This study session will provide you with the knowledge of how to counsel pregnant women on the common danger symptoms that some of them may develop in the course of their pregnancy. Effective counselling in language that the women in your community can understand will enable them to know when to get help quickly from you or from a health facility, if one of these danger symptoms develops.
You have already understood the different meaning of symptoms and signs in Study Session 8, and in Study Session 9 you learned about the common danger signs and symptoms during pregnancy. This study session will start by briefly explaining the general principles of counselling and the special features of counselling pregnant women. Then we summarise the common pregnancy-related or unrelated danger symptoms that pregnant women themselves can feel or notice in relation to the gestational age. Later in this session, we guide you about when and how to counsel pregnant women in relation to these danger symptoms, and we emphasise the importance of involving the husband/partner in this counselling.
After completing this session, you should be able to:
15.1 Define and use correctly all of the key words printed in bold. (SAQ 15.2)
15.2 Discuss the general principles of counselling and summarise the skills and attitudes of an effective counsellor. (SAQs 15.1, 15.3, 15.4 and 15.5)
15.3 Explain the special nature of counselling pregnant women. (SAQs 15.1 and 15.3)
15.4 Describe the common danger symptoms that can be felt or noticed by pregnant women, the gestational age at which each symptom is most likely to appear, and the appropriate actions that the woman should take. (SAQs 15.2 and 15.5)
15.5 Identify the appropriate timing of counselling on different types of danger symptoms, in relation to gestational age. (SAQ 15.3)
15.6 Explain the importance of husband/partner involvement in the counselling of pregnant women about danger symptoms. (SAQ 15.4)
Counselling the pregnant woman is a process of two-way interpersonal communication in which you help her to know about possible problems that she may encounter during pregnancy, and make her own decisions about how to respond. When you create a two-way discussion with good understanding of each other, it not only helps the woman to know the possible problems that she may encounter and when to take appropriate action, but it also establishes a trusting relationship with you. Additionally, such two-way communication helps the woman to feel more comfortable and freely express her worries and needs to you.
Remember that the pregnant woman is also an expert on her own needs and situation. She has learnt informally many things about pregnancy (sometimes right and sometimes wrong). Therefore, never discourage her from expressing her beliefs and thoughts to you from the outset — you should develop tolerance for every woman’s values and beliefs, while you gently and sensitively try to dispel any important misconceptions she may have. Respect and tolerance for wrong beliefs doesn’t mean accepting that they cannot be changed. Sensitivity and tolerance are two of the most important qualities of an effective counsellor.
Box 15.1 summarises the skills and attitudes you need in order to develop good communication with any client, including pregnant women. The counselling process goes through the following stages: opening building relationships with pregnant women, exploring their issues, facilitating exchange of information (two-way) and closing the counselling process with gratification and the next appointment.
In the pregnant woman, the general purpose of counselling is to provide her with essential information for improving or maintaining her health and the health of her baby before and after birth. To be specific, the counselling will help the pregnant woman to stay healthy through advising her about health promotion issues such as nutrition (you learned about this in Study Session 14), and also to know the common symptoms of health risks that may affect her or her baby. In addition, counselling will be an entry point to the family, in particular to her husband/partner, so they also know the potential risks encountered during pregnancy and get prepared for them both psychologically and economically. Box 15.2 summarises the outcomes of successful counselling about danger symptoms during the antenatal period.
Counselling has succeeded when the pregnant woman:
The occurrence of the common danger symptoms that can be felt or noticed by the pregnant woman vary in their timing in relation to the gestational age.
What is meant by the first, second and third trimester of pregnancy?
Trimester means ‘three month period’. The first trimester is the first 3 months of the pregnancy (i.e. from conception to the 14th completed week of gestation, measured from the woman’s last normal menstrual period or LNMP); the second trimester is from 3-6 months (i.e. from 15 to 27 completed weeks); and the third trimester is the final 3 months of pregnancy (i.e. from 28 weeks to delivery at up to 42 weeks).
You have already learnt about the assessment of some pregnancy-related and medical problems by taking the woman’s history and doing a physical examination (recall Study Sessions 8 and 9). However, you can only detect health risks to the mother or to the baby during the routine antenatal checkups, so it is very important to help the mother detect any symptoms by herself and know when to come to you quickly.
