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Importance of Antenatal Care during Pregnancy

Every woman hopes for a normal pregnancy so that she can cradle and nurse her baby. In order to have normal pregnancy and healthy childbirth, women require comprehensive antenatal care in order to ensure a normal physiological process (Devi, Khandelwal & Das, 2016). Antenatal care mainly deals with education counselling, screening and treatment of the expecting mother in order to promote well-being of both the mother and foetus. However, as per the reports published by The Australian Institute of Health and Welfare (2017), the maternal mortality rate in Australia during the year 2012 to 2014 is 6.8 out of 100,000 women. Though that is the lowest maternal mortality rate in the world but the common cause highlighted for the death includes abdominal bleeding and non-obstetric and non-obstetric bleeding. This shows that the antenatal care activity is extremely poor in Australia. The main reasons that hamper the comprehensive use of the antenatal care is haemorrhage, eclampsis, infection, spontaneous abortion and obstructed labour. Other issues which create hindrance in successful antenatal care are lack of preparedness and knowledge about the importance of the reproductive health in the community, family and healthcare provider (Finlayson & Downe, 2013). Pacagnellaet al. (2014)further highlighted that reason behind the poor antenatal care. The main reasons highlighted by Pacagnella et al. (2014) include lack of knowledge of the healthcare provides about the concept of labour and obstetric complications. Moreover, a high percentage of healthcare providers indulge in harmful practice of fundal pressure during the process of vaginal delivery. Only a negligible amount of health care providers indulge in the active management of the third stage of labour in all kind of deliveries (Chandra-Mouli et al., 2013).

One of the important yet successful ways of delivering antenatal care is the implementation of the abdominal palpation. Abdominal palpation is a kind of examination that is performed during each antenatal appointment starting from 24th week of pregnancy till 36th week of pregnancy in order to estimate the foetal size and foetal presentation (Nishikawa & Sakakibara, 2013).  Nishikawa and Sakakibara (2013) is of the opinion that abdominal palpation which is performed upon hospital admission is a form of four manoeuvre technique (Leopold’s maneuvers)that helps in the identifications of limbs, size and position of foetus in-utero. It is also used as a medium to access the length, frequency and strength of uterine contraction and to gauge the uterine involution postnatally (Nishikawa & Sakakibara, 2013).  

Barriers to Comprehensive Antenatal Care

Nurses are an important part of abdominal palpation during pregnancy and proper nursing education and skill development is crucial in delivering high-quality nursing care. However, gap in the theory and practise continues to be a prevailing problem of nurses and midwifery education (Birks et al., 2013). Birks et al. (2013) identified that the nurses and midwives though nurture positive attitudes towards abdominal palpation, lacks adequate knowledge towards executing the procedure successfully. So the following report aim towards analysing how the implementation of the motor skill learning theory can help the nurses to successfully adopt and implement the theoretical and practical concept of abdominal palpitation during pregnancy.

