UNIT SIX COMPONENT OF FOCUSED ANC (FANC) APPROACH Learning objectives Explain steps of history taking Perform physical

ical examination Perform abdominal examination Calculate EDD & G.A

Introduction
Traditional or western antenatal care model => in low risk pregnancy, the pregnant woman is seen every four weeks until 28 weeks, then every two weeks till the 36th weeks and weekly until delivery. For high risk woman the obstetrician decide the frequency of visit according to the risk situation. Traditional or western model was criticized for being traditional rather than scientific evidence based screening method. Studies showed that it was not effective in reducing most adverse pregnancy out comes and hence could not justify the enormous cost incurred in the process. The only disease for which antenatal care was shown to be effective in reducing includes detection and treatment of anemia, possible prevention of eclampsia and detection of UTI. Most complications of pregnancy were noted to be sudden in onset and unpredictable by screening procedure & hence not preventable. Based on the above findings, WHO has suggested a new model of antenatal care with fewer antenatal visits in which targeted and evidence based tests are conducted at specific phases of pregnancy. The new antenatal care model reduces cost and leads to better time for evaluation of patients due to small number of visits. Pregnancy outcome was not adversely affected by a shift to the new component.

In the new antenatal care model an initial assessment is made to classify pregnant mothers in to those who are eligible for the basic component and those that need specialized care.

What is Focused / Goal - Oriented Antenatal Care ? Focused antenatal care (FANC) refers to a minimum number of 4 antenatal clinic visits, each of which has item of client assessment, education and care to ensure the prevention of or early detection and prompt management of complications. A major new focus is on birth planning and emergency preparedness.

ANC provides opportunities for:

1. Promoting healthy living. 4 GOALS 2. Preventing some complications of pregnancy and child birth. 3. Early detection and prompt management of problems. 4. Birth and emergency planning.

COMPONENTS OF FANC: includes 1. Assessment of Pregnant women 2. Detection and management of complication 3. Health promotion and preventive care and support including HIV. 4. Birth planning and emergency preparedness

DEFINITION OF TERMS. GRAVIDITY - Pregnancy GRAVIDA PARA A pregnant women.

Primigravida - A woman pregnant for the first time. Multigravida - A woman who has had two or more pregnancies. - A woman who has produced a viable infant (28 wks of gestation)

regardless of the outcome. 2

 Examples

Nullipara - a woman who has not given birth to a child. Primipara a woman who has given birth to one child only. Multipara - a woman who has given birth to more than one child. Grandmultipara - A woman who has given birth to 5 or more children.

1. A woman with 2 abortion and 2 deliveries are G IV P II abortion II . 2. A woman with 1 abortion, 3 deliveries and 2 stillbirth are G VI P V abortion I 3. A woman with 1 abortion and no alive children are G I P 0. Abortion I. 4. A pregnant woman with one abortion, 2 still birth, and two deliveries are G VI P IV abortion I.

1. Assessment of pregnant woman 1.1.History taking (personal, social, & family history) Purpose of history taking To assess the health of the woman. To find out any condition that may affect child bearing. For statistical purpose to record facts. 1. Personal and social history. Name, age, marital status, occupation, religion and address. Information on marital status and occupation are important in assessing socio economic status of pregnant woman. 2. Family history. Ask history of chronic illnesses like hypertension, diabetes, and psychiatric disorders. Family history of twinning, birth defects and hereditary illnesses is very important.

3. Past medical and surgical history. Ask past episodes of acute or chronic medical illnesses, their duration, treatment outcome, follow up and current status. History of previous blood transfusions, drug hypersensitivity. History of maternal infection and treatment during pregnancy including syphilis and other sexually transmitted infections is noted. 3

A history of pelvic surgery is important- Surgery involving the uterus resulting in uterine scars is of particular significance. Such scar may dehisce during pregnancy or labour.