First, you have to know very well the timing of occurrence of common pregnancy-related or other medical problems, taking the gestational age as the milestones (see Table 15.1). Secondly, you have to be selective not to overwhelm the pregnant mother with too much information at a time. Thirdly, remember that counselling is not a one-time business - you should be prepared to repeat the messages about danger symptoms at every visit and check that the woman has understood correctly.
You already know about some of the conditions listed in Table 15.1 (e.g. ectopic and molar pregnancy). Later in this Module, you will learn in detail about the other common causes of maternal and fetal mortality and morbidity during pregnancy: hyperemesis gravidarum was in Study Session 12; premature rupture of membranes (PROM) is in Study Session 17; malaria, anaemia and urinary tract infections are covered in Study Session 18; hypertensive disorders of pregnancy are in Study Session 19; and spontaneous and induced abortion and vaginal bleeding in early and late pregnancy are in Study Sessions 20 and 21 respectively.
On and off lower abdominal pain alone is very common in early pregnancy and is not a danger symptom on its own.
Symptoms the mother experiences
(terms in italics are the most important)
|She may have this medical condition|
|Conception to 20 weeks of pregnancy|
|Persistent vomiting, weight loss||Hyperemesis gravidarum|
Characterised by persistent vomiting, weight loss of 5 kg and above, urine analysis shows ketones 2+ or more (You learnt about this in Study Session 12; how to do the urine analysis is in Study Session 19)
|Vaginal bleeding (fresh), may include passage of clots and fleshy material, with crampy lower abdominal pain||Abortion (acute)|
All types of spontaneous abortions except missed abortion are acute ‘sudden’ events (You will learn about abortions in Study Session 20)
|Pregnancy symptoms disappear, abdomen is not growing or is even decreasing in size, there may be minimal dark vaginal bleeding||Missed abortion |
When the fetus or fetal tissue is entirely in the uterus, but it has no signs of life and the cervix is completely closed
|Vaginal bleeding (menstrual-like), lower abdominal pain, missed or irregular period||Ectopic pregnancy |
(covered in Study Sessions 5 and 12)
|Vaginal bleeding (fresh), passage of tissues which look like an ice spoiled with blood (grape-like tissues), fast abdominal growth||Molar pregnancy|
(covered in Study Sessions 10 and 20)
|20 weeks to full term pregnancy|
|Headache, burning epigastric pain (Figure 15.4), blurred vision, generalised body swelling (involving the back, abdominal wall, hands and face), decreased urine output|
Hypertensive disorders of pregnancy
(pre-eclampsia and eclampsia were introduced in Study Sessions 8 and 9; you will learn more in Study Session 19)
|Vaginal bleeding in late pregnancy, even a minimal amount||Late abortion (20-27 weeks) or antepartum haemorrhage (28 weeks +) (You will learn more in Study Session 20)|
|Leakage of watery fluid from the vagina that wets her underwear significantly and may be extensive||Premature rupture of membranes (PROM)|
(You will learn about PROM in Study Session 17)
|Progressively increasing pushing down pain in the lower abdomen before 9 months of gestation||Preterm labour|
(This is covered in the Module on Labour and Delivery Care)
|No change in abdominal growth, fetal kick felt less than 10 times in 12 hours. (Any number of fetal kicks felt in one minute is counted as one kick)||Intrauterine fetal growth restriction (IUGR) (Briefly mentioned in Study Session 7)|
|Absent fetal kick for more than 6 hours||Intrauterine fetal death (IUFD)|
|At any time during pregnancy|
|Fever, headache, chills, rigor, sweating, feels thirsty, generalised aching pain, lost appetite||Malaria, typhoid fever, typhus fever or relapsing fever|
(You will learn about these infections in the Module on Communicable Diseases)
|Urination becomes painful, frequent, urgent and may be bloody or look like pus||Urinary tract infections (UTIs, cystitis or urethritis)|
(You will learn about UTIs in Study Session 18)
|Pain in the sides (flanks), fever, vomiting, bloody urine, urgency and frequency in urination||Acute pyelonephritis|
(Figure 15.5 shows the specific area in the kidney where this infection can occur)
|Yellowish discolouration of the eyes, loss of appetite, hate spicy food smell, feels exhausted, nausea and vomiting||Liver disease|
|Thirsty, drinks excessive amounts of water, urinates a lot, feels hungry, weight loss||Diabetes mellitus|
|Persistent cough||Lung and heart disease|
Table 15.1 is a detailed summary for you to study as a healthcare provider. It would not be appropriate or useful to show it to pregnant women during antenatal visits.