According to Nishikawa and Sakakibara (2013), the main aim of the abdominal palpation is observation of the signs of pregnancy, estimation of gestation, proper assessment of the fetal growth, fetal position, presentation and engagement and detection of any deviation from the normal. Abdominal palpation in conducted in highly aseptic condition under utmost privacy and comfort. The main process of the abdominal palpation is initiated via fundal palpation in order to assess if the fetal growth is consistent with the gestational age. In order to do this the distance between the symphysis pubis and fundus (SFH) is measured in cm via the use of disposable tape. The tape is required to be place longitudinally along the abdomen starting from symphysis pubis. The change in the symphysis-fundal height should be measured and recorded starting from 24th week of gestation and this data should be used to plot customised growth chart and if any deviation from the normal is being observed then proper actions must be taken (Nishikawa & Sakakibara, 2013). Fundal palpation is also used to determine uterine contractions which is helpful to the gauge the time to start pain relief. Lateral palpation is used to determine the fetal position (oblique, longitudinal or transverse). It is done via the use of both the hand on the either side of the uterus via stroking the hand movements down the length of the uterus. Pelvic palpation is used to determine the fetal presentation and the degree of flexion. Here the fingers are directed downwards and inwards and is more preferred than the Pawlik’s manoeuvre (Macaluso & McNamara, 2012). Abdominal palpation is also used to access the fetal heart rate and maternal pulse (Macaluso & McNamara, 2012). Apart from clinical significance, abdominal palpation also had psychological significance. For example, Nishikawa and Sakakibara (2013) highlighted that the abdominal palpation of Leopold’s Maneuvers is used to enhance maternal awareness about the feral position, attachment with mother and fetus and frequency of mother talking with the fetus. The survey conducted by Birks et al. (2013) over the Australian nurses highlighted that there are at least 43 skills which are learnt by the nurses during their internship session but are never performed during the professional life. 37 skills are skills are used occasionally, 28 skills are used frequently and only 13 skills are used regularly. In this skills training and practice and survey, the abdominal palpation of the pregnancy women falls under the category of skills which are practiced only occasionally. The main reason highlighted by Birks et al. (2013) behind the occasional employment of the skill includes blurring roles between the doctors and the nurses. For example, in a busy ward, a nurse might lack adequate time to perform palpation, auscultation and percussion thinking that the medical team will also be conducting the same checkups as the part of their role. This lack of performance decreases the level of expertise and thereby increasing the chances of error or lack of precision in conducting the abdominal palpation in pregnant women. Moreover, Birks et al. (2013) lack of prolong practice generates lack of confidence, which prevents them to perform the task even if the situation demands. Thus in order to increase the precision and confidence, proper practice and execution of the procedure is important.

Abdominal Palpation: An Important Aspect of Antenatal Care

In order to train the nurses in abdominal palpation in pregnant women, motor skill learning theory can be applied. According to the motor learning principles help in proper learning of the procedural skills among the nurses. The learning of the procedural or clinical skills under the banners of the motor learning texts has different parts including part practice or whole practice, blocked practice or random practice, mental practice and augmented feedback (concurrent feedbacks or terminal feedback) (Sattelmayer et al., 2016).

Part practice or whole practice means sub-dividing the procedure into numerous fundamental movement segments. After obtaining precision in the isolated parts, the learner is required to proceed to practice the parts in altogether. In whole practice, the entire practice is either taught in a serial order or as a whole entity (Sattelmayer et al., 2016). So in case of abdominal palpation, the nurses must be trained in parts starting from setting up the aseptic condition along with a private atmosphere and then learning to perform the hand and finger strokes over the abdomen and finally via training with the plotting of the graphs. Learning in parts will help the nurses to attain precision over the entire technique in a gradually (Zwicker & Harris, 2009).

Steps

Actions

1

Setting up a private atmosphere

2

Maintenance of aseptic condition

3

Hands movements

4

Finger movements

5

Recording the change on the basis of measurement (diagram provided in appendix A)

6

Plotting the graph (customised growth chart)

Table: Step by step action in part practice

Source: Created by author

In random practice, numerous components of the procedural skills are taught in under a single session but in a random order. On contrary, in blocked practice demands skills to be practiced under closed blocks followed by progression to the next preceding skills after the previous task has been accomplished under predefined amount of practice. Random practice deals with gradual increase in the level of difficulty (Sattelmayer et al., 2016). Sattelmayer et al. (2016) is of the opinion that this can have negative effects on the overall performance as the pressure increases. Thus in order to decrease the pressure and increase the performance, intensive motor planning operations must be undertaken which will help in better retrieval of memory on subsequent transfer tests (Kantak & Winstein, 2012). Thus the planning of the random practice should be done in a pictorial representation of the data or the practice procedure as this will help in memory retention and thereby aiding the nurses to perform random tasks having a clear view of the overall anatomical features (Please refer to appendix B) (Zwicker & Harris, 2009).  Kantak and Winstein (2012) are of the opinion that the random practice or block practice is best suited after the execution of the whole practice.