4. Past obstetric history ( Gravida, Para, Abortion, SB, LBW). This section of the obstetric history includes a detailed chronological documentation of all previous pregnancies. This includes year of occurrence of the pregnancy, the length of gestation, duration of labour, fetal birth weight, fetal outcome, whether alive or dead, fetal presentation, mode of delivery and the presence of antepartum, intrapartum or post partum complications. Such detailed information is important because almost all major obstetric complications have significant recurrence risks. Detail information is required on number of total pregnancies (gravida), number of deliveries after 28 weeks ( para), abortion, stillbirth, and number of live births. Important obstetric conditions like ectopic pregnancy, preterm labour, post term pregnancy, abnormal labour including prolonged and obstructed labour, and fetal congenital anomalies have significant recurrence risks. 5. Present pregnancy history (LMP, EDD, GA by date). This is the most important part of the obstetric history. It includes detailed chronological description of the pregnancy from the first missed period. History of present pregnancy begins with a summary of past reproductive history and then the first day of the last normal menstrual period (LNMP), the expected dates of delivery (EDD) or confinement (EDC) and the gestational age (GA) in completed weeks are documented. Up to 25% or more may not remember their LNMP. These pregnancies with unknown LMP are considered highrisk pregnancies, as they are often associated with low socio economic status, illiteracy and repeated pregnancies. In order to ascertain the reliability of the LNMP, the menstrual cycle should have been regular, the last cycle should have been normal and similar to previous cycle in amount and duration of flow, and hormonal contraception should not have been in use for the three months prior to the LNMP. If there is question as to the reliability of LNMP, confirm it by other means.

Once LNMP is ascertained, we can calculate the EDD and gestational age. The EDD for the European (Gregorian) calendar is calculated using the Naegles rule that subtracts three months and adds seven days to the LNMP. (or adding 9 months ). eg. LMP 10 / 4 / 80 +7 +9 EDD 17 / 1 / 81 or 10 / 4 / 80 +7 - 3 17/ 1 / 81

In the Ethiopian calendar each month has 30 days. Average duration of a human pregnancy is 280 days or 10 lunar months. To count 280 days from NMP Count 9 months forward x30 = 270 days, 10 days are added if this pregnancy does not pass pagume. If this pregnancy passes pagume we add 5 days if pagume has 5 days, and we add 4 days if pagume has 6 days.

1. LMP

3/ 4/ + 5 +9

87

2.

3 / 4 / 87 +5 -3

EDD

8 / 1 / 88

EDD

8 / 1 / 88

3. LMP 3 / 2 / 88 + 10 +9 EDD 13 / 11 / 88

4. LMP 6 / 8 / 90 + 4 +9 EDD 10 / 5 / 91

GESTATIONAL AGE Gestation - The length of time from conception to birth. Gestational age is the estimated age of the fetus expressed in weeks. Counting from the first day of LMP up to the date when the mother comes for antenatal examination. Gestational age calculation is based on the assumption of a regular twenty - eight days cycle with ovulation occurring on the fourteenth day. eg. 1. LMP 1 / 8 / 96 Examination day 8 +6 3 / 10 / 96

62 days G.A =

8 weeks + 6 days.

2.

LMP

6 / 7 / 98 211 days 7

Examination day = 30 +1

2 / 2 / 99

G.A = 30 weeks +1 day.

1.2. PHYSICAL

EXAMINATION

Physical examination of the obstetric mother includes evaluation of the general appearance, vital signs, anthropometric measurements, examination of various organ systems, abdominal examination and pelvic assessment. Privacy should be maintained. A comfortable couch should be available. The

abdominal examination should be completed in a reasonable period of time in order to avoid fainting and dizziness due to supine hypotension syndrome following vena caval compression by the gravid uterus: 1.2.1. EXAMINATION OF VITAL SIGNS Measuremement of blood pressure; pulse rate, respiratory rate, & temperature are important in the evaluation of the obstetric client particularly in emergency obstetric situations. The pulse rate increased by 10-15 beats per minute during normal pregnancy. However a rate of more than 100 per minute (tachycardia) is abnormal during pregnancy. 6