Can you suggest why not?
The table uses medical language that the woman is unlikely to understand (unless she is also a health worker), and it may overwhelm her with too much information all at once and make her anxious to see so many potential risks to herself and her baby.
Table 15.2 is a simplified summary in two parts, which can be shared with pregnant women at the appropriate stage of gestation. Women in the basic component of the focused antenatal care (FANC) programme, described in Study Session 13, should be seen for the first antenatal visit before 16 weeks of gestation if possible, and for the second visit at 20-24 weeks. Make sure every woman knows the common danger symptoms that are more likely to occur at each stage.
|In all visits before 20 weeks||In all visits after 20 weeks|
No change in abdominal growth
Burning epigastric pain (see Figure 15.4)
Leakage of fluid
No change in abdominal growth
You should realise that pregnant women have many responsibilities at home and usually also in the fields, and they may already be overwhelmed by too much information about the current pregnancy. Table 15.2 presents what the mother primarily needs to know, but you shouldn’t tell her everything all at the same time. Counselling the pregnant woman in relation to the stages of pregnancy is a good strategy from the perspective of the pregnant woman’s understanding and using your time as efficiently as possible. In other words, you need to discuss the common danger symptoms with her, taking into account the stage of pregnancy. For instance, a pregnant woman coming for antenatal care before 20 weeks of gestation should be counselled about the danger symptoms of miscarriage, which are usually manifested by vaginal bleeding. She should also be aware of danger symptoms of common medical disorders that can occur any time during pregnancy - in the same way that they could occur to anyone in the rest of the population.
Most pregnancy-related serious problems occur in the third trimester. Therefore, it is a good opportunity to counsel the mother about them during the second trimester, to let her prepare ahead of time. If you have them, using printed instructions, diagrams, photos or pictures, which improve the pregnant woman’s understanding and her ability to remember the key points. It is also a good approach to remind her about what was discussed at earlier antenatal visits (see Box 15.3).
In subsequent antenatal visits, helping the woman to go over what was discussed before will help you to:
It will also help her to express her concerns and doubts, so that you can:
The majority of pregnancy-related problems are unpredictable and late phenomena. On the other hand, public awareness of pregnancy-related maternal and fetal health risks is very minimal. So far in Ethiopia, the husband or male partner is usually more influential, economically empowered and socially accepted than the woman. Counselling as many pregnant women as possible is one way of accessing the public by involving the husband, who can act as the second agent on dissemination of potential risks of pregnancy to the majority (the public).
Therefore, involving the husband/partner in antenatal visits has many advantages (Box 15.4).
Finally, we conclude this study session with a checklist that you can use to evaluate your own counselling skills and attitudes (Table 15.3). It has been adapted for use in counselling pregnant women, but it incorporates the general principles of counselling that you can apply to any client in your health care.
Welcome each pregnant woman on arrival?
Discuss in a comfortable and private place?
Assure the pregnant woman of confidentiality?
Express caring and acceptance by words and gestures throughout the meeting?
Explain what to expect?
Ask the pregnant woman’s reason for the visit?
Encourage the pregnant woman to do two-thirds of the talking?
Ask mostly ‘open’ questions?
Pay attention to both what the client said and how it was said?
Put yourself in the woman’s shoes — expressing understanding of what she said without criticism or judgment?
Ask about the pregnant woman’s feelings?
Ask about her preferences?
Start the discussion focusing on the pregnant woman’s preference(s)?
Discuss the danger symptoms of pregnancy in relation to the gestational age?
Give information about danger symptoms of pregnancy to help her make her own decisions?
Avoid ‘information overload’?
Use words familiar to the client?
Discuss the advantages of early reporting if she encountered danger symptoms during pregnancy?
Let the pregnant women know that the decision is hers?
Help the pregnant women be able to realise common danger symptoms?
Help her think over the consequences for her own or her baby’s life?
Advise the pregnant women without controlling and frustrating?
Let the pregnant women decide?
Make sure the pregnant women’s choices are based on accurate understanding?
List any medical, social, cultural or religious reasons for making a different decision – probably different from what you might like to achieve?
