatal death is probable applicable aspect to

distinguish women and neonates who may need comprehensive and enhance pregnancy

care[ CITATION Mud20 \l 1033 ].

As for the study that was conducted in India it signifies the importance of obtaining detail

maternal history as it is the basis of identifying high risk pregnancies.

Detail maternal history of Ms. Wati was obtained whilst attending to her clinic. Ms. Wati a

primigravida she does not have any previous history of stil birth or neonatal loss, no history

of miscarriages or history of large baby weight or small weight. She has no history of

admission for hypertension or caesarian section. Currently she was booked at 28 weeks of

gestation, a late booker according to her age of gestation, relevant screening such as blood

count, serology status and grouping were documented. As a late booker and according to

her positive family history of diabetes, she was given a date to have glucose tolerance to

rule out gestational diabetes.

Anthropometric measurement was taken to determine the nutritional status as well as her

baseline blood pressure and random blood sugar level. Immunization was given as per

Expanded Program me Immunization Guideline. Indeed she lives in an informal settlement

with her elderly aunt with no proper electricity supply and they have to store water due to

poor supply. Additionally there’s no financial security to support her as she depends on her

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aunt who sold vegetables in the mini market. In analyzing her history she has no previous

maternal history ,however her current history of an elderly primp with the positive family

history of diabetes and her current social status poses a risk that needs to be addressed. As

midwifes her risk is identified how best she can be assisted from midwifery perspective in

terms of her social status? As midwifes our role is not only care for the physical body but

holistically.

Psychosocial refers to physical well-being of a person .As midwives it is important to be

able to detect and identify women with psychosocial problems. Inadequate psychosocial

risk assessment can lead possible psychosocial problems later in postpartum. According to

study a focus group interview was conducted through interpretive and descriptive

qualitative approach to midwives in three maternity unit in Gauteng Province in Africa. The

purpose of the study was to investigate and outline perception of psychosocial risk

assessment and psychosocial care by midwives providing antenatal care. Outcome revealed

that midwives are aware of and have experience a high prevalence of psychosocial

problems in pregnancy women. Moreover, they recognize the importance of psychosocial

assessment for pregnant women even though they expressed that they were not equipped

appropriately to provide psychosocial assessment and psychosocial care. [ CITATION

JMM19 \l 1033 ] Midwives should have power of observation in attending to client in the

clinic, in observing how client presented herself , such as how she dress up her physical

expression. In relation to Ms. Wati factors that could affect her such as stress, anxiety and

fatigue. Ensure to offer support to her at the clinic through sharing of information allow her

to share her thought and ideas regarding her pregnancy it could be the changers in her body

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image or marital status. Emotional factors refers to ones feeling, the feeling of being

stigmatized in regards to her social status that affects her self-confidence and self-esteem. A

cross sectional study was conducted to 210 pregnant women between the ages of 18-40

years old in Balbol. The aim of this study is to determine the role of social support in

prediction of stress during pregnancy. The outcomes shows that social support had a

significant positive relationship with experience and a negative relationship with unpleasant

experience.[ CITATION MFa151 \l 1033 ]

Since Ms. Wati is 37 weeks of gestation she will be followed up weekly and monitored

with her blood pressure urine dipstick hemoglobin level (Hb), fetal heart rate, ultrasound

scan to determine fetal weight and fetal growth and glucose tolerance test which determine

where the she has diabetes .She has been advised on the importance of attending clinic, the

importance of taking her iron tablet, maintaining of good personal hygiene, breast feeding,

family planning and preconception advice. Birth preparedness and community readiness

plan advised as well, indeed all the advice given accordingly at each visit.

According to in-depth interview to 24 women in Nepal. The purpose of this study was to

investigate the quality of family planning counselling services given during antenatal clinic

and the women’s insight of its benefit in determine family planning usage. Result shows

that the quality of family planning at antenatal clinic was dissatisfying based on patients

views and exploit while communicating with the care provider. There were insufficient

information received, in spite of their attentive most women were unsatisfied due to the

environment, limited time given prolong waiting hours and shortage of IEC materials

needed for counselling.[ CITATION Mah20 \l 1033 ]

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The importance of communicating clear and concise information to the client is essential

referring to the case study in Nepal.