This may indicate anaemia, cardiac illness, febrile illness or respiratory tract infection among other possible causes. Progesterone induced central respiratory stimulation during pregnancy increases respiratory rate by 14 breaths per minute. This is also responsible for the breathlessness and dyspnea experienced by the pregnant mother. Arterial blood pressure (ABP) measurement is an important evaluation during pregnancy because of increased prevalence of hypertensive disorder of pregnancy and hemorrhagic shock. Hence correct and accurate measurement of ABP is essential. The patient should be sitting or at 30 degrees left lateral tilt with measurement taken from the right arm. The measuring apparatus should be at the level of the heart. Blood pressure should never be taken in the supine position in a pregnant mother due to supine hypotension syndrome leading to a false lowering of the blood pressure. Due to changes in vascular tone and blood volume alterations in cardiovascular physiology during pregnancy, the ABP gradually decreases until the second trimester from the pre pregnant level. Then after, it gradually increases as pregnancy approaches term. Hence the true pre pregnancy ABP can be depicted from pre-pregnancy or early pregnancy measurements only. If a pregnant woman is first seen for the first time at mid pregnancy the diagnosis of chronic hypertension may be masked due to normalization of the high B/P due to the physiologic lowering of B/P at this time. Hypertension during pregnancy is defined as an ABP above 140/90mmHg measured at least twice six hours apart. However, a measurement of severe hypertension of 160/110 mmHg or more only once is adequate for diagnosing hypertension. Another less commonly used definition is a rise of 30 mmHg and 15mmHg in the systolic and diastolic level respectively compared to the prepregnancy (early pregnancy) levels. The last definition is said to have a sensitivity of less than 30% and is not nowadays used to diagnose hypertension during pregnancy. Fever during pregnancy is a very important finding as it indicates the presence of serious illnesses lead to serious complications such as abortion, preterm labour etc. Important causes of fever include chorioamnionitis, urinary tract infection, and acute febrile illnesses.

Anthropometric measurements include: Weight - please refer to previous note. Height Previously maternal height less than 150cm was considered as a risk factor for contracted pelvis and development of cephalo-pelvic disproportion nowadays we consider every pregnancy is at risk. 1.2.2. SYSTEMATIC PHYSICAL EXAMINATION Examination started as she walks in: Any deformity Stunted growth. Head clean & healthy Face does she look healthy? Check for signs of anaemia (conjunctiva), bad teeth, oedema of the face etc. Ear any discharge Nose any bleeding or polyp

Heads, ears, eyes, nose, & throat examination

Lymph glandular examination The thyroid gland volume increases by about 25% during pregnancy. However the thyroid should not be visibly enlarged. Breasts o Size, any lump o Retracted nipples, flat. N.B - palpation of a breast lump is more difficult during pregnancy due to increased vascularity & fat deposition. It is important to identify and treat retracted nipples during antenatal period as time will not allow this to be performed in the puerperium when breast feeding has to be initiated as soon as possible. Chest examination - Examine chest for any breathing problem. Cardiovascular examination Cardiovascular system should be examined. Pregnant women may have

symptomatic or asymptomatic heart disease. Abdominal examination 8

- Abdominal examination, including the obstetric palpation is the most important component of the examination of obstetric women. - Use comfortable couch. - She should not be kept in supine position for long. - At the end of the examination the woman should be placed in the lateral position first before being asked to rise from the supine position. Vulva Any vaginal bleeding, discharge etc Pelvic examination - Strict asepsis. - Specific contraindications to the pelvic examination in pregnancy include vaginal bleeding after the 28th week of pregnancy and premature rupture of the membranes. Pelvic assessment may be conducted at any time during pregnancy when a specific complication arises. In routine antenatal care follow up, however, pelvic assessment is usually performed on two occasions. 1. Early pregnancy pelvic examination 2. Pelvic assessment at term 1. Early pregnancy pelvic examination. This is performed during the first trimester as early as possible during pregnancy when the uterine size is small and does not preclude adnexal assessment. The purposes of this examination are to diagnose pregnancy, to date pregnancy by assessing uterine size & to diagnose adnexal & uterine pathologies such as myoma and ovarian tumors. 2. Pelvic assessment at term. The assessment is performed at term because the increased secretion of estrogen and progesterone make the soft tissues of the pelvis and vagina lax to perform and less discomforting. The purpose of pelvic assessment is it help to decide on the mode of delivery. Mothers who need pelvic assessment at term include: Primigravida Multiparous mother 9 making the procedure easier