Provide what the client wants, if there is no medical reason not to?
Explain when the woman should come to you if one of the danger symptoms appeared?
Help her to explain in her own words how much she understands each of the danger symptoms of pregnancy?
Explain using printed instructions, pictures and diagrams?
Plan when the next visit should be?
Discuss with the pregnant woman if she can come back with her husband or partner?
Assure the pregnant woman that she should come back at any time, for any reason?
Assure her to come back soon, even if she missed the day of her scheduled appointment for some reason beyond her control?
Assure her that it is her full right to go to any other health facility at any time?
Thank the pregnant woman for attending for antenatal care?
In Study Session 15 you learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
For each of the following statements, say whether it is true or false. Explain what is incorrect about any statement that you judge to be false.
A Saying welcome, showing a smiling face, letting her express her concerns and doubts, helps the mother feel comfortable and develop confidence in you.
B You have to tell her that unless she comes on the day of her scheduled appointment, you will not see her at any other time.
C You should not allow her to ask questions till you finish telling her what she needs to know.
D You can counsel one woman who is sitting with you while you are conducting a physical exam of another one.
E If she tells you that her two daughters were circumcised on the day she gave birth at home, tell her harshly that she shouldn’t do it again, and if she plans to do the same thing if this baby is a girl, she should not come back for any other visits.
F Counselling a pregnant woman on danger symptoms is essential in every visit.
A is true. Welcoming the mother, smiling and letting her express her concerns and doubts, helps her to feel comfortable and develops confidence in you.
B is false. It is not an easy task always to come on the day of appointment for the majority of rural Ethiopian pregnant women, who typically have many personal and social responsibilities at home. It is their right to come earlier or later than the appointed date, or even not to come at all. It is the duty and responsibility of any health professional to say welcome with open hands at whatever time and date women come for their antenatal check-up.
C is false. The health service is primarily the client’s/patient’s business. The duty of the health professionals is to deliver a service which makes the client comfortable and satisfied. With that understanding, you have to be prepared to receive questions and do the best to encourage women to raise any questions which are not clear for them.
D is false. By its principle, counselling is discussing personal issues which the client may not like to be shared with other persons outside the family. Therefore, even when you are in a hurry, it is not advisable to counsel one woman while you are examining another. In such an environment, the one to be counselled may not freely share her feelings and concerns with you.
E is false. You cannot encourage behavioural change in adults by criticising, frustrating, demoralising and openly discouraging them. This woman will not feel respected by you and she may not return for further antenatal care. To make a positive change in unhealthy behaviour, the best method with adults is open discussion, letting them know the risks/disadvantages and giving them a chance to evaluate the options for themselves and make their own decision.
F is true. During every antenatal care visit, pregnant women should be counselled on the danger symptoms of pregnancy, so they can take swift action if an emergency arises.
Based on what you have learned from Table 15.1, match each of the danger symptoms with the appropriate medical condition.
Using the following two lists, match each numbered item with the correct letter.
Leakage of fluid from the vagina
Abdominal size decreasing
For each of the following statements, say whether it is true or false. Explain what is incorrect about any statement that you judge to be false.
A. The counsellor should tell the pregnant woman about all the danger symptoms of pregnancy during her first focused antenatal visit before 16 weeks of gestation.
B. Encouraging the pregnant woman to repeat what has been discussed during counselling will increase her memory (retention capacity) of the key points.
A is false. The area of counselling that pregnant women need should be appropriate to their stage of pregnancy, because:
B is true. Repeating what has been discussed/said will help:
List some of the advantages of involving the husband/partner in antenatal counselling on danger symptoms.
First read Case Study 15.1 carefully and then answer the questions that follow it.
Mrs H is a 25-year-old woman in her second pregnancy, who came to see her Health Extension Practitioner (HEP) for the first time when she was 34 weeks pregnant. The HEP asked where she gave birth previously. Her blood pressure and weight was measured and her general health seemed good; her abdomen was examined, and the pregnancy seemed to be progressing normally. Lastly, she was told to come back after 3 weeks.
Two weeks later, she developed excess leakage of watery fluid from her vagina. She informed her neighbours and they told her not worry about it. Since it continued flowing, on the third day after the leakage began, she went back to the HEP and got the same advice she got at home. On the fifth day, she developed a high fever (temperature 39oC) and an offensive smelling vaginal discharge.