Antenatal Care Module: 15. Counselling Pregnant Women on Danger Symptoms

Study Session 15  Counselling Pregnant Women on Danger Symptoms

Introduction

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.

Learning Outcomes for Study Session 15

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)

15.1  General principles of counselling the pregnant woman

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.

Figure 15.1  Maintaining confidentiality builds trust.

Figure 15.2  Healthcare providers should talk less and encourage their clients to talk more.

15.2  What is special about counselling pregnant women?

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.

Figure 15.3  If the pregnant woman trusts you, she is more likely to come for her antenatal checkups.

15.3  What are the common danger symptoms during pregnancy?

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.

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.

Table 15.1  Danger symptoms during pregnancy.

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) Figure 15.4  Burning epigastric pain is a danger symptom.
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) Figure 15.5  Infection in this part of the kidney leads to danger symptoms.
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.

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.

15.4  Telling pregnant women about the danger symptoms

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).

15.5  Advantages of husband/partner involvement in antenatal counselling

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).

15.6  Checklist after each antenatal counselling session

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.

Summary of Study Session 15

In Study Session 15 you learned that:

1. Counselling is a two-way confidential communication process that helps pregnant women to examine their personal issues, make decisions, and make plans for taking action if they develop danger symptoms.
2. Basic skills in counselling include the use of active listening, encouraging the pregnant woman to talk, to ask questions freely, and focusing on relevant issues in relation to danger symptoms and gestational age.
3. Every pregnant woman has the right to decide what happens to her pregnancy.
4. All information that the pregnant woman provides during her visit should be kept confidential.
5. Common errors in counselling include interrupting the woman when she is talking, looking away frequently, criticising her cultural and religious values, finishing off her sentences and judging her.
6. The counselling process goes through the following stages: opening and building relationships, exploring the issues, facilitating change, and closing.
7. The pregnant woman should be counselled to come to you at once if she develops one or more of the following danger symptoms:
   • Usually in the first half of pregnancy: persistent vomiting, weight loss, vaginal bleeding and no change in abdominal growth.
   • Usually in the second half of pregnancy: headache, blurred vision, epigastric burning pain, vaginal bleeding, leakage of fluid from the vagina, no change in abdominal growth, decreased or absent fetal kick.
   • Any time during pregnancy: fever, vomiting, flank pain, yellowish discoloration of eyes or persistent cough.
8. Involving the husband or partner in the antenatal care visits makes care of the pregnant woman a family concern and responsibility, and also helps them to be alert to danger symptoms that need urgent action.

Self-Assessment Questions for Study Session 15

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.

First read Case Study 15.1 carefully and then answer the questions that follow it.