 History of difficult and prolonged labour Breech presentation. Mother with previous caesarean who require decision on vaginal after caesarean ( VBAC ). Mother with skeletal anomalies. Previous history of pelvic fracture. N.B The pelvic assessment is also performed for every mother in labour at admission. Pelvic assessment - head is the best pelvimeter and head fitting can be of great value. Genitourinary examination The presence of costovertebral and suprapubic tenderness is important in the diagnosis of UTI. Acute pyelonephritis is a common complication of pregnancy. Examination of the extremities - Oedema if there is generalized oedema - Any deformity - Varicose vein. N. B - Deep vein thrombosis (DVT) may lead to the development of unilateral oedema. The presence of varicose veins is also a risk factor for the development of DVT. It may be aggravated during pregnancy. Central nervous system examination Examination of the level of consciousness and deep tendon reflexes may be important in obstetric patients with per eclampsis , eclampsia and embolization. birth

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1.3.ABDOMINAL EXAMINATION AIMS OF ABDOMINAL EXAMINATION To observe signs of pregnancy. To assess fetal size and growth. To assess fetal & maternal health. To diagnose the location of fetal parts. To detect any deviation from normal.

N. B - The mother should be with empty bladder. - Should lie on her back, with her arms down by her side. DEFINITION OF TERMS FETO PELVIC RELATION SHIP MECHANISM - Series of movements of the fetus in his passage through the birth canal. LIE - Relationship between the long axis of the fetus and the long axis of the mothers uterus. ATTITUDE - Relationship of the fetal parts to one another. Normal flexion. Abnormal Extension. Vertex 96. 8% Shoulder 4% (1 in 250) Face 0.2% (1 in 500) Brow 0.1% (1 in 1000) PRESENTING PART - The part of the fetus coming first and felt on vaginal examination. POSITION Relationship of the denominator to the six areas of the mothers pelvis. Normal anterior or lateral. Abnormal Posterior ( malposition).

PRESENTATION - the part of the fetus which lies in the lower pole of the uterus. Normal Abnormal breech 2.5%

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DENOMINATOR The part of the fetus which tells the position. In vertex In breech In face Occiput. Sacrum. Mentum. No denominator is used.

In shoulder Acromion process. In brow

ENGAGED - when the bi parietal pass the pelvic brim. CROWNED - when the bi parietals pass the ischial spines and the head no longer recedes between contractions.

________________
o

LONGITUDINAL LIE ________________

Figs 10.11

Figs 10.10

OBLIQUE LIE

Figs 10.13

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SIX POSITIONS IN VERTEX PRESENTATION

Left occipitoanterior.

Right occipitoanterior.

Left occipitolateral.

Right occipitolateral.

Left occipitoposterior.

Right occipitoposterior.

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THE FIVE PRESENTATIONS

Vertex presentation

Face presentation Brow presentation

Breech Presentation

Shoulder, dorso-anterior presentation

Shoulder, dorso-posterior presentation

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STEPS FOR ABDOMINAL EXAMINATION 1. Inspection. 2. Palpation. 3. Auscultation. INSPECTION Remember the 4 S. Size - should correspond with the estimated period of gestation. - Is it roughly the size it should be? twins, hydramnios etc.

Shape - note contour - is it round, oval, irregular or pendulous? o Primigravida - usually ovoid with longitudinal lie. o Multipara - round. o Transverse lie - broad.

Skin - lineanigra, any rash. Scar - Any operation scar, previous section, myomectomy scar. N. B - Sometimes the fetus can be seen moving.

PALPATION The hand should be clean and warm. Use the whole hand with fingers together and move hands gently.

Fundal height - measure distance of fundus with points on abdomen. Fundal height can be determined by the finger method, by using landmarks on the abdominal wall and by the tape measure of symphysis fundal height (SFH) in centimeters. 1 - Fundal palpation Purpose - To know lie, G.A and presentation It is the first maneuver palpate fundus, see if head or breech is there.

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After determining the location of the fundus, one finger breadth is taken as one week below the umbilicus and two weeks above the umbilicus due to the faster growth of the fetus in the second half of pregnancy.