Involving Ms. Wati in designing birth plan is important in informing her on the purpose of

the plan in providing guideline to the midwife and the team of how she wishes to go

through labor, birthing and afterbirth.

Ensure to re advice on birth preparedness, at this point in time she should be ready with the

baby’s and her birthing clothes. Confirm her to save some money for transportation to the

hospital. Reemphasize on the danger signs and when to report immediately.

Devise a plan includes her detail and her expected date of delivery, the contact of the

midwife of her choice, the contact of the hospital she wishes to attend to and the name of

the support person whom she wishes to be with her in the birthing room.

During labor what positions she wishes to try. If labor is not progressing, does she want to

be induce? Is there any alternate measures to assist her in coping with the pain? How would

she like to be hydrated? Is it possible for her mobilize in a room conducive with dim light

and quite environment?

At birth would she prefer to have episiotomy? Does she wants her baby to be placed on her

chest? Does she wants her relative to hold her baby?

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In the provision of midwifery care, women centered is the focal point of care. Women

centered care promotes holistic approach by which midwives are able to recognize

women’s emotional, social, spiritual and cultural needs. It is the care whereby midwives

respects the decision of women in regards to her health.

In regards to Ms. Wati, she presented to the clinic how as a midwife will approach her in

the clinic. Build a trust relationship with her and involve her family, her aunt for that

matter. Ensure to be friendly and assertive in communicating with her, avoid judgmental

words, nonverbal cues should be appropriate, maintain eye contact and tone of voice should

be clear and calm as well.

According to her background, she is not financially secure and depends on her aunt for

support and shelter. Allow her to voice out her concern or if any plans in regards to how

she is supported financially. Is there any family member or friends that she is aware of that

could come to her aid. As a midwife offer help, advocate for her in regards to social support

request, help through referral to the social welfare department to assist financially in

preparedness of birthing. Ensure that she is in good health, offer spiritual support, and seek

her consent if she wants to be prayed for or if she wishes to be attended by a religious

minister.

Fostering of physiological birth initiates from antenatal clinic, accommodate her on what

she needs to know regarding normal pregnancy journey to birthing. Empower her through

sharing of information, prepare her psychologically instil positive advice regarding

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physiological birth. Assist in physical preparation advise her on adequate exercise,

squatting and booked her for physiotherapist.

Assist in relaxation techniques such as breathing techniques while she still pregnant. Ensure

that her decisions and choices is respected. Encourage oral hydration and well balance diet.

Enlighten on the mechanism of labor which is dilatation, effacement, hormonal

orchestration and her part is to actively involved in normal birth. Reassured her that labor is

hard work, she needs to work with her pain rather than avoiding it.

A qualitative approach for data collection and data presentation based on in-depth interview

conducted to 12 healthy mothers aged between 22- 34years and they were interviewed at 5

to 6 weeks post-partum .The purpose of the study was to gain deeper understanding

experienced of first time mothers in regards to how midwifes promote physiological birth

and positive experience. Outcome shows midwives who has real promoting perspective can

easily assist mother in developing inner strength and coping strategies. [ CITATION Unn16 \l

1033 ]

Indeed as midwifes preparation of mothers should be initiated from antenatal clinic and not

when they are in the birthing bed.

Post-partum physiological changers is expected to occur after child birth. As midwifes this

changers that indicate the onset of the return of pre pregnancy physiology and of

breastfeeding should be communicated to our client .The physical changes such as breast

and lactations, encourage her to spend more time in breastfeeding as suckling reflexes

cause the release of hormone (oxytocin) which contracts the uterus and prevents

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bleeding .Ensure to assist mothers in attachment and positioning of baby to prevent crack

nipples and breast engorgement. At times mothers develop breast conditions after birth may

due lack of confidence in breastfeeding technique. The changers in the uterus should also

be informed to our mothers, they will experience postpartum uterine contraction due to the

contracting uterus as it change to its pre pregnant state. The vagina contracts and return to

its pre pregnancy state at post-partum period vaginal discharge which is lochia will

discharge with blood mucous and uterine tissue. Psychological adaptation in postpartum is

a mental process, which relates to how a person adjust herself after birth. Psychological

support is important in the case of Ms. Wati she needs psychological support with her new

role of being a mother. Assist her through support in cash or kind, ensure that she receive

assistance from relevant authorities that will support her when discharge from hospital. A

positive appraisal will boost her self-esteem. As midwife spiritual support is essential in

offering care to such case as Ms. Wati in which she need divine intervention

Maternal role define by Mercer is a process in which the mother executes ability in the role

and blends maternal behaviors into her fixed role set so she identifies as mother. (Mercer