Role of Nurses in Abdominal Palpation during Pregnancy

Mental practice is defined as a method of the learning without physically performing it. Metal practice is associated with the concept of the mental rehearsal which involves exercises like thinking about the procedure. So the nurses must be aided with proper inforgraphic representation of the entire procedure of abdominal palpation during their recess hours. This will help them to relate with their learned practice in a relaxed mood (Schmidt & Lee, 2013) (please refer to appendix C).  

Augmented feedback is defined as the procedure about providing information about the overall performance. This feedback will help in the evaluation of the proposed implementation. This augmented feedback will be based on a set of questions (please refer to appendix D) which will help to review the current status of the nurses in the domain of exposure to the skills. On the basis of the score of the coding scale, proper training session (random practice or whole practice can be designed). Moreover, augmented feedback will also be used to measure the outcome of the motor skills learning theory and thereby helping to determine the factors which are influencing the performance and thereby setting the practice procedure accordingly (Sattelmayer et al., 2016).Further evaluation of the proposed implementation will be determined by driving a comparative analysis of learning vs. the performance and this will be done under the control supervision of healthcare physicians of the maternity ward (Sattelmayer et al., 2016).

Conclusion

Thus from the above discussion it can be concluded that the abdominal palpation is a driving aspect behind the successful normal delivery of the child and health of mother and the baby. However, the nurses due to high work-pressure and lack of proper training fail to undertaken a comprehensive abdominal palpation. So in order to increase the level of practice and precision of performing abdominal palpation among the nursing professionals motor skill learning theory can be applied. Under the motor skill learning theory, the nurses will be provided training on the basis of whole practice, blocked practice or random practice, mental practice. Finally augmented feedbacks will be used in order to evaluate the success of the proposed implementation.

References

Australian Institute of Health and Welfare (2017). Maternal deaths in Australia 2012–2014. Access date: 7th June 2018. Retrieved from: https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-in-australia-2012-2014/contents/table-of-contents

Birks, M., Cant, R., James, A., Chung, C., & Davis, J. (2013). The use of physical assessment skills by registered nurses in Australia: Issues for nursing education. Collegian, 20(1), 27-33.

Chandra-Mouli, V., Camacho, A. V., & Michaud, P. A. (2013). WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. Journal of Adolescent Health, 52(5), 517-522.

Devi, B., Khandelwal, B., & Das, M. (2016). Factors Associated with Nursing Students’ Level of Knowledge Regarding Abdominal Palpation at Gangtok, Sikkim. International Journal of Health Sciences and Research (IJHSR), 6(10), 162-173.

Finlayson, K., & Downe, S. (2013). Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies. PLoS medicine, 10(1), e1001373.

Kantak, S. S., & Winstein, C. J. (2012). Learning–performance distinction and memory processes for motor skills: A focused review and perspective. Behavioural brain research, 228(1), 219-231.

Macaluso, C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal pain in the emergency department. International journal of general medicine, 5, 789.

Nishikawa, M., & Sakakibara, H. (2013). Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment. Reproductive health, 10(1), 12.

Pacagnella, R. C., Cecatti, J. G., Parpinelli, M. A., Sousa, M. H., Haddad, S. M., Costa, M. L., ... & Pattinson, R. C. (2014). Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC pregnancy and childbirth, 14(1), 159.

Sattelmayer, M., Elsig, S., Hilfiker, R., & Baer, G. (2016). A systematic review and meta-analysis of selected motor learning principles in physiotherapy and medical education. BMC medical education, 16(1), 15.

Schmidt, R., & Lee, T. (2013). Motor Learning and performance, 5E with web study guide: from principles to application. Human Kinetics.

Zwicker, J. G., & Harris, S. R. (2009). A reflection on motor learning theory in pediatric occupational therapy practice. Canadian Journal of Occupational Therapy, 76(1), 29-37.

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