This method is believed to be less reliable than the tape measure due to individual variations in finger size and methods of measurement. The fundus just palpable above the symphysis is taken as 12 wks size. It reaches the umbilicus at 20 22 wks, the xyphoid process at 36 weeks, and then often returns to about 4cm below the xyphoid due to lightening at 40 weeks. Fundal height to gestational age discrepancy of less than plus or minus (+) two weeks is considered acceptable. More than two weeks positive or negative discrepancy requires further investigation as to possible cause.

Fig. 10.2 Fundal palpation

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2 - Lateral palpation. Purpose - To know lie & position. It is the second Leopold maneuver is intended to determine the lie of the fetal back. The lie of the fetus implies the configuration of the longitudinal axis of the fetus in relation to the longitudinal axis of the uterus. The lie can be longitudinal, transverse or oblique. The lateral palpation is performed alternately on both sides by using one hand to stabilize the uterus at the same time using the other hand for palpation. Identification of the back helps in auscultating the fetal heart beat. The flat and straight surface n ne side signifies the back whereas the irregular soft parts indicate the side where the fetal extremities are located.

Fig. 10.3 Lateral palpation. Hands placed at umbilical level on either side of the uterus. Pressure is applied alternately with each hand.

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Fig. 10.4 'Walking' the finger tips across the abdomen to locate the position of the fetal back

3 - Deep pelvic palpation. Purpose To know presentation and attitude It is the third Leopold palpation. The palpation is conducted by using both hands starting from the level of umbilicus and gradually descending downwards to the pelvis. The midwife should ask the woman to bend her knees slightly in order to relax the abdominal muscles and suggest that she breaths steadily through an open mouth.

Fig 10.5 Method of pelvic palpation used to determine position in a vertex presentation. The higher cephalic prominence (the sincipital) will be on the side opposite to the back.

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The examiner faces the foot of the patient while performing the third palpation In cephalic presentation, a hard mass with distinctive round, smooth surface will be felt. In order to determine if the vertex is presenting, the occipital and sincipital prominences are located.

If the head is well flexed, the sinciput will be felt on the opposite side from the back and higher than the occiput.

If the head is deflexed, the prominences are on the same level.

Fig 10.6 Pelvic palpation. If the hands are in the correct position, the outstretched thumbs will meet at about umbilical level. The fingers are directed inwards and downwards.

If the head is extended, the bulk of the head is felt on the same side as the back. Although it is not part of the third palpation, descent of the fetal head can be identified as fifth of fetal head felt above the brim. Fetal head above the brim is measured in fingers and expressed as fifth (five fingers are taken as the breadth of the fetal head). A floating head is taken as 5/5th above the brim. 2/5th denotes an engaged fetal head. One should be particularly gentle in performing the third and fourth palpations in a patient with ante partum haemorrhage due to placenta praevia.

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4 - pawliks grip. Purpose - To identify the fetal presentation and its mobility above the pelvic brim. It is also used to judge the size and flexion. The midwife facing the womans head and grasps the lower pole of the uterus between the fingers and thumb which should be spread wide enough apart to accommodate the fetal head. One may skip this palpation if all information is obtained from the third palpation (pelvic palpation). N. B - This palpation is more discomforting than the other palpations perform gently.

Fig. 10.7 Pawlik's manoeuvre. The lower pole of the uterus is grasped with the right hand, the midwife facing the woman's head.

N. B - In some books deep pelvic palpation is taken as fourth Leopold maneuver and pawliks grip as third Leopold maneuver.

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AUSCULTATION Purpose - To assess fetal wellbeing Pinards fetal stethoscope is commonly used to hear the fetal heart. It is placed in the mothers abdomen and at right angles to it. The ear must be in close, firm contact with the stethoscope but the hand should not touch it while listening because extraneous sounds are produced. The stethoscope should be moved about until the point of maximum intensity is located where the fetal heart is heard most clearly. The fetal heart sounds are heard over the area of the left scapula. Normal fetal heart beat is between 120 and 160, count for a full minute. Fetal heart can be auscultated starting from the 10thweek using doppler ultrasonography. With ultrasound it can be auscultated from the 6th weeks. With the fetal heart stethoscope it can be auscultated from the 20th week on wards. In cephalic presentation, the FH are best heard below the umbilicus. In breech presentation, the FH are best heard above the umbilicus. In occipitoposterior position, the FH are best heard in the region of the flanks.