2004) This means in her new role of mother her focus is in the case of the child as

additional responsibility apart from the role of a housewife. A hybrid concept analysis was

used to identify basic characteristic and practical definition of maternal role attainment in

mothers with term neonate. Result identifies the idea of maternal role attainment in nursing

providing a good basis for evaluation and applying this concept. [ CITATION For20 \l 1033 ]

Indeed for the women, resumption of sexual intercourse is perceived differently.

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At this stage of puerperium recovery and healing process takes place. It is important to

involve partners and explain the changers that women go through in post-partum and the

need to allow women to recover before resumption of sexual activity.

Family planning advice is given prenatally and upon discharge from post natal ward.

The main purpose is to assist couple to plan the spacing of their children allowing the

women to recover well after birth. In regards to Ms. Wati she is advised on the methods

available, the advantage, and side effects of the contraceptives. She will be provided with

the method that is applicable to her according to the Medical Eligible Criteria (MEC)

wheel.

An institutional based cross- sectional study was conducted from March to April2019 the

aim of the study was therefore to assess the early resumption of sexual intercourse and its

associated factors among postpartum women attending public health institutions in

Nekemte town, Western Ethiopia. The result shows woman were forced by husband to

initiate sexual intercourse were remarkably associated with early resumption of sexual

intercourse.[ CITATION Ebi20 \l 1033 ]

Locally at our setting postpartum clinic is given at six weeks, women will be attended too,

vitals checked, normal menstrual checked before commencing on contraceptive methods

they wishes to use.

Home visiting is a care that purposely provide support to new mothers. The purpose of the

visit is to follow up both the women and the child and to observe how Ms. Wati is able to

look after her child in terms of breastfeeding, cord care, bathing of the baby as well as how

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she is coping with her new role as a mother, and how is the support provided at home is

there any other person with her apart from her aunt. A retrospective cross-sectional survey

conducted to in Queensland between Februarys to May 2010. The objective was to

investigate patterns of postpartum home visit in public and private sector.

The result shows that public sector woman were visited by nurse or midwife from hospital

within 10 days of discharge compared to private sector women.[ CITATION Wen14 \l

1033 ]

As midwifes our role continues in the community setting in reaching through home visit of

mother to ensure that she’s well equipped in knowledge and skills in the care of the baby

and herself.

To conclude in ensuring healthy lives and promotion of wellbeing for all at all ages, with

the target indicators of reducing maternal death globally and promoting the provision of

quality care to pregnant women and newborns, midwifes play an important predominant

role in implementing the care. Midwifery care in antenatal clinic is not routine it demands

meticulous holistic approach in serving our pregnant mothers.

(Approximately 2837 words)

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Ebisa Turi Jambola, 1. A. (2020). Early Resumption of Sexual Intercourse and Its Associated Factors
Among Postpartum Women in Western Ethiopia: A Cross-Sectional Study. International
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Forough Rafii, 1. M.-N. (2020). Maternal Role Attainment in Mothers with Term Neonate: A Hybrid
Concept Analysis. Iranian Journal of Nursing and Midwifery Research.

LisaM. GarnweidnerMSc(PhD candidate, p. h. (2013). Experiences with nutrition-related

information during antenatal care of pregnant women of different ethnic backgrounds
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M Faramarzi, H. P. (:: Volume 17, Issue 11 (11-2015)). The Role of Social Support in Prediction of
Stress During Pregnancy. Journal of Babol University of Medical Sciences .

Mahesh C. Puri, M. M. (2020). Investigating the quality of family planning counselling as part of
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MaritTorvikbIngvildAunec, U.-K.-T. (Volume 7, March 2016,). How can midwives promote a normal
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Mudit Kapoor, P., Rockli Kim, S., Tanushree Sahoo, M. D., & al, e. (2020). Association of Maternal
History of Neonatal Death With Subsequent Neonatal Death in India. JAMA Netw Open.
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Ritchie, R. M.-O. (2018). Measuring progress towards the Sustainable Development Goals. SDG
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