Fig. 10.8 Auscultation of the fetal heart. Vertex left occipito-anterior.

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1.4.LABORATORY INVESTIGATIONS Laboratory investigations and diagnostic procedures are performed with the intention of identifying risk factors that cannot be identified from the history and physical examination.

Hematological tests Some of the hematological tests commonly performed are:Hemoglobin => Hgb concentration level falls during normal pregnancy due to

physiological hydremia following excessive plasma volume increase compared to red cells increment. This Physiological anemia of pregnancy decreases the hemoglobin level up to 11gm /dl. Anemia is defined as a Hgb level of less than 10.5 gm / dl. Determine Hgb at the first visit and repeated at 32 36 weeks of gestation. Blood group and Rh status => Performed at initial assessment. Rh ve mother is at risk for isoimmunization injury to her fetus if her partner is Rh positive. For Rh ve woman indirect coombs test is performed on first visit and repeat at 28 and 34 weeks. ABO blood grouping of the mother and the fetus is also important in rare instances of ABO incompatibility leading to hemolytic disease of the new born. Serology for syphilis. Screening tests for syphilis like the VDRL (venereal diseases research laboratories) or RPR (rapid plasma regain) should be done at initial visit and repeated during pregnancy. Treat syphilis before 18 wks or earlier so that congenital infection and resulting injury can be avoided. Screening for the human immunodeficiency and hepatitis B virus infections. For all pregnant women voluntary confidential counseling and testing (VCCT) should be done. Screen all pregnant mothers for HBV using the HB surface antigen (HbsAg).

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Urinalysis Urine is analyzed for protein, glucose, ketones and presence of WBC indicating infection. During pregnancy protein excretion is increased from the non pregnant level of less than 16 mg / dl to 300mg / dl per 24 hrs. Proteinuria is detected in UTI, pregnancy induced hypertension, contamination by vaginal discharge or bleeding etc. To avoid contamination careful specimen collection (clean catch midstream specimen). Glycosuria is detectable in up to 50% of pregnancies due to increase in the glomerular filtration rate. It should be investigated by blood glucose testing. Ketonuria indicates severe nausea and vomiting which has lead to starvation ketosis.

Urine culture and sensitivity Asymptomatic bacteruria - absence of symptoms or signs of UTI. Its incidence in pregnancy is about 7%. 40% of women with asymptomatic bacteruria develop acute pyelonephritis during pregnancy. It is important to perform urine culture and sensitivity for all pregnant mothers at initial visit and treat accordingly to prevent pyelonephritis.

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UNIT 7 TIMING AND FREQUENCY OF FOCUSED ANC APPROACH Traditional or western antenatal care model => in low risk pregnancy, the pregnant woman is seen every four weeks until 28 weeks, then every two weeks till the 36th weeks and weekly until delivery. For high risk woman the obstetrician decide the frequency of visit according to the risk situation. Traditional or western model was criticized for being traditional rather than scientific evidence based screening method. Studies showed that it was not effective in reducing most adverse pregnancy out comes and hence could not justify the enormous cost incurred in the process. The only disease for which antenatal care was shown to be effective in reducing includes detection and treatment of anemia, possible prevention of eclampsia and detection of UTI. Most complications of pregnancy were noted to be sudden in onset and unpredictable by screening procedure & hence not preventable. Based on the above findings, WHO has suggested a new model of antenatal care with fewer antenatal visits in which targeted and evidence based tests are conducted at specific phases of pregnancy. The new antenatal care model reduces cost and leads to better time for evaluation of patients due to small number of visits. Pregnancy outcome was not adversely affected by a shift to the new component. In the new antenatal care model an initial assessment is made to classify pregnant mothers in to those who are eligible for the basic component and those that need specialized care. Women with the following conditions are not eligible for the basic components of the new antenatal care model. Obstetric history Previous stillbirth or neonatal loss. History of three or more consecutive spontaneous abortions. Birth weight of last baby < 2500gm. Birth weight of last baby > 4500gm. Last pregnancy: hospital admission for hypertension or preeclampsia / eclampsia. Previous surgery on reproductive tract (myomectomy, removal of septum, cone biopsy, classical C/S, cervical cerclage). 24

Current pregnancy Diagnosed or suspected multiple pregnancy. Age less than 16 yrs. Age greater than 40 years. Isoimmunization in current or previous pregnancy. Vaginal bleeding. Pelvic mass. Diastolic blood pressure > 90 mmHg at booking.

General medical conditions Insulin dependent diabetes mellitus. Renal disease. Cardiac disease. Known substance abuse including alcohol. Any other severe medical disease or condition.

N.B The obstetrician decides the frequency of visits and pattern of care for mothers with the above risks on an individual basis. What is Focused / Goal - Oriented Antenatal Care ? Focused antenatal care (FANC) refers to a minimum number of 4 antenatal clinic visits, each of which has item of client assessment, education and care to ensure the prevention of or early detection and prompt management of complications. A major new focus is on birth planning and emergency preparedness.

ANC provides opportunities for:

1. Promoting healthy living. 4 GOALS 2. Preventing some complications of pregnancy and child birth. 3. Early detection and prompt management of problems. 4. Birth and emergency planning.

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How frequently should women be seen in pregnancy? 1. 1st visit : before 12 weeks (<16 weeks). 2. 2nd visit: 26 weeks (24-28 weeks). 3. 3rd visit : 32 weeks (30-32 weeks). 4. 4th visit : 38 weeks (36-40 weeks). Each visit should be targeted to specific tasks. Activities to be conducted at each visit are as follows. These activities are supported by currently available scientific evidence to have benefits that justifies the cost. First visit activities (before 12 weeks (<16 weeks). Classify the women for the basic and specialized component of the program. Clinical examination. Request relevant laboratory investigation (Hb, VDRL, blood group and Rhesus type, urine analysis). Obstetric exam - gestational age estimation, uterine height. Blood pressure measurement. Tetanus toxoid administration. Iron / folic acid supplementation. Educate and counsel client. Initiate discussion on birth and emergency planning. Complete antenatal card. Give appointment for the 2nd visit.

Second visit: 26 weeks (24-28 weeks). Clinical examination for anemia Obstetric examination: gestational age estimation, uterine height, and fetal heart rate. Blood pressure measurement. Maternal weight (only women with low weight at first visit). Urine test for protein (only nulliparous women / women with previous pre eclampsia) Iron / folic acid supplementation. Take action on result of laboratory tests e.g. Treat syphilis. Recommendation for emergencies. 26

Complete antenatal card. Tetanus toxoid (1month after the first TT).

Third visit 32 weeks (30-32 weeks): In addition to 1st and 2nd visit. Hgb test requested. Instructions for delivery / plan for birth. Recommendation for lactation / contraception. Check the uterine size and palpate the fetus (lie, presentation etc).

Fourth visit 38 weeks (36-40 weeks): in addition to second and third visit activities. Detection of breech presentation and referral for external cephalic version. Check the uterine size and palpate fetus (lie, presentation, engagement, FH sound etc). Perform pelvic examination to defect any soft tissue abnormality. Educate and counsel about symptoms / signs of labour. Review Birth plans with client. AVOID WASTING TIME ON UNPROVEN PRACTICES There is no evidence that the following procedures are of value during antenatal care: Routine weighing of woman Measurement of womans height Measurement of womans shoe size. Checking for leg oedema (except when included in generalized oedema).

Use the time saved to discuss the womans birth plan and educate her on symptoms and signs of pregnancy complications or complications in labour.

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UNIT 8 Health promotion and preventive care and support including HIV 2.0.ADVICE TO THE PREGNANT WOMAN The antenatal clinic is the school of the pregnant woman; she is usually very willing to listen. POINTS TO BE ADVICED ON Exercise, recreation. Not lifting heavy loads. Rest, at least 10 hrs at night and 2 hrs in the afternoon. Breast care teach how to take care of her breasts so as to promote successful breast feeding. Daily cleaning with particular attention to the nipples is encouraged. Pull out and roll each nipple between the fingers about three times a day to make it more protractile. Clothing, comfortable shoes. Bathing Diet rich in iron, protein, vitamins and minerals. Pregnant woman should have liberal fluid intake. Daily fluid requirement of 2 lit could be taken in the form of water, fruit juice, milk etc. Adequate intake of fluid and fruit should prevent constipation. Marital relations should be avoided if history of abortion. Advice on TT vaccination. NO SMOKING and NO ALCOHOL.

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2.1.TETANUS TOXOID VACCINATION Tetanus toxoid (TT) immunizations of child bearing women in national EPI are 15 49 years. A five dose of TT immunization for women of child bearing age is recommended schedule. There is no contraindication to administration of TT.

Tetanus toxoid immunization schedule for women of child bearing age DOSE WHEN TO GIVE EXPECTED DURATION OF PROTECTION TT1 TT2 TT3 TT4 TT5 At first contact or as early as possible in pregnancy At least 4 weeks after TT 1 At least 6 months after TT 2 At least one year after TT 3 or during subsequent pregnancy At least one year after TT4 or during subsequent pregnancy Lifelong 3 years 5years 10 years None

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ANTENATAL COUNSELING

USE GATHER COUNSELING STEPS FOR ANTENATAL VISITS Greet Ask Tell Help Explain and examine. Refer / Give Return appointment.

G - Greet the client: - With respect and kindness. - Offer her a seat. - Ensure privacy and confidentiality. - Encourage her to feel free to discuss any concerns about her current pregnancy or future delivery. A - Ask the client about: - Any complaints. - Previous pregnancies & their outcome. - Her family / home situation. - Danger signals in pregnancy and during child birth. - Birth plans.

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- What she would do if she developed an unexpected complication in pregnancy or during child birth. T - Tell the client about: Appropriate diet and nutrition. Importance of personal hygiene. Rest and exercise in pregnancy. Effects of STIs / HIV / AIDS in pregnancy and the need for VCT and PMTCT. Importance of TT vaccine. Malaria prevention as per national guide lines with ITN (insecticide treated net). Harmful traditional practices. Care of the breast & breast feeding : Danger signs in pregnancy and / or at child birth.

H - Help the client to make a Birth plan: When is her expected date of delivery? Where will she deliver? Who will assist her at delivery? Who will look after her other children when she is away? What transportation will she use to reach her chosen place of delivery or if complications arise? How will she raise funds for transportation and the cost of delivery? What is her preferred position for delivery? What family planning method will she like to use after delivery & where will she obtain it? E - Explain and Examine Explain about: The benefits of goal oriented ANC. Need to have some laboratory tests. Importance of compliance with medications and health advice given. The importance of having a skilled professional attends her delivery.

Examine the client to:

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Confirm that the uterine size is compatible with the gestational age and that the baby is alive.

Detect abnormalities such as anaemia, multiple pregnancy, STIs etc.

R - Refer the client: If she has a complication that cannot be managed at your facility. For VCT. For laboratory investigations. If she requests to be referred.

Reassure (share your finding on her progress). Give an appointment for her return visit.

DANGER SIGNS IN PREGNANCY Vaginal bleeding. Fits or convulsions Loss of consciousness Severe headache Blurred vision Swelling of the face, hands and legs. Abdominal pains. Fever and chills. Severe vomiting Weakness, lethargy and breathlessness Decreased or absent fetal movements Dysuria and supra pubic pain. Draining of liquor from vagina without labour. Foul - smelling vaginal discharge. Premature labour pains.

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DANGER SIGNS IN LABOUR Excessive vaginal bleeding during or after delivery. Placenta is undelivered more than 1 hour after the baby has been delivered. Labour pain lasting more than 12 hrs without delivery. Draining of liquor without labour for more than 12 hrs. Convulsions / fits or loss of consciousness. Fever or foul smelling vaginal discharge. Severe abdominal pains. Cord, arm or leg prolapse